Dialysis Dependence Is Associated With Significantly Increased Odds of Perioperative Adverse Events After Geriatric Hip Fracture Surgery Even After Controlling for Demographic Factors and Comorbidities

Use of Direct Oral Anticoagulants Among Patients With Hip Fracture Is Not an Indication to Delay Surgical Intervention

OBJECTIVES

To compare outcomes in patients on direct oral anticoagulants (DOACs) treated within 48 hours of last preoperative dose with those with surgical delays >48 hours.

METHODS

DESIGN

Retrospective cohort study.

SETTING

Three academic Level 1 trauma centers.

PATIENT SELECTION CRITERIA

Patients 65 years of age or older on DOACs before hip fracture treated between 2010 and 2018. Patients were excluded if last DOAC dose was >24 hours before admission, patient suffered from polytrauma, and/or delay to surgery was not attributed to DOAC.

OUTCOME MEASURES AND COMPARISONS

Primary outcome measures were the postoperative complication rate as determined by diagnosis of deep venous thrombosis or pulmonary embolus, wound breakdown, drainage, or infection. Secondary outcomes included transfusion requirement, perioperative bleeding, length of stay, reoperation rates, readmission rates, and mortality.

RESULTS

Two hundred five patients were included in this study, with a mean cohort age of 81.9 years (65-100 years), 64% were (132/205) female, and a mean Charlson Comorbidity Index of 6.4 (2-20). No significant difference was observed among age, sex, Charlson Comorbidity Index, or fracture pattern between cohorts (P > 0.05 for all comparisons). Seventy-one patients had surgery <48 hours after final preoperative DOAC dose; 134 patients had surgery >48 hours after. No significant difference in complication rate between the 2 cohorts was observed (P = 0.30). Patients with delayed surgical management were more likely to require transfusion (OR 2.39, 95% CI, 1.05-5.44; P = 0.04). Patients with early surgical management had significantly shorter lengths of stay (5.9 vs. 7.6 days, P < 0.005). There was no difference in estimated blood loss, anemia, reoperations, readmissions, 90-day mortality, or 1-year mortality (P > 0.05 for all comparisons).

CONCLUSIONS

Geriatric patients with hip fracture who underwent surgical management within 48 hours of their last preoperative DOAC dose required less transfusions and had decreased length of stay, with comparable mortality and complication rates with patients with surgery delayed beyond 48 hours. Providers should consider early intervention in this population rather than adherence to elective procedure guidelines.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Hospital characteristics and perioperative complications of Hispanic patients following reverse shoulder arthroplasty-a large database study

BACKGROUND

Hispanic patients are the youngest and fastest-growing ethnic group in the USA. Many of these patients are increasingly met with orthopedic issues, often electing to undergo corrective procedures such as reverse shoulder arthroplasty (RSA). This patient population has unique medical needs and has been reported to have higher incidences of perioperative complications following major procedures. Unfortunately, there is a lack of information on the hospitalization data and perioperative complications in Hispanic patients following procedures such as RSA. This project aimed to query the Nationwide Inpatient Sample (NIS) database to assess patient hospitalization information, demographics, and the prevalence of perioperative complications among Hispanic patients who received RSA.

METHODS

Information from 2016-2019 was queried from the NIS database. Demographic information, incidences of perioperative complications, length of stay, and costs of care among Hispanic patients undergoing RSA were compared to non-Hispanic patients undergoing RSA. A subsequent propensity matching was conducted to consider preoperative comorbidities.

RESULTS

The query of NIS identified 59,916 patients who underwent RSA. Of this sample, 2,656 patients (4.4%) were identified to be Hispanic, while the remaining 57,260 patients (95.6%) were found to belong to other races (control). After propensity matching, Hispanic patients had a significantly longer LOS (median = 1.4 days) than the patients in the control group (median = 1.0, P < 0.001). The Hispanic patients (89,168.5 USD) had a significantly higher cost of care than those in the control group (67,396.1 USD, P < 0.001). In looking at postoperative complications, Hispanic patients had increased incidences of acute renal failure (Hispanics: 3.1%, control group: 1.1%, P = 0.03) and blood loss anemia (Hispanics: 12.7%, control group: 10.9%, P = 0.03).

CONCLUSIONS

Hispanic patients had significantly longer lengths of stay, higher costs of care, and higher rates of perioperative complications compared to the control group. For patients who are Hispanic and undergoing RSA, this information will aid doctors in making comprehensive decisions regarding patient care and resource allocation.

Total knee arthroplasty in dialysis patients: a national in-patient sample-based study of perioperative complications

BACKGROUND

Chronic kidney disease (CKD) is a growing disease that affects millions of people in the USA every year. Many CKD patients progress to end-stage renal disease (ESRD), necessitating the use of hemodialysis to alleviate symptoms and manage kidney function. Furthermore, many of these patients have lower bone quality and experience more postoperative complications. However, there is currently limited information on hospitalization information and perioperative complications in this population following procedures such as total knee arthroplasty (TKA). The purpose of this study was to assess the patient characteristics, demographics, and prevalence of postoperative problems among dialysis patients who received TKA.

METHODS

In this retrospective study, we used the Nationwide Inpatient Sample (NIS) data from 2016 to 2019 to analyze the incidence of perioperative complications, length of stay (LOS), and the cost of care (COC) among patients undergoing TKA who were categorized as dialysis patients, compared with those who were not. Propensity matching was conducted to consider associated factors that may influence perioperative complications.

RESULTS

From 2016 to 2019, 558,371 patients underwent TKAs, according to the National In-Sample (NIS) database. Of those, 418 patients (0.1%) were in the dialysis group, while the remaining 557,953 patients were included in the control group. The mean age of the dialysis group was 65.4 ± 9.8 years, and the mean age in the control group was 66.7 ± 9.5 years (p = 0.006). After propensity matching, dialysis group patients had a higher risk of receiving blood transfusions [odds ratio (OR): 2; 95% confidence interval (CI): 1.2, 3.4] and a significantly larger COC in comparison to those in the control group (91,434.3 USD versus 71,943.6 USD, p < 0.001). In addition, dialysis patients had significantly higher discharges to another facility, as compared with the control group patients.

CONCLUSIONS

The dialysis group had a significantly higher cost of care, higher rates of requiring blood transfusion, and more cases of being discharged to another facility than non-dialysis patients. This data will help providers make informed decisions about patient care and resource allocation for dialysis patients undergoing TKA.

Underweight patients are the highest risk body mass index group for perioperative adverse events following stand-alone anterior lumbar interbody fusion

BACKGROUND CONTEXT

Prior studies investigating the association between Body Mass Index (BMI) and patient outcomes following spine surgery have had inconsistent conclusions, likely owing to insufficient power, confounding variables, and varying definitions and cutoffs for BMI categories (eg, underweight, overweight, obese, etc.). Further, few studies have considered outcomes among low BMI cohorts.

PURPOSE

The current study analyzes how anterior lumbar interbody fusion (ALIF) perioperative outcomes vary along the BMI spectrum, using World Health Organization (WHO) categories of BMI.

STUDY DESIGN/SETTING

A retrospective cohort study.

PATIENT SAMPLE

Patients undergoing stand-alone one or two-level anterior lumbar interbody fusion (ALIF) found in the 2005-2018 American College of Surgeons National Surgical Quality Improvement Program (NSQIP) databases.

OUTCOME MEASURES

Thirty-day adverse events, hospital readmissions, post-operative infections, and mortality.

METHODS

Stand-alone one or two-level ALIF surgical cases were identified and extracted from the 2005-2018 National Surgical Quality Improvement Program (NSQIP) database. Posterior cases and those primary diagnoses of trauma, tumor, infection, or emergency presentation were excluded. Patients were then binned into WHO guidelines of BMI. The incidence of adverse outcomes within 30-day post-operation was defined. Odds ratios of adverse outcomes, normalized to the average risk of normal-weight subjects (BMI 18.5-24.9 kg/m³), were calculated. Multivariate analysis was then performed controlling for patient factors.

RESULTS

In total, 13,710 ALIF patients were included in the study. Incidence of adverse events was elevated in both the underweight (BMI<18.5 kg/m³) and super morbidly obese (>50 kg/m³), however, multivariate risks for adverse events and postoperative infection were elevated for underweight patients beyond those found in any other BMI category. No effect was noted in these identical variables between normal, overweight, obese class 1, or even obese class 2 patients. Multivariate analysis also found overweight patients to show a slightly protective trend against mortality while the super morbidly obese had elevated odds.

CONCLUSIONS

Underweight patients are at greater odds of experiencing postoperative adverse events than normal, overweight, obese class 1, or even obese class 2 patients. The present study identifies underweight patients as an at-risk population that should be given additional consideration by health systems and physicians, as is already done for those on the other side of the BMI spectrum.

Underweight patients are an often under looked “At risk” population after undergoing posterior cervical spine surgery

Background

Body Mass Index (BMI) is a weight-for-height metric that is used to quantify tissue mass and weight levels. Past studies have mainly focused on the association of high BMI on spine surgery outcomes and shown variable conclusions. Prior results may have varied due to insufficient power or inconsistent categorical separation of BMI groups (e.g. underweight, overweight, or obese). Additionally, few studies have considered outcomes of patients with low BMI. The aim of the current study was to analyze patients along the entirety of the BMI spectrum and to establish specific granular BMI categories for which patients become at risk for complication and mortality following posterior cervical spine surgery.

Methods

Patients undergoing elective posterior cervical spine surgery were abstracted from the 2005–2016 National Surgical Quality Improvement Program (NSQIP) databases. Patients were aggregated into pre-established WHO BMI categories and adverse outcomes were normalized to average risk of normal-weight subjects (BMI 18.5–24.9 kg/m²). Risk-adjusted multivariate regressions were performed controlling for patient demographics and overall health.

Results

A total of 16,806 patients met inclusion criteria. Odds for adverse events for underweight patients (BMI < 18.5 kg/m²) were the highest among any category of patients along the BMI spectrum. These patients experienced increased odds of any adverse event (Odds Ratio (OR) = 1.67, p = 0.008, major adverse events (OR=2.08, p = 0.001), post-operative infection (OR = 1.95, p = 0.002), and reoperation (OR = 1.84, p = 0.020). Interestingly, none of the overweight or obese categories were found to be correlated with increased risk of adverse event categories other than super-morbidly obese patients (BMI>50.0 kg/m²) for post-operative infection (OR = 1.54, p = 0.041).

Conclusions

The current study found underweight patients to have the highest risk of adverse events after posterior cervical spine surgery. Increased pre-surgical planning and resource allocation for this population should be considered by physicians and healthcare systems, as is often already done for patients on the other end of the BMI spectrum.

Underweight Patients Are the Greatest Risk Body Mass Index Group for 30-Day Perioperative Adverse Events After Total Shoulder Arthroplasty

INTRODUCTION

Existing literature investigating the correlation of body mass index (BMI) with surgical complications has focused on those with elevated BMI. These investigations have reported mixed conclusions, possible because of insufficient power, poor controlling of confounding variables, and inconsistent definitions of BMI categories (eg, underweight, overweight, and varying classifications of obese). Few studies have considered complications of patients with low BMI. The aim of the current study was to analyze the spectrum of categories for BMI with 30-day perioperative adverse events after primary total shoulder arthroplasty (TSA) to better assess where along the BMI spectrum patients are at risk for complications.

METHODS

Patients undergoing elective TSA were abstracted from the National Surgical Quality Improvement Program (NSQIP) databases from 2005 to 2016. Patients were then aggregated into BMI categories, and 30-day adverse events were normalized to average risk of normal-weight subjects (BMI 18.5 to 24.9 kg/m2). Risk-adjusted multivariate regressions were performed, controlling for demographic variables and overall health.

RESULTS

In total, 15,717 patients met the inclusion criteria. Underweight TSA patients (BMI < 18.5 kg/m2) had the greatest odds for multiple perioperative adverse events compared with any other BMI category. By multivariate analysis, underweight patients were more likely to experience any adverse event (odds ratio [OR] = 2.22, P = 0.034), serious adverse events (OR = 3.18, P = 0.004), or have postoperative infections (OR = 2.77, P = 0.012) within 30 days when compared with normal-weight patients. No significant difference was observed in these complications for elevated BMI categories when compared with normal-weight patients.

CONCLUSIONS

Only underweight TSA patients were found to have higher rates of 30-day perioperative adverse events than normal BMI patients, unlike any overweight/obese category including the super morbidly obese. Underweight TSA patients were thus identified as an at-risk subpopulation of TSA patients who had not previously been described. Physicians and healthcare systems should give additional consideration to this fragile cohort because they often already do for those at the other end of the BMI spectrum.

LEVEL OF EVIDENCE

III.

Underweight patients are at just as much risk as super morbidly obese patients when undergoing anterior cervical spine surgery

BACKGROUND CONTEXT

Past studies have focused on the association of high body mass index (BMI) on spine surgery outcomes. These investigations have reported mixed conclusions, possible due to insufficient power, poor controlling of confounding variables, and inconsistent definitions of BMI categories (e.g. underweight, overweight, and obese). Few studies have considered outcomes of patients with low BMI.

PURPOSE

To analyze how anterior cervical spine surgery outcomes track with World Health Organization categories of BMI to better assess where along the BMI spectrum patients are at risk for adverse perioperative outcomes.

DESIGN/SETTING

Retrospective cohort study.

PATIENT SAMPLE

Patients undergoing elective anterior cervical spine surgery were abstracted from the 2005 to 2016 American College of Surgeons National Surgical Quality Improvement Program database.

OUTCOME MEASURES

Thirty-day adverse events, hospital readmissions, postoperative infections, and mortality.

METHODS

Patients undergoing anterior cervical spine procedures (anterior cervical discectomy and fusion, anterior cervical corpectomy, cervical arthroplasty) were identified in the 2005 to 2016 National Surgical Quality Improvement Program database. Patients were then aggregated into modified World Health Organization categories of BMI. Odds ratios of adverse outcomes, normalized to average risk of normal weight subjects (BMI 18.5-24.9 kg/m²), were calculated. Multivariate analyses were then performed on aggregated adverse outcome categories controlling for demographics (age, sex, functional status) and overall health as measured by the American Society of Anesthesiologists classification.

RESULTS

In total, 51,149 anterior cervical surgery patients met inclusion criteria. Multivariate analyses revealed the odds of any adverse event to be significantly elevated for underweight and super morbidly obese patients (Odds Ratios [OR] of 1.62 and 1.55, respectively). Additionally, underweight patients had elevated odds of serious adverse events (OR=1.74) and postoperative infections (OR=1.75) and super morbidly obese patients had elevated odds of minor adverse events (OR=1.72). Relative to normal BMI patients, there was no significant elevation for any adverse outcomes for any of the other overweight/obese categories, in fact some had reduced odds of various adverse outcomes.

CONCLUSIONS

Underweight and super morbidly obese patients have the greatest odds of adverse outcomes after anterior cervical spine surgery. The current study identifies underweight patients as an at-risk population that has previously not received significant focus. Physicians and healthcare systems should give additional consideration to this population, as they often already do for those at the other end of the BMI spectrum.

The Influence of Renal Dialysis on All-Cause Mortality in Older Patients with Hip Fracture: a Korean Nationwide Cohort Study

BACKGROUND

The purpose of this study was to analyze the all-cause mortality rate over time after elderly hip fracture in end-stage renal disease (ESRD) patients with dialysis, using a Korean nationwide claims database.

METHODS

This retrospective nationwide study identified subjects from the Korean National Health Insurance Service-Senior cohort (NHIS-Senior). The NHIS-Senior (total of 588,147 participants) was constructed by 10% random sampling and was designed to represent the elderly living in Korea. Subjects were patients aged 65-99 years who underwent surgical treatment for femoral neck fractures or intertrochanteric fractures. A generalized estimating equation model with Poisson distribution and logarithmic link function was used to estimate adjusted risk ratios (aRRs) and 95% confidence intervals (CIs) to measure associations between renal dialysis and cumulative mortality in various time frames.

RESULTS

The total number of patients included in this study was 16,818. These patients were divided into two groups: 116 (0.69%) in the dialysis group and 16,702 (99.31%) in the no-dialysis group. The mean length of hospital stay was 43.87 ± 48.45 days in the dialysis group and 36.29 ± 37.49 days in the no-dialysis group (P = 0.095). The effect of renal dialysis on all-cause mortality was 2.29-fold (aRR; 95% CI, 1.29-4.06; P = 0.005) within 30 days and 1.72-fold (aRR; 95% CI, 1.34-2.21; P < 0.001) within 1-year after hip fracture compared to the no-dialysis group. And, the effect of renal dialysis of in-hospital mortality was 2.72-fold (aRR; 95% CI, 1.71-4.33; P < 0.001) compared to the no-dialysis group.

CONCLUSION

Elderly patients who underwent dialysis have very high mortality rates after hip fracture. Therefore, it is considered that postoperative care through multidisciplinary management and understanding of pathophysiology for the ESRD patients is necessary.

Perioperative adverse events after different fusion approaches for single-level lumbar spondylosis

Background

Low back pain from lumbar spondylosis affects a large proportion of the population. In select cases, lumbar fusion may be considered. However, cohort studies have not shown clear differences in long-term outcomes between PSF, TLIF, ALIF, and AP fusion. Thus, differences in perioperative complications might affect choice between these procedures for the given diagnosis. The current study seeks to compare perioperative adverse events for patients with lumbar spondylosis treated with single-level: posterior spinal fusion (PSF), transforaminal lumbar interbody fusion (TLIF), anterior lumbar interbody fusion (ALIF), or combined anterior and posterior lumbar fusion (AP fusion).

Methods

Patients with a diagnosis of lumbar spondylosis who underwent single-level lumbar fusion without decompression were identified in the 2010-2016 National Quality Improvement Program (NSQIP) database. Patients were categorized based on their procedure (PSF, TLIF, ALIF, or AP fusion). Unadjusted Fisher's exact and Pearson's chi-squared tests were used to compare demographics and comorbid factors. Analysis was secondarily done with propensity score matching to address potential differences in patient selection between the study cohorts.

Results

In total, 1816 patients were identified: PSF n=322, TLIF n=800, ALIF n=460, AP fusion n=234. The procedures did not have different thirty-day individual or aggregated (any, serious, minor, or infection) adverse events. Further, propensity score matched analysis also revealed no differences in individual or aggregated thirty-day perioperative events.

Conclusion

The current study demonstrates a lack of difference in thirty-day perioperative adverse events for different fusion procedures performed for lumbar spondylosis, consistent with prior longer-term outcome studies. These findings suggest that patient/surgeon preference and other factors not captured here should be considered to determine the best surgical technique for the select patients with the given diagnosis who are considered for lumbar fusion.

Summary Sentence

Using the NSQIP 2010-2016 databases, this study showed that perioperative adverse events were similar for different surgical approaches of single-level fusion for single-level lumbar spondylosis.