The Influence of Obesity on Total Elbow Arthroplasty

Short-term adverse event rates and risk factors following total elbow arthroplasty for fracture and arthropathy: a matched analysis of nationally representative data

BACKGROUND

Total elbow arthroplasty (TEA) is a mainstay treatment for elbow arthropathy and elbow fracture that can relieve pain and restore functional motion. The purpose of this study was to determine the role of surgical indication in the incidence of short-term adverse events and risk factors influencing complications in TEA to treat arthropathy compared to TEA for fracture. Matched cohorts were created to better isolate the impact of the surgical indication.

METHODS

The study identified patients within the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database that underwent TEA to treat arthropathy or fracture from 2010 to 2020. Matched cohorts were created to analyze the incidence of 30 day adverse events and risk factors for complications.

RESULTS

The study included 599 patients for analysis. The overall incidence of any adverse event was 9.7%. In matched cohorts of 218 patients, the fracture group experienced a higher incidence of overall adverse events (13.8% vs. 6.0% in the arthropathy group, p = 0.009) and postoperative transfusions (9.6% vs. 1.8% in the arthropathy group, p < 0.001). Logistic regression revealed an increased risk of any adverse event in the combined matched cohort with longer operative times (OR = 1.007, CI: 1.002-1.012, p = 0.006) and those undergoing fracture treatment (OR = 2.447, CI: 1.047-5.717, p = 0.039). Outpatient status was associated with a lower risk of adverse events in the combined matched cohort (OR = 0.207, CI: 0.058-0.739, p = 0.015).

CONCLUSIONS

Even when controlling for comorbidities, patients undergoing TEA for fracture have a greater likelihood of short-term complications, particularly requiring a blood transfusion. Treatment of a fracture and increased operative time were risk factors for all patients, while outpatient status was protective.

LEVEL OF EVIDENCE

III.

Complex elbow fracture-dislocations- what factors are associated with a poor post-operative outcome?

PURPOSE

Despite standardized treatment algorithms, patients with complex elbow fracture-dislocation frequently suffer from poor post-operative elbow function leading to reduced quality of life. Up to now, there is no valuable data regarding risk factors that lead to poor post-operative outcome after surgical reconstruction of complex elbow fracture-dislocations.

METHODS

From 06/2010 to 12/2020 134 patients (51.3 ± 15.1 years, 44% women) undergoing surgical treatment of complex elbow fracture-dislocations could be included in this study. Follow-up period was 4.4 years (SD 2.5). All patients were clinically evaluated for elbow movement, elbow stability and common elbow scores (MEPS, OES, DASH-Score). Potential risk factors for poor post-operative outcome were identified using bi- and multivariate analyses.

RESULTS

Overall good post-operative outcome has been achieved, mean MEPS was 88.8 ± 17.6. Post-operative complications occurred in 31.3% of the cases, while 25.4% required surgical revision. Patients with transolecranon dislocation fractures showed the significantly worst functional outcomes (p = 0.01). In addition, it has been shown that a patient's age of more than 70 years (OR = 10, p = 0.003) and a BMI of more than 35 kg/m2 (OR = 7.6, p = 0.004) are independent risk factors for a poor post-operative outcome. In contrast, gender and time to surgery showed no significant influence on post-operative outcome.

CONCLUSION

In most cases, good post-operative functional results can be achieved using standardized treatment protocols. However, complication and revision rates remain high. Patients older than 70 years of age or with a BMI over 35 kg/m2 are at risk for an inferior outcome and require close follow-up monitoring.

Comparison of baseline demographics and risk factors for aseptic loosening following primary total elbow arthroplasty

BACKGROUND

Aseptic loosening is a feared complication following total elbow arthroplasty (TEA); however, literature regarding factors that may contribute to this complication is limited. The aims of this investigation were to: (1) compare baseline demographics of patients who developed aseptic loosening following primary TEA; and (2) identify patient-specific risk factors for the development of loosening.

METHODS

Retrospective analysis using a nationwide claims database was performed to identify patients who underwent primary TEA and developed aseptic loosening within 2 years (study n = 307, control n = 10,741). Multivariate regression analysis generated odds ratio (OR), 95% confidence interval (95% CI), and p-value of risk factors. p < 0.05 was considered statistically significant.

RESULTS

Patients who developed aseptic loosening had significant differences in numerous demographics, including age (p = 0.0001), sex (p = 0.0251), and various comorbid conditions such as obesity (15.96% vs. 8.36%, p < 0.0001). Furthermore, the risk factors most associated with aseptic loosening were obesity (OR 1.65, 95% CI 1.18-2.28, p = 0.002), male sex (OR 1.51, 95% CI 1.13-2.00, p = 0.004), and concomitant opioid use disorder (OR 1.58, 95% CI 1.14-2.15, p = 0.004).

DISCUSSION

This study is the first to identify demographics and patient-related risk factors associated with aseptic loosening following primary TEA. This evidence could be applied to the clinical setting in order to educate at-risk patients of this potential complication as well as inform their post-operative clinical management.

LEVEL OF EVIDENCE

Level III: Prognostic.

Implant survival of total elbow arthroplasty: analysis of 514 cases from the Dutch Arthroplasty Registry

The aim of this study is to report the implant survival and factors associated with revision of total elbow arthroplasty (TEA) using data from the Dutch national registry. All TEAs recorded in the Dutch national registry between 2014 and 2020 were included. The Kaplan-Meier method was used for survival analysis, and a logistic regression model was used to assess the factors associated with revision. A total of 514 TEAs were included, of which 35 were revised. The five-year implant survival was 91%. Male sex, a higher BMI, and previous surgery to the same elbow showed a statistically significant association with revision (p < 0.036). Of the 35 revised implants, ten (29%) underwent a second revision. This study reports a five-year implant survival of TEA of 91%. Patient factors associated with revision are defined and can be used to optimize informed consent and shared decision-making. There was a high rate of secondary revisions.

Total Elbow Arthroplasty: A Descriptive Analysis of 170 Patients From a United States Integrated Health Care System

PURPOSE

Total elbow arthroplasty (TEA) can be used, with varying degrees of success, for the treatment of rheumatoid arthritis, osteoarthritis, and distal humerus fractures and their sequelae in elderly patients. Some of the largest studies of TEA have included data from more than 20 years ago and may not reflect the current practice of TEA. We sought to describe a modern cohort of patients who underwent TEA in a United States integrated health care system.

METHODS

All patients aged 18 years and older who underwent primary unilateral TEA from January 1, 2009, through March 31, 2018, were identified to conduct a descriptive study. The patients' characteristics and demographics, including age, body mass index, sex, diabetes status, American Society of Anesthesiologists classification, and surgical indication, were recorded. The crude cumulative revision probability as well as the 90-day postoperative incidence rate of emergency department visit, readmission, and mortality was calculated.

RESULTS

A total of 170 patients met our inclusion criteria. The annual procedure volume nearly doubled, from 11 procedures in 2009 to 21 procedures in 2017. The most common indication for TEA was fracture (40.6%), followed by rheumatoid arthritis (36.5%). At 4-year follow up, the crude cumulative revision probability was 9.8% (95% confidence interval, 5.6%-16.9%). Of the 170 patients who underwent TEA, 43 (25.3%) experienced a 90-day emergency department visit, 24 (14.1%) experienced a 90-day readmission, and 2 (1.2%) died within 90 days postoperatively.

CONCLUSIONS

This cohort of patients who underwent TEA using modern implants showed a notable increase in the volume of TEA over the study period, with more TEAs performed for trauma. The incidence of readmission and emergency department visits following TEA were high in this study. Further studies are needed to better define the current practice of TEA in the community at large.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Thirty-day readmissions and reoperations after total elbow arthroplasty: a national database study

BACKGROUND

The purpose of this study was to determine the rate of short-term complications after total elbow arthroplasty (TEA) and identify predictors of readmission and reoperation. We hypothesized that TEA performed for acute elbow trauma would have higher rates of 30-day readmission and reoperation than TEA performed for osteoarthritis (OA).

METHODS

Using the National Surgical Quality Improvement Program for the years 2011-2017, we identified patients undergoing TEA for fracture, OA, or inflammatory arthritis. Patient demographic characteristics, comorbidities, reoperations, and readmissions within 30 days of surgery were analyzed. Potential predictors of reoperation and readmission in the model included age, sex, race, body mass index (BMI), diabetes, hypertension, chronic obstructive pulmonary disease, congestive heart failure, smoking, bleeding disorders, American Society of Anesthesiologists classification, wound classification, operative time, and indication for surgery.

RESULTS

A total of 414 patients underwent TEA from 2011-2017. Of these patients, 40.6% underwent TEA for fracture; 37.0%, for OA; and 22.7%, for inflammatory arthritis. The overall rate of unplanned readmissions was 5.1% (21 patients). The rate of unplanned reoperations was 2.4% (10 patients). Infection was the most common reason for both unplanned readmissions and reoperations. The rates of reoperations and readmissions were not significantly associated with any of the 3 operative indications: fracture, OA, or inflammatory arthritis. Multiple logistic regression analysis found increased BMI to be associated with lower odds of an unplanned readmission (odds ratio [OR], 0.883; 95% confidence interval [CI], 0.798-0.963; P = .0035) and found wound classification ≥ 3 to be associated with increased odds of an unplanned reoperation (OR, 16.531; 95% CI, 1.300-167.960; P = .0144) and total local complications (OR, 17.587; 95% CI, 2.207-132.019; P = .0057). Patients who were not functionally independent were more likely to experience local complications (OR, 4.181; 95% CI, 0.983-15.664; P = .0309) than were functionally independent patients.

CONCLUSIONS

The 30-day unplanned reoperation rate after TEA was 2.4%, and the unplanned readmission rate was 5.1%. Low BMI was predictive of readmission. Wounds classified as contaminated or dirty were predictive of reoperation. Dependent functional status and contaminated wounds were predictive of local complications. The indication for TEA (fracture vs. OA vs. inflammatory arthritis) was not found to be a risk factor for reoperation or readmission after TEA.