ORIGINAL ARTICLE

Obesity Is Associated With More Complications and Longer Hospital Stays After Orthopaedic Trauma Benjamin R. Childs, BS,* Nickolas J. Nahm, MD,* Andrea J. Dolenc, BS,* and Heather A. Vallier, MD*

Objective: The objective of this study was to characterize relationships between obesity and initial hospital stay, including complications, in patients with multiple system trauma and surgically treated fractures.

Design: Prospective, observational. Setting: Level 1 trauma center. Patients: Three hundred seventy-six patients with an Injury Severity Score greater than 16 and mechanically unstable highenergy fractures of the femur, pelvic ring, acetabulum, or spine requiring stabilization.

Main Outcome Measurements: Data for obese (body mass index $ 30) versus nonobese patients included presence of pneumonia, deep vein thrombosis, pulmonary embolism, infection, organ failure, and mortality. Days in ICU and hospital, days on ventilator, transfusions, and surgical details were documented. Results: Complications occurred more often in obese patients (38.0% vs. 28.4%, P = 0.03), with more acute renal failure (5.70% vs. 1.38%, P = 0.02) and infection (11.4% vs. 5.50%, P = 0.04). Days in ICU and mechanical ventilation times were longer for obese patients (7.06 vs. 5.25 days, P = 0.05 and 4.92 vs. 2.90 days, P = 0.007, respectively). Mean total hospital stay was also longer for obese patients (12.3 vs. 9.79 days, P = 0.009). No significant differences in rates of mortality, multiple organ failure, or pulmonary complications were noted. Medically stable obese patients were almost twice as likely to experience delayed fracture fixation due to preference of the surgeon and were more likely to experience delay overall (26.0% vs. 16.1%; P = 0.02). Mean time from injury to fixation was 34.9 hours in obese patients versus 23.7 hours in nonobese patients (P = 0.03). Conclusions: Obesity was noted among 42% of our trauma patients. In obese patients, complications occurred more often and hospital and ICU stays were significantly longer. These increases are Accepted for publication February 26, 2015. From the *Department of Orthopaedic Surgery, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH. Presented as a poster at the Annual Meeting of the Orthopaedic Trauma Association, October 2013, Phoenix, AZ. The authors report no conflict of interest. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.jorthotrauma.com). The MetroHealth IRB approved this study. Reprints: Heather A. Vallier, MD, Department of Orthopaedic Surgery, 2500 MetroHealth Drive, Cleveland, OH 44109 (e-mail: [email protected]). Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

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likely to be associated with greater hospital costs. Surgeon decision to delay procedures in medically stable obese patients may have contributed to these findings; definitive fixation was more likely to be delayed in obese patients. Further study to optimize the care of patients with increased body mass index may help to improve outcomes and minimize additional treatment expenses. Key Words: obesity, fracture, fixation, complication, BMI

Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence. (J Orthop Trauma 2015;29:504–509)

INTRODUCTION In the United States, over one-third of adults (35.7% in 2010) and one-sixth of children and adolescents (16.9% in 2010) are obese.1–3 Recently, heightened awareness of the role of obesity in heart disease, diabetes, and asthma has been seen. However, there has been less research on effects of obesity in injured patients. Recent studies have indicated that obese trauma patients are more likely to need mechanical ventilation, develop multiple organ failure (MOF), and spend more time in the ICU.4–7 Others have also cited increased mortality, length of hospital stay, overall complication rate, and infections in obese patients.8–10 Specific challenges and complications after musculoskeletal injury have also been associated with obesity, including difficulty in sacral imaging,11 early failure after fixation of syndesmosis injuries,12 difficulty reducing acetabular fractures,13 and more complications after surgical treatment of pelvic ring injuries.14 Such issues are likely to generate substantial additional costs of care. Our purpose was to study the experience of a major urban level 1 trauma center to determine the frequency of complications among multiply injured obese patients treated surgically for unstable axial fractures. We hypothesized that obesity would be associated with more complications during the initial hospital course and that obesity would result in longer ICU and hospital stays.

PATIENTS AND METHODS Data were prospectively collected for 30 months for all 376 skeletally mature patients surgically treated for a highenergy fracture of the proximal or diaphyseal femur (n = 165), pelvic ring (n = 72), acetabulum (n = 53), or spine (n = 104). Patients without an associated major injury to another body system were excluded. All patients had an Injury Severity Score (ISS) of 16 or higher. J Orthop Trauma  Volume 29, Number 11, November 2015

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J Orthop Trauma  Volume 29, Number 11, November 2015

Effects of Obesity on Hospital Course

Patients with a body mass index (BMI) of 30 or greater were considered obese. Those with a BMI less than 30 were considered nonobese. Age, gender, injury characteristics, laboratory values, hospital stay, length of mechanical ventilation, and transfusion records were obtained from electronic hospital records. Complications were adjudicated by a panel of physicians not involved in other data collection or analysis. Deep venous thrombosis (DVT) was diagnosed by positive duplex ultrasound proximal to the knee. Pulmonary embolism was diagnosed by computed tomography. Pneumonia was defined as culture-positive sputum with new persistent infiltrate on chest radiograph, a temperature .388C, and a white blood cell count .10,000/mL.15 Acute respiratory distress syndrome was defined as an acute onset of bilateral infiltrates on chest radiography and a PaO2:FiO2 ratio of less than 200 mm Hg for 4 consecutive days in the absence of cardiogenic pulmonary edema.16 Acute renal failure (ARF) was defined as 50% increase in creatinine from baseline level.17 Sepsis was defined as infection manifested by at least 2 of the following: temperature .388C or ,368C, heart rate .90 beats per minute, respiratory rate .20 breaths per minute or PaCO2 , 32 mm Hg, and white blood cell count .12,000/mm3, ,4000/mm3, or .10% immature (band) forms.18 MOF was defined as failure of 2 or more organ systems.19 Independent samples t tests were used to compare means of continuous and ordinal variables between obese and nonobese patients. P values less than 0.05 were considered to represent a significant difference. For variables with Levene Test for Equality of Variances greater than 0.05, equal variance was not assumed. Pearson x2 test less than 0.05 was considered to represent a significant difference in categorical variables between obese and nonobese patients. Multivariate regression

techniques were used to control for age and American Society of Anesthesiologists (ASA) score. All analyses were performed in SPSS (version 21.0; IBM Corporation, Armonk, NY).

RESULTS Three hundred seventy-six patients (264 men and 112 women) were treated for 394 fractures of interest, and 158 of them (42.0%) had a BMI greater than 30 and were considered obese (Table 1). The mean BMI for the obese group and the nonobese group were 36.8 6 6.8 (range, 30.0–62.9) and 24.7 6 3.2 (range, 16.4–29.9), respectively (P , 0.0001). Thirtyseven patients had BMI .40 (9.8%). Female patients were more likely to be obese: 38.0% of obese patients were women versus 26.1% of nonobese patients (P = 0.003). Mean age of obese patients was also higher than nonobese patients (44.7 6 16.3 years vs. 36.4 6 16.5 years; P , 0.001). Mean ISS was 28.1 6 12.7 for obese patients and 26.1 6 11.4 for nonobese patients (P = 0.12). Obese patients were twice as likely to have diabetes mellitus (P , 0.0001). Injuries to other body systems are listed in Table 1. No differences were seen in the presence or severity of injuries to the head, chest, or abdomen, between obese and nonobese patients. Fractures of interest are also noted in Table 1. Nonobese patients were more likely to be treated for femoral fractures, occurring in 48.2% versus 38.0% (P = 0.049). There was also a trend for obese patients to be more likely to be treated for pelvic ring injuries, occurring in 23.4% versus 16.1% (P = 0.07). Time from the injury until definitive fixation of the fractures of interest was studied (Table 2). Mean time to fixation for obese patients was 34.9 hours after injury versus 23.7 hours for nonobese patients (P = 0.03). In other words, obese patients waited a mean of 47% longer to have their

TABLE 1. Demographic and Injury Information Female Male Mean age (years) Mean ISS Mean GCS Mean ASA Diabetes mellitus Tobacco usage COPD Alcohol abuse Abdominal injury Chest injury Head injury Pelvis ring injury Acetabulum fracture Femur fracture Spine fracture

All patients (N = 376), n (%)

Obese (N = 158), BMI ‡30, n (%)

Nonobese (n = 218)

P

112 264 39.9 6 16.9 26.9 6 12.0 13.6 6 3.1 2.84 6 0.84 113 (30) 192 (51) 22 (5.9) 31 (8.2) 103 (27.4) 226 (60.1) 220 (58.5) 72 53 165 104

60 (38.0) 98 (62.0) 44.7 6 16.3 28.1 6 12.7 13.7 6 3.1 3.00 6 0.78 67 (42) 77 (49) 10 (6.3) 14 (8.9) 48 (30.4) 100 (63.3) 92 (58.2) 37 (23.4) 25 (15.8) 60 (38.0) 40 (25.3)

52 (23.9) 166 (76.1) 36.4 6 16.5 26.1 6 11.4 13.6 6 3.1 2.73 6 0.87 46 (21) 115 (53) 12 (5.5) 17 (7.8) 55 (25.2) 126 (58.0) 128 (58.7) 35 (16.1) 28 (12.8) 105 (48.2) 64 (29.4)

0.003 ,0.001 0.12 NS 0.002 ,0.0001 NS NS NS 0.27 0.31 0.93 0.073 0.41 0.049 0.39

P values comparing obese and nonobese patients are shown. The presence of surgically treated fractures of interest and the presence of associated injuries are indicated. GCS, glasgow coma scale; COPD, chronic obstructive pulmonary disease.

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Childs et al

TABLE 2. Surgical Timing and Duration Timing to fixation (hrs) Number with delayed fixation Length of surgery (hr:min) (hr:min) (hr:min) Transfusions (units)

All patients (N = 376), n (%)

Obese (N = 158) BMI ‡30, n (%)

Nonobese (N = 218), n (%)

P

28.4 6 43.7 76 (20.2) 3:20 6 2:02

34.9 6 60 41 (26.0) 3:38 6 2:13

23.7 6 25 35 (16.1) 3:08 6 1:52

0.030 0.018 0.025

5.8 6 10

6.6 6 8.5

5.2 6 11

0.16

Delayed fixation was defined as more than 36 hr after injury, occurring in 20% of all patients. P values comparing obese and nonobese patients are shown.

fractures stabilized. Reasons for all surgical delays were noted. Seventy-six of all 376 patients had definitive fixation more than 36 hours after injury (20.2%). Thirty-one of 41 (76%) of the delayed surgeries in obese patients were due to surgeon choice, whereas 24 of the 35 delays (69%) in nonobese patients were by surgeon choice (P = 0.02). Mean timing of fracture fixation was not different between obese and nonobese patients when those due to surgeon choice were excluded: 19.2 hours for obese patients versus 18.3 for nonobese (P = 0.67). Despite no differences in ISS or in injuries to other body systems, longer hospital stays were observed in obese patients (see Table, Supplemental Digital Content 1, http:// links.lww.com/BOT/A334), which compares length of stay and ventilation times in obese and nonobese patients. Obese patients spent more days in the ICU (7.06 6 9.2 vs. 5.25 6 8.6, P = 0.054), more days on mechanical ventilation (4.92 6 7.8 vs. 2.90 6 6.2, P , 0.01), and more total days in the hospital (12.3 6 9.5 vs. 9.79 6 8.8, P , 0.01). A total of 106 patients developed 150 early complications (Table 3). Obese patients were more likely to have complications (38.0% vs. 28.4%, P = 0.03). Thirty patients had soft tissue infections (7.98%), and 6 of them developed sepsis. Obese patients were more likely to develop infections (11.4% vs. 5.50%, P = 0.04), with rates of sepsis in 8.28% versus 4.13% (P = 0.09) for obese versus nonobese patients, respectively. ARF was significantly more frequent in obese patients (5.70% vs. 1.38%, P = 0.02), and there was a trend toward more DVTs in obese patients (4.43% vs. 1.38%,

P = 0.07). No differences in the rates of pulmonary complications, MOF, and death were noted between the 2 groups. Post hoc power analysis revealed our study to be underpowered to identify a difference between obese and nonobese patients for comparisons of pulmonary complications, MOF, or mortality, as these would require study of 412, 3644, and 3233 patients, respectively. Eight patients had early failure of fixation (2.1%), requiring revision surgery. This occurred more often in obese patients (3.80% vs. 0.92%, P = 0.056). However, rates of nonunion were not different when the 2 groups were compared. Nonunions occurred overall in 12 patients (3.2%). We further divided patients into groups of increasing BMI (Table 4). Obese patients were subdivided into three BMI groups: 30–34.9, 35–39.9, and greater than 40. The frequency of some complications increased as BMI increased from normal (,25) to overweight (25–29.9) and to obese. This is further depicted in Figure 1. Patients with BMI over 40 also had longer mechanical ventilation times versus normal BMI patients (5.51 days vs. 2.78, P = 0.02) and a trend toward longer total length of hospital stay (14.0 days vs. 10.9, P = 0.08). Mean length of surgery was also an hour longer in patients with BMI over 40 versus those with normal BMI (4:03 vs. 3:07, P = 0.02). Controlling for the significantly higher mean age of the obese population, increasing BMI was a significant predictor of increased duration of surgery (b = 1.35, t(374) = 2.575, P = 0.01, r2 = 0.02), increased length of hospital stay (b = 0.120, t(374) = 2.298, P = 0.017, r2 = 0.017), and increased length of

TABLE 3. Complications in Obese and Nonobese Patients Obese (N = 158) BMI ‡30, n (%) Complication Infection Sepsis DVT PE Pneumonia ARDS ARF MOF Death Implant failure Nonunion

60 18 13 7 3 16 1 9 2 8 6 5

(38.0) (11.4) (8.28) (4.43) (1.90) (10.1) (0.63) (5.70) (1.27) (5.06) (3.80) (3.16)

Nonobese (N = 218), n (%) 62 12 9 3 8 22 6 3 1 9 2 7

(28.4) (5.50) (4.13) (1.38) (3.67) (10.1) (2.75) (1.38) (0.46) (4.13) (0.92) (3.21)

P 0.033 0.038 0.091 0.069 0.31 0.99 0.13 0.019 0.38 0.67 0.056 0.98

Early complications are listed along with complications requiring revision surgery due to implant failure or nonunion, occurring within 6 mo after injury. ARDS, acute respiratory distress syndrome; PE, pulmonary embolism.

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Effects of Obesity on Hospital Course

TABLE 4. Frequency of Complications, Length of Hospital Stay, Including ICU Days and Time on Mechanical Ventilation, Based on BMI

Any complication ARF DVT Infection Sepsis Death Mean mechanical ventilation days Mean surgical ICU days Mean total length of hospital stay (d) Mean surgical duration (hr:min)

Normal BMI ,25 (N = 107), n (%)

Overweight BMI 25–29.9 (N = 111), n (%)

Obese 1 BMI 30–34.9 (N = 89), n (%)

Obese 2 BMI 35–39.9 (N = 32), n (%)

Obese 3 BMI .40 (N = 37), n (%)

25 (23.3) 0 2 (1.87) 5 (4.67) 4 (3.74) 1 (0.93) 2.78 6 5.7

30 (27.0) 3 (2.70) 1 (0.90) 7 (6.31) 5 (4.50) 8 (7.21) 3.03 6 6.8

26 (29.2) 2 (2.25) 2 (2.25) 10 (11.2) 5 (5.62) 4 (4.49) 4.03 6 7.2

13 (40.6) 3 (9.38) 2 (6.25) 4 (12.5) 5 (15.6) 1 (3.13) 6.72 6 9.3

12 (32.4) 4 (10.8) 3 (10.8) 4 (10.8) 3 (8.11) 3 (8.11) 5.51 6 7.7

5.53 6 8.6

4.97 6 8.7

5.74 6 8.3

10.0 6 11.9

7.69 6 8.2

10.9 6 9.1

8.76 6 8.4

10.8 6 8.6

14.8 6 11

14.0 6 10

3:07 6 1:58

3:10 6 1:46

3:23 6 2:02

3:48 6 2:25

4:03 6 2:26

Obese patients were divided into 3 groups based on increasing BMI.

time on mechanical ventilation (b = 0.118, t(374) = 2.267, P = 0.024, r2 = 0.026). BMI was not an significant predictor of increased time in the ICU (b = 0.085, t(374) = 1.619, P = 0.106, r2 = 0.018). Binary logistic regression did not show a significant per BMI unit increase in the odds of infection (P = 0.181), sepsis (P = 0.153), pulmonary embolism (P = 0.676), pneumonia (P = 0.290), acute respiratory distress syndrome (P = 0.496), MOF (P = 0.512), death (P = 0.200), implant failure (P = 0.176), pulmonary complications (P = 0.306), or complications (P = 0.148) regardless of age or ASA score. Odds of developing ARF increased by 7.5% per unit BMI controlled for ASA score (P = 0.010) or by 7.0% controlled for age (P = 0.023). The odds of developing a DVT increased by 9.1% per BMI unit controlled for ASA score (P = 0.005) or 10.1% when controlled for age (P = 0.003). Notably, due to the effects of multicollinearity, because age is a key determinant

of ASA score, the concurrent adjustment of ASA score and age is not reported.

DISCUSSION From 1991 to 1998, the prevalence of obesity in the United States increased from 12% to 17.9%. This trend was reflected across all states, age groups, education levels, and sexes.2,20,21 Obesity has continued to climb and is a major public health issue, as it is widely and credibly linked to chronic heath conditions including heart disease, diabetes, and premature mortality.20,22 If current obesity trends and health care costs continue to progress at the same rate, the majority of adults in the United States would be obese by 2030, and obesity-related health care costs would double every decade, reaching 860 billion dollars by 2030.23 These trends are reflected in our study with 42% of our cohort found

FIGURE 1. Frequency of complications (percent of patients) based on increasing BMI. Patients with BMI ,25, 25–29, 30–24, 35–40, and .40 are presented. Editor’s note: A color image accompanies the online version of this article. Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.

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Childs et al

J Orthop Trauma  Volume 29, Number 11, November 2015

in the obese group, and obese patients were twice as likely to have a diagnosis of diabetes mellitus. This finding is especially salient, as recent studies have shown that obesity not only contributes to chronic systemic illness but also can pose problems for orthopedic patients. Similar to our findings, other studies have shown longer surgical times and longer hospital stays in obese patients24,25 as well as more frequent complications for elective orthopedic patients.26–31 Previous studies of various groups of trauma patients have described an association between obesity and complications,4,7–10,32,33 specifically sepsis,4,6 other infections,4,10 organ failure,5,6 and death.6–8 It is believed that diabetes mellitus and potential for poor glycemic control may contribute to septic complications in diabetic patients.8,26,27,33 Other studies have reported diabetes in association with obesity, similar to our data.8,9,17,26,27,33 Consistent with these studies, we identified more complications in obese patients. Significantly, more infections and renal failure were found. More DVTs were identified when controlled for age or ASA score. Corresponding increases in length of hospital stays and mechanical ventilation times were also detected in our obese patients. This is similar to other studies on blunt general trauma patients.4,6–8 Considering the higher complications and increased utilization of resource-intensive treatment measures, we anticipate higher costs of care although our study did not specifically measure costs.34 We also reported significantly longer surgical times and longer times on mechanical ventilation in our obese patients, both of which would be associated with higher costs of initial care. These findings are even more concerning because hospitals are under increasing scrutiny for rising costs. The Center for Medicare and Medicaid Services, as well as some insurers, has begun to penalize hospitals and providers for complications and readmissions, which may occur with higher frequency in obese patients. Neither the occurrence of trauma nor underlying patient risk factors such as obesity is under the control of the providers of care. Of note, we observed longer surgical times and a trend toward more frequent loss of fracture fixation and secondary procedures in our obese patients. These findings are likely attributable to the difficulty obtaining adequate fracture reduction and fixation in obese patients and are consistent with the previous work demonstrating increased loss of fracture fixation in obese patients with ankle or pelvic injuries.12–14 These factors also translate into greater costs of care for obese patients.34 Despite no difference in overall injury severity or injury to other body systems, obese patients experienced longer delay to the time of definitive fixation when compared with nonobese patients. This was primarily due to surgeon choice to delay these cases. Of note, the mean duration of surgery progressively increased with increasing BMI. The mean duration of surgery in morbidly obese patients was 30% longer versus nonobese patients. It is possible that surgeons faced with anticipated longer procedure times and associated difficulty due to technical and imaging considerations in larger patients deferred these procedures until more favorable conditions, including time and personnel, were available.

The strengths of this study are numerous. The data were collected prospectively over a short period of time with strict oversight of the data, ensuring accuracy. A large proportion of our study cohort was obese, allowing us to have narrow confidence intervals. Furthermore, the severity of injury in our patients was consistent with other studies investigating obesity in general trauma, allowing us to make direct comparisons to the existing literature. Weaknesses include a disparity in age and gender in the obese and nonobese populations. Some of these differences may be unavoidable due to the direct relationship between body weight and age, both increasing over time (0.093 BMI points per year; r2 = 0.041, b = 0.093, P , 0.01).20,22 We performed regression to account for age, and BMI remained an independent predictor of these outcomes. However, our sample size was not large enough to detect statistical differences between obese and nonobese groups for certain comparisons, such as differences in pulmonary complications, MOF, or mortality, as we would have required more than 3000 patients. Optimization of care for obese orthopedic patients is critical for trauma centers. Obese patients form a substantial portion of the patient population in the United States, and the percentage of patients who are obese is likely to increase in the future. It is clear that care of obese patients raises unique challenges. Elucidating the risks associated with treating obese patients is necessary to determine if action can be taken to optimize treatment not only to avoid costs associated with increases in ICU days, mechanical ventilation times, and infections and other complications but also to benefit these often challenging patients.

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Obesity Is Associated With More Complications and Longer Hospital Stays After Orthopaedic Trauma.

The objective of this study was to characterize relationships between obesity and initial hospital stay, including complications, in patients with mul...
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