Is Body Mass Index a Risk Factor for Complications following Arthroscopy of the Knee, Hip and Shoulder?

Transcription

1 Abstract No Is Body Mass Index a Risk Factor for Complications following Arthroscopy of the Knee, Hip and Shoulder? Richard W. Nicolay, MD, Ryan S. Selley, MD, Michael A. Terry, MD, Vehniah K. Tjong, MD Department of Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA Published in Arthroscopy since Submission PMID:

2 Disclosures Authors: Richard W. Nicolay, MD No financial conflicts to disclose. Ryan S. Selley, MD No financial conflicts to disclose. Michael A. Terry, MD Paid consultant for Arthrex, Smith & Nephew. Vehniah K. Tjong, MD Paid consultant for Smith & Nephew.

3 Introduction Aim: Utilize the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database to determine if body mass index (BMI) is associated with 30- day postoperative complications following arthroscopic surgery. Hypothesis: Elevated BMI is an independent risk factor for postoperative morbidity, mortality, readmission, reoperation and venothromboembolism (VTE) following arthroscopic surgery of the knee, hip and shoulder. Level of Evidence: Level III

4 Methods Data source: NSQIP Participant Use File (PUF) was queried between 2006 and 2016 Case identification: CPT and ICD-10 codes were used to isolate cases of elective arthroscopy of the knee, hip and shoulder Design: A retrospective comparative analysis was conducted Statistics: Univariate analyses and binary logistic regressions were used to ascertain the adjusted effect of BMI on: - Morbidity - Mortality - Readmission - Reoperation - VTE

5 Results 141,335 patients met criteria Most common complications - Deep vein thrombosis (0.27%) - Superficial surgical site infection (SSI) (0.17%) - Urinary tract infection (0.13%) - Pulmonary embolism (PE) (0.11%) All morbidity Superficial SSI Deep SSI Organ/space SSI (septic arthritis) Wound disruption Pneumonia Unplanned reintubation PE Prolonged ventilation Progressive renal failure Acute renal failure Urinary tract infection Cerebrovascular accident Cardiac arrest Myocardial infarction Bleeding requiring transfusion Deep vein thrombosis (DVT) Sepsis VTE

6 Multivariate analysis: Binary logistic regression of predictors of All Morbidity SHOULDER (n=56449) HIP (n=2023) KNEE (n=82817) Morbidity (%) P-value Morbidity (%) P-value Morbidity (%) P-value Mean age (years) [SD] 58 (13.8) < (16.67) (14.62) Sex Male 233 (0.7) 10 (1.2) 433 (1.0) Female 168 (0.8) 14 (1.2) 449 (1.1) BMI < Normal Weight 55 (0.5) 7 (1.0) 139 (1.0) Underweight 6 (2.0) (0.0) 2 (0.6) Overweight 122 (0.6) (1.5) 267 (1.0) Obesity I 88 (0.8) (1.1) 190 (1.0) Obesity I w/ DM 26 (1.1) (0.0) 32 (1.4) Obesity II 46 (1.0) (1.1) 109 (1.2) Obesity II w/ DM 18 (1.2) (0.0) 26 (1.5) Obesity III 21 (0.7) (1.7) 85 (1.2) Obesity III w/ DM 19 (1.6) < (0.0) 32 (1.6) Comorbidities < < (*reference) 124 (0.5) 11 (0.8) 422 (1.0) (0.7) (2.2) 278 (1.0) >=2 142 (1.4) < (1.4) 182 (1.6) <0.001 ASA < < (0.5) 21 (1.2) 636 (1.0) (1.2) 3 (1.5) 245 (1.4) *Reference = the reference group to which all other groups were compared in order to generate the adjusted OR and p-value.

7 All Morbidity versus BMI Class

8 Multivariate analysis: Binary logistic regression of predictors of Readmission, Reoperation and VTE Readmission Reoperation VTE Adjusted OR (95%CI) P-value Adjusted OR (95%CI) P-value Adjusted OR (95%CI) P-value Age ( ) < ( ) ( ) Female Sex ( ) ( ) ( ) BMI ASA Normal Weight (*reference) Underweight ( ) ( ) ( ) Overweight ( ) ( ) ( ) Obesity I ( ) ( ) ( ) Obesity I w/ DM ( ) ( ) ( ) Obesity II ( ) ( ) ( ) Obesity II w/ DM ( ) ( ) ( ) Obesity III ( ) ( ) ( ) Obesity III w/ DM ( ) ( ) ( ) ASA 1-2 (*reference) ASA ( ) < ( ) < ( ) Principle arthroscopic procedure Shoulder (*reference) Hip ( ) ( ) ( ) Knee ( ) ( ) < ( ) *Reference = the reference group to which all other groups were compared in order to generate the adjusted OR and p-value.

9 Results All Procedures (Knee, Hip & Shoulder) Obesity class III with diabetes was an independent risk factor - Morbidity (OR 1.522, 95% CI, ) - Readmission (OR 2.342, 95% CI, ) Obesity class I was independently protective - Reoperation (OR 0.687, 95% CI, ) VTE risk factors included - Overweight (OR 1.474, 95% CI, ) - Obesity class 1 with diabetes (OR 1.469, 95% CI, )

10 Results Shoulder Arthroscopy risk factors for all morbidity: - Underweight patients (OR 3.776, 95% CI, ) - Class I obese (OR 1.421, 95% CI, ) - Class II obese (OR 1.726, 95% CI, ) Knee Arthroscopy - BMI did not significantly affect morbidity Hip Arthroscopy - Subgroup had a low event rate of morbidity, the analysis could not be performed

11 Conclusion Arthroscopic procedures are safe with very low complication rates However, certain patients are at higher risk: Higher morbidity following shoulder arthroscopy Underweight Class I obese Class II obese Higher morbidity and readmission following all arthroscopy Class III obesity with diabetes Because BMI is a modifiable risk factor, these patients should be evaluated carefully before being considered for outpatient arthroscopic surgery

12 Since Submission, the manuscript has been published in Arthroscopy. References Nicolay RW, Selley RS, Terry MA, Tjong VK. Body Mass Index as a Risk Factor for 30-Day Postoperative Complications in Arthroscopy. Arthroscopy Mar;35(3): e3. doi: /j.arthro Hall MJ, Schwartzman A, Zhang J, Liu X. Ambulatory Surgery Data From Hospitals and Ambulatory Surgery Centers: United States, Natl Health Stat Report. 2017: Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and adult obesity in the United States, JAMA. 2014;311: Grundy SM. Hypertriglyceridemia, insulin resistance, and the metabolic syndrome. Am J Cardiol. 1999;83:25F-29F. 4. Guidelines (2013) for managing overweight and obesity in adults. Preface to the Expert Panel Report (comprehensive version which includes systematic evidence review, evidence statements, and recommendations). Obesity (Silver Spring). 2014;22 Suppl 2:S Kessler KE, Robbins CB, Bedi A, Carpenter JE, Gagnier JJ, Miller BS. Does Increased Body Mass Index Influence Outcomes After Rotator Cuff Repair? Arthroscopy Namdari S, Baldwin K, Glaser D, Green A. Does obesity affect early outcome of rotator cuff repair? J Shoulder Elbow Surg. 2010;19: Cancienne JM, Brockmeier SF, Carson EW, Werner BC. Risk Factors for Infection After Shoulder Arthroscopy in a Large Medicare Population. Am J Sports Med. 2018: Cancienne JM, Brockmeier SF, Carson EW, Werner BC. Risk Factors for Infection After Shoulder Arthroscopy in a Large Medicare Population. Am J Sports Med. 2018;46: Kuyucu E, Erdil M. Impact of Obesity on the Results of Arthroscopic Surgery of the Lower Extremity. Annals of Orthopedics & Rheumatology. 2016;4: Tilinca M, Pop TS, Băţagă T, Zazgyva A, Niculescu M. Obesity and Knee Arthroscopy - a Review. Journal of Interdisciplinary Medicine. 2016;1: Werner BC, A. H, D. MM, W. GF. Obesity Significantly Increases Postoperative Complications after Knee and Shoulder Arthroscopy. AAOS 2015 Annual Meeting. Las Vegas, Nevada2015: Kessler KE, Robbins CB, Bedi A, Carpenter JE, Gagnier JJ, Miller BS. Does Increased Body Mass Index Influence Outcomes After Rotator Cuff Repair? Arthroscopy. 2018;34: Gurunathan U, Myles PS. Limitations of body mass index as an obesity measure of perioperative risk. Br J Anaesth. 2016;116: Stamou SC, Nussbaum M, Stiegel RM, et al. Effect of body mass index on outcomes after cardiac surgery: is there an obesity paradox? Ann Thorac Surg. 2011;91:42-47.

13 References 15. Mullen JT, Davenport DL, Hutter MM, et al. Impact of body mass index on perioperative outcomes in patients undergoing major intra-abdominal cancer surgery. Ann Surg Oncol. 2008;15: Mullen JT, Moorman DW, Davenport DL. The obesity paradox: body mass index and outcomes in patients undergoing nonbariatric general surgery. Ann Surg. 2009;250: Tjeertes EK, Hoeks SE, Beks SB, Valentijn TM, Hoofwijk AG, Stolker RJ. Obesity--a risk factor for postoperative complications in general surgery? BMC Anesthesiol. 2015;15: Rickles AS, Iannuzzi JC, Mironov O, et al. Visceral obesity and colorectal cancer: are we missing the boat with BMI? J Gastrointest Surg. 2013;17: ; discussion p Gage MJ, Schwarzkopf R, Abrouk M, Slover JD. Impact of metabolic syndrome on perioperative complication rates after total joint arthroplasty surgery. J Arthroplasty. 2014;29: Edelstein AI, Lovecchio F, Delagrammaticas DE, Fitz DW, Hardt KD, Manning DW. The Impact of Metabolic Syndrome on 30-Day Complications Following Total Joint Arthroplasty. J Arthroplasty. 2017;32: Bostman OM. Prevalence of obesity among patients admitted for elective orthopaedic surgery. Int J Obes Relat Metab Disord. 1994;18: Flegal KM, Carroll MD, Kit BK, Ogden CL. Prevalence of obesity and trends in the distribution of body mass index among US adults, JAMA. 2012;307: Cheryl D. Fryar MSPH, and Cynthia L. Ogden, Ph.D.,. Prevalence of Underweight Among Adults Aged 20 and Over: United States, Through National Health Examination Survey. NCHS Health E-Stats Center for Disease Control; Rubenstein WJ, Pean CA, Colvin AC. Shoulder Arthroscopy in Adults 60 or Older: Risk Factors That Correlate With Postoperative Complications in the First 30 Days. Arthroscopy. 2017;33: Martin CT, Gao Y, Pugely AJ, Wolf BR. 30-day morbidity and mortality after elective shoulder arthroscopy: a review of 9410 cases. J Shoulder Elbow Surg. 2013;22: e Westermann RW, Pugely AJ, Ries Z, et al. Causes and Predictors of 30-Day Readmission After Shoulder and Knee Arthroscopy: An Analysis of 15,167 Cases. Arthroscopy. 2015;31: e Hill JR, McKnight B, Pannell WC, et al. Risk Factors for 30-Day Readmission Following Shoulder Arthroscopy. Arthroscopy. 2017;33: Shiloach M, Frencher SK, Jr., Steeger JE, et al. Toward robust information: data quality and inter-rater reliability in the American College of Surgeons National Surgical Quality Improvement Program. J Am Coll Surg. 2010;210: Henderson WG, Daley J. Design and statistical methodology of the National Surgical Quality Improvement Program: why is it what it is? Am J Surg. 2009;198:S19-27.