Is delayed time to surgery associated with increased postoperative complications in patients with pathologic humerus fractures?

INTRODUCTION: Delayed time to surgery, in the case of orthopedic trauma, is well known to be associated with higher morbidity and mortality, an extended duration of hospitalization, and an associated rise in overall cost. Delayed time to surgery of at least 3 days following hospital admission is associated with elevated risk of complications following surgery for a standard, non-pathologic, humeral shaft fracture. To our knowledge, it is unknown whether the same association is present for pathologic humerus fractures. The primary objective of this study was to identify risk factors, including patient characteristics, comorbidities, and postoperative complications, that are associated with delayed time to surgery following pathologic humeral fracture. METHODS: All patients undergoing surgical management of pathologic humerus fractures across a 6-year period from 2015 to 2021 were queried using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. Postoperative complications were reported within 30 days of procedure. Delayed time to surgery was defined by ≥ 2 days from hospital admission to surgery. We identified a total of 248 patients, and 39.9% (n = 99) of patients had delayed time to surgery. Multivariate logistic regression adjusted for all significantly associated variables was employed to identify predictors of delayed time to surgery for pathologic humerus fractures. RESULTS: The characteristics of patients significantly associated with delayed time to surgery were ASA classification ≥ 3 (p = 0.016), dependent functional status (p = 0.041), and congestive heart failure (p = 0.008). After adjusting for all significantly associated patient variables, the characteristics of patients independently associated with delayed time to surgery were non-home discharge (OR: 2.93, 95% CI 1.53-5.63; p = 0.001) and extended length of stay (OR: 2.00, 95% CI 1.06-3.77; p = 0.033). CONCLUSION: Delayed time to surgery of at least 2 days was independently associated with non-home discharge and extended postoperative length of stay. After controlling for baseline patient characteristics and comorbidities, delayed time to surgery was not independently associated with increased 30-day complications after surgical treatment of pathologic humeral fractures. This is in contrast to standard, non-pathologic humerus fractures in which delayed time to surgery is associated with an increased risk of postoperative complications. LEVEL OF EVIDENCE III: Retrospective Cohort Comparison; Prognosis Study.

Smoking Is Markedly Associated With 30-Day Readmission and Revision Surgery After Surgical Treatment of Clavicle Fracture.

BACKGROUND: A recent database study found that 15.2% of clavicle fractures underwent surgical treatment. Recent evidence accentuates the role of smoking in predicting nonunion. The purpose of this study was to further elucidate the effect of smoking on the 30-day postoperative outcomes after surgical treatment of clavicle fractures. METHODS: The authors queried the American College of Surgeons National Surgical Quality Improvement Program database for all patients who underwent open reduction and internal fixation of clavicle fracture between 2015 and 2020. Multivariate logistic regression, adjusted for notable patient demographics and comorbidities, was used to identify associations between current smoking status and postoperative complications. RESULTS: In total, 6,132 patients were included in this study of whom 1,510 (24.6%) were current smokers and 4,622 (75.4%) were nonsmokers. Multivariate analysis found current smoking status to be significantly associated with higher rates of deep incisional surgical-site infection (OR, 7.87; 95% CI, 1.51 to 41.09; P = 0.014), revision surgery (OR, 2.74; 95% CI, 1.67 to 4.49; P < 0.001), and readmission (OR, 3.29; 95% CI, 1.84 to 5.89; P < 0.001). CONCLUSION: Current smoking status is markedly associated with higher rates of deep incisional surgical-site infection, revision surgery, and readmission within 30 days after open reduction and internal fixation of clavicle fracture.

Hypoalbuminemia predicts early postoperative complications following noninfectious revision total shoulder arthroplasty.

PURPOSE: This study investigates the association between preoperative hypoalbuminemia and 30-day postoperative complications following noninfectious revision total shoulder arthroplasty (TSA). METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried for all patients who underwent noninfectious revision TSA from 2015 to 2021. The study population was divided into two groups based on preoperative serum albumin: normal albumin (≥ 3.5 g/dL) and hypoalbuminemia (< 3.5 g/dL). Logistic regression analysis was conducted to investigate the relationship between preoperative hypoalbuminemia and postoperative complications. RESULTS: Compared to normal albumin, hypoalbuminemia was independently associated with a significantly greater likelihood of experiencing any complication (odds ratio [OR] 3.26, 95% confidence interval [CI] 2.04-5.19; P < .001), sepsis (OR 9.92, 95% CI 1.29-76.35; P = .028), blood transfusions (OR 2.89, 95% CI 1.20-6.93; P = .017), non-home discharge (OR 2.88, 95% CI 1.55-5.35; P < .001), readmission (OR 3.46, 95% CI 1.57-7.58; P = .002), and length of stay > 2 days (OR 3.00, 95% CI 1.85-4.86; P < .001). CONCLUSIONS: Preoperative hypoalbuminemia was associated with early postoperative complications following revision TSA. LEVEL OF EVIDENCE: Level III; Retrospective Cohort Comparison; Prognosis Study.

Preoperative chronic steroid use as a risk factor for complications following open reduction internal fixation for proximal humerus fracture.

PURPOSE: The primary objective of this study was to investigate the association between preoperative chronic steroid use and postoperative complications following open reduction internal fixation (ORIF) for proximal humerus fractures (PHF). METHODS: The American College of Surgeons National Surgical Quality Improvement (ACS-NSQIP) database was queried for all patients who underwent PHF ORIF between 2015 and 2021. A total of 6,273 patients were included in this study, of which 3.4% (n = 212) were in the chronic steroid use cohort. Patient characteristics including demographics, comorbidities, and 30-day postoperative complications after PHF ORIF were collected. Bivariate logistic regression and multivariate logistic regression analysis, adjusted for all significantly associated variables, was conducted to investigate the relationship between preoperative chronic steroid use and postoperative complications. RESULTS: Chronic steroid use was significantly associated with age ≥ 75 (p < 0.001), male gender (p =0.006), dependent functional status (p = 0.008), American Society of Anesthesiologist (ASA) ≥ 3 (p < 0.001), CHF (p = 0.007), hypertension (p < 0.001), COPD (p < 0.001), bleeding disorder (p = 0.007), ascites (p = 0.040), disseminated cancer (p< 0.001), and systemic sepsis (p < 0.001). After adjusting for all significantly associated variables, chronic steroid use was independently associated with major complication (OR 1.60, 95% CI 1.06-2.43; p = 0.026), and non-home discharge (OR 1.05, 95% CI 1.01-1.08; p = 0.014). CONCLUSION: Preoperative chronic steroid use is associated with increasing rate of postoperative complications following PHF ORIF. Better understanding and characterizing chronic steroid use as a preoperative risk factor can aid physicians in risk stratification to reduce rates of postoperative complications following PHF ORIF. LEVEL OF EVIDENCE: III. Retrospective Cohort Comparison; Prognosis Study.

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.

Postoperative complications associated with congestive heart failure in aseptic revision total shoulder arthroplasty.

PURPOSE: The aim of this study is to explore potential complications and risk factors associated with revision TSA in patients with congestive heart failure (CHF). METHODS: This study examined all individuals who underwent revision total shoulder arthroplasty (TSA) from 2015 to 2022, sourced from the American College of Surgeons National Surgical Quality Improvement database. The analysis encompassed patient demographics, comorbidities, and 30-day postoperative complications. Logistic regression was employed to analyze the postoperative complications linked to patients with preoperative CHF. RESULTS: Compared to patients without CHF, patients with CHF were significantly associated with dependent functional status (P < .001), chronic obstructive pulmonary disease (P < .001), and hypertension (P = .002). Compared to patients without CHF, patients with CHF were independently associated with a significantly greater likelihood of experiencing any complication (OR 2.19, 95% CI 1.12-4.29; P = .022) and non-home discharge (OR 3.02, 95% CI 1.37-6.65; P = .006). CONCLUSION: Congestive heart failure was identified as an independent risk factor for experiencing any complication and non-home discharge in patients undergoing revision TSA. Awareness of the cardiovascular health status of a patient and its severity can influence the decision-making process when considering revision TSA. LEVEL OF EVIDENCE III: Retrospective Cohort Comparison Using Large Database; Prognosis Study.

Role of insulin-dependent and non-insulin-dependent diabetes in aseptic revision total shoulder arthroplasty.

PURPOSE: This study investigates the association between insulin-dependent and non-insulin-dependent diabetes and 30-day postoperative complications following aseptic revision total shoulder arthroplasty (TSA). METHODS: The American College of Surgeons National Surgical Quality Improvement Program database was queried for all patients who underwent aseptic revision TSA from 2015 to 2021. The study population was divided into three groups based on diabetic status: nondiabetes, insulin-dependent diabetes, and non-insulin-dependent diabetes. Logistic regression analysis was conducted to investigate the relationship between diabetic status and postoperative complications. RESULTS: Compared to nondiabetes, insulin-dependent diabetes was independently associated with a significantly greater likelihood of experiencing any complication (OR 1.59, 95% CI 1.08-2.35; P = 0.020) and LOS > 2 days (OR 1.73, 95% CI 1.13-2.65; P = 0.012). Compared to nondiabetes, non-insulin-dependent diabetes was not independently associated with a significantly greater likelihood of experiencing complications. Preoperative insulin-dependent diabetic status was significantly associated with a greater rate of early postoperative complications following aseptic revision TSA, while preoperative non-insulin-dependent diabetic status was not. CONCLUSION: Preoperative insulin-dependent diabetic status was significantly associated with a greater rate of early postoperative complications following aseptic revision TSA. A better understanding of the role diabetes, both insulin-dependent and non-insulin-dependent, as a risk factor may help physicians better risk stratify and select surgical candidates for revision TSA.

Six-Item Modified Frailty Index independently predicts complications following total shoulder arthroplasty.

Background: In the realm of orthopedic surgery, frailty has been associated with higher rates of complications following total hip and total knee arthroplasties. Among various measures of frailty, the Six-Item Modified Frailty Index (MF-6) has recently gained popularity as a predictor for postoperative complications. The purpose of this study was to investigate MF-6 as a predictor for early postoperative complications in the elderly patient population following total shoulder arthroplasty (TSA). Methods: The authors queried the American College of Surgeons National Surgical Quality Improvement Program database for all patients who underwent TSA between 2015 and 2020. Patient demographics and comorbidities were compared between cohorts using bivariate logistic regression analysis. Multivariate logistic regression, adjusted for all significantly associated patient demographics and comorbidities, was used to identify associations between the MF-6 score and postoperative complications. Results: Of total, 9228 patients were included in this study: 8764 (95.0%) had MF-6 <3, and 464 (5.0%) patients had MF-6 ≥3. Multivariate analysis found MF-6 ≥3 to be independently associated with higher rates of urinary tract infection (odds ratio [OR]: 2.79, 95% confidence interval [CI]: 1.49-5.23; P = .001), blood transfusion (OR: 1.53, 95% CI: 1.01-2.32; P = .045), readmission (OR: 1.58, 95% CI: 1.06-2.35; P = .024), and non-home discharge (OR: 2.60, 95% CI: 2.08-3.25; P < .001). Conclusion: A high MF-6 score (≥3) in patients aged 65 and older is independently associated with higher rates of urinary tract infection, blood transfusion, readmission, and non-home discharge following TSA. The MF-6 score can be easily calculated preoperatively and may allow for better preoperative risk stratification.

Components of metabolic syndrome as significant risk factors for postoperative complications following total shoulder arthroplasty: hypertension, diabetes, and obesity.

Background: Metabolic syndrome (MetS) is a known risk factor for adverse postoperative outcomes. However, the literature surrounding the effects of MetS on orthopedic surgery outcomes following total shoulder arthroplasty (TSA) remains understudied. The purpose of this study is to investigate the effect of MetS on postoperative 30-day adverse outcomes following 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. After exclusion criteria, patients were divided into MetS and no MetS cohorts. MetS patients were defined as presence of hypertension, diabetes, and body mass index > 30 kg/m2. Bivariate logistic regression was used to compare patient demographics, comorbidities, and complications. Multivariate logistic regression, adjusted for all significant patient demographics and comorbidities, was used to identify the complications independently associated with MetS. Results: A total of 26,613 patients remained after exclusion criteria, with 23,717 (89.1%) in the no MetS cohort and 2896 (10.9%) in the MetS cohort. On multivariate analysis, MetS was found to be an independent predictor of postoperative pneumonia (odds ratio [OR] 1.61, 95% confidence interval [CI] 1.02-2.55; P = .042), renal insufficiency (OR 4.09, 95% CI 1.67-10.00; P = .002), acute renal failure (OR 4.17, 95% CI 1.13-15.31; P = .032), myocardial infarction (OR 2.11, 95% CI 1.21-3.69; P = .009), nonhome discharge (OR 1.41, 95% CI 1.24-1.60; P < .001), and prolonged hospital stay > 3 days (OR 1.44, 95% CI 1.25-1.66; P < .001). Conclusion: MetS was identified as an independent risk factor for postoperative pneumonia, renal insufficiency, acute renal failure, myocardial infarction, nonhome discharge, and prolonged hospital stay following TSA. These findings encourage physicians to medically optimize MetS patients prior to surgery to limit adverse outcomes.

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.

Chronic Steroid Use Does Not Increase the Risk of Superficial Surgical Site Infection or Wound Dehiscence Following Total Ankle Arthroplasty.

Introduction Total ankle arthroplasty (TAA) is an effective treatment for end-stage ankle arthritis. Recent surgical and technological advances have led to a significant increase in the surgical volume of TAA. While a majority of ankle arthritis is post-traumatic in nature, other causes include autoimmune or inflammatory conditions. Medical management of these conditions frequently requires chronic corticosteroid administration, which is a well-established risk factor for complications following surgery. The purpose of this study was to investigate the association between chronic preoperative steroid use and postoperative complications following TAA. Methods The American College of Surgeons National Surgical Quality Improvement (NSQIP) database was analyzed to identify all patients who underwent TAA between 2015 and 2020. Patient characteristics including demographics, comorbidities, surgical characteristics, and 30-day postoperative complication data were collected. The data was analyzed using bivariate and multivariate logistic regression to identify all postoperative complications associated with chronic preoperative steroid use. Results A total of 1,606 patients were included in this study: 1,533 (95.5%) were included in the non-steroid cohort, and 73 (4.5%) were included in the chronic steroid cohort. Chronic steroid use was significantly associated with female sex (p < 0.001) and American Society of Anesthesiologists (ASA) ≥3 (p < 0.001). Chronic steroid use was not associated with superficial surgical site infection (SSI) (p = 0.634) or wound dehiscence (p = 0.999). The postoperative complication that was significantly associated with chronic steroid use was sepsis (p = 0.031). After adjusting for female sex and the ASA grade, chronic steroid use was found to be independently associated with sepsis (p = 0.013). Conclusion Preoperative chronic steroid use is not associated with superficial SSI or wound dehiscence within 30 days following TAA. As TAA becomes a more attractive alternative to ankle arthrodesis, a better understanding of preoperative risk factors can aid in widening indications and knowing what patients are at risk for complications.

Daily low-intensity pulsed ultrasound stimulation mitigates joint degradation and pain in a post-traumatic osteoarthritis rat model.

Objectives: The aim of this study was to investigate the effects of low-intensity pulsed ultrasound (LIPUS) in a post-traumatic osteoarthritis (OA) rat model and in vitro. Methods: Thirty-eight male, four-month-old Sprague Dawley rats were randomly assigned to Sham, Sham â€‹+ â€‹US, OA, and OA â€‹+ â€‹US. Sham surgery was performed to serve as a negative control, and anterior cruciate ligament transection was used to induce OA. Three days after the surgical procedures, Sham â€‹+ â€‹US and OA â€‹+ â€‹US animals received daily LIPUS treatment, while the rest of the groups received sham ultrasound (US) signals. Behavioral pain tests were performed at baseline and every week thereafter. After 31 days, the tissues were collected, and histological analyses were performed on knees and innervated dorsal root ganglia (DRG) neurons traced by retrograde labeling. Furthermore, to assess the activation of osteoclasts by LIPUS treatment, RAW264.7 â€‹cells were differentiated into osteoclasts and treated with LIPUS. Results: Joint degradation in cartilage and bone microarchitecture were mitigated in OA â€‹+ â€‹US compared to OA. OA â€‹+ â€‹US showed improvements in behavioral pain tests. A significant increase of large soma-sized DRG neurons was located in OA compared to Sham. In addition, a greater percentage of large soma-sized innervated neurons were calcitonin gene-related peptide-positive. Daily LIPUS treatment suppressed osteoclastogenesis in vitro, which was confirmed via histological analyses and mRNA expression. Finally, lower expression of netrin-1, a sensory innervation-related protein, was found in the LIPUS treated cells. Conclusion: Our findings demonstrate that early intervention using LIPUS treatment has protective effects from the progression of knee OA, including reduced tissue degradation, mitigated pain characteristics, improved subchondral bone microarchitecture, and less sensory innervation. Furthermore, daily LIPUS treatment has a suppressive effect on osteoclastogenesis, which may be linked to the suppression of sensory innervation in OA. The translational potential of this article: This study presents a new potential for early intervention in treating OA symptoms through the use of LIPUS, which involves the suppression of osteoclastogenesis and the alteration of DRG profiles. This intervention aims to delay joint degradation and reduce pain.

Preoperative Anemia as a Risk Factor for Postoperative Complications After Open Reduction Internal Fixation of Distal Radius Fractures.

Purpose: The incidence of distal radius fractures (DRFs) in the United States is more than 640,000 cases per year and is projected to increase. The overall prevalence of anemia in the United States increased from 5.71% in 2005 to 6.86% in 2018. Therefore, preoperative anemia may be an important risk factor to consider before surgical fixation of a distal radius fracture. The purpose of this study was to investigate preoperative anemia and its association with short-term complications after surgical treatment of DRFs. Methods: The American College of Surgeons National Surgical Quality Improvement Program database was queried for all patients who underwent open reduction internal fixation (ORIF) of DRFs between 2015 and 2020. The initial pool of patients was divided into cohorts based on preoperative hematocrit. Multivariate logistic regression, adjusted for all significantly associated patient demographics and comorbidities, was used to identify associations between preoperative anemia and postoperative complications after ORIF of DRFs. Results: A total of 22,923 patients who underwent ORIF of DRFs were identified in National Surgical Quality Improvement Program from 2015 to 2020. Of the 12,068 patients remaining after exclusion criteria, 9,616 (79.7%) patients were included in the normal cohort, 2,238 (18.5%) patients were included in the mild anemia cohort, and 214 (1.8%) patients were included in the severe anemia cohort. Compared with the reference cohort, patients with any anemia were independently associated with higher rates of reintubation (odds ratio [OR], 6.51; 95% confidence interval [CI], 1.29-32.80; P = .023), blood transfusion (OR, 11.83; 95% CI, 3.95-35.45; P < .001), septic shock (OR, 10.76; 95% CI, 1.19-97.02; P = .034), readmission (OR, 2.10; 95% CI, 1.60-2.76; P < .001), nonhome discharge (OR, 2.22; 95% CI, 1.84-2.68; P < .001), and mortality (OR, 2.70; 1.03-7.07; P = .043). Conclusions: Preoperative anemia, both mild and severe, were clinically significant predictors for postoperative complications within 30-day after ORIF of DRFs. Severe anemia was associated with higher rates of blood transfusion, nonhome discharge, and mortality compared with mild anemia. Type of study/level of evidence: Prognostic III.

Chronic Steroid Use, Complications, and Readmission Following Open Reduction Internal Fixation of Distal Radius Fracture.

Purpose: The increasing incidence of both distal radius fractures (DRFs) and chronic conditions that necessitate long-term steroid use has resulted in a growing intersection between the patient populations of the two. Chronic steroid use is known to increase bone frailty and the likelihood of fractures but may also contribute to poorer outcomes following the repair of DRF. The purpose of this study was to investigate the association between preoperative chronic steroid use, postoperative complications, and readmission after open reduction internal fixation (ORIF) of DRF. Methods: The American College of Surgeons National Surgical Quality Improvement database was queried for all patients who underwent DRF ORIF between 2015 and 2021. However, 30-day postoperative complications after DRF ORIF were collected. Multivariate logistic regression analysis was conducted to investigate the relationship among preoperative chronic steroid use, postoperative complications, and patient factors associated with readmission. Results: The postoperative complications associated with the steroid cohort were categorized as major, minor, and overall complications. Additionally, pneumonia, stroke, myocardial infarction, bleeding transfusions, deep vein thrombosis, pulmonary embolism, readmission, non-home discharge, and mortality were recorded. Chronic steroid use was found to be independently associated with major , minor, and overall complications, deep vein thrombosis, and readmission. Further investigation of readmission showed that male sex and comorbid chronic obstructive pulmonary disease were the only two patient factors independently associated with a greater likelihood of readmission after DRF ORIF. Conclusions: Preoperative chronic steroid use was associated with an increasing rate of postoperative complications after DRF ORIF. Male sex and comorbid chronic obstructive pulmonary disease were characteristics of chronic steroid-use patients independently associated with increased risk of readmission after DRF ORIF. A better understanding of preoperative chronic steroid use as a risk factor for postoperative complications may allow surgeons to improve preoperative risk stratification and patient counseling in the management of DRF. Type of study/level of evidence: Prognostic III.

Body Mass Index as a Predictor for Postoperative Complications Following Carpometacarpal Arthroplasty.

Purpose: Carpometacarpal (CMC) arthroplasty is an effective surgical treatment to relieve pain and improve function for osteoarthritis of the CMC joint. The association between body mass index (BMI) and postoperative complications has been studied for other orthopedic procedures, including total knee arthroplasty, total hip arthroplasty, and total shoulder arthroplasty. However, BMI has not been studied as a risk factor for postoperative complications following CMC arthroplasty. The purpose of this study was to determine the postoperative complications associated with different categories of BMI following CMC arthroplasty. We hypothesized that increasing BMI is associated with more severe complications. Methods: The American College of Surgeons National Surgical Quality Improvement Program database was queried for all patients who underwent CMC arthroplasty between 2015 and 2020. Patient demographics, comorbidities, surgical characteristics, and 30-day postoperative complication data were collected. Patients were stratified into cohorts based on BMI as follows: underweight (BMI < 18.5 kg/m2), normal/reference (18.5 kg/m2 ≤ BMI < 30.0 kg/m2), obese (30.0 kg/m2 ≤ BMI < 35.0 kg/m2), severely obese (35.0 kg/m2 ≤ BMI < 40.0 kg/m2), and morbidly obese (BMI ≥ 40.0 kg/m2). Multivariate logistic regression was used to identify postoperative complications associated with each cohort. Results: In total, 6,432 patients were included in this study: 3,622 (56.3%) patients were included in the normal/reference cohort, 77 (1.2%) patients were included in the underweight cohort, 1,479 (23.0%) patients were included in the obese cohort, 718 (11.2%) patients were included in the severely obese cohort, and 536 (8.3%) patients were included in the morbidly obese cohort. The obese cohort was independently associated with a higher rate of superficial incisional surgical-site infection (odds ratio [OR], 2.11; 95% confidence interval [CI], 1.00-4.44; P = .050). The morbidly obese cohort was independently associated with readmission (OR, 3.35; 95% CI, 1.15-9.74; P = .026) and reoperation (OR, 3.40; 95% CI, 1.04-1.11; P = .043). Conclusions: Morbid obesity is a clinically significant predictor for readmission and reoperation within 30 days following CMC arthroplasty. Obesity is a clinically significant predictor for superficial incisional surgical-site infection within 30 days following CMC arthroplasty. Clinical relevance: A better understanding of BMI as a risk factor for postoperative complications may allow surgeons to improve preoperative risk stratification and patient counseling. 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.

Identifying risk factors for 30-day readmission after outpatient total shoulder arthroplasty to aid in patient selection.

Background: A recent meta-analysis comparing inpatient and outpatient total shoulder arthroplasty (TSA) showed no statistically significant differences in complications, readmissions, revisions, and infections. However, there remains no research on the appropriate patient selection for outpatient TSA surgeries. This retrospective review seeks to aid surgeons in refining a safe patient selection algorithm by evaluating risk factors through a large database analysis of TSA surgeries. Methods: Patients who underwent TSA between 2015 and 2020 were identified in the National Surgical Quality Improvement Program database. Patients with a hospital stay of 0 days were designated as outpatient procedures. Multivariate analyses were used to determine risk factors for 30-day readmission following outpatient TSA and whether risk factors remained significant following overnight hospital stay. Results: A total of 2431 outpatient TSA patients were identified. The incidence of 30-day readmission was 1.8%. The majority of readmissions were due to pulmonary complications. The clinically significant risk factors for 30-day readmission were chronic steroid use (odds ratio [OR] 3.55, 95% confidence interval [CI] 1.34-9.43; P = .011), chronic obstructive pulmonary disease (COPD) (OR 3.11, 95% CI 1.16-8.34; P = .024), and current smoking status (OR 2.27, 95% CI 1.02-5.03; P = .045). After overnight hospital stay, chronic steroid use and current smoking status were not significant, but COPD remained significant. Conclusion: Patients with chronic steroid use, COPD, or current smoking status are at increased risk for 30-day readmission. Inpatient hospital stay appears to benefit patients with chronic steroid use and current smoking status. Patients with COPD should be admitted for inpatient stay postoperatively but may still have high 30-day readmission rates following discharge.

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.