Current Quality Measurement Tools Are Insufficient to Assess Complications in Orthopedic Surgery

Complications in Hand Surgery During Early Independent Practice: A Single Surgeon's 5-Year Experience

BACKGROUND

The objective of this study was to understand the frequency and types of complications, and the associated postoperative outcomes within the first 5 years of practice after hand and upper extremity surgery fellowship.

METHODS

This was a retrospective observational study of all patients seen and surgically treated by a single surgeon at a single institution from August 2014 to September 2019. This corresponded to the first 5 years of practice after fellowship. Data collected included patient demographics, perioperative data, complication type, and outcome of the complication (better/same/worse than preoperative status). Complications were classified using the Clavien-Dindo system and a unique, self-derived system.

RESULTS

In total, 3301 surgeries were performed during the first 5 years of practice. The overall complication rate was 7.9% (261 complications from 239 patients). The 30-day complication rate was 5.2% (171/3301). Eleven (4.2%) of the 261 complications occurred intraoperatively. The total number of complications significantly declined during the first 5 years of practice as follows: 74, 71, 46, 37, and 33 (P = .010, R2 = .92). Hand and wrist were the most frequent anatomic locations involved and bone pathology was the predominant indication.

CONCLUSION

The overall surgical complication rate for hand and upper extremity surgery was 7.9%, with a 30-day complication rate of 5.2% (171/3301). The rate of complications after fellowship declined over the first 5 years of independent practice. Superficial infections were the most common complication. More than 90% of patients ultimately improved after addressing the complication.

LEVEL OF EVIDENCE

IV.

NSQIP data collection up to 30 postoperative days is sufficient to capture some complications in orthopedic surgeries

PURPOSE

The primary aim of this study is to determine if the 30-day follow-up period used by the National Surgical Quality Improvement Program (NSIQP) is an appropriate timeframe to capture complications after orthopedic surgeries.

METHODS

The 2019 NSQIP data were used. The independent variables were complication type. The dependent variable was days to complication. A Shapiro-Wilk test was used to determine if the data were normally distributed.

RESULTS

271,397 orthopedic cases were included. Myocardial infarction, pneumonia, ventilator over 48 h, progressive renal insufficiency, acute renal failure, stroke, and cardiac arrest had positive skewness and positive kurtosis. Deep incisional surgical site infection (SSI), organ/space SSI, wound disruption, unplanned reoperation one, unplanned reoperation two, readmission two, and readmission three had negative kurtosis and negative skewness. Complications with positive kurtosis and positive skewness are more likely to be confined to the 30-day postoperative period, whereas complications with negative skewness and negative kurtosis may be underreported within the 30-day follow-up.

CONCLUSIONS

These findings are useful in their ability to inform future orthopedic research using NSQIP which continues to generate new data for surgeons to consider for their postoperative care and complication management.

Using machine-learning to decode postoperative hip mortality Trends: Actionable insights from an extensive clinical dataset

BACKGROUND

Hip fractures are one of the most common injuries experienced by the general population. Despite advances in surgical techniques, postoperative mortality rates remain high. identifying relevant clinical factors associated with mortality is essential to preoperative risk stratification and tailored post-surgical interventions to improve patient outcomes. The purpose of this study aimed to identify preoperative risk factors and develop predictive models for increased hip fracture-related mortality within 30 days post-surgery, using one of the largest patient cohorts to date.

METHODS

Data from the American College of Surgeons National Surgical Quality Improvement Program database, comprising 107,660 hip fracture patients treated with surgical fixation was used. A penalized regression approach, least absolute shrinkage and selection operator was employed to develop two predictive models: one using preoperative factors and the second incorporating both preoperative and postoperative factors.

RESULTS

The analysis identified 68 preoperative factor outcomes associated with 30-day mortality. The combined model revealed 84 relevant factors, showing strong predictive power for determining postoperative mortality, with an AUC of 0.83.

CONCLUSIONS

The study's comprehensive methodology provides risk assessment tools for clinicians to identify high-risk patients and optimize patient-specific care.

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.

Hypertension and postoperative complications following arthroscopic rotator cuff repair

Background

The purpose of this study was to investigate the relationship between hypertension and postoperative complications following arthroscopic rotator cuff repair (aRCR).

Methods

The American College of Surgeons National Surgical Quality Improvement Program database was surveyed for all patients who underwent aRCR between 2015 and 2021. Patient demographics, comorbidities, and 30-day postoperative complication data were analyzed. Multivariate logistic regression identified postoperative complications associated with hypertension.

Results

Forty-six thousand five hundred and sixty-two patients were included in the analysis: 20,999 (45.1%) patients in the hypertensive cohort and 25,563 (54.9%) in the nonhypertensive cohort. Hypertension was associated with male gender (P < .001), age ≥ 65 years (P < .001), body mass index > 30 (P < .001), dependent functional status (P < .001), American Society of Anesthesiologists classification ≥ 3 (P < .001), current smoker (P < .001), diabetes (P < .001), chronic obstructive pulmonary disease (P < .001), and bleeding disorders (P < .001). Thrity-day postoperative complications significantly associated with hypertension included pneumonia (P = .012), reintubation (P = .009), urinary tract infection (P = .002), stroke (P = .044), myocardial infarction (P = .004), ventilator > 48 hours (P = .017), readmission (P < .001), non-home discharge (P < .001), and mortality (P = .020). After adjusting for patient demographics and comorbidities, readmission (odds ratio [OR] 1.41; 95% confidence interval [CI] 1.13-1.75; P = .002) was independently associated with hypertension.

Conclusion

Hypertension was identified as a risk factor for various postoperative complications following aRCR. Hypertension was found to be an independent predictor for readmission following aRCR.

Hospital spending and length of stay attributable to perioperative adverse events for inpatient hip, knee, and spine surgery: a retrospective cohort study

BACKGROUND

The incremental hospital cost and length of stay (LOS) associated with adverse events (AEs) has not been well characterized for planned and unplanned inpatient spine, hip, and knee surgeries.

METHODS

Retrospective cohort study of hip, knee, and spine surgeries at an academic hospital in 2011-2012. Adverse events were prospectively collected for 3,063 inpatient cases using the Orthopaedic Surgical AdVerse Event Severity (OrthoSAVES) reporting tool. Case costs were retrospectively obtained and inflated to equivalent 2021 CAD values. Propensity score methodology was used to assess the cost and LOS attributable to AEs, controlling for a variety of patient and procedure factors.

RESULTS

The sample was 55% female and average age was 64; 79% of admissions were planned. 30% of cases had one or more AEs (82% had low-severity AEs at worst). The incremental cost and LOS attributable to AEs were $8,500 (95% confidence interval [CI]: 5100-11,800) and 4.7 days (95% CI: 3.4-5.9) per admission. This corresponded to a cumulative $7.8 M (14% of total cohort cost) and 4,290 bed-days (19% of cohort bed-days) attributable to AEs. Incremental estimates varied substantially by (1) admission type (planned: $4,700/2.4 days; unplanned: $20,700/11.5 days), (2) AE severity (low: $4,000/3.1 days; high: $29,500/11.9 days), and (3) anatomical region (spine: $19,800/9 days; hip: $4,900/3.8 days; knee: $1,900/1.5 days). Despite only 21% of admissions being unplanned, adverse events in these admissions cumulatively accounted for 59% of costs and 62% of bed-days attributable to AEs.

CONCLUSIONS

This study comprehensively demonstrates the considerable cost and LOS attributable to AEs in orthopaedic and spine admissions. In particular, the incremental cost and LOS attributable to AEs per admission were almost five times as high among unplanned admissions compared to planned admissions. Mitigation strategies focused on unplanned surgeries may result in significant quality improvement and cost savings in the healthcare system.

Preoperative demographics and laboratory markers may be associated with early dislocation after total hip arthroplasty

PURPOSE

The purpose of this study was to identify modifiable medical comorbidities, laboratory markers and flaws in perioperative management that increase the risk of acute dislocation in total hip arthroplasty (THA) patients.

METHODS

All THA with primary indications of osteoarthritis from 2007 to 2020 were queried from the National Surgical Quality Improvement Program (NSQIP) database. Demographic data, preoperative laboratory values, recorded past medical history, operative details as well as outcome and complication information were collected. The study population was divided into two cohorts: non-dislocation and dislocation patients. Statistics were performed to compare the characteristics of both cohorts and to identify risk factors for prosthetic dislocation (α < 0.05).

RESULTS

275,107 patients underwent primary THA in 2007 to 2020, of which 1,258 (0.5%) patients experienced a prosthetic hip dislocation. Demographics between non-dislocation and dislocation cohorts varied significantly in that dislocation patients were more likely to be female, older, with lower body mass index and a more extensive past medical history (all p < 0.05). Moreover, hypoalbuminemia and moderate/severe anemia were associated with increased risk of dislocation in a multivariate model (all p < 0.05). Finally, use of general anesthesia, longer operative time, and longer length of hospital stay correlated with greater risk of prosthetic dislocation (all p < 0.05).

CONCLUSIONS

Elderly female patients and patients with certain abnormal preoperative laboratory values are at risk for sustaining acute dislocations after index THA. Careful interdisciplinary planning and medical optimization should be considered in high-risk patients as dislocations significantly increase the risk of sepsis, cerebral vascular accident, and blood transfusions on readmission.

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.

Epidemiology of postoperative spinal wound infection in the Middle East and North Africa (MENA) region

Background

Despite the extensive literature on postoperative spinal wound infection, yet to our knowledge, there is no previous study containing combined data from several sites in the Middle East and North Africa (MENA) region. This study aimed to estimate the incidence of surgical site infection (SSI) following spine surgeries, its associated factors, and management.

Methods

In a retrospective cohort study, medical records of all patients ≥18 years of age who underwent spine surgery at 6 tertiary referral centers in the MENA region between January 2014 to December 2019 (n=5,872) were examined to collect data on the following: (1) Patient's characteristics, (2) Disease characteristics, (3) Spine surgery approach, and (4) Characteristics of Postoperative SSI. The determinants of postoperative SSI were identified using logistic regression analysis. Receiver operating characteristic (ROC) curve was applied to identify the cut-off of the length of stay in the hospital postoperatively till the infection is likely to occur. Significance was set at p<.05.

Results

The overall incidence of SSI was 4.2% (95% CI: 3.72-4.77), in the form of deep (46.4%), superficial (43.1%), dehiscence (9.3%), and organ space (1.2%) infections. After adjusting for all possible confounders, significant predictors of postoperative SSI were; diabetes (OR=2.12, p<.001), smoking (OR=1.66, p=.002), revision surgery (OR=2.20, p<.001), open surgery (OR=2.73, p<.001), perioperative blood transfusion (OR=1.45, p=.033), ASA class III(OR=2.08, p=.002), and ≥4 days length of stay "LOS" (OR= 1.71, p=.001). A cut-off of 4 days was the optimum LOS above which postoperative SSI is more likely to occur, with 0.70 sensitivity, 0.47 specificity, and 0.61 area under the curve.

Conclusions

This is the first study that highlighted the incidence of postoperative SSI in spine surgery in the MENA region. Incidence figures are comparable to figures in different areas of the world. Identifying predictors of SSI might help high‑risk patients benefit from more intensive wound management.

Frequency and Associated Factors of Postoperative Wound Dehiscence in Posterior Cervical Spine Surgery

OBJECTIVE

Wound dehiscence after cervical spine surgery is a well-known complication that can be a challenge for spine surgeons to manage, especially in cases of exposed implants. However, few studies have focused primarily on this phenomenon in cervical spine surgery to date. This investigation sought to determine the frequency of wound dehiscence following posterior cervical spine surgery and identify patient-based risk factors.

METHODS

The medical data of 405 consecutive patients (290 male and 115 female; mean age: 68.9 years) who underwent posterior cervical spine surgery were retrospectively examined. Logistic regression models were employed to examine the prevalence, characteristics, and risk factors of postoperative wound dehiscence.

RESULTS

We observed that 5.2% of cervical spine surgery patients experienced procedural postoperative wound dehiscence. In comparisons of dehiscence and non-dehiscence groups, significant differences were found for posterior instrumented fusion (81.0% vs. 45.3%; P < 0.01), extended T1 fusion (57.1% vs. 12.8%; P < 0.01), occipitocervical fusion (19.0% vs. 6.2%; P = 0.048), fused intervertebral levels (4.0 vs. 1.5; P < 0.01), surgical time (246 minutes vs. 165 minutes; P < 0.01), blood loss volume (228 mL vs. 148 mL; P = 0.023), and dialysis (14.3% vs. 1.8%; P = 0.011). Multivariate analysis identified extended T1 fusion and dialysis to be significantly associated with wound dehiscence with odds ratios of 5.82 and 10.70, respectively.

CONCLUSIONS

The observed frequency of postoperative wound dehiscence in cervical spine surgery was 5.2%. As extended T1 fusion and dialysis may increase the risk of dehiscence after surgery, patients who display such risk factors may require additional observation and care.

Alkaline Phosphatase is an Independent Risk Factor for Periprosthetic Fractures in Total Joint Arthroplasty

BACKGROUND

Serum alkaline phosphatase (ALP) is a biomarker for chronic low-grade inflammation along with hepatobiliary and bone disorders. High abnormal ALP levels in blood have been associated with metabolic bone disease and high bone turnover.

METHODS

All primary total hip and knee arthroplasties from 2005 to 2019 were queried from the National Surgical Quality Improvement Program database. Patients with available serum ALP levels were included and stratified to low (<44 IU/L), normal (44 to 147 IU/L), and high (>147 IU/L). A risk-adjusted multivariate logistic regression was used to analyze ALP as an independent risk factor of complications.

RESULTS

The analysis included 324,592 patients, consisting of 11,427 low ALP, 305,977 normal ALP, and 7,188 high preoperative ALP level patients undergoing total joint arthroplasty. Adjusted multivariate logistic regression analysis showed high ALP level patients had an overall increased risk of readmission within 30 days of surgery compared with the control group (odds ratio [OR], 1.69; P < 0.01). High ALP patients also had an increased risk of postoperative periprosthetic fracture (OR, 1.6), postoperative wound infection (OR, 1.81), pneumonia (OR, 2.24), renal insufficiency (OR, 2.39), cerebrovascular disease (OR, 2.2), postoperative bleeding requiring transfusion (OR, 1.83), sepsis (OR, 2.35), length of stay > 2 days (OR, 1.47), Clostridium difficile infection (OR, 2.07), and discharge to a rehab facility (OR, 1.41) (all P < 0.05). A low ALP level was also associated with increased postoperative bleeding transfusion risk (OR, 1.12; P < 0.01) and developing a deep vein thrombosis (OR, 1.25; P = 0.03).

CONCLUSION

Abnormal serum ALP levels in patients undergoing primary total joint arthroplasty are associated with increased postoperative periprosthetic fracture risk and medical complications requiring increased length of stay and discharge to a rehabilitation facility.

Preoperative Malnutrition and Metabolic Markers May Predict Periprosthetic Fractures in Total Hip Arthroplasty

Background

Periprosthetic fractures are a devastating complication of total hip arthroplasty (THA) and are associated with significantly higher mortality rates in the postoperative period. Given the strain that periprosthetic fractures place on the patient as well as the healthcare system, identifying and optimizing medical comorbidities is essential in reducing complications and improving outcomes.

Methods

All THA with primary indications of osteoarthritis from 2007 to 2020 were queried from the National Surgical Quality Improvement Program database. Demographic data, preoperative laboratory values, medical comorbidities, hospital course, and acute complications were collected and compared between patients with and without readmission for a periprosthetic fracture. A multivariate logistic regression analysis was performed to determine associated independent risk factors for periprosthetic fractures after index THA.

Results

The analysis included 275,107 patients, of which 2539 patients were readmitted for periprosthetic fractures. Patients with postoperative fractures were more likely to be older (>65 years), females, BMI >40, and increased medical comorbidities. Preoperative hypoalbuminemia, hyponatremia, and abnormal estimated glomerular filtration rates were independent risk factors for sustaining a periprosthetic fracture and readmission within 30 days. Modifiable patient-related factors of concurrent smoking and chronic steroid use at the time of index THA were also independent risk factors for periprosthetic fractures. Inpatient metrics of longer length of stay, operative time, and discharge to rehab predicted postarthroplasty fracture risk. Readmitted fracture patients subsequently had increased risks of developing a surgical site infection, urinary tract infection, and requiring blood transfusions.

Conclusions

Patients with hypoalbuminemia, hyponatremia, and abnormal estimated glomerular filtration rate are at increased risk for sustaining periprosthetic fractures after THA. Preoperative optimization with close monitoring of metabolic markers and modifiable risk factors may help not only prevent acute periprosthetic fractures but also associated infection and bleeding risk with fracture readmission.

Large Surgical Databases with Direct Data Abstraction: VASQIP and ACS-NSQIP

Direct data abstraction from a patient's chart by experienced medical professional data abstractors has been the historical gold standard for quality and accuracy in clinical medical research. The limiting challenge to population-wide studies for quality and public health purposes is the high personnel costs associated with very large-scale efforts of this type. Two historically related programs that are at least partially able to successfully circumvent this problem and provide high-quality data relating to surgical procedures and the early postoperative period are reviewed in this article. Both utilize similar data abstraction efforts by specially trained and qualified medical abstractors of a sample subset of the total procedures performed at participating hospitals.The Veterans Affairs Surgical Quality Improvement Program (VASQIP), detailed by Nicholas J. Giori, MD, PhD, in the first section of this article, makes use of trained abstractors and has undergone recent additions and updates, including the development of an associated total hip registry for the VA system. The data elements and data integrity provided by both of these programs establish important benchmarks for other "big data" efforts, which often attempt to use alternative less-expensive methods of data collection in order to achieve more widespread or even nationwide data collection.In the second section, Elizabeth B. Habermann, PhD, MPH, provides a detailed review of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP), the data elements collected, and examples of the range of quality improvement and outcomes studies in orthopaedic surgery that it has made possible, along with information on data that have not been collected and the resulting limitations. The ACS NSQIP was actually modeled after the very similar earlier effort started by the United States Department of Veterans Affairs (VA).

Chronic steroid use and readmission following total shoulder arthroplasty

Background

Degenerative arthritis is a major indication for both anatomic and reverse total shoulder arthroplasty (TSA). Degenerative arthritis is an age-related process that can be secondary to mechanical wear or inflammatory or autoimmune diseases, such as rheumatoid arthritis or systemic lupus erythematosus. Management of these diseases can include chronic corticosteroid for their anti-inflammatory and immunosuppressive effects. Given the well-known complications of chronic steroid use on other surgical procedures, investigation into postoperative complications specific to TSA will assist physicians in risk stratification and preoperative planning. The purpose of this study was to investigate the association between chronic preoperative steroid use and postoperative complications following TSA.

Methods

The American College of Surgeons National Surgical Quality Improvement database was queried for all patients who underwent TSA between 2015 and 2020. Patient demographics, comorbidities, surgical characteristics, and 30-day postoperative complication data were collected. Multivariate logistic regression was used to identify postoperative complications associated with chronic preoperative steroid use. Reasons and risk factors for readmission among chronic steroid users were subsequently identified, as well.

Results

A total of 26,669 patients were included in this study: 25,376 (95.2%) were included in the nonsteroid cohort and 1293 (4.8%) were included in the chronic steroid cohort. The postoperative complications that were significantly associated with chronic preoperative steroid use were septic shock (P = .007), urinary tract infection (P = .016), myocardial infarction (P = .022), ventilator >48 hours (P = .028), readmission (P < .001), nonhome discharge (P < .001), and mortality (P = .007). The only postoperative complication independently associated with chronic preoperative steroid use was readmission (odds ratio, 1.36; 95% confidence interval, 1.04-1.79; P = .027).

Conclusion

Preoperative chronic steroid use is an independent predictor for readmission following TSA. As procedural improvement increases surgical volume for TSA, a better understanding of preoperative risk factors can improve perioperative risk stratification and help to minimize adverse outcomes.

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.

Development of a Risk Stratification Scoring System to Predict General Surgical Complications for Patients Undergoing Foot and Ankle Surgery

Preventing postoperative complications is crucial for patients, surgeons, and health care facilities. We developed a risk stratification scoring system to optimize postoperative outcomes for patients undergoing foot and ankle surgery. A total of 35,580 patients who underwent foot and ankle procedures from 2005 to 2017 were identified as part of the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). To assess the risk of a postoperative complication, we identified several independent risk factors associated with 30-day postoperative complications, then proceeded to develop a point-based risk scoring system. To validate our scoring system, we used it on a cohort of patients from the database who underwent foot and ankle surgery. Risk factors that correlated with postoperative complications included tobacco abuse, age (≥65 years), diabetes mellitus, hypertension, elevated creatinine level (≥1.3 mg/dL), hypoalbuminemia (<3.5 g/dL), chronic obstructive pulmonary disease (COPD), congestive heart failure (CHF), hyponatremia (<135 mEq/L), and anemia (hematocrit value, men <42%; women <38%). Point scores for each factor were: anemia, +10; hypoalbuminemia, +9; elevated creatinine level, +6; CHF, +4; diabetes mellitus, +3; hyponatremia, +3; COPD, +2; hypertension, +2; age, +1; and tobacco abuse, +1. For the validation cohort, we stratified patients according to risk as low (0-20 points), medium (21-30 points), and high (≥31 points) risk. In terms of having a postoperative complication, compared with low-risk patients, patients who were at medium risk had an odds ratio of 4.7 (95% CI, 2.8-7.9) and those at high risk had an odds ratio of 8.3 (95% CI, 4.8-14.5). [Orthopedics. 2022;45(3):139-144.].

Readmission, Reoperation, and Non-home Discharge Rates in Patients Receiving Surgical Treatment for Proximal Humerus Fractures

Background

Proximal humerus fractures (PHFs) are generally surgically treated with open reduction internal fixation (ORIF), hemiarthroplasty (HA), or total shoulder arthroplasty (TSA). Diverse fracture patterns and a high prevalence in the elderly population make it difficult to establish objective guidelines for the decision to undergo surgical treatment. The purpose of this study was to investigate risk factors associated with readmission, reoperation, and nonhome discharge following ORIF, HA, and TSA for PHFs.

Methods

Data on all patients who underwent ORIF, TSA, or HA for treatment of closed PHF between 2015 and 2017 were obtained by querying the American College of Surgeons National Surgical Quality Improvement database. Rates of postoperative readmission, nonhome discharge, and reoperation within 30 days were collected. Multivariate logistic regression was employed to identify predictors of readmission, nonhome discharge, and reoperation.

Results

A total of 2825 patients were included in this study: 1829 underwent ORIF, 707 underwent TSA, and 289 underwent HA. The significant predictors for readmission were having an American Society of Anesthesiologists class ≥ 3 (odds ratio [OR] 1.95, P = .003) and being of dependent functional status (OR 3.15, P < .001). The significant predictors for reoperation were male sex (OR 2.41, P < .001) and dependent functional status (OR 2.92, P = .006). The significant predictors for nonhome discharge were age 66-80 years (OR 7.00, P < .001), age ≥ 81 years (OR 16.31, P < .001), American Society of Anesthesiologists ≥3 (OR 2.34, P < .001), dependent functional status (OR 2.48, P < .001), and inpatient status (OR 3.32, P < .001). TSA showed slightly higher rates of nonhome discharge than HA and ORIF.

Conclusion

Significant risk factors for readmission, reoperation, and nonhome discharge within 30 days following surgical treatment for PHF were identified. Additionally, TSA was significantly associated with nonhome discharge compared with HA and ORIF.

Artificial Neural Networks Predict 30-Day Mortality After Hip Fracture: Insights From Machine Learning

OBJECTIVES

Accurately stratifying patients in the preoperative period according to mortality risk informs treatment considerations and guides adjustments to bundled reimbursements. We developed and compared three machine learning models to determine which best predicts 30-day mortality after hip fracture.

METHODS

The 2016 to 2017 National Surgical Quality Improvement Program for hip fracture (AO/OTA 31-A-B-C) procedure-targeted data were analyzed. Three models-artificial neural network, naive Bayes, and logistic regression-were trained and tested using independent variables selected via backward variable selection. The data were split into 80% training and 20% test sets. Predictive accuracy between models was evaluated using area under the curve receiver operating characteristics. Odds ratios were determined using multivariate logistic regression with P < 0.05 for significance.

RESULTS

The study cohort included 19,835 patients (69.3% women). The 30-day mortality rate was 5.3%. In total, 47 independent patient variables were identified to train the testing models. Area under the curve receiver operating characteristics for 30-day mortality was highest for artificial neural network (0.92), followed by the logistic regression (0.87) and naive Bayes models (0.83).

DISCUSSION

Machine learning is an emerging approach to develop accurate risk calculators that account for the weighted interactions between variables. In this study, we developed and tested a neural network model that was highly accurate for predicting 30-day mortality after hip fracture. This was superior to the naive Bayes and logistic regression models. The role of machine learning models to predict orthopaedic outcomes merits further development and prospective validation but shows strong promise for positively impacting patient care.

Level of obesity is directly associated with complications following arthroscopic rotator cuff repair

BACKGROUND

The purpose of this study was to investigate the association between increasing levels of obesity and postoperative complications within 30 days of arthroscopic rotator cuff repair (ARCR).

METHODS

We queried the American College of Surgeons National Surgical Quality Improvement Program database for all patients who underwent ARCR from 2015 to 2017. Patients were stratified into 3 cohorts according to their body mass index (BMI). Patients with a BMI < 30 kg/m² were placed in the non-obese cohort, patients with a BMI between 30 and 40 kg/m² were placed in the obese cohort, and patients with a BMI > 40 kg/m² were placed in the morbidly obese cohort. Postoperative complications within 30 days of the procedure were collected. Multivariate logistic regression was used to investigate the relationship between increasing levels of obesity and postoperative complications.

RESULTS

There were 18,521 patients included in this study. Of these patients, 9548 (51.6%) were non-obese, 7438 (40.2%) were obese, and 1535 (8.3%) were morbidly obese. A comparison among non-obese, obese, and morbidly obese patients showed increasing rates of medical complications (0.5% vs. 1.0% vs. 1.4%), pulmonary complications (0.1% vs. 0.3% vs. 0.5%), renal complications (0.0% vs. 0.1% vs. 0.2%), readmission (0.9% vs. 1.2% vs. 1.6%), nonhome discharge (0.4% vs. 0.5% vs. 1.2%), and overall complications (0.8% vs. 1.3% vs. 1.8%). In comparison to non-obesity, both obesity and morbid obesity were identified by multivariate analysis as significant predictors of medical complications (odds ratio [ORs] of 1.72 and 2.16, respectively), pulmonary complications (ORs of 2.66 and 4.06, respectively), and overall complications (ORs of 1.52 and 1.77, respectively).

CONCLUSION

This study used a large national database to identify increasing levels of obesity as a risk factor for medical complications, pulmonary complications, and overall complications within 30 days of ARCR.

Smoking as a risk factor for complications following arthroscopic rotator cuff repair

Background

The purpose of this study was to investigate the association between smoking status and postoperative complications within 30 days of arthroscopic rotator cuff repair (ARCR).

Methods

The American College of Surgeons National Surgical Quality Improvement Program database was queried to identify all patients who underwent ARCR from 2015 to 2017. Smokers were defined as patients who reported smoking cigarettes in the year prior to rotator cuff repair. Patients who used chewing tobacco, cigars, or electronic cigarettes were not included in the smoking cohort. Postoperative complications were reported within 30 days of the procedure. Multivariate logistic regression was performed to investigate the relationship between smoking status and postoperative complications.

Results

There were 18,594 patients included in this study. Of these patients, 2834 (15.2%) were current smokers. Smokers were more likely to be men, to be aged < 65 years, and to have a body mass index < 30. Smokers were also more likely to have chronic obstructive pulmonary disease, to be functionally dependent, and to have an American Society of Anesthesiologists (ASA) class ≥ 3. After adjustment for all significantly associated patient demographic characteristics and comorbidities, smoking was identified as a significant predictor of surgical complications (odds ratio [OR], 1.955; P = .022), return to the operating room (OR, 2.547; P = .003), readmission (OR, 1.570; P = .014), and sepsis or septic shock (OR, 4.737; P = .021). Smoking was not a significant predictor of medical complications (OR, 1.105; P = .687) or surgical-site infections (OR, 1.216; P = .713).

Conclusion

Smoking may be a risk factor for surgical complications, readmission, and sepsis or septic shock within 30 days of ARCR.

The Impact of Preoperative Anemia on Complications After Total Shoulder Arthroplasty

This study investigated the relationship between varying levels of preoperative anemia and postoperative complications within 30 days of total shoulder arthroplasty (TSA).

Creating a Value Dashboard for Orthopaedic Surgical Procedures

BACKGROUND

Value-based health-care delivery is a framework for restructuring our health-care systems with the goal of providing better outcomes for patients at lower cost. Value is determined by patient health outcomes per dollar spent on health services. We sought to develop a value dashboard that could be used to easily track and improve the value of total hip and knee arthroplasty (THA and TKA).

METHODS

We created a value dashboard for TKAs and THAs at our institution. Value was defined as quality of outcomes per dollar spent. The dashboard for each procedure displayed the average value by surgeon, compared with institutional averages for physical function scores and cost. Quality metrics were determined by weighted surgeon ranking using a modified Delphi process and included both clinical and patient-reported outcomes, as measured by the mean change in the Patient-Reported Outcomes Measurement Information System Global-10 (PROMIS-10) physical function score, mean change in the Hip disability and Osteoarthritis Outcome Score-Joint Replacement (HOOS-JR) or the Knee injury and Osteoarthritis Outcome Score-Joint Replacement (KOOS-JR), mean change in the modified Single Assessment Numeric Evaluation (SANE) score, complication rate, periprosthetic joint infection (PJI) rate, and 30-day readmission rate. Average direct costs per surgeon were used. Data from January 2017 through April 2018 were included to ensure 1-year follow-up.

RESULTS

Six surgeons were included in the value dashboard for TKA, and 5 were included in the THA dashboard. The value for TKA by surgeon ranged from 7% below to 12% above the institutional benchmark. The value for THA by surgeon ranged from 12% below to 7% above the institutional benchmark.

CONCLUSIONS

The proposed dashboard utilizes value in a health-care framework and could be used for comparing and improving value for THA and TKA. This dashboard successfully combined patient outcome metrics and direct costs of surgical procedures. Future studies should focus on involving patients in this process and using national data to create benchmarks, which could provide a more accurate representation of value than using institutional averages.

Validation of adverse events after hip arthroplasty: a Swedish multi-centre cohort study

OBJECTIVES

Preventing adverse events (AEs) after orthopaedic surgery is a field with great room for improvement. A Swedish instrument for measuring AEs after hip arthroplasty based on administrative data from the national patient register is used by both the Swedish Hip Arthroplasty Register and the Swedish Association of Local Authorities and Regions. It has never been validated and its accuracy is unknown. The aim of this study was to validate the instrument's ability to detect AEs, and to calculate the incidence of AEs following primary hip arthroplasties.

DESIGN

Retrospective cohort study using retrospective record review with Global Trigger Tool methodology in combination with register data.

SETTING

24 different hospitals in four major regions of Sweden.

PARTICIPANTS

2000 patients with either total or hemi-hip arthroplasty were recruited from the SHAR. We included both acute and elective patients.

PRIMARY AND SECONDARY OUTCOME MEASURES

The sensitivity and specificity of the instrument. Adjusted cumulative incidence and incidence rate.

RESULTS

The sensitivity for all identified AEs was 5.7% (95% CI: 4.9% to 6.7%) for 30 days and 14.8% (95% CI: 8.2 to 24.3) for 90 days, and the specificity was 95.2% (95% CI: 93.5% to 96.6%) for 30 days and 92.1% (95% CI: 89.9% to 93.8%) for 90 days. The adjusted cumulative incidence for all AEs was 28.4% (95% CI: 25.0% to 32.3%) for 30 days and 29.5% (95% CI: 26.0% to 33.8%) for 90 days. The incidence rate was 0.43 AEs per person-month (95% CI: 0.39 to 0.47).

CONCLUSIONS

The AE incidence was high, and most AEs occurred within the first 30 days. The instrument sensitivity for AEs was very low for both 30 and 90 days, but the specificity was high for both 30 and 90 days. The studied instrument is insufficient for valid measurements of AEs after hip arthroplasty.

Frequency and Impact of Adverse Events in Patients Undergoing Surgery for End-Stage Ankle Arthritis

BACKGROUND

This study summarized the frequency and functional impact of adverse events (AEs) that occur after surgery for end-stage ankle arthritis (ESAA) to inform decision making.

METHODS

This was a multisite prospective cohort study to compare ankle arthroplasty to ankle arthrodesis in the treatment of ESAA among 6 participating sites. We compared the risk and impact of nonankle AEs and ankle-specific AEs versus no AEs controlling for potential confounding factors, including operative procedure using multinomial logistic regression. We estimated differences in postoperative functional outcomes by AE occurrence using linear mixed effects regression. Among 517 patients who had surgery for ankle arthritis and completed the full baseline assessment, follow-up scores were available in 494 (95%) patients.

RESULTS

There were a total of 628 reported AEs (477 in the arthroplasty group and 151 in the arthrodesis group). These occurred in 261 (63%) arthroplasty patients and 67 (65%) arthrodesis patients. There were 50 (8%) ankle-specific AEs. The risk of an ankle-specific AE was slightly higher in the arthrodesis group versus the arthroplasty group, odds ratio (OR) 1.84, 95% confidence interval (CI, 0.85, 3.98). The OR for the risk of non-ankle-specific AE versus no AE was 0.96, 95% CI (0.57, 1.61) for those receiving arthrodesis compared to arthroplasty. Compared to patients with no AEs, those experiencing ankle-specific AEs had significantly less improvement in Foot and Ankle Ability Measure Sports and activities of daily living (ADL) subscores and worst pain outcomes; however, both groups improved significantly in all measures except mental health.

CONCLUSIONS

Ankle-specific AEs were infrequent and only weakly associated with operative procedure. Although patients improved in all functional outcomes except mental health, regardless of AE occurrence, ankle-specific AEs negatively impacted patient improvement compared to those with no AEs or a nonankle AE. The logistical effort and cost of tracking nonankle AEs does not seem to be justified.

LEVEL OF EVIDENCE

Level II, prospective comparative study.

Development of a Risk Stratification Scoring System to Predict General Surgical Complications in Hand Surgery Patients

PURPOSE

Avoidance of postoperative complications is important to both patients and surgeons. In an attempt to optimize postoperative outcomes, a risk stratification scoring system has been created to aid in optimizing risk factors for general surgical complications in hand surgery patients.

METHODS

Patients were identified who underwent hand procedures as part of the American College of Surgeons National Surgical Quality Improvement Program. Independent risk factors associated with postoperative complications within 30 days of surgery were identified and used to develop a point-scoring system to estimate the relative risk for sustaining complications. For validation, the system was tested on a subset of patients from the database who had undergone hand surgery.

RESULTS

A total of 49,272 patients were identified as having undergone hand surgery from 2005 to 2015. The incidence of postoperative complications within 30 days of hand surgery was 2.3%. Risk factors associated with postoperative complications were male sex, tobacco abuse, congestive heart failure, anemia (male hematocrit less than 42; female less than 38), elevated creatinine (greater than 1.3 mg/dL), hypoalbuminemia (less than 3.5 g/dL), and hyponatremia (less than 135 mEq/L). Point scores derived for each of these factors were: hypoalbuminemia, +5; congestive heart failure, +2; anemia, +2; elevated creatinine, +2; male sex, +1; tobacco abuse, +1; and hyponatremia, +1. In the validation cohort, patients categorized as low-risk (0-3) using the point-scoring system had a 2.4% rate of 30-day complications; patients categorized as medium risk (4-7) had a 10.4% complication rate (relative risk = 4.3; 95% confidence interval, 3.1-5.9 compared with low risk) and high risk (≥8), 28.9% (relative risk = 11.9; 95% confidence interval, 9.0-15.7).

CONCLUSIONS

This point-scoring system predicts risk for general postoperative complications after hand surgery. These data may help surgeons identify areas of clinical concern with patients to reduce the risk for sustaining postoperative complications.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Usefulness of sonication for diagnosing infection in explanted orthopaedic implants

BACKGROUND

Orthopaedic implant infection is a rare but serious complication whose optimal treatment requires an accurate microbiological diagnosis. The objective of this study was to determine whether culturing sonicated explants improved sensitivity compared to culturing standard sonicated soft-tissue samples.

HYPOTHESIS

Cultures of explant sonication fluid are more sensitive than cultures of soft-tissue sonication fluid in patients with implant infection.

METHODS

This single-centre retrospective study included all sonication fluid samples from implants explanted in orthopaedic surgery theatres for any reason. The microbiological results of the implant sonication fluid cultures were compared to those of cultures of sonicated soft-tissue and bone samples taken during the same procedure. The primary evaluation criterion was the difference in microorganisms recovered from explant sonication fluids versus fluid/tissue cultures.

RESULTS

The study included 187 explants removed between September 2009 and June 2015. Of the definite infections, 83% were identified by explant sonication, 86% by fluid/tissue cultures, and 91% by both techniques combined. Explant sonication recovered causative organisms in 10 patients with definite infection but negative fluid/soft tissue cultures. Antibiotic therapy prior to explantation was associated with lower sensitivity of explant sonication (57% vs. 67% for fluid/soft tissue cultures).

CONCLUSION

Explant sonication improved the diagnosis of infection when combined with fluid/soft tissue cultures.

LEVEL OF EVIDENCE

IV, retrospective single-centre study.

Inpatient and 90-day post-discharge outcomes in elective Medicare spine fusion surgery

BACKGROUND CONTEXT

Elective spine surgery is a commonly performed operative procedure, that requires knowledge of risk-adjusted results to improve outcomes and reduce costs.

PURPOSE

To develop risk-adjusted models to predict the adverse outcomes (AOs) of care during the inpatient and 90-day post-discharge period for spine fusion surgery.

STUDY DESIGN/SETTING

To identify the significant risk factors associated with AOs and to develop risk models that measure performance.

PATIENT SAMPLE

Hospitals that met minimum criteria of both 20 elective cervical and 20 elective non-cervical spine fusion operations in the 2012-2014 Medicare limited dataset.

OUTCOME MEASURES

The risk-adjusted AOs of inpatient deaths, prolonged length-of-stay for the index hospitalization, 90-day post-discharge deaths, and 90-day post-discharge readmissions were dependent variables in predictive risk models.

METHODS

Over 500 candidate risk factors were used for logistic regression models to predict the AOs. Models were then used to predicted risk-adjusted AO rates by hospitals.

RESULTS

There were 874 hospitals with a minimum of both 20 cervical and 20 non-cervical spine fusion patients. There were 167,395 total cases. A total of 7,981 (15.9%) of cervical fusion patients and 17,481 (14.9%) of non-cervical fusion patients had one or more AOs for an overall AO rate of 15.2%. A total of 54 hospitals (6.2%) had z-scores that were 2.0 better than predicted with a median risk adjusted AO rate of 9.2%, and 75 hospitals (8.6%) were 2.0 z-scores poorer than predicted with a median risk-adjusted AO rate of 23.2%.

CONCLUSIONS

Differences among hospitals defines opportunities for care improvement.

Risk factors for wound complications following spine surgery

Background

Wound complications, including surgical site infections (SSIs) and wound dehiscence, are among the most common complications following spine surgery often leading to readmission. The authors sought to identify preoperative characteristics predictive of wound complications after spine surgery.

Methods

The American College of Surgeons National Surgical Quality Improvement Program database for years 2012-2014 was reviewed for patients undergoing spine surgery, defined by the Current Procedural Terminology codes. Forty-four preoperative and surgical characteristics were analyzed for associations with wound complications.

Results

Of the 99,152 patients included in this study, 2.2% experienced at least one wound complication (superficial SSI: 0.9%, deep SSI: 0.8%, organ space SSI: 0.4%, and dehiscence: 0.3%). Multivariate binary logistic regression testing found 10 preoperative characteristics associated with wound complications: body mass index ≥30, smoker, female, chronic steroid use, hematocrit <38%, infected wound, inpatient status, emergency case, and operation time >3 hours. A risk score for each patient was created from the number of characteristics present. Receiver operating characteristic curves of the unweighted and weighted risk scores generated areas under the curve of 0.701 (95% CI: 0.690-0.713) and 0.715 (95% CI: 0.704-0.726), respectively. Patients with unweighted risk scores >7 were 25-fold more likely to develop a wound complication compared to patients with scores of 0. In addition, mortality rate, reoperation rate, and total length of stay each increased nearly 10-fold with increasing risk score.

Conclusion

This study introduces a novel risk score for the development of wound dehiscence and SSIs in patients undergoing spine surgery, using new risk factors identified here.

Recording Adverse Events Following Joint Arthroplasty: Financial Implications and Validation of an Adverse Event Assessment Form

BACKGROUND

In Ireland, funding of joint arthroplasty procedures has moved to a pay-by-results national tariff system. Typically, adverse clinical events are recorded via retrospective chart-abstraction methods by administrative staff. Missed or undocumented events not only affect the quality of patient care but also may unrealistically skew budgetary decisions that impact fiscal viability of the service. Accurate recording confers clinical benefits and financial transparency. The aim of this study was to compare a prospectively implemented adverse events form with the current national retrospective chart-abstraction method in terms of pay-by-results financial implications.

METHODS

An adverse events form adapted from a similar validated model was used to prospectively record complications in 51 patients undergoing total hip or knee arthroplasties. Results were compared with the same cohort using an existing data abstraction method. Both data sets were coded in accordance with current standards for case funding.

RESULTS

Overall, 114 events were recorded during the study through prospective charting of adverse events, compared with 15 events documented by customary method (a significant discrepancy). Wound drainage (15.8%) was the most common complication, followed by anemia (7.9%), lower respiratory tract infections (7.9%), and cardiac events (7%). A total of €61,956 ($67,778) in missed funding was calculated as a result.

CONCLUSION

This pilot study demonstrates the ability to improve capture of adverse events through use of a well-designed assessment form. Proper perioperative data handling is a critical aspect of financial subsidies, enabling optimal allocation of funds.