Insulin Dependence Is Associated With Increased Risk of Complications After Upper Extremity Surgery in Diabetic Patients

EDITOR’S CHOICE

Insulin Dependence Is Associated With Increased Risk of Complications After Upper Extremity Surgery in Diabetic Patients Jeffrey G. Stepan, MD, MS,* Venkat Boddapati, BA,† Hayley A. Sacks, BA,† Michael C. Fu, MD, MHS,* Daniel A. Osei, MD, MS,* Duretti T. Fufa, MD* Diabetes mellitus (DM) is associated with the development of carpal tunnel syndrome, Dupuytren disease, trigger digits, and limited joint mobility. Despite descriptions of poorer response to nonsurgical treatment, previous studies have not shown increased complication rates in diabetic patients after hand surgery. Few studies, however, differentiate between insulin-dependent (IDDM) and noneinsulin-dependent (NIDDM) diabetes mellitus. The purpose of this study was to evaluate the impact of insulin dependence on the postoperative risk profile of diabetic patients after hand surgery using a national database. Materials and methods The data were obtained through the National Surgical Quality Improvement Program (NSQIP) database. Patients undergoing surgery from the distal humerus to the hand, between 2005 and 2015, were identified using 297 distinct Current Procedural Terminology codes. Thirty-day postoperative complications were collected and categorized into medical complications, surgical site complications, and readmission. Surgical complications, medical complications, and readmissions were compared between patients with NIDDM or IDDM to those without DM using multivariable logistic regression, adjusting for baseline patient and operative characteristics. Results The study cohort included 52,727 patients. Patients with IDDM had a 5.7% overall complication rate compared with 2.3% and 1.5% in NIDDM and nondiabetic patients, respectively. After controlling for differences in patient and surgical characteristics, patients with IDDM had a statistically significant increased rate of any complication, surgical site complications, superficial surgical site infections, and readmission. There was no significant difference in complication rates between patients with NIDDM and nondiabetic patients. Conclusions Our data demonstrate a greater risk of complications following hand and upper extremity surgery for patients with IDDM, specifically surgical site infections. The NIDDM patients did not have an increased rate of complications relative to nondiabetic patients. These findings are important for patient risk stratification and may guide further investigation to decrease complication rates in IDDM patients after upper extremity surgery. (J Hand Surg Am. 2018;-(-):-e-. Copyright Ó 2018 by the American Society for Surgery of the Hand. All rights reserved.) Type of study/level of evidence Prognostic II. Key words Hand, insulin-dependent diabetes mellitus, noneinsulin-dependent diabetes mellitus, surgical site infections, upper extremity.

From the *Department of Orthopedic Surgery, Hospital for Special Surgery; and the †Weill Cornell Medical College, New York, NY.

Corresponding author: Jeffrey G. Stepan, MD, MS, Department of Orthopedic Surgery. Hospital for Special Surgery, 535 East 70th St., New York, NY; e-mail: [email protected].

Received for publication August 10, 2017; accepted in revised form May 23, 2018.

0363-5023/18/---0001$36.00/0 https://doi.org/10.1016/j.jhsa.2018.06.006

No benefits in any form have been received or will be received related directly or indirectly to the subject of this article.

Ó 2018 ASSH

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Published by Elsevier, Inc. All rights reserved.

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epidemic in the United States. Currently, over 30 million Americans are living with the disease, and the national prevalence of DM is expected to increase by 54% by 2030.1 Diabetes mellitus is associated with an increased predisposition to multiple orthopedic disorders, including hip fracture, osteoarthritis, septic arthritis, shoulder capsulitis, foot and ankle pathology, and osteoporosis.2 Diabetes mellitus has been shown to increase complication rates after procedures in most orthopedic subspecialties, including foot and ankle, adult reconstructive surgery, spine, and sports medicine.3e11 This is likely secondary to impaired bone and soft tissue healing, increased risk of nonunion, peripheral neuropathy, and end-stage renal disease in diabetic patients.3 Recent studies in the arthroplasty literature have found that patients with uncontrolled DM had a significantly increased risk of postoperative infection, stroke, transfusion, shock and death.12,13 In the hand, DM has been associated with development of carpal tunnel syndrome, Dupuytren disease, trigger digits, and limited joint mobility.14,15 These conditions occur so frequently in diabetic patients that they have collectively been labeled “the diabetic hand.”16 Despite the increased frequency of hand pathology and the description of poorer responses to nonsurgical treatments, surgical outcomes in this population are not as clearly understood. Several studies investigating complication rates after carpal tunnel surgery found no significant differences between diabetic and nondiabetic patients, but these studies were small and likely underpowered.14,17e19 For trigger finger, there is evidence that steroid injections are less effective in diabetic patients, but it is unclear whether DM patients experience increased complications after A1 pulley release.20,21 Previous data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database haves not shown an increased rate of complications in diabetic patients after hand surgery.22e25 However, none of the studies differentiated between insulin-dependent (IDDM) and noneinsulin-dependent (NIDDM) diabetes mellitus. Patients with IDDM have been shown to have a different risk profile than patients with NIDDM.26e32 Multiple studies have shown increased rates of surgical site infections, systemic complications, and readmissions in IDDM compared with NIDDM after colorectal surgery, cardiothoracic surgery, plastic surgery, and vascular surgery.28e34 Within

orthopedics, studies have shown increased postoperative complications in IDDM patients after total joint arthroplasty, spine surgery, and open reduction internal fixation of humerus fractures.13,27,35e37 In hand surgery, only the outcomes after carpal tunnel release have been examined in IDDM and NIDDM patients, and no overall difference in motor function or patient satisfaction were found.17,18 The purpose of this study was to evaluate the impact of insulin-dependence on the postoperative risk profile of diabetic patients after hand and upper extremity surgery using a national database. The NSQIP database provides large patient numbers and has been used extensively in other surgical fields to study 30-day complication profiles and risk factors.22,23,32,38,39 We hypothesized that patients with IDDM will have increased complications compared qirh patients without DM or with NIDDM.

IABETES MELLITUS (DM) IS AN

J Hand Surg Am.

MATERIALS AND METHODS Data source The data for this study were obtained from the NSQIP database from 2005 to 2015. The NSQIP is a multi-institutional registry that collects data from over 600 participating sites, ranging from large academic to community centers. Variables and outcomes in this registry are documented by trained and certified surgical clinical reviewers who capture complications and hospital readmissions during the 30-day postoperative period regardless of hospital discharge.40,41 Multiple studies have documented the robust and reliable nature of the outcomes collected in the database.42,43 All data are deidentified prior to dissemination. This study was exempt from institutional review board approval by the Hospital for Special Surgery. Study sample Patients undergoing surgery from the distal humerus to the hand were identified in the NSQIP database using Current Procedural Terminology codes. Two hundred ninety-seven codes were included in the study. and can be found in the Appendix A (available on the Journal’s Web site at www.jhandsurg.org). The top 15 most frequent procedures included in the study are outlined in Table 1 and represent a range of common soft tissue and joint and fracture procedures of the distal upper limb. Independent variables Patient variables including age, sex, medical comorbidities (hypertension, chronic obstructive pulmonary r

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TABLE 1.

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Top 15 Most Frequent Hand and Upper Extremity Procedures Included in NSQIP

CPT Code

n

% Total Cases

Description of Procedure

25607-9

8,124

15.4

Open treatment of distal radial extra-articular fracture or epiphyseal separation, with internal fixation

25111

3,542

6.7

Excision of ganglion, wrist (dorsal or volar); primary

25447

3,187

6.0

Arthroplasty, interposition, intercarpal or carpometacarpal joints

26615

1,951

3.7

Open treatment of metacarpal fracture, single, includes internal fixation, when performed, each bone

24685

1,389

2.6

Open treatment of ulnar fracture, proximal end (eg, olecranon or coronoid process [es]), includes internal fixation, when performed

25000

1,338

2.5

Incision, extensor tendon sheath, wrist (eg, deQuervain disease)

24342

1,184

2.2

Reinsertion of ruptured biceps or triceps tendon, distal, with or without tendon graft

24341

1,059

2.0

Repair, tendon or muscle, upper arm or elbow, each tendon or muscle, primary or secondary (excludes rotator cuff)

26735

988

1.9

Open treatment of phalangeal shaft fracture, proximal or middle phalanx, finger or thumb, includes internal fixation, when performed

29846

949

1.8

Arthroscopy, wrist, surgical; excision and/or repair of triangular fibrocartilage and/or joint debridement

24515

897

1.7

Open treatment of humeral shaft fracture with plate/screws, with or without cerclage

24075

793

1.5

Excision, tumor, soft tissue of upper arm or elbow area, subcutaneous; > 3 cm

24105

751

1.4

Excision, olecranon bursa

26727

728

1.4

Percutaneous skeletal fixation of unstable phalangeal shaft fracture, proximal or middle phalanx

26418

652

1.2

Repair, extensor tendon, finger, primary or secondary; without free graft, each tendon

CPT, Current Procedural Terminology.

disease [COPD], smoking history, steroid use), American Society of Anesthesiologists (ASA) class, functional status (totally dependent on others for care vs partially dependent/independent), anesthesia type (general vs regional), operative time, and the location of the procedure were recorded (hand and wrist, forearm, or elbow/distal humerus). Body mass index (BMI) was calculated from patient height and weight data. The NSQIP maintains definitions for each these characteristics, which can be found in the NSQIP user guide.40 The NSQIP database categorizes patients into 1 of 3 health states based on diabetic status. Patients requiring daily insulin are categorized as IDDM, those who control their DM with noninsulin antidiabetic agents are categorized as NIDDM, and patients without a diagnosis of DM or who control their DM with diet alone are categorized as nondiabetics.40,41

definitions for each the following complications, which can be found in the NSQIP user guide.40 Surgical complications: The NSQIP defines and records surgical site infections using stringent Centers for Disease Control and Prevention (CDC) definitions.44 Superficial surgical site infections involve only skin and subcutaneous tissues and deep surgical site infections involve deep soft tissues such as fascia and muscle layers.45 Wound dehiscence is the separation of the margins of a primarily closed wound. Medical complication: Medical complications include death, cardiac, respiratory, and renal complications, deep vein thrombosis or pulmonary embolus, stroke, sepsis, or urinary tract infection. Cardiac complications were an aggregate of myocardial infarction or cardiac arrest requiring cardiopulmonary resuscitation. Respiratory complications were failure to wean from the ventilator within 48 hours after surgery, unplanned reintubation, or pneumonia. Renal complications were acute or progressive renal insufficiency.

Perioperative outcome variables Thirty-day postoperative complications were divided into medical complications, surgical site complications, and readmissions. The NSQIP maintains J Hand Surg Am.

Readmissions: Patients readmitted within the 30-day postoperative period. r

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TABLE 2.

Baseline Patient and Operative Characteristics of Patients Undergoing Upper Extremity Procedures History of DM All Patients

No DM

NIDDM

IDDM

52,727

48,726

2,679

1,772

 40

16,842 (31.9%)

16,526 (33.9%)

154 (5.7%)

162 (9.1%)

41e55

14,468 (27.4%)

13,403 (27.5%)

630 (23.5%)

435 (24.5%)

56e70

14,857 (28.2%)

12,819 (26.3%)

1,244 (46.4%)

194 (10.9%)

Number of Patients Patient Characteristics Age (y)

> 70

6,560 (12.4%)

5,528 (11.3%)

651 (24.3%)

381 (21.5%)

27,251 (51.7%)

24,687 (50.7%)

1,552 (57.9%)

1,012 (57.1%)

< 30 (nonobese)

34,926 (66.2%)

33,153 (68.0%)

1,052 (39.3%)

721 (40.7%)

30e34.9 (obese I)

Female (%) Body mass index (kg/m2)

10,293 (19.5%)

9,079 (18.6%)

764 (28.5%)

450 (25.4%)

35.0e39.9 (obese II)

4,393 (8.3%)

3,635 (7.5%)

461 (17.2%)

297 (16.8%)

> 40 (obese III)

3,115 (5.9%)

2,409 (4.9%)

402 (15.0%)

304 (17.2%)

15,707 (29.8%)

12,398 (25.4%)

1,992 (74.4%)

1,317 (74.3%)

1,462 (2.8%)

1,171 (2.4%)

143 (5.3%)

148 (8.4%)

11,590 (22.0%)

10,845 (22.3%)

414 (15.5%)

331 (18.7%)

1,420 (2.7%)

1,222 (2.5%)

95 (3.5%)

103 (5.8%)

I

12,255 (23.2%)

12,218 (25.1%)

26 (1.0%)

11 (0.6%)

II

28,370 (53.8%)

26,903 (55.2%)

1,014 (37.8%)

453 (25.6%)

III

11,301 (21.4%)

8,651 (17.8%)

1,528 (57.0%)

1,122 (63.3%)

801 (1.5%)

504 (1.0%)

111 (4.1%)

186 (10.5%)

931 (1.8%)

720 (1.5%)

80 (3.0%)

131 (7.4%)

Comorbidities Hypertension COPD Smoking history Steroid use ASA class

IV Dependent functional status Surgical Characteristics Anesthesia type General

39,064 (74.1%)

35,869 (73.6%)

1,962 (73.2%)

1,233 (69.6%)

Regional

13,663 (25.9%)

12,407 (25.5%)

717 (26.8%)

539 (30.4%)

 60

26,384 (50.0%)

24,103 (49.5%)

1,393 (52.0%)

890 (50.2%)

> 60

26,341 (50.0%)

24,173 (50.5%)

1,286 (48.0%)

882 (49.8%)

26,954 (51.1%)

24,924 (51.2%)

1,215 (45.4%)

815 (46.0%)

Forearm

15,703 (29.8%)

14,372 (29.5%)

792 (29.6%)

539 (30.4%)

Elbow or distal humerus

10,070 (19.1%)

8,980 (18.4%)

672 (25.1%)

418 (23.6%)

Operative time (min)

Anatomical location of procedure Hand or wrist

Data analysis Patient demographic characteristics (age, sex, BMI, medical comorbidities, ASA classification, and functional status) and surgical characteristics (anesthesia type, operative time, and location of procedure) were compared among patients without DM, with IDDM, and with NIDDM using the Pearson chi-square test. All baseline patient and surgical variables with a P value less than .2 were carried forward as J Hand Surg Am.

independent variables into a binary logistic regression model.22,37 Covariates included were age (< 40, 41e55, 56e70, > 70 years old), sex, BMI (< 30, 30e34, 35e39, > 40 kg/m2), medical comorbidities, ASA class, anesthesia type, location of procedure, operative time (< 1 hour vs > 1 hour), and functional status. Age and BMI were represented as categorical variables in the model to facilitate risk stratification.22,37 Diabetic status (IDDM, NIDDM, nondiabetic) was also

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TABLE 3.

Rates of Adverse Outcomes After Upper Extremity Procedures by DM Status All Patients

No DM

NIDDM

IDDM

Number of Patients

52,727

48,726

2,679

1,772

Any Complication

906 (1.72%)

744 (1.53%)

61 (2.28%)

101 (5.70%)

431 (0.82%)

337 (0.64%)

40 (1.49%)

54 (3.05%)

60 (0.11%)

47 (0.10%)

4 (0.15%)

9 (0.51%)

Medical complications Death Cardiac complications Respiratory complications

37 (0.07%)

26 (0.05%)

4 (0.15%)

7 (0.40%)

110 (0.21%)

85 (0.17%)

5 (0.51%)

16 (0.90%)

Renal Complications

15 (0.03%)

11 (0.02%)

0 (0%)

4 (0.23%)

Deep vein thrombosis/pulmonary embolism

54 (0.10%)

42 (0.09%)

8 (0.30%)

4 (0.23%)

Stroke

15 (0.03%)

12 (0.02%)

2 (0.07%)

2 (0.11%)

Sepsis

80 (0.15%)

57 (0.12%)

13 (0.49%)

10 (0.56%)

Urinary tract infection

142 (0.27%)

120 (0.25%)

9 (0.34%)

13 (0.73%)

Surgical site complications

500 (0.95%)

425 (0.87%)

23 (0.86%)

52 (2.93%)

Deep surgical site infection

111 (0.21%)

96 (0.20%)

3 (0.11%)

12 (0.68%)

Superficial surgical site infection

339 (0.64%)

285 (0.58%)

17 (0.63%)

37 (2.09%)

Wound dehiscence Readmission (30-d)

69 (0.13%)

60 (0.12%)

4 (0.15%)

5 (0.28%)

732 (1.68%)

576 (1.46%)

77 (3.15%)

79 (5.43%)

entered as an independent variable using nondiabetic patients as the reference. To assess multicollinearity, we examined a correlation matrix that assessed all independent explanatory variables.46 Outcome variables in our binary logistic regression models included any complication (all complications taken together), medical complications, surgical site complications, and readmission. Statistical significance was initially set at an alpha level of 0.05. Bonferroni corrections were applied to correct for multiple group comparisons.

Rates of all complications, medical complications, surgical site complications, and readmission are recorded in Table 3 for each of the 3 DM disease states (no DM, NIDDM, IDDM). The majority of the complications were surgical site complications whereas the rest were related to medical complications. In the cohort without DM, the rate of medical complications was 0.64%, surgical complication was 0.87%, and readmission was 1.46%. The medical, surgical, and readmission rates were 1.49%, 0.86%, and 3.15% in the NIDDM group, and 3.05%, 2.93%, and 5.43% in the IDDM group, respectively. When comparing patients with IDDM with those without DM, patients with IDDM were at an increased risk of having a complication after surgery (odds ratio [OR], 1.82; 95% confidence interval [95% CI], 1.44e2.3) and readmission (OR, 1.99; 95% CI, 1.28e2.16) after controlling for the variables listed in Table 2. The IDDM patients were also at increased risk of surgical site complications (OR, 2.35; 95% CI, 1.71e3.24) as well as superficial surgical site infections (OR, 2.57; 95% CI, 1.75e33.76) (Table 4). When comparing patients with NIDDM to those without DM, there were no statistically significant differences in any of the assessed medical complication rates, surgical complication rates, or readmission when controlling for all baseline patient and operative characteristics (Table 4). When assessing the correlation between independent variables, only age, hypertension, and ASA class

RESULTS There were 52,727 patients identified in the study cohort and 4,451 patients with DM (8.4%); 2,679 patients (5.1%) had NIDDM and 1,772 patients (3.4%) had IDDM. The CDC estimates that 9.4% of the U.S. population has DM, whereas 7.2% of the U.S. population are diagnosed.47 These values are similar to our cohort, which had a total of 8.4% patients with diagnosed DM. Approximately 5% of those with DM have type 1 DM, this indicates that the overwhelming majority of our cohort, even those with IDDM have type 2 DM.47 Demographic information, patient characteristics, anesthesia type, and anatomical location of surgery are presented in Table 2. Patients with both IDDM and NIDDM were more likely to be older, female, have more comorbidities, more regional anesthesia, a higher ASA class, and have more proximal procedures performed than those without DM (Table 2). J Hand Surg Am.

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TABLE 4. Status

Multivariable Logistic Regression of Adverse Outcomes in Upper Extremity Procedures by DM No DM Versus NIDDM OR

Any complication Medical complications

95% CI

P Value

No DM Versus IDDM OR

95% CI

P Value

0.86

0.62e1.13

.23

1.82

1.44e2.30

< .003*

0.94

0.67e1.33

.74

1.48

1.07e2.04

.02

Death

0.64

0.22e1.85

.41

1.13

0.52e2.47

.76

Cardiac complications

0.86

0.29e2.52

.78

1.63

0.67e3.98

.28

Respiratory complications

0.74

0.36e1.51

.41

1.35

0.75e2.43

.32

—

—

—

3.40

0.96e12.11

.06

Deep vein thrombosis/pulmonary embolism

1.54

0.69e3.42

.29

0.99

0.34e2.92

.99

Stroke

1.20

0.25e5.65

.82

2.20

0.44e11.05

.34

Renal complications

Sepsis

1.94

1.02e3.70

.04

1.47

0.71e3.06

.30

Urinary tract infection

0.63

0.31e1.26

.19

1.20

0.65e2.21

.57

Surgical site complications Deep surgical site infection

0.75

0.48e1.16

.19

2.35

1.70e3.23

< .003*

0.42

0.13e1.35

.15

2.20

1.14e4.27

.02

Superficial surgical site infection

0.83

0.50e1.39

.48

2.55

1.74e3.73

< .003*

Wound dehiscence

0.87

0.30e2.49

.80

1.36

0.52e3.60

.53

1.17

0.90e1.51

.24

1.68

1.29e2.19

< .003*

Readmission (30-d)

*Significant P values are defined as < .003 to correct for multiple group comparisons and are presented in bold.

surgeries.3,6,7,9,10,13,36 Although this has not been demonstrated in the hand literature, most studies of hand and upper extremity surgery patients have not specifically evaluated IDDM patients as a separate cohort from other diabetic patients. This study evaluated the impact of insulin dependence on complications after hand, wrist, forearm, and elbow/humerus surgeries. We found that patients with IDDM had greater rates of complications than patients without DM. In contrast, we did not observe an increased rate of complications in patients with NIDDM compared with nondiabetic patients. Overall, we found that rates of recorded complications following hand and upper extremity surgery are low. Previous large database studies have specifically identified insulin dependence as a risk factor for complications following orthopedic surgery.13,36,37 Patterson et al37 analyzed 1,391 patients who underwent surgical treatment of a proximal humerus fracture. They noted significantly increased rates of pneumonia and prolonged lengths of stay after surgery. Other larger studies have evaluated the impact of insulin dependence after spine surgery and total knee arthroplasty, both finding increased rates of complications after surgery.13,36 In 113,102 patients undergoing total knee arthroplasty, Webb et al13 found that patients with IDDM were at greater risk for multiple medical and surgical complications than

were moderately correlated with each other (correlation coefficients, > 0.3). None of the variables, however, were strongly correlated (all correlation coefficients, < 0.5). This suggested multicollinearity was not an issue in our model and no independent variables were removed. Other risk factors for all complications, surgical site complications, and readmissions after multivariable analysis are listed in Table 5. Patients with higher rates of any complication included those with COPD, a smoking history, ASA class IV, a dependent functional status, patients older than 70 years, and patients who underwent an elbow or distal humerus procedure. Patients with higher rates of surgical site complications were male, ASA class IV, between 41 and 55 years old, had a smoking history, and had undergone an elbow or distal humerus procedure. Patients with higher odds of readmission were those with COPD, a smoking history, ASA class III or IV, dependent functional status, procedures longer than 1 hour, and had undergone more proximal procedures. Neither BMI nor anesthesia type affected complication rates or readmission rates. Odds ratios and confidence intervals are shown in Table 5. DISCUSSION Diabetic patients consistently demonstrate higher complication rates after a variety of orthopedic J Hand Surg Am.

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TABLE 5.

Multivariable Logistic Regression of Adverse Outcomes in Upper Extremity Procedures Any Complication

Surgical Site Complication

Readmission

OR (95% CI)

P Value

OR (95% CI)

P Value

OR (95% CI)

P Value

Reference

—

Reference

—

Reference

—

Age (y)  40

†

41e55

1.24 (1.00e1.54)

.05

1.50 (1.16e1.93)

< .003

1.10 (0.85e1.42)

.47

56e70

1.19 (0.94e1.549)

.15

1.29 (0.97e1.72)

.08

1.08 (0.83e1.42)

.56

1.59 (1.21e2.08)

< .003*

1.08 (0.72e1.60)

.72

1.54 (1.13e2.10)

.007

0.81 (0.70e0.94)

.005

0.56 (0.46e0.68)

< .003*

0.87 (0.73e1.03)

.10

> 70 Female (%) Body mass index kg/m2) < 30 (nonobese)

Reference

—

Reference

—

Reference

—

30e34.9 (obese I)

0.88 (0.73e1.06)

.16

1.05 (0.83e1.33)

.67

0.85 (0.69e1.05)

.13

35.0e39.9 (obese II)

0.98 (0.77e1.25)

.78

1.39 (1.03e1.87)

.03

0.82 (0.62e1.10)

.19

> 40 (obese III)

1.04 (0.79e1.35)

.80

1.33 (0.93e1.89)

.12

1.03 (0.77e1.38)

.83

Hypertension

1.08 (0.91e1.28)

.36

0.94 (0.74e1.18)

.57

1.30 (1.08e1.57)

.006

COPD

1.52 (1.17e2.00)

< .003*

1.22 (0.78e1.88)

.38

1.96 (1.50e2.58)

< .003*

1.3 (1.13e1.58)

< .003*

1.37 (1.11e1.70)

.003

1.40 (1.16e1.69)

< .003*

1.52 (1.13e2.02)

0.005

1.36 (0.87e2.14)

.18

1.43 (1.04e1.98)

0.03

Comorbidities

Smoking history Steroid use ASA class

Reference

—

Reference

—

Reference

—

III

1.39 (1.08e1.78)

.01

1.24 (0.94e1.65)

.13

1.74 (1.27e2.38)

< .003*

IV

3.1 (2.31e4.04)

< .003*

1.95 (1.38e2.76)

< .003*

4.13 (2.92e5.83)

< .003*

2.5 (1.95e3.36)

< .003*

1.36 (0.80e2.33)

.26

1.85 (1.31e2.62)

< .003*

I or II

Dependent functional status General anesthesia Operative time > 60 min

1.1 (0.95e1.32)

.24

1.10 (0.88e1.38)

.39

1.24 (1.01e1.53)

.04

1.08 (0.94e1.25)

.26

1.01 (0.84e1.21)

.94

1.43 (1.21e1.680)

< .003*

Procedure type Reference

—

Reference

—

Reference

—

Forearm

0.99 (0.82e1.18)

.86

0.78 (0.61e1.00)

.05

1.46 (1.20e1.77)

< .003*

Elbow or distal humerus

1.77 (1.49e2.10)

< .003*

1.43 (1.15e1.79)

< .003*

1.64 (1.33e2.03)

< .003*

Hand or wrist

*Significant P values are defined as < .003 to correct for multiple group comparisons and are presented in bold.

difference in outcomes or complications.17,18 These studies were underpowered to detect a difference in rates of complications with only 59 patients with DM in the 2 studies combined. In contrast, the current study evaluated the rates of complications of 4,451 diabetic patients who underwent hand and upper extremity surgery. Several studies have investigated complications and readmissions using the NSQIP database after hand and elbow surgery; however, no study stratified diabetic patients into IDDM and NIDDM groups.24,22,48 Lipira et al24 examined 10,646 patients

nondiabetic patients. These associations were not found in similar patients with NIDDM.13 Similarly, Qin et al33 evaluated 51,277 patients undergoing lumbar spine surgery finding all diabetics to be at increased risk for medical complications after surgery; however, only patients with IDDM were at increased risk for surgical site complications. There are few studies within hand and upper extremity surgery that have investigated complications after surgery in patients with IDDM. Two studies have evaluated outcomes of patients with IDDM after carpal tunnel release, both finding no J Hand Surg Am.

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INSULIN-DEPENDENT DIABETES IN HAND SURGERY

identified by 208 Current Procedural Terminology hand and wrist codes in the NSQIP database from 2006 to 2011. After multivariable analysis they found males, preoperative blood transfusions, higher ASA class, dirty/infected wounds, and in-patient procedures were associated with increased risk of any postoperative complication. They did not find an association between DM and complications after hand and wrist surgery. The differences between the 2 studies are likely due to several reasons. The current study includes 4 years of patient data (2012e2015) that may have been unavailable to the previous authors, leading to a much larger cohort. We also stratified diabetic patients into NIDDM and IDDM leading to our key findings. Despite this, we had similar findings of higher ASA class and males having higher rates of complications after hand and upper extremity surgery. Noureldin et al48 evaluated readmissions after 14,106 outpatient hand or elbow procedures in 2012 and 2013. They found that patients with anemia, end-stage renal disease, and smokers had a higher risk of unplanned readmissions. Our analysis similarly showed an increased risk of readmission in smokers, patients with ASA class IV, and those who underwent elbow surgery. Schick et al22 analyzed risk factors for complications following 1,673 distal radius fractures identified in the NSQIP database between 2005 and 2011. Their multivariable analysis showed recent myocardial infarction, hypertension, dependent functional status, and higher ASA class predicted higher rates of complications after open reduction and internal fixation of the distal radius. Although we evaluated complications after a greater variety of hand and elbow surgery, we also found smokers and higher ASA class to predict complications after surgery. In the current study, which likely encompassed the patient populations from both studies, we stratified between IDDM and NIDDM patients and found a statistically significant increased rate in readmissions and complications in patients with IDDM compared with patients without DM. There were several limitations to the study inherent to the use of the NSQIP database. Only 30-day complications are collected, and orthopedicspecific complications are not collected in the database. Complications such as nonunion, malunion, chronic regional pain syndrome, delayed healing, or poor functional outcomes were not captured. Therefore, the rates of all complications documented in this study are lower than the true rates of clinical complications in this population. Despite this, we expect that the relative risk of complication between J Hand Surg Am.

our study groups would likely remain similar. Furthermore, NSQIP data have been shown to be more accurate and of higher quality than the data in administratively coded databases.49,50 Second, NSQIP collects data from patients at participating hospitals undergoing inpatient and outpatient “major” surgical procedures. As such, no data from ambulatory surgery centers where only outpatient procedures are performed were included in this analysis. Whereas higher-risk patients often are referred to a hospital setting, possibly leading to higher overall complication rates in our study, this limitation also suggests our sample includes surgical patients at highest perioperative risk. In addition, some common hand and elbow procedures such as carpal tunnel release, trigger finger release, ulnar nerve decompression, and certain arthrodeses are excluded from NSQIP sampling because they are deemed “minor” procedures. Despite this, our cohort does include a wide range of procedures representative of a spectrum of hand and upper extremity surgeries such as excision of ganglion cysts, de Quervain release, and carpometacarpal arthroplasty. Taken together, it is important to note these methodological weaknesses limit the external validity of the study. The NSQIP does not differentiate between type I and type II diabetic patients, instead dividing patients into IDDM, NIDDM, and non-DM categories. Furthermore, patients not using prescription medication to control their DM were categorized into the nonDM group, possibly decreasing the actual difference in complication rates between patients with DM and nondiabetic patients. Hemoglobin A1C levels are also not recorded in the database, limiting the ability to associate perioperative glycemic control and complication rates. We also were unable to assess the efficacy of antibiotics on complication rates because this is not collected in the database. Currently, perioperative administration of antibiotics in clean, elective hand procedures is not recommended. Our results suggest that more directed studies are needed to assess the effect of perioperative antibiotics on surgical site infections in the IDDM population. Future research should also help further stratify risk in patients with DM by type of procedure, glycemic control, and diabetic type. Our study shows that patients IDDM have an increased risk of complications, specifically, surgical site infection, after hand and upper extremity surgery. This information can be used to help identify and counsel higher-risk patients who may require closer perioperative medical follow-up and postoperative monitoring. r

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REFERENCES

23. Jiang JJ, Phillips CS, Levitz SP, Benson LS. Risk factors for complications following open reduction internal fixation of distal radius fractures. J Hand Surg Am. 2014;39(12):2365e2372. 24. Lipira AB, Sood RF, Tatman PD, Davis JI, Morrison SD, Ko JH. Complications within 30 days of hand surgery: an analysis of 10,646 patients. J Hand Surg Am. 2015;40(9):1852e1859. 25. Noureldin M, Habermann EB, Ubl DS, Kakar S. Unplanned readmissions following outpatient hand and elbow surgery. J Bone Joint Surg Am. 2017;99(7):541e549. 26. Stepan JG, London DA, Boyer MI, Calfee RP. Blood glucose levels in diabetic patients following corticosteroid injections into the hand and wrist. J Hand Surg Am. 2014;39(4):706e712. 27. Lovecchio F, Beal M, Kwasny M, Manning D. Do patients with insulin-dependent and noninsulin-dependent diabetes have different risks for complications after arthroplasty? Clin Orthop Relat Res. 2014;472(11):3570e3575. 28. Serio S, Clements JM, Grauf D, Merchant A. Outcomes of diabetic and nondiabetic patients undergoing general and vascular surgery. ISRN Surg. 2013;2013:963930. 29. Berkovitch A, Segev A, Barbash I, et al. Clinical impact of diabetes mellitus in patients undergoing transcatheter aortic valve replacement. Cardiovasc Diabetol. 2015;14(1):131. 30. Kumbhani DJ, Healey NA, Thatte HS, et al. Patients with diabetes mellitus undergoing cardiac surgery are at greater risk for developing intraoperative myocardial acidosis. J Thorac Cardiovasc Surg. 2007;133(6):1566e1572. 31. Bakken AM, Palchik E, Hart JP, Rhodes JM, Saad WE, Davies MG. Impact of diabetes mellitus on outcomes of superficial femoral artery endoluminal interventions. J Vasc Surg. 2007;46(5): 946e958. 32. Kazaure HS, Roman SA, Rosenthal RA, Sosa JA. Cardiac arrest among surgical patients. JAMA Surg. 2013;148(1):14e21. 33. Qin C, Vaca E, Lovecchio F, Ver Halen JP, Hansen NM, Kim JYS. Differential impact of non-insulin-dependent diabetes mellitus and insulin-dependent diabetes mellitus on breast reconstruction outcomes. Breast Cancer Res Treat. 2014;146(2):429e438. 34. Ata A, Valerian BT, Lee EC, Bestyle SL, Elmendorf SL, Stain SC. The effect of diabetes mellitus on surgical site infections after colorectal and noncolorectal general surgical operations. Am Surg. 2010;76(7):697e702. 35. Watts CD, Houdek MT, Wagner ER, Abdel MP, Taunton MJ. Insulin dependence increases the risk of failure after total knee arthroplasty in morbidly obese patients. J Arthroplasty. 2016;31(1):256e259. 36. Qin C, Kim JYS, Hsu WK. Impact of insulin dependence on lumbar surgery outcomes. Spine (Phila Pa 1976). 2016;41(11): E687eE693. 37. Patterson DC, Shin JI, Andelman SM, Olujimi V, Parsons BO. Increased risk of 30-day postoperative complications for diabetic patients following open reduction-internal fixation of proximal humerus fractures: an analysis of 1391 patients from the American College of Surgeons National Surgical Quality Improvement Program. JSES Open Access. 2017;1(1):19e24. 38. Fischer JP, Wink JD, Tuggle CT, Nelson JA, Kovach SJ. Wound risk assessment in ventral hernia repair: generation and internal validation of a risk stratification system using the ACS-NSQIP. Hernia. 2015;19(1):103e111. 39. Merkow RP, Ju M, Chung J, et al. Underlying reasons associated with hospital readmission following surgery in the United States. JAMA. 2015;313(5):541e549. 40. American College of Surgeons, National Surgical Quality Improvement Program. User Guide for the 2015 ACS NSQIP Participant Use Data File (PUF). October 2016. Available at: https://www.facs.org/w/media/files/ qualityprograms/nsqip/nsqip_puf_user_guide_2015.ashx. Accessed December 15, 2017. 41. American College of Surgeons, Quality Programs, ACS National Surgical Quality Improvement Program, Program Specifics. Available at: https://www.facs.org/quality-programs/acs-nsqip/about. Accessed June 27, 2017.

1. Rowley WR, Bezold C, Arikan Y, Byrne E, Krohe S. Diabetes 2030: insights from yesterday, today, and future trends. Popul Health Manag. 2017;20(1):6e12. 2. Arkkila PE, Gautier J-F. Musculoskeletal disorders in diabetes mellitus: an update. Best Pract Res Clin Rheumatol. 2003;17(6): 945e970. 3. Wukich DK. Diabetes and its negative impact on outcomes in orthopaedic surgery. World J Orthop. 2015;6(3):331e339. 4. Wukich D, Crim B, Frykberg R, Rosario B. Neuropathy and poorly controlled diabetes increase the rate of surgical site infection after foot and ankle surgery. J Bone Joint Surg Am. 2014;96(10):832e839. 5. Myers T, Lowery N, Frykberg R, Wukich D. Ankle and hindfoot fusions: comparison of outcomes in patients with and without diabetes. Foot Ankle Int. 2012;33(1):20e28. 6. Wukich D, Joseph A, Ryan M, Ramirez C, Irrgang J. Outcomes of ankle fractures in patients with uncomplicated versus complicated diabetes. Foot Ankle Int. 2011;32(1):120e130. 7. Karunakar M, Staples K. Does stress-induced hyperglycemia increase the risk of perioperative infectious complications in orthopedic trauma patients? J Orthop Trauma. 2010;24(12):752e756. 8. Richards J, Kauffmann R, Zuckerman S, Obremskey W, May A. Relationship of hyperglycemia and surgical-site infection in orthopedic surgery. J Bone Joint Surg Am. 2012;94(13):1181e1186. 9. Dowsey M, Choong P. Obese diabetic patients are at substantial risk for deep infection after primary TKA. Clin Orthop Relat Res. 2009;467(6):1577e1581. 10. Bolognesi M, Marchant M, Viens N, Cook C, Pietrobon R, Vail T. The impact of diabetes on perioperative patient outcomes after total hip and total knee arthroplasty in the United States. J Arthroplasty. 2008;23(6 Suppl 1):92e98. 11. Browne J, Cook C, Pietrobon R, Bethel M, Richardson W. Diabetes and early postoperative outcomes following lumbar fusion. Spine (Phila Pa 1976). 2007;32(20):2214e2219. 12. Marchant MH, Viens NA, Cook C, Vail TP, Bolognesi MP. The impact of glycemic control and diabetes mellitus on perioperative outcomes after total joint arthroplasty. J Bone Joint Surg Am. 2009;91(7):1621e1629. 13. Webb ML, Golinvaux NS, Ibe IK, Bovonratwet P, Ellman MS, Grauer JN. Comparison of perioperative adverse event rates after total knee arthroplasty in patients with diabetes: insulin dependence makes a difference. J Arthroplasty. 2017;32(10):2947e2951. 14. Brown E, Genoway KA. Impact of diabetes on outcomes in hand surgery. J Hand Surg Am. 2011;36(12):2067e2072. 15. Fitzgibbons PG, Weiss APC. Hand manifestations of diabetes mellitus. J Hand Surg Am. 2008;33(5):771e775. 16. Papanas N, Maltezos E. The diabetic hand: a forgotten complication? J Diabetes Complications. 2010;24(3):154e162. 17. Mondelli M, Padua L, Reale F, Signorini AM, Romano C. Outcome of surgical release among diabetics with carpal tunnel syndrome. Arch Phys Med Rehabil. 2004;85(1):7e13. 18. Thomsen NOB, Cederlund R, Rosén I, Björk J, Dahlin LB. Clinical outcomes of surgical release among diabetic patients with carpal tunnel syndrome: prospective follow-up with matched controls. J Hand Surg Am. 2009;34(7):1177e1187. 19. Harness NG, Inacio MC, Pfeil FF, Paxton LW. Rate of infection after carpal tunnel release surgery and effect of antibiotic prophylaxis. J Hand Surg Am. 2010;35(2):189e196. 20. Baumgarten KM, Gerlach D, Boyer MI. Corticosteroid injection in diabetic patients with trigger finger. A prospective, randomized, controlled double-blinded study. J Bone Joint Surg Am. 2007;89(12): 2604e2611. 21. Stahl S, Kanter Y, Karnielli E. Outcome of trigger finger treatment in diabetes. J Diabetes Complications. 1997;11(5):287e290. 22. Schick CW, Koehler DM, Martin CT, et al. Risk factors for 30-day postoperative complications and mortality following open reduction internal fixation of distal radius fractures. J Hand Surg Am. 2014;39(12):2373e2380.

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47. Centers for Disease Control and Prevention. National Diabetes Statistics Report, 2017: Estimates of Diabetes and Its Burden in the United States. Available at: https://www.cdc.gov/diabetes/pdfs/data/ statistics/national-diabetes-statistics-report.pdf. Accessed April 17, 2018. 48. Noureldin M, Habermann E, Ubl D, Kakar S. Unplanned readmissions following outpatient hand and elbow surgery. J Bone Joint Surg Am. 2017;99(7):541e549. 49. Bohl DD, Singh K, Grauer JN. Nationwide databases in orthopaedic surgery research. J Am Acad Orthop Surg. 2016;24(10): 673e682. 50. Bohl DD, Russo GS, Basques BA, et al. Variations in data collection methods between national databases affect study results: a comparison of the nationwide inpatient sample and national surgical quality improvement program databases for lumbar spine fusion procedures. J Bone Joint Surg Am. 2014;96(23):e193.

42. Davis C, Pierce J, Henderson W, et al. Assessment of the reliability of data collected for the Department of Veterans Affairs National Surgical Quality Improvement Program. J Am Coll Surg. 2007;204(4):550e560. 43. Shiloach M, Frencher SJ, Steeger J, 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(1):6e16. 44. Ju MH, Ko CY, Hall BL, Bosk CL, Bilimoria KY, Wick EC. A comparison of 2 surgical site infection monitoring systems. JAMA Surg. 2015;150(1):51. 45. Centers for Disease Control and Prevention. Surgical Site Infection (SSI) Event. Available at: https://www.cdc.gov/nhsn/pdfs/pscmanual/ 9pscssicurrent.pdf. Accessed December 15, 2017. 46. Fox J, Monette G. Generalized collinearity diagnostics. J Am Stat Assoc. 1992;87(417):178e183.

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APPENDIX A.

10.e1

APPENDIX A. CPT Codes (Continued)

CPT Codes

CPT Codes

CPT Codes 25111

25405

25447

24666

25607

24340

25609

25215

25608

25115

26615

25390

24685

26531

25000

24586

24342

26536

24341

26952

26735

25210

29846

24366

24515

26535

24075

25116

24105

25295

26727

24149

26418

26480

25628

35045

26356

24546

26540

24579

24358

26525

24359

26546

25440

26370

25515

64702

24076

25574

26440

25118

25320

25077

25310

26541

25575

26650

25112

25260

24516

25270

24363

25240

26445

26530

26746

26665

26410

24635

25400

29844

26951

25337

24077

26989

26350

24006

24665

26123

25545

24140

26765

25332

24545

26520

25076

25130 (Continued)

(Continued)

J Hand Surg Am.

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10.e2

APPENDIX A.

INSULIN-DEPENDENT DIABETES IN HAND SURGERY

APPENDIX A. CPT Codes (Continued)

CPT Codes (Continued)

CPT Codes

CPT Codes

26676

26390

24000

26460

25105

26502

25248

25040

25525

24615

26442

26373

25110

25230

26548

24365

25107

35207

26565

26686

26567

24305

25312

25431

25350

26420

25360

25120

25645

26492

26455

24900

24344

25446

24575

26485

24999

25695

26785

25020

26433

26545

24120

24102

25526

25280

26910

26145

26426

26498

26357

24361

25101

25415

26437

26776

24587

24110

24346

24301

25445

25685

25290

26358

25652

24310

24201

26121

25275

24150

26715

24345

29847

24360

26117

25449

24130

26471

24343

25900

26497

26500

26542

25301

26483

26412

26685

29845 (Continued)

J Hand Surg Am.

(Continued)

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INSULIN-DEPENDENT DIABETES IN HAND SURGERY

APPENDIX A.

10.e3

APPENDIX A. CPT Codes (Continued)

CPT Codes (Continued)

CPT Codes

CPT Codes

25420

25025

26449

25355

24152

26415

25085

26434

25442

26591

26489

24145

25150

24802

25490

25024

26593

24134

25272

24155

26392

24538

26490

25300

25001

25927

25365

25931

25023

24320

25035

25136

25170

25145

25263

25315

25425

25391

26496

25443

26510

26135

25126

26180

25151

24330

25670

24925

26478

25316

26352

25444

25274

25909

26561

25920

24362

26608

25676

24332

25135

24566

25999

24800

26450

25125

26706

26125

24495

26130

25265

26555

24116

26587

25075

20816

25119

24138

25430

24582

25441

24930

26372

25392

26476

25491

26568

25492 (Continued)

J Hand Surg Am.

(Continued)

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10.e4

APPENDIX A.

INSULIN-DEPENDENT DIABETES IN HAND SURGERY

CPT Codes (Continued)

CPT Codes 25905 26205 26215 26230 26428 26477 26499 26590 26596 20824 20827 24125 25375 25929 26160 26235 26494 26550 26560 20808 20822 24115 24331 25393 25426 25907 26185 26236 26250 26260 26479 26580 26756

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