Robert Thorsness

Perioperative complications after hemiarthroplasty and total shoulder arthroplasty are equivalent

BACKGROUND Total shoulder arthroplasty (TSA) results in superior clinical outcomes to hemiarthroplasty (HA); however, TSA is a more technical and invasive procedure. This study retrospectively compares perioperative complications after HA and TSA using the National Surgical Quality Improvement Program (NSQIP) database. METHODS The NSQIP user file was queried for HA and TSA cases from the years 2005 through 2010. Major complications were defined as life-threatening or debilitating. All complications occurred within 30 days of the initial procedure. We performed multivariate analysis to compare complication rates between the two procedures, controlling for patient comorbidities. RESULTS The database returned 1,718 patients (HA in 30.4% [n = 523] and TSA in 69.6% [n = 1,195]). The major complication rates in the HA group (5.2%, n = 29) and TSA group (5.1%, n = 61) were similar (P = .706). Rates of blood transfusions for postoperative bleeding in patients undergoing HA (2.3%, n = 12) and TSA (2.9%, n = 35) were indistinguishable (P = .458). Venous thromboembolism was a rare complication, occurring in 0.4% of patients in each group (2 HA patients and 5 TSA patients, P > .999). On multivariate analysis, the operative procedure was not associated with major complications (P = .349); however, emergency case, pulmonary comorbidity, anemia with a hematocrit level lower than 36%, and wound class of III or IV increased the risk of a major complication (P < .05 for all). CONCLUSION Multivariate analysis of patients undergoing TSA or HA in the NSQIP database suggests that patient factors-not the procedure being performed-are significant predictors of major complications. Controlling for patient comorbidities, we found no increased risk of perioperative major complications in patients undergoing TSA compared with HA.

Proximal Humerus Fractures with Associated Axillary Artery Injury

Summary: Proximal humerus fractures have rarely been associated with injuries to the axillary artery. Most of the fractures described have been Neer 2-part surgical neck fractures with medialization of the shaft fragment and resultant laceration or thrombosis of the axillary artery. No intraoperative deaths have been reported. We present a series of 3 proximal humerus fractures, 2 of which are Neer 3- to 4-part anterior fracture dislocations, and associated axillary artery injury. There were 2 mortalities, 1 intraoperative. After a thorough review of the English literature, we identified an additional 11 cases of axillary artery injury associated with proximal humerus fracture. The purpose of this study was to heighten the clinical suspicion of this vascular injury in patients with proximal humerus fracture dislocations and surgical neck fractures with shaft medialization, as well as to review pathogenesis and guide management decisions.

Postoperative Morbidity by Procedure and Patient Factors Influencing Major Complications Within 30 Days Following Shoulder Surgery

Background: Little data are available to prioritize quality improvement initiatives in shoulder surgery. Purpose: To stratify the risk for 30-day postoperative morbidity in commonly performed surgical procedures about the shoulder completed in a hospital setting and to determine patient factors associated with major complications. Study Design: Cohort study; Level of evidence, 3. Methods: This retrospective study utilized the National Surgical Quality Improvement Program (NSQIP) database from the years 2005 to 2010. Using Current Procedural Terminology codes, the database was queried for shoulder cases that were divided into 7 groups: arthroscopy without repair; arthroscopy with repair; arthroplasty; clavicle/acromioclavicular joint (AC) open reduction and internal fixation (ORIF)/repair; ORIF of proximal humeral fracture; open tendon release/repair; and open shoulder stabilization. The primary end point was any major complication, with secondary end points of incisional infection, return to the operating room, and venothromboembolism (VTE), all within 30 days of surgery. Results: Overall, 11,086 cases were analyzed. The overall major complication rate was 2.1% (n = 234). Factors associated with major complications on multivariate analysis included: procedure performed (P < .001), emergency case (P < .001), pulmonary comorbidity (P < .001), preoperative blood transfusion (P = .033), transfer from an outside institution (P = .03), American Society of Anesthesiologists (ASA) score (P = .006), wound class (P < .001), dependent functional status (P = .027), and age older than 60 years (P = .01). After risk adjustment, open shoulder stabilization was associated with the greatest risk of major complications relative to arthroscopy without repair (odds ratio [OR], 5.56; P = .001), followed by ORIF of proximal humerus fracture (OR, 4.90; P < .001) and arthroplasty (OR, 4.40; P < .001). These 3 groups generated over 60% of all major complications. Open shoulder stabilization had the highest odds of reoperation (OR, 8.34; P < .001), while ORIF of proximal humerus fracture had the highest risk for VTE (OR, 6.47; P = .001) compared with the reference group of arthroscopy without repair. Conclusion: Multivariable analysis of the NSQIP database suggests that open shoulder stabilization, ORIF for proximal humerus fractures, and shoulder arthroplasty are associated with the highest risk of major complications within 30 days after shoulder surgery in a hospital setting. Age, functional status, ASA score, pulmonary comorbidity, emergency case, preoperative blood transfusion, and transfer from an outside institution are patient variables that significantly influence complication risk.

Open Reduction and Internal Fixation Versus Hemiarthroplasty in the Management of Proximal Humerus Fractures

Objectives: The purpose of this study was to use a nationally representative database to determine the differences in 30-day outcomes based on procedure type for management of proximal humerus fractures including complications, readmission, operative time, and length of stay. Further, we sought to determine patient characteristics and perioperative factors associated with poor outcomes. Design/Setting: This was a retrospective study of the National Surgical Quality Improvement Program (NSQIP) database. The NSQIP comprises a clinical database with systematic patient tracking at multiple hospitals across the United States. Patients: A total of 413 patients with proximal humerus fractures managed surgically were included. Intervention: Of 413 patients, 330 underwent open reduction and internal fixation (ORIF) and 83 underwent hemiarthroplasty. Main Outcomes/Measurements: The primary end points included major and minor complications, operative time, rate of return to the operating room, and length of stay. Results: Compared to the hemiarthroplasty cohort, patients in the ORIF cohort were significantly younger (64.2; 17-90 and 69.3; 20-90, respectively, P = .007) and were significantly less likely to be of functionally dependent status (17.5% and 27.7%, P = .036). Compared to the hemiarthroplasty cohort, the ORIF cohort demonstrated fewer postoperative bleeding complications (2.4% and 8.4%, respectively, P = .016) and shorter operative times (115 vs 131 minutes, P = .017). There were no significant differences between the groups with respect to complications, reoperation rates, or length of hospital stay. On multivariable analysis, hemiarthroplasty demonstrated increased risk of postoperative bleeding compared to ORIF (odds ratio = 7.06, confidence interval: 2.06-24.24; P = .002) as well as increased operative time (P = .01). Conclusions: Patients who undergo hemiarthroplasty for management of proximal humerus fractures are significantly older and often functionally dependent. When compared to ORIF, hemiarthroplasty is associated with longer operative times and greater risk of bleeding complications.

Cost Drivers After Surgical Management of Proximal Humerus Fractures in Medicare Patients.

Objectives: This comparative effectiveness study sought to determine the impact of complications, readmission, and procedure choice on in-hospital and total 90-day costs for surgical management of proximal humerus fractures. Methods: Medicare claims data from the Upstate New York area (2008–2009) were evaluated. The study included all patients treated with open reduction and internal fixation (ORIF) or hemiarthroplasty for proximal humerus fracture identified by ICD-9 codes. The primary end points included in-hospital costs and total health care costs within 90 days after the index operation. Multivariable generalized linear models with negative binomial distributions and log link function were used for cost analysis. Results: ORIF was performed in 52 cases and hemiarthroplasty in 57 cases, total n = 109. On univariate analysis, readmission increased in-hospital cost by

Functional and Imaging Outcomes of Arthroscopic Simultaneous Rotator Cuff Repair and Bankart Repair After Shoulder Dislocations

54,345 and total 90-day costs by

Cost-effectiveness of Open Reduction and Internal Fixation Compared With Hemiarthroplasty in the Management of Complex Proximal Humerus Fractures:

63,104, whereas complications increased in-hospital cost by

Open Reduction and Internal Fixation Versus Hemiarthroplasty in the Management of Complex Articular Fractures and Fracture-dislocations of the Proximal Humerus

23,300 and total 90-day costs by

Perioperative management of rheumatoid medications.

30,237. On multivariable analysis, ORIF was associated with 29% lower in-hospital cost compared with hemiarthroplasty [Odds Ratio 0.71; 95% Confidence Interval (CI), 0.54–0.92; P = 0.01], and readmission was associated with a 5.68-fold in-hospital cost increase (Odds Ratio 5.68; CI, 3.57–9.03; P < 0.0001). Conclusions: Complications and hospital readmission continue to drive cost upward underscoring the need for best practice. The acute inpatient period costs may be decreased with ORIF in appropriately selected patients with proximal humerus fractures in comparison with hemiarthroplasty. This study provides real world cost estimates with the cost implications of complications, readmissions, and procedure choice. Level of Evidence: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

An Analysis of Adult Patient Risk Factors and Complications Within 30 Days After Arthroscopic Shoulder Surgery

Background: Previous studies have investigated outcomes of simultaneous rotator cuff (RC) repair and superior labral injury repair; however, there is limited information in the literature on outcomes of simultaneous RC repair and Bankart lesion repair after acute shoulder dislocations. Purpose: To determine functional and imaging outcomes of simultaneous arthroscopic RC repair and Bankart repair after acute shoulder dislocations and to compare functional outcomes to contralateral, asymptomatic shoulders. Study Design: Cohort study; Level of evidence, 3. Methods: Consecutive patients who underwent arthroscopic simultaneous RC repair and Bankart repair with a minimum of 2 years’ follow-up were recruited. All patients had suffered an acute shoulder dislocation. The American Shoulder and Elbow Surgeons (ASES), Constant-Murley, and Short Form (SF)–36 scores were obtained. The affected shoulder also underwent ultrasound imaging to assess the integrity of the RC. Results: Thirteen patients (mean age, 58.8 ± 11.2 years; mean follow-up, 38.5 ± 12.3 months) were recruited. In a comparison of the affected versus unaffected shoulder, there were no significant differences in the mean ASES score (89.7 ± 12.6 vs 95.0 ± 6.7, respectively), mean Constant score (80.5 ± 18.9 vs 86.8 ± 7.9, respectively), or mean abduction strength (15.4 ± 6.4 lb vs 15.4 ± 5.2 lb, respectively) (P > .05). The mean SF-36 physical component summary was 48.4. According to ultrasound imaging, there were persistent/recurrent full-thickness tears in 4 patients, and 1 patient had a new full-thickness tear. At follow-up, patients with full-thickness RC tears in the affected shoulder compared with their unaffected shoulder showed similar mean ASES scores (90.9 ± 11.8 vs 97.6 ± 4.3, respectively), mean Constant scores (77.8 ± 20.3 vs 84.8 ± 7.2, respectively), and mean abduction strength (11.5 ± 5.3 lb vs 12.6 ± 4.5 lb, respectively) (P > .05). Conclusion: After simultaneous arthroscopic repair of the RC and a Bankart lesion in patients after shoulder dislocations, the affected extremity had similar functional outcomes compared to the noninjured, asymptomatic side at a mean of 3 years after surgery. Persistent or recurrent RC tears involving the operative extremity were common, but they did not significantly affect functional outcomes in this small study.