title: What Are Risk Factors for 30-day Morbidity and Transfusion in Total Shoulder Arthroplasty? A Review of 1922 Cases.
abstract: BACKGROUND
  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.
  
  
  OBJECTIVE
  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.
  
  
  METHODS
  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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
  
  
  METHODS
  Level III, therapeutic study.
authors.affiliation: The Department of Orthopaedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, 01008 JPP, Iowa City, IA, 52242, USA, Chris-Anthony@uiowa.edu.
authors.forename: Chris A
authors.initials: CA
authors.lastname: Anthony
authors.forename: Robert W
authors.initials: RW
authors.lastname: Westermann
authors.forename: Yubo
authors.initials: Y
authors.lastname: Gao
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Pugely
authors.forename: Brian R
authors.initials: BR
authors.lastname: Wolf
authors.forename: Carolyn M
authors.initials: CM
authors.lastname: Hettrich
mesh_terms: D019643:Arthroplasty, Replacement / Q000009:adverse effects* / Q000401:mortality; D016063:Blood Loss, Surgical / Q000401:mortality / Q000517:prevention & control*; D001803:Blood Transfusion / Q000401:mortality; D016009:Chi-Square Distribution; D016208:Databases, Factual; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D015994:Incidence; D008297:Male; D015999:Multivariate Analysis; D016017:Odds Ratio; D019106:Postoperative Hemorrhage / Q000401:mortality / Q000628:therapy*; D015995:Prevalence; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D012785:Shoulder Joint / Q000473:pathology / Q000503:physiopathology / Q000601:surgery*; D013997:Time Factors; D065227:Transfusion Reaction; D016896:Treatment Outcome; D014481:United States