Rheum Round-up: VTE Risk in Shoulder Surgery, Knee Replacement Timing, and more

Here are the top stories recently covered by DocWire News in the Rheumatology section. In this edition, read about cardiovascular risks in shoulder surgery, why most patients don’t receive knee replacements at the right time, racial differences in spine surgery outcomes, and the association between rates of operative treatment for proximal humerus fracture and surgery outcomes.

Patients undergoing total shoulder arthroplasty (TSA) may have a greater risk for venous thromboembolism (VTE) if they have a history of cancer. The PearlDiver patient records database was queried for data on male patients with a history of prostate cancer (n = 5,078) and female patients with a history of breast cancer (n = 5,035) who underwent TSA. Patients in both groups were matched 3:1 to control patients (male controls, n = 15,234; female controls, n = 15,105). Outcomes included 90-day rates of acute VTE, in-hospital death, hospital admission, emergency department (ED) visit, urinary tract infection (UTI), pneumonia, myocardial infarction (MI), acute renal failure, cerebrovascular accident, blood transfusion, periprosthetic fracture, and prosthetic dislocation. Among the female groups, those with a history of breast cancer were significantly more likely to sustain 90-day VTE compared to the controls (0.9% vs. 0.6%); 90-day incidence rates of in-hospital death, hospital admission, ED visit, UTI, pneumonia, MI, acute renal failure, cerebrovascular accident, blood transfusion, periprosthetic fracture, and prosthetic dislocation did not largely differ. Outcomes were similar in the male cohorts.

Most patients who undergo knee replacement for osteoarthritis do so at an inopportune time. Two multicenter cohort studies were queried for data. Patients who had or were at risk for knee OA were followed for eight years. Total knee replacement (TKR) appropriateness criteria were applied to stratify patients into two groups: potentially appropriate or likely inappropriate for TKR. Those who received TKR were further stratified: timely (the patient received TKR within two years of the procedure becoming potentially appropriate), potentially appropriate but knee not replaced (TKR remained unperformed for more than two years after the procedure had become potentially appropriate), and premature (TKR was likely inappropriate but had been performed). Of 8,002 total patients, 3,417 were eligible for inclusion and stratified into one of the three utilization categories: timely, n = 290 (8% of the total, 9% of the potentially appropriate knees); potentially appropriate but not replaced, n = 2,833 (83% of the total, 91% of the potentially appropriate knees); and likely inappropriate but received TKR prematurely, n = 294 (9% of the total, 26% of TKRs performed). Among the potentially appropriate but not replaced knees, 1,204 (42.5%) had severe symptoms.

A study published in the latest issue of Spine observed worse outcomes for black patients compared to their white counterparts following lumbar spinal fusion surgery. Black patients, compared to white patients, were 8% more likely to sustain spine surgery specific complications (adjusted odds ratio [aOR]=1.08; 95% confidence interval [CI], 1.03–1.13) and general postoperative complications (aOR=1.14; 95% CI, 1.07–1.20). Black patients were also more likely to experience 30-day readmissions (aOR=1.13; 95% CI, 1.07–1.20) and 90-day readmissions (aOR=1.07; 95% CI, 1.02–1.13), as well as longer length of stay and higher total charges.

A study examined the association between rates of operative treatment for proximal humerus fracture (PHF) and surgery outcomes. Final analysis included 72,823 PHF patients (mean [SD] age, 80.0 [7.9] years; 19.2% were male [n = 13,958]). Operative treatment rates varied significantly across hospital regions, from as low as 1.8% to up to 33.3%. Patients who received surgery compared to conservative management tended to be younger, healthier, and female. Upon instrumental variable analysis, the study authors observed that higher proximal humerus fracture surgery rates were correlated with increased total costs ($8,913) during the treatment period, rates of adverse events, and mortality risk. Outcomes were more significant for proximal humerus fracture patients who were older and had higher comorbidity burdens and greater frailty: “Risk-adjusted estimates suggested that surgical patients had higher costs (increase of $17 278) and more adverse events (a 1–percentage point increase in the surgery rate was associated with a 0.12–percentage point increase in the 1-year adverse event rate; β = 0.12; 95% CI, 0.11 to 0.13; P < .001) but lower risk of mortality after PHF (a 1–percentage point increase in the surgery rate was associated with a 0.01–percentage point decrease in the 1-year mortality rate; β = −0.01; 95% CI, −0.015 to −0.005; P < .001),” the researchers wrote.