Risk Factors for 30-Day Postoperative Complications Following Open Reduction Internal Fixation of Proximal Ulna Fractures

Complications in Hand Surgery During Early Independent Practice: A Single Surgeon's 5-Year Experience

BACKGROUND

The objective of this study was to understand the frequency and types of complications, and the associated postoperative outcomes within the first 5 years of practice after hand and upper extremity surgery fellowship.

METHODS

This was a retrospective observational study of all patients seen and surgically treated by a single surgeon at a single institution from August 2014 to September 2019. This corresponded to the first 5 years of practice after fellowship. Data collected included patient demographics, perioperative data, complication type, and outcome of the complication (better/same/worse than preoperative status). Complications were classified using the Clavien-Dindo system and a unique, self-derived system.

RESULTS

In total, 3301 surgeries were performed during the first 5 years of practice. The overall complication rate was 7.9% (261 complications from 239 patients). The 30-day complication rate was 5.2% (171/3301). Eleven (4.2%) of the 261 complications occurred intraoperatively. The total number of complications significantly declined during the first 5 years of practice as follows: 74, 71, 46, 37, and 33 (P = .010, R2 = .92). Hand and wrist were the most frequent anatomic locations involved and bone pathology was the predominant indication.

CONCLUSION

The overall surgical complication rate for hand and upper extremity surgery was 7.9%, with a 30-day complication rate of 5.2% (171/3301). The rate of complications after fellowship declined over the first 5 years of independent practice. Superficial infections were the most common complication. More than 90% of patients ultimately improved after addressing the complication.

LEVEL OF EVIDENCE

IV.

Impact of Missing Data on Identifying Risk Factors for Postoperative Complications in Hand Surgery

BACKGROUND

The mismanagement of missing data in large clinical databases may lead to inaccurate findings. The purpose of this study was to demonstrate the effects of missing data on hand surgery research findings using an analysis of postoperative morbidity in patients undergoing hospital-based hand surgery.

METHODS

The National Surgical Quality Improvement Program database was queried for patients undergoing common hand and upper extremity surgery between 2011 and 2016. Major and minor postoperative complications were identified. Demographics, comorbidity, and preoperative laboratory values were identified, and the percentage missing of each was tabulated. To demonstrate how missing data can alter analysis results, these variables were evaluated for an association with major complications using multivariable regression on 3 separate cohorts: (1) all patients; (2) all patients after exclusion of any patient entry with >10% of missing data; and (3) after removal of any patient entry with any missing data.

RESULTS

Groups 1, 2, and 3 had 48 370, 23 118, and 6280 patients, respectively. There were 14 variables associated with increased odds of major complications in group 1, yet only 10 and 9 variables for groups 2 and 3, respectively. Six variables were associated with increased major complications across all 3 groups, whereas only 1 was associated with decreased odds of major complications across all groups.

CONCLUSIONS

Filtering patient cohorts according to the amount of missing patient information affected analyses of predictors for major complications associated with hospital-based hand surgery. These findings highlight the importance of considering and addressing missing data in large database studies.

Unplanned Return to the Operating Room in Upper-Extremity Surgery: Incidence and Reason for Return

PURPOSE

Complications after upper-extremity surgery are generally infrequent. The purpose of this study was to assess the rate of early unplanned return to the operating room (URTO) within 3 months after surgery) in upper-extremity surgical procedures. Our hypotheses were that the rate of URTO in upper-extremity surgery would be low and that surgically treated fractures would be at greatest risk for complications.

METHODS

We performed a retrospective review of all upper-extremity surgical procedures performed at a large academic practice of fellowship-trained hand surgeons over a 5-year period. A chart review was conducted of all patients who underwent a second surgery within 3 months of the initial surgery. The surgical billing database was queried to determine the incidence of URTO per Current Procedural Terminology code.

RESULTS

There were 422 Current Procedural Terminology codes with URTO out of a total of 62,608, for an incidence of 0.6%. The most frequently performed procedures were carpal tunnel release (10,674; 0.1% URTO), trigger finger release (4,549; 0.5% URTO), and open reduction internal fixation (ORIF) for distal radius fracture (2,728; 1.2% URTO). Procedures with the highest incidences of URTO were open reduction and internal fixation of the ulna (4.9%) and excision of the olecranon bursa (4.1%). Traumatic injuries were more commonly associated with URTO compared with elective procedures. Bony trauma and soft tissue trauma had URTO incidences of 1.4% and 1.1%, respectively, whereas bony elective and soft tissue elective cases were 0.6% and 0.4%, respectively.

CONCLUSIONS

The 90-day URTO rate after upper-extremity surgery was low but higher than previously reported 30-day reoperation rates. Elbow procedures were most likely to result in URTO, as were procedures relating to bony and soft tissue trauma. Based on these results, we are able to counsel patients that the most common procedures we perform have low URTO rates, but surgically treated fractures are at greatest risk.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Missing Data in the National Surgical Quality Improvement Program Database: How Does It Affect the Identification of Risk Factors for Shoulder Surgery Complications?

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.

Understanding the Radiographic Anatomy of the Proximal Ulna and Avoiding Inadvertent Intraarticular Screw Placement

OBJECTIVES

To map the proximal ulnar articular margins and ensure safe extraarticular placement of implants.

METHODS

Ten fresh frozen adult elbow cadaver specimens were obtained. Radiopaque wire was applied to the articular margin of the articular facets and the central trochlear ridge of the proximal ulna. Fluoroscopic images were obtained demonstrating the articular facet margins. Radiographic measurements were performed and used to identify relative safe screw zones.

RESULTS

All specimens demonstrated marked extension of the ulnar and radial facets dorsal to the central trochlear ridge. The dorsal extent of the ulnar facets from the central trochlear ridge averaged 9.7 mm (range, 7.9-13 mm; SD, 1.5 mm) and 6.2 mm (range, 3.4-9.4 mm; SD, 1.9 mm), respectively. The average footprint of the posterior ulnar facet occupied 44% (±4.9%) of the total ulnar height from the dorsal cortex to the trochlear ridge.

CONCLUSIONS

The articular margins of the anterior and posterior facets of the proximal ulna are challenging to identify radiographically. A surgical "at-risk zone" exists within 9.7 mm from the radiographic margin of the central trochlear ridge. Implants placed within this zone have the potential to violate the articular surface.

Thirty-Day Reoperation and/or Admission After Elective Hand Surgery in Adults: A 10-Year Review

PURPOSE

Whereas acute complications following elective hand surgery have been assumed to be rare, the incidence of 30-day unplanned reoperation and/or admission for the most common elective procedures has not been well described. Our goal was to calculate the incidence and identify the risk factors associated with these complications in a busy academic practice.

METHODS

Our institution's quality assurance database was examined retrospectively for unplanned reoperations and/or admissions within 30 days in adults undergoing elective procedures with 2 senior attending surgeons from February 2006 to January 2016. Each event was categorized by causative factor and charts were reviewed to establish risk factors and cultured organisms. Our billing database was examined for the concomitant procedural volume.

RESULTS

In our cohort of 18,081 surgeries (57.6% carpal tunnel or trigger digit releases), 27 patients had an unplanned reoperation and/or admission within 30 days (0.15% total incidence; including carpal tunnel release, 0.10%; trigger digit release, 0.09%; major wrist surgery, 0.74%) including 17 infections (0.09%). These were unevenly distributed over time after surgery with 29.6% occurring within 7 days, 59.2% in 8 to 14 days, 11.1% in 15 to 21 days, and none between 22 and 30 days.

CONCLUSIONS

Reoperations and/or unplanned admission within 30 days after elective hand surgery are infrequent (15 per 10,000 cases) and are most commonly related to infections (63.0%). More invasive surgeries are associated with a higher incidence than simpler procedures, and these complications are most likely to occur within 3 weeks after surgery. These data in elective patients do not cover certain clinically relevant outcomes, such as chronic pain or limited function, and may not be generalizable to all practices.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.