Nomogram to predict postoperative complications in elderly with total hip replacement

lNTRODUCTlON

Hip replacement is a frequently done and highly successful surgical intervention[1]. More than one million hip arthroplasties are performed annually worldwide[2]. Kurtz

[3] projected the demand for primary total hip arthroplasty (THA) to grow 174% to 572000 procedures per year by 2030. These procedures carry a complication rate estimated to be between 2% and 14%; higher complication rates are associated with more elderly and comorbid patient populations[4]. Numerous clinical tools have been developed to predict a variety of THA patient outcomes[5-7], but the risk calculator to be a poor predictor of postoperative complications in Chinese. This is likely due to the complexity of the environment, race and personal differences. As an anesthetist, when we go to the inpatient ward for preoperative evaluation, patient often ask: what is the proportion of risk in my surgery? The answer is perhaps or we don’t know. So we want to create a tool not only can predict the risk precisely, but also guide the clinical work. Therefore this study will analyze clinical data, explored the independent risk factors for postoperative complications in elderly patients undergoing total hip replacement, develop a nomogram for accurate risk stratification of postoperative complications based on preoperative and intraoperative variables, and verify whether this tool would have good predictive for patients undergoing total hip replacement in our hospital.

MATERlALS AND METHODS

Patients

Approved by the Ethics Committee of the Affiliated Hospital of Guangdong Medical University committee (PJ2020-022), we were collected from all patients undergoing total hip replacement from March 1, 2017 to August 31, 2019 at the Affiliated Hospital of Guangdong Medical University. Inclusion criteria were age ＞ 65 years, elective surgical treatment with total hip replacement. Non-inclusion criteria were age ＜ 65 years, electronic medical records incomplete, patients or family members disagree with the study.

Research methods

Interestingly, our data suggest that low preoperative albumin levels can predict the incidence of postoperative complications following surgery for total hip replacement. The result is consistent with Kishawi

[25]. Since ALB is a biomarker of visceral protein and immune-competence status, it is commonly used for nutritional assessment[26]. Preoperative albumin bears strong potential as a practical metric to assess a patient’s overall health[27]. Recent studies even show that low ALB rather reflects a state of persistent inflammation[28]. The perhaps reason for ALB as an independent predictor of major complications is that ALB recapitulates the physiological stress intensity triggered by surgery,which is determined by several factors, such as the invasiveness of surgery and its duration, as well as the intrinsic characteristics of the patient[29]. Our results pointed out that the weight of 12.7 points in the nomogram model score will be increased for every 5 g/L decrease in ALB. We recommend surgeons and anesthetists should ideally attempt to optimize patient nutritional status before total hip replacement in elderly in order to avoid a greater likelihood of postoperative complications or mortality.

Using nomogram model to predict postoperative complications in elderly total hip replacement patients risk receive operating characteristic (ROC) curve, area under curve (AUC) is 0.8254 (95%CI:0.78-0.87), indicating that the nomogram model has a good bootstrap-corrected concordance (Figure 2).

另外，借助專門的辦公軟件，醫(yī)院的5家分院跟本部的檢查預(yù)約通道基本打通。宣姝姝指出，天臺(tái)分院目前沒有部分大型儀器設(shè)備，如3.0MRI，如果患者要求到本部來(lái)做大型檢查，醫(yī)生在辦公軟件上發(fā)起檢查申請(qǐng)，預(yù)約中心處理好以后將信息反饋給他們。然后，這些轉(zhuǎn)診患者按照預(yù)約時(shí)間到醫(yī)院，現(xiàn)場(chǎng)交費(fèi)就可以進(jìn)行檢查，讓基層患者享受便捷就醫(yī)的實(shí)惠。

寫作是指學(xué)生以文字的形式來(lái)描述自己的經(jīng)歷與真情實(shí)感。但是在這個(gè)過程中，多數(shù)學(xué)生為了完成老師留下來(lái)的任務(wù)而應(yīng)付式的寫作。由于缺乏教師針對(duì)性的指導(dǎo)，很多學(xué)生不重視實(shí)際生活中素材積累的意識(shí)，在寫作的過程中多是以模仿的形式去創(chuàng)作，缺乏自己的真實(shí)情感，導(dǎo)致創(chuàng)作出來(lái)的文章太過形式化，毫無(wú)獨(dú)特性。還有普遍的虛假作文、“造文”現(xiàn)象非常嚴(yán)重，作為缺少創(chuàng)新，文章缺少靈性。

選取CBOE的新興市場(chǎng)ETF波動(dòng)率指數(shù)作為衡量原油金融屬性的指標(biāo)，代碼VXEEM，該指標(biāo)于2011年3月16日開始發(fā)布。VXEEM是采用CBOE的VIX計(jì)算方法對(duì)跟蹤新興市場(chǎng)ETF的期權(quán)計(jì)算出來(lái)，反映MSCI新興市場(chǎng)指數(shù)基金的隱含波動(dòng)率（見圖9）。股市是經(jīng)濟(jì)的晴雨表，相較于滯后公布的許多宏觀數(shù)據(jù)，股市的波動(dòng)率直接反映了投資者對(duì)于未來(lái)宏觀經(jīng)濟(jì)的信心。

盡管國(guó)外如此重視無(wú)障礙網(wǎng)絡(luò)教育，但是仍然存在一些問題。比如：設(shè)計(jì)和開發(fā)時(shí)沒有完全符合無(wú)障礙標(biāo)準(zhǔn), 一些障礙學(xué)習(xí)者使用時(shí)仍存在障礙。

Statistical analysis

All statistical analyses were performed using the STATA14.0 statistical software package and R software(R3.2.3) with rms package added. Differences between patients with and without complications were compared with t-test or Wilcoxon rank-sum test using the mean ± SD and the median (range) for quantitative variables and chi-squared test using

(%) for qualitative variables. Univariate logistic regression for patients clinical data were analyzed to identify the independent risk factors for postoperative complications after surgery. A multivariate logistic regression model was built using the factors associated with

values ＜ 0.05 by univariate analysis. Selection values of

＜ 0.05 variables by multivariate analysis to create a nomogram model by R software (R3.2.3) rms package, evaluated the nomogram by assessing discrimination and calibration.

RESULTS

In our study 414 elderly total hip replacement patients of 59 cases with postoperative complications after surgery, the incidence was 14.3%. The demographics and descriptive statistics for our patient cohort are given in Table 1. Multivariable logistic regression of each clinical variable of patients related factors for postoperative complications include patients age (OR = 1.05, 95%CI: 1.00-1.09), renal failure(OR = 0.90, 95%CI: 0.83-0.97), diabetes (OR = 2.37, 95%CI: 1.04-5.40) and ALB (OR = 0.91, 95%CI: 0.83-0.99) (Table 2).

According to the above multivariable logistic regression analysis results, choose

＜ 0.05 variable apply R software to build a nomogram model of postoperative complications in elderly total hip replacement patients (Figure 1).

西雙說這仍然不是問題的關(guān)鍵，大不了我真的喪盡天良，結(jié)了婚就盼著她死掉，結(jié)果她真的死掉了，可是，后面的問題呢？你知道樓蘭有個(gè)女兒吧？本來(lái)是她和禿頭的女兒，但是復(fù)婚以后，就會(huì)變成她和我的女兒，對(duì)不對(duì)？等于從結(jié)婚那天起，我就得替她養(yǎng)個(gè)女兒。然后，她去了，一了百了，我呢？我敢撒手不管？我能撒手不管？我是她父親啊！我得送她去幼兒園，送她讀小學(xué)，讀中學(xué)，讀大學(xué)，直到她有經(jīng)濟(jì)來(lái)源，這是什么概念？無(wú)底深淵啊！還有樓蘭那個(gè)媽，老成那樣，一身窮病，怎么辦？我敢不管？我能不管？復(fù)了婚，我還得管她叫媽啊！我管？我心里怎么能痛快？再說我拿什么管？一邊是假女兒一邊是假媽，把我賣十遍也供不起啊。

The primary outcome measure was the incidence of a postoperative complication or death during hospitalization. Complications were identified from diagnoses in discharge summaries, operative reports, and International Classification of Diseases-9 codes by a single investigator. Included: cardiac arrest, deep venous thrombosis, myocardial infarction, pneumonia, pulmonary embolism, systemic inflammatory response syndrome, infection, dislocation, delirium, according to definitions from the National Quality Improvement Project[8].

Perform Hosmer-Lemeshow goodness-of-fit test and evaluate nomogram Model accuracy, Hosmer-Lemeshow fit goodness test

= 10.16,

= 0.4264 (Figure 3), calibration in rms package by R software E

= 0.176, E

= 0.027 (Figure 4), all shows that the model appears to be well-calibrated, with predicted outcome rates closely reflecting the observed rates.

DlSCUSSlON

China is the most populated country in the world, and now has the second-largest economy in the world[9]. As nearly 166 million Chinese are aged more than 65 years[10]. The demand for healthcare,including hip arthroplasty is increasing[11,12]. There are several predict complications model have be reported[13-15], but on one is modeling by Chinese. In this study, 59 of the 414 elderly total hip replacement patients who underwent surgical treatment were developed postoperative complication,the incidence is 14.3%, morbidity is much higher than 3.9%[16]. Probably because our definition of complications not only included dislocation, pulmonary embolism, and infection as reported previously, but included systemic inflammatory response syndrome, delirium which are common in elderly. Among 566 older patients (mean age, 76.7 years) undergoing a variety of elective operations(including orthopedic, general, and vascular), 23.9% patients developed postoperative delirium[17]. The incidence of postoperative delirium was reported as 7.0%-30.2% in hip arthroplasty[18,19]. In this study the average age is 75.09 ± 7.8. As a result, the morbidity 14.3% is considered to be reasonable.

Age is a recognized risk factor for postoperative complications. The results of this study indicate that elderly patients with renal failure and diabetes are more likely to have postoperative complications after total hip replacement. It is Consistent with the research results of Merrill

[20]. One possible reason is that elderly patients have more comorbidities will make them less able to withstand the stresses of anesthesia and surgery[21,22]. Diabetes have been reported to be significant predictors for complications such as surgical site infections[23]. The available data suggest that diabetes may promote the development of osteoarthritis[24]. Our results for the outcome measure indicate that elderly patients with renal failure and diabetes increase the weight of the nomogram model score by 25 points and 24 points, respectively.

Data on general patient information, comorbidities, laboratory test results, intraoperative variables, and postoperative complications during hospitalization were collected from electronic medical records and electronic Anesthesia Information Management System. Known patient-related factors of complications are age, gender, fractures or not and comorbidity such as renal failure, hypertension, diabetes, coronary heart disease, stroke, laboratory test results of white blood cells, red blood cells, hemoglobin, platelets,albumin (ALB) and blood urea nitrogen. Intraoperative variables included estimated blood loss, lowest heart rate, the type of anesthesia, preoperative American Society of Anesthesiologists Score and operation time.

No additional data are available.

Risk calculators should serve as a tool to help clinical decision-making, promote individualized medicine, and aid in the shared decision-making process[30]. Many of the studies report poor discrimination and calibration of the investigated risk calculators. In our study, founded that age, diabetes,renal failure, and Albumin value are independent risk factors for postoperative complications in elderly patients with total hip replacement, ROC curve shows the AUC is 0.8254, indicating that the nomogram model has a good discrimination. The Hosmer-Lemeshow fit goodness test

= 10.16,

= 0.4264 and calibration curve is a straight line with a slope close to 1, indicating that the nomogram model has good accuracy in predicting the risk of postoperative complications in elderly patients with total hip replacements surgery and has clinical application value.

CONCLUSlON

We have no financial relationships to disclose.

ARTlCLE HlGHLlGHTS

FOOTNOTES

Tan ΧJ is first Author, participated in protocol writing, collecting data, statistical analysis,interpretation of results and manuscript writing; Ge FM helped collection of cases; Li ZY participated in protocol writing, essay writing; Gu ΧΧ helped interpretation of results and manuscript writing; Zhang LQ did the statistical analysis and reviewed the manuscript.

This study was reviewed and approved by the Ethics Committee of the Affiliated Hospital of Guangdong Medical University with the reference number PJ2020-022.

This study created a nomogram model based on age, diabetes, renal failure, and albumin value independent risk factors for postoperative complications, has good indexing and accuracy can provide scientific guidance for individualized clinical prevention and treatment of postoperative complications in elderly patients with total hip replacements surgery in our hospital. This four variables are easy to get in clinical practice, has clinical application value especially for basic-level hospital.

However our study has several limitations. First, our data were limited only 414 patients, it only represents an elective patient population. Second, complications were only collected while in hospital,some of these complications could have occurred after discharge. Third, the predict model quality checks only with internal validation, so external validation will have to be included in future studies in order to promote use. Fourth, this was a retrospective study that relied on 9th edition coding, which can lead to errors and/or incomplete coding.

This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BYNC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is noncommercial. See: https://creativecommons.org/Licenses/by-nc/4.0/

China

(3)Mg2+和礦化度變異系數(shù)均呈現(xiàn)出：哈拉湖南部高山區(qū)﹤北側(cè)區(qū)域﹤四周河谷平原﹤周圍湖泊融區(qū)，反應(yīng)了Mg2+和礦化度在地下水中的含量逐步變大；

Χiu-Juan Tan 0000-0003-0608-9045; Χiao-Χia Gu 0000-0002-6059-9479; Feng-Min Ge 0000-0001-5462-9654; Zhi-Yi Li 0000-0001-5775-9593; Liang-Qing Zhang 0000-0003-4131-2097.

Zhang H

A

另外，在漢語(yǔ)中是謂語(yǔ)動(dòng)詞如以下的“順應(yīng)”，以謂語(yǔ)出現(xiàn)，但是在英語(yǔ)中卻可以翻譯成狀語(yǔ)或就是狀語(yǔ)，這類情況也要善于識(shí)別。因?yàn)闈h語(yǔ)的表達(dá)有時(shí)是多樣性的，不是唯一性，而英語(yǔ)變化性較小。

Zhang H

1 Ferguson RJ, Palmer AJ, Taylor A, Porter ML, Malchau H, Glyn-Jones S. Hip replacement. Lancet 2018 ; 392 : 1662 -1671 [PMID: 30496081 DOI: 10 .1016 /S0140 -6736 (18 )31777 -Χ]

2 Pivec R, Johnson AJ, Mears SC, Mont MA. Hip arthroplasty. Lancet 2012 ; 380 : 1768 -1777 [PMID: 23021846 DOI:10 .1016 /S0140 -6736 (12 )60607 -2 ]

3 Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030 . J Bone Joint Surg Am 2007 ; 89 : 780 -785 [PMID: 17403800 DOI: 10 .2106 /JBJS.F.00222 ]

4 Nanjayan SK, Swamy GN, Yellu S, Yallappa S, Abuzakuk T, Straw R. In-hospital complications following primary total hip and knee arthroplasty in octogenarian and nonagenarian patients.

2014 ; 15 : 29 -33 [PMID:23989856 DOI: 10 .1007 /s10195 -013 -0262 -y]

5 Konopka JF, Hansen VJ, Rubash HE, Freiberg AA. Risk assessment tools used to predict outcomes of total hip and total knee arthroplasty.

2015 ; 46 : 351 -362 , ix [PMID: 26043049 DOI: 10 .1016 /j.ocl.2015 .02 .004 ]

6 Schwartz PB, Stahl CC, Ethun C, Marka N, Poultsides GA, Roggin KK, Fields RC, Howard JH, Clarke CN, Votanopoulos KI, Cardona K, Abbott DE. Retroperitoneal sarcoma perioperative risk stratification: A United States Sarcoma Collaborative evaluation of the ACS-NSQIP risk calculator.

2020 [PMID: 32557654 DOI:10 .1002 /jso.26071 ]

7 Lakomkin N, Lajam C, Holt GE, Hutzler L, Iorio R, Bosco JA III. The Utility of Preoperative Labs in Predicting Postoperative Complications Following Primary Total Hip and Knee Arthroplasty.

013 ) 2020 ; 78 : 266 -274 [PMID: 33207149 ]

8 Khuri SF, Daley J, Henderson W, Barbour G, Lowry P, Irvin G, Gibbs J, Grover F, Hammermeister K, Stremple JF. The National Veterans Administration Surgical Risk Study: risk adjustment for the comparative assessment of the quality of surgical care.

1995 ; 180 : 519 -531 [PMID: 7749526 ]

9 Open Knowledge Repository (OKR). World Bank Group. World Development Indicators 2017 . [cited 2019 Jul 8 ].Available from: https://openknowledge.worldbank.org/han-dle/10986 /26447

10 National Bureau of Statistics of China. China Statistics Press. China Statistical Yearbook 2017 . [cited 2019 Jul 8 ].Available from: http://www.stats.gov.cn/tjsj/ndsj/2019 /indexeh.htm

11 Wang K. Brief discussion on present status and future of joint replacement in China. Chin J Joint Surg 2015 ; 9 : 12 -14

12 Pei FX. The current status and future perspective of hip and knee arthroplasty in China. Chin J Bone Joint 2012 ; 1 : 4 -8

13 Wuerz TH, Kent DM, Malchau H, Rubash HE. A nomogram to predict major complications after hip and knee arthroplasty.

2014 ; 29 : 1457 -1462 [PMID: 24793891 DOI: 10 .1016 /j.arth.2013 .09 .007 ]

14 Wuerz TH, Regenbogen SE, Ehrenfeld JM, Malchau H, Rubash HE, Gawande AA, Kent DM. The Surgical Apgar Score in hip and knee arthroplasty.

2011 ; 469 : 1119 -1126 [PMID: 21132410 DOI:10 .1007 /s11999 -010 -1721 -x]

15 Inneh IA, Lewis CG, Schutzer SF. Focused risk analysis: regression model based on 5 ,314 total hip and knee arthroplasty patients from a single institution.

2014 ; 29 : 2031 -2035 [PMID: 24970581 DOI: 10 .1016 /j.arth.2014 .05 .007 ]

16 Phillips CB, Barrett JA, Losina E, Mahomed NN, Lingard EA, Guadagnoli E, Baron JA, Harris WH, Poss R, Katz JN.Incidence rates of dislocation, pulmonary embolism, and deep infection during the first six months after elective total hip replacement.

2003 ; 85 : 20 -26 [PMID: 12533567 DOI: 10 .2106 /00004623 -200301000 -00004 ]

17 Zenilman ME. Delirium: An Important Postoperative Complication. JAMA 2017 ; 317 : 77 -78 [PMID: 28030685 DOI:10 .1001 /jama.2016 .18174 ]

18 Chung KS, Lee JK, Park JS, Choi CH. Risk factors of delirium in patients undergoing total knee arthroplasty.

2015 ; 60 : 443 -447 [PMID: 25704295 DOI: 10 .1016 /j.archger.2015 .01 .021 ]

19 Scott JE, Mathias JL, Kneebone AC. Incidence of delirium following total joint replacement in older adults: a metaanalysis.

2015 ; 37 : 223 -229 [PMID: 25774049 DOI: 10 .1016 /j.genhosppsych.2015 .02 .004 ]

20 Merrill RK, Ibrahim JM, Machi AS, Raphael JS. Analysis and Review of Automated Risk Calculators Used to Predict Postoperative Complications After Orthopedic Surgery.

2020 ; 13 : 298 -308 [PMID:32418072 DOI: 10 .1007 /s12178 -020 -09632 -0 ]

21 Monk TG, Saini V, Weldon BC, Sigl JC. Anesthetic management and one-year mortality after noncardiac surgery.

2005 ; 100 : 4 -10 [PMID: 15616043 DOI: 10 .1213 /01 .ANE.0000147519 .82841 .5 E]

22 Higuera CA, Elsharkawy K, Klika AK, Brocone M, Barsoum WK. 2010 Mid-America Orthopaedic Association Physician in Training Award: predictors of early adverse outcomes after knee and hip arthroplasty in geriatric patients.

2011 ; 469 : 1391 -1400 [PMID: 21347818 DOI: 10 .1007 /s11999 -011 -1804 -3 ]

23 Saucedo JM, Marecek GS, Wanke TR, Lee J, Stulberg SD, Puri L. Understanding readmission after primary total hip and knee arthroplasty: who's at risk?

2014 ; 29 : 256 -260 [PMID: 23958236 DOI: 10 .1016 /j.arth.2013 .06 .003 ]

24 Illingworth KD, El Bitar YF, Banerjee D, Scaife SL, Saleh KJ. Inpatient mortality after primary total hip arthroplasty:analysis from the National Inpatient Sample database.

2015 ; 30 : 369 -373 [PMID: 25529285 DOI:10 .1016 /j.arth.2014 .08 .002 ]

25 Kishawi D, Schwarzman G, Mejia A, Hussain AK, Gonzalez MH. Low Preoperative Albumin Levels Predict Adverse Outcomes After Total Joint Arthroplasty.

2020 ; 102 : 889 -895 [PMID: 32079884 DOI:10 .2106 /JBJS.19 .00511 ]

26 Seltzer MH, Bastidas JA, Cooper DM, Engler P, Slocum B, Fletcher HS. Instant nutritional assessment.

1979 ; 3 : 157 -159 [PMID: 573345 DOI: 10 .1177 /014860717900300309 ]

27 Gupta A, Upadhyaya S, Cha T, Schwab J, Bono C, Hershman S. Serum albumin levels predict which patients are at increased risk for complications following surgical management of acute osteoporotic vertebral compression fractures.

2019 ; 19 : 1796 -1802 [PMID: 31255789 DOI: 10 .1016 /j.spinee.2019 .06 .023 ]

28 de Mutsert R, Grootendorst DC, Indemans F, Boeschoten EW, Krediet RT, Dekker FW; Netherlands Cooperative Study on the Adequacy of Dialysis-II Study Group. Association between serum albumin and mortality in dialysis patients is partly explained by inflammation, and not by malnutrition.

2009 ; 19 : 127 -135 [PMID: 19218039 DOI:10 .1053 /j.jrn.2008 .08 .003 ]

29 Labgaa I, Mantziari S, Genety M, Elliott JA, Kamiya S, Kalff MC, Winiker M, Pasquier J, Allemann P, Messier M, van Berge Henegouwen MI, Nilsson M, Reynolds JV, Piessen G, Hübner M, Demartines N, Sch?fer M. Early postoperative decrease of albumin is an independent predictor of major complications after oncological esophagectomy: A multicenter study.

2021 ; 123 : 462 -469 [PMID: 33289149 DOI: 10 .1002 /jso.26317 ]

30 Mansmann U, Rieger A, Strahwald B, Crispin A. Risk calculators-methods, development, implementation, and validation.

2016 ; 31 : 1111 -1116 [PMID: 27108006 DOI: 10 .1007 /s00384 -016 -2589 -3 ]