Predictors of Inpatient Mortality and Systemic Complications in Acetabular Fractures Requiring Operative Treatment

Underweight patients experience higher inpatient complication and mortality rates following acetabular fracture

PURPOSE

Underweight patients experience poor outcomes after elective orthopaedic procedures. The effect of underweight body mass index (BMI) on complications after acetabular fracture is not well-described. We evaluate if underweight status is associated with inpatient complications after acetabular fractures.

METHODS

Adult patients (≥ 18 years) presenting with acetabular fracture between 2015 and 2019 were identified from Trauma Quality Program data. Adjusted odds (aOR) of any inpatient complication or mortality were compared between patients with underweight BMI (< 18.5 kg/m2) and normal BMI (18.5-25 kg/m2) using multivariable logistic regression and stratifying by age ≥ 65 years.

RESULTS

The 1299 underweight patients aged ≥ 65 years compared to 11,629 normal weight patients experienced a 1.2-times and 2.7-times greater aOR of any complication (38.6% vs. 36.6%, p = 0.010) and inpatient mortality (7.9% vs. 4.2%, p < 0.001), respectively. The 1688 underweight patients aged 18-64 years compared to 24,762 normal weight patients experienced a 1.2-times and 1.5-times greater aOR of any inpatient complication (38.9% vs. 34.8%, aOR p = 0.006) and inpatient mortality (4.1% vs. 2.5%, p < 0.001), respectively.

CONCLUSION

Underweight adult patients with acetabular fracture are at increased risk for inpatient complications and mortality, particularly those ≥ 65 years old.

LEVEL OF EVIDENCE

Prognostic Level III.

Predictors of adverse outcomes in elders hospitalised for isolated orthopaedic trauma: a multicentre cohort study

BACKGROUND

Patients >64 years of age now represent more than 51% of injury hospitalisations in Canada. The tools used to identify older patients who could benefit the most from an interdisciplinary approach include complex parameters difficult to collect in the ED, which suggests that better tools with higher accuracy and using items that can be derived from routinely collected data are needed. We aimed to identify variables that are associated with adverse outcomes in older patients admitted to a trauma centre for an isolated orthopaedic injury.

METHODS

We conducted a multicentre retrospective cohort study between 1 April 2013 and 31 March 2019 on older patients hospitalised with a primary diagnosis of isolated orthopaedic injury (n=19 928). Data were extracted from the provincial trauma registry (Registre des traumatismes du Québec). We used multilevel logistic regression to estimate the associations between potential predictors and adverse outcomes (extended length of stay, mortality, complications, unplanned readmission and adverse discharge destination).

RESULTS

Increasing age, male sex, specific comorbidities, type of orthopaedic injuries, increasing number of comorbidities, severe orthopaedic injury, head injuries and admission in the year before the injury were all significant predictors of adverse outcomes.

CONCLUSION

We identified eight predictors of adverse outcomes in patients >64 years of age admitted to a trauma centre for orthopaedic injury. These variables could eventually be used to develop a clinical decision rule to identify elders who may benefit the most from interdisciplinary care.

Early Postoperative Vital Signs Predict Subsequent 90-Day Mortality After Pancreaticoduodenectomy

BACKGROUND

While complication rates after pancreaticoduodenectomy (PD) have improved in recent decades, surgical-related death remains a possibility. Postoperative vital signs offer an untapped opportunity to identify predictors of 90-day mortality.

METHODS

We performed a retrospective chart review interrogating postoperative day (POD 0-7) vital sign measurements from patients undergoing a PD at Thomas Jefferson University Hospital, Philadelphia, PA (2009-2014). Five specific vital signs were examined as predictors of mortality: temperature, heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), and mean arterial pressure. Statistical analyses and logic algorithms were employed to rank vital sign parameters, with cut-points, to identify those associated with the highest risk of mortality and the most clinical relevance.

RESULTS

In our cohort, 11/750 patients (1.5%) died within 30 days of surgery, and 21/750 patients (2.8%) died within 90 days of surgery. Vital sign perturbations associated with the highest risk of mortality included mean SBP < 95 mmHg on POD 7 (odds ratio 51.46) and the mean temperature < 96.9℉ on POD 3 (odds ratio 22.63) with specificities exceeding 99%. The most clinically relevant predictor (i.e., a higher sensitivity) was DBP < 60.5 mmHg on POD 7 (odds ratio 12.45, sensitivity of 75%). These predictors remained statistically significant in a multivariable model.

CONCLUSIONS

Vital signs can be more effectively utilized to predict 90-day mortality after pancreaticoduodenectomy. Values beyond an informative threshold can potentially identify patients for more intensive monitoring with a goal of rescuing patients and preventing death.

Cirrhosis is independently associated with complications and mortality following operative treatment of acetabular fractures

INTRODUCTION

Patients with cirrhosis are at higher risk for morbidity after injury. Acetabular fractures represent a highly morbid injury pattern. Few studies have specifically examined an effect of cirrhosis on risk of complications after acetabular fracture. We hypothesized that cirrhosis is independently associated with increased risk of inpatient complications following operative treatment of acetabular fractures.

METHODS

Adults patients with acetabular fracture who underwent operative treatment were identified from Trauma Quality Improvement Program data from 2015 to 2019. Patients with and without cirrhosis were matched on a propensity score predicting cirrhotic status and inpatient complications based on patient, injury, and treatment characteristics. The primary outcome was overall complication rate. Secondary outcomes included serious adverse event rate, overall infection rate, and mortality.

RESULTS

After propensity score matching, 137 cirrhosis+ and 274 cirrhosis- remained. No significant differences existed in observed characteristics after matching. Compared to cirrhosis- patients, cirrhosis+ patients experienced 43.4% (83.9 vs 40.5%, p < 0.001) greater absolute risk difference of any inpatient complication, 29.9% (51.8 vs 21.9%, p < 0.001) greater absolute risk difference of serious adverse events, 28.5% (41.6 vs 13.1%, p < 0.001) greater absolute risk difference of any infection, and 2.9% (2.9% vs 0.0%, p = 0.02) greater absolute risk difference of inpatient mortality.

CONCLUSION

Cirrhosis is associated with higher rates of inpatient complications, serious adverse events, infection, and mortality among patients undergoing operative repair of acetabular fracture.

LEVEL OF EVIDENCE

Prognostic Level III.

Patients of Obese Representation Require Longer Operative Times: An Evaluation of Acetabular and Pelvic Ring Operative Duration

Recent literature has determined that operative times for the obese population are greater for both elective and nonelective orthopedic procedures. If time allotted for a given surgical procedure is used as a measure of procedural difficulty, then consideration can be given for using an additional coding modifier (i.e., Modifier 22) for the increased skill and effort associated with longer procedures. A retrospective chart review was conducted on all patients who underwent surgical treatment for an acute fracture about the pelvis at an urban level-1 trauma center from October 1, 2010 through October 31, 2018. After allowing for both inclusion and exclusion criteria, 102 patients with acetabular fractures and 55 patients with pelvic ring injuries were included in this investigation. The obese population within the acetabular fracture cohort demonstrated significantly longer mean times for the duration of surgery, total time in spent in the operating room, and duration under anesthesia (P values of 0.038, 0.05 and 0.035, respectively). Similar results were observed with the pelvic ring injury cohort, with significantly longer procedural times (P = 0.019), total time in the operating room (P = 0.034), and total duration under anesthesia (P = 0.0395). A trend towards a greater risk of infection was found in obese patients (7%) when compared with nonobese patients (1.6%) within the acetabular fracture subset (P = 0.093). Operative duration for acetabular fractures and pelvic ring injuries is significantly longer in the obese population. Furthermore, this indicates that a Modifier 22 may be justified for the surgical treatment of these injuries in the obese and morbidly obese patient populations.

The effect of obesity on complications following isolated posterior cruciate ligament reconstruction

BACKGROUND

This study assessed the risk of 30-day complications for obese patients compared to non-obese patients undergoing isolated posterior cruciate ligament (PCL) reconstruction.

METHODS

From 2006 to 2019, the National Surgical Quality Improvement Program database was queried for patients undergoing isolated PCL reconstruction. Two patient cohorts were defined: patients with obesity (BMI ≥ 30.0 kg/m²) and patients without obesity (BMI < 30 kg/m²). Patients' baseline demographics and medical comorbidities were collected and compared between the cohorts. Postoperative outcomes were assessed using bivariate and multivariate analyses.

RESULTS

414 patients underwent PCL reconstruction. 258 patients (62.3%) were non-obese and 156 patients (37.7%) were obese. Obese patients were more likely to be older, have a higher American Society of Anesthesiologists classification, and have hypertension compared to non-obese patients (p < 0.05 for all). The rates of superficial surgical site infections, wound dehiscence, transfusion necessity, deep vein thrombosis, and re-operation were not significant between obese and non-obese patients. Following adjustment on multivariate analyses, relative to patients without obesity, those with obesity had an increased risk of admission to the hospital overnight (OR 1.66; p = 0.048).

CONCLUSIONS

To our knowledge, this is the first study to evaluate obesity on complications in isolated PCL reconstruction. Our results and the heterogeneity in the literature indicate that obesity significantly impacts the rates of hospital readmission for PCL reconstruction. Therefore, surgeons should carefully weigh the risks and benefits of operating on obese patients and plan accordingly as obese patients may require postoperative hospital admission after PCL reconstruction.

LEVEL OF EVIDENCE

III.

Survival bias may explain the appearance of the obesity paradox in hip fracture patients

Patients with low-energy hip fractures do not follow the obesity paradox as previously reported. In datasets where injury mechanism is not available, the use of age >50 years (as opposed to commonly used >65 years) as a surrogate for a low-energy hip fracture patients may be a more robust inclusion criterion.  PURPOSE: In elderly patients with a hip fracture, limited data suggests that obese patients counterintuitively have improved survival compared to normal-weight patients. This "obesity paradox" may be the byproduct of selection bias. We hypothesized that the obesity paradox would not apply to elderly hip fracture patients.

METHODS

The National Surgical Quality Improvement Project dataset identified 71,685 hip fracture patients ≥50 years-of-age with complete body mass index (BMI) data that underwent surgery. Patients were stratified into under and over 75-year-old cohorts (n=18,956 and 52,729, respectively). Within each age group, patients were stratified by BMI class and compared with respect to preoperative characteristics and 30-day mortality. Significant univariate characteristics (p<0.1) were included in multivariate analysis to determine the independent effect of obesity class on 30-day mortality (p<0.05).

RESULTS

Multivariate analysis of <75-year-old patients with class-III obesity were more likely to die within 30-days than similarly aged normal-weight patients (OR 1.91, CI 1.06-3.42, p=0.030). Multivariate analysis of ≥75-year-old overweight (OR 0.69, CI 0.62-0.77, p<0.001), class-I obese (OR 0.62, CI 0.51-0.74, p<0.001), or class-II obese (OR=0.69, CI 0.50-0.95, p=0.022) patients were less likely to die within 30-days when compared to similarly aged normal-weight patients.

CONCLUSIONS

Our data suggest that obesity is a risk factor for mortality in low-energy hip fracture patients, but the appearance of the "obesity paradox" in elderly hip fracture patients results from statistical bias that is only evident upon subgroup analysis.

Three-dimensional printing combined with open reduction and internal fixation versus open reduction and internal fixation in the treatment of acetabular fractures: A systematic review and meta-analysis

PURPOSE

This meta-analysis compared the clinical outcome of three-dimensional (3D) printing combined with open reduction and internal fixation (ORIF) to traditional ORIF in the treatment of acetabular fractures.

METHODS

We searched the Cochrane Library, PubMed, Embase, VIP database, CNKI, and Wanfang database with keywords "acetabular fracture", "3D printing", "three-dimensional printing", "open reduction and internal fixation", "Acetabulum", "Acetabula" from January 2000 to March 2020. Two reviewers independently selected articles, extracted data, assessed the quality evidence and risk bias of included trials using the Cochrane Collaboration' s tools and/or Newcastle-Ottawa scale. When the two analysts had different opinions, they would ask the third analyst for opinion. Randomized controlled trials or retrospective comparative studies of 3D printing combined with ORIF (3D printing group) versus traditional ORIF (conventional group) in the treatment of acetabular fractures were selected. The data of operation time, intraoperative blood loss, intraoperative fluoroscopy times, incidence of complications, excellent and good rate of Matta score for reduction, and excellent and good rate of hip function score were extracted. Stata14.0 statistical software was used for data analysis.

RESULTS

Altogether 9 articles were selected, including 5 randomized controlled trials and 4 retrospective studies. A total of 467 patients were analyzed, 250 in the conventional group, and 217 in the 3D printing group. The operation time in the 3D printing group was less than that in the conventional group and the difference was statistically significant (standardized mean difference (SMD) = -1.19, 95% CI: -1.55 to -0.82, p < 0.05). The intraoperative bleeding volume of the 3D printing group was significantly lower than that of the conventional group (SMD = -1.08, 95% CI: -1.65 to -0.51, p < 0.05). The fluoroscopy times were less in the 3D printing group than in the conventional group and the difference was statistically significant (SMD = -1.64, 95% CI: -2.35 to -0.93, p < 0.05). The total incidence of complications in the 3D printing group was significantly lower than that in the conventional group (OR = 0.43, 95% CI: 0.24-0.79, p < 0.05). There was no significant difference in the excellent and good rate of Matta score for reduction between the two groups (OR = 0.60, 95% CI: 0.34-1.06, p > 0.05). There was no significant difference in the excellent and good rate of hip function score at the end of postoperative follow-up between the two groups (OR = 0.84, 95% CI: 0.46-1.56, p > 0.05), but the follow-up time varies from 6 months to 40 months.

CONCLUSION

Compared with traditional ORIF, 3D printing combined with ORIF has certain advantages in terms that 3D printing not only helps surgeons to understand acetabular fractures more intuitively, but also effectively reduces operation time, intraoperative blood loss, intraoperative fluoroscopy times, and postoperative complications. However, there were no significant differences in the excellent and good rate of Matta score for reduction and the excellent and good rate of hip function score at the end of follow-up.

Is Obesity Associated With an Increased Risk of Complications After Surgical Management of Acetabulum and Pelvis Fractures? A Systematic Review

Background:

When considering surgical fixation of acetabulum and pelvis fractures in patients with obesity, a thorough understanding of the risks of potential complications is important. We performed a systematic review to evaluate whether obesity is associated with an increased risk of complications after surgical management of acetabulum and pelvis fractures.

Methods:

We searched PubMed/MEDLINE, EMBASE, and the Cochrane Library for studies published through December 2020 that reported the effect of increased body mass index (BMI) or obesity on the risk of complications after surgical treatment of acetabulum and pelvis fractures.

Results:

Fifteen studies were included. Eight of the 11 studies that included infection or wound complication as end points found that increased BMI or some degree of obesity was a significant risk factor for these complications. Two studies found that obesity was significantly associated with loss of reduction. Other complications that were assessed in a few studies each included venous thromboembolism, nerve palsy, heterotopic ossification, general systemic complications, and revision surgery, but obesity was not clearly associated with those outcomes.

Conclusions:

Obesity (or elevated BMI) was associated with an increased risk of complications—infection being the most commonly reported—after surgical management of acetabulum and pelvis fractures, which suggests the need for increased perioperative vigilance.

High- Versus Low-Energy Acetabular Fracture Outcomes in the Geriatric Population

Introduction:

High-energy mechanisms of acetabular fracture in the geriatric population are becoming increasingly common as older adults remain active later in life. This study compared outcomes for high- versus low-energy acetabular fractures in older adults.

Materials and Methods:

We studied outcomes of 22 older adults with acetabular fracture who were treated at a level-I trauma center over a 4-year period. Fourteen patients were categorized as low-energy mechanism of injury, and 8 were identified as a high-energy mechanism. We analyzed patient demographics with univariate logistic regressions performed to assess differences in high- and low-energy group as well as patient characteristics compared with surgical outcomes.

Results:

Most high-energy mechanisms were caused by motor vehicle collision (n = 4, 50.0%), with most having posterior wall fractures (50.0%). Among patient characteristics, the mechanism of injury, hip dislocation, fracture types, and fracture gap had the largest differences between energy groups effect size (ES: 2.45, 1.43, 1.36, and 0.83, respectively). The high-energy group was more likely to require surgery (odds ratio [OR] = 2.80, 95% CI: 0.26-30.70), develop heterotopic bone (OR = 4.33, 95% CI: 0.33-57.65), develop arthritis (OR = 3.60, 95% CI: 0.45-28.56), and had longer time to surgery (mean = 4.8 days, standard deviation [SD] = 5.8 days) compared to low-energy group (mean = 2.5 days, SD = 2.3 days).

Discussion:

The results of this case series confirm previous findings that patients with high-energy acetabular fractures are predominantly male, younger, and have fewer comorbidities than those who sustained low-energy fractures. Our results demonstrate that the majority of the high-energy fracture patients also suffered a concurrent hip dislocation with posterior wall fracture and experienced a longer time to surgery than the low-energy group.

Conclusion:

Geriatric patients who sustained high-energy acetabular fractures tend to have higher overall rates of complications, including infection, traumatic arthritis, and heterotopic bone formation when compared with patients with a low-energy fracture mechanism.

The Effect of an Abnormal BMI on Orthopaedic Trauma Patients: A Systematic Review and Meta-Analysis

Aims: The aim of this systemic review is to identify the complications that arise in operating on orthopaedic trauma patients with an abnormal body mass index (BMI). Materials and Methods: Systematic literature search using a combination of MESH subject headings and free text searching of Medline, Embase, SCOPUS and Cochrane databases in August 2019. Any orthopaedic injury requiring surgery was included. Papers were reviewed and quality assessed by two independent reviewers to select for inclusion. Where sufficiently homogenous, meta-analysis was performed. Results: A total of 26 articles (379,333 patients) were selected for inclusion. All complications were more common in those with a high BMI (>30). The odds ratio (OR) for high BMI patients sustaining post-operative complication of any type was 2.32 with a 23% overall complication rate in the BMI > 30 group, vs. 14% in the normal BMI group (p < 0.05). The OR for mortality was 3.5. The OR for infection was 2.28. The OR for non-union in tibial fractures was 2.57. Thrombotic events were also more likely in the obese group. Low BMI (<18.5) was associated with a higher risk of cardiac complications than either those with a normal or high BMI (OR 1.56). Conclusion: Almost all complications are more common in trauma patients with a raised BMI. This should be made clear during the consent process, and strategies developed to reduce these risks where possible. Unlike in elective surgery, BMI is a non-modifiable risk factor in the trauma context, but an awareness of the complications should inform clinicians and patients alike. Underweight patients have a higher risk of developing cardiac complications than either high or normal BMI patient groups, but as few studies exist, further research into this group is recommended.

Body Mass Index Screening in Knee Arthroscopy: An Analysis Using the National Surgical Quality Improvement Database

PURPOSE

To analyze patients undergoing knee arthroscopy stratified by body mass index (BMI) and assess the tradeoffs in complications avoided versus access to care that occur when instituting BMI eligibility criteria.

METHODS

The National Surgical Quality Improvement Program (NSQIP) database was used to identify patients who underwent knee arthroscopy from 2015 to 2016. Patients were categorized by BMI, and differences in complication rates between BMI categories were assessed. The positive predictive value (PPV) was calculated for various BMI cutoffs, with further analysis performed to identify the number of surgeries that would be denied to avoid a single complication.

RESULTS

There were 44,153 knee arthroscopy cases identified and an overall complication rate of 1.7%. There was no significant difference found in major complication rate between those with a BMI >40 kg/m² and those with a BMI <40 (1.7% vs 1.7%, P = .70), and no significant associations between increased complications and a higher BMI were found on binary logistic regression. Instituting a BMI cutoff of 40 has a PPV of 1.7% and would result in the avoidance of 11% of complications while denying 10% of otherwise uncomplicated surgeries. This cutoff would deny 57 surgeries for every complication avoided.

CONCLUSION

In patients undergoing knee arthroscopy, this study failed to detect a significant increased risk of major complications associated with having a BMI >40. The institution of BMI eligibility cutoffs would result in low PPVs and a high number of denials for surgery that would otherwise be complication free.

LEVEL OF EVIDENCE

Level IV, retrospective cohort-based database study.

Sarcopenia Is Predictive of 1-Year Mortality After Acetabular Fractures in Elderly Patients

OBJECTIVES

To determine whether sarcopenia is an independent predictor of mortality in geriatric acetabular fractures.

DESIGN

Retrospective cohort.

SETTING

American College of Surgeons Level I trauma center.

PATIENTS/PARTICIPANTS

One hundred and forty-six patients over the age 60 with acetabular fractures treated at our institution over a 12-year period.

MAIN OUTCOME MEASUREMENTS

The primary outcome was 1-year mortality, collected using the Social Security Death Index. We used the psoas:lumbar vertebral index (PLVI), calculated using the cross-sectional area of the L4 vertebral body and the left and right psoas muscles, to assess for sarcopenia.

RESULTS

Using a multivariate logistic regression model, we found that low PLVI was associated with increased 1-year mortality (P = 0.046) when controlling for age, gender, Charlson Comorbidity Index, Injury Severity Score (ISS), smoking status, and associated pelvic ring injury. Increasing age and ISS also showed a relationship with 1-year mortality in this cohort (P < 0.001, P < 0.001, respectively). We defined sarcopenia as those patients in the lowest quartile of PLVI. The mortality rate of this cohort was 32.4%, compared with 11.0% in patients without sarcopenia (odds ratio 4.04; 95% confidence interval 1.62-10.1). Age >75 years, ISS >14, and sarcopenia had 1-year mortality rates of 37.1%, 30.9%, and 32.4%, respectively. In patients with all 3 factors, the mortality rate was 90%.

CONCLUSION

Sarcopenia is an independent risk factor for 1-year mortality in elderly patients with acetabular fractures. This study highlights the importance of objective measures to assess frailty in elderly patients who have sustained fractures about the hip and pelvis.

LEVEL OF EVIDENCE

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