Hypothyroidism increases 90-day postoperative complications in patients undergoing primary single level anterior cervical disectomy and fusion: a matched control analysis

Hypothyroidism as an Independent Predictor of 30-day Readmission in Head and Neck Cancer Patients

OBJECTIVES

To define the role of hypothyroidism and other risk factors for unplanned readmissions after surgery for head and neck cancer.

STUDY DESIGN

Retrospective cohort study.

METHODS

The Nationwide Readmission Database (NRD) was used to identify patients who underwent surgery for mucosal head and neck cancer (oral cavity, oropharynx, larynx, and hypopharynx) between 2010 and 2017. Univariate and multivariate logistic regression were performed to determine patient, tumor, and hospital related risk factors for 30-day readmission. Readmitted patients were stratified by preoperative diagnosis of hypothyroidism to compare readmission characteristics.

RESULTS

For the 131,013 patients who met inclusion criteria, the readmission rate was 15.9%. Overall, 11.91% of patients had a preoperative diagnosis of hypothyroidism. After controlling for other variables, patients with a preoperative diagnosis of hypothyroidism had 12.2% higher odds of readmission compared to those without hypothyroidism (OR: 1.12, 1.03-1.22, p = 0.008). Patients with hypothyroidism had different reasons for readmission, including higher rates of wound dehiscence, fistula, infection, and electrolyte imbalance. Among readmitted patients, the length of stay for index admission (mean 10.5 days vs. 9.2 days, p < 0.001), readmission (mean 7.0 vs. 6.6 days, p = 0.05), and total hospital charge were higher for hypothyroid patients ($137,742 vs. $119,831, p < 0.001).

CONCLUSION

Hypothyroidism is an independent risk factor for 30-day readmission following head and neck cancer resection. Furthermore, hypothyroid patients are more likely to be readmitted for wound complications, infection, and electrolyte imbalance. Targeted interventions should be considered for hypothyroid patients to decrease readmission rates and associated patient morbidity, potentially leading to earlier initiation of adjuvant treatment.

LEVEL OF EVIDENCE

3 Laryngoscope, 133:2988-2998, 2023.

Hypothyroidism and Spine Surgery: a Review of Current Findings

PURPOSE OF REVIEW

Hypothyroidism is a common medical comorbidity and has been linked to adverse surgical outcomes. However, its effect on spine surgery outcomes is less clear. The aim of this review is to compile current literature to serve as a guide for spine surgeons when treating patients with hypothyroidism.

RECENT FINDINGS

In both the cervical and lumbar spine, patients with hypothyroidism are at increased risk of postoperative medical complications. Consequently, patients with hypothyroidism experience increased healthcare costs and readmission rates. However, there are some contradictory findings with some studies suggesting that hypothyroidism may have a protective effect in patients undergoing lumbar fusion, specifically against postoperative myocardial infraction and decreased inpatient mortality. When examining spine surgery outcomes, there are mixed results when considering the effect of hypothyroidism. Some studies have shown increased medical complications, hardware failure, and increased expenditure; however, other recent findings suggest possible protective effects. Future studies are needed to help create concrete guidelines for treating patients with hypothyroidism.

Patients With Opioid Use Disorder Have Increased Readmission Rates, Emergency Room Visits, and Costs Following a Hallux Valgus Procedure

BACKGROUND

Patients with a history of opioid use disorder (OUD) tend to have more complications, higher readmission rates, and increased costs following orthopaedic procedures. This study evaluated patients undergoing hallux valgus correction for their odds of increased (1) readmission rates, (2) emergency room (ER) visits, and (3) costs.

METHODS

Patients undergoing hallux valgus corrections with OUD history were identified using a national Medicare administrative claims database of approximately 24 million orthopaedic surgery patients. OUD patients were matched to non-opioid use disorder (NUD) patients in a 1:4 ratio by age, sex, Elixhauser-Comorbidity Index (ECI), diabetes mellitus, hyperlipidemia, hypertension, and tobacco use. The query yielded 6318 patients (OUD = 1276; NUD = 5042) who underwent a hallux valgus correction. Primary outcomes analyzed included odds of 90-day readmission rates, 30-day ER visits, and 90-day episode-of-care costs. Demographics, odds ratios (ORs), ECI, and cost were assessed as appropriate using a Pearson χ² test, logistic regression, and a t test. A P value <.05 was considered statistically significant.

RESULTS

There were no significant differences in demographics between OUD and NUD patients. OUD patients had higher incidence and odds of 90-day readmission (9.56% vs 6.04%; OR = 1.55; P < .001) and 30-day ER visits (0.86% vs 0.35%; OR = 2.42; P = .021) and incurred greater 90-day episode-of-care costs ($7208.28 vs $6134.75; P < .001) compared with NUD patient controls.

CONCLUSION

The study demonstrates the possible influence of OUD on higher odds of readmission, ER visits, and costs following a hallux valgus correction.

LEVELS OF EVIDENCE

Level III: Retrospective cohort study.

A nationwide analysis on the effects of chronic obstructive pulmonary disease following primary total shoulder arthroplasty for glenohumeral osteoarthritis

BACKGROUND

Chronic obstructive pulmonary disease patients have been shown in orthopedic literature to have poorer outcomes and higher rates of complications from surgery. In this retrospective review, medical complications, length of stay, and costs were obtained to explore the effects of chronic obstructive pulmonary disease on patients undergoing primary total shoulder arthroplasty.

METHODS

Total shoulder arthroplasty cases from January 2005 to March 2014 were queried and analyzed from a nationwide database. Study patients were matched 1:5 to controls by age, sex, and medical comorbidities associated with chronic obstructive pulmonary disease. In-hospital length of stay, 90-day medical complications, day of surgery, and total global 90-day episode of care costs were obtained for comparison.

RESULTS

Chronic obstructive pulmonary disease patients were found to have higher incidence and odds (53.91 vs. 11.95%; OR: 3.58, 95%CI: 3.18-3.92, p < 0.0001) of 90-day medical complications, longer in-hospital length of stay (3 vs. 2 days, p < 0.0001), and significantly higher 90-day costs ($14,768.37 vs. $13,379.20, p < 0.0001) following primary total shoulder arthroplasty compared to matched controls.

DISCUSSION

Chronic obstructive pulmonary disease patients undergoing primary total shoulder arthroplasty have higher rates of medical complications, in-hospital length of stay, and costs of care. This represents an important factor that will allow orthopedic surgeons to adequately manage expectations and educate chronic obstructive pulmonary disease patients of the potential complications which may occur following total shoulder arthroplasty.

Factors associated with post-operative delirium in hip fracture patients: what should we care

Background

The postoperative delirium is a common yet serious complication in elderly patients with hip fracture. We aimed to evaluate the potential risk factors of delirium in patients with hip fracture, to provide reliable evidence to the clinical management of hip fracture.

Methods

This study was a retrospective design. Elderly patients who underwent hip fracture surgery in our hospital from June 1, 2019 to December 30, 2020 were selected. The characteristics and treatment data of delirium and no delirium patients were collected and compared. Multivariate logistic regression analysis was performed to analyze the influencing factors affecting postoperative delirium in elderly patients with hip fracture.

Results

A total of 245 patients with hip fracture were included, the incidence of postoperative delirium in patients with hip fracture was 13.06%. There were significant differences in the age, BMI, history of delirium, estimated blood loss and duration of surgery (all p  < 0.05). There were significant differences in the albumin and TSH between delirium and no delirium group (all p < 0.05), Logistics analyses indicated that age ≥ 75 years (OR 3.112, 95% CI 1.527–5.742), BMI ≥ 24 kg/m² (OR 2.127, 95% CI 1.144–3.598), history of delirium (OR 1.754, 95% CI 1.173–2.347), estimated blood loss ≥ 400 mL (OR 1.698, 95% CI 1.427–1.946), duration of surgery ≥ 120 min (OR 2.138, 95% CI 1.126–3.085), preoperative albumin ≤ 40 g/L (OR 1.845, 95% CI 1.102–2.835) and TSH ≤ 2 mU/L (OR 2.226, 95% CI 1.329–4.011) were the independent risk factors of postoperative delirium in patients with hip fracture(all p < 0.05).

Conclusions

Postoperative delirium is very common in elderly patients with hip fracture, and it is associated with many risk factors, clinical preventions targeted on those risk factors are needed to reduce the postoperative delirium.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40001-022-00660-9.

Incidence and Clinical Outcomes of Hypothyroidism in Patients Undergoing Spinal Fusion

Background

Hypothyroidism has been independently associated with the development of several comorbidities and is known to increase complication rates in non-spinal surgeries. However, there are limited data regarding the effects of hypothyroidism in major spine surgery. Therefore, we present the largest retrospective analysis evaluating outcomes in hypothyroid patients undergoing spinal fusion.

Methods

A retrospective review of the National Inpatient Sample (NIS) from 2004-2014 was performed. Patients with an International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM) procedure code indicating spinal fusion (81.04-81.08, 81.34-81.38, 81.0x, 81.3x) were included. Patients with an ICD-9-CM diagnosis code indicating hypothyroidism (244.x) were compared to those without. Cervical and lumbar fusions were evaluated independently. Significant covariates in univariable logistic regression were utilized to construct multivariable models to analyze the effect of hypothyroidism on perioperative morbidity and mortality.

Results

A total of 4,149,125 patients were identified, of which 9.4% were hypothyroid. Although, hypothyroid patients had a higher risk of hematologic complications (lumbar - odds ratio [OR] 1.176, p < 0.0001; cervical - OR 1.162, p < 0.0001), they exhibited decreased in-hospital mortality (lumbar - OR .643, p < 0.0001; cervical - OR .606, p < 0.0001). Hypothyroid lumbar fusion patients also demonstrated decreased rates of perioperative myocardial infarction (MI) (OR .851, p < 0.0001). All these results were independent of patient gender.

Conclusions

Hypothyroid patients undergoing spinal fusion demonstrated lower rates of inpatient mortality and, in lumbar fusions, also had lower rates of acute MI when compared to their euthyroid counterparts. This suggests that hypothyroidism may offer protection against all-cause mortality and may be cardioprotective in the postoperative period for lumbar spinal fusions independent of patient gender.

Comparison of Patient Demographics and Utilization Trends of Robotic-Assisted and Non-Robotic-Assisted Unicompartmental Knee Arthroplasty

Robotic-assisted unicompartmental knee arthroplasty (RAUKA) is an emerging area of interest. The purpose of this study was to compare (1) different patient demographic profiles; (2) annual primary and revision utilization rates; (3) risk factors for revision procedures; and (4) survivorship between RAUKA and manual UKA (MUKA). Using the PearlDiver database, patients who underwent RAUKA or MUKA between 2005 and 2014 within the Medicare database were identified, yielding a total of 35,061 patients (RAUKA = 13,617; manual = 21,444). Patient demographics (age, gender, comorbidities, Charlson-Comorbidity Index, and geographic region) were compared between cohorts. Annual primary and revision utilization rates as well as risk factors for revision procedures were also compared. Kaplan-Meier survivorship was also calculated. The Pearson χ² test was used to test for significance in patient demographics, whereas the Welch t-test was used to compare the incidence of revisions as well as the revision burden (proportion of revisions to total sum of primary and revision procedures). Multivariate binomial logistic regression analysis was performed to compare risk factors for revision procedures. There were statistically significant differences in RAUKA versus MUKA patients with respect to age (p < 0.001), gender (p < 0.001), and region (p < 0.001). RAUKA procedures performed increased over 12-fold compared with manual, which increased only 4.5-fold. RAUKA procedures had significantly lower revision incidence (0.99 vs. 4.24%, p = 0.003) and revision burden (0.91 vs. 4.23%, p = 0.005) compared with manuals. For patients undergoing RAUKA, normal (19-24 kg/m²) and obese (30-39 kg/m²) body mass index (p < 0.05), congestive heart failure (p = 0.004), hypothyroidism (p < 0.001), opioid dependency (p = 0.002), and rheumatoid arthritis (p < 0.001) were risk factors for a revision procedure. Kaplan-Meier survival curve 3 years following the index procedure to all-cause revisions demonstrated that RAUKA patients maintained nearly 100% survivorship compared with manual patients who had 97.5% survivorship. The data demonstrate increased utilization of RAUKA in the United States. The current data indicated that RAUKA has significantly lower revision rates and improved survivorship compared with patients undergoing non-RAUKA within Medicare patients.

Does Hypothyroidism Increase Complications, Lengths of Stay, Readmissions, and Costs Following Primary 1- to 2-Level Lumbar Fusion?

STUDY DESIGN

Level III-retrospective review.

OBJECTIVE

To evaluate the impact of hypothyroidism in patients undergoing 1- to 2-level lumbar fusion (1-2LF).

SUMMARY OF BACKGROUND DATA

Hypothyroidism is a common cause of morbidity and mortality following surgery. Studies have demonstrated the effects of hypothyroidism following orthopedic surgery, but not 1-2LF.

MATERIALS AND METHODS

Patients undergoing 1-2LF with hypothyroidism were identified within the Medicare population, and served as the study group. Study group patients were randomly matched to controls in a 1:5 ratio by age, sex, and medical comorbidities. Primary outcomes analyzed included in-hospital lengths of stay (LOS), 90-day readmission rates, 90-day medical complications, and costs of care. Pearson χ tests were used to compare patient demographics. Logistic regression analyses were used to calculate odds ratios (OR) for medical complications and readmissions. Welch t test was used to test for significance in cost between the cohorts. An α value <0.002 was considered statistically significant.

RESULTS

The query yielded 417,483 patients who underwent 1-2LF with (n=69,584) and without (n=347,899) hypothyroidism. Hypothyroid patients had significantly longer in-hospital LOS (8 vs. 4 d; P<0.0001) compared with controls. In addition, study group patients had significantly higher incidence and odds of 90-day readmissions (20.22% vs. 17.62%; OR, 1.18; P<0.0001) and 90-day medical complications (6.38% vs. 1.89%; OR, 3.53; P<0.0001) compared with controls. Study group patients had higher day of surgery costs ($97,304.01 vs. $95,168.35; P=0.014) and 90-day costs of care ($113,514.15 vs. $108,860.60; P=0.0001) compared with controls.

CONCLUSIONS

After adjusting for age, sex, and medical comorbidities, the study demonstrates patients who have hypothyroidism have longer in-hospital LOS and higher rates of readmissions, complications, and costs. The study is vital as it can allow orthopedic surgeons to adequately counsel and educate these patients of the potential complications that may occur following their procedure.

Identification of Risk Factors for Readmission in Patients Undergoing Anterior Cervical Discectomy Fusion: A Predictive Risk Scale

STUDY DESIGN

This was a retrospective cohort study.

OBJECTIVE

The objective of this study was to analyze readmission rates among patients undergoing anterior cervical discectomy and fusion (ACDF), determine which factors were associated with higher readmission rates, and develop a scale for utilization during surgical planning.

SUMMARY OF BACKGROUND DATA

ACDF is the most common surgical treatment for many cervical disk pathologies. With the Centers for Medicare and Medicaid Services selecting readmissions as a measure of health care quality, there has been an increased focus on reducing readmissions.

MATERIALS AND METHODS

There were 114,174 recorded ACDF surgeries in the derivation cohort, the State Inpatient Database (SID) of New York and California between 2006 and 2014. There were 115,829 ACDF surgeries recorded in the validation cohort, the SID from Florida and Washington over the same time period. After identification of risk factors using univariate and multivariate analysis of the derivation cohort, a predictive scale was generated and tested utilizing the validation cohort.

RESULTS

Overall, readmission rates within 30 days of discharge were 5.87% and 5.52% in the derivation and validation cohorts, respectively. On multivariate analysis of the derivation cohort, age older than 80 years [odds ratio (OR), 1.67] male sex (OR, 1.16), Medicaid insurance (OR, 1.90), Medicare insurance (OR, 1.64), revision ACDF (OR, 1.43), anemia (OR, 1.45), chronic lung disease (OR, 1.23), coagulopathy (OR, 1.42), congestive heart failure (OR, 1.31), diabetes (OR, 1.23), fluid and electrolyte disorder (OR, 1.56), liver disease (OR, 1.37), renal failure (OR, 1.59), and myelopathy (OR, 1.19) were found to be statistically significant predictors for readmission. These factors were incorporated into a numeric scale that, that when tested on the validation cohort, could explain 97.1% of the variability in readmission rate.

CONCLUSIONS

Overall, 30-day readmission following ACDF surgery was 5%-6%. A novel risk scale based on factors associated with increased readmission rates may be helpful in identifying patients who require additional optimization to reduce perioperative morbidity.

LEVEL OF EVIDENCE

Level III-prognostic.

High Altitude Is an Independent Risk Factor for Developing a Pulmonary Embolism, but Not a Deep Vein Thrombosis Following a 1- to 2-Level Lumbar Fusion

STUDY DESIGN

Retrospective study.

OBJECTIVE

To identify if a 1- to 2-level posterior lumbar fusion at higher altitude is an independent risk factor for postoperative deep vein thrombosis (DVT) and pulmonary embolism (PE).

METHODS

A national Medicare database was queried for all patients undergoing 1- to 2-level lumbar fusions from 2005 to 2014. Those with a prior history of DVT, PE, coagulopathy, or peripheral vascular complications were excluded to better isolate altitude as the dependent variable. The groups were matched 1:1 based on age, gender, and comorbidities to limit potential cofounders. Using ZIP codes of the hospitals where the procedure occurred, we separated our patients into high (>4000 feet) and low (<100 feet) altitudes to investigate postoperative rates of DVTs and PEs at 90 days.

RESULTS

Compared with lumbar fusions performed at low-altitude centers, patients undergoing the same procedure at high altitude had significantly higher PE rates (P = .010) at 90 days postoperatively, and similar rates of 90-day postoperative DVTs (P = .078). There were no significant differences in age or comorbidities between these cohorts due to our strict matching process (P = 1.00).

CONCLUSION

Spinal fusions performed at altitudes >4000 feet incurred higher PE rates in the first 90 days compared with patients receiving the same surgery at <100 feet but did not incur higher rates of postoperative DVTs.

Perioperative complications in patients with sleep apnea following primary total shoulder arthroplasty: An analysis of 33,366 patients

Introduction

The study evaluated whether sleep apnea (SA) patients undergoing total shoulder arthroplasty (TSA) are at greater odds of: 1) medical complications; 2) implant-related complications; 3) readmission rates; and 4) costs.

Methods

Complications and readmissions were assessed using logistic regression analysis. Welch's t-test was used to compare CCI and cost between cohorts.

Results

33,366 patients equally distributed in both cohorts. SA increased the odds of medical [Odds-ratio (OR)]: 2.52, p < 0.001) and implant-related complications (OR: 1.43, p < 0.001). Readmission rates were similar to controls (OR: 0.99, p = 0.878), whereas costs were higher (p < 0.001).

Conclusion

SA increases complications and costs following TSA.