Almousa SA. Quality of primary total knee arthroplasty operative reports in a tertiary teaching hospital. World J Orthop 2025; 16(5): 104438 [DOI: 10.5312/wjo.v16.i5.104438]
Corresponding Author of This Article
Sulaiman A Almousa, FRCS, MD, Assistant Professor, Department of Orthopedic Surgery, College of Medicine, Imam Abdulrahman Bin Faisal University, King Faisal Road, Dammam 31441, Saudi Arabia. smousa@iau.edu.sa
Research Domain of This Article
Orthopedics
Article-Type of This Article
Observational Study
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
World J Orthop. May 18, 2025; 16(5): 104438 Published online May 18, 2025. doi: 10.5312/wjo.v16.i5.104438
Quality of primary total knee arthroplasty operative reports in a tertiary teaching hospital
Sulaiman A Almousa
Sulaiman A Almousa, Department of Orthopedic Surgery, College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam 31441, Saudi Arabia
Author contributions: Almousa SA designed the research study, performed the research, analyzed the data, wrote the manuscript, and read and approved the final manuscript.
Institutional review board statement: Ethical approval for this study was obtained from the institutional review board at Imam Abdulrahman Bin Faisal University (No. IRB-2024-01-682).
Informed consent statement: All study participants, or their legal guardian, provided informed written consent prior to study enrollment.
Conflict-of-interest statement: The author reports no relevant conflicts of interest for this article.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Data sharing statement: Dataset available from the corresponding author at smousa@iau.edu.sa. Consent was not obtained but the presented data are anonymized, and risk of identification is low.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Sulaiman A Almousa, FRCS, MD, Assistant Professor, Department of Orthopedic Surgery, College of Medicine, Imam Abdulrahman Bin Faisal University, King Faisal Road, Dammam 31441, Saudi Arabia. smousa@iau.edu.sa
Received: December 20, 2024 Revised: March 22, 2025 Accepted: April 14, 2025 Published online: May 18, 2025 Processing time: 147 Days and 11.1 Hours
Abstract
BACKGROUND
Operative reports (OP-Rs) are essential for communication among healthcare providers. They require accuracy and completeness to serve as a quality indicator of patient care. Objective assessment of primary total knee replacement (TKR) OP-Rs has never been reported. Therefore, a standardized benchmark for assessment and factors affecting the completeness of TKR OP-Rs needs to be evaluated.
AIM
To evaluate the completeness rate of primary TKR OP-Rs in a teaching hospital and to assess the factors affecting completeness.
METHODS
A retrospective review of 58 consecutive primary TKR OP-Rs in a tertiary teaching hospital were included in this study. We used document analysis to review the OP-Rs against a standardized list of six subsets of mandatory variables. The correlation between the percentage of completeness and the specific variables was determined.
RESULTS
After analyzing 58 cases, we found that the time to documentation was 1.5 hours. Out of the 52 mandatory variables, a median of 30 variables were documented yielding a completeness of 58%. Administrative, procedural, exposure, and implant variables were documented the most often, whereas clinical and process variables were most frequently left uncompleted. The documentation of the operative maneuver was variable. There was no association between the completeness of the reports and the time to documentation, documenter level, complication rate, operative duration, or length of hospital stay.
CONCLUSION
Multiple variables were left undocumented on the unstructured primary TKR OP-Rs. The completeness percentage will likely improve after the implementation of a standardized structured OP-R.
Core Tip: Operative reports (OP-Rs) are a crucial part of patient care and safety. Currently, there is no standardized method for the documentation of the primary total knee replacement (TKR) procedure. A standardized list of documentation variables was created and the completeness of the primary TKR OP-Rs was assessed. It was found that multiple mandatory variables were infrequently documented. This study proposes a standardized method for documenting primary TKR OP-R to improve the reliability of this crucial document.
