Known Risk Factor For Complications Research Articles

Poster 299: Body mass index does not affect outcomes following isolated medial patellofemoral ligament reconstruction

Objectives: Patellar instability may cause significant pain and disability and recurrent dislocations are often treated with reconstruction of the medial patellofemoral ligament (MPFL). Obesity is a known risk factor for complications following numerous surgical procedures, yet there exists a lack of data regarding the influence of body mass index (BMI) on outcomes following MPFL reconstruction. The purpose of this study was to evaluate complications and outcomes following isolated MPFL reconstruction in obese and non-obese patients. We hypothesized that patients with a BMI ≥ 30 would exhibit increased complication risk and worse patient-reported outcomes. Methods: A billing query identified all patients at one academic medical center who underwent isolated MPFL reconstruction over an 8 year period. Chart review extracted demographic, physical exam, radiographic, surgical, and complication data. Patients were contacted and outcomes were assessed with the Norwich Patellar Instability (NPI) score, Marx activity rating, and Knee Injury and Osteoarthritis Outcome Score (KOOS). Complications and outcomes were compared based on the presence of a BMI ≥ 30 kg/m2. Results: A total of 161 patients who underwent isolated MPFL reconstruction were included. Of this cohort, there were115 with BMI < 30 and 46 with BMI ≥ 30. Early outcomes (time in brace, time to weight bearing) and postop complications (deep vein thrombosis, infection, pain, repeat dislocation/instability) were similar between groups (p>0.50). A total of 97 patients (60%) completed patient-reported outcomes at a mean of 5 years post-operative, with no differences noted in patient- reported outcomes based on BMI (Table). Conclusions: Obesity (defined as BMI ≥ 30) was not associated with increased complications of poorer patient- reported outcomes 5 years following isolated MPFL reconstruction. [Table: see text]

Robotic Versus Open Incisional Ventral Hernia Repair with Sublay Mesh in Overweight Patients: A Case-Control Analysis of Clinical Outcomes and Costs

Abstract Background Robotic incisional hernia repair (RIHR) with sublay mesh is gaining traction as a minimally-invasive alternative to open retro-rectus reconstruction (OIHR). Obesity is a known risk factor for complications following hernia repair. Aims The objective of this study is to compare the clinical outcomes and costs of RIHR versus OIHR with sublay mesh in overweight patients. Methods Patients with a body mass index (BMI) of 25-35 kg/m2 who underwent OIHR or RIHR with sublay mesh over a 2 years’ period were included. Recurrent hernias after mesh repair were excluded. The main outcome was length of hospital stay (LOS). Secondary outcomes included surgical site complications (SSC), visual analog pain score (VAS), analgesic methods, and general complications. Results Ninety patients were included, 45 in each group. The mean length of stay (LOS) was significantly shorter in RIHR (6.8 days ± 4.6 vs. 2.3 days ± 2, p < 0.001), as were VAS at day 0 (3.0 ± 2.7 vs. 1.7 ± 1.8, p = 0.005) and day 1 (4.2 ± 2.2 vs. 2.4 ± 1.8, p < 0.001), with a significant reduction in morphine consumption and epidural analgesia. The mean operative time was 163 min. ± 65 in OIHR and 191 min. ± 94 in RIHR (p = 0.06), despite a higher proportion of component separation in the robotic group (18% vs 33.3%, p = 0.005). The open group had higher rates of SSC (20% vs 2.2%, p = 0.015) and general complications (40% vs 13.3%, p = 0.004). General costs per diagnosis showed a mean reduction of 4797 CHF in the robotic group, mostly due to reduced hospitalization costs (9364 CHF vs. 3472 CHF). Conclusions The robotic approach improved post-operative outcomes of incisional hernia repair with sublay mesh compared to the open approach in overweight patients, without significantly increasing operative time and costs.

How Does Preoperative Anemia Impact Clinical Outcomes Following Primary Total Hip Arthroplasty?: Experience From Colombia

BackgroundAnemia is a common condition and a known risk factor for complications after primary total hip arthroplasty. Few studies have evaluated this topic in Latin American countries where this problem can be more important. The purpose of this study was to determine the role of preoperative anemia in 30-day complications after primary total hip arthroplasty. MethodsThis was a retrospective observational study involving patients who had a primary total hip arthroplasty aged more than 18 years and did not have any type of malignancy. Two hundred thirty six patients were divided into 2 groups: 58 who had anemia and 178 who did not have anemia. Multivariate logistic regressions were used to assess the relationship between anemia as a risk factor for blood transfusions, extended lengths of stay, and intensive care unit (ICU) admissions. ResultsA higher proportion of patients in the anemia group required blood transfusions (24.1% versus 7.3%, < 0.001), ICU admission (39.7% versus 11.2%, P ≤ .001), and a hospital stay of more than 5 days (37.9% versus 11.8%, < .001). Preoperative anemia was identified as a risk factor for requiring transfusions (Odds ratio 3.82, Confidence Interval 95%: 1.47-9.94, P = .006) and ICU admission (Odds ratio 2.48, Confidence interval 95%: 1.11-5.50, P = .026). ConclusionPreoperative anemia proved to be a risk factor for requiring blood transfusions and ICU admission. Treating this potentially modifiable risk factor can improve patient morbidity and mortality, while positively impacting healthcare costs, reducing the need for postsurgical services such as ICU management, and extended hospitalizations.

What Is the Fate of Total Joint Arthroplasty Patients Who Are Asked to Quit Smoking Prior to Surgery?

BackgroundSmoking is a known risk factor for complications following primary total joint arthroplasty (TJA). Little is known regarding the fate of patients who are asked to quit smoking before surgery. The purpose of this study was to evaluate the success of smoking cessation prior to primary TJA and the impact of smoking cessation on perioperative outcomes. MethodsThis is a retrospective review of patients who presented between 2008 and 2020 to a single academic medical center with a documented smoking history and were asked to quit smoking prior to receiving a date for primary TJA. The cohort was surveyed about smoking cessation, smoking history, use of quit aids, seeking surgery elsewhere due to the cessation policy, and postoperative complications. Descriptive statistics evaluated the relationship between demographics, smoking cessation, and postoperative complications. ResultsA total of 101 patients completed the survey with an overall response rate of 48%. Sixty-two percent of patients quit smoking before surgery, and 51% of these patients reported remaining smoke-free at 6 months postoperatively. The average time to quit before TJA was 45 days (range: 1-365 days), and 62% quit without quit aids. The wound complication/infection rate was significantly higher for patients who did not stop smoking prior to TJA (4 of 16; 27%) than for those who did quit prior to surgery (3 of 63; 5%; P = .02). ConclusionsThis study demonstrates that most patients (62%) will stop smoking, if required, prior to primary TJA. Furthermore, 51% of patients reported abstinence from smoking at 6 months following TJA. TJA appears to be an effective motivator for smoking cessation. Level of EvidenceIII (retrospective cohort study).

Association of Both High and Low Left Ventricular Ejection Fraction With Increased Risk After Coronary Artery Bypass Grafting

While reduced left ventricular ejection fraction (LVEF) is a known risk factor for complications after coronary artery bypass grafting (CABG), the relevance of higher LVEF values has not been established. Currently, most risk stratification tools consider LVEF values above a certain point as normal. However, since this does not account for insufficient ventricular filling or increased adrenergic tone, higher values may have clinical significance. To improve our understanding of this situation, we investigated the relationship of preoperative LVEF values with short- and long-term outcomes after CABG using a strategy that allowed for the identification of nonlinear relationships. We hypothesised that both higher and lower values are independently associated with increased postoperative complications and death in this population. We performed a single-centre retrospective cohort study of patients undergoing isolated CABG surgery. All patients had a preoperative measurement of their LVEF. Surgery involving mitral valve repair was excluded in order to eliminate the impact of mitral regurgitation. The primary outcome was long-term mortality; secondary outcomes included atrial fibrillation, operative mortality, and a composite outcome including any postoperative adverse event. Fractional polynomial equations were used to model the relationship between LVEF and outcomes so we could account for nonlinear relationships if present. Adjustments for confounders were made using multivariable logistic regression and Cox models. A total of 7,932 subjects were included in the study. After adjusting for patient and surgical characteristics, LVEF remained associated with the primary outcome as well as the composite outcome of any postoperative adverse event. Both these relationships were best described by a J-shaped curve given that higher LVEF values were associated with increased risk, albeit not as high has lower values. Regarding long-term mortality, individuals with a preoperative LVEF of 60% demonstrated the longest survival. A statistically significant relationship was not found between LVEF and operative mortality or atrial fibrillation after adjustment for confounders. Higher preoperative LVEF values may be associated with increased risk for patients undergoing CABG surgery. Future studies are needed to better characterise this phenotype.

The Cost of Malnutrition in Total Joint Arthroplasty

BackgroundMalnutrition is a known risk factor for complications and adverse outcomes after elective total joint arthroplasty (TJA), but little is known about the burden this risk factor places on the healthcare system. The purpose of this study was to evaluate the 90-day impact of malnutrition on medical and surgical complications and understand the increase in global reimbursements associated with TJA in malnourished patients. MethodsWe queried a combined private-payer and Medicare database from 2007 to 2016 for TJA using International Classification of Diseases, 9th revision and Current Procedural Terminology codes. Patients with serum albumin level of <3.5 g/dL were gender, age, and mean Elixhauser Comorbidity Index matched against a cohort with a normal serum albumin level. Odds ratios and confidence intervals were calculated for complications at 90 days postoperatively. Mean index and 90-day global reimbursements were calculated for the two matched groups and compared using P-values. Results3053 protein malnourished patients receiving TJA were identified, and 12,202 matched protein nourished patients receiving TJA served as controls. At 90 days, the malnourished groups had increased risk for failure of multiple organ systems, periprosthetic joint infection, and reoperation. The mean 90-day increase in reimbursement was $3875 associated with performing a TJA on a protein malnourished patient (P < .001). ConclusionThis study demonstrates an association between malnourished patients and postoperative complications as well as significantly increased reimbursements. Understanding the reimbursement increases at 90 days for TJA in protein malnourished patients is important in the era of bundled payments.

Early complications of revision total knee arthroplasty in morbidly obese patients.

Morbid obesity is a known risk factor for complications and failure following primary total knee arthroplasty. Complications following revision total knee arthroplasty (rTKA) in the morbidly obese (BMI > 40) have not been well described. A retrospective cohort study was designed to investigate the early complications of rTKA in morbidly obese patients. Revision TKA procedures were performed between January 2009 and December 2012 at a single institution. Comparisons were made between patients with a normal BMI (18.5-25) and patients with morbid obesity (BMI > 40). Thirty-three of 141 morbidly obese patients (23.4%) had a complication compared to 10 of 96 patients with a BMI 18.5-25 (10.4%) (p = 0.011). Morbidly obese patients were younger (69.3 vs. 61.4years, p < 0.0001), and their most frequent complication in comparison with patients with normal BMI was wound healing problems (p = 0.01). Morbidly obese patients are at a significantly increased rate of early complications following rTKA compared to a normal weight cohort, especially with regard to wound complications. The morbidly obese group was significantly younger at the time of rTKA. In addition, this study highlights the importance of risk stratification for morbidly obese patients undergoing rTKA.

Dexamethasone and postoperative hyperglycemia in diabetics undergoing elective hip or knee arthroplasty: a case control study in 238 patients

BackgroundDexamethasone has been routinely used in the pre-operative setting to enhance analgesia and decrease the incidence of nausea and vomiting in patients undergoing primary arthroplasty. However, dexamethasone has the potential to increase blood glucose levels postoperatively, which is a known risk factor for complications after total joint arthroplasty. The aim of this study was to analyze the effect of dexamethasone administration on post-operative blood glucose levels in diabetic patients after primary hip and knee arthroplasty.MethodsThis study was a retrospective review of 238 diabetic patients who underwent primary hip and knee arthroplasty between May 1, 2014 and September 30, 2016 at a single urban academic medical center. A total of 77 patients (32.4%) received dexamethasone and 161 (67.7%) did not. Oral hyperglycemic agents were held during the inpatient stay and blood glucose was controlled either with sliding scale insulin or home insulin regimens were continued. All analyses were adjusted for age, BMI, gender, type of diabetes, pre-operative diabetic medication, type of surgical procedure, and pre-operative HgbA1c level. The primary outcome was post-operative hyperglycemia within 72 h of surgery defined as any blood glucose level greater than or equal to 200 mg/dL.ResultsPost-operative hyperglycemia was observed in 17.1 and 20.6% of the measurements during the first 24 and 72 h respectively. After controlling for confounding variables, patients who received dexamethasone had 4.07 (95% CI: 2.46, 6.72) and 3.08 (95% CI: 2.34, 4.04) higher odds of post-operative hyperglycemia in the first 24 and 72 h respectively.ConclusionsDexamethasone administration in diabetic patients undergoing primary arthroplasty increases post-operative hyperglycemia during the first 24 and 72 h. While our data did not investigate causation, dexamethasone use in this patient population should be thoughtfully considered, as post-operative hyperglycemia is a known risk factor for complications.

Risk of complication during surgical abortion in obese women

Surgical abortion is a generally safe procedure. Obesity is a known risk factor for complications in other surgical procedures, but insufficient information exists to determine the effects of increasing body mass index on the risk of surgical abortions. The purpose of this study was to determine whether obesity is a risk factor for major complications in surgical abortions. A quality control database from a single outpatient center was analyzed to determine rates of major complications during surgical abortions in relation to obesity class. Complications included hemorrhage, need for repeat evacuation, uterine perforation, cervical laceration, medication reaction, unexpected surgery, or unplanned admission to the hospital. Chi-squared and analysis of variance were used for analysis. We included 2468 procedures: 1475 procedures (59.8%) in the first trimester and 993 procedures (40.2%) in the second trimester. The overall complications rate was 2.2%. Second-trimester procedures were more likely than those in the first trimester to have complications (3.1% vs 1.6%; P=.009). Overall, 39.6% of the women were obese, and9.6% of them met criteria for class 3 obesity (body mass index, >40kg/m2). Women who underwent second-trimester abortions with class 3 obesity had a rate of complication of 8.7%, which was significantly more than normal weight women (odds ratio, 5.90; 95% confidence interval, 1.93-8.07; P<.001). Surgical abortions are overall safe procedures, but class 3obesity increases the rate of complication in second-trimester procedures.

Extending the Limits of Microsurgical Reconstruction in Patients with Moderate to Very Severe Obesity: Single-Center 6-Year Experiences.

Background Worldwide obesity has more than doubled since 1980. Given this epidemic change, surgical and medical care has become more complex as obesity is a known risk factor for complications. Consequently, one could expect a higher prevalence of medical and surgical complications in an obese patient collective in the setting of free tissue transfer. Goal of this study was to evaluate whether this assumption holds true. Material and Methods Between January 2009 and June 2015, 838 patients underwent free tissue transfers at a single institution. The cases were divided into three groups using the World Health Organization body mass index (BMI) criteria into a nonobese (n = 751), a moderately obese (n = 59), and a severely to very severely obese group (n = 28). The series was retrospectively analyzed and the groups were compared regarding the potential influence of BMI in respect to surgical complications and outcomes. Results Overall, there was no significant difference in morbidity between the groups of patients regarding the rate of surgical complications during our 3-month follow-up period. Conclusion This study analyzed a large series of microsurgical reconstructions, with a focus on the impact of patient obesity on outcomes. Our findings suggest that despite higher rates of patient comorbidities, successful free tissue transfer can be achieved in this population with acceptable risk for complications.

The effect of tobacco use on outcomes of laparoscopic and open ventral hernia repairs: a review of the NSQIP dataset.

Tobacco smoking is a known risk factor for complications after major surgical procedures. The full effect of tobacco use on these complications has not been studied over large populations for ventral hernia repairs. This effect is more important as the preoperative conditioning, and optimization of patients is adopted. We sought to use the prospectively collected ACS-NSQIP dataset to evaluate respiratory and infectious complications for patients undergoing both laparoscopic and open ventral hernia repairs. The ACS-NSQIP dataset was queried for patients who underwent open or laparoscopic ventral hernia repairs, by primary procedure CPT codes, between years 2009-2012. Smoking use was registered as defined by the ACS-NSQIP, as both a current smoker (within the prior 12months) or as a history of smoking (having ever smoked). Univariate and multivariate analyses were used to investigate postoperative complications for 30-day morbidity and mortality by smoking status while adjusting for preoperative risk factors. The majority of cases were open, 82%, compared to laparoscopic 18%. Sex was evenly distributed with 58% female and 42% male; however, there was a difference in the distribution of current smokers (p=0.03). On analysis there were significantly more respiratory complications (p=0.0003) and infectious complications (p<0.0001). When controlling for sex, age, and type of surgery, using logistic regression, there were associations between smoking in the prior 12months and respiratory complications, including pneumonia (p<0.0001), and re-intubation (p<0.0001). Similar associations were seen on logistic regression if a patient ever smoked; including pneumonia (p<0.0001), re-intubation (p<0.0001), and failure to wean (p<0.0001). Smoking tobacco, both current and historical use, leads to an increase in both respiratory and infectious complications. As more centers try to preoperatively condition patients for elective hernia repairs, it is important to note that patients may never return to the baseline outcomes of patients who never smoked.

Excessive visceral fat area as a risk factor for early postoperative complications of total gastrectomy for gastric cancer: a retrospective cohort study.

BackgroundObesity is a known risk factor for complications after digestive surgery. Body mass index (BMI) is commonly used as an index of obesity but does not always reflect the degree of obesity. Although some studies have shown that high visceral fat area (VFA) is associated with poor outcomes in digestive surgery, few have examined the relationship between VFA and total gastrectomy. In this study, we demonstrated that VFA is more useful than BMI in predicting complications after total gastrectomy.MethodsSeventy-five patients who underwent total gastrectomy for gastric cancer were enrolled in this study; they were divided into two groups: a high-VFA group (n = 26, ≥100 cm2) and a low-VFA group (n = 49, <100 cm2). We retrospectively evaluated the preoperative characteristics and surgical outcomes of all patients and examined postoperative complications within 30 days of surgery (including cardiac complications, pneumonia, ileus, anastomotic leakage, pancreatic fistula, incisional surgical site infection [SSI], abdominal abscess, and hemorrhage).ResultsThe incidence of anastomotic leakage (p = 0.03) and incisional SSI (p = 0.001) were higher in the high-VFA group than in the low-VFA group. No significant differences were observed in the other factors. We used univariate analysis to identify risk factors for anastomotic leakage and incisional SSI. Age and VFA were risk factors for anastomotic leakage, and BMI and VFA were risk factors for incisional SSI. A multivariate analysis including these factors found that only VFA was a predictor of anastomotic leakage (hazard ratio [HR] 4.62; 95 % confidence interval [CI] 1.02–21.02; p = 0.048) and incisional SSI (HR 4.32; 95 % CI 1.18–15.80; p = 0.027].ConclusionsHigh VFA is more useful than BMI in predicting anastomotic leakage and SSI after total gastrectomy. Therefore, we should consider the VFA value during surgery

Effects of Sex on the Incidence of Cardiac Tamponade After Catheter Ablation of Atrial Fibrillation

Background— Cardiac tamponade is the most dramatic complication observed during atrial fibrillation (AF) ablation and the leading cause of procedure-related mortality. Female sex is a known risk factor for complications during AF ablation; however, it is unknown whether women have a higher risk of tamponade. Methods and Results— A systematic Medline search was used to locate academic electrophysiological centers that reported cases of tamponade occurring during AF ablation. Centers were asked to provide information on cases of acute tamponade according to sex and their mode of management including any case of related mortality. Nineteen electrophysiological centers provided information on 34 943 ablation procedures involving 25 261 (72%) men. Overall, 289 (0.9%) cases of tamponade were reported: 120 (1.24%) in women and 169 (0.67%) in men (odds ratio, 1.83; P &lt;0.001). There was a reciprocal association between center volume and the occurrence of tamponade with substantially lower risk in high-volume centers. Most cases of tamponade occurred during catheter manipulation or ablation; women tended to develop more tamponades during transseptal catheterization. No sex difference in the mode of management was observed. However, 16% cases of tamponade required surgery with lower rates in high-volume centers. Three cases of tamponade (1%) culminated in death. Conclusions— Tamponade during AF ablation procedures is relatively rare. Women have an ≈2-fold higher risk for developing this complication. The risk of tamponade among women decreases substantially in high-volume centers. Surgical backup and acute management skills for treating tamponade are important in centers performing AF ablation.

Optimizing the Safety of Surgery, Before Surgery

Optimizing the Safety of Surgery, Before Surgery

Older Age Increases Short-term Surgical Complications After Primary Knee Arthroplasty

Age is a known risk factor for complications after knee arthroplasty; however, age-related risks for a variety of complications of total and partial knee arthroplasties have not been well quantified. Our study addressed three questions to better understand age-related risk of complications: (1) At what age do different types of complications increase? (2) Is the increase in complications with age resulting from age-related patient comorbidities, sociodemographic characteristics, and surgical conditions? (3) What is the probability of complications at different ages for an average patient? The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database from 2005 to 2009 was used to analyze complications for 8950 patients. Complications included NSQIP events, and complications described by the 2003 National Institutes of Health (NIH) consensus statement on total knee arthroplasty as well as 30-day mortality, deep vein thrombosis, return to the operating room, extended length of stay, and technical aspects of the surgery itself. Logistic regression analysis was performed. Mortality was higher for those aged 85 and older. NSQIP complications increased starting at age 70 years and NIH complications at 85 years. Age remained an independent risk factor for multiple complications with controls. The predicted risk for an average patient ranged from 4% (40-64 years old) to 17% (90 years or older) for NSQIP complications and 2.8% to 8.8% for NIH complications. Age is an important independent predictor of surgical complications after knee arthroplasties. Surgeons can share these quantified age-specific risks with patients to guide management decisions.

Prospective study on cranioplasty with individual carbon fiber reinforced polymere (CFRP) implants produced by means of stereolithography

The aim of this study was to evaluate the value of carbon fiber reinforced polymer (CFRP) cranial implants produced by means of 3-dimensional (3D) stereolithography (SL) and template modeling for reconstructions of complex or extensive cranial defects. A series of 41 cranioplasties with individual CFRP implants was performed in 37 patients between April 1996 and November 2002. Only patients with complex and/or large cranial defects were included, most of them having extended scarring or dural calcification and poor quality of the overlying soft-tissue cover after infection or multiple preceding operations. Involvement of frontal sinus, a known risk factor for complications after cranioplasty, was the case in 21 patients (51.2%). A computer-based 3D model of the skull with the bony defect was generated by means of stereolithography after acquisition, evaluation and transfer of the patient's helical computed tomography (CT) data. A wax template of the defect that was used to design the individual prosthesis-shape was invested in dental stone. Then, the cranial implant was fabricated out of CFRP by loosen mold. Reconstruction of defects measuring up to 17 x 9 cm was performed. The intra-operative fit of the implants was excellent in 36 (87.8%), good in 1 (2.4%), and fair in 4 (9.8%) of the cases. Problems of implant fit occurred because of extended scarring and poor quality of soft-tissue cover. Adverse reactions were observed in 5 patients (1 subdural, 1 subcutaneous hematoma, 2 infections, 1 allergic reaction). Excellent contours and a solid stable reconstruction have been maintained in 30 out of 35 remaining plates (mean follow-up 3.6 years). No adverse effects concerning postoperative imaging, the accuracy of electroencephalograms and radiation therapy have been observed. The authors believe that this relatively new technique represents an advance in the management of complex and large cranial defects, but seems less suitable for simple defects because of cost-intensive techniques. Because of the high mechanical strength, biocompatibility, innovative design, and especially radiolucency, CFRP implants should, however, be considered in smaller defects if further imaging investigations or irradiation therapies are necessary.