A Matched Comparison of Postoperative Complications Between Smokers and Nonsmokers Following Open Reduction Internal Fixation of Distal Radius Fractures

Are There Racial and Ethnic Disparities in Management and Outcomes of Surgically Treated Distal Radius Fractures?

BACKGROUND

Racial/ethnic disparities have been demonstrated across multiple orthopedic sub-specialties. There is a paucity of literature examining disparities in distal radius fracture (DRF) management.

METHODS

Using the National Surgical Quality Improvement Program database, we analyzed 15 559 non-Hispanic (NH) White, NH Black, NH Asian, and Hispanic adults who underwent open reduction and internal fixation for DRF from 2013 to 2019. We evaluated time from hospital admission to surgery and length of stay using Poisson regression. Deep venous thrombosis, pulmonary embolism (PE), and wound complications were reported using descriptive statistics. Thirty-day reoperation and readmission were analyzed using binary logistic regression.

RESULTS

Wait time to surgery was longer for Hispanic patients than NH White patients (incidence rate ratio [IRR]: 2.54, P < .001); this narrowed over time (IRR: 0.944, P = .047). Length of stay was longer for NH Black (IRR: 1.78, P < .001) and Hispanic patients (IRR: 1.83, P < .001), but shorter for NH Asian (IRR: 0.715, P = .019) than NH White patients; this temporally narrowed for NH Black patients (IRR: 0.908, P = .001). Deep venous thrombosis, PE, and wound complications occurred at a rate less than 0.30% across all groups. Hispanic patients were less likely to undergo reoperation than NH White patients (odds ratio [OR]: 0.254, P = .003). While there was no difference in readmission between groups in the aggregated study period, NH Black patients experienced a temporal increase in readmissions relative to NH White patients (OR: 1.40, P = .038).

CONCLUSIONS

Racial and ethnic disparities exist in DRF management. Further investigation on causes for and solutions to combat these disparities in DRF care may help improve the inequities observed.

Cannabis Abuse Is Associated With Greater Medical Complications, Emergency Department Visits, and Readmissions Following Open Reduction and Internal Fixation for Distal Radius Fractures

BACKGROUND

Despite increased legalization, little is known about the influence of cannabis use disorder (CUD) following open reduction and internal fixation (ORIF) for distal radius fractures (DRFs). The aims were to determine whether CUD patients undergoing ORIF for DRF have increased: (1) medical complications; and (2) health care utilization (emergency department [ED] visits and readmission rates).

METHODS

Patients were identified from an insurance database from 2010 to 2020 using Current Procedural Terminology codes: 25607, 25608, and 25609. Patients with a history of CUD were 1:5 ratio matched to controls by age, sex, tobacco use, alcohol abuse, opioid dependence, and comorbidities. This yielded 13,405 patients with (n = 2,297) and without (n = 11,108) CUD. Outcomes were to compare 90-day medical complications, ED visits, and readmissions. Multivariable logistic regression models computed the odds ratios of CUD on dependent variables. P values less than .005 were significant.

RESULTS

The incidence of CUD among patients aged 20 to 69 years undergoing ORIF increased from 4.0% to 8.0% from 2010 to 2020 (P < .001). Cannabis use disorder patients incurred significantly higher rates and odds of developing 90-day medical complications (15.24% vs 5.76%), including pneumoniae (3.66% vs 1.67%), cerebrovascular accidents (1.04% vs 0.32%), pulmonary emboli (0.57% vs 0.16%), respiratory failures (1.00% vs 0.48%), and surgical site infections (1.70% vs 1.04%; all P < .004). Emergency department visits (2.53% vs 1.14%) and readmission rates (5.79% vs 4.29%) within 90 days were higher among cannabis abusers.

CONCLUSIONS

With a greater number of states legalizing cannabis, hand surgeons should be cognizant of the association with increased 90-day complications and health care utilization parameters.

Strategies for Perioperative Optimization in Upper Extremity Fracture Care

Perioperative optimization in upper extremity fracture care must balance the need for timely treatment with the benefits of medical optimization. Care pathways directed at optimizing glycemic control, chronic anticoagulation, smoking history, nutrition, and frailty can reduce surgical risk in upper extremity fracture care. The development of multidisciplinary approaches that tie risk modification with risk stratification is needed.

Cannabis Use in Patients With Distal Radius Fractures: A Moment of Unity?

BACKGROUND

As legalization of cannabis spreads, an increasing number of patients who use cannabis are being seen in the clinical setting. This study examined the impact of cannabis and tobacco use on postoperative complications following open reduction and internal fixation (ORIF) of distal radius fractures.

METHODS

A national, all-payer database was queried to identify patients who underwent ORIF of a distal radius fracture between 2015 and 2020 (n = 970 747). Patients were stratified into the following groups: (1) tobacco use (n = 86 941), (2) cannabis use (n = 898), (3) tobacco and cannabis use (n = 9842), and (4) neither tobacco nor cannabis use ("control", 747 892). Multivariable logistic regression was used to identify risk factors for infection, nonunion, and malunion within the first postoperative year.

RESULTS

Concomitant use of tobacco and cannabis was associated with a higher rate of nonunion (5.0%) compared to tobacco or cannabis use alone (P < .001). Multivariate analysis identified cannabis-only use (odds ratio [OR] 1.25), tobacco-only use (OR 2.17), and concurrent tobacco and cannabis use (OR 1.78) as risk factors for infection within the first postoperative year. Similarly, cannabis-only use (OR 1.47), tobacco-only use (OR 1.92), and concurrent tobacco and cannabis use (OR 2.52) were associated with an increased risk of malunion.

CONCLUSIONS

Cannabis use is associated with an elevated risk of infection and malunion following operative management of a distal radius fracture. Concomitant use of cannabis and tobacco poses an elevated risk of nonunion and malunion compared to tobacco use alone.

Racial Disparities in Surgical Versus Nonsurgical Management of Distal Radius Fractures in a Medicare Population

BACKGROUND

As racial/ethnic disparities in management of distal radius fractures (DRFs) have not been well elucidated in the literature, this study sought to evaluate the correlation of race/ethnicity on surgical versus nonsurgical management of DRFs in a Medicare population.

METHODS

The PearlDiver Standard Analytical Files Medicare claims database was used to identify patients ≥65 years old with isolated DRF. Patients with polytrauma or surgery performed for upper extremity neoplasm were excluded. Surgical versus nonsurgical management was compared based on demographics, comorbidity (Elixhauser Comorbidity Index, ECI), race/ethnicity, and whether the fracture was open or closed. Univariate and multivariable analyses were used to assess for independent predictors.

RESULTS

Of 54 564 isolated DRFs identified, surgery was performed for 20 663 (37.9%). On multivariable analysis, patients were independently less likely to receive surgical management if they were: older (relative to 65- to 69-year-olds, incrementally decreasing by age bracket up to >85 years where odds ratio [OR] was 0.27, P < .001), higher ECI (per 2 increase OR: 0.96, P < .001), and closed fractures (OR: 0.35, P < .001). For race/ethnicity: black (OR: 0.64, P < .001), Hispanic (OR: 0.71, P < .001), and Asian (OR: 0.60, P < .001) patients were less likely to undergo surgery.

CONCLUSIONS

While age, comorbidities, and fracture type are known to affect surgical decision-making for DRF, race/ethnicity has not previously been reported, and its independent prediction of nonsurgical management for several groups points to a disparity in surgical decision-making/access to care. This highlights the need for increased attention to initiatives that seek to provide equitable care to all patients.

LEVEL OF EVIDENCE

Level III-Retrospective review of national database.

Modified Frailty Index Identifies Increased Risk of Postoperative Complications in Geriatric Patients After Open Reduction Internal Fixation for Distal Radius and Ulna Fractures: Analysis of 5654 Geriatric Patients, From the 2005 to 2017 the National Surgical Quality Improvement Project Database

BACKGROUND

Open reduction internal fixation (ORIF) of distal radius and ulnar fractures (DRUFs) is one of the most common fracture surgeries for hand surgeons. Few studies have evaluated how frailty contributes to outcomes in geriatric hand surgery patients. This study hypothesizes that geriatric patients scoring higher on the modified Frailty Index 5 (mFI-5) are at greater risk of postoperative complications following DRUF fixation.

METHODS

The American College of Surgeons National Surgical Quality Improvement Project database was reviewed for ORIF for DRUFs from 2005 to 2017. Statistically significant differences for demographics, comorbidities, mFI-5, and postoperative complications between geriatric and nongeriatric patients were evaluated with multivariate logistic regression analysis.

RESULTS

A total of 17,097 ORIF for DRUFs were collected by the National Surgical Quality Improvement Project 2005-2017, with 5654 patients older than 64 years (33.2%). Average age for geriatric patients undergoing ORIF for DRUFs was 73.7 years. Within geriatric patients, an mFI-5 score >2 confers 1.6-times increased risk of returning to the operating room following ORIF for DRUF (adjusted odds ratio, 1.6; P = 0.02), whereas an increase in mFI-5 score >2 confers a 3.2-times increased risk of deep vein thrombosis among geriatrics (adjusted odds ratio, 3.2 P < 048).

CONCLUSION

Frailty among geriatric patients confers increased risk of deep vein thrombosis postoperatively. Geriatric patients with higher frailty scores carry a significantly increased risk of returning to the operating room within 30 days. Hand surgeons can use the mFI-5 to screen geriatric patients with DRUF patients to guide perioperative decision-making.

Correlation of Patient Reported Satisfaction With Adverse Events Following Elective Posterior Lumbar Fusion Surgery: A Single Institution Analysis

Background

With increasing emphasis on patient satisfaction metrics, such as the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, hospital reputations and reimbursements are being affected by their results. The purpose of the current study is to determine if post-operative self-reported patient satisfaction differed among patients who experienced any adverse event (AAE) following elective posterior lumbar fusion (PLF) surgery compared to those who did not.

Methods

Patients who underwent elective PLF surgery performed at a single institution between February 2013 and May 2020 and returned an HCAHPS survey following discharge were included in the retrospective cohort analysis. Demographic, comorbidity, and HCAHPS survey data were compared between patients who did and did not experience any adverse event (AAE) in the 30-days postoperatively.

Results

Of 5,117 PLF patients, the HCAHPS survey was returned by 1,071 patients, of which 30-day AAE was experienced by 40 (3.73%). Of those that experienced AAE, the survey response rate was significantly lower (13.94% versus 21.35%, p=0.003). Those responding reported lower scores pertaining to if medication side-effects were adequately explained (22.22% versus 52.56%, p=0.002) and if post-discharge care was adequately explained (79.17% versus 93.76%, p=0.005), as well as overall top-box responses (67.62% versus 75.93% survey average, p<0.001).

Conclusions

Patients experiencing AAE after elective PLF surgery are less likely to respond to surveys about their hospital experience. For those who did respond, they report less satisfaction with multiple aspects of their hospital care measured by the HCAHPS survey. Understanding how postoperative adverse events impact patients' perception of healthcare quality provides insight into what patients value and has implications for optimizing their care.

Resident and Fellow Participation Does Not Affect Short-Term Postoperative Complications After Distal Radius Fracture Fixation

Background  Complications after open reduction internal fixation (ORIF) for distal radius fractures (DRF) are well documented, but the impact of trainee involvement on postoperative outcomes has not been studied. Questions  Does trainee involvement affect postoperative complication rates and length of hospital stay? Methods  The American College of Surgeons National Surgical Quality Improvement Program was queried from 2006 to 2012 for patients undergoing DRF ORIF. A 1:1 propensity score matched resident/fellow involved cases to attending-only cases. Demographics, length of stay, and postoperative complications were compared between the two groups. Logistic regression was used to evaluate independent predictors of adverse events and to evaluate cases with and without trainee involvement. Results  Overall, 3,003 patients underwent DRF ORIF from 2006 to 2012. After matching, 1,150 cases (50% with resident/fellow involvement) were included. The overall rate of adverse events was 4.4% (46/1,050). There were no significant differences in the short-term complication rate in trainee-involved (2.3%) versus attending-only cases (3.9%) ( p  = 0.461). For ORIF of DRF, there were no significant differences, between attending-only cases and resident/fellow-involved cases, with regard to short-term major complications ( p  = 0.720) or minor complications ( p  = 0.374). Length of hospital stay was similar between cohorts (1.22 vs. 0.98 days) ( p  = 0.723). On multivariate analysis, trainee involvement was not an independent predictor of minor, major, or any complication after DRF fixation after controlling for multiple independent factors (all p  > 0.364). Discussion  Trainee participation in DRF ORIF is not associated with increased risk of short-term (30 days) medical or surgical postoperative complications. Level of Evidence  This is a Level IV case-control study.

Minimal important difference and patient acceptable symptom state for the Numerical Rating Scale (NRS) for pain and the Patient-Rated Wrist/Hand Evaluation (PRWHE) for patients with osteoarthritis at the base of thumb

Background

The Numerical Rating Scale (NRS) and Patient-rated wrist/hand evaluation (PRWHE) are patient-reported outcomes frequently used for evaluating pain and function of the wrist and hand. The aim of this study was to determine thresholds for minimal important difference (MID) and patient acceptable symptom state (PASS) for NRS pain and PRWHE instruments in patients with base of thumb osteoarthritis.

Methods

Fifty-two patients with symptomatic base of thumb osteoarthritis wore a splint for six weeks before undergoing trapeziectomy. NRS pain (0 to 10) and PRWHE (0 to 100) were collected at the time of recruitment (baseline), after splint immobilization prior to surgery, and at 3, 6, 9 and 12 months after surgery. Four anchor-based methods were used to determine MID for NRS pain and PRWHE: the receiver operating characteristics (ROC) curve, the mean difference of change (MDC), the mean change (MC) and the predictive modelling methods. Two approaches were used to determine PASS for NRS pain and PRWHE: the 75^th percentile and the ROC curve methods. The anchor question for MID was the change perceived by the patient compared with baseline; the anchor question for PASS was whether the patient would be satisfied if the condition were to stay similar. The correlation between the transition anchor at baseline and the outcome at all time points combined was calculated using the Spearman’s rho analysis.

Results

The MID for NRS pain was 2.5 using the ROC curve method, 2.0 using the MDC method, 2.8 using the MC method, and 2.5 using the predictive modelling method. The corresponding MIDs for PRWHE were 22, 24, 10, and 20. The PASS values for NRS pain and PRWHE were 2.5 and 30 using the ROC curve method, and 2.0 and 22 using the 75th percentile method, respectively. The area under curve (AUC) analyses showed excellent discrimination for all measures.

Conclusion

We found credible MID estimates for NRS and PRWHE (including its subscales), although the MID estimates varied depending on the method used. The estimates were 20-30% of the range of scores of the instruments. The cut-offs for MID and PASS showed good or excellent discrimination, lending support for their use in future studies.

Trial registration

This clinimetrics study was approved by the Helsinki University ethical review board (HUS1525/2017).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12874-022-01600-1.

30-Day outcomes analysis of surgical management of radial head fractures comparing radial head arthroplasty to open reduction internal fixation

INTRODUCTION

Radial head arthroplasty and open reduction internal fixation are two commonly utilized treatment options for radial head fractures. The purpose of this study is to assess the incidence of and risk factors for short-term complications following radial head arthroplasty and open reduction internal fixation of radial head fractures.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program was queried to identify patients that underwent radial head arthroplasty or open reduction internal fixation for radial head fractures between January 1st, 2015 and December 31st, 2017. The incidence of various 30-day complications, including unplanned readmission, reoperation, non-home discharge, mortality, surgical/medical complications, and extended length-of-stay were compared between the two propensity matched groups. Multivariate logistic regression was used to identify independent risk factors for various short-term complications.

RESULTS

After propensity matching, a total of 435 patients were included in our analysis. 250 patients underwent radial head arthroplasty, and 185 patients underwent open reduction internal fixation. Arthroplasty treated patients had a significantly longer mean total operative time (p = .031) and length-of-stay (p = .003). No significant 30-day complications differences were found for unplanned readmission, reoperation, non-home discharge, mortality, surgical complications or medical complications. Independent risk factors for any complications of both procedures included a history of chronic obstructive pulmonary disease and American Society of Anesthesiologists class III. Significant risk factors for length-of-stay greater than two days included a history of bleeding disorder and American Society of Anesthesiologists class III.

CONCLUSION

Our study revealed there were no significant differences in 30-day perioperative surgical or medical complications from either surgical treatment of radial head fractures; however, radial head arthroplasty treated patients were met with a significantly longer length-of-stay and longer duration of operating time. We also identified risk factors that were independently associated with higher rates of complications regardless of treatment type.

Comparison of Complication Risk Following Trigger Digit Release Performed in the Office Versus the Operating Room: A Population-Based Assessment

PURPOSE

Trigger digit release (TDR) performed in an office-based procedure room (PR) setting minimizes surgical costs compared with that performed in an operating room (OR); yet, it remains unclear whether the rates of major complications differ by setting. We hypothesized that surgical setting does not have an impact on the rate of major complications after TDR.

METHODS

Adult patients who underwent isolated TDR from 2006 to 2015 were identified from the MarketScan commercial database (IBM) using the provider current procedural terminology code 26055 with a concordant diagnosis on the same claim line (International Classification of Diseases, ninth revision, clinical modification 727.03). The PR cohort was defined by presence of a place-of-service code for an in-office procedure without OR or ambulatory center revenue codes, or anesthesiologist claims, on the day of the surgery. The OR cohort was defined by presence of an OR revenue code. We identified major medical complications, surgical site complications, as well as iatrogenic neurovascular and tendon complications within 90 days of the surgery using International Classification of Diseases, ninth revision, clinical modification diagnosis and/or current procedural terminology codes. Multivariable logistic regression was used to compare the risk of complications between the PR and OR groups while controlling for Elixhauser comorbidities, smoking, and demographics.

RESULTS

For 7,640 PR and 29,962 OR cases, the pooled rate of major medical complications was 0.99% (76/7,640) and 1.47% (440/29,962), respectively. The PR setting was associated with a significantly lower risk of major medical complications in the multivariable analysis (adjusted odds ratio 0.76; 95% confidence interval 0.60-0.98). The pooled rate of surgical site complications was 0.67% (51/7,640) and 0.88% (265/29,962) for the PR and OR cases, respectively, with no difference between the surgical settings in the multivariable analysis (adjusted odds ratio 0.81; 95% confidence interval 0.60-1.10). Iatrogenic complications were infrequently observed (PR 5/7,640 [0.07%]; OR 26/29,962 [0.09%]).

CONCLUSIONS

Compared with performing TDR in the OR using a spectrum of commonly used anesthesia types, performing TDR in the PR using local-only anesthesia was associated with a comparably low risk of major medical complications, surgical complications, and iatrogenic complications.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.