Friday, February 10, 2017

Total shoulder complications and risk factors

Total shoulder arthroplasty: risk factors for intraoperative and postoperative complications in patients with primary arthritis

These authors evaluated patient-specific factors, including age, sex, body mass index, prior nonarthroplasty surgery, smoking, alcohol consumption, and the American Society of Anesthesiologists (ASA) Physical  Status Classification System in 275 patients having total shoulder arthroplasty (76 men, 199 women) with an average age of 68 years (range, 51-85 years).

They identifiedwenty-seven complications (9.8%) in 275 shoulder arthroplasties, 22 patients (8%) with category I complications and 5 (2.8%) with category II complications

Patients with an ASA score of 3 showed an increased likelihood of having a surgical complication compared with the control group with ASAscores of 1 and 2 (odds ratio, 4.28; 95% confidence interval, 1.79-10.20; P < .01).

Smokers were more prone to surgical complications than nonsmokers (odds ratio, 5.08; 95% confidence interval, 1.96-13.11; P = .02).

This article can be compared to this one with a much larger sample and a lower complication rate:
Risk factors for and timing of adverse events after total shoulder arthroplasty

Those authors collected data for 5801 patients undergoing TSA from 2009 to 2014 in the American College of Surgeons National Surgical Quality Improvement Program.

146 (2.5%) suffered severe adverse events, and 158 (2.7%) had a 30-day unplanned readmission. 

The most common severe adverse events were reoperation (40%), thrombolic event (deep venous thrombosis or pulmonary embolism; 14%), cardiac event (10%), and death (8.2%). Pneumonia (8.9%) and thrombolic event (7.6%) were the most common medically related causes, whereas dislocation (7.6%) and postoperative infection or wound complication (5.1%) were the most common surgical causes for readmission. 

Multivariate analysis identified inflammatory arthritis (P = .026), male gender (P = .019), age (P < .001), functional status (P = .024), and American Society of Anesthesiologists class 3/4 (P = .01) as independent predictors for unplanned 30-day readmission and all but inflammatory arthritis for severe adverse events (P ≤ .05 for all). 

Patients with ≥3 risk factors had an 11.56 (P = .002) and 3.43 (P = .013) times increased odds of unplanned readmission and severe adverse events occurring within 2 weeks after surgery, respectively, compared with patients with 0 risk factors.

Comment: These are cautionary tales. They suggests that we should be conservative in offering elective surgery to patients at high risk for complications (i.e. ASA score above 2, young males, those with inflammatory arthritis) and assure that these patients are informed of their increased risk for complications. 

The observation that dislocation was the major surgical adverse event suggests that surgeon experience may have been a contributing factor, although the authors did not analyze this variable. 

While it has been suggested that risk stratification would lead to more cost effective care, paying increased attention to the appropriateness of elective surgery and surgeon experience may be even more effective.


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