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Momenzadeh K, Yeritsyan D, Mortensen S, Kheir N, Khak M, Caro D, Kahe F, Abbasian M, Mo C, McNichol M, Paschos N, Nazarian A. While the Incidence of Venous Thromboembolism After Shoulder Arthroscopy Is Low, the Risk Factors Are a Body Mass Index Greater than 30 and Hypertension. Arthrosc Sports Med Rehabil 2024; 6:100815. [PMID: 38149088 PMCID: PMC10749995 DOI: 10.1016/j.asmr.2023.100815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 09/20/2023] [Indexed: 12/28/2023] Open
Abstract
Purpose This study aims to determine the overall incidence of venous thromboembolism (VTE) following shoulder arthroscopy and to define potential risk factors associated with its development that may help define guidelines for the use of thromboprophylaxis. Methods A systematic review was performed using PubMed, Embase, Web of Science, CINAHL, and Cochrane databases per PRISMA guidelines. The search terms consisted of variations of "Venous Thromboembolism" and "Shoulder Arthroscopy." Information regarding arthroscopy indication, risk factors, outcomes, and patient demographics was recorded and analyzed, and pooled odds ratios were reported for each variable. Results Six hundred eighty-five articles were identified in the initial search, and 35 articles reported DVT, PE, or VTE incidence following shoulder arthroscopy. Seventeen nonoverlapping articles with a unique patient population incidence rates. Four articles were then used for subgroup meta-analysis. The incidence rate of VTE was 0.24%, ranging from 0.01% to 5.7%. BMI >30 (OR = 1.46; 95% CI = [1.22, 1.74]; I2 = 0%) and hypertension (OR = 1.64; 95% CI = [1.03, 2.6]; I2 = 75%) were significant risk factors (P < .05) for developing VTE following shoulder arthroscopy. Diabetes (OR = 1.2; 95% CI = [0.97, 1.48]; I2 = 0%), insulin-dependent diabetes (OR = 5.58; 95% CI = [0.12, 260.19]; I2 = 85%), smoking (OR = 1.04; 95% CI = [0.79, 1.37]; I2 = 12%), male sex (OR = 0.95; 95% CI = [0.49, 1.85]; I2 = 86%) and age over 65 (OR = 4.3; 95% CI = [0.25, 72.83]; I2 = 85%) were not associated with higher VTE risk. Conclusion The VTE incidence following shoulder arthroscopy is low at 0.24%. Patients with BMI >30 and hypertension are at a higher risk for VTE after shoulder arthroscopy. Level of Evidence Level IV, systematic review and meta-analysis of Level I-IV studies.
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Affiliation(s)
- Kaveh Momenzadeh
- Musculoskeletal Translational Innovation Initiative, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Diana Yeritsyan
- Musculoskeletal Translational Innovation Initiative, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Sharri Mortensen
- Musculoskeletal Translational Innovation Initiative, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Nadim Kheir
- Musculoskeletal Translational Innovation Initiative, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Mohammad Khak
- Musculoskeletal Translational Innovation Initiative, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Daniela Caro
- Musculoskeletal Translational Innovation Initiative, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Farima Kahe
- Cardiovascular Department, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Mohammadreza Abbasian
- Musculoskeletal Translational Innovation Initiative, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Chen Mo
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Megan McNichol
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Nikolaos Paschos
- Orthopaedic Surgery Department, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Ara Nazarian
- Musculoskeletal Translational Innovation Initiative, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, U.S.A
- Department of Orthopaedic Surgery, Yerevan State Medical University, Yerevan, Armenia
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Liu SH, Cerri-Droz P, Loyst RA, Komatsu DE, Wang ED. Shoulder arthroscopy in elderly patients: malnutrition and early postoperative outcomes. JSES Int 2024; 8:41-46. [PMID: 38312264 PMCID: PMC10837690 DOI: 10.1016/j.jseint.2023.08.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2024] Open
Abstract
Background This study investigates the association between the Geriatric Nutritional Risk Index (GNRI), a simple, readily available malnutrition risk index, and 30-day postoperative complications following shoulder arthroscopy. Methods The American College of Surgeons National Surgical Quality Improvement Program database was used to identify all patients aged ≥65 years who underwent shoulder arthroscopy between 2015 and 2021. The study population was indexed into 3 cohorts of preoperative GNRI: normal/reference (GNRI >98), moderate malnutrition (92≤ GNRI ≤98), and severe malnutrition (GNRI <92). Multivariate logistic regression analysis was conducted to investigate the connection between preoperative GNRI and postoperative complications. Results Severe malnutrition was independently significantly associated with a greater likelihood of any complication (odds ratio [OR]: 11.70, 95% confidence interval [CI]: 8.58-15.94; P < .001), sepsis (OR: 26.61, 95% CI: 10.86-65.21; P < .001), septic shock (OR: 7.53, 95% CI: 1.56-36.32; P = .012), blood transfusions (OR: 25.38, 95% CI: 6.40-100.59; P < .001), pulmonary embolism (OR: 7.25, 95% CI: 1.27-41.40; P = .026), surgical site infection (OR: 22.08, 95% CI: 7.51-64.97; P < .001), nonhome discharge (OR: 15.75, 95% CI: 9.83-25.23; P < .001), readmission (OR: 2.69, 95% CI: 1.52-4.74; P < .001), unplanned reoperation (OR: 6.32, 95% CI: 2.23-17.92; P < .001), length of stay >2 days (OR: 23.66, 95% CI: 16.25-34.45; P < .001), and mortality (OR: 14.25, 95% CI: 2.89-70.40; P = .001). Conclusion GNRI-based malnutrition is strongly predictive of perioperative complications following shoulder arthroscopy in geriatric patients and has utility as an adjunctive risk stratification tool.
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Affiliation(s)
- Steven H. Liu
- Renaissance School of Medicine, Stony Brook University, Stony Brook, NY, USA
| | - Patricia Cerri-Droz
- Renaissance School of Medicine, Stony Brook University, Stony Brook, NY, USA
| | - Rachel A. Loyst
- Renaissance School of Medicine, Stony Brook University, Stony Brook, NY, USA
| | - David E. Komatsu
- Department of Orthopaedics, Stony Brook University, Stony Brook, NY, USA
| | - Edward D. Wang
- Department of Orthopaedics, Stony Brook University, Stony Brook, NY, USA
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Sclafani SJ, Partan MJ, Tarazi JM, Sherman AE, Katsigiorigis G, Cohn RM. Risk Factors for Unexpected Admission Following Outpatient Rotator Cuff Repair: A National Database Study. Cureus 2023; 15:e40536. [PMID: 37461791 PMCID: PMC10350331 DOI: 10.7759/cureus.40536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/16/2023] [Indexed: 07/20/2023] Open
Abstract
Introduction Rotator cuff repair (RCR) procedures are some of the most common orthopaedic surgeries performed in the United States. Compared to other orthopaedic procedures, RCRs are of relatively low morbidity. However, complications may arise that result in readmission to an inpatient healthcare facility. The purpose of this study is to identify the demographics and risk factors associated with unplanned 30-day readmission after RCR. Methods The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify patients that underwent elective RCR from 2015-2019. Univariate and multivariate analyses were utilized to assess patient demographics, comorbidities, and peri-operative variables predicting unplanned 30-day readmission. Results Of the identified 45,548 patients that underwent RCR, 597 (1.3%) required readmission within 30 days of the procedure. Multivariate analysis identified male sex (OR 1.36, 95% CI: 1.10, 1.67), hypertension (OR 1.29, 95% CI:1.03, 1.62), chronic obstructive pulmonary disease (COPD) (OR 2.07, 95% CI: 1.46, 2.93), American Society of Anesthesiologists (ASA) Class III (OR 1.85, 95% CI: 1.07, 3.18), ASA Class IV (OR 5.38, 95% CI: 2.70, 10.72), and total operative time (OR 1.002, 95% CI: 1.000, 1.004) as independent risk factors for unplanned readmission. Conclusion Unplanned 30-day readmission after RCR is infrequent. However, certain patients may be at increased risk for unplanned 30-day admission to an inpatient facility. This study confirmed male sex, COPD, hypertension, ASA Class III, ASA Class IV, and total operative time to be independent risk factors for readmission following outpatient RCR.
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Affiliation(s)
- Salvatore J Sclafani
- Department of Orthopaedic Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, USA
- Department of Orthopaedic Surgery, Northwell Health-Huntington Hospital, Huntington, USA
| | - Matthew J Partan
- Department of Orthopaedic Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, USA
- Department of Orthopaedic Surgery, Northwell Health-Huntington Hospital, Huntington, USA
| | - John M Tarazi
- Department of Orthopaedic Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, USA
- Department of Orthopaedic Surgery, Northwell Health-Huntington Hospital, Huntington, USA
| | - Alain E Sherman
- Department of Orthopaedic Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, USA
- Department of Orthopaedic Surgery, Northwell Health-Lenox Hill Hospital, Manhattan, USA
| | - Gus Katsigiorigis
- Department of Orthopaedic Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, USA
- Department of Orthopaedic Surgery, Northwell Health-Huntington Hospital, Huntington, USA
- Department of Orthopaedic Surgery, Northwell Health-Long Island Jewish Valley Stream, Valley Stream, USA
| | - Randy M Cohn
- Department of Orthopaedic Surgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, USA
- Department of Orthopaedic Surgery, Northwell Health-Huntington Hospital, Huntington, USA
- Department of Orthopaedic Surgery, Northwell Health-Long Island Jewish Valley Stream, Valley Stream, USA
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Li T, Li Y, Zhang L, Pang L, Tang X, Zhu J. Venous thromboembolism after arthroscopic shoulder surgery: a systematic review. J Orthop Surg Res 2023; 18:103. [PMID: 36788620 PMCID: PMC9927062 DOI: 10.1186/s13018-023-03592-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 02/08/2023] [Indexed: 02/16/2023] Open
Abstract
PURPOSE To summarize the incidence, risk factors, diagnosis methods, prophylaxis methods, and treatment of venous thromboembolism (VTE) following arthroscopic shoulder surgery. METHODS Literature on VTE after arthroscopic shoulder surgeries was summarized, and all primary full-text articles reporting at least 1 case of deep vein thrombosis (DVT) or pulmonary embolism (PE) after arthroscopic shoulder surgeries were included. Articles were critically appraised and systematically analyzed to determine the incidence, risk factors, diagnosis, prophylaxis, and management of VTE following arthroscopic shoulder surgeries. RESULTS This study included 42 articles in which the incidence of VTE ranges from 0 to 5.71% and the overall incidence was 0.26%. Most VTE events took place between the operation day and the 14th day after the operation (35/51). Possible risk factors included advanced age (> 70 years), obesity (BMI ≥ 30 kg/m2), diabetes mellitus, thrombophilia, history of VTE, prolonged operation time, hormone use, and immobilization after surgery. The most common prophylaxis method was mechanical prophylaxis (13/15). No statistical difference was detected when chemoprophylaxis was applied. The management included heparinization followed by oral warfarin, warfarin alone and rivaroxaban, a direct oral anticoagulant. CONCLUSION Based on the included studies, the incidence rate of VTE after arthroscopic shoulder surgeries is relatively low. The risk factors for VTE are still unclear. CT/CTA and ultrasound were the mainstream diagnosis methods for PE and DVT, respectively. Current evidence shows that chemical prophylaxis did not deliver significant benefits, since none of the existing studies reported statistically different results. High-quality studies focusing on the prophylaxis and management of VTE population undergoing arthroscopic shoulder surgeries should be done in the future.
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Affiliation(s)
- Tao Li
- grid.13291.380000 0001 0807 1581Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, No. 37, Guoxue Road, Wuhou District, Chengdu, 610041 Sichuan Province People’s Republic of China
| | - Yinghao Li
- grid.13291.380000 0001 0807 1581Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, No. 37, Guoxue Road, Wuhou District, Chengdu, 610041 Sichuan Province People’s Republic of China
| | - Linmin Zhang
- grid.13291.380000 0001 0807 1581West China School of Medicine, Sichuan University, Chengdu, People’s Republic of China
| | - Long Pang
- grid.13291.380000 0001 0807 1581Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, No. 37, Guoxue Road, Wuhou District, Chengdu, 610041 Sichuan Province People’s Republic of China
| | - Xin Tang
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, No. 37, Guoxue Road, Wuhou District, Chengdu, 610041, Sichuan Province, People's Republic of China.
| | - Jing Zhu
- Department of Respiratory and Critical Care Medicine, West China Hospital, West China School of Nursing, Sichuan University, No. 37, Guoxue Road, Wuhou District, Chengdu, Sichuan Province, People's Republic of China.
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Triplet JJ, Schuette HB, Cheema AN, Marigi EM, Hassett LC, Barlow JD, Camp CL, Morrey ME, Sperling JW, Sanchez-Sotelo J. Venothromboembolism following shoulder arthroscopy: a systematic review. JSES REVIEWS, REPORTS, AND TECHNIQUES 2022; 2:464-468. [PMID: 37588470 PMCID: PMC10426627 DOI: 10.1016/j.xrrt.2022.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Abstract
Background Venous thromboembolic events (VTEs) following orthopedic surgery may lead to serious morbidity and mortality. Fortunately, VTEs following upper extremity procedures are uncommon. However, the true incidence is likely underreported. The aim of this study is to provide a systematic review, excluding large database studies, to report on the incidence of VTEs following shoulder arthroscopic procedures. Methods Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, a systematic review of multiple databases was performed. A comprehensive search of several databases from inception to September 1, 2021, limited to English language and excluding animal studies, was designed and conducted. Studies were screened by 2 independent reviewers. A decision to exclude studies from large surgical or insurance claim databases was made to minimize the risk of including overlapping data points in this systematic review. Results Thirteen studies met inclusion and exclusion criteria and form part of this systematic review. A total of 32,407 patients were included in this study. Among these patients, the deep vein thrombosis, pulmonary embolism, and overall VTE rates were 0.15%, 0.08%, and 0.21%, respectively. Among the patients specified to have undergone arthroscopic rotator cuff repair, the rate of deep vein thrombosis, pulmonary embolism, and overall VTE was 0.71%, 0.37%, and 1.04%, respectively. Conclusion While symptomatic VTEs are rare following shoulder arthroscopic procedures, surgeons must be aware that they still account for a certain number of postoperative complications. Factors such as operative time, open procedures, obesity, and altitude may increase the risk of postoperative VTE although conflicting data exist. Current literature supports the idea that chemical antithrombotic prophylaxis likely provides no significant advantage over early mobilization in reducing VTEs following shoulder arthroscopy in low-risk patients.
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Ifarraguerri AM, Quan T, Bernstein SL, Malyavko A, Gioia C, Gu A, Doerre T, Best MJ. The effect of obesity on complications following isolated posterior cruciate ligament reconstruction. Knee 2022; 38:164-169. [PMID: 36058124 DOI: 10.1016/j.knee.2022.08.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 07/27/2022] [Accepted: 08/17/2022] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Anna M Ifarraguerri
- Department of Orthopaedic Surgery, George Washington University School of Medicine and Health Sciences, Washington, DC, United States.
| | - Theodore Quan
- Department of Orthopaedic Surgery, George Washington University School of Medicine and Health Sciences, Washington, DC, United States
| | - Sophie L Bernstein
- University of Missouri-Kansas City School of Medicine, Kansas City, MO, United States
| | - Alisa Malyavko
- Department of Orthopaedic Surgery, George Washington University School of Medicine and Health Sciences, Washington, DC, United States
| | - Casey Gioia
- Department of Orthopaedic Surgery, George Washington University School of Medicine and Health Sciences, Washington, DC, United States
| | - Alex Gu
- Department of Orthopaedic Surgery, George Washington University School of Medicine and Health Sciences, Washington, DC, United States
| | - Teresa Doerre
- Department of Orthopaedic Surgery, George Washington University School of Medicine and Health Sciences, Washington, DC, United States
| | - Matthew J Best
- Department of Orthopaedic Surgery, Johns Hopkins, Columbia, MD, United States
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Resident Involvement in Posterior Lumbar Interbody Fusion is Associated With Increased Readmissions and Operative Time, But No Increased Short-term Risks. Clin Spine Surg 2021; 34:E364-E369. [PMID: 34156038 DOI: 10.1097/bsd.0000000000001157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 11/07/2020] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN A retrospective cohort study. OBJECTIVE The aim was to compare rates of adverse events and additional posterior lumbar interbody fusion (PLIF) cases assisted by residents versus cases performed solely by an orthopedic attending. SUMMARY OF BACKGROUND DATA PLIF is a widely accepted surgical technique for the management of a variety of spinal conditions requiring spinal stabilization and fusion. However, no published studies have assessed the effects of resident involvement on intraoperative and postoperative outcomes in PLIF. METHODS This retrospective study utilized the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) registry from 2007 to 2012 to identify patients who underwent PLIF procedures. A propensity score matching model was utilized to reduce patient cohort variances. The perioperative data and outcomes in the matched population were analyzed using paired t test and the McNemar test in order to assess, based on resident presence, the rates of postoperative adverse events, readmission, reoperation within 30 days, and operative time. RESULTS In total, 1633 patients undergoing PLIF were included in the study, with 24.62% involving resident participation. The propensity score matching algorithm yielded 396 well-matched resident and nonresident pairs. Patients undergoing PLIF involving a resident were associated with a higher rate of readmission (1.77% vs. 0.00%; P=0.008), and longer operative time (245.7 vs. 197.7 min; P<0.001). However, these procedures were not associated with any significant difference in minor or severe adverse events. CONCLUSIONS Resident involvement in PLIF was associated with an increased rate of readmissions, and operative time; however, was not associated with an increase in minor or severe adverse events. Further investigation is needed to characterize the role of resident involvement based on level of training experience, as well as methods to improve the learning curve to independence while reducing postoperative hospital length of stay. LEVEL OF EVIDENCE Level III-retrospective comparative study.
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The Impact of Resident Involvement on Postoperative Complications After Shoulder Arthroscopy: A Propensity-Matched Analysis. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2020; 4:e20.00138. [PMID: 33939395 PMCID: PMC7494138 DOI: 10.5435/jaaosglobal-d-20-00138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
PURPOSE Shoulder arthroscopy is the second most frequently performed procedure by orthopaedic surgeons taking the American Board of Orthopaedic Surgery part II examination. However, the impact of resident involvement on outcomes after shoulder arthroscopy is poorly understood. The aim of this study was to investigate whether resident involvement in shoulder arthroscopic procedures affects postoperative complication rates and surgical time using propensity score-matched cohorts. METHODS The American College of Surgeons National Surgical Quality Improvement Program registry was queried to identify patients who underwent common shoulder arthroscopic procedures between 2006 and 2012. Cases without information on resident involvement, treatment of septic arthritis or osteomyelitis of the shoulder, or concomitant open or miniopen procedures were excluded from the study. A 1:1 propensity score match was used based on demographic and comorbidity factors to match cases with resident involvement to nonresident cases. Patient demographics, comorbidities, surgical time, length of hospital stay, and 30-day postoperative complications were compared between the two groups. RESULTS Overall, 15,857 patients who underwent shoulder arthroscopy were identified. After propensity score matching, 3474 cases (50% with resident involvement) were included. Appropriate matching was verified with no difference in demographic or health characteristics. No significant differences in the overall rate of 30-day complications was noted in resident-involved versus nonresident group (P = 0.576). No significant difference was observed in postoperative surgical or medical complications. Resident involvement was significantly longer surgical time (75.9 ± 35.9 versus 75.1 ± 40.5 minutes, P = 0.03) when compared with cases performed without a resident. CONCLUSIONS Resident involvement in shoulder arthroscopy is not associated with increased risk for medical or surgical 30-day postoperative complications. Resident participation in shoulder arthroscopy cases did increase surgical time; however, this finding is likely clinically insignificant.
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Aziz KT, Best MJ, Shi BY, Srikumaran U. Missing Data in the National Surgical Quality Improvement Program Database: How Does It Affect the Identification of Risk Factors for Shoulder Surgery Complications? Arthroscopy 2020; 36:1233-1239.e3. [PMID: 31954805 DOI: 10.1016/j.arthro.2019.12.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 12/13/2019] [Accepted: 12/13/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE The main purpose of this study was to establish whether different approaches to handling missingness affect the determination of risk factors associated with 30-day postoperative major and minor complications. A secondary purpose was to determine the frequency of missingness in the National Surgical Quality Improvement Program (NSQIP) records of patients who underwent shoulder surgery. METHODS We queried the American College of Surgeons NSQIP database using Current Procedural Terminology codes to identify patients who underwent shoulder surgery from 2011 to 2016 (n = 61,963). Data on major and minor postoperative complications were extracted. We also extracted data on patient characteristics, comorbidities, American Society of Anesthesiologists classifications, and preoperative laboratory values. We calculated the percentages of missingness for each variable. Each variable was then evaluated for associations with major and minor complications by using multivariable regression and 4 methods of handling missingness (involving imputation or exclusion, depending on the completeness of the data set). For 10 variables, the method using no exclusion or imputation produced higher odds of major complications compared with imputation. For 5 variables, the method using no exclusion or imputation produced higher odds of minor complications compared with imputation. RESULTS Only 6.5% of all patients had no missing data (n = 4,042), whereas 44% had <10% missingness (n = 27,165). Fewer variables were associated with both major and minor complications after shoulder surgery when patient records with missing data were excluded from analysis. CONCLUSIONS Different methods of handling missingness produced different odds ratios for some variables when determining risk factors for complications after shoulder surgery. LEVEL OF EVIDENCE III, Case control study.
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Affiliation(s)
- Keith T Aziz
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD
| | - Matthew J Best
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD
| | - Brendan Y Shi
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD
| | - Uma Srikumaran
- Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD.
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Sochacki KR, Dillingham MF, Abrams GD, Sherman SL, Donahue J. Humeral Head Osteochondral Allograft Reconstruction with Arthroscopic Anterior Shoulder Stabilization at a Long-Term Follow-Up: A Case Report. JBJS Case Connect 2020; 10:e0555. [PMID: 32649125 DOI: 10.2106/jbjs.cc.19.00555] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
CASE The authors report a case of recurrent anterior shoulder instability in a 19-year-old man. Intraoperative arthroscopic examination identified Bankart and engaging Hill-Sachs lesions. The patient was treated with humeral head osteochondral allograft reconstruction and concomitant arthroscopic anterior stabilization. At the 14-year follow-up, there was no recurrent instability. CONCLUSION Humeral head osteochondral allograft reconstruction combined with an arthroscopic anterior stabilization procedure can be successful for recurrent shoulder instability and engaging Hill-Sachs lesion.
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Affiliation(s)
- Kyle R Sochacki
- 1Department of Orthopaedic Surgery, Stanford University Medical Center, Palo Alto, California
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Li NY, DeFroda SF, Durand W, Reid DBC, Owens BD, Daniels AH. Risk of Revision Shoulder Surgery, Complications, and Prolonged Opioid Use in Patients Undergoing Shoulder Arthroscopy Who Have Previously Undergone Anterior Cervical Discectomy and Fusion. Arthroscopy 2020; 36:367-372.e2. [PMID: 31864815 DOI: 10.1016/j.arthro.2019.08.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Revised: 08/08/2019] [Accepted: 08/14/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare postoperative complications, rates of revision, and opioid use of those who undergo shoulder arthroscopy with and without previous anterior cervical discectomy and fusion (ACDF). METHODS The PearlDiver database from 2007 to 2017 was used to query all patients who underwent shoulder arthroscopy as determined by Current Procedural Terminology (CPT). Patients were then separated among those who had a previous instance of ACDF and those who did not as filtered by CPT. Postoperative complications within 30 days, readmission rates, opioid use, and revision procedures were assessed for each cohort using a mix of International Classification of Diseases Ninth and Tenth Revision Clinical Modification codes, CPT, as well as generic drug codes. RESULTS A total of 91,029 patients undergoing shoulder arthroscopy were identified, of whom 1,267 (1.4%) had a history of ACDF. Compared with patients without previous ACDF, patients with a history of ACDF had significantly greater respiratory complication rates (1.3% vs 0.5%: adjusted odds ratio [aOR] 2.16, 95% confidence interval [CI]1.30-3.59, P = .003), 30-day complication rates (3.7% vs 2.2%: aOR 1.48, 95% CI 1.10-1.99, P = .011), 1-year revision rates (15.2% vs 7.7%: aOR 2.00, 95% CI 1.71-2.33, P < .0001), and greater opioid use at 1 month, 3 months, 6 months, and 12 months (P < .0001). CONCLUSIONS This study revealed that patients who undergo shoulder arthroscopy with a history of ACDF are twice as likely to undergo revision arthroscopy within 2 years of surgery and are at an increased risk of complications within 30 days postoperatively as well as prolonged opioid use compared with those without a history of ACDF. With these findings, both spine and shoulder surgeons should aim to be more aware of surgical history, especially of the cervical spine, to better counsel patients' clinical course and expected outcomes following shoulder arthroscopy. LEVEL OF EVIDENCE III, retrospective cohort study.
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Affiliation(s)
- Neill Y Li
- Department of Orthopaedic Surgery, Brown University, Providence, Rhode Island, U.S.A.; Warren Alpert Medical School, Brown University, Providence, Rhode Island, U.S.A
| | - Steven F DeFroda
- Department of Orthopaedic Surgery, Brown University, Providence, Rhode Island, U.S.A.; Warren Alpert Medical School, Brown University, Providence, Rhode Island, U.S.A
| | - Wesley Durand
- Warren Alpert Medical School, Brown University, Providence, Rhode Island, U.S.A
| | - Daniel B C Reid
- Department of Orthopaedic Surgery, Brown University, Providence, Rhode Island, U.S.A.; Warren Alpert Medical School, Brown University, Providence, Rhode Island, U.S.A
| | - Brett D Owens
- Department of Orthopaedic Surgery, Brown University, Providence, Rhode Island, U.S.A.; Warren Alpert Medical School, Brown University, Providence, Rhode Island, U.S.A
| | - Alan H Daniels
- Department of Orthopaedic Surgery, Brown University, Providence, Rhode Island, U.S.A.; Warren Alpert Medical School, Brown University, Providence, Rhode Island, U.S.A..
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Li NY, Patel SA, Durand WM, Ready LV, Owens BD, Daniels AH. Increased Risk of Chronic Opioid Use and Revision After Anterior Cervical Diskectomy and Fusion in Patients with Prior Shoulder Arthroscopy. World Neurosurg 2019; 135:e202-e208. [PMID: 31786377 DOI: 10.1016/j.wneu.2019.11.116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 11/19/2019] [Accepted: 11/20/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE The purpose of this study was to compare differences in the outcomes of patients who undergo anterior cervical diskectomy and fusion (ACDF) with and without a history of shoulder arthroscopy. METHODS The PearlDiver Patient Records Database (www.peardiverinc.com) from 2007 to 2017 was used to query patients by Current Procedural Terminology, isolating those who underwent ACDF with and without prior shoulder arthroscopy. Postoperative complications within 30 days of the index procedure, opioid use, and revision procedures were assessed for each cohort using ICD-9/10 and Current Procedural Terminology coding. RESULTS A total of 39,969 ACDF patients were queried, of which 38,859 (97.2%) underwent ACDF alone and 1110 (2.8%) underwent ACDF with prior shoulder arthroscopy. ACDF revision rates were significantly greater in patients with prior shoulder arthroscopy compared with ACDF alone (5.8% vs. 3.6%, aOR = 1.64, P = 0.0002). Patients with prior shoulder arthroscopy were also significantly more likely to fill opioid prescriptions at 3 months (aOR 1.19, P = 0.02), 6 months (aOR 1.22, P = 0.01), and 12 months (aOR 1.18, P = 0.04). CONCLUSIONS Patients who undergo ACDF with a prior shoulder arthroscopy have significantly greater revision rates, respiratory complications, and prolonged opioid use compared with patients without prior shoulder arthroscopy. With efforts to limit narcotic use and the importance of maximizing patient satisfaction, this analysis improves on the surgeon's ability to set expectations and postoperative plans for patients undergoing ACDF who have a history of shoulder arthroscopy.
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Affiliation(s)
- Neill Y Li
- Department of Orthopaedics, Alpert Medical School of Brown University, Providence, Rhode Island, USA.
| | - Shyam A Patel
- Department of Orthopaedics, Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Wesley M Durand
- Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Lauren V Ready
- Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Brett D Owens
- Department of Orthopaedics, Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Alan H Daniels
- Department of Orthopaedics, Alpert Medical School of Brown University, Providence, Rhode Island, USA
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Rubenstein WJ, Lansdown DA, Feeley BT, Ma CB, Zhang AL. Body Mass Index Screening in Knee Arthroscopy: An Analysis Using the National Surgical Quality Improvement Database. Arthroscopy 2019; 35:3289-3294. [PMID: 31785760 DOI: 10.1016/j.arthro.2019.06.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 06/10/2019] [Accepted: 06/21/2019] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- William J Rubenstein
- Department of Orthopedics, University of California San Francisco, San Francisco, CA, U.S.A..
| | - Drew A Lansdown
- Department of Orthopedics, University of California San Francisco, San Francisco, CA, U.S.A
| | - Brian T Feeley
- Department of Orthopedics, University of California San Francisco, San Francisco, CA, U.S.A
| | - C Benjamin Ma
- Department of Orthopedics, University of California San Francisco, San Francisco, CA, U.S.A
| | - Alan L Zhang
- Department of Orthopedics, University of California San Francisco, San Francisco, CA, U.S.A
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Cancienne JM, Deasey MJ, Kew ME, Werner BC. The Association of Perioperative Glycemic Control With Adverse Outcomes Within 6 Months After Arthroscopic Rotator Cuff Repair. Arthroscopy 2019; 35:1771-1778. [PMID: 31027919 DOI: 10.1016/j.arthro.2019.01.035] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 12/16/2018] [Accepted: 01/04/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine the association between glycemic control and adverse events after arthroscopic rotator cuff repair (RCR). METHODS Patients with a diagnosis of diabetes mellitus who underwent arthroscopic RCR and had a hemoglobin A1c (HbA1c) level determined within 3 months before or after surgery were identified in a national database and stratified by HbA1c level. The incidence of postoperative infection within 6 months was determined using Current Procedural Terminology and International Classification of Diseases, Ninth Revision codes. A receiver operating characteristic (ROC) curve analysis was performed to determine whether a threshold HbA1c level existed above which the risk of infection, revision rotator cuff surgery, and lysis of adhesions (LOA)-manipulation under anesthesia (MUA) after arthroscopic RCR was significantly increased. This threshold was then tested using a logistic regression analysis. RESULTS The study included 3,740 patients with an infection rate ranging from a low of 0.29% to a high of 1.14% after RCR. The inflection point of the ROC curve for infection corresponded to an HbA1c level between 7.0 and 8.0 mg/dL (P = .035; area under the curve, 0.648; specificity, 61%; sensitivity, 59%). We then used 8.0 mg/dL as a threshold to test for adverse outcomes. We found a significant difference in infection rates for patients with levels below versus above the threshold (0.30% vs 0.84%; OR, 2.0; 95% confidence interval, 1.2-3.4; P = .014) but no difference in revision rates (P = .240) or LOA-MUA (P = .650) in patients with levels above versus below the threshold. CONCLUSIONS The risk of infection after RCR in patients with diabetes mellitus increases as the perioperative HbA1c level increases and, although statistically significant, remains low. ROC curve analysis determined that a perioperative HbA1c level above 8.0 mg/dL could serve as a threshold level; however, the area under the curve and low sensitivity reflected the poor utility of this test as an independent predictor. This study did not find an association between increased perioperative HbA1c levels and rates of revision rotator cuff surgery or LOA-MUA after RCR. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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Affiliation(s)
- Jourdan M Cancienne
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A
| | - Matthew J Deasey
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A
| | - Michelle E Kew
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A
| | - Brian C Werner
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia, U.S.A..
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Traven SA, Reeves RA, Walton ZJ, Woolf SK, Slone HS. Insulin Dependence Is Associated With Increased Medical Complications and Mortality After Shoulder Arthroscopy. Arthroscopy 2019; 35:1316-1321. [PMID: 30979624 DOI: 10.1016/j.arthro.2018.11.059] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Revised: 11/25/2018] [Accepted: 11/26/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To compare complications after shoulder arthroscopy in patients with insulin-dependent diabetes mellitus (IDDM), patients with non-insulin-dependent diabetes mellitus (NIDDM), and nondiabetic patients. METHODS A retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program database for the years 2005 to 2016 was conducted. Logistic regression analyses were used to assess the relation between diabetic status (nondiabetic patients, n = 50,626; NIDDM patients, n = 5,332; and IDDM patients, n = 2,484) and outcomes. Multivariate models were established to adjust for age, sex, body mass index, hypertension, congestive heart failure, chronic obstructive pulmonary disease, smoking status, American Society of Anesthesiologists classification, and functional status. RESULTS Patients with IDDM were at a higher risk of medical complications, with an adjusted odds ratio (AOR) of 1.524 (95% confidence interval [CI], 1.082-2.147), including pulmonary complications (AOR, 2.078; 95% CI, 1.089-3.964) and urinary tract infections (AOR, 2.129; 95% CI, 1.027-4.415). Patients with IDDM also had a higher risk of 30-day hospital admission (AOR, 1.581; 95% CI, 1.153-2.169) and 30-day mortality (AOR, 3.821; 95% CI, 1.243-11.750). Conversely, patients with NIDDM had comparable risks of medical and surgical complications, unplanned hospital admission, and death to nondiabetic patients. CONCLUSIONS Medical complications, 30-day hospital admission, and death after shoulder arthroscopy were more likely in patients with IDDM. These risks diminished among patients with NIDDM, with their risks being comparable with those of nondiabetic patients. LEVEL OF EVIDENCE Level III, retrospective comparison study.
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Affiliation(s)
- Sophia A Traven
- Department of Orthopaedics, Medical University of South Carolina, Charleston, South Carolina, U.S.A..
| | - Russell A Reeves
- Department of Orthopaedics, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Zeke J Walton
- Department of Orthopaedics, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Shane K Woolf
- Department of Orthopaedics, Medical University of South Carolina, Charleston, South Carolina, U.S.A
| | - Harris S Slone
- Department of Orthopaedics, Medical University of South Carolina, Charleston, South Carolina, U.S.A
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Gowd AK, Liu JN, Garcia GH, Agarwalla A, Cabarcas BC, Manderle BJ, Verma NN. Open Biceps Tenodesis Associated With Slightly Greater Rate of 30-Day Complications Than Arthroscopic: A Propensity-Matched Analysis. Arthroscopy 2019; 35:1044-1049. [PMID: 30857905 DOI: 10.1016/j.arthro.2018.11.036] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 11/09/2018] [Accepted: 11/13/2018] [Indexed: 02/08/2023]
Abstract
PURPOSE To compare the early complication risk associated with open biceps tenodesis (OBT) and arthroscopic biceps tenodesis (ABT) and determine which preoperative factors may influence complication rate. METHODS The American College of Surgeons National Surgical Quality Improvement Program database was retrospectively queried from 2008 to 2016 for all procedures with CPT codes for ABT (29828) and OBT (23430). Patients were excluded if they received concomitant rotator cuff repair or shoulder arthroplasty. Patients undergoing OBT and ABT were matched by propensity scores based on age, body mass index, operative time, proportion of smokers, and proportion of concomitant subacromial decompression, distal clavicle excision, SLAP, and debridement. The incidence of adverse events in the 30-day postoperative period was compared. RESULTS A total of 8,032 patients met the inclusion and exclusion criteria. Prior to propensity match, patients receiving OBT and ABT, respectively, differed with respect to age (49.4 ± 13.8 vs 51.4 ± 13.2; P < .001), body mass index (29.6 ± 6.8 vs 29.9 ± 7.0; P = .029), and operative time (91.2 ± 51.3 vs 85.3 ± 43.4; P < .001). Following propensity match, 6,330 remained in the study (3,165 ABT and 3,165 OBT). OBT had significantly greater incidence of any adverse events (1.58% vs 0.95%; P = .032) and anemia requiring transfusion (0.35% vs 0%; P = .001). Multivariate analysis suggested that OBT (relative risk [RR] = 1.7, 95% confidence interval [CI], 1.1-2.7; P = .020), old age (RR = 1.6, 95% CI, 1.0-2.5), history of dyspnea (RR = 3.8, 95% CI, 1.8-7.7; P < .001), and congestive heart failure (RR = 5.5, 95% CI, 1.3-22.7; P = .019) were associated with developing a postoperative adverse event within 30 days of surgery. CONCLUSIONS Both procedures were found to have a low rate of complications, although OBT had a slightly greater (1.58% vs 0.95%) rate of 30-day complications than ABT. Early complication rate should not serve as impetus to direct surgical technique as number needed to treat is high, although ABT may be considered in more high-risk individuals. LEVEL OF EVIDENCE Level III, retrospective comparative database study.
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Affiliation(s)
- Anirudh K Gowd
- Department of Orthopedics, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Joseph N Liu
- Loma Linda University Medical Center, Loma Linda, California
| | | | - Avinesh Agarwalla
- Department of Orthopedics, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Brandon C Cabarcas
- Department of Orthopedics, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Brandon J Manderle
- Department of Orthopedics, Rush University Medical Center, Chicago, Illinois, U.S.A
| | - Nikhil N Verma
- Department of Orthopedics, Rush University Medical Center, Chicago, Illinois, U.S.A.
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Rubenstein WJ, Lansdown DA, Feeley BT, Ma CB, Zhang AL. The Impact of Body Mass Index on Complications After Shoulder Arthroscopy: Should Surgery Eligibility Be Determined by Body Mass Index Cutoffs? Arthroscopy 2019; 35:741-746. [PMID: 30704887 DOI: 10.1016/j.arthro.2018.10.136] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Revised: 10/28/2018] [Accepted: 10/28/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE The goal of this study is to analyze postoperative complications after shoulder arthroscopy stratified by body mass index (BMI) and to quantify the trade-off in postsurgical complications and access to care that occurs with BMI eligibility cutoffs. METHODS Patients who underwent shoulder arthroscopy in the National Surgical Quality Improvement Program database from 2015 to 2016 were identified. Patients were categorized on the basis of their BMI. χ2 tests were used to identify differences in complication rates between different BMI categories. Logistic regression was used to calculate the odds ratio of having a major complication by BMI category. The positive predictive value (PPV) was calculated at different BMI cutoffs. RESULTS There were 26,509 shoulder arthroscopy cases identified in the National Surgical Quality Improvement Program database with 383 major complications, for an overall rate of 1.4%. Patients with a BMI >40 had a higher overall complication rate (2.3% vs 1.4%, P = .001), as well as higher rates of readmission (P = .012), pneumonia (P = .030), progressive renal insufficiency (P = .006), and cardiac arrest (P = .008). BMI >40 was associated with an increased risk of major complications (odds ratio, 1.84; confidence interval, 1.29-2.61). A BMI cutoff of 40 would avoid 12% of major complications while excluding 8% of complication-free surgeries. At a BMI cutoff of 40, the PPV was 2.3% where 43 surgeries would be denied for every complication avoided. CONCLUSION Patients with a BMI >40 have a statistically significant but only slightly increased risk of 30-day complications after shoulder arthroscopy. Instituting a BMI eligibility cutoff at 40 has a low PPV and would prevent 43 complication-free surgeries from proceeding for every complication prevented. Patients should be counseled individually about their risk factors, but denial of shoulder arthroscopy on the basis of BMI alone may not be an appropriate strategy for risk reduction. LEVEL OF EVIDENCE Level III, comparative prognostic trial.
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Affiliation(s)
- William J Rubenstein
- Department of Orthopedics, University of California at San Francisco, San Francisco, California, U.S.A..
| | - Drew A Lansdown
- Department of Orthopedics, University of California at San Francisco, San Francisco, California, U.S.A
| | - Brian T Feeley
- Department of Orthopedics, University of California at San Francisco, San Francisco, California, U.S.A
| | - C Benjamin Ma
- Department of Orthopedics, University of California at San Francisco, San Francisco, California, U.S.A
| | - Alan L Zhang
- Department of Orthopedics, University of California at San Francisco, San Francisco, California, U.S.A
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Nicolay RW, Selley RS, Terry MA, Tjong VK. Body Mass Index as a Risk Factor for 30-Day Postoperative Complications in Knee, Hip, and Shoulder Arthroscopy. Arthroscopy 2019; 35:874-882.e3. [PMID: 30733034 DOI: 10.1016/j.arthro.2018.10.108] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 10/13/2018] [Accepted: 10/21/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To use the American College of Surgeons National Surgical Quality Improvement Program database to determine whether body mass index (BMI) is associated with 30-day postoperative complications following arthroscopic surgery. METHODS Cases of elective knee, hip, and shoulder arthroscopy were identified. A retrospective comparative analysis was conducted, and the overall rates of morbidity, mortality, readmission, reoperation, and venothromboembolism (VTE) were compared using univariate analyses and binary logistic regressions to ascertain the adjusted effect of BMI, with and without diabetes, on morbidity, readmission, reoperation, and VTE. RESULTS There were 141,335 patients who met the criteria. The most common complications were deep vein thrombosis (0.27%), superficial surgical site infection (0.17%), urinary tract infection (0.13%), and pulmonary embolism (0.11%). Obesity class III with diabetes was a risk factor for morbidity (odds ratio [OR] = 1.522; 95% confidence interval [CI], 1.101-2.103) and readmission (OR = 2.342; 95% CI, 1.998-2.745) following all procedures, while obesity class I was protective toward reoperation (OR = 0.687, 95% CI, 0.485-0.973). Underweight patients were at higher risk for morbidity following shoulder arthroscopy (OR = 3.776; 95% CI, 1.605-8.883), as were the class I obese (OR = 1.421; 95% CI, 1.010-1.998) and class II obese (OR = 1.726, 95% CI, 1.159-2.569). BMI did not significantly affect morbidity following knee arthroscopy. VTE risk factors included being overweight (OR = 1.474; 95% CI, 1.088-1.996) or diabetic with class I obesity (OR = 1.469; 95% CI, 1.027-2.101). CONCLUSIONS Arthroscopic procedures are safe with very low complication rates. However, underweight and class I and class II obese patients are at higher risk for morbidity following shoulder arthroscopy, and diabetic patients with class III obesity are at higher risk for morbidity and readmission following all arthroscopy. Because BMI is a modifiable risk factor, these patients should be evaluated carefully before being considered for outpatient arthroscopic surgery. LEVEL OF EVIDENCE Level III, retrospective comparative study.
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Affiliation(s)
- Richard W Nicolay
- Department of Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, U.S.A..
| | - Ryan S Selley
- Department of Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, U.S.A
| | - Michael A Terry
- Department of Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, U.S.A
| | - Vehniah K Tjong
- Department of Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, U.S.A
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Cooper JD, Lorenzana DJ, Heckmann N, McKnight B, Mostofi A, Gamradt SC, Rick Hatch GF. The Effect of Obesity on Operative Times and 30-Day Readmissions After Anterior Cruciate Ligament Reconstruction. Arthroscopy 2019; 35:121-129. [PMID: 30611339 DOI: 10.1016/j.arthro.2018.07.032] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 07/18/2018] [Accepted: 07/20/2018] [Indexed: 02/02/2023]
Abstract
PURPOSE To understand the effect of obesity on operative times and 30-day readmission rates after arthroscopic anterior cruciate ligament reconstruction (ACLR). METHODS The American College of Surgeons National Surgical Quality Improvement Program database was queried using Current Procedural Terminology billing codes to identify all patients aged 18 years and older who underwent ACLR between 2007 and 2014. The Student t test was used for continuous variables, and the χ-square or Fisher exact test was used for categorical variables. Multivariate analysis was conducted to identify factors associated with 30-day readmission. RESULTS We identified 9,000 patients who underwent ACLR. In the readmission analysis, the total readmission rate was 0.70%. After multivariate analysis, a body mass index (BMI) of 40 or greater was associated with a significantly increased risk of 30-day readmission (odds ratio, 3.06; 95% confidence interval, 1.09-8.57). An operative time of less than 80 minutes was associated with a decreased risk of readmission (odds ratio, 0.40, 95% confidence interval, 0.18-0.92). In the operative-time analysis, the mean operative time was 100.7 minutes. Older age was predictive of decreasing operative time, with the operative time being 32.75 minutes shorter in patients aged 65 years or older than in those younger than 25 years. After multivariate analysis, class II obesity (BMI of 35-39.9) predicted an increase of 7.11 minutes and class III obesity (BMI ≥ 40) predicted an increase of 8.70 minutes compared with normal weight (BMI of 18.5-24.9). CONCLUSIONS Obesity is associated with longer operative times and increased 30-day readmissions after ACLR, with patients with a BMI of 40 or greater having over 3 times the risk of readmission compared with patients with a normal weight. Male sex, black race, and younger age are all also associated with increased operative times. LEVEL OF EVIDENCE Level III, observational, retrospective cohort study.
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Affiliation(s)
- Joseph D Cooper
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, U.S.A..
| | - Daniel J Lorenzana
- Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, North Carolina, U.S.A
| | - Nathanael Heckmann
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, U.S.A
| | - Braden McKnight
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, U.S.A
| | - Amir Mostofi
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, U.S.A.; Huntington Memorial Hospital, Pasadena, California, U.S.A
| | - Seth C Gamradt
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, U.S.A
| | - George F Rick Hatch
- Department of Orthopaedic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, U.S.A
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Complications After Arthroscopic Shoulder Surgery: A Review of the American Board of Orthopaedic Surgery Database. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2018; 2:e093. [PMID: 30680371 PMCID: PMC6336573 DOI: 10.5435/jaaosglobal-d-18-00093] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Introduction: Shoulder arthroscopies are among the most frequently performed surgeries by orthopaedic surgeons. Little is known about complication rates among recently trained surgeons. The purpose of this study was to examine the type and frequency of complications of common arthroscopic shoulder procedures performed by candidates challenging the American Board of Orthopaedic Surgery: Part II, certification examination. Methods: Data were obtained from the American Board of Orthopaedic Surgery database for orthopaedic surgeons who sat for the part II examination from 2012 to 2016. In total, 27,072 procedures were reviewed. The database was queried to determine the type and frequency of complications for patients who underwent shoulder arthroscopy, including arthroscopic rotator cuff repair, labrum repair, biceps tenodesis, and bony/soft tissue débridement procedures. Complications were classified as surgical, anesthetic, or medical. Factors affecting complication rates were investigated including surgeon's fellowship training, geographic location, and patients’ age and sex. Results: Patients with surgical complications (n = 2,133; 7.9%) were more common than anesthetic (n = 263; 1.0%) or medical (n = 607; 2.2%) complications. There was a significant variation in the surgical complication rate among different arthroscopic shoulder procedures, ranging from 5.4% for labral repair to 10.3% for rotator cuff repair and biceps tenodesis. Stiffness/arthrofibrosis was the most commonly recorded surgical complication (2.2%). Surgical complication rates were lowest in the Northeast region (6.7%; P < 0.01) and in patients younger than 21 years (3.8%; P < 0.01). Women had significantly higher rate of complications than men (8.4% versus 7.6%; P = 0.02). Among anesthetic-related complications, 61.6% were related to regional nerve blocks. The overall revision surgery and readmission rates were 0.8% and 1.0%, respectively. Conclusion: The overall self-reported surgical complication rate for arthroscopic shoulder procedures was 7.9%, which is higher than the rates reported in the literature. Although the rate of anesthetic complications is low (1.0%), adverse events related to nerve blocks made up most of the overall anesthetic related complications.
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Safety of Outpatient Shoulder Surgery at a Freestanding Ambulatory Surgery Center in Patients Aged 65 Years and Older: A Review of 640 Cases. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2018; 2:e075. [PMID: 30211375 PMCID: PMC6132319 DOI: 10.5435/jaaosglobal-d-17-00075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Introduction With increasing utilization of surgery centers, it is important to demonstrate the safety of outpatient shoulder surgery in freestanding ambulatory surgery centers. No studies have specifically looked at the Medicare-age population and the rate of outpatient shoulder procedure complications in these patients at an ambulatory surgery center. Methods Six hundred forty patients were included in our study between 2000 and 2015. The incidence of major complications was identified, including acute infection requiring intravenous antibiotics or irrigation and débridement, postoperative transfer to a hospital, wrong-site surgical procedures, retention of a foreign object, postoperative symptomatic thromboembolism, medication errors, and bleeding/wound complications. Results There was a total of seven occurrence reports in seven patients, for a reported adverse event rate of 1.01%. Conclusions Our findings are consistent with currently reported outpatient hospital-based data and illustrate the safety of outpatient shoulder procedures at a freestanding ambulatory surgery center in Medicare-age patients.
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Risk Factors for Short-term Complications After Rotator Cuff Repair in the United States. Arthroscopy 2018; 34:1158-1163. [PMID: 29242096 DOI: 10.1016/j.arthro.2017.10.040] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2017] [Revised: 10/14/2017] [Accepted: 10/15/2017] [Indexed: 02/02/2023]
Abstract
PURPOSE To use a population-level dataset to evaluate the rate of 30-day complications after rotator cuff repair, and to evaluate the risk factors for complication and unplanned hospital readmission. METHODS We used the American College of Surgeons National Surgical Quality Improvement Program from 2011 to 2015 to identify patients who underwent rotator cuff repair and concomitant procedures using Current Procedural Terminology codes. Postoperative complications and unplanned hospital readmissions were identified. Patient demographics, medical comorbidities, and perioperative variables were used in a multivariate logistic regression model to identify the risk factors for infection, any complication, and unplanned hospital readmission. RESULTS A total of 23,741 patients were identified who underwent rotator cuff repair. Overall, 1.39% of patients experienced at least 1 complication, with 0.66% minor complications and 0.85% major complications. Unplanned readmission occurred in 1.16% of patients. Infection was the most common complication, occurring in 0.3% of patients (n = 72), and was the most common reason for return to the operating room. Open rotator cuff repair and male gender were independent risk factors for all outcomes. Increased age and numerous medical comorbidities were associated with the risk of any complication or unplanned hospital readmission. CONCLUSIONS Rotator cuff repair has a low incidence of short-term complications. Infection was the most common complication. Open repair, male gender, increased age, and medical comorbidities all significantly increased the risk of complications and hospital readmission. LEVEL OF EVIDENCE Level IV, case series.
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Heyer JH, Kuang X, Amdur RL, Pandarinath R. Identifiable risk factors for thirty-day complications following arthroscopic rotator cuff repair. PHYSICIAN SPORTSMED 2018; 46:56-60. [PMID: 28974126 DOI: 10.1080/00913847.2018.1388732] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Shoulder arthroscopy has increased in frequency over the past decade, with rotator cuff repair comprising the majority of cases performed. Prior studies have detailed risk factors for 30-day complications and readmission rates after arthroscopic shoulder surgery using the National Surgical Quality Improvement Program (NSQIP) database, but no study has specifically looked at arthroscopic rotator cuff repair. The purpose of the study is to evaluate the risk factors for 30-day complications following arthroscopic rotator cuff repair using the NSQIP database. METHODS The NSQIP database was queried for all patients undergoing arthroscopic rotator cuff repair from 2006-2015. Demographics and thirty-day outcomes for these patients were analyzed using univariate analyses and multivariate regression analysis to determine the risk factors for complications. RESULTS 21,143 patients underwent arthroscopic rotator cuff repair, with 147 patients (0.70%) having a complication within 30-days. Univariate analysis found age >65 (p = 0.0028), male gender (p = 0.0053), elevated BMI (p = 0.0054), ASA class >2 (p < 0.0001), history of chronic obstructive pulmonary disease (p < 0.0001), hypertension (p < 0.0002), dyspnea (p < 0.0001), steroid use (p = 0.0350), and operative time >90 min (p = 0.0316) to be associated with increased risk of complications. Multivariate analysis found female sex to be protective or complication (OR 0.56, p = 0.0017), while American Society of Anesthesiology (ASA) class >2 (OR 1.51, p = 0.0335) and history of COPD (OR 2.41, p = 0.0030) and dyspnea (OR 1.89, p = 0.0359) to be risk factors for complication. The most common complication is venothromboembolic events, accounting for 36.7% of all complications. CONCLUSION Male sex, ASA class > 2, and history of COPD and dyspnea were independent risk factors for thirty-day complications following arthroscopic rotator cuff repair. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Jessica H Heyer
- a George Washington University Hospital , Department of Orthopaedic Surgery , Washington , DC , USA
| | - Xiangyu Kuang
- b Department of Surgery , Medical Faculty Associates at the George Washington University , Washington , DC , USA
| | - Richard L Amdur
- b Department of Surgery , Medical Faculty Associates at the George Washington University , Washington , DC , USA
| | - Rajeev Pandarinath
- a George Washington University Hospital , Department of Orthopaedic Surgery , Washington , DC , USA
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Dhawan A, Brand JC, Provencher MT, Rossi MJ, Lubowitz JH. Research Pearls: The Significance of Statistics and Perils of Pooling. Arthroscopy 2017; 33:1099-1101. [PMID: 28578761 DOI: 10.1016/j.arthro.2017.03.013] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Accepted: 03/14/2017] [Indexed: 02/02/2023]
Abstract
A series of articles on statistics are intended for an audience of clinicians, as well as statisticians and authors. Statistical significance is different than clinical significance. Understanding of clinical outcomes, value, quality, or generalizability requires critical analysis of medical research literature to ensure that statistical analyses have been properly applied and interpreted.
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Rossi MJ, Brand JC, Provencher MT, Lubowitz JH. Shoulder Arthroscopy Complication and Readmission Rates: Impact on Value. Arthroscopy 2017; 33:4-5. [PMID: 28003074 DOI: 10.1016/j.arthro.2016.11.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 11/07/2016] [Indexed: 02/02/2023]
Abstract
In medicine, value is defined as outcome divided by cost. Adverse events after medical treatment result in diminished outcomes and increased costs. As we evolve toward value-driven care, we must quantify the incidence of and risk factors for adverse events in order to minimize this dual-and multiplicative-effect.
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