Analysis of complication rates following perioperative transfusion in shoulder arthroplasty

Increasing severity of preoperative anemia is associated with higher postoperative medical and surgical complications after primary shoulder arthroplasty

BACKGROUND

Anemia is a major cause of morbidity worldwide and compounds numerous medical conditions. Studies have found associations between anemia and both medical and surgical complications after shoulder arthroplasty (SA); however, most of these studies have used commercially available national databases with limited information on outcomes and typically short-term follow-up. Our study sought to evaluate the midterm outcomes of primary SA at a single institution when stratified by the degree of preoperative anemia.

METHODS

Between 2000 and 2020, 5231 primary SA (477 hemiarthroplasties, 2091 anatomic total SA, and 2335 reverse SA) with preoperative hematocrit values available and a minimum follow-up of 2 years were collected from a single-institution joint registry database. The severity of anemia was subclassified as no anemia (hematocrit >39% for males, >36% for females; n = 4194 [80.2%]), mild anemia (hematocrit 33%-39% for males, 33%-36% for females; n = 742 [14.2%]), and moderate-to-severe anemia (hematocrit <33% for both males and females; n = 295 [5.6%]). The mean follow-up time for the entire cohort was 5.9 years (range, 2-22 years). Medical and surgical complications, reoperations, revisions, and implant survivorship were assessed.

RESULTS

SA with moderate-to-severe anemia had the highest rate of nonfatal and nontransfusion medical complications (5.1%) relative to the nonanemic (1.2%; P < .001) and mild anemic groups (1.5%; P < .001). Similarly, SA with moderate-to-severe anemia had the highest rate of surgical complications (19.3%) compared with mild anemia (14.3%; P = .044) and no anemia (11.6%; P < .001). Postoperative transfusion was most frequent in the moderate-to-severe anemia cohort (40.3%) compared with the mild anemia (14.2%; P < .001) and nonanemic groups (2.5%; P < .001). Furthermore, SA who received postoperative transfusions had a higher risk of nonfatal medical complications (8.2% vs. 1.0%; P < .001), 90-day mortality (1.5% vs. 0.03%; P = .001), and surgical complications (19.5% vs. 12.0%; P < .001) when compared with those without transfusion.

CONCLUSIONS

Moderate-to-severe anemia (hematocrit <33% for both males and females) was identified in approximately 5.6% of patients who underwent SA at a single institution and was associated with increased medical and surgical complications. Patients who received postoperative transfusions presented elevated rates of medical complications, 90-day mortality, and surgical complications. Health care teams should be aware of these risks in order to provide more individualized medical optimization and postoperative monitoring.

Over the Past Decade, Preoperative Anemia Has Become a Greater Predictor of Transfusions After Total Knee Arthroplasty

BACKGROUND

With advancements in perioperative blood management and the use of tranexamic acid, the rate of transfusions after total knee arthroplasty (TKA) has substantially decreased. As these principles are refined, other modifiable risk factors, such as preoperative anemia, may play an increasingly important role in transfusion risk for patients undergoing TKA.

METHODS

A multicenter, national database was utilized to identify patients undergoing TKA from 2010 to 2021. Anemia was defined by World Health Organization definitions as < 12 g/dL for women and < 13 g/dL for men. A predictive model was created using backwards elimination logistic regression to predict transfusion risk, controlling for demographic and medical covariates. The coefficient of anemia was then analyzed for each year. The trend over time was fitted with a best-fit linear regression equation.

RESULTS

There were 509,117 patients who underwent TKA, and had a mean age of 67 years (range, 18 to 89). There were 57,716 (11%) patients who were anemic preoperatively, and 15,426 (3%) of patients required a transfusion. Rate of transfusion decreased from 10.6% in 2010 to 0.6% in 2021. The odds ratio associated with anemia as a predictor of transfusion increased from 3.1 (95% confidence interval: 2.1 to 4.6) in 2010 to 14.0 (95% confidence interval: 8.9 to 24) in 2021.

CONCLUSIONS

The results of this study demonstrate that the importance of preoperative anemia as a predictor of transfusion has increased over the past decade as rates of transfusion have decreased. As perioperative blood management protocols improve, preoperative anemia should be considered an important focus of intervention to reduce the risk of transfusion prior to TKA.

LEVEL OF EVIDENCE

III.

The efficacy of topical tranexamic acid in reverse shoulder arthroplasty

INTRODUCTION

Topical tranexamic acid (TXA) has been shown to decrease blood loss in knee and hip arthroplasty. Despite there is evidence about its effectiveness when administered intravenous, its effectiveness and optimal dose when used topically has not been established. We hypothesized that the use of 1.5g (30mL) of topical TXA could decrease the amount of blood loss in patients after reverse total shoulder arthroplasty (RTSA).

MATERIAL AND METHODS

One hundred and seventy-seven patients receiving a RSTA for arthropathy or fracture were retrospectively reviewed. Preoperative-to-postoperative change in hemoglobin (ΔHb) and hematocrit (ΔHct) level drain volume output, length of stay and complications were evaluated for each patient.

RESULTS

Patients receiving TXA has significant less drain output in both for arthropathy (ARSA) (104 vs. 195mL, p=0.004) and fracture (FRSA) (47 vs. 79mL, p=0.01). Systemic blood loss was slightly lower in TXA group, but this was not statistically significant (ARSA, ΔHb 1.67 vs. 1.90mg/dL, FRSA 2.61 vs. 2.7mg/dL, p=0.79). This was also observed in hospital length of stay (ARSA 2.0 vs. 2.3 days, p=0.34; 2.3 vs. 2.5, p=0.56) and need of transfusion (0% AIHE; AIHF 5% vs. 7%, p=0.66). Patients operated for a fracture had a higher rate of complications (7% vs. 15.6%, p=0.04). There were no adverse events related to TXA administration.

CONCLUSION

Topical use of 1.5g of TXA decreases blood loss, especially on the surgical site without associated complications. Thus, hematoma decrease could avoid the systematic use of postoperative drains after reverse shoulder arthroplasty.

[Translated article] The efficacy of topical tranexamic acid in reverse shoulder arthroplasty

INTRODUCTION

Topical tranexamic acid (TXA) has been shown to decrease blood loss in knee and hip arthroplasty. Despite there is evidence about its effectiveness when administered intravenous, its effectiveness and optimal dose when used topically have not been established. We hypothesised that the use of 1.5g (30mL) of topical TXA could decrease the amount of blood loss in patients after reverse total shoulder arthroplasty (RTSA).

MATERIAL AND METHODS

One hundred and seventy-seven patients receiving a RSTA for arthropathy or fracture were retrospectively reviewed. Preoperative-to-postoperative change in haemoglobin (ΔHb) and hematocrit (ΔHct) level drain volume output, length of stay and complications were evaluated for each patient.

RESULTS

Patients receiving TXA has significant less drain output in both for arthropathy (ARSA) (104 vs. 195mL, p=0.004) and fracture (FRSA) (47 vs. 79mL, p=0.01). Systemic blood loss was slightly lower in TXA group, but this was not statistically significant (ARSA, ΔHb 1.67 vs. 1.90mg/dL, FRSA 2.61 vs. 2.7mg/dL, p=0.79). This was also observed in hospital length of stay (ARSA 2.0 vs. 2.3 days, p=0.34; 2.3 vs. 2.5, p=0.56) and need of transfusion (0% AIHE; AIHF 5% vs. 7%, p=0.66). Patients operated for a fracture had a higher rate of complications (7% vs. 15.6%, p=0.04). There were no adverse events related to TXA administration.

CONCLUSION

Topical use of 1.5g of TXA decreases blood loss, especially on the surgical site without associated complications. Thus, haematoma decrease could avoid the systematic use of postoperative drains after reverse shoulder arthroplasty.

Incidence and risk factors of in-hospital prosthesis-related complications following total shoulder arthroplasty

BACKGROUND

The occurrence of prosthesis-related complications after total shoulder arthroplasty is devastating and costly. The purpose was to determine the incidence and risk of in-hospital prosthesis-related complications after total shoulder arthroplasty utilizing a large-scale sample database.

METHODS

A retrospective database analysis was performed based on Nationwide Inpatient Sample from 2010 to 2014. Patients who underwent total shoulder arthroplasty were included. Patient demographics, hospital characteristics, length of stay, economic indicators, in-hospital mortality, comorbidities, and peri-operative complications were evaluated.

RESULTS

A total of 34,198 cases were capture from the Nationwide Inpatient Sample database. There were 343 cases of in-hospital prosthesis-related complications after total shoulder arthroplasty and the overall incidence was 1%, with a more than 2.5-fold decrease from 2010 to 2014. Dislocation was the most common category among prosthesis-related complications (0.1%). The occurrence of in-hospital prosthesis-related complications was associated with significantly more total charges and slightly longer length of stay while less usage of Medicare. Risk factors of prosthesis-related complications were identified including younger age (<64 years), female, the native American, hospital in the South, alcohol abuse, depression, uncomplicated diabetes, diabetes with chronic complications, fluid and electrolyte disorders, metastatic cancer, neurological disorders, and renal failure. Interestingly, advanced age (≥65 years) and proprietary hospital were found as protective factors. Furthermore, prosthesis-related complications were associated with aseptic necrosis, rheumatoid arthritis, rotator cuff tear arthropathy, Parkinson's disease, prior shoulder arthroscopy, and blood transfusion.

CONCLUSIONS

It is of benefit to study risk factors of prosthesis-related complications following total shoulder arthroplasty to ensure the appropriate management and optimize consequences although a relatively low incidence was identified.

Preventing and Treating Infection in Reverse Total Shoulder Arthroplasty

PURPOSE OF REVIEW

Periprosthetic infection after shoulder arthroplasty is relatively uncommon though associated with severe long-term morbidity when encountered. The purpose of the review is to summarize the recent literature regarding the definition, clinical evaluation, prevention, and management of prosthetic joint infection after reverse shoulder arthroplasty.

RECENT FINDINGS

The landmark report generated at the 2018 International Consensus Meeting on Musculoskeletal Infection has provided a framework for diagnosis, prevention, and management of periprosthetic infections after shoulder arthroplasty. Shoulder specific literature with validated interventions to reduce prosthetic joint infection is limited; however existing literature from retrospective studies and from total hip and knee arthroplasty allows us to make relative guidelines. One and two-stage revisions seem to demonstrate similar outcomes; however, no controlled comparative studies exist limiting the ability to make definitive recommendations between the two options. We report on recent literature regarding the current diagnostic, preventative, and treatment options for periprosthetic infection after shoulder arthroplasty. Much of the literature does not distinguish between anatomic and reverse shoulder arthroplasty, and further high-level shoulder specific studies are needed to answer questions generated from this review.

Systemic medical complications following joint replacement: a review of the evidence

INTRODUCTION

Arthroplasty procedures are commonly performed in the UK. Informed consent is required for each procedure. To obtain informed consent the patient and their surgeon should discuss the risks and benefits of the proposed operation. This discussion should include both regional and systemic complication rates. Regional complications of arthroplasty are generally well documented in the literature. Systemic medical complications are less well described. This lack of accurate data could make it difficult for the treating surgeon to obtain valid consent. The aim of this paper was to review and compare the literature regarding the rate of systemic medical complications after common arthroplasty procedures.

METHODS

A literature search was conducted using the PubMed, Cochrane Library and MEDLINE databases. Studies regarding the systemic medical complications and mortality rate of joint replacement were included.

FINDINGS

We found that systemic complications were more frequent than regional complications following arthroplasty. The systemic complication rates were: hip, 5.1%; knee, 6.9%; ankle, 3.0%; shoulder, 11.2%; elbow, 8.5%; and wrist, 0%. Mortality rates for arthroplasty procedures were: hip, 0.3%; knee, 0.2%; ankle, 0.3%; shoulder, 0.3%; elbow, 0.2%; and wrist, 0%.

CONCLUSIONS

The most common systemic medical complication following arthroplasty was venous thromboembolism. Preoperative comorbidity was the most important risk factor for both postoperative mortality and systemic medical complications following arthroplasty procedures. We recommend that to obtain informed consent the given rates of systemic medical complications of joint replacement should be discussed and documented.

Anemia and Its Severity Is Associated With Worse Postoperative Outcomes Following Open Reduction Internal Fixation of Ankle Fractures

BACKGROUND

Ankle fractures are often treated in a nonemergent fashion and therefore offer the chance for treatment of preoperative anemia. Although preoperative anemia has been associated with postoperative morbidity following certain types of orthopaedic procedures, its effect on postoperative outcomes following open reduction internal fixation (ORIF) of ankle fractures has not been evaluated. The purpose of this study was to determine the influence of preoperative anemia on 30-day postoperative outcomes following ankle fracture ORIF.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ASC-NSQIP) registry was queried from 2005 to 2019 for patients undergoing ankle fracture ORIF. Patients were stratified into nonanemic, mildly anemic, and moderately to severely anemic. Univariate analyses were used to assess differences in patient characteristics between cohorts. Multivariate logistic regressions adjusting for these differences were performed to assess the effect of preoperative anemia on 30-day postoperative outcomes.

RESULTS

We obtained data for 21 211 patients, of whom 14 931 (70.39%) were not anemic, 3982 (18.77%) were mildly anemic, and 2298 (10.83%) were moderately to severely anemic. After adjustment, mild preoperative anemia was associated with higher odds of any adverse event (P < .001), deep surgical site infections (SSIs; P = .013), sepsis (P = .001), 30-day readmission (P < .001), and extended length of stay (LOS) (P < .001). Similarly, moderate to severe anemia in these patients was also associated with increased odds of any adverse event (P < .001), deep SSIs (P = .003), sepsis (P = .001), readmission (P < .001), and extended LOS (P < .001). Both mild (P = .004) and moderate to severe (P < .001) anemia groups had higher odds of requiring a blood transfusion.

CONCLUSION

Preoperative anemia is associated with an increased risk of adverse postoperative outcomes in patients undergoing ORIF for ankle fractures. Future studies should evaluate whether optimization of hematocrit in these patients results in improved outcomes.

LEVEL OF EVIDENCE

Level III, comparative study.

Systemic medical complications following total ankle arthroplasty: A review of the evidence

BACKGROUND

Total Ankle Arthroplasty (TAA) is increasingly undertaken for the treatment of end-stage ankle arthritis. For each TAA procedure informed consent is required. The consent process should include discussion of the relevant complications, both systemic and regional. There is a lack of data regarding the systemic complications of TAA. This might cause problems in obtaining valid informed consent.

METHODS

We reviewed and summarised the literature regarding the systemic complications and mortality rate of TAA.

RESULTS

The average rate of systemic medical complications after TAA was 3% (range: 0-7%). The average mortality rate following TAA was 0.3% (range: 0-0.72%). The following were risk factors for systemic medical complications: obesity, diabetes, systemic co-morbidities, preoperative blood transfusion, revision procedures, and long anaesthetic duration.

CONCLUSIONS

When obtaining informed consent for TAA a systemic complication rate of 3% and a mortality rate of 0.3% ought to be included and documented.

Impact of tranexamic acid on clinical and hematologic outcomes following total shoulder arthroplasty

Background

The purpose of this study is to evaluate the impact of intravenous tranexamic acid on clinical and hematologic outcomes after total shoulder arthroplasty.

Methods

Retrospective review was conducted for 282 consecutive patients undergoing either anatomic shoulder arthroplasty or reverse total shoulder arthroplasty. Univariate analysis and multivariate linear regression were used to compare outcomes for patients receiving intravenous tranexamic acid with those who did not.

Results

Of the 282 patients included in this study, 78 patients received intravenous tranexamic acid and 204 did not. Patients who received intravenous tranexamic acid had significantly lower pre- to postoperative change in hemoglobin and hematocrit, and decreased postoperative drain output. In addition, patients receiving intravenous tranexamic acid were significantly less likely to have a postoperative hematocrit <30. There were no significant differences in length of stay, rate of 30 day hematoma, surgical site infection, deep vein thrombosis, or readmission between groups.

Conclusion

Intravenous tranexamic acid is associated with a significant reduction in change in hematocrit and hemoglobin and postoperative drain output after both anatomic and reverse total shoulder arthroplasty. Despite improving hematologic outcomes for these patients, tranexamic acid appears to have little impact on clinical outcomes such as length of stay and 30-day complication rates.

Few UK vascular centres offer a fully NICE-compliant supervised exercise programme: a national audit

INTRODUCTION

To determine the current (pre-COVID-19) provision of supervised exercise training (SET) for patients with peripheral arterial disease (PAD) in UK Vascular Centres.

METHODS

Hospital Trusts delivering vascular care to patients with PAD were identified from the National Vascular Registry and asked to complete an online questionnaire on their provisions for SET. If a centre offered SET, they were asked questions to determine whether the programme was compliant with NICE guidelines and the difficulties they faced delivering the service. If centres did not offer SET, they were asked what obstacles prevented them implement SET.

RESULTS

Of the 78 UK vascular centres, 59 (76%) responded and were included in the audit. Of these, 27 (46%) were able to offer SET but only 21 (36%) could offer it to all their patients with PAD. Only four (6.8%) offered SET that was fully compliant with current NICE guidelines. Reasons identified included insufficient funding, lack of resource and poor patient compliance.

CONCLUSIONS

The benefits of SET are well established yet the availability of the service in the UK is poor. The reasons for this are readily identified but have not yet been overcome. Research on novel methods of delivering supervised exercise that mitigates existing barriers, such as home exercise with remote monitoring, should be prioritised to facilitate optimal management for our patients with PAD.

Risk Factors for Blood Transfusions in Primary Anatomic and Reverse Total Shoulder Arthroplasty for Osteoarthritis

BACKGROUND

The purpose of this study was to determine risk factors for blood transfusion in primary anatomic and reverse total shoulder arthroplasty (TSA) performed for osteoarthritis.

METHODS

Patients who underwent anatomic or reverse TSA for a diagnosis of primary osteoarthritis were identified in a national surgical database from 2005 to 2018 by utilizing both CPT and ICD-9/ICD-10 codes. Univariate analysis was performed on the two transfused versus non-transfused cohorts to compare for differences in comorbidities and demographics. Independent risk factors for perioperative blood transfusions were identified via multivariate regression models.

RESULTS

305 transfused and 18,124 nontransfused patients were identified. Female sex (p<0.001), age >85 years (p=0.001), insulin-dependent diabetes mellitus (p=0.001), dialysis dependence (p=0.001), acute renal failure (p=0.012), hematologic disorders (p=0.010), disseminated cancer (p<0.001), ASA ≥ 3 (p<0.001), and functional dependence (p=0.001) were shown to be independent risk factors for blood transfusions on multivariate logistic regression analysis.

CONCLUSION

Several independent risk factors for blood transfusion following anatomic/reverse TSA for osteoarthritis were identified. Awareness of these risk factors can help surgeons and perioperative care teams to both identify and optimize high-risk patients to decrease both transfusion requirements and its associated complications in this patient population. Level of Evidence: III.

Impact of Intraoperative Hypothermia on Transfusion Requirements in Patients With Pelvic and Acetabular Trauma

OBJECTIVES

To explore the association between intraoperative hypothermia and perioperative blood loss and blood transfusion requirements in patients with operative pelvic and acetabular fractures.

DESIGN

Retrospective review.

SETTING

Single, Level 1 trauma center in Atlanta, Georgia.

PATIENTS/PARTICIPANTS

Three hundred seventy-four patients who underwent surgical fixation of an acetabular fracture and/or pelvic ring injury at a single Level 1 trauma center during the years 2013-2017.

MAIN OUTCOME MEASURES

Estimated blood loss during surgery (EBL, mL), drain output (mL) on postoperative day 1 (POD1), and rate of postoperative packed red blood cell (pRBC) transfusion (%).

RESULTS

A significant association was found between intraoperative hypothermia and postoperative transfusion requirement (P = 0.016). The rate of postoperative blood transfusion was 42% for patients with intraoperative hypothermia compared with 28% for controls. In a subgroup analysis of patients presenting with an admission acidosis, the rate of postoperative transfusion was significantly increased to more than 4 times as likely when intraoperative hypothermia was present, even after controlling for admission hemoglobin, Injury Severity Score, and rate of preoperative transfusion (OR 4.4; P = 0.018).

CONCLUSIONS

For patients with pelvic trauma who present with an admission acidosis, intraoperative hypothermia is an independent risk factor for postoperative blood transfusion. This information is clinically important given the modifiable nature of intraoperative patient temperature and the known complications and sequelae associated with increased transfusion rates.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Clinical Effectiveness of Intraoperative Tranexamic Acid Use in Shoulder Surgery: A Systematic Review and Meta-analysis

BACKGROUND

Tranexamic acid (TXA) is widely used across surgical specialties to reduce perioperative bleeding. It has been shown to be effective in spinal surgery and lower limb arthroplasty. Among all languages, there are no systematic reviews or meta-analyses investigating its clinical effectiveness for all types of shoulder surgery.

PURPOSE

To investigate the clinical effectiveness of TXA in all types of shoulder surgery, including open and arthroscopic procedures. To investigate the effect of TXA on bleeding and non-bleeding-related outcomes.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

A protocol for the study was designed and registered with PROSPERO (CRD42020185482). The literature search included the MEDLINE, Embase, PsycINFO, and Cochrane Library databases. All randomized controlled trials evaluating the use of TXA against placebo, in all types of shoulder surgery, were included. Assessments were undertaken for risk of bias and certainty of evidence. The primary outcome was total blood loss. Secondary outcomes included those not directly related to bleeding. Data from comparable outcomes were pooled and analyzed quantitatively or descriptively, as appropriate.

RESULTS

Eight randomized controlled trials were included in the systematic review, and data from 7 of these studies were pooled in the meta-analysis. Pooled analysis demonstrated a significant reduction in 2 of 3 outcomes measuring perioperative bleeding with TXA compared with controls: estimated total blood loss (mean difference, -209.66 mL; 95% CI, -389.11 to -30.21; P = .02) and postoperative blood loss as measured by drain output (mean difference, -84.8 mL; 95% CI, -140.04 to -29.56; P = .003). Hemoglobin reduction was reduced but not statistically significant (mean difference, -0.33 g/dL; 95% CI -0.69 to 0.03; P = .07). This result became significant with sensitivity analysis excluding arthroscopic procedures.

CONCLUSION

This systematic review and meta-analysis indicated that TXA was effective in reducing blood loss in shoulder surgery. Larger randomized controlled trials with low risk of bias for specific surgical shoulder procedures are required.

CLINICAL RELEVANCE

TXA can be used across shoulder surgery to reduced perioperative blood loss. The use of TXA may have other beneficial features, including reduced postoperative pain and reduced operative time.

A single dose of tranexamic acid reduces blood loss after reverse and anatomic shoulder arthroplasty: a randomized controlled trial

BACKGROUND

Hematoma formation and the need for blood transfusions are commonly reported complications after shoulder arthroplasty. Tranexamic acid (TXA) has been widely used in hip and knee arthroplasty to decrease perioperative blood loss. The role of TXA is still being established in shoulder arthroplasty.

MATERIALS AND METHODS

We conducted a double-blind randomized controlled trial comparing intravenous TXA vs. placebo in 60 patients undergoing primary anatomic or reverse shoulder arthroplasty. Of these patients, 29 received a placebo whereas 31 received a single dose of 2 g of intravenous TXA. Patient demographic characteristics, as well as drain tube output, blood loss, hematoma formation, transfusion requirement, length of hospital stay, and pain score, were recorded. Patients were followed up for 12 weeks to assess for complications.

RESULTS

Patients who received TXA had a lower drain tube output at all time points: 41 mL vs. 133 mL at 6 hours, 75 mL vs. 179 mL at 12 hours, and 94 mL vs. 226 mL at 24 hours (P < .001 for all). They also had a higher postoperative hemoglobin (Hb) level (12.3 g/dL vs. 11.4 g/dL, P = .009), lower change in Hb level (1.7 g/dL vs. 2.3 g/dL, P = .011), lower total Hb loss (0.078 g vs. 0.103 g, P = .042), lower blood volume loss (0.55 L vs. 0.74 L, P = .021), higher postoperative hematocrit level (36.7% vs. 34.6%, P = .020), and lower hematocrit change (5.4% vs. 7.6%, P = .022). There was no significant difference in pain score or length of hospital stay, and no patients required a transfusion.

CONCLUSION

A single dose of 2 g of intravenous TXA decreases blood loss and drain tube output in primary anatomic and reverse arthroplasty of the shoulder. No differences were detected in the occurrence of complications, need for transfusion, pain score, or length of hospital stay. With the mounting evidence now available, patients undergoing elective primary shoulder arthroplasty should be given intravenous TXA to decrease perioperative blood loss.

The effect of operative time on early postoperative complications in total shoulder arthroplasty: An analysis of the ACS-NSQIP database

BACKGROUND

Total shoulder arthroplasty has been demonstrated to be an effective treatment for arthritis of the glenohumeral joint. Prior studies have identified longer operative times as a risk factor for complications after numerous types of procedures. We hypothesized that increased operative time, in 20-min intervals, would be associated with complications following total shoulder arthroplasty.

METHODS

Patients undergoing total shoulder arthroplasty from 2006 to 2015 were identified from the ACS-NSQIP database. Patient demographic information, perioperative parameters, and 30-day outcomes were retrieved. Pearson's Chi-square test and multivariate Poisson regression with robust error variance were used to analyze the relationship of operative time and outcomes.

RESULTS

A total of 10,082 patients were included. Multivariate analysis revealed that for each increase in 20 min of operative time, there were significantly increased rates of any complication (relative risk (RR) 1.24, 95% confidence interval (CI) 1.19-1.26), anemia requiring transfusion (RR 1.33, 95%CI 1.26-1.4), peripheral nerve injury (RR 1.88, 95%CI 1.53-2.31), and urinary tract infection (RR 1.24, 95%CI 1.09-1.41).

DISCUSSION

This study indicates that increasing operative time confers increased risk for postoperative complications following total shoulder arthroplasty. We anticipate the results of this manuscript will be used for provider education, policy decision-making, and potentially to derive algorithms that can improve safety and efficiency in total shoulder arthroplasty.

LEVEL OF EVIDENCE

III.

Tranexamic acid use is associated with lower transfusion rates in shoulder arthroplasty patients with preoperative anaemia

BACKGROUND

We evaluate tranexamic acid use in high-risk shoulder arthroplasty patients, hypothesizing that tranexamic acid will decrease transfusion rates in patients with low preoperative haematocrit.

METHODS

A retrospective review of shoulder arthroplasty patients with preoperative anaemia compared those treated with and without perioperative tranexamic acid. Inclusion criterion was any shoulder arthroplasty with a preoperative haematocrit (Hct) <38%. Tranexamic acid was given generally as 1 g intravenously before incision and 1 g during wound closure; topical tranexamic acid was used in cases of contraindication to IV tranexamic acid. Preoperative Hct, postoperative Hct, estimated blood loss, preoperative anticoagulation use, American Society of Anesthesiologist score, transfusion rate and demographic data were compared between groups with and without tranexamic acid.

RESULTS

Of the 435 arthroplasties performed, 109 patients had preoperative Hct < 38% (haemoglobin of 12.7 g/dL); 69 had tranexamic acid perioperatively and 40 did not. Demographics, anticoagulation use, diagnosis, arthroplasty types, estimated blood loss and preoperative Hct were similar between groups. The tranexamic acid group had a higher postoperative Hct, significantly lower transfusion rate and significantly smaller drop in Hct. Hct levels, Hct change and transfusion rate for topical versus intravenous tranexamic acid were not significantly different.

DISCUSSION

Perioperative tranexamic acid in high-risk shoulder arthroplasty patients with preoperative Hct <38% is associated with higher postoperative Hct and lower transfusion rates.

Periprosthetic Infection After Reverse Shoulder Arthroplasty: a Review

PURPOSE OF REVIEW

Periprosthetic infection is a relatively rare but potentially devastating complication after shoulder arthroplasty. The purpose of this article is to review the incidence, diagnosis, prevention, and management of periprosthetic infections after reverse shoulder arthroplasty, with a focus on literature published within the last 5 years.

RECENT FINDINGS

The 2018 International Consensus Meeting on Musculoskeletal Infection provides us with a framework for the diagnosis and management of periprosthetic infections after shoulder arthroplasty. Reverse shoulder arthroplasty has a higher reported rate of infection compared with anatomic total shoulder arthroplasty. Our current diagnostic tests do not appear to be as sensitive when compared with the hip and knee literature. Similar success has been reported with single and two-stage revision protocols, although prospective comparative data are lacking. The significance of unexpected positive cultures during revision arthroplasty remains unclear. We report current diagnostic and therapeutic options for periprosthetic infection after reverse shoulder arthroplasty. Much of the current literature does not distinguish between anatomic and reverse shoulder arthroplasty. Further high-level studies are warranted to refine these definitions and guide management.

Utility of postoperative hemoglobin testing following total shoulder arthroplasty

Background

Identifying areas of excess cost for shoulder arthroplasty patients can play a role in effective health care spending. The purpose of this study was to assess the utility of postoperative complete blood count (CBC) testing after total shoulder arthroplasty (TSA) and identify which patients benefit from routine CBC testing.

Methods

We performed a retrospective review of a cohort of patients who underwent primary TSA from January 2018 through January 2019. All patients in this cohort received tranexamic acid. Patient demographic characteristics and patient-specific risk factors such as American Society of Anesthesiologists score, Elixhauser index, body mass index, smoking status, and coagulopathy history were obtained. Perioperative values including length of surgery, preoperative and postoperative hemoglobin (Hgb) levels, and need for transfusion were also obtained.

Results

This study included 387 TSA patients in the final analysis. Comparison between the cohort requiring transfusion and the cohort undergoing no intervention revealed no statistically significant differences in age, sex, body mass index, American Society of Anesthesiologists score, or Elixhauser index. The group receiving transfusions was found to have significantly lower levels of preoperative Hgb (11.3 g/dL) and postoperative Hgb (8.1 g/dL) (P < .0001). Additionally, the percentages of patients with abnormal preoperative Hgb levels (<12 g/dL) (72.3%) and postoperative day 1 Hgb levels < 9 g/dL (81.8%) were significantly higher in the group receiving transfusions (P < .0001). A multivariate regression model identified an abnormal preoperative Hgb level (<12 g/dL), with an odds ratio of 3.8 (95% confidence interval, 1.5-6.2; P < .001), and postoperative day 1 Hgb level < 9 g/dL, with an odds ratio of 3.3 (95% confidence interval, 0.4-6.1; P < .03), as significant predictors of the risk of transfusion with a sensitivity of 64% and specificity of 96.2% with an area under the curve of 0.87.

Conclusion

Routine CBC testing may not be necessary for patients who receive tranexamic acid and have preoperative Hgb levels > 12 mg/dL and first postoperative Hgb levels > 9 mg/dL. This translates to potential health care cost savings and improves current evidence-based perioperative management in shoulder arthroplasty.

The use of intra-operative tranexamic acid in shoulder surgery: Protocol for a systematic review and meta-analysis

INTRODUCTION

Blood loss is an important consideration in all types of shoulder surgery. Excessive bleeding is associated with increased morbidity. Tranexamic acid (TXA) is an antifibrinolytic agent. It has been demonstrated to be effective in reducing blood loss across multiple surgical specialties. The aim of this systematic review and meta-analysis is to review the literature evaluating clinical outcomes associated with the use of TXA in shoulder surgery.

METHODS

The study protocol was designed and registered prospectively on PROSPERO (International prospective register for systematic reviews). Literature search will include the MEDLINE, EMBASE, PsycINFO, and Cochrane Library databases. Randomised controlled trials (RCTs) evaluating the use of TXA against placebo, in all types of shoulder surgery, will be included. Our primary outcome is total blood loss (ml). Secondary outcomes include patient-reported outcome measures (PROMs), adverse events, and number of blood transfusions required. Risk of bias will be assessed within each study using The Cochrane Risk of Bias Tool 2.0 and the Jadad score. Inconsistency and bias across included studies will be assessed statistically. Data from comparable outcomes will be pooled and analysed quantitatively or descriptively as appropriate.

ETHICS AND DISSEMINATION

No ethical clearances required for this study. This systematic review and meta-analysis will be published in a peer-reviewed journal. It will be presented a various national and international conferences.

Construct validation of machine learning in the prediction of short-term postoperative complications following total shoulder arthroplasty

BACKGROUND

We aimed to demonstrate that supervised machine learning (ML) models can better predict postoperative complications after total shoulder arthroplasty (TSA) than comorbidity indices.

METHODS

The American College of Surgeons-National Surgical Quality Improvement Program database was queried from 2005-2017 for TSA cases. Training and validation sets were created by randomly assigning 80% and 20% of the data set. Included variables were age, body mass index (BMI), operative time, smoking status, comorbidities, diagnosis, and preoperative hematocrit and albumin. Complications included any adverse event, transfusion, extended length of stay (>3 days), surgical site infection, return to the operating room, deep vein thrombosis or pulmonary embolism, and readmission. Each SML algorithm was compared with one another and to a baseline model using American Society of Anesthesiologists (ASA) classification. Model strength was evaluated by calculating the area under the receiver operating characteristic curve (AUC) and the positive predictive value (PPV) of complications.

RESULTS

We identified a total of 17,119 TSA cases. Mean age, BMI, and length of stay were 69.5 ± 9.6 years, 31.1 ± 6.8, and 2.0 ± 2.2 days. Percentage hematocrit, BMI, and operative time were of highest importance in outcome prediction. SML algorithms outperformed ASA classification models for predicting any adverse event (71.0% vs. 63.0%), transfusion (77.0% vs. 64.0%), extended length of stay (68.0% vs. 60.0%), surgical site infection (65.0% vs. 58.0%), return to the operating room (59.0% vs. 54.0%), and readmission (64.0% vs. 58.0%). SML algorithms demonstrated the greatest PPV for any adverse event (62.5%), extended length of stay (61.4%), transfusion (52.2%), and readmission (10.1%). ASA classification had a 0.0% PPV for complications.

CONCLUSION

With continued validation, intelligent models could calculate patient-specific risk for complications to adjust perioperative care and site of surgery.

Blood transfusion rates following shoulder arthroplasty in a high volume UK centre and analysis of risk factors associated with transfusion

AIMS

To determine the blood transfusion rates following shoulder arthroplasty and to establish risk factors associated with increased risk of transfusion.

MATERIALS AND METHODS

All shoulder arthroplasty cases performed between January 2012 and March 2017 in a tertiary upper limb unit were identified. Patients who received perioperative tranexamic acid were excluded. Retrospective review of case notes was completed to identify transfusion rate and risk factors. Univariate and multivariate analysis were performed to analyse the association between risk factors and transfusion rate.

RESULTS

Five hundred and thirty-seven shoulder arthroplasties performed in 474 patients were included. Peri- or post-operative transfusion was required in 21 cases (3.9%). Univariate analysis suggested significant association with age (p = 0.005), female sex (0.015), preoperative haemoglobin/haematocrit (p < 0.001), perioperative drop in haemoglobin (p < 0.001), ASA grade (p < 0.001) and transfusion rate. Only perioperative drop in haemoglobin (p < 0.001) and American Society of Anaesthesiologist score (ASA) grade (p = 0.039) retained significance on multivariable analysis.

CONCLUSIONS

The blood transfusion rate following shoulder arthroplasty was 3.9%. Greater perioperative drop in haemoglobin and higher ASA grade were associated with increased risk of transfusion on multivariate analysis.

Proceedings from the 2018 International Consensus Meeting on Orthopedic Infections: prevention of periprosthetic shoulder infection

The Second International Consensus Meeting on Orthopedic Infections was held in Philadelphia, Pennsylvania, in July 2018. Over 800 international experts from all 9 subspecialties of orthopedic surgery and allied fields of infectious disease, microbiology, and epidemiology were assembled to form a consensus workgroup. The following proceedings on the prevention of periprosthetic shoulder infection come from 16 questions evaluated by delegates from the shoulder section.

Optimizing Preoperative Anemia to Improve Patient Outcomes

Anemia is a decrease in red blood cell mass, which hinders oxygen delivery to tissues. Preoperative anemia has been shown to be associated with mortality and morbidity following major surgery. The preoperative care clinic is an ideal place to start screening for anemia and discussing potential interventions in order to optimize patients for surgery. This article (1) reviews the relevant literature and highlights consequences of preoperative anemia in the surgical setting, and (2) suggests strategies for screening and optimizing anemia in the preoperative setting.

Lack of level I evidence on how to prevent infection after elective shoulder surgery

PURPOSE

Infection is a concern after all orthopedic procedures, including shoulder surgery. This systematic review of literature aimed to determine risk factors for infection as well as the availability and effectiveness of measures utilized to prevent infection after elective shoulder surgery.

METHODS

An electronic database search was performed using MEDLINE (1950-October 2017), EMBASE (1980-October 2017), CINAHL (1982-October 2017), and the Cochrane database to identify studies reporting a risk factor or preventive measure for infection after shoulder surgery.

RESULTS

Fifty-one studies were eligible for inclusion. Risk factors identified for infection were male sex, the presence of hair, receiving an intra-articular cortisone injection within the 3 months prior to surgery, smoking, obesity, and several comorbidities. The only preventive measure with level I evidence was for the use of chlorhexidine wipes for cleansing the skin in the days prior to surgery and for the use of ChloraPrep or DuraPrep over povodine and iodine to prep the skin at the time of surgery. Level II-IV evidence was found for other infection prevention methods such as intravenous antibiotic prophylaxis.

CONCLUSION

There are many risk factors associated with developing an infection after elective shoulder surgery. Many preventive measures have been described which may decrease the risk of infection; however, most lack a high level evidence to support them. The findings of this systematic review are clinically relevant as it has been shown that infection after shoulder surgery results in poor patient-reported outcomes and pose a significant financial burden. As surgeons the goal should be to prevent infections to avoid the morbidity for patients and the increased cost for society.

LEVEL OF EVIDENCE

IV systematic review of literature.

Tranexamic acid in total shoulder arthroplasty and reverse shoulder arthroplasty: a systematic review and meta-analysis

BACKGROUND

The effects of tranexamic acid (TXA) in the setting of shoulder arthroplasty are unclear. The objective of this study was to examine the effects of TXA in reducing the need for blood transfusions and blood loss in patients undergoing primary total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RTSA).

METHODS

We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) and retrospective cohort studies (RCS) that compared outcomes of patients who did and did not receive TXA during TSA or RTSA. We searched Cochrane Central Register of Controlled Trials, EMBASE, and MEDLINE for relevant studies. We assessed the risk of bias of the included studies and calculated pooled risk estimates. The primary outcome was transfusion rate, and secondary outcomes were changes in hemoglobin, estimated total blood loss (ETBL), blood loss via drainage, operative time, hospital stay, overall complications, and thromboembolic events.

RESULTS

We identified 3 RCTs and 3 RCS including 677 patients with 680 shoulders (343 TXA and 337 non-TXA). The random-effects model meta-analysis showed that TXA group had a lower transfusion rate (risk ratio (RR) 0.34, 95% CI 0.14 to 0.79), less change in hemoglobin (mean difference (MD) -0.64 g/dl, 95% CI -0.81 to - 0.46), and reduced ETBL (MD -249.24 ml, 95% CI -338.74 to - 159.74). In patients with RTSA, the TXA group had a lower transfusion rate (RR 0.28, 95% CI 0.14 to 0.79), less ETBL (MD -249.15 ml, 95% CI -426.60 to - 71.70), less change in hemoglobin (MD - 0.64 g/dl, 95% CI -0.86 to - 0.42), and less blood loss via drainage (MD - 84.56 ml, 95% CI -145.72.14 to - 23.39) than non-TXA group.

CONCLUSIONS

The use of TXA in primary shoulder arthroplasty appears safe, and can reduce transfusion rate, changes in hemoglobin, and perioperative total blood loss, especially in patients with RTSA.

LEVEL OF EVIDENCE

Systematic Review and meta-analysis, III.

Safety and patient satisfaction of outpatient shoulder arthroplasty

Background

There is increasing interest in outpatient shoulder arthroplasty (SA); however, the clinical evidence behind this practice is sparse. The purpose of this study was to assess the safety of outpatient SA performed in an ambulatory surgery center and to determine patient factors that are associated with increased risk for perioperative complications or dissatisfaction.

Methods

Patient demographics and operative variables were collected retrospectively for patients undergoing outpatient SA at 2 ambulatory surgery centers with a minimum follow-up of 90 days. Patients completed a postsurgery questionnaire about their experience, satisfaction, pain control, and health care use.

Results

Forty-one anatomic total SAs (n = 32) and reverse SAs (n = 9) with a mean follow-up of 60 weeks (16.4 weeks-3 years) were included. The mean age, body mass index, Charlson Comorbidity Index, and American Society of Anesthesiologists class were 60.6 ± 4.8 years, 31.8 ± 6.6, 2.9 ± 1.9, and 2.3 ± 0.6, respectively. Three (7.3%) minor complications occurred within 90 days of the SA, none before first follow-up. Two patients stayed in the ambulatory surgery center 23-hour observation unit. Thirty-five patients (85.4%) completed the questionnaire, of whom 97.0% (n = 32) were satisfied with the outpatient procedure. Two patients had difficulties with postoperative pain control and were taking chronic narcotic medication before surgery.

Conclusion

Outpatient SA in an ambulatory surgery center is safe with high patient satisfaction and low rates of perioperative complications. Although larger cohorts are required to adequately determine which patients will be appropriate candidates for an outpatient SA, our findings do suggest that patients with a history of preoperative narcotic use may have difficulties or dissatisfaction with outpatient SA.