Predictors of Extended Length of Stay Following Open Reduction and Internal Fixation for Proximal Humerus Fractures.

Purpose: An extended length of stay following open reduction and internal fixation (ORIF) for proximal humerus fractures (PHFs) is associated with increased patient morbidity and health care costs. The primary purpose of this study was to identify risk factors for an extended length of stay following ORIF for PHF. Methods: All patients who underwent ORIF for PHF between 2015 and 2021 were queried from the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. Patient demographics, comorbid conditions, and postoperative complications within 30 days of procedure were collected. Extended length of stay (eLOS) was defined by ≥ 3 days from operation to discharge. Multivariate logistic regression was employed to identify predictors of eLOS following ORIF. Results: Characteristics of patients significantly associated with eLOS included age ≥ 75 years (p < .001), male gender (p < 0.001), body mass index (BMI) < 18.5 (P = .001), American Society of Anesthesiologists (ASA) classification ≥ 3 (P < .001), dependent functional status (P < .001), noninsulin-dependent diabetes (P = .037), insulin-dependent diabetes (P < .001), chronic obstructive pulmonary disease (P < .001), congestive heart failure (CHF) (P < .001), hypertension (P < 0.001), dialysis (P < .013), disseminated cancer (P < 0.001), chronic steroid use (P = .004), and bleeding disorder (P < .001). Independent predictors of eLOS were age ≥ 75 years (OR = 2.69; P < .001), BMI < 18.5 (OR = 1.70; P = .016), ASA ≥ 3 (OR = 2.70; P < .001), dependent functional status (OR = 2.30; P < .001), CHF (OR = 3.57; P < .001), disseminated cancer (OR = 7.62; P < .001), and bleeding disorder (OR = 2.68; P < .001). Conclusion: Age ≥ 75, BMI < 18.5, ASA ≥ 3, functional dependence, CHF, disseminated cancer, and bleeding disorder were independently associated with eLOS. Clinical Relevance: Assessing specific patient factors prior to ORIF for PHF can assist in managing perioperative risks and decreasing expenses related to eLOS. Level of Evidence: Prognosis III.

Aspartate Aminotransferase-to-Platelet Ratio Index Suggestive of Liver Dysfunction Predicts Early Complications After Open Reduction Internal Fixation of Distal Radius Fractures.

Purpose: Aspartate aminotransferase-to-platelet ratio index (APRI) is a cost-effective and noninvasive measure of liver function, an alternative to the gold standard liver biopsy, which is resource-intensive and invasive. The purpose of this study was to investigate the association between preoperative APRI and 30-day postoperative complications after isolated open reduction internal fixation (ORIF) of distal radius fractures (DRFs). Methods: The American College of Surgeons National Surgical Quality Improvement Program database was queried for all patients who underwent isolated ORIF of DRFs between 2015 and 2021. The study population was divided into two groups on the basis of preoperative APRI: normal/reference (APRI, <0.5) and liver dysfunction (APRI, ≥0.5). Information on patient demographics, comorbidities, and 30-day postoperative complications after isolated ORIF of DRFs was collected. Multivariate logistic regression analysis was performed to investigate the relationship between preoperative APRI and postoperative complications. Results: Compared to patients with normal APRI, patients with preoperative APRI associated with liver dysfunction were significant for male sex (P < .001), younger age (P < .001), American Society of Anesthesiologists classification grade ≥3 (P < .001), being smokers (P < .001), and having comorbid diabetes (P = .002) and bleeding disorders (P < .001). Preoperative APRI associated with liver dysfunction was independently associated with a greater likelihood of any complications (odds ratio [OR], 1.49; 95% confidence interval [CI], 1.19-1.87; P < .001), nonhome discharge (OR, 1.62; 95% CI, 1.15-2.27; P = .005), and a length of stay of >2 days (OR, 1.70; 95% CI, 1.32-2.20; P < .001). Conclusions: Aspartate aminotransferase-to-platelet ratio index values associated with liver dysfunction were associated with an increased rate of early postoperative complications after DRF ORIF. Clinical relevance: This study suggests APRI's utility as a cost-effective, noninvasive measure of liver function that physicians can use before surgery to better identify surgical candidates with DRFs and suspicion of liver dysfunction. Type of study/level of evidence: Prognostic III.

Risk factors for postoperative transfusion in diabetic patients following total shoulder arthroplasty.

Background: Diabetes has been reported as a risk factor for postoperative transfusion following total shoulder arthroplasty (TSA). However, the risk factors specific to diabetic patients that increase their likelihood of postoperative blood transfusion remains understudied. The purpose of the study was to investigate the risk factors that are associated with 30-day postoperative transfusion among diabetic patients who undergo TSA. Methods: The American College of Surgeons National Surgical Quality Improvement Program database was queried for all patients who underwent TSA between 2015 and 2020. Both patients with and without diabetes were divided into cohorts based on 30-day postoperative transfusion requirement. Bivariate logistic regression was used to compare patient demographics and comorbidities. Multivariate logistic regression, adjusted for all significant patient demographics and comorbidities, was used to identify the characteristics independently associated with postoperative transfusion. Results: A total of 4376 diabetic patients remained after exclusion criteria, with 4264 (97.4%) patients who did not require postoperative transfusion and 112 (2.6%) patients who did require postoperative transfusion. On multivariate analysis, female gender (odds ratio [OR] 2.43, 95% confidence interval [CI] 1.52-3.89; P < .001), American Society of Anesthesiologists ≥3 (OR 2.46, 95% CI 1.10-5.48; P = .028), bleeding disorder (OR 2.94, 95% CI 1.50-5.76; P = .002), transfusion prior to surgery (OR 12.19, 95% CI 4.25-35.00; P < .001), preoperative anemia (OR 8.76, 95% CI 5.47-14.03; P < .001), and operative duration ≥129 minutes (OR 4.05, 95% CI 2.58-6.36; P < .001) were found to be independent risk factors for postoperative transfusion among diabetic patients. Our nondiabetic cohort included 19,289 patients, with 341 (1.8%) requiring postoperative transfusion. On Multivariate analysis, we found similar risk factors for transfusion to our diabetic population, as well as age ≥75 (OR 1.80, 95% CI 1.37-2.35; P < .001) and dependent functional status (OR 2.16, 95% CI 1.40-3.32; P < .001) to be independent risk factors for postoperative transfusion among nondiabetic patients. Conclusion: Female gender, American Society of Anesthesiologists ≥3, bleeding disorder, transfusion prior to surgery, preoperative anemia, and operative duration ≥129 minutes were independently associated with postoperative transfusion following TSA in diabetic patients. These findings encourage physicians to carefully assess patients with diabetes preoperatively to minimize adverse outcomes.

Investigating immediate postoperative medical complication risks relative to in-hospital length of stay after total shoulder arthroplasty.

Background: The purpose of this study was to investigate the association between in-hospital length of stay (LOS) and postoperative complication rates within 30 days of total shoulder arthroplasty (TSA). Methods: All patients who underwent either anatomic or reverse TSA between 2015 and 2019 were queried from the American College of Surgeons National Surgical Quality Improvement database. The study population was stratified into three cohorts as follows: LOS 0 (same-day discharge), LOS 1 (next-day discharge), and LOS 2-3 (LOS of 2-3 days). Patient demographics and comorbidities were compared between cohorts using bivariate analysis. Multivariate logistic regression analysis was conducted to investigate the relationship between LOS and postoperative complications. Results: In comparison to the LOS 0 day cohort, LOS 2-3 day cohort had a greater likelihood of developing overall complication (OR, 2.598; P < .001), major complication (OR, 1.885; P < .001), minor complication (OR: 3.939; P < .001), respiratory complication (OR: 12.979; P = .011), postoperative anemia requiring transfusion (OR, 23.338; P < .001), non-home discharge (OR, 10.430; P < .001), and hospital readmission (OR, 1.700; P = .012). Similarly, in comparison to the LOS 1 cohort, LOS 2-3 cohort had a greater likelihood of developing overall complication (OR: 2.111; P < .001), major complication (OR, 1.423; P < .001), minor complication (OR, 3.626; P < .001), respiratory complication (OR, 2.057; P < .001), sepsis or septic shock (OR: 2.795; P = .008), urinary tract infection (OR, 1.524; P = .031), postoperative anemia requiring transfusion (OR, 10.792; P < .001), non-home discharge (OR: 10.179; P < .001), hospital readmission (OR, 1.395; P < .001), and return to the operating room (OR. 1.394; P = .014). There was no significant difference in the risk of developing postoperative complications between LOS 0 day and LOS 1 day cohort. On baseline, the LOS 1 and LOS 2-3 day cohort had a higher proportion of patients with the following demographics and comorbidities compared to LOS 0 day cohort: advanced age, higher body mass index, female gender, positive smoking status, insulin-dependent diabetes, noninsulin-dependent diabetes, dyspnea at rest and moderate exertion, partially dependent functional status, an American Society of Anesthesiologists classification of 3 or higher, a history of severe chronic obstructive pulmonary disease, a history of congestive heart failure, the use of hypertension medication, disseminated cancer, wound infection, the use of steroids, and a history of bleeding disorder. Conclusion: Patients who were discharged on the same and next day following TSA demonstrated a reduced probability of experiencing respiratory complications, infections, postoperative anemia requiring transfusion, non-home discharge, and readmission in comparison to those with a LOS of 2-3 days. There was no difference in postoperative complications between same and nextday discharged patients. Patients who underwent outpatient arthroplasty were healthier at baseline compared to those who underwent inpatient arthroplasty.

Smoking is an independent risk factor for complications in outpatient total shoulder arthroplasty.

Background: Smoking is a major public health concern and an important risk factor to consider during preoperative planning. Smoking has previously been reported as the single most important risk factor for developing postoperative complications after elective orthopedic surgery. However, there is limited literature regarding the postoperative complications associated with smoking following outpatient total shoulder arthroplasty (TSA). The purpose of this study was to investigate the association between smoking status and early postoperative complications following outpatient TSA using a large national database. Methods: We queried the American College of Surgeons National Surgical Quality Improvement Program database for all patients who underwent TSA between 2015 and 2020. Smoking status in National Surgical Quality Improvement Program is defined as any episode of smoking with 12 months prior to surgery. Bivariate logistic regression was used to identify patient demographics, comorbidities, and complications significantly associated with current or recent smoking status in patients who underwent TSA with a length of stay (LOS) of 0. Multivariate logistic regression, adjusted for all significantly associated patient demographics and comorbidities, was used to identify associations between current or recent smokers and 30-day postoperative complications. Results: 22,817 patients were included in the analysis, 2367 (10.4%) were current or recent smokers and 20,450 (89.6%) were nonsmokers. These patients were further stratified based on LOS: 2428 (10.6%) patients had a LOS of 0 days, 15,267 (66.9%) patients had a LOS of 1 day, and 5122 (22.4%) patients had a LOS of 2 days. Within the outpatient cohort (LOS = 0), 202 (8.3%) patients were current or recent smokers and 2226 (91.7%) were nonsmokers. Multivariate logistic regression identified current or recent smoking status to be independently associated with higher rates of myocardial infarction (odds ratio [OR] 9.80, 95% confidence interval [CI] 1.48-64.96; P = .018), deep vein thrombosis (OR 20.05, 95% CI 1.63-247.38; P = .019), and readmission (OR 2.82, 95% CI 1.19-6.67; P = .018) following outpatient TSA. Readmission was most often due to pulmonary complication (n = 10, 22.7%). Conclusion: Current or recent smoking status is independently associated with higher rates of myocardial infarction, deep vein thrombosis, and readmission following TSA performed in the outpatient setting. Current or recent smokers may benefit from an inpatient setting of minimum 2 nights. As outpatient TSA becomes increasingly popular, refining proper patient selection criteria is imperative to optimizing postoperative outcomes.

Chronic steroid use as a risk factor for postoperative complications following arthroscopic rotator cuff repair.

Background: Steroids are a common treatment for many rheumatologic and inflammatory disorders. Chronic steroid use has been studied in joint arthroplasty and arthroscopy, but studies specifically on preoperative chronic steroid use in arthroscopic rotator cuff repair (aRCR) are limited. The purpose of this study is to determine the association between chronic steroid use and 30-day postoperative outcomes following aRCR. Methods: The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) was queried to identify all patients who underwent aRCR between 2015 and 2020. Patients were divided into 2 cohorts: nonsteroid users and chronic steroid users. Univariate binomial regression analysis was used to compare demographics, comorbidities, and postoperative outcomes between cohorts. Multivariate regression analysis, adjusted for all significant demographics and comorbidities, was used to identify significant 30-day postoperative outcomes. Results: A total of 39,876 patients remained after exclusion criteria, with 39,068 (97.97%) in the nonsteroid group and 808 (2.02%) in the chronic steroid group. Patient demographics and comorbidities significantly associated with chronic steroid use were age ≥65 (P < .001), female gender (P < .001), body mass index (BMI) ≥35, American Society of Anesthesiologists (ASA) ≥3 (P < .001), dependent functional status (P < .001), nonsmokers (P = .046), higher rates of dyspnea (P < .001), chronic obstructive pulmonary disease (COPD) (P < .001), congestive heart failure (P < .001), hypertension requiring medication (P < .001), open wound infection (P = .018), unintentional weight loss (P < .001), bleeding disorders (P < .001), and inpatient procedure (P = .013). Multivariate analysis found preoperative chronic steroid use to be an independent predictor of mortality within 30 days following aRCR (OR 8.15, confidence interval (CI) 1.45-45.86; P = .017). Conclusion: Chronic steroid use was not found to be an independent risk factor for infection, readmission, or reoperation following aRCR. It was, however, found to be independently associated with higher rates of 30-day mortality following aRCR, although with a limited overall number of deaths reported.

Outcomes of reverse shoulder arthroplasty in patients with previous rotator cuff repair: a systematic review and meta-analysis.

Background: Rotator cuff tears are a common injury encountered by orthopedic surgeons. Reverse shoulder arthroplasty (RSA) has become a treatment option for those with acute tears, as well as those with prior failed rotator cuff repair (RCR). The objective of this study was to determine if there are differences in postoperative outcomes for patients with previous RCR compared to those undergoing primary RSA for rotator cuff tears. Methods: A comprehensive literature search was conducted using PubMed, EMBASE, Scopus, and Cochrane Library databases. All relevant studies were reviewed by two authors according to inclusion and exclusion criteria defined in the study. Demographics and postoperative outcomes including functional scores, range of motion, pain scores, and complications were recorded. Results: Six level III articles encompassing 2176 shoulders were included in the analysis (846 with previous RCR and 1330 without). Average postoperative American Shoulder and Elbow Surgeons scores were 75.41 in the prior RCR group and 81.61 in the group without prior repair (mean difference [MD] = -5.95, P ≤ .0001 I2 = 36). Average postoperative Simple Shoulder Test scores were 8.40 in the RCR group and 9.57 in the group without prior RCR (MD = -0.93, P ≤ .0001, I2 = 66). Average postoperative Constant Score was 62.97 in the RCR group and 66.63 in the group without prior RCR (MD = -5.02, P ≤ .0001, I2 ≤ 0.001). Average postoperative University of California at Los Angeles Shoulder Scale score was 28.27 in the RCR group and 29.13 in the group without prior RCR (MD = -1.75, P ≤ .001, I2 ≤ 0.001). Average postoperative visual analog scale pain score was 1.77 in the RCR group and 0.95 in the group without prior RCR (MD = 0.75, P ≤ .0001, I2 = 35). Conclusion: Patients with prior RCR undergoing RSA have worse postoperative functional scores and pain scores than those without prior RCR. However, these differences are below the minimal clinically important difference for each outcome.

The prevalence of Dupuytren's disease in patients with diabetes mellitus.

BACKGROUND: Dupuytren's disease (DD) is a fibroproliferative hand disorder associated with various medical conditions, including diabetes mellitus (DM). The reported prevalence of DM among DD patients varies widely, primarily due to small sample sizes in previous studies. METHODS: This was a retrospective cohort study using data from the TriNetX Research Database. We analyzed the overall prevalence of DD between 2010 and 2020, comparing the DM, type 1 diabetes mellitus (T1DM), and type 2 diabetes mellitus (T2DM) cohorts. Within the DM group, patients were further categorized based on hemoglobin A1c (HbA1c) values and prescribed anti-diabetic agents (insulin or metformin). We compared the prevalence of DD diagnosis in each group using prevalence ratios and differences. RESULTS: There is a higher prevalence of DD in patients with T2DM than in patients with T1DM (relative risk [RR]: 1.641; 95% confidence interval [CI]: [1.356, 1.986]). Among patients with diabetes, there is a higher prevalence of DD in those taking insulin compared to those taking metformin (RR: 0.801, 95% CI: [0.774, 0.83]). The prevalence of DD varies depending on HbA1c levels, with a prevalence of 0.463% in patients having levels within the diabetic range, while lower prevalences of 0.392% and 0.416% are found in patients with prediabetes or uncontrolled diabetes, respectively. CONCLUSIONS: This study provides further insight into the relationship between DM and DD. These findings may be attributed to the increased accumulation of advanced glycosylated end products (AGEs) in patients with diabetes. Future research exploring the connection between AGE accumulation and DD development may enhance our understanding of the relationship between DD and DM.

Dupuytren's disease (DD), commonly known as Dupuytren's contracture, is a disorder of the hand that has been associated with various conditions including diabetes. The relationship between the two has not been studied in large populations; therefore, we used a large electronic medical record database to better understand the association between these two conditions. Our analyses show that within the population of patients with diabetes, DD is more common in patients with adult-onset diabetes and patients with blood sugar levels corresponding to moderate diabetes. This finding may be related to biochemical changes in the body as a result of elevated blood sugar levels found in these patients. Future investigation into this biochemical change may contribute further to our understanding of the relationship between these two conditions.

Abnormal preoperative platelet count may predict postoperative complications following shoulder arthroplasty.

Background: The purpose of this study is to investigate the association between preoperative platelet counts and postoperative complication rates within 30 days of total shoulder arthroplasty (TSA). Methods: The American College of Surgeons National Surgical Quality Improvement database was queried for all patients who underwent TSA between 2015 and 2019. The study population was then divided into 5 groups based on their preoperative platelet count: <100k (moderate-to-severe thrombocytopenia), 100-150k (mild thrombocytopenia), 150-200k (low-normal preoperative platelet count), 200-450k (normal, reference cohort), and >450k (thrombocytosis). Postoperative complications within 30 days of the TSA were collected. Multivariate logistic regression analysis was conducted to investigate the relationship between preoperative platelet counts and postoperative complications. Results: A total of 19,721 patients undergoing TSA between 2015 and 2019 were included in this study. One hundred fifty-five patients (0.8%) had moderate-to-severe thrombocytopenia, 982 (5.0%) had mild thrombocytopenia, 3945 (20.0%) had a low-normal preoperative platelet count, 14,386 (72.9%) had a normal preoperative platelet count, and 253 (1.3%) had thrombocytosis. An increasing rate of overall complications was observed as the severity of thrombocytopenia progressed from low-normal (6.4%) to mild thrombocytopenia (10.2%) and to moderate-to-severe thrombocytopenia (18.7%). The overall complication rate of the thrombocytosis cohort was 14.6%. In comparison to normal platelet count, low-normal thrombocytopenia, mild thrombocytopenia, moderate-to-severe thrombocytopenia, and thrombocytosis were identified by multivariate analysis as significant predictors of overall complications (odds ratios [ORs] of 1.12, 2.15, 2.43, 2.71, respectively), postoperative anemia requiring transfusion (ORs of 1.63, 3.45, 5.97, 4.21, respectively), and minor complications (ORs of 1.39, 2.64, 3.40, 3.34, respectively). Minor complications include progressive renal insufficiency, urinary tract infection, transfusions within 72 hours after surgery, pneumonia, and superficial incisional surgical site infection. Conclusion: Increasing severity of thrombocytopenia correlated with higher overall postoperative complication rates following TSA. Interestingly, patients with thrombocytosis had the highest overall postoperative complication rates among all cohorts included in this study. Platelet counts are often the reflection of other comorbidities and a good indicator of patient's general health status. Long-term optimization of abnormal platelet counts may potentially reduce surgical complications.

Outcomes of orthopaedic trauma surgery in COVID-19 positive patients.

OBJECTIVES: To investigate outcomes for operative orthopaedic trauma in patients who tested positive for coronavirus disease 2019 (COVID-19) during the height of the COVID-19 pandemic in New York. DESIGN: Retrospective case series. SETTING: Urban Level-1 academic trauma center. PATIENTS/PARTICIPANTS: Thirteen patients diagnosed with COVID-19 who underwent surgical management for orthopaedic trauma between January 21, 2020 and May 11, 2020. INTERVENTION: Does not apply to this study. MAIN OUTCOME MEASUREMENTS: Complications including death, coma lasting more than 24 hours, prolonged mechanical ventilation, unplanned intubation, blood transfusion, postoperative pneumonia, cerebrovascular event, thromboembolic event, myocardial infarction, urinary tract infection, acute renal failure, septic shock, return to the operating room, wound dehiscence, surgical site infection, graft/prosthesis/flap failure, and peripheral nerve injury. RESULTS: Two (18%) patients had symptoms of COVID-19 (cough, shortness of breath, fevers, chills, nausea/vomiting, diarrhea, abdominal cramps/pains) on admission. Average length of stay (standard deviation) was 6.6 (4.31) days. Average time to follow up was 29 (10.77) days. Three (27%) patients developed pneumonia postoperatively and 1 (9%) underwent unplanned intubation. One (9%) patient was intubated for greater than 48 hours. Two (18%) patients developed postoperative deep venous thromboembolism. Three (27%) patients developed acute renal failure postoperatively. Six (55%) patients underwent blood transfusion intraoperatively or postoperatively. Two (18%) patients died postoperatively. CONCLUSION: In this small series surgical management in Coronavirus-19 positive patients with skeletal injuries was successfully accomplished with patient anticoagulation, hematologic, and pulmonary status in mind. Therapeutic anticoagulation and patient hematologic status were optimized prior to the operating room to minimize development of venous thromboembolism and avoid blood transfusion. LEVEL OF EVIDENCE: Level IV prognostic.

Hip Fractures Before and During the COVID-19 Pandemic: Comparative Demographics and Outcomes.

INTRODUCTION: During the height of the COVID-19 pandemic in New York, hip fractures requiring operative management continued to present to Stony Brook University Hospital. Given the novelty of SARS-CoV-2, there is recent interest in the pandemic and its relationship to orthopedic operative outcomes. This retrospective cohort study compared outcomes for operative hip fractures in patients prior to and during the COVID-19 pandemic at a level 1 academic center. Materials and Methods: Data was collected on patients age 18 years or older who underwent operative management for hip fractures performed from January 21, 2019 to July 1, 2019 (pre-pandemic) or from January 21, 2020 to July 1, 2020 (pandemic). COVID-19 status, demographics and outcomes were analyzed. RESULTS: Overall, 159 patients with hip fractures were included in this study, 103 in the 2019 group and 56 in the 2020 group. Within the 2019 group, there was a significantly greater proportion of female patients compared to 2020 (p = 0.0128). The length of hospital stay was shorter for the 2020 group by 1.84 days (p = 0.0138). COVID-19 testing was positive in 4 (7.1%) patients in the 2020 group, negative for 22 patients (39.3%), and the remaining 30 patients in the 2020 group (53.7%) were not tested during their admission. There were no other significant differences in demographics or outcomes between the 2019 and 2020 groups. DISCUSSION: The COVID-19 pandemic did not significantly alter most aspects of care for hip fracture patients at our institution. Interestingly, postoperative pulmonary outcomes were not affected by the pandemic. CONCLUSIONS: In this study, a significantly higher proportion of males presented with hip fractures in the pandemic group. In addition, the average length of hospital stay was shorter during the COVID-19 pandemic. Further research is needed to understand the nuances that may lead to improved care for patients with hip fractures during a pandemic.