Effect of chronic kidney disease on outcomes following proximal humerus fragility fracture surgery in diabetic patients: A nationwide population-based cohort study

Abstract

Background The proximal humerus fracture (PHF) is the third most common fragility fracture. Diabetes mellitus (DM) and chronic kidney disease (CKD) are both risks for fragility fractures; however, the interplay of DM and CKD makes treatment outcomes unpredictable. This study aimed to investigate and compare early and late outcomes following proximal humerus fracture fixation surgery in diabetic patients with different renal function conditions. Methods DM patients receiving PHF fixation surgery during 1998–2013 were recruited from Taiwan’s National Health Insurance Research Database. According to their renal function, patients were divided into three study groups: non-chronic kidney disease (CKD), non-dialysis CKD, and dialysis. Outcomes of interest were early and late perioperative outcomes. Early outcomes included in-hospital newly-onset morbidities. Late outcomes included infection, revision, readmission, and all-cause mortality. Results This study included a total of 10,850 diabetic patients: 2152 had CKD (non-dialysis CKD group), 196 underwent permanent dialysis (dialysis group), and the remaining 8502 did not have CKD (non-CKD group). During a mean follow-up of 5.56 years, the dialysis group showed the highest risk of overall infection, all-cause revision, readmission, and mortality compared to the non-dialysis CKD group and non-CKD group. Furthermore, subgroup analysis showed that CKD patients had a higher risk of surgical infection following PHF surgery than non-CKD patients in cases with a traffic accident or fewer comorbidities (Charlson Comorbidity Index, CCI <3) (P for interaction: 0.086 and 0.096, respectively). Also, CKD patients had an even higher mortality risk after PHF surgery than non-CKD patients, in females, those living in higher urbanization areas, or with more comorbidities (CCI ≥3) (P for interaction: 0.011, 0.057, and 0.069, respectively). Conclusion CKD was associated with elevated risks for infection, revision, readmission, and mortality after PHF fixation surgery in diabetic patients. These findings should be taken into consideration when caring for diabetic patients.

Predictors of Deep Infection After Distal Femur Fracture: A Multicenter Study

“…14 Accordingly, CKD has been shown to be associated with surgical site infection after hip fracture treatment, proximal humerus fracture treatment, and total joint arthroplasty among other orthopaedic procedures. [15][16][17] Alcohol abuse, the other significant comorbidity in this analysis, is postulated to cause immune dysfunction by blunting negative feedback on the hypothalamic-pituitary-adrenal stress response, upregulating proinflammatory cytokines, and impairing neutrophil and macrophage function. 18,19 In one study of 465 nondiabetic orthopaedic trauma patients, 20 alcohol abuse nearly doubled the odds of surgical site infection, while another study on proximal tibia fractures showed an OR of 6.7 for this association.…”

Assessing the Risk of Postoperative Complications for Proximal Humeral Fractures Treated by Open Reduction and Internal Fixation in Patients With Diabetes and Chronic Kidney Disease

“… 26 In addition, when taking patients with DM and CKD into account, risk factors become even more notable. Chen et al 9 found that patients with DM and CKD had a notable increased risk of postoperative infection with a subdistribution hazard ratio of 1.51 (95% CI, 1.18 to 1.93) after ORIF for PHF. This finding supports the pathophysiology associated with DM and CKD, such as immune system impairment resulting in delayed healing along with infectious risk.…”

“… 6 - 8 Although prior studies have analyzed the various complications after ORIF for PHF in patients with DM and CKD, they have not specifically assessed the rates of nonunion. 9 , 10 In addition, using a large national insurance database, correlation can be helpful for future causation studies. National insurance databases provide large trends in complications, such as nonunion, all-cause revision surgery, and postoperative infection, compared with institutional databases that may lack the event rate of these issues to provide unbiased relationships.…”

Fracture Risk In Chronic Kidney Disease Patients

“…При 196 болни със захарен диабет и хронична бъбречна недостатъчност, подложени на хемодиализа в Тайван през периода между 1998 г. и 2013 г. и проследени в продължение на средно 5,56 г., се установява по-висок риск за обща инфекция, повторна хоспитализация и смърт след фиксационна хирургия поради проксимална фрактура на раменната кост, отколкото при други 2152 болни със захарен диабет и хронична бъбречна недостатъчност, които не са на хемодиализа, и 8502 болни само със захарен диабет (2).…”