Pediatric obesity is associated with short-term risks after pelvic osteotomy

Obesity Increases Risk for Wound Complications After Pediatric Foot Surgery: A Retrospective Cohort Review Using the NSQIP-Pediatric Database

BACKGROUND

As the incidence of childhood obesity continues to rise, so too does the number of obese children who undergo foot surgery. As the childhood obesity epidemic rolls on, pediatric orthopaedic surgeons will encounter obese patients with even greater frequency. Therefore, a comprehensive understanding of the risks associated with obesity is valuable to maximize patient safety. The purpose of this study is to retrospectively evaluate the relationship between obesity and postoperative outcomes in patients undergoing pediatric foot surgery across multiple institutions using a large national database.

METHODS

Pediatric patients who had undergone foot surgery were retrospectively identified using the American College of Surgeons 2012-2017 Pediatric National Surgical Quality Improvement (ACS-NSQIP-Pediatric) database by cross-referencing reconstructive foot-specific CPT codes with ICD-9/ICD-10 diagnosis codes. Center for Disease Control BMI-to-age growth charts were used to stratify patients into normal-weight and obese cohorts. Univariate and multivariate analyses were performed to describe and assess outcomes in obese compared with normal-weight patients.

RESULTS

Of the 3924 patients identified, 1063 (27.1%) were obese. Compared with normal-weight patients, obese patients were more often male (64.7% vs. 58.7%; P =0.001) and taller (56.3 vs. 51.3 inches; P <0.001). Obese patients had significantly higher rates of overall postoperative complications (3.01% vs. 1.32%; P =0.001) and wound dehiscence (1.41% vs. 0.59%; P =0.039). Multivariate analysis found that obesity was an independent predictor of both wound dehiscence [adjusted odds ratio (OR)=2.16; 95% CI=1.05-4.50; P =0.037] and surgical site infection (adjusted OR=3.03; 95% CI=1.39-6.61; P =0.005). Subgroup analysis of patients undergoing clubfoot capsular release procedures identified that obese patients had a higher rate of wound dehiscence (3.39% vs. 0.51%; P =0.039) compared with normal-weight patients. In multivariate analysis, obesity was an independent predictor of dehiscence (adjusted OR=5.71; 95% CI=1.46-22.31; P =0.012) in this procedure group. There were no differences in complication rates between obese and normal-weight patients in a subgroup analysis of tarsal coalition procedures or clubfoot tibialis anterior tendon transfer procedures.

CONCLUSION

Obese children undergoing foot surgery had higher overall complication rates, wound complications, and surgical site infections compared with children of normal weight. As the incidence of childhood obesity continues to rise, this information may be useful in assessing and discussing surgical risks with patients and their families.

LEVEL OF EVIDENCE

III.

Effect of Obesity on Surgical Outcomes and Complication Rates in Pediatric Patients: A Comprehensive Systematic Review and Meta-Analysis

Obesity is one of the primary public health problems faced by children. The increased incidence of obesity in the pediatric population poses significant challenges during and after surgical procedures. This systematic review and meta-analysis aimed to understand to what extent obesity is to surgical complications in pediatric patients. A systematic database search of PubMed, Web of Science, Scopus, and Science Direct was performed in June 2023. According to the inclusion and exclusion criteria, two evaluators independently conducted literature screening, data extraction, and quality evaluation of the retrieved literature. The Newcastle-Ottawa Scale score was used for quality evaluation, and a meta-analysis was performed using Review Manager software 5.4.1. A total of 1,170 relevant articles were initially identified, and 20 articles were finally included for data extraction and meta-analysis. The results of the meta-analysis showed that compared with normal-weight individuals, obese pediatric patients had a higher risk of developing surgical site infection (SSI) (relative risk (RR) = 1.63; 95% confidence interval (CI) = 1.33-2.00), wound dehiscence (RR = 2.01; 95% CI = 1.24-3.23), and underwent procedures that were 11.32 minutes longer (95% CI = 5.36-17.29). There were no differences in bleeding requiring transfusion, deep venous thromboembolism, postoperative abscess rate, and length of stay. Obese pediatric patients have a higher risk of SSI and dehiscence, along with a longer operative time. The established risks in obese adults undergoing surgery suggest a similar risk for obese pediatric patients. The findings of this study hold significant implications for clinical practice, suggesting the potential for additional measures to prevent surgical complications in children.

Rates of readmission and reoperation following pelvic osteotomy in adolescent patients: a database study evaluating the pediatric health information system

Rates and reasons for readmission and reoperation following adolescent pelvic osteotomy are not well-defined. This study aimed to (1) determine 30-day and 90-day readmission rates and the 2-year reoperation rate after pelvic osteotomy in adolescents and (2) identify reasons for readmission and reoperation. The Pediatric Health Information System database was queried between 10 January 2015 and 1 January 2020 for patients meeting selected International Classification of Diseases (ICD-10) procedure and diagnosis codes relating to pelvic osteotomies. Readmission rates were calculated within 30 and 90 days from index osteotomy. The ipsilateral reoperation rate was calculated within 2 years from index osteotomy. Reasons for these outcomes were identified. Univariate and multivariate analyses were utilized to identify readmission risks. Of 1475 patients, 5.4% and 9.2% were readmitted within 30 and 90 days, respectively. Reasons for readmission were consistent across both time points and included infection, hip-related orthopedic conditions and neurologic conditions. Younger age (OR 0.83, 95% CI: 0.76, 0.89; P < 0.0001) and male sex (OR 1.77, 95% CI: 1.23–2.54; P = 0.002) were predictive of readmission within 90 days. The 2-year reoperation rate was 32.1%, of which 79.8% underwent reoperation for hardware removal, 17.7% for revision and 1.3% for hip replacement. 30-day readmission, 90-day readmission and 2-year reoperation rates after adolescent pelvic osteotomy were 5.4%, 9.2% and 32.1%, respectively. Younger age and male sex were predictive of 90-day readmission. Most ipsilateral reoperations were for hardware removal. Understanding readmission and reoperation risks following pelvic osteotomy can benefit patient counseling and improve expectations of post-surgical outcomes.

Level of Evidence:

IV, case series.

Postoperative Outcomes in Diabetic Pediatric Orthopaedic Surgery Patients: A National Database Study

BACKGROUND

Although the negative effects of diabetes mellitus (DM) on operative outcomes in orthopaedic surgery is a well-studied topic in adults, little is known about the impact of this disease in children undergoing orthopaedic procedures. This study aims to describe the postoperative complications in pediatric orthopaedic surgery patients with DM.

METHODS

Pediatric patients with insulin-dependent diabetes mellitus (IDDM) and non-insulin-dependent diabetes mellitus (NIDDM) were retrospectively identified while selecting for elective orthopaedic surgery cases from the American College of Surgeons National Surgical Quality Improvement Program Pediatric (ACS-NSQIP-Pediatric) database from 2012 to 2015. Univariate and multivariate analyses were performed to describe and assess outcomes when compared with nondiabetic patients undergoing similar procedures.

RESULTS

Of the 17,647 patients identified, 105 (0.60%) had DM. Of those 105 patients, 68 had IDDM and 37 had NIDDM. The median age of DM patients was 13.8 years (11.9 to 15.5 y) and 37.1% of all DM patients were male. Comparing DM to non-DM patients, no significant differences were noted in the overall complications (1.4% vs. 1.9%, P>0.05) or reoperation rates (1.2% vs. 1.9%, P>0.05); however, DM patients did have a higher occurrence of unplanned readmissions (4.8% vs. 1.7%; P=0.037). Diabetic patients were statistically more likely to have an unplanned readmission with 30 days (adjusted odds ratio=3.34; 95% confidence interval=1.21-9.24, P=0.021). when comparing IDDM to NIDDM, there was no significant difference in outcomes. Comparing NIDDM to non-DM patients, there was an increased incidence of nerve injury (5.6% vs. 0.18%; P=0.023), readmission rate (11.1% vs. 1.8%; P=0.043), and reoperation rate (11.1% vs. 1%; P=0.013) in nonspinal procedures and an increased incidence of pulmonary embolism (10% vs. 0%; P=0.002) in spinal arthrodesis procedures. NIDDM predicted longer hospital stays (adjusted odds ratio=1.49; 95% confidence interval=1.04, 2.14; P=0.028) compared with nondiabetic patients in extremity deformity procedures.

CONCLUSIONS

The 30-day complication, reoperation, and readmission rates for NIDDM patients were higher than that of non-DM patients. Furthermore, NIDDM is a predictor of longer hospital stays while DM is a predictor of unplanned readmissions. No statistical differences were noted when comparing outcomes of NIDDM to IDDM patients.

LEVEL OF EVIDENCE

Level III.

Tranexamic acid reduces blood loss in paediatric proximal femoral and/or pelvic osteotomies

PURPOSE

Proximal femoral and/or pelvic osteotomies (PFPO) are associated with significant blood loss, which can be harmful, especially in paediatric patients. Therefore, considering methods to reduce blood loss is important. The purpose of this study was to examine the efficacy of tranexamic acid (TXA) in reducing intraoperative estimated blood loss (EBL) in paediatric patients undergoing a PFPO.

METHODS

Paediatric patients who had a PFPO between 2014 and 2019 were retrospectively reviewed. Outcome measures included patient demographics, TXA use (none, preoperative and/or intraoperative bolus, pump), EBL, transfusion rate and thromboembolic complications. Univariate and multivariate analyses were performed to assess associations between investigated outcome measures and EBL.

RESULTS

A total of 340 PFPO (263 patients) were included. Mean age at surgery was 8.0 years (sd 4.3). In all, 269 patients received no TXA, 20 had a preoperative bolus, 43 had an intraoperative bolus and eight patients had other TXA regimes (preoperative and intraoperative bolus or pump). Overall, mean blood loss was 211 ml (sd 163). Multivariate analysis showed significant associations between higher EBL and higher age at surgery, male sex, higher body mass index and longer procedure time. There was a significant association between lower EBL and a preoperative TXA bolus: 66 ml (33%) less EBL compared with patients without TXA (95% confidence interval -129 to -4; p = 0.04). No thromboembolic complications were reported in any of the studied patients.

CONCLUSION

Preoperative TXA administration is associated with a decreased EBL in PFPO. No thromboembolic events were reported. Administering TXA preoperatively appears to be effective in paediatric patients undergoing a PFPO.

LEVEL OF EVIDENCE

Level III - retrospective comparative study.

Pediatric obesity and perioperative medicine

PURPOSE OF REVIEW

Childhood obesity is a public health emergency that has reached a pandemic level and imposed a massive economic burden on healthcare systems. Our objective was to provide an update on (1) challenges of obesity definition and classification in the perioperative setting, (2) challenges of perioperative patient positioning and vascular access, (3) perioperative implications of childhood obesity, (3) anesthetic medication dosing and opioid-sparing techniques in obese children, and (4) research gaps in perioperative childhood obesity research including a call to action.

RECENT FINDINGS

Despite the near axiomatic observation that obesity is a pervasive clinical problem with considerable impact on perioperative health, there have only been a handful of research into the many ramifications of childhood obesity in the perioperative setting. A nuanced understanding of the surgical and anesthetic risks associated with obesity is essential to inform patients' perioperative consultation and their parents' counseling, improve preoperative risk mitigation, and improve patients' rescue process when complications occur.

SUMMARY

Anesthesiologists and surgeons will continue to be confronted with an unprecedented number of obese or overweight children with a high risk of perioperative complications.