Total Hip Arthroplasty: COPD and its Effect on Postoperative Complications

Introduction The demand for Total Hip Arthroplasty (THA) has rapidly risen and continues to due to high success rates of this procedure and the growing aging population. Particularly in Chronic Obstructive Pulmonary Disease (COPD), studies have indicated an increased risk of various postoperative complications across several surgery types. Despite the prevalence of COPD, very little has been investigated regarding postsurgical complications in patients with COPD following a THA. The aim of the current study is to utilize the NSQIP database and determine differences in short-term postoperative complications after undergoing THA, comparing patients with and without COPD. Methods In total, 74,814 patients were included in the analysis looking at how COPD contributes to the rates of postoperative complications in primary THA. Data was obtained from the National Surgical Quality Improvement Project Database years 2005-2014, with readmission/reoperation data beginning in 2011. THA cases were selected out of the database using current procedural terminology (CPT) code 27130. On univariate analysis, p-values were calculated using chi-square for categorical variables and one-way ANOVA for continuous variables. On multivariate analysis, logistic regression was used to control for preoperative comorbidities and calculate p-values. Results On multivariate analysis and after controlling for contributing comorbidities, having COPD was found to be an independent predictor of superficial surgical site infection (OR: 1.74), pneumonia (OR: 3.69), reintubation (OR: 2.65) failure to wean (OR: 3.45), urinary tract infection (OR: 1.46), needing a postoperative transfusion (OR: 1.19), and sepsis (OR: 1.97). COPD also independently predicted whether a patient would be discharged home or not (OR: 1.50). Discussion Although COPD has been linked to negative postoperative outcomes across several surgeries, few studies have examined postsurgical complications in patients with COPD following a THA. Our study found patients with COPD to have higher rates of superficial surgical site infection, pneumonia, reintubation, failure to wean, urinary tract infection, needing a postoperative transfusion, and sepsis. COPD also independently predicted whether a patient would be discharged home or not. Managing high-risk surgical patients requires a better understanding of possible complications a patient faces and enhancing perioperative conditions to improve outcomes. Given our study identified certain complications as independent risk factors for patients with COPD, surgeons and other healthcare providers can use this information to more accurately counsel patients and make perioperative adjustments accordingly

Lumbar Decompression Surgery: Does Chronic Steroid Use Increase the Risk of Postoperative Infectious Complications? – A Study of the National Surgical Quality Improvement Program (NSQIP) Database

Intro: It has long been established that corticosteroids have a negative impact on the human immune system’s ability to function at an optimal level. Many past studies have shown that patient’s will have higher rates of infection if they are taking chronic steroids. What has yet to be established is just how much of an increased risk patients on chronic steroids have for infection after undergoing lumbar decompression surgeries, of which there are thousands per year. We hypothesize that patients on chronic steroids will have higher rates of surgical site infections and higher rates of other infections (UTI, pneumonia, etc.) after undergoing lumbar decompression surgery of the spine. Methods: To test our hypothesis, we looked at the ACS National Surgical Quality Improvement Program (NSQIP) database data from 2005-2014. Using CPT codes, we selected out all spine surgeries where the purpose of surgery was to decompress an area of the lumbar spine, including herniated discectomies, laminectomies, among others. Chi-square analysis was done to evaluate for differences among the steroid and non-steroid groups for demographics, preoperative comorbidities, and postoperative complications. Binary regression analysis was done to determine if chronic steroid use independently predicts rates of postoperative infections. Results: Though chronic steroid use was not found to increase rates of surgical site infections, chronic steroid use was found to independently predict rates of pneumonia (OR: 3.06, p=0.030) and septic shock (OR: 3.79, p=0.008). Discussion: While steroid use has been established as immunosuppressive, it has not been established to what extent steroid use increases infection rates postoperatively in lumbar decompression surgeries, of which there are thousands each year. Spine surgeons should remain vigilant regarding postoperative infections in patients on chronic steroids, especially as it relates to pneumonia and propensity to decompensate into septic shock as these occur at significantly higher rates than the general population

The Effect of PGY Status on Rates of Postoperative Complications in All Orthopedic Surgeries – A study on the National Surgical Quality Improvement Project Database

Background: The influence of residents’ participation on patient morbidity has been thoroughly studied across all specialties in the field of medicine. The focus of these studies was on residents as a whole relative to a control (i.e. attending only). The present study assessed the influence of resident involvement on patient morbidity, but stratified the data among residents based on level of experience. Methods: The present study utilized the 2005-2014 NSQIP dataset to assess rate of complications in 36,020 patients after all orthopedic surgeries between two tiers of residents by PGY status. Only residents with PGY value of 1-6 were included in the study. Orthopedic training was separated into two groups: PGY 1-3 and PGY 4-6, signifying first and second half of orthopedic surgery training. Results: Univariate analysis for operative complications showed higher rate of organ space infection in PGY 4-6 group (0.4% vs. 0.3%, p-value: 0.042). Once controlling for comorbidities on multivariate analysis, these differences disappeared (p-value: 0.111). On univariate analysis for non-operative complications, PGY 4-6 group had higher rates of pulmonary embolism (0.5% vs. 0.3%, p-value: 0.006), requiring transfusion (9.0% vs. 7.7%, pvalue: \u3c0.001), and myocardial infarction (0.4% vs. 0.2%, p-value: 0.009). On multivariate analysis, pulmonary embolism (Odds ratio: 1.74, p-value: 0.004), post-operative transfusions (Odds ratio: 1.12, p-value: 0.007), and myocardial infarction (Odds ratio: 2.35, pvalue: 0.001) were shown to be higher in the more experienced residents, even after controlling for pre-operative comorbidities. Conclusion: We found no significant difference between inexperienced residents (PGY 1-3) and more experienced residents (PGY 4-6) in rates of operative complications. However, it was found that there is a greater risk of non-operative complications in the group of more experienced residents, signifying a discrepancy exists in medical management post-operatively as orthopedic residents advance through training. Level of Evidence: Level II Retrospective Cohort Stud

The Theorized Effects of Cold Atmospheric Plasma on the Membrane Potential Across the Glioma Cell Membrane

TITLE: The Theorized Effects of Cold Atmospheric Plasma on the Membrane Potential Across the Glioma Cell Membrane BACKGROUND: Cold atmospheric plasma (CAP) is a novel but promising potential therapy for specifically targeting neoplastic cells. It has been shown to selectively induce apoptosis in certain types of cancer cells to a much larger extent than healthy cells via generation of reactive oxygen and nitrogen species, which damage DNA. The mechanism by which CAP preferentially targets cancer cells over normal cells is unknown at this time. HYPOTHESIS: We hypothesize that treating glioma cells with CAP will transiently hyperpolarize the cell membrane, pausing cells in the G2 phase of the cell cycle and preventing progression to mitosis in glioma cells at a higher rate than healthy cells. We believe that this will be subsequently followed by cell membrane depolarization and apoptosis in glioma cells at a higher rate than healthy glial cells. We believe that the hyperpolarization differences seen between cell lines will be due to increased aquaporin expression on glioma cell membranes and that the depolarization differences will be due to the increased inward calcium channel expression on the glioma cell membrane, which can be directly activated by CAP. PROPOSED METHODS: We anticipate measuring glioma cell membrane potentials before and after CAP treatment and comparing our results to glial cell controls over a specified time period. We plan to measure the potentials using a fluorescent membrane potential-measuring dye, which can be visualized by microscopy. Another possibility would be to directly measure individual cell’s membrane potentials and their changes using a microelectrode inserted directly into an individual cell. RESULTS/CONCLUSION: Upon conclusion of the project

Impact of Age on 30-day Postoperative Complications Following Spine Surgery

Introduction Age has been shown to increase risk of postoperative complications. The current study is the largest known study of postoperative complications after spine surgery by age cohort, using the National Surgical Quality Improvement Program (NSQIP) database. Methods A retrospective analysis NSQIP data of 46,509 patients undergoing spine surgery from 2005 to 2014 was performed using specific Current Procedural Terminology (CPT) codes. 30-day postoperative data was collected, analyzed, and broken into age cohorts \u3c30, 30-39, 40-49, 50-59, 60-69, 70-79, and 80-89, to determine differences in complications by age group. Results 46,509 patients were analyzed. Age was a significant predictor of deep surgical site infection, reoperation rate, pneumonia, pulmonary embolism, unplanned intubation, urinary tract infection, requiring postoperative transfusion, postoperative myocardial infarction, cardiac arrest requiring resuscitation, and DVT. Older patients also had longer overall hospital stays and higher rates of hospital readmission. There was no difference in the rate of superficial SSI based on age groups and the highest rate of wound disruption was found in the \u3c30 age group. Discussion Age is a significant predictor of most 30-day postoperative complications after spine surgery. Higher rates of complications in older age cohorts, as well as increased length of stay and higher readmission rates, suggest the need for individualized counseling and decision-making around spine surgery in the elderly

The Impact of COPD on Postoperative Outcome and Complications in Patients Undergoing Primary Total Knee Arthroplasty

Background: Total knee arthroplasty (TKA) is one of the most common operating room procedures performed in the United States and has been increasing over the past decade as the population continues to age. The incidence of chronic obstructive pulmonary disease (COPD) in the aging population has been steadily increasing as well. As a result, a larger percentage of patients who undergo TKA have COPD. In this study we assessed the following: (1) What demographics and comorbidities are most likely to present concurrently in patients with COPD? (2) Are patients with COPD undergoing TKA at increased risk for development of postoperative complications within 30 days? (3) Do patients with COPD have a higher propensity for extended hospital stay or unplanned return to operating room? (4) Does COPD act as an independent risk factor for development of postoperative complications within 30 days? Methods: A retrospective cohort study was conducted utilizing data collected via the American College of Surgeons National Quality Improvement Program Database. Patients who underwent primary TKA from 2005 to 2014 were included in this study. Complications were classified into operative, directly related to surgical procedure, and non-operative, indirectly related to surgical procedure. Univariate and multivariate analyses were conducted on appropriate data. Results: COPD was an independent risk factor for complications including deep surgical site infections (DSSI), pneumonia, re-intubation, failure to wean \u3e 48 hours, progressive renal insufficiency, acute renal failure and cardiac arrest requiring resuscitation. Patients with COPD were additionally found to have longer hospital stays and non-home discharge

Perioperative Complications and Impact of Operation Time on Revision Total Knee Arthroplasty

Background: Total knee arthroplasty (TKA) is a common and effective treatment of knee osteoarthritis. As more TKAs are performed, there will be more subsequent revisions and failures. In multiple studies, operation length was shown to be a risk factor for postoperative infection and venous thromboembolism. Thus, it is important to understand the association between length of operation time and the risk of these various postoperative complications following revision TKA. Methods: A retrospective cohort study was conducted using the American College of Surgeons National Surgical Quality Improvement Program database. Patients who underwent unilateral revision TKAs between 2007 and 2014 were identified and sorted into three different cohorts- below standard operation length (BSOL), standard operation length (SOL), and above standard operation length (ASOL). SOL was defined as between 40-100 minutes. Univariate and multivariate analyses were used to evaluate the incidence of multiple 30-day adverse outcomes after revision TKA with statistical significance as p\u3c.05. Results: Patients that were BSOL were more likely to develop a deep surgical site infection (OR 3.3; CI 1.2-9.0; p=0.017) compared to SOL. Patients that were ASOL were more likely to develop a pulmonary embolism (OR 2.5; CI 1.1-6.1; p=0.038), but less likely to develop an organ/space infection (OR 0.5; CI 0.4-0.7; p\u3c0.001) or sepsis (OR 0.5; CI 0.3-0.6; p\u3e0.001) compared to patients with SOL. Conclusion: Relative to patients with SOL, those with BSOL or ASOL have a greater likelihood of developing certain postoperative complications. However, there were also certain decreased risks associated with ASOL, particularly infection. Orthopedic surgeons should keep in consideration the implication of operation time as a risk factor for postoperative outcomes. Keywords: revision, knee, arthroplasty, operation length, postoperativ

The Impact of Anesthesia Type on Postoperative Outcome and Complications in Patients Undergoing Revision Total Knee Arthroplasty

Background: Revision total knee arthroplasty is an increasingly common procedure and is effective in treating knee osteoarthritis, but has higher complication rates than primary total knee arthroplasty. Anesthetic choice offers a perioperative risk factor that has been extensively studied in primary total knee arthroplasty, showing favorable results for regional anesthesia compared to general anesthesia. Anesthetic choice in revision total knee arthroplasties can be optimized to reduce complications and improve health outcomes. Methods: A retrospective study was conducted using the American College of Surgeons National Surgical Quality Improvement Program database. Patients who underwent revision total knee arthroplasties between 2007 and 2014 were divided into three anesthesia cohorts. Univariate and multivariate analyses were used to analyze perioperative factors. Results: From 9899 patients, 6435 received general anesthesia, 3098 received regional anesthesia, and 366 received Monitored Anesthesia Care/IV Sedation. Patients receiving general anesthesia had increased risk for six adverse outcomes compared to patients receiving regional anesthesia, and one adverse outcome compared to patients receiving Monitored Anesthesia Care/IV sedation. General anesthesia independently increased risk for deep surgical site infection, urinary tract infection, and sepsis compared with regional anesthesia. General anesthesia was shown to be an independent risk factor for having an extended length of hospital stay compared with regional anesthesia or Monitored Anesthesia Care/IV sedation. Conclusion: Patients receiving general anesthesia have increased likelihood for developing adverse postoperative outcomes relative to patients receiving regional anesthesia and Monitored Anesthesia Care/IV sedation. Though complication rates remained low, anesthesiologists must consider the implications of anesthetic choice on postoperative outcomes

Postoperative Complications and Impact of Gender on Operative Treatment of Distal Radius Fractures

Background: Distal Radius Fracture Repair procedures remain commonly performed. While numerous studies have attempted to differentiate gender impact on operative outcomes, the literature remains inconclusive. In particular, gender impact on orthopedic procedures is controversial. In our study, we examined the effects of gender on postoperative complications following distal radius fracture repairs. We predict that males will have increased morbidity and mortality following operative treatment of distal radius fractures than their female counterparts. Methods: Data was collected from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) for all operative treatments for distal radius fractures from 2007 through 2014. Data includes preoperative demographic information and risk factors, perioperative events, and complications occurring within 30 days of initial surgical intervention. Subjects were identified using Current Procedural Terminology (CPT) codes. Primary CPT codes 25607, 25608, 25609 were used to identify patients receiving operative treatment for distal radius fractures. Two cohorts were defined in this study: (1) Male and (2) Female. Data on patients’ demographics, comorbidities, and postoperative complications were analyzed with univariate and multivariate analyses on SPSS software. Univariate analysis was performed using Pearson’s Chi-square for categorical variables or one-way ANOVA for continuous variables. Variables with p\u3c0.05 were selected for multivariate analyses. For the multivariate analyses, Poisson logistic linear regression analyses were performed to determine independent associations of risk factors for postoperative complications. Multivariate analysis results were reported as odds-ratios and 95% confidence intervals. A p-value of \u3c0.05 was used. Results: A total of 6,450 subjects were included in this study. Females comprised the majority of the study, with 4,675 (72%) patients. There were 1,775 male patients included in this study (28%). In total, there were 196 postoperative complications (4.2%) amongst females, and 75 postoperative complications (4.8%) seen in the male cohort. Men have an increased likelihood of failure to wean from anesthesia (p=0.022). There was no observed difference between males and females amongst all other comorbidities. Multivariate analysis did not identify gender as an independent risk for post-operative complications. Summary: There was no difference in postoperative complications based on gender analysis. Furthermore, Gender was not determined to be an independent risk factor for any post-operative complication. Overall complications for operative treatment of distal radius fractures were low for both groups. Based upon our results, risk for postoperative complications should not be stratified based off gender. Patients who stand to benefit from operative treatment of distal radius fractures should receive treatment

The Effect of BMI on Rates of Postoperative Complications after Open Reduction and Internal Fixation of Distal Radius Fractures – A Study on the National Surgical Quality Improvement Project Database

Background: A patient’s Body Mass Index (BMI) has a wide variety of correlations in the orthopedic perioperative setting including post-operative complications. With the current increasing obesity epidemic in the population, understanding the effects of BMI across surgical outcomes can help highlight specific populations that may warrant further management. This study examines the outcomes of patients categorized by BMI receiving operative treatment for distal radius fractures. Methods: A retrospective cohort study was conducted using the American College of Surgeons National Surgical Quality Improvement Program database. Patients who underwent operative management for distal radius fractures between 2007 and 2014 were identified and stratified into groups based on World Health Organization BMI guidelines: (1) \u3c18.5, (2) 18.5-24.9, (3) 25-29.9, (4) \u3e30. Univariate and multivariate analysis were used to evaluate the incidence of multiple adverse events within 30 days after operation. Results: A total of 6,078 subjects were included in this study, with patients who were underweight having the highest percentage of complications at 4.5%. Underweight patients were seen to have an increased likelihood of developing sepsis (p=0.003), myocardial infarction (p\u3c0.001) and progressive renal insufficiency (p\u3c0.001). There were no observed differences seen between BMI groups amongst other comorbidities. Multivariate analysis did not identify BMI as an independent risk factor for any post-operative complications. Conclusion: Relative to non-obese patients (BMI\u3c30), patients with BMI\u3e30 were not observed to be at an increased risk for any post-operative complications. On the contrary patients underweight (BMI\u3c18.5) were found to be at increased risk for developing sepsis, progressive renal insufficiency, and myocardial infarction. Overall complications for operative treatment of distal radius fracture were low for all groups, and patients who stand to benefit from operative treatment should still receive treatment