Increasing severity of anemia is associated with poorer 30-day outcomes for total shoulder arthroplasty

Worsening of anemia increases the risks of complications and prolonged length of stay following revision total shoulder arthroplasty

Background

There are no studies currently in the literature that assesses complications following revision total shoulder arthroplasty (TSA) in patients with varying severity of anemia. The purpose of this study was to determine the impact of preoperative anemia severity on postoperative complications following revision TSA.

Methods

Patients undergoing revision TSA from 2013 to 2019 were queried in a national database. Based on previous studies' definitions of anemia, three subgroups were stratified: patients without anemia (hematocrit >36% for women, hematocrit >39% for men), patients with mild anemia (hematocrit 33% to 36% for women, hematocrit 33% to 39% for men) and patients with moderate to severe anemia (hematocrit <33% for both women and men). In this analysis, patient demographics, comorbidities, and postoperative complications were compared between the three groups.

Results

Of 1559 total patients undergoing revision TSA, 1178 patients (75.6%) did not have anemia, 255 (16.3%) had mild anemia, and 126 (8.1%) had moderate/severe anemia. Following adjustment on multivariate analysis, patients with mild anemia were more likely to have postoperative transfusion and extended length of stay compared to non-anemic patients. Patients with moderate/severe anemia were at increased risk of postoperative transfusion, sepsis, extended length of stay, and reoperation compared to non-anemic patients.

Discussion

From mild anemia to moderate/severe anemia, there was a stepwise increase in the risk of postoperative complications. Our study showed that there is clinical value in the preoperative correction of anemia for these patients as it relates to complications and hospital stay.

Level of Evidence

III.

Preoperative factors predict prolonged length of stay, serious adverse complications, and readmission following operative intervention of proximal humerus fractures: a machine learning analysis of a national database

Background

Proximal humerus fractures are a common injury, predominantly affecting older adults. This study aimed to develop risk-prediction models for prolonged length of hospital stay (LOS), serious adverse complications, and readmission within 30 days of surgically treated proximal humerus fractures using machine learning (ML) techniques.

Methods

Adult patients (age >18) who underwent open reduction internal fixation (ORIF), hemiarthroplasty, or total shoulder arthroplasty for proximal humerus fracture between 2016 and 2021 were included. Preoperative demographic and clinical variables were collected for all patients and used to establish ML-based algorithms. The model with optimal performance was selected according to area under the curve (AUC) on the receiver operating curve (ROC) curve and overall accuracy, and the specific predictive features most important to model derivation were identified.

Results

A total of 7473 patients were included (72.1% male, mean age 66.2 ± 13.7 years). Models produced via gradient boosting performed best for predicting prolonged LOS and complications. The model predicting prolonged LOS demonstrated good discrimination and performance, as indicated by (Mean: 0.700, SE: 0.017), recall (Mean: 0.551, SE: 0.017), accuracy (Mean: 0.717, SE: 0.010), F1-score (Mean: 0.616, SE: 0.014), AUC (Mean: 0.779, SE: 0.010), and Brier score (Mean: 0.283, SE: 0.010) Preoperative hematocrit, preoperative platelet count, and patient age were considered the strongest predictive features. The model predicting serious adverse complications exhibited comparable discrimination [precision (Mean: 0.226, SE: 0.024), recall (Mean: 0.697, SE: 0.048), accuracy (Mean: 0.811, SE: 0.010), F1-score (Mean: 0.341, SE: 0.031)] and superior performance relative to the LOS model [AUC (Mean: 0.806, SE: 0.024), Brier score (Mean: 0.189, SE: 0.010), noting preoperative hematocrit, operative time, and patient age to be most influential. However, the 30-day readmission model achieved the weakest relative performance, displaying low measures of precision (Mean: 0.070, SE: 0.012) and recall (Mean: 0.389, SE: 0.053), despite good accuracy (Mean: 0.791, SE: 0.009).

Conclusion

Predictive models constructed using ML techniques demonstrated favorable discrimination and satisfactory-to-excellent performance in forecasting prolonged LOS and serious adverse complications occurring within 30 days of surgical intervention for proximal humerus fracture. Modifiable preoperative factors such as hematocrit and platelet count were identified as significant predictive features, suggesting that clinicians could address these factors during preoperative patient optimization to enhance outcomes. Overall, these findings highlight the potential for ML techniques to enhance preoperative management, facilitate shared decision-making, and enable more effective and personalized orthopedic care by exploring alternative approaches to risk stratification.

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.

The geriatric nutritional risk index as a strong predictor of adverse outcomes following total shoulder arthroplasty

Background

This study investigates the association between the Geriatric Nutritional Risk Index (GNRI), a simple readily available measure of malnutrition risk, and 30-day postoperative complications following total shoulder arthroplasty (TSA).

Methods

The American College of Surgeons National Surgical Quality Improvement Program database was queried for all patients who underwent TSA between 2015 and 2021. The study population was divided into 3 groups based on preoperative GNRI: normal/reference (GNRI > 98), moderate malnutrition (92 ≤ GNRI ≤ 98), and severe malnutrition (GNRI < 92). Logistic regression analysis was conducted to investigate the connection between preoperative GNRI and postoperative complications.

Results

Compared to normal nutrition, moderate malnutrition was independently significantly associated with a greater likelihood of any complications (odds ratio [OR]: 1.74, 95% confidence interval [CI]: 1.54-1.96; P < .001), blood transfusions (OR: 1.52, 95% CI: 1.09-2.11; P = .013), failure to wean off a ventilator within 48 hours (OR: 3.84, 95% CI: 1.26-11.72; P = .018), wound dehiscence (OR: 15.80, 95% CI: 1.61-155.28; P = .018), nonhome discharge (OR: 1.90, 95% CI: 1.63-2.22; P < .001), readmission (OR: 1.54, 95% CI: 1.19-1.99; P = .001), unplanned reoperation (OR: 1.87, 95% CI: 1.27-2.74; P = .001), length of stay > 2 days (OR: 1.85, 95% CI: 1.63-2.12; P < .001), and mortality (OR: 3.38, 95% CI: 1.32-8.71; P = .011). Severe malnutrition was independently significantly associated with a greater likelihood of any complication (OR: 3.33, 95% CI: 2.80-3.97; P < .001), sepsis (OR: 9.83, 95% CI: 2.94-32.85; P < .001), pneumonia (OR: 3.30, 95% CI: 1.71-6.38; P < .001), unplanned reintubation (OR: 5.77, 95% CI: 2.47-13.51; P < .001), urinary tract infection (OR: 2.15, 95% CI: 1.19-3.87; P = .011), stroke (OR: 3.57, 95% CI: 1.18-10.84; P = .024), blood transfusions (OR: 5.27, 95% CI: 3.86-7.20; P < .001), failure to wean off a ventilator within 48 hours (OR: 7.64, 95% CI: 2.29-25.55; P < .001), Clostridioides difficile infection (OR: 4.17, 95% CI: 1.21-14.32; P = .023), nonhome discharge (OR: 3.56, 95% CI: 2.92-4.34; P < .001), readmission (OR: 2.05, 95% CI: 1.46-2.89; P < .001), length of stay > 2 days (OR: 3.27, 95% CI: 2.73-3.92; P < .001), and mortality (OR: 4.61, 95% CI: 1.51-14.04; P = .007).

Conclusion

Malnutrition based on GNRI is a strong predictor of complications following TSA, with increasing severity related to an increased rate of complications.

Anemia Severity and the Risks of Postoperative Complications and Extended Length of Stay Following Primary Total Elbow Arthroplasty

BACKGROUND

Anemia is a modifiable risk factor that may influence postoperative complications following orthopedic surgical procedures. The objective was to determine the influence of preoperative anemia severity on postoperative complications and length of stay (LOS) following total elbow arthroplasty (TEA).

METHODS

The American College of Surgeons National Surgical Quality Improvement Program registry was queried from 2006 to 2019 for patients undergoing primary TEA. Using the World Health Organization definitions of anemia, patients undergoing TEA were stratified into 3 cohorts: nonanemia (hematocrit >36% for women, >39% for men), mild anemia (hematocrit 33%-36% for women, 33%-39% for men), and moderate-to-severe anemia (hematocrit <33% for both women and men). Patient demographics, surgical time, LOS, and postoperative complications were compared between the groups. A P value <.004 was considered significant.

RESULTS

After exclusion, 589 patients, of whom 369 (62.6%) did not have anemia, 129 (21.9%) had mild anemia, and 91 (15.5%) had moderate/severe anemia, were included. Increasing severity of anemia was associated with an increased average hospital LOS (2.30 vs 2.81 vs 4.91 days, P < .001). There was a statistically significant increase in blood transfusions (1.08% vs 7.75% vs 17.58%, P < .001), major complications (9.21% vs 17.83% vs 34.07%, P < .001), any complications (11.11% vs 23.26% vs 36.26%, P < .001), and extended LOS ≥6 days (6.23% vs 6.98% vs 31.87%, P < .001) with increasing severity of anemia. Multivariate analysis identified moderate-to-severe anemia was significantly associated with major complications and extended LOS (P < .001).

CONCLUSIONS

Preoperative anemia is a modifiable risk factor for medical and surgical complications within 30 days of TEA.

Understanding Medical Optimization for Patients Undergoing Shoulder Arthroplasty

Many surgeons seek to optimize their patients' comorbid conditions preoperatively to reduce postoperative complications. To effectively optimize patients before total shoulder arthroplasty, the surgeon should be familiar with recognizing and treating common medical comorbidities found in an orthopedic patient including anemia, diabetes, malnutrition, cardiovascular conditions, and history of deep venous thrombosis. Screening for depression or other mental illness should also be conducted preoperatively and managed accordingly before surgery. Preoperative opioid use and smoking have significant effects on postoperative outcomes and should be addressed before surgery.

Anemia Severity and the Risks of Postoperative Complications Following Total Ankle Arthroplasty

BACKGROUND

Although studies have demonstrated the effect of anemia severity on postoperative complications after arthroplasties of the shoulder, hip, and knee, no studies have investigated the effect on total ankle arthroplasty (TAA). The objective was to determine the influence of preoperative anemia severity on complications following TAA.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) was queried from 2006 to 2019 for patients undergoing TAA. Utilizing the World Health Organization (WHO) definitions of anemia, patients were stratified into 3 cohorts: nonanemia (hematocrit >36% for women, >39% for men), mild anemia (hematocrit 33%-36% for women, 33%-39% for men), and moderate to severe anemia (hematocrit <33% for both women and men). Demographics, comorbidities, length of stay, and short-term (30-day) postoperative complications were compared between groups. Bivariate analyses, including χ2 and analysis of variance, and multivariable logistical regression were performed.

RESULTS

After exclusion, 1490 patients (1313 nonanemia [88.1%], 154 mild anemia [10.3%], and 23 moderate/severe anemia [1.6%]) were included. Increasing severity of anemia was associated with an increased average hospital length of stay (1.84 vs 2.19 vs 2.78 days, P < .001) and rate of reoperation (0.38% vs 3.90% vs 4.35%, P < .001). There was a statistically significant increase in wound disruptions (0.15% vs 1.95% vs 4.35%, P = .001), minor complications (1.52% vs 4.55% vs 8.70%, P = .008), major complications (1.98% vs 5.84% vs 4.35%, P < .033), and any complications (3.50% vs 10.39% vs 13.04%, P = .001) between groups. Multivariate analysis identified mild and moderate/severe anemia as a predictor of reoperation and extended length of stay (P ≤ .033).

DISCUSSION

Preoperative anemia is a modifiable risk factor for medical and surgical complications within 30 days of TAA. Medical optimization prior to surgical intervention is necessary in patients undergoing TAA.

LEVEL OF EVIDENCE

Level III: Retrospective comparative study.