Short-term Complications for Proximal Humerus Fracture Surgery Have Decreased: An Analysis of the National Surgical Quality Improvement Program Database
Multiple surgical treatments exist for proximal humerus fractures (PHFs), but current practice patterns and short-term complication profiles remain poorly understood. This is in part due to changes in treatment paradigms over the past decade. A more thorough understanding of the evolution in managem...
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Published in | Clinical orthopaedics and related research Vol. 480; no. 11; pp. 2122 - 2133 |
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Main Authors | , , , , , |
Format | Journal Article |
Language | English |
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United States
Wolters Kluwer
01.11.2022
Lippincott Williams & Wilkins Ovid Technologies |
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Abstract | Multiple surgical treatments exist for proximal humerus fractures (PHFs), but current practice patterns and short-term complication profiles remain poorly understood. This is in part due to changes in treatment paradigms over the past decade. A more thorough understanding of the evolution in management over this time as well as an appreciation of the preoperative factors associated with both the chosen surgical modality and short-term complications will help inform future surgical considerations.
In this study, we sought to: (1) characterize trends in the surgical management of PHFs over time, including usage rates of various surgical modalities and changes in complication rates; (2) identify preoperative variables associated with the selection of surgical modality; and (3) assess the independent covariates of acute 30-day complications, including demographic variables, injury characteristics, and treatment type.
The National Surgical Quality Improvement Program (NSQIP) database was queried using Current Procedural Terminology and ICD-9 and ICD-10 codes to identify individuals with PHF undergoing open reduction and internal fixation (ORIF), hemiarthroplasty (HA), or reverse total shoulder arthroplasty (RTSA) from 2007 to 2018. The NSQIP database was utilized because of its collection of detailed preoperative demographic information and large repository of clinically derived data, which is felt to be more accurate than claims or administrative data. In total, 5889 patients with PHFs met the inclusion criteria. Patients 17 years or older were included. Patients with isolated greater tuberosity, humeral shaft, and distal humerus fractures; nonunions; malunions; and those undergoing revision procedures were excluded. A Cochran-Armitage test was used to evaluate surgical trends over time. Multivariable logistic regression models were created to identify covariates associated with surgical modality and complications. Although complications were either classified as major or minor, specific complications were also individually analyzed to avoid potentially misleading conclusions associated with pooling.
The proportion of patients with PHFs undergoing RTSA (4% in 2007 and 34% in 2018; p < 0.001) and ORIF (46% in 2007 and 57% in 2018; p < 0.001) increased over time, and the proportion of those undergoing HA (50% in 2007 and 9% in 2018; p < 0.001) decreased. Across each surgical modality, minor complication rates decreased over time (RTSA: 10% in 2018; p < 0.001; ORIF: 5% in 2018; p = 0.01; and HA: 6% in 2018; p = 0.01). After controlling for confounding variables like diabetes, chronic obstructive pulmonary disease, congestive heart failure, dialysis, and preoperative blood transfusion, the following factors were independently associated with an increased odds of a patient undergoing RTSA rather than HA: older age, higher BMI, independent functional status, and smoking. The following factors were independently associated with a decreased odds of a patient undergoing ORIF rather than RTSA and HA: older age, higher BMI, higher American Society of Anesthesiologists (ASA) classification, smoking, steroid/immunosuppressant use, as well as three- and four-part fractures. After controlling for age, ASA classification, functional status, and preoperative blood transfusion, we also found that in the latter part of the study period, arthroplasty (RTSA and HA) was no longer independently associated with 30-day major or minor complications compared with ORIF.
The increasing utilization of RTSA and decreasing short-term complication rates for fixation and arthroplasty alike represent a substantial change compared even with recent historic norms in the management of proximal humerus fractures. Quantifying demographics, injury characteristics, and comorbidities associated with both the choice of surgical modality and complications serves as the groundwork for decision support tools, which can inform patients and surgeons of the probability of a particular surgical modality being chosen and the risk of complications, based on national benchmarks. Future studies should investigate longer term complication rates, as many differences between the approaches being compared might occur beyond the perioperative period and our study had no means to address questions about complications beyond that period, but obviously those must be considered when choosing a treatment for patients with these injuries. Future work might also investigate the mechanisms behind the decreasing rates of short-term complications.
Level III, therapeutic study. |
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AbstractList | Multiple surgical treatments exist for proximal humerus fractures (PHFs), but current practice patterns and short-term complication profiles remain poorly understood. This is in part due to changes in treatment paradigms over the past decade. A more thorough understanding of the evolution in management over this time as well as an appreciation of the preoperative factors associated with both the chosen surgical modality and short-term complications will help inform future surgical considerations.
In this study, we sought to: (1) characterize trends in the surgical management of PHFs over time, including usage rates of various surgical modalities and changes in complication rates; (2) identify preoperative variables associated with the selection of surgical modality; and (3) assess the independent covariates of acute 30-day complications, including demographic variables, injury characteristics, and treatment type.
The National Surgical Quality Improvement Program (NSQIP) database was queried using Current Procedural Terminology and ICD-9 and ICD-10 codes to identify individuals with PHF undergoing open reduction and internal fixation (ORIF), hemiarthroplasty (HA), or reverse total shoulder arthroplasty (RTSA) from 2007 to 2018. The NSQIP database was utilized because of its collection of detailed preoperative demographic information and large repository of clinically derived data, which is felt to be more accurate than claims or administrative data. In total, 5889 patients with PHFs met the inclusion criteria. Patients 17 years or older were included. Patients with isolated greater tuberosity, humeral shaft, and distal humerus fractures; nonunions; malunions; and those undergoing revision procedures were excluded. A Cochran-Armitage test was used to evaluate surgical trends over time. Multivariable logistic regression models were created to identify covariates associated with surgical modality and complications. Although complications were either classified as major or minor, specific complications were also individually analyzed to avoid potentially misleading conclusions associated with pooling.
The proportion of patients with PHFs undergoing RTSA (4% in 2007 and 34% in 2018; p < 0.001) and ORIF (46% in 2007 and 57% in 2018; p < 0.001) increased over time, and the proportion of those undergoing HA (50% in 2007 and 9% in 2018; p < 0.001) decreased. Across each surgical modality, minor complication rates decreased over time (RTSA: 10% in 2018; p < 0.001; ORIF: 5% in 2018; p = 0.01; and HA: 6% in 2018; p = 0.01). After controlling for confounding variables like diabetes, chronic obstructive pulmonary disease, congestive heart failure, dialysis, and preoperative blood transfusion, the following factors were independently associated with an increased odds of a patient undergoing RTSA rather than HA: older age, higher BMI, independent functional status, and smoking. The following factors were independently associated with a decreased odds of a patient undergoing ORIF rather than RTSA and HA: older age, higher BMI, higher American Society of Anesthesiologists (ASA) classification, smoking, steroid/immunosuppressant use, as well as three- and four-part fractures. After controlling for age, ASA classification, functional status, and preoperative blood transfusion, we also found that in the latter part of the study period, arthroplasty (RTSA and HA) was no longer independently associated with 30-day major or minor complications compared with ORIF.
The increasing utilization of RTSA and decreasing short-term complication rates for fixation and arthroplasty alike represent a substantial change compared even with recent historic norms in the management of proximal humerus fractures. Quantifying demographics, injury characteristics, and comorbidities associated with both the choice of surgical modality and complications serves as the groundwork for decision support tools, which can inform patients and surgeons of the probability of a particular surgical modality being chosen and the risk of complications, based on national benchmarks. Future studies should investigate longer term complication rates, as many differences between the approaches being compared might occur beyond the perioperative period and our study had no means to address questions about complications beyond that period, but obviously those must be considered when choosing a treatment for patients with these injuries. Future work might also investigate the mechanisms behind the decreasing rates of short-term complications.
Level III, therapeutic study. BackgroundMultiple surgical treatments exist for proximal humerus fractures (PHFs), but current practice patterns and short-term complication profiles remain poorly understood. This is in part due to changes in treatment paradigms over the past decade. A more thorough understanding of the evolution in management over this time as well as an appreciation of the preoperative factors associated with both the chosen surgical modality and short-term complications will help inform future surgical considerations.Questions/purposesIn this study, we sought to: (1) characterize trends in the surgical management of PHFs over time, including usage rates of various surgical modalities and changes in complication rates; (2) identify preoperative variables associated with the selection of surgical modality; and (3) assess the independent covariates of acute 30-day complications, including demographic variables, injury characteristics, and treatment type.MethodsThe National Surgical Quality Improvement Program (NSQIP) database was queried using Current Procedural Terminology and ICD-9 and ICD-10 codes to identify individuals with PHF undergoing open reduction and internal fixation (ORIF), hemiarthroplasty (HA), or reverse total shoulder arthroplasty (RTSA) from 2007 to 2018. The NSQIP database was utilized because of its collection of detailed preoperative demographic information and large repository of clinically derived data, which is felt to be more accurate than claims or administrative data. In total, 5889 patients with PHFs met the inclusion criteria. Patients 17 years or older were included. Patients with isolated greater tuberosity, humeral shaft, and distal humerus fractures; nonunions; malunions; and those undergoing revision procedures were excluded. A Cochran-Armitage test was used to evaluate surgical trends over time. Multivariable logistic regression models were created to identify covariates associated with surgical modality and complications. Although complications were either classified as major or minor, specific complications were also individually analyzed to avoid potentially misleading conclusions associated with pooling.ResultsThe proportion of patients with PHFs undergoing RTSA (4% in 2007 and 34% in 2018; p < 0.001) and ORIF (46% in 2007 and 57% in 2018; p < 0.001) increased over time, and the proportion of those undergoing HA (50% in 2007 and 9% in 2018; p < 0.001) decreased. Across each surgical modality, minor complication rates decreased over time (RTSA: 10% in 2018; p < 0.001; ORIF: 5% in 2018; p = 0.01; and HA: 6% in 2018; p = 0.01). After controlling for confounding variables like diabetes, chronic obstructive pulmonary disease, congestive heart failure, dialysis, and preoperative blood transfusion, the following factors were independently associated with an increased odds of a patient undergoing RTSA rather than HA: older age, higher BMI, independent functional status, and smoking. The following factors were independently associated with a decreased odds of a patient undergoing ORIF rather than RTSA and HA: older age, higher BMI, higher American Society of Anesthesiologists (ASA) classification, smoking, steroid/immunosuppressant use, as well as three- and four-part fractures. After controlling for age, ASA classification, functional status, and preoperative blood transfusion, we also found that in the latter part of the study period, arthroplasty (RTSA and HA) was no longer independently associated with 30-day major or minor complications compared with ORIF.ConclusionThe increasing utilization of RTSA and decreasing short-term complication rates for fixation and arthroplasty alike represent a substantial change compared even with recent historic norms in the management of proximal humerus fractures. Quantifying demographics, injury characteristics, and comorbidities associated with both the choice of surgical modality and complications serves as the groundwork for decision support tools, which can inform patients and surgeons of the probability of a particular surgical modality being chosen and the risk of complications, based on national benchmarks. Future studies should investigate longer term complication rates, as many differences between the approaches being compared might occur beyond the perioperative period and our study had no means to address questions about complications beyond that period, but obviously those must be considered when choosing a treatment for patients with these injuries. Future work might also investigate the mechanisms behind the decreasing rates of short-term complications.Level of EvidenceLevel III, therapeutic study. |
Author | Mason, Gabriel Arana, Allyson A. Cognetti, Daniel J. Hoof, Marcus Sheean, Andrew J. Lin, Albert |
AuthorAffiliation | United States Army Institute of Surgical Research, San Antonio, TX, USA Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA Department of Orthopaedic Surgery, San Antonio Military Medical Center, San Antonio, TX, USA |
AuthorAffiliation_xml | – name: Department of Orthopaedic Surgery, San Antonio Military Medical Center, San Antonio, TX, USA – name: United States Army Institute of Surgical Research, San Antonio, TX, USA – name: Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA |
Author_xml | – sequence: 1 givenname: Daniel J. surname: Cognetti fullname: Cognetti, Daniel J. organization: Department of Orthopaedic Surgery, San Antonio Military Medical Center, San Antonio, TX, USA – sequence: 2 givenname: Allyson A. surname: Arana fullname: Arana, Allyson A. organization: United States Army Institute of Surgical Research, San Antonio, TX, USA – sequence: 3 givenname: Marcus surname: Hoof fullname: Hoof, Marcus organization: Department of Orthopaedic Surgery, San Antonio Military Medical Center, San Antonio, TX, USA – sequence: 4 givenname: Gabriel surname: Mason fullname: Mason, Gabriel organization: Department of Orthopaedic Surgery, San Antonio Military Medical Center, San Antonio, TX, USA – sequence: 5 givenname: Albert surname: Lin fullname: Lin, Albert organization: Department of Orthopaedic Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA – sequence: 6 givenname: Andrew J. surname: Sheean fullname: Sheean, Andrew J. organization: Department of Orthopaedic Surgery, San Antonio Military Medical Center, San Antonio, TX, USA |
BackLink | https://www.ncbi.nlm.nih.gov/pubmed/36111889$$D View this record in MEDLINE/PubMed |
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Cites_doi | 10.1097/BOT.0000000000000312 10.1016/j.jse.2016.02.015 10.1016/j.jse.2014.01.005 10.2106/JBJS.16.01611 10.1016/j.jse.2015.09.011 10.2106/JBJS.20.00665 10.1016/j.jse.2020.08.010 10.1097/CORR.0000000000001776 10.1007/s00264-016-3227-y 10.1097/BOT.0000000000000229 10.1302/2046-3758.610.BJR-2017-0170 10.1186/s12891-018-1972-3 10.1016/j.jse.2015.03.018 10.1097/BOT.0b013e3181bdc46a 10.1007/s00264-017-3569-0 10.2106/JBJS.J.01994 |
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References_xml | – volume: 29 start-page: e242 year: 2015 ident: R8-20230814 article-title: The epidemiology of upper extremity fractures in the United States, 2009 publication-title: J Orthop Trauma doi: 10.1097/BOT.0000000000000312 contributor: fullname: Karl – volume: 25 start-page: e295 year: 2016 ident: R6-20230814 article-title: Complications of locked plating for proximal humeral fractures—are we getting any better? publication-title: J Shoulder Elbow Surg doi: 10.1016/j.jse.2016.02.015 contributor: fullname: Haasters – volume: 23 start-page: 1363 year: 2014 ident: R1-20230814 article-title: Reverse total shoulder arthroplasty for the treatment of proximal humeral fractures: patterns of use among newly trained orthopedic surgeons publication-title: J Shoulder Elbow Surg doi: 10.1016/j.jse.2014.01.005 contributor: fullname: Acevedo – volume: 100 start-page: 155 year: 2018 ident: R13-20230814 article-title: Resident participation in fixation of intertrochanteric hip fractures: analysis of the NSQIP database publication-title: J Bone Joint Surg Am doi: 10.2106/JBJS.16.01611 contributor: fullname: Neuwirth – volume: 25 start-page: 624 year: 2016 ident: R3-20230814 article-title: Open reduction internal fixation has fewer short-term complications than shoulder arthroplasty for proximal humeral fractures publication-title: J Shoulder Elbow Surg doi: 10.1016/j.jse.2015.09.011 contributor: fullname: Cvetanovich – volume: 103 start-page: 829 year: 2021 ident: R12-20230814 article-title: Current controversies in the treatment of geriatric proximal humeral fractures publication-title: J Bone Joint Surg Am doi: 10.2106/JBJS.20.00665 contributor: fullname: Mease – volume: 30 start-page: 1159 year: 2021 ident: R2-20230814 article-title: Increasing incidence of primary reverse and anatomic total shoulder arthroplasty in the United States publication-title: J Shoulder Elbow Surg doi: 10.1016/j.jse.2020.08.010 contributor: fullname: Best – volume: 479 start-page: 2284 year: 2021 ident: R10-20230814 article-title: In-hospital complications are more likely to occur after reverse shoulder arthroplasty than after locked plating for proximal humeral fractures publication-title: Clin Orthop Relat Res doi: 10.1097/CORR.0000000000001776 contributor: fullname: Köppe – volume: 40 start-page: 1919 year: 2016 ident: R15-20230814 article-title: Survey study suggests that reverse total shoulder arthroplasty is becoming the treatment of choice for four-part fractures of the humeral head in the elderly publication-title: Int Orthop doi: 10.1007/s00264-016-3227-y contributor: fullname: Savin – volume: 29 start-page: 54 year: 2015 ident: R4-20230814 article-title: Surgical management of complex proximal humerus fractures—a systematic review of 92 studies including 4500 patients publication-title: J Orthop Trauma doi: 10.1097/BOT.0000000000000229 contributor: fullname: Gupta – volume: 6 start-page: 590 year: 2017 ident: R7-20230814 article-title: Impact of the PROFHER trial findings on surgeons’ clinical practice: an online questionnaire survey publication-title: Bone Joint Res doi: 10.1302/2046-3758.610.BJR-2017-0170 contributor: fullname: Jefferson – volume: 19 start-page: 60 year: 2018 ident: R11-20230814 article-title: Tranexamic acid in total shoulder arthroplasty and reverse shoulder arthroplasty: a systematic review and meta-analysis publication-title: BMC Musculoskelet Disord doi: 10.1186/s12891-018-1972-3 contributor: fullname: Kuo – volume: 24 start-page: 1560 year: 2015 ident: R16-20230814 article-title: Reverse shoulder arthroplasty versus hemiarthroplasty for treatment of proximal humerus fractures publication-title: J Shoulder Elbow Surg doi: 10.1016/j.jse.2015.03.018 contributor: fullname: Schairer – volume: 24 start-page: 250 year: 2010 ident: R5-20230814 article-title: Treatment preferences for displaced three- and four-part proximal humerus fractures publication-title: J Orthop Trauma doi: 10.1097/BOT.0b013e3181bdc46a contributor: fullname: Guy – volume: 41 start-page: 1749 year: 2017 ident: R14-20230814 article-title: Orthopaedic surgeons’ opinions surrounding the management of proximal humerus fractures: an international survey publication-title: Int Orthop doi: 10.1007/s00264-017-3569-0 contributor: fullname: Nowak – volume: 93 start-page: 2249 year: 2011 ident: R9-20230814 article-title: Increasing incidence of shoulder arthroplasty in the United States publication-title: J Bone Joint Surg Am doi: 10.2106/JBJS.J.01994 contributor: fullname: Kim |
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Snippet | Multiple surgical treatments exist for proximal humerus fractures (PHFs), but current practice patterns and short-term complication profiles remain poorly... BackgroundMultiple surgical treatments exist for proximal humerus fractures (PHFs), but current practice patterns and short-term complication profiles remain... BACKGROUNDMultiple surgical treatments exist for proximal humerus fractures (PHFs), but current practice patterns and short-term complication profiles remain... |
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SubjectTerms | Arthroplasty Arthroplasty, Replacement, Shoulder - adverse effects Arthroplasty, Replacement, Shoulder - methods Blood transfusion Blood transfusions Chronic obstructive pulmonary disease Classification Comorbidity Computer programs Congestive heart failure Coronary artery disease Demography Diabetes mellitus Dialysis Fracture Fixation, Internal - adverse effects Fractures Humans Humerus Humerus - surgery Immunosuppressive Agents Joint surgery Lung diseases Obstructive lung disease Patients Postoperative Complications - etiology Postoperative Complications - surgery Quality control Quality Improvement Regression analysis Retrospective Studies Shoulder Fractures - surgery Smoking Steroids Terminology Treatment Outcome Trends |
Title | Short-term Complications for Proximal Humerus Fracture Surgery Have Decreased: An Analysis of the National Surgical Quality Improvement Program Database |
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