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Truong NM, Stroud SG, Zhuang T, Fernandez A, Kamal RN, Shapiro LM. The Association Between Social Determinants of Health and Distal Radius Fracture Outcomes. J Hand Surg Am 2024; 49:875-884. [PMID: 38934997 DOI: 10.1016/j.jhsa.2024.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Revised: 03/25/2024] [Accepted: 04/10/2024] [Indexed: 06/28/2024]
Abstract
PURPOSE The purpose of this study was to determine if adverse social determinants of health (SDOH) are associated with differential complication rates following surgical fixation of distal radius fractures and assess which SDOH domain (economic, educational, social, health care, or environmental) is most associated with postoperative complications. METHODS Using a national administrative claims database, we conducted a retrospective cohort analysis of patients undergoing open treatment for an isolated distal radius fracture between 2010 and 2020. Patients were stratified based on the presence/absence of at least one SDOH code and propensity score matched to create two cohorts balanced by age, sex (male or female), insurance type, and comorbidities. Social determinants of health examined included economic, educational, social, health care, and environmental factors. Multivariable logistic regression analyses were performed to assess the isolated effect of SDOH on 90-day and 1-year complication rates. RESULTS After propensity matching, 57,025 patients in the adverse SDOH cohort and 57,025 patients in the control cohort were included. Patients facing an adverse SDOH were significantly more likely to experience 90-day complications, including emergency department visits (Odds ratio (OR): 3.18 [95% confidence interval (CI): 3.07-3.29]), infection (OR: 2.37 [95% CI: 2.12-2.66]), wound dehiscence (OR: 2.06 [95% CI: 1.72-2.49]), and 1-year complications, including complex regional pain syndrome (OR: 1.35 [95% CI: 1.15-1.58]), malunion/nonunion (OR: 1.18 [95% CI: 1.08-1.29]), and hardware removal (OR: 1.13 [95% CI: 1.07-1.20]). Additionally, patients facing an adverse SDOH had a significantly increased risk of 90-day complications, regardless of fracture severity, and patients with economic and social challenges had the highest odds of both 90-day and 1-year postoperative complications. CONCLUSIONS Social determinants of health are associated with increased complications following distal radius fracture fixation, even when controlling for demographic and clinical factors. We recommend routine screening for adverse SDOH and inclusion of SDOH data into health records to not only inform quality improvement initiatives and risk adjustment for outcome-based quality measurements but also to allow providers to begin to discuss and address such barriers during the perioperative period. TYPE OF STUDY/LEVEL OF EVIDENCE Prognosis II.
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Affiliation(s)
- Nicole M Truong
- Department of Orthopaedic Surgery, University of California, San Francisco, CA
| | - Sarah G Stroud
- Department of Orthopaedic Surgery, University of California, San Francisco, CA
| | - Thompson Zhuang
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA
| | - Alicia Fernandez
- Department of Internal Medicine, University of California, San Francisco, CA
| | - Robin N Kamal
- VOICES Health Policy Research Center, Department of Orthopaedic Surgery, Stanford University, Redwood City, CA
| | - Lauren M Shapiro
- Department of Orthopaedic Surgery, University of California, San Francisco, CA.
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Stam M, Dankelman LHM, Wijffels MME, Chen NC, Bhashyam AR, Laane CLE. Factors Associated With Reoperation After Distal Radius Nonunion Repair. J Hand Surg Am 2024:S0363-5023(24)00304-6. [PMID: 39140921 DOI: 10.1016/j.jhsa.2024.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Revised: 06/20/2024] [Accepted: 07/03/2024] [Indexed: 08/15/2024]
Abstract
PURPOSE This study aimed to evaluate the incidence of, and factors associated with, reoperation after distal radius nonunion repair. METHODS We conducted a retrospective cohort study at a multicenter academic institution and identified adult patients who underwent open reduction and internal fixation for distal radius nonunion between January 2005 and August 2021. Thirty-three patients were included in this study. The cohort consisted of 13 males (13/33) and had a median age of 56 years (interquartile ranges: 49-64). Median follow-up was 59 months (interquartile ranges: 23-126). RESULTS Unplanned reoperations occurred in eight of 33 patients. The most common reasons for reoperation were irrigation and debridement for infection, revision surgery for persistent nonunion, and unplanned hardware removal. In total, 10 complications occurred in nine patients. The most common complications were infection and persistent nonunion; both occurred in three cases. CONCLUSIONS Complications after distal radius nonunion repair are common. Reoperation after distal radius nonunion repair is required in approximately one of four cases. TYPE OF STUDY/LEVEL OF EVIDENCE Prognosis IV.
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Affiliation(s)
- Mark Stam
- Division of Hand Surgery, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA
| | - Lente H M Dankelman
- Division of Hand Surgery, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA; Department of Surgery, Trauma Research Unit, University Medical Centre, Rotterdam, Erasmus MC, The Netherlands
| | - Mathieu M E Wijffels
- Department of Surgery, Trauma Research Unit, University Medical Centre, Rotterdam, Erasmus MC, The Netherlands
| | - Neal C Chen
- Division of Hand Surgery, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Abhiram R Bhashyam
- Division of Hand Surgery, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Charlotte L E Laane
- Division of Hand Surgery, Department of Orthopaedic Surgery, Massachusetts General Hospital, Boston, MA; Department of Surgery, Trauma Research Unit, University Medical Centre, Rotterdam, Erasmus MC, The Netherlands.
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Moura SP, McLaughlin MT, Gowda M, Shaffrey EC, Edalatpour A, Chu DY, Michelotti BF. The Impact of Neighborhood and Socioeconomic Disparities on Distal Radius Fracture Follow-Up Adherence. Plast Reconstr Surg 2024; 154:306e-316e. [PMID: 37566490 DOI: 10.1097/prs.0000000000010984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/13/2023]
Abstract
BACKGROUND The aims of this retrospective cohort study were (1) to assess whether the Area Deprivation Index (ADI), a novel neighborhood-level socioeconomic disparities metric, is associated with follow-up nonadherence, and (2) to determine the individual-level socioeconomic factors associated with follow-up nonadherence after treatment of distal radius fractures (DRFs). METHODS The authors included all patients who underwent nonoperative or operative management of DRFs at an academic level I trauma center between 2019 and 2021. A manual chart review was performed to collect data on ADI, sociodemographic factors, injury characteristics, conservative and surgical interventions, and health care utilization. RESULTS There was a significant weak negative Spearman-ranked correlation between ADI state deciles and clinic attendance rates ( rs [220] = -0.144 [95% CI, -0.274 to -0.009]; P = 0.032). Socioeconomic factors associated with significant differences in clinic attendance rates were having a spouse or partner (protective) ( P = 0.007), Medicaid insurance ( P = 0.013), male sex ( P = 0.023), and current smoking ( P = 0.026). Factors associated with differences in no-show rates were having a spouse or partner (odds ratio [OR], 0.326 [95% CI, 0.123 to 0.867]; P = 0.025), Medicaid insurance (OR, 7.78 [95% CI, 2.15 to 28.2]; P = 0.002), male sex (OR, 4.09 [95% CI, 1.72 to 9.74]; P = 0.001), and cigarette use (OR, 5.07 [95% CI, 1.65 to 15.6]; P = 0.005). CONCLUSIONS ADI has a weak, negative correlation with clinic attendance rates after DRF treatment. Significant disparities in clinic follow-up adherence exist between patients on the basis of marital status, insurance, sex, and cigarette use. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, III.
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Affiliation(s)
- Steven P Moura
- From the Division of Plastic and Reconstructive Surgery, University of Wisconsin School of Medicine and Public Health
- Boston University School of Medicine
| | - Matthew T McLaughlin
- From the Division of Plastic and Reconstructive Surgery, University of Wisconsin School of Medicine and Public Health
| | - Madhu Gowda
- From the Division of Plastic and Reconstructive Surgery, University of Wisconsin School of Medicine and Public Health
| | - Ellen C Shaffrey
- From the Division of Plastic and Reconstructive Surgery, University of Wisconsin School of Medicine and Public Health
| | - Armin Edalatpour
- From the Division of Plastic and Reconstructive Surgery, University of Wisconsin School of Medicine and Public Health
| | - Daniel Y Chu
- From the Division of Plastic and Reconstructive Surgery, University of Wisconsin School of Medicine and Public Health
| | - Brett F Michelotti
- From the Division of Plastic and Reconstructive Surgery, University of Wisconsin School of Medicine and Public Health
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4
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Ibelli TJ, Alerte E, Akhavan A, Liu H, Kuruvilla A, Katz A, Etigunta S, Taub PJ. The Modified Five-Item Frailty Index to Predict Hand and Wrist Surgical Repair Postoperative Outcomes: An ACS-NSQIP Analysis of 11 369 Patients. Hand (N Y) 2024; 19:433-441. [PMID: 36194006 PMCID: PMC11067845 DOI: 10.1177/15589447221124270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Hand and wrist injuries can cause painful, everyday obstacles for patients. Carefully indexing preoperative patient health conditions may better inform surgical care, leading to improved postoperative outcomes. The purpose of the present study is to evaluate if the Modified Five-Item Frailty Index (mFI-5) can accurately predict postoperative complications for hand and wrist surgical repair. METHODS A retrospective review of the American College of Surgeons' National Surgical Quality Improvement Program database was conducted to investigate patients who underwent hand and wrist surgical repair from January 2013 to December 2019. Patient demographics, comorbidities, surgical logistics, and 30-day readmission due to postoperative complications were extracted. Surgical risk proxies including the mFI-5, age, body mass index (BMI), smoking status within 1 year, the Modified Charlson Comorbidity Index (mCCI), comorbidities, and American Society of Anaesthesiologists Physical Status Classification (ASA class) were calculated. RESULTS A total of 11 369 patients were included. Thirty-day readmission for total postoperative complications (n = 258) was significantly associated with all surgical risk proxies. However, age, mFI-5 > 2, mCCI > 2, comorbidities > 1, and ASA class 2/3 had the highest statistical significance (P = <.001). Thirty-day readmission rates for surgical site infections (n = 118) had the highest statistical significance with age, BMI, mFI-5 > 2, and ASA class 2/3 (P = <.001). A Clavien-Dindo score > 1 (n = 224) had the highest statistical significance with age, mCCI > 2, comorbidity of 1, and an ASA class 3 (P = <.001). CONCLUSIONS The mFI-5 may have value in predicting 30-day readmission due to postoperative complications after surgical repair of hand and wrist injuries.
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Affiliation(s)
| | - Eric Alerte
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Helen Liu
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Abigail Katz
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Suhas Etigunta
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Peter J. Taub
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
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5
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Kong L, Li H, Zhou Y, Zhang B, Han Q, Fu M. Factors predicting complications following open reduction and internal fixation of intra-articular distal radius fracture. Front Surg 2024; 11:1356121. [PMID: 38586239 PMCID: PMC10998443 DOI: 10.3389/fsurg.2024.1356121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Accepted: 03/11/2024] [Indexed: 04/09/2024] Open
Abstract
Objective This study aimed to determine the incidence and predictors of the complications after open reduction and internal fixation (ORIF) of intra-articular distal radius fracture (IADRF) with a minimum follow-up of 12 months. Methods Medical records and outpatient follow-up records were retrospectively reviewed to collect medical, surgical, and complication data on consecutive patients who had undergone an ORIF procedure for an IADRF between January 2019 and June 2022. Data included demographics, comorbidities, injury, surgical characteristics, and laboratory findings on admission. A multivariate logistic regression model was constructed to identify the significant predictors, with a composite of any complications occurring within 12 months after the operation as the outcome variable and potentially a range of clinical data as the independent variables. The magnitude of the relationship was indicated by the odds ratio (OR) and the 95% confidence interval (CI). Results During the study period, 474 patients were included, and 64 had documented complications (n = 73), representing an accumulated rate of 13.5%. Among them, carpal tunnel syndrome was the most common, followed by tenosynovitis caused by tendon irritation/rupture, superficial or deep wound infection, complex regional pain syndrome (CRPS) type 1, radial shortening (≥4 mm), plate/screw problems, and others. The multivariate results showed the following factors significantly associated with increased risk of complications: experience of DRF surgery with <30 cases (OR: 2.2, 95% CI: 1.6-3.5), AO type C fracture (OR: 1.7, 95% CI: 1.2-2.9), initial lunate facet collapse of ≥5 mm (OR: 4.2, 95% CI: 1.4-8.9), and use of temporary external fixation before index surgery (OR: 2.4, 95% CI: 1.5-4.3). Conclusions These findings may aid in patient counseling and quality improvement initiatives, and IADRF should be directed by an experienced surgeon.
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Affiliation(s)
- Lingde Kong
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Hua Li
- Department of Hand and Foot Surgery, Hengshui People’s Hospital, Hengshui, Hebei, China
| | - Yanqing Zhou
- Department of Hand and Foot Surgery, Hengshui People’s Hospital, Hengshui, Hebei, China
| | - Bing Zhang
- Department of Orthopaedic Surgery, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
| | - Quan Han
- Department of Orthopaedic Surgery, Hengshui Sixth People’s Hospital, Hengshui, Hebei, China
| | - Meng Fu
- Medical Examination Center, The Third Hospital of Hebei Medical University, Shijiazhuang, Hebei, China
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Hassoun A, Haroun R, Hoyek F, Lahoud JC, Tawk C, Moussa MEH, Khalil R, Mandour J, Tannoury BE. Relation between the dash score and radiographic evaluation of the wrist in patients with wrist fracture. BMC Musculoskelet Disord 2024; 25:217. [PMID: 38491493 PMCID: PMC10941398 DOI: 10.1186/s12891-024-07307-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 02/24/2024] [Indexed: 03/18/2024] Open
Abstract
Traditionally, the assessment of distal radius fracture outcomes has been based on radiological measurements and self-evaluation scores. However, there is uncertainty regarding how accurately these measurements reflect the patient's perception of their outcome. In this study, we examined the correlation between radiological measurements and patient-perceived outcomes using the Disabilities of the Arm, Shoulder, and Hand outcome (DASH) score. 140 individuals who had recovered from a distal radius fracture. and had been treated with DVR, Kapandji, percutaneous pinning or closed reduction were included in the study. The retrospective assessment included 78 females and 62 males, with a mean DASH score of 3.54 points.Except for the ulnar variance, the study found little to no significant association between the DASH score and the final radiological measurement.In summary, the DASH score did not always indicate that a superior radiological result translated into a better patient-perceived outcome.
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Affiliation(s)
- Anthony Hassoun
- Department of Orthopedic Surgery, CHU Notre Dame Des Secours, Holy Spirit University of Kaslik - School of Medicine and Medical Sciences, Jbeil, Lebanon.
| | - Rami Haroun
- Department of Orthopedic Surgery, CHU Notre Dame Des Secours, Holy Spirit University of Kaslik - School of Medicine and Medical Sciences, Jbeil, Lebanon
| | - Fadi Hoyek
- Department of Orthopedic Surgery, CHU Notre Dame Des Secours, Holy Spirit University of Kaslik - School of Medicine and Medical Sciences, Jbeil, Lebanon
- Department of Orthopedics at Notre Dame des Secours University Hospital, Jbeil, Lebanon
| | - Jean Claude Lahoud
- Department of Orthopedic Surgery, CHU Notre Dame Des Secours, Holy Spirit University of Kaslik - School of Medicine and Medical Sciences, Jbeil, Lebanon
| | - Charbel Tawk
- Department of Orthopedic Surgery, CHU Notre Dame Des Secours, Holy Spirit University of Kaslik - School of Medicine and Medical Sciences, Jbeil, Lebanon
| | - Majd El Hajj Moussa
- Department of Orthopedic Surgery, CHU Notre Dame Des Secours, Holy Spirit University of Kaslik - School of Medicine and Medical Sciences, Jbeil, Lebanon
| | - Rita Khalil
- Department of Orthopedic Surgery, CHU Notre Dame Des Secours, Holy Spirit University of Kaslik - School of Medicine and Medical Sciences, Jbeil, Lebanon
| | - Joseph Mandour
- Department of Orthopedic Surgery, CHU Notre Dame Des Secours, Holy Spirit University of Kaslik - School of Medicine and Medical Sciences, Jbeil, Lebanon
| | - Boutros El Tannoury
- Department of Orthopedic Surgery, CHU Notre Dame Des Secours, Holy Spirit University of Kaslik - School of Medicine and Medical Sciences, Jbeil, Lebanon
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Crook JL, Pientka W, Zhang AY, Golden A, Koehler D, Sammer D. Risk factors for surgical site infection after surgical treatment of closed distal radial fractures. J Hand Surg Eur Vol 2024; 49:310-315. [PMID: 37666217 DOI: 10.1177/17531934231194672] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/06/2023]
Abstract
We assessed operatively treated closed distal radial fractures to identify independent risk factors for surgical site infection after treatment. A retrospective review was carried out of 531 operatively treated closed distal radial fractures over a 5-year period. Multiple logistic regression was performed with infection as the dependent variable, using a stepwise regression procedure to select variables to construct the final model. In total, 19 (3.6%) fractures were complicated by postoperative surgical site infection. Uncontrolled diabetes with HbA1c >7, the presence of external fixation or external Kirschner wires, and tobacco use were significant independent predictors of infection. Age and time in the operating room were also statistically significant predictors but deemed to be not clinically meaningful.Level of evidence: IV.
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Affiliation(s)
- Jennifer L Crook
- Department of Plastic Surgery, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, USA
| | - William Pientka
- Department of Orthopaedic Surgery, John Peter Smith Hospital, Fort Worth, TX, USA
| | - Andrew Y Zhang
- Department of Plastic Surgery, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, USA
| | - Ann Golden
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, USA
| | - Daniel Koehler
- Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, USA
| | - Douglas Sammer
- Department of Plastic Surgery, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, USA
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Zhuang T, Kamal RN. Strategies for Perioperative Optimization in Upper Extremity Fracture Care. Hand Clin 2023; 39:617-625. [PMID: 37827614 DOI: 10.1016/j.hcl.2023.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/14/2023]
Abstract
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.
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Affiliation(s)
- Thompson Zhuang
- Department of Orthopaedic Surgery, VOICES Health Policy Research Center, Stanford University, 450 Broadway Street MC: 6342, Redwood City, CA 94603, USA
| | - Robin N Kamal
- Department of Orthopaedic Surgery, VOICES Health Policy Research Center, Stanford University, 450 Broadway Street MC: 6342, Redwood City, CA 94603, USA.
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Livesey MG, Bains SS, Stern JM, Chen Z, Dubin JA, Monárrez R, Remily EA, Ingari JV. Cannabis Use in Patients With Distal Radius Fractures: A Moment of Unity? Hand (N Y) 2023:15589447231196905. [PMID: 37787484 DOI: 10.1177/15589447231196905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
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.
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Affiliation(s)
- Michael G Livesey
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Sandeep S Bains
- Rubin Institute for Advanced Orthopedics, Baltimore, MD, USA
| | | | - Zhongming Chen
- Rubin Institute for Advanced Orthopedics, Baltimore, MD, USA
| | - Jeremy A Dubin
- Rubin Institute for Advanced Orthopedics, Baltimore, MD, USA
| | - Rubén Monárrez
- Rubin Institute for Advanced Orthopedics, Baltimore, MD, USA
| | - Ethan A Remily
- Rubin Institute for Advanced Orthopedics, Baltimore, MD, USA
| | - John V Ingari
- Rubin Institute for Advanced Orthopedics, Baltimore, MD, USA
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Grier AJ, Chen KJ, Paul AV, Green CL, Richard MJ, Ruch DS, Pidgeon TS. Impact of Time to Fixation on Outcomes of Operative Treatment of Intra-articular Distal Radius Fractures. Hand (N Y) 2023:15589447231174642. [PMID: 37243339 DOI: 10.1177/15589447231174642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
BACKGROUND The incidence of operative treatment of distal radius fractures (DRFs) has increased recently, but the optimal timing for surgical fixation remains unclear. We hypothesized that: (1) an increase in time to fixation of intra-articular DRFs would increase the likelihood of postoperative complications; and (2) increased time from injury to fixation would lead to longer surgical time and worse range of motion (ROM) outcomes. METHODS We retrospectively reviewed 299 fractures in 284 adult patients who underwent open reduction and internal fixation (ORIF) of a closed, intra-articular DRF at our institution over a 10.5-year period. Demographic information, time to surgery (TTS) from injury, surgical time, tourniquet time, complications, and final postoperative ROM were collected for logistic regression modeling to predict the risk of postoperative complication. RESULTS Twenty-seven (9.0%) patients experienced postoperative complications. The median TTS (Q1-Q3) for all patients was 7.0 (4.0-12.0) days. Patients who experienced an early postoperative complication had significantly longer median TTS (10.0 days) than those who did not (7.0 days). Patients with longer TTS were more likely to experience a complication (odds ratio, 1.11; 95% confidence interval, 1.04-1.19; P = .006). Tourniquet time and final wrist ROM were not related to TTS. A logistic regression analysis found that early complication rate doubles at 7.0 days after injury (from 3.5% to 6.9%). CONCLUSIONS Patients with operative intra-articular distal radius fractures should ideally be fixed within 7 to 10 days of injury to minimize the risk of early postoperative complications. The tourniquet time and final ROM were not associated with time to surgery.
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Affiliation(s)
| | - Kallie J Chen
- University Hospitals Cleveland Medical Center, OH, USA
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Luttwak R, Ibelli TJ, Taub PJ, Melamed E, Wiser I. Predicting early term complications of ORIF distal radius fracture in outpatient settings using NSQIP data. Injury 2023:S0020-1383(23)00353-4. [PMID: 37095046 DOI: 10.1016/j.injury.2023.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 04/08/2023] [Accepted: 04/11/2023] [Indexed: 04/26/2023]
Abstract
PURPOSE There is no consensus on which risk factors are most predictive for complications following open reduction internal fixation of distal radius fractures (ORIF-DRF) in an outpatient setting. This study is a complication risk analysis for ORIF-DRF in outpatient settings based on data obtained from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP). METHODS A nested, case-control study, was conducted in ORIF-DRF cases performed in outpatient settings from 2013 to 2019 obtained from the ACS-NSQIP database. Cases with documented local or systemic complications were age and gender-matched in a 1:3 ratio. The association between patient and procedure-dependent risk factors for systemic and local complications in general and for different subpopulations was examined. Bivariate and multivariable analyses were performed to evaluate the association between risk factors and complications. RESULTS From a total of 18,324 ORIF-DRF, 349 cases with complications were identified and matched to 1047 Controls. Independent patient-related risk factors included a history of smoking, the American Society of Anesthesiologists (ASA) Physical Status Classification 3 and 4, and bleeding disorder. The intra-articular fracture with three or more fragments was found to be an independent risk factor of all procedure-related risk factors. History of smoking was found to be an independent risk factor for all gender populations, as well as for patients younger the 65 years old. For older patients (age ≥65) bleeding disorder was found to be an independent risk factor. CONCLUSION Complications of ORIF-DRF in outpatient settings have many risk factors. This study provides surgeons with specific risk factors for possible complications following ORIF-DRF.
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Affiliation(s)
- Ruth Luttwak
- Division of Plastic and Reconstructive Surgery, Elmhurst Hospital Center, New York, New York, USA; Division of Plastic and Reconstructive Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| | - Taylor J Ibelli
- Division of Plastic and Reconstructive Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Peter J Taub
- Division of Plastic and Reconstructive Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| | - Eitan Melamed
- Division of Plastic and Reconstructive Surgery, Elmhurst Hospital Center, New York, New York, USA; Division of Plastic and Reconstructive Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| | - Itay Wiser
- Division of Plastic and Reconstructive Surgery, Elmhurst Hospital Center, New York, New York, USA; Division of Plastic and Reconstructive Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
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12
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The Impact of Smoking on Delayed Osseous Union After Arthrodesis Procedures in the Hand and Wrist. J Hand Surg Am 2023; 48:158-164. [PMID: 35933253 DOI: 10.1016/j.jhsa.2022.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 04/08/2022] [Accepted: 05/25/2022] [Indexed: 02/07/2023]
Abstract
PURPOSE The purpose of this study was to evaluate the relationship between smoking and delayed radiographic union after hand and wrist arthrodesis procedures. We hypothesized that smoking would be associated with a higher rate of delayed union. METHODS All cases of hand or wrist arthrodesis procedures in patients aged ≥18 years from 2006 to 2020 were identified. Cases were included if they had >90 days of radiographic follow-up or evidence of union before 90 days. Baseline demographics were recorded for each case including smoking status at the time of surgery. Complications were recorded and all postoperative radiographs were reviewed to assess for evidence of delayed union (defined as lack of osseous union by 90 days after surgery). We compared active smokers and nonsmokers and performed a logistic regression analysis to estimate the odds of experiencing a delayed radiographic union. RESULTS A total of 309 arthrodesis cases were included and 24% were active smokers. Overall, radiographic evidence of a delayed union was found in 17% of cases. Smokers were significantly more likely to have a delayed union compared with nonsmokers (27% vs 14%). Results of the adjusted logistic regression analysis demonstrated that there was a significantly increased odds of experiencing a delayed union for patients who were active smokers compared with nonsmokers (odds ratio, 2.20; 95% confidence interval, 1.09-4.43). In addition, the rate of symptomatic nonunion requiring reoperation was higher in smokers (15%) compared with nonsmokers (6%). CONCLUSIONS Smoking was associated with increased odds of delayed radiographic union in patients undergoing hand and wrist arthrodesis procedures. Patients should be counseled appropriately on the risks of smoking on bone healing and encouraged to abstain from nicotine use in the perioperative period. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic II.
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Aspera-Werz RH, Mück J, Linnemann C, Herbst M, Ihle C, Histing T, Nussler AK, Ehnert S. Nicotine and Cotinine Induce Neutrophil Extracellular Trap Formation-Potential Risk for Impaired Wound Healing in Smokers. Antioxidants (Basel) 2022; 11:antiox11122424. [PMID: 36552632 PMCID: PMC9774423 DOI: 10.3390/antiox11122424] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 11/28/2022] [Accepted: 12/06/2022] [Indexed: 12/13/2022] Open
Abstract
Smoking undoubtedly affects human health. Investigating 2318 representative patients at a level 1 trauma center identified delayed wound healing, tissue infections, and/or sepsis as main complications in smokers following trauma and orthopedic surgery. Therefore, smoking cessation is strongly advised to improve the clinical outcome in these patients, although smoking cessation often fails despite nicotine replacement therapy raising the need for specific interventions that may reduce the complication rate. However, the underlying mechanisms are still unknown. In diabetics, delayed wound healing and infections/sepsis are associated with increased neutrophilic PADI4 expression and formation of neutrophil extracellular traps (NETs). The aim was to investigate if similar mechanisms hold for smokers. Indeed, our results show higher PADI4 expression in active and heavy smokers than non-smokers, which is associated with an increased complication rate. However, in vitro stimulation of neutrophils with cigarette smoke extract (CSE) only moderately induced NET formation despite accumulation of reactive oxygen species (ROS). Physiological levels of nicotine and its main metabolite cotinine more effectively induced NET formation, although they did not actively induce the formation of ROS, but interfered with the activity of enzymes involved in anti-oxidative defense and NET formation. In summary, we propose increased formation of NETs as possible triggers for delayed wound healing, tissue infections, and/or sepsis in smokers after a major trauma and orthopedic surgery. Smoking cessation might reduce this effect. However, our data show that smoking cessation supported by nicotine replacement therapy should be carefully considered as nicotine and its metabolite cotinine effectively induced NET formation in vitro, even without active formation of ROS.
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Logli AL, Rizzo M. Operative Treatment of Distal Radius Fractures in Patients With Parkinson Disease. Hand (N Y) 2022; 17:37S-42S. [PMID: 34218706 PMCID: PMC9793611 DOI: 10.1177/15589447211028931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Owing to the many unique disease characteristics of Parkinson disease (PD)-namely resting tremors, muscular rigidity, and poor bone quality-we hypothesized that this patient population would have inferior outcomes with surgical management of acute distal radius fractures (DRFs) compared with the literature available on the general population. METHODS This is a retrospective observational study performed at a single, level 1, academic center from 2001 to 2020 capturing all adult patients with an isolated, acute, and closed DRF that ultimately underwent operative treatment. International Classification of Diseases 10 codes were used to identify 30 patients for manual chart review. Several patient and fracture characteristics were accounted for and complications, reoperations, and failures of surgical intervention were recorded. RESULTS There was a total of 7/30 failures (23%), 6/30 reoperations (20%), and 12 complications in 9/30 wrists (complication rate, 30%) at a mean latest follow-up of 11 months (1.2-158 months). Of the 7 failures, 5 were due to loss of reduction, and 2 of them were deep infections with mean time to failure of 8.3 weeks (range, 11 days-5.2 months). CONCLUSIONS This study found a high rate of complications, reoperations, and early failure despite a short follow-up period and a small cohort of patients with PD treated surgically for a DRF. We recommend locked plating if suitable for the fracture type and early involvement of a multidisciplinary team to assist with medical optimization of PD to increase chances of a successful outcome.
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Risk Factors for Complications following Volar Locking Plate (VLP) Fixation of Unstable Distal Radius Fracture (DRF). BIOMED RESEARCH INTERNATIONAL 2022; 2022:9117533. [PMID: 36483632 PMCID: PMC9726249 DOI: 10.1155/2022/9117533] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 11/09/2022] [Accepted: 11/15/2022] [Indexed: 12/05/2022]
Abstract
Objective To evaluate the incidence and risk factors for complications following volar locking plate (VLP) fixation of unstable distal radius fracture (DRF). Methods This retrospective study identified patients who underwent VLP fixation of unstable DRF between 2017 and 2020 with a minimum 12-month follow-up assessments. By reviewing electronic medical records and follow-up notes, patients were categorized complication or noncomplication group. Differences in variables were detected by using univariate analyses, and independent factors were identified using multivariate logistic regression analysis. Results During this study period, 423 patients were included, and 63 (rate, 14.9%) complications in 58 patients were documented. Wound infection (17, 4.0%) was most common, followed in decreasing frequency by carpal tunnel syndrome (13, 3.1%), tendon rupture/irritation (10, 2.4%), complex regional pain syndrome (8, 1.9%), and plate/screw-related complications (5, 1.7%). In the univariate analyses, 18 variables were found to be significantly different (p < 0.05). Logistic regression analysis identified 5 independent factors, including being male (OR, 3.5; p = 0.014), type C fracture (vs. type A, OR: 2.7, and p = 0.035), general anesthesia (vs. regional, OR: 2.4, and p = 0.045), bone grafting (OR, 6.3; p < 0.001), and surgery performed by less experienced surgeons (OR, 3.1; p = 0.003). The goodness-of-fit of the final model was acceptable. Conclusions These factors will help surgeons individualize and stratify the risk of complications and help patients for risk counselling; especially, an informed clinical decision targeting those modifiable factors (anesthesia mode, bone grafting, and surgeon experience) can be considered, when indicated.
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Samade R, Zaki O, Farrell N, Farrar N, Goyal KS. Treatment Patterns for Distal Radius Fractures Before and After Appropriate Use Criteria Adoption. Hand (N Y) 2022; 17:1177-1186. [PMID: 33349040 PMCID: PMC9608299 DOI: 10.1177/1558944720975147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The purpose of this study was to determine agreement with the American Academy of Orthopaedic Surgery Appropriate Use Criteria (AUC) for distal radius fractures (DRFs), before and after their adoption, and secondarily determine predictors of operative management. METHODS A single-institution retrospective cohort study comparing patients treated either nonoperatively (115 patients) or operatively (767 patients) for DRFs between May 1, 2008, and May 1, 2018, by 8 hand surgeons was performed. Data included demographics, injury characteristics, DRF radiographic measurements, treatment rendered, and their appropriateness according to the AUC. Statistical testing used the Fisher and χ2 tests, t test, and multiple variable logistic regression, with a significance level of .05. RESULTS Overall, there was a significant increase in AUC agreement for operatively treated DRFs (82.7%-89.3%, P = .01), but no difference in agreement for nonoperatively treated DRFs (12.5%-10.7%, P = .77). Age <80 years, AO classes other than B, intra-articular displacement >1 mm, radial inclination <18°, high-energy mechanism of injury, and greater than 1 week to treatment were independent predictors of operative treatment. The area under the curve for the validated regression model using the aforementioned predictors was 0.82. CONCLUSION Agreement with AUC for DRFs increased after its adoption for operatively treated, but not for nonoperatively treated, fractures. In addition, a predictive model for operative treatment was developed and validated. Future studies may benefit from further model refinement and testing in other patient cohorts.
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Affiliation(s)
- Richard Samade
- The Ohio State University Wexner Medical Center, Columbus, USA
| | - Omar Zaki
- The Ohio State University Wexner Medical Center, Columbus, USA
| | - Nolan Farrell
- The Ohio State University Wexner Medical Center, Columbus, USA
| | - Nicholas Farrar
- The Ohio State University Wexner Medical Center, Columbus, USA
| | - Kanu S. Goyal
- The Ohio State University Wexner Medical Center, Columbus, USA
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Malige A, Konopitski A, Nwachuku CO, Matullo KS. Distal Radius Fractures in Diabetic Patients: An Analysis of Surgical Timing and Other Factors That Affect Complication Rate. Hand (N Y) 2022; 17:764-771. [PMID: 32940062 PMCID: PMC9274893 DOI: 10.1177/1558944720944262] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND While not studied for distal radius fractures, the effect of surgical timing on complication rate has been extensively analyzed in the treatment of pilon fractures. The primary aim of this study was to identify any effect surgical timing has on postoperative complication rates after surgical fixation of distal radius fractures in diabetic patients. METHODS All patients who underwent surgical fixation of distal radius fractures at a single suburban academic hospital between 2012 and 2019 were reviewed. For each patient, demographics, comorbidities, injury details, fixation method, and postoperative complications were noted. The effect surgical delay, among other factors, had on complication rate in diabetic and nondiabetic patients was explored. RESULTS Overall, 124 diabetic and 371 nondiabetic distal radius fractures were included. While diabetics had a statistically higher rate of total complications (21.0 vs. 13.5%, P = .045) but similar major complications requiring surgery (P = .12), there was no difference in surgical delay between groups among patients who had total (P = .31) or major (P = .69) complications. Surgical timing was not a risk factor for total (P = .50) or major complications (P = .32) in diabetic fracture bivariate or multivariate analysis. Only younger age and higher energy injuries were significant risk factors for total complications in bivariate (P = .02, P = .03) and multivariate (P = .04, P < .05) analysis. CONCLUSION Complication rates after surgically stabilized distal radius fractures in diabetic patients are higher than in nondiabetic patients. However, this rate is not affected by surgical timing. Instead, surgeons should consider factors such as diabetic control in an effort to maximize outcomes and decrease complications. LEVEL OF EVIDENCE Prognostic Level III.
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Affiliation(s)
- Ajith Malige
- St. Luke’s University Health Network, Bethlehem, PA, USA
| | | | | | - Kristofer S. Matullo
- St. Luke’s University Health Network, Bethlehem, PA, USA
- Kristofer Matullo, St. Luke’s University Health Network, PPHP 2, 801 Ostrum Street, Bethlehem, PA 18015, USA.
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Constantine RS, Le EL, Gehring MB, Ohmes L, Iorio ML. Risk Factors for Infection After Distal Radius Fracture Fixation: Analysis of Impact on Cost of Care. JOURNAL OF HAND SURGERY GLOBAL ONLINE 2022; 4:123-127. [PMID: 35601524 PMCID: PMC9120794 DOI: 10.1016/j.jhsg.2021.12.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 12/28/2021] [Indexed: 11/28/2022] Open
Abstract
Purpose Infection after distal radius fracture fixation can be a devastating complication, leading to potential hardware removal, prolonged antibiotic courses, multiple office visits, and increased costs. This study aimed to identify potential risk factors for infectious complications after distal radius fracture fixation and assess the impacts on cost. Methods This study used the PearlDiver national database, encompassing 53 million unique patients from January 1, 2010, to March 31, 2020. The cohort included patients undergoing distal radius fracture fixation. The endpoint was postoperative infection within 180 days of fixation. Two-sample t test was used to compare rates of infection between open and percutaneous fracture fixation techniques. A propensity-matched cohort was created using patient age, gender, and open fracture. Logistic regression analyses defined independent risk factors for developing a postoperative infection among all patients and within the matched cohorts. A Mann-Whitney U test was used to compare costs of care with and without infection. Results The database included 87,169 patients who underwent distal radius fracture fixation. Postoperative infections were identified in 781 patients (0.9%). There was a significant difference in rates of postoperative infection with percutaneous fixation (1.3%) versus open fixation (0.8%). Logistic regression analysis identified male gender, open fracture, lung disease, chronic kidney disease, diabetes, hypertension, liver disease, obesity, and tobacco to be independent risk factors for developing a postoperative infection. Logistic regression analysis of the propensity-matched cohorts identified tobacco use as a significant risk factor. The average cost of care for patients undergoing fracture fixation without an infection was $6,383, versus $23,355 for those with an infection, which was significantly different. Conclusions Multiple risk factors for postoperative infection were identified. Cost is significantly increased after postoperative infection, by almost 4-fold. Attempts to correct or optimize modifiable risk factors may lead to substantial cost savings, and potentially decreased rates of infection. Type of study/level of evidence Prognostic III.
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Affiliation(s)
- Ryan S. Constantine
- Division of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Center, Aurora, CO
| | - Elliot L.H. Le
- Division of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Center, Aurora, CO
| | - Michael B. Gehring
- Division of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Center, Aurora, CO
| | - Lucas Ohmes
- Division of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Center, Aurora, CO
| | - Matthew L. Iorio
- Division of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Center, Aurora, CO
- Corresponding author: Matthew L. Iorio, MD, Division of Plastic and Reconstructive Surgery, University of Colorado Anschutz Medical Center, 12631 E. 17th Ave, C309 (Room 6414), Aurora, CO 80045.
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Analysis of Postoperative Complications and Related Factors Affecting Prognosis in 50 Patients with Distal Radius Fractures. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2021; 2021:8005945. [PMID: 34691224 PMCID: PMC8536404 DOI: 10.1155/2021/8005945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 09/29/2021] [Indexed: 11/18/2022]
Abstract
Objective To explore the postoperative complications of distal radius fractures and analyze the related factors that affect its prognosis. Methods The clinical data of 50 patients with distal radius fractures admitted to our hospital from October 2016 to September 2019 were retrospectively analyzed. All patients were followed up for 6–12 months, and their postoperative complications were recorded. Collect general patient information and related clinical data. During the follow-up process, Gartland and Werley wrist function scoring system was used to evaluate the prognosis of patients' joint function. Univariate analysis and multiple logistic regression models were used to analyze the related factors that affected the prognosis of patients. Results 15 patients with postoperative complications were found during the follow-up period, with an incidence rate of 30.00%. Univariate analysis showed that the patient's age, cause of injury, AO classification, shortened deformity, whether it was osteoporosis, surgical method, whether it was combined with other fractures on the same side, whether it was comminuted fracture, and the time to start postoperative exercise were all related to the distal radius. The prognosis of fractures is related (P < 0.05). Multivariate logistic analysis showed that age, AO classification, surgical method, whether it was combined with other fractures on the same side, whether it was comminuted fracture, and the time to start postoperative exercise were the independent factors affecting the prognosis of distal radius fractures (P < 0.05). Conclusion The postoperative complications of distal radius fractures are higher. The prognosis is related to the patient's age, AO classification, surgical method, whether it is combined with other fractures on the same side, whether it is comminuted fracture, and the time to start postoperative exercise. Therefore, choosing an appropriate surgical method and starting exercise in time can effectively improve the recovery of the patient's wrist function and reduce the occurrence of complications.
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The Impact of Smoking on Early Postoperative Complications in Hand Surgery. J Hand Surg Am 2021; 46:336.e1-336.e11. [PMID: 32868099 DOI: 10.1016/j.jhsa.2020.07.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 05/25/2020] [Accepted: 07/21/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE Smoking is a prevalent modifiable risk factor that has been associated with adverse postoperative outcomes across numerous surgical specialties. We examined the impact of smoking on 30-day complications in patients undergoing hand surgery procedures. METHODS The American College of Surgeons National Surgical Quality Improvement Program data sets were queried for patients who underwent common hand surgery procedures from 2011 to 2016. Cohorts were divided into smoking and nonsmoking and compared in terms of demographic characteristics, comorbidities, and postoperative complications. Multivariable logistic regression models were used to control for demographic characteristics and comorbidities in assessing the association between smoking and postoperative infections as well as other major and minor complications. RESULTS We identified a cohort of 48,370 patients in the National Surgical Quality Improvement Program who underwent certain outpatient and inpatient hospital facility-based hand surgery procedures from 2011 to 2016. Up to 22% of these patients reported active smoking. Compared with nonsmokers, smokers were more likely to be younger and male and to have a lower body mass index. In addition, they were more likely to have a higher American Society of Anesthesiologists classification and to report dyspnea and chronic obstructive pulmonary disease. Multivariable logistic regression identified an independent association between smoking and major complications. Smoking was not significantly associated with minor complications. When regrouped by complication type, smoking was associated with infectious and wound healing complications. In subgroup analysis, smokers undergoing elective hand surgery had increased odds of wound healing complications but not major, minor, or infectious complications. CONCLUSIONS Smokers may be at a significantly higher odds of certain complications compared with nonsmokers. For patients undergoing the elective procedures evaluated in this study, perioperative smoking may increase the risk of wound-healing complications. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic II.
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Galivanche AR, FitzPatrick S, Dussik C, Malpani R, Nduaguba A, Varthi AG, Grauer JN. A Matched Comparison of Postoperative Complications Between Smokers and Nonsmokers Following Open Reduction Internal Fixation of Distal Radius Fractures. J Hand Surg Am 2021; 46:1-9.e4. [PMID: 33390240 DOI: 10.1016/j.jhsa.2020.09.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Revised: 07/13/2020] [Accepted: 09/22/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of the present study was to identify differences in 30-day adverse events, reoperations, readmissions, and mortality for smokers and nonsmokers who undergo operative treatment for a distal radius fracture. METHODS The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database was queried for patients who had operatively treated distal radius fractures between 2005 and 2017. Patient characteristics and surgical variables were assessed. Thirty-day outcome data were collected on serious (SAEs) and minor adverse events (MAEs), as well as on infection, return to the operating room, readmission, and mortality. Multivariable logistic analyses with and without propensity-score matching was used to compare outcome measures between the smoker and the nonsmoker cohorts. RESULTS In total, 16,158 cases were identified, of whom 3,062 were smokers. After 1:1 propensity-score matching, the smoking and nonsmoking cohorts had similar demographic characteristics. Based on the multivariable propensity-matched logistic regression, cases in the smoking group had a significantly higher rate of any adverse event (AAE) (odds ratio [OR], 1.75; 95% confidence interval [95% CI], 1.28-2.38), serious adverse event (SAE) (OR, 1.75; 95% CI, 1.22-2.50), and minor adverse event (MAE) (OR, 1.84; 95% CI, 1.04-3.23). Smokers also had higher rates of infection (OR, 1.73; 95% CI, 1.26-2.39), reoperation (OR, 2.07; 95% CI, 1.13-3.78), and readmission (OR, 1.83; 95% CI, 1.20-2.79). There was no difference in 30-day mortality rate. CONCLUSIONS Smokers who undergo open reduction internal fixation of distal radius fractures had an increased risk of 30-day perioperative adverse events, even with matching and controlling for demographic characteristics and comorbidity status. This information can be used for patient counseling and may be helpful for treatment/management planning. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic II.
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Affiliation(s)
- Anoop R Galivanche
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Shannon FitzPatrick
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Christopher Dussik
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Rohil Malpani
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Afamefuna Nduaguba
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Arya G Varthi
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT
| | - Jonathan N Grauer
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT.
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Chou TFA, Chang CY, Huang CC, Chang MC, Chen WM, Huang TF. The outcome for surgical fixation of distal radial fractures in patients with idiopathic Parkinson's disease: a cohort study. J Orthop Surg Res 2020; 15:125. [PMID: 32238187 PMCID: PMC7110736 DOI: 10.1186/s13018-020-01642-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 03/20/2020] [Indexed: 11/22/2022] Open
Abstract
Introduction Idiopathic Parkinson’s disease (PD) is a progressive neurologic disorder causing postural instability and unsteady gait. These patients are at increased risk for fractures and have inferior outcomes after treatment. Several studies have evaluated the incidence and outcome of PD patients after hip fractures. However, there are limited studies assessing the outcome of upper extremity fractures in these patients. In this study, we evaluated the outcome of PD patients that received surgical intervention for distal radial fractures (DRF). We hypothesize that these patients have an inferior outcome after surgery in comparison with non-PD patients. Methods Between May 2005 and May 2017, we retrospectively reviewed all of the patients with DRF and subsequently underwent open reduction and internal fixation (ORIF) at a level 1 trauma center. All of the surgeries were performed by fellowship-trained orthopedic surgeons. The inclusion criteria include patients with a definitive diagnosis of PD, non-pathological DRF, and a minimum follow-up of 1 year or up until the time of treatment failure was noted. Each PD patient was matched for age and gender to 3 non-PD patients. The primary objective was to determine the failure rate after surgical fixation for DRF. The secondary outcomes include time to treatment failure, reoperation rate, readmission rate, length of hospital stay, and postoperative complications. Results A total of 88 patients were included in this study (23 PD, 65 non-PD patients). All underwent ORIF and received standard postoperative follow-ups. The overall treatment failure rate in PD was 39.1% vs. 4.6% in the non-PD group (p < 0.05). The time to treatment failure were 9.11 ± 3.86 weeks and 14.67 ± 5.8 weeks for PD and non-PD, respectively (p < 0.05). PD patients had a significantly higher rate of failure when k-wires and ESF were used (p < 0.05%), while loss of reduction was the most common mode of failure in PD (44.4%). The length of hospital stay for PD was 5.3 ± 4.69 days compared with 3.78 ± 0.96 days for non-PD (p = 0.01). There were 3 PD patients readmitted within 30 days after surgery, and 1 patient had pneumonia after the surgery. Conclusion This study revealed that patients with PD have a high treatment failure rate despite surgical intervention for DRF. PD patients had a longer hospital stay and had a shorter time to treatment failure. In treating PD patients complicated with DRF, the surgeon must take into consideration the complex disease course of PD and the associated comorbidities such as osteoporosis, frail status, and frequent falls. Rehabilitation and disposition plans should be discussed in advance and longer hospital stays should be expected. Level of evidenceLevel IV, retrospective cohort study
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Affiliation(s)
- Te-Feng Arthur Chou
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, No. 201, Sec. 2, Shi-Pai Road, Taipei, 112, Taiwan, Republic of China.,Department of Orthopaedics, School of Medicine, National Yang-Ming University, No. 201, Sec. 2, Shi-pai Road, Beitou District, Taipei City, 11217, Taiwan, ROC
| | - Chun Yao Chang
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, No. 201, Sec. 2, Shi-Pai Road, Taipei, 112, Taiwan, Republic of China
| | - Chun-Ching Huang
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, No. 201, Sec. 2, Shi-Pai Road, Taipei, 112, Taiwan, Republic of China.,Department of Exercise and Health, National Taipei University of Nursing and Health Science, No. 201, Sec. 2, Shi-Pai Road, Taipei, 112, Taiwan, Republic of China
| | - Ming-Chau Chang
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, No. 201, Sec. 2, Shi-Pai Road, Taipei, 112, Taiwan, Republic of China.,Department of Orthopaedics, School of Medicine, National Yang-Ming University, No. 201, Sec. 2, Shi-pai Road, Beitou District, Taipei City, 11217, Taiwan, ROC
| | - Wei-Ming Chen
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, No. 201, Sec. 2, Shi-Pai Road, Taipei, 112, Taiwan, Republic of China.,Department of Orthopaedics, School of Medicine, National Yang-Ming University, No. 201, Sec. 2, Shi-pai Road, Beitou District, Taipei City, 11217, Taiwan, ROC
| | - Tung-Fu Huang
- Department of Orthopaedics and Traumatology, Taipei Veterans General Hospital, No. 201, Sec. 2, Shi-Pai Road, Taipei, 112, Taiwan, Republic of China. .,Department of Orthopaedics, School of Medicine, National Yang-Ming University, No. 201, Sec. 2, Shi-pai Road, Beitou District, Taipei City, 11217, Taiwan, ROC. .,Department of Exercise and Health, National Taipei University of Nursing and Health Science, No. 201, Sec. 2, Shi-Pai Road, Taipei, 112, Taiwan, Republic of China.
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Ehnert S, Aspera-Werz RH, Ihle C, Trost M, Zirn B, Flesch I, Schröter S, Relja B, Nussler AK. Smoking Dependent Alterations in Bone Formation and Inflammation Represent Major Risk Factors for Complications Following Total Joint Arthroplasty. J Clin Med 2019; 8:jcm8030406. [PMID: 30909629 PMCID: PMC6462941 DOI: 10.3390/jcm8030406] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 03/15/2019] [Accepted: 03/19/2019] [Indexed: 12/21/2022] Open
Abstract
Numerous studies have described a correlation between smoking and reduced bone mass. This not only increases fracture risk but also impedes reconstruction/fixation of bone. An increased frequency of complications following surgery is common. Here, we investigate the effect of smoking on the clinical outcome following total joint arthroplasty (TJA). 817 patients receiving primary or revision (including clinical transfers) TJA at our level-one trauma center have been randomly interviewed twice (pre- and six months post-surgery). We found that 159 patients developed complications (infections, disturbed healing, revisions, thrombosis, and/or death). Considering nutritional status, alcohol and cigarette consumption as possible risk factors, OR was highest for smoking. Notably, mean age was significantly lower in smokers (59.2 ± 1.0a) than non-smokers (64.6 ± 0.8; p < 0.001). However, the number of comorbidities was comparable between both groups. Compared to non-smokers (17.8 ± 1.9%), the complication rate increases with increasing cigarette consumption (1⁻20 pack-years (PY): 19.2 ± 2.4% and >20 PY: 30.4 ± 3.6%; p = 0.002). Consequently, mean hospital stay was longer in heavy smokers (18.4 ± 1.0 day) than non-smokers (15.3 ± 0.5 day; p = 0.009) or moderate smokers (15.9 ± 0.6 day). In line with delayed healing, bone formation markers (BAP and CICP) were significantly lower in smokers than non-smokers 2 days following TJA. Although, smoking increased serum levels of MCP-1, OPG, sRANKL, and Osteopontin as well as bone resorption markers (TRAP5b and CTX-I) were unaffected. In line with an increased infection rate, smoking reduced 25OH vitamin D3 (immune-modulatory), IL-1β, IL-6, TNF-α, and IFN-γ serum levels. Our data clearly show that smoking not only affects bone formation after TJA but also suppresses the inflammatory response in these patients. Thus, it is feasible that therapies favoring bone formation and immune responses help improve the clinical outcome in smokers following TJA.
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Affiliation(s)
- Sabrina Ehnert
- Department of Trauma and Reconstructive Surgery, Siegfried Weller Research Institute, Eberhard Karls University Tuebingen, BG Trauma Center Tuebingen, 72076 Tuebingen, Germany.
| | - Romina H Aspera-Werz
- Department of Trauma and Reconstructive Surgery, Siegfried Weller Research Institute, Eberhard Karls University Tuebingen, BG Trauma Center Tuebingen, 72076 Tuebingen, Germany.
| | - Christoph Ihle
- Department of Trauma and Reconstructive Surgery, Siegfried Weller Research Institute, Eberhard Karls University Tuebingen, BG Trauma Center Tuebingen, 72076 Tuebingen, Germany.
| | - Markus Trost
- Department of Trauma and Reconstructive Surgery, Siegfried Weller Research Institute, Eberhard Karls University Tuebingen, BG Trauma Center Tuebingen, 72076 Tuebingen, Germany.
| | - Barbara Zirn
- Department of Trauma and Reconstructive Surgery, Siegfried Weller Research Institute, Eberhard Karls University Tuebingen, BG Trauma Center Tuebingen, 72076 Tuebingen, Germany.
| | - Ingo Flesch
- Department of Trauma and Reconstructive Surgery, Siegfried Weller Research Institute, Eberhard Karls University Tuebingen, BG Trauma Center Tuebingen, 72076 Tuebingen, Germany.
| | - Steffen Schröter
- Department of Trauma and Reconstructive Surgery, Siegfried Weller Research Institute, Eberhard Karls University Tuebingen, BG Trauma Center Tuebingen, 72076 Tuebingen, Germany.
| | - Borna Relja
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Frankfurt, Goethe University, 60590 Frankfurt, Germany.
| | - Andreas K Nussler
- Department of Trauma and Reconstructive Surgery, Siegfried Weller Research Institute, Eberhard Karls University Tuebingen, BG Trauma Center Tuebingen, 72076 Tuebingen, Germany.
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