Diabetes mellitus effect on rates of perioperative complications after operative treatment of distal radius fractures

Can Machine Learning Identify Patients Who are Appropriate for Outpatient Open Reduction and Internal Fixation of Distal Radius Fractures?

Purpose

This study aimed to identify which patients were "unsafe" for outpatient surgery patients and determine the most predictive demographic and clinical factors contributing to postoperative risk following open reduction internal fixation for distal radius fractures.

Methods

Adult patients (aged ≥18 years) who presented with distal radius fracture and underwent open reduction internal fixation were identified using the American College of Surgeons National Surgical Quality Improvement Program database for years 2016 to 2021. Patients who were deemed "unsafe" therefore contraindicated for outpatient open reduction internal fixation of distal radius fracture if they required admission (length of stay of one or more days) or experienced any complication or required readmission within 7 days of the index operation. The model with optimal performance was determined according to area under the curve on the receiver operating characteristic curve and overall accuracy. Additional model metrics were also evaluated, and predictive factors (ie, features) that were most important to model derivation were identified.

Results

A total of 2,020 eligible patients underwent open reduction and internal fixation for distal radius fractures. The majority (78.6%) were women, with a mean age of 57.5 ± 16.0 years. Of these patients, 21.5% experienced short-term adverse events. Gradient boosting was the optimal model for predicting patients who were "unsafe" for outpatient surgery, with key features including International Classification of Diseases, 10th Revision code, preoperative white blood cell count, age, body mass index, and Hispanic ethnicity.

Conclusions

Using machine learning techniques, a predictive model was developed, which demonstrated good discrimination and excellent performance in predicting which patients were "unsafe" for outpatient operative fixation of distal radius fracture. Findings of this study highlight the predictive value of artificial intelligence and machine learning for the purposes of preoperative risk stratification as well as its potential to better inform shared decision making and guide personalized fracture care.

Level of evidence/type of study

Prognostic IV.

Risk Factors for 30-Day Complications and Unplanned Reoperation Following Surgical Treatment of Distal Radius Fractures

BACKGROUND

The purpose of this study was to identify demographic data, medical comorbidities, and perioperative factors that are associated with increased risk of overall surgical complications, wound complications, and reoperation within 30 days of open reduction and internal fixation (ORIF) of distal radius fractures.

METHODS

All adult patients undergoing ORIF of distal radius fractures in the National Surgical Quality Improvement Program database between 2005 and 2020 were identified. Patients were excluded for secondary procedures, open/infected injuries, or inpatient surgical setting. Demographic data, medical comorbidities, and perioperative data were examined for each patient, and patients were grouped by the presence or absence of any surgical complication. Univariate analysis and multivariate logistic regression were used to identify risk factors.

RESULTS

A total of 20 301 patients from between 2005 and 2020 met the inclusion criteria, of which 219 complications (1.1% of cases) were identified. Following multivariate analysis, independent risk factors found to be associated with surgical complications included male sex, smoking, heart failure, longer operative time, and American Society of Anesthesiologists (ASA) classification of 3 or higher.

CONCLUSION

Male sex, smoking, heart failure, prolonged operative time, and ASA status of 3 or higher are associated with an increased risk of surgical complications following ORIF of distal radius fractures. These complications, with the exception of heart failure, were also associated with an increased risk of wound complications. Finally, male sex, nonwhite race, smoking, dialysis, prolonged operative time, and 3 or higher ASA class were associated with reoperations. Understanding these risk factors allows surgeons to better predict and prevent complications in high-risk populations.

Strategies for Perioperative Optimization in Upper Extremity Fracture Care

Perioperative optimization in upper extremity fracture care must balance the need for timely treatment with the benefits of medical optimization. Care pathways directed at optimizing glycemic control, chronic anticoagulation, smoking history, nutrition, and frailty can reduce surgical risk in upper extremity fracture care. The development of multidisciplinary approaches that tie risk modification with risk stratification is needed.

Surgical site infection following surgery for hand trauma: a systematic review and meta-analysis

Surgical site infection is the most common healthcare-associated infection. Surgical site infection after surgery for hand trauma is associated with increased antibiotic prescribing, re-operation, hospital readmission and delayed rehabilitation, and in severe cases may lead to amputation. As the risk of surgical site infection after surgery for hand trauma remains unclear, we performed a systematic review and meta-analysis of all primary studies of hand trauma surgery, including randomized controlled trials, cohort studies, case-control studies and case series. A total of 8836 abstracts were screened, and 201 full studies with 315,618 patients included. The meta-analysis showed a 10% risk of surgical site infection in randomized control trials, with an overall risk of 5% when all studies were included. These summary statistics can be used clinically for informed consent and shared decision making, and for power calculations for future clinical trials of antimicrobial interventions in hand trauma.

The Effect of Obesity on Distal Radius Fractures: An Analysis from the NSQIP Database

The rate and severity of obesity has risen over the past 40 years, and class III (formerly morbid) obesity presents additional sequelae. The effect of obesity on the incidence and recovery of hand and wrist fractures remains unclear. We sought to quantify the relationship between class III obesity and postoperative distal radius fracture (DRF) complications.

Methods

We performed a retrospective analysis of the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database for surgical DRF patients more than 50 years old from 2015 to 2020. We then stratified patients into class III obese (BMI > 40) and compared the rates of postoperative complications to a control group with BMI less than 40.

Results

We included 10,022 patients (570 class III obese vs. 9,452 not class III obese). Patients with class III obesity had significantly increased odds of experiencing any complication (OR 1.906, p<0.001), adverse discharge (OR 2.618, p<0.001), delayed hospital stay of longer than three days (OR 1.91, p<0.001), and longer than seven days (OR 2.943, p<0.001) than controls. They also had increased odds of unplanned reoperation (OR 2.138, p = 0.026) and readmission (OR 2.814, p < 0.001) than non-class III obese patients. Class III obese patients had a significantly longer average operation time (79.5 min vs. 72.2 min, p < 0.001). They also spent more time in the hospital postoperatively (0.86 days vs. 0.57 days, p = 0.001).

Conclusion

Class III obese patients undergoing DRF repair are more likely to experience postoperative complications than non-class III obese patients.

Impact of Excess Body Weight on Postsurgical Complications

BACKGROUND

Obesity is considered a risk factor for postoperative complications as it can limit exposure to the operation field, thereby significantly prolonging surgery time. Obesity-associated comorbidities, such as low-grade systemic inflammation, impaired functional status, and type 2 diabetes, are independent risk factors for impaired anastomotic wound healing and nonsurgical site infections. If obesity itself is an independent risk factor for surgical complications remains controversial, but the reason for this is largely unexplored.

SUMMARY

A MEDLINE literature search was performed using the terms: "obesity," "excess body weight," and "surgical complications." Out of 65,493 articles 432 meta-analyses were screened, of which 25 meta-analyses were on the subject. The vast majority of complex oncologic procedures in the field of visceral surgery have shown higher complication rates in obese patients. Meta-analyses from the last 10 to 15 years with high numbers of patients enrolled consistently have shown longer operation times, higher blood loss, longer hospital stay for colorectal procedures, oncologic upper gastrointestinal (GI) procedures, and pancreatic surgery. Interestingly, these negative effects seem not to affect the overall survival in oncologic patients, especially in esophageal resections. A selection bias in oncologic upper GI patients may have influenced the results with higher BMI in upper GI cancer to be a predictor for better nutritional and performance status.

KEY MESSAGES

Contrary to bariatric surgery, only limited evidence indicated that site and type of surgery, the approach to the abdominal cavity (laparoscopic vs. open), institutional factors, and the type of perioperative care such as ERAS protocols may play a role in determining postsurgical complications in obese patients. The initial question remains therefore partially unanswered. Large nationwide register-based studies are necessary to better understand which aspects of obesity and its related comorbidities define it as a risk factor for surgical complications.