Anthony Chris A, Westermann Robert W, Gao Yubo, Pugely Andrew J, Wolf Brian R, Hettrich Carolyn M
The Department of Orthopaedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, 01008 JPP, Iowa City, IA, 52242, USA,
Clin Orthop Relat Res. 2015 Jun;473(6):2099-105. doi: 10.1007/s11999-014-4107-7. Epub 2014 Dec 19.
Total shoulder arthroplasty (TSA) is an effective treatment for end-stage glenohumeral joint pathology with good long-term results. Previous descriptions of morbidity and blood transfusion in TSA are limited by preoperative risk factors and postoperative complications considered and single-center studies.
QUESTIONS/PURPOSES: The purpose of this study was to define in a group of patients undergoing TSA (1) the type and incidence of complications; (2) the frequency of and risk factors for both minor and major complications; and (3) the risk factors for bleeding resulting in transfusion.
We retrospectively queried the National Surgical Quality Improvement Program database using Current Procedural Terminology billing codes and identified 1922 cases of TSA performed between 2006 and 2011. Postoperative outcomes were divided into one of four categories: any complication, major morbidity (systemic life-threatening event or a substantial threat to a vital organ) or mortality, minor morbidity (localized to the operative upper extremity or not posing a major systemic threat to the patient), or bleeding resulting in transfusion. Univariate and multivariate analyses were then used to identify risk factors for complications.
There were a total of 155 complications (8% of the 1922 patients identified). The most common complication was bleeding resulting in transfusion (82 patients [4.26%]) followed by urinary tract infections (27 patients [1.40%]), return to the operating room (14 patients [0.73%]), pneumonia (10 patients [0.52%]), and peripheral nerve injury (nine patients [0.47%]). The incidence of major morbidity was 2% (44 patients), which included five patients (0.26%) who died; the incidence of any minor morbidity was 7% (136 patients). After controlling for likely confounding variables, we found steroid use (odds ratio [OR], 3; 95% confidence interval [CI], 2-6), hematocrit < 38% (OR, 2; 95% CI, 1-3), American Society of Anesthesiologists (ASA) Class 4 (OR, 3; 95% CI, 1-7), and operating time > 2 hours (OR, 2; 95% CI, 1-3) as independent predictors of complication and congestive heart failure (OR, 12; 95% CI, 1-106) as an independent risk factor for major morbidity or mortality. Hematocrit < 38% (OR, 3; 95% CI, 2-6), resident involvement (OR, 3; 95% CI, 2-5), steroid use (OR, 3; 95% CI, 1-6), and ASA Class 3 versus 1 or 2 (OR, 2; 95% CI, 1-5) were independent risk factors for bleeding resulting in transfusion.
Short-term morbidity after TSA is higher than previously reported. The prevalence of complications within 30 days of surgery and our outlined risk factors should guide surgeon-driven preoperative patient evaluation, management, and counseling. Surgeons who perform TSA should be aware operative time > 2 hours is associated with increased complications. Patients with preoperative hematocrit < 38%, history of steroid use, ASA Class > 2, and patients with congestive heart failure should receive medical optimization before TSA.
Level III, therapeutic study.
全肩关节置换术（TSA）是治疗终末期盂肱关节病变的有效方法，长期效果良好。既往关于TSA的发病率和输血情况的描述受术前危险因素、术后并发症以及单中心研究的限制。
问题/目的：本研究的目的是在一组接受TSA的患者中确定：（1）并发症的类型和发生率；（2）轻微和严重并发症的发生频率及危险因素；（3）导致输血的出血危险因素。
我们使用现行手术操作术语计费代码回顾性查询国家外科质量改进计划数据库，确定了2006年至2011年间进行的1922例TSA病例。术后结果分为四类之一：任何并发症、严重发病（全身性危及生命事件或对重要器官的重大威胁）或死亡、轻微发病（局限于手术上肢或对患者不构成重大全身威胁）、或导致输血的出血。然后使用单因素和多因素分析来确定并发症的危险因素。
共有155例并发症（占所确定的1922例患者的8%）。最常见的并发症是导致输血的出血（82例患者[4.26%]），其次是尿路感染（27例患者[1.40%]）、返回手术室（14例患者[0.73%]）、肺炎（10例患者[0.52%]）和周围神经损伤（9例患者[0.47%]）。严重发病的发生率为2%（44例患者），其中包括5例死亡患者（0.26%）；任何轻微发病的发生率为7%（136例患者）。在控制了可能的混杂变量后，我们发现使用类固醇（比值比[OR]，3；95%置信区间[CI]，2 - 6）、血细胞比容<38%（OR，2；95%CI，1 - 3）、美国麻醉医师协会（ASA）分级4级（OR，3；95%CI，1 - 7）以及手术时间>2小时（OR，2；95%CI，1 - 3）是并发症的独立预测因素，而充血性心力衰竭（OR，12；95%CI，1 - 106）是严重发病或死亡的独立危险因素。血细胞比容<38%（OR，3；95%CI，2 - 6）、住院医师参与（OR，3；95%CI，2 - 5）、使用类固醇（OR，3；95%CI，1 - 6）以及ASA分级3级与1级或2级相比（OR，2；95%CI，1 - 5）是导致输血的出血的独立危险因素。
TSA后的短期发病率高于先前报道。手术30天内并发症的发生率以及我们概述的危险因素应指导外科医生主导的术前患者评估、管理和咨询。进行TSA的外科医生应意识到手术时间>2小时与并发症增加有关。术前血细胞比容<38%、有类固醇使用史、ASA分级>2级的患者以及充血性心力衰竭患者在TSA前应进行医学优化。
III级，治疗性研究。
