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Medical comorbidities increase the rate of surgical site infection in primary Achilles tendon repair

  • ANKLE
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Knee Surgery, Sports Traumatology, Arthroscopy Aims and scope

Abstract

Purpose

To assess the effects of medical comorbidities on the incidence of surgical site infection following primary Achilles tendon repair. A secondary aim was to assess the effects of specific medical comorbidities on the cost and extent of healthcare utilization related to surgical site infection following primary Achilles tendon repair.

Methods

24,269 patients undergoing primary Achilles tendon repair between 2005 and 2012 were examined. Current Procedural Terminology codes for primary Achilles tendon repair, and incision and drainage were used to search for and compile patient data from the United Healthcare Orthopedic and Medicare databases. Primary outcome measures regarding surgical site infection following primary Achilles tendon repair included the rate of occurrence, cost, and duration of treatment.

Results

Patients with one or more preexisting medical comorbidities at the time of surgery had an increased rate of surgical site infection compared to those without. Diabetes and vascular complications were associated with the highest surgical site infection rates. The rate of surgical incision and drainage was higher in patients with cardiac arrhythmias and uncomplicated hypertension. The presence of a medical comorbidity significantly increased the cost and duration of surgical site infection treatment.

Conclusions

Medical comorbidities can complicate the postoperative course for patients undergoing Achilles tendon repair, which increases the cost of care and duration of treatment. A better understanding of the relationship between each medical comorbidity and surgical site infections following Achilles tendon repair may be ascertained with additional prospective studies, thus, allowing for a more accurate evaluation and stratification of surgical candidates to improve patient outcomes.

Level of evidence

Retrospective cohort study, Level III.

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Abbreviations

SSI:

Surgical site infection

HIPAA:

Health Insurance Portability and Accountability

CPT:

Current procedural terminology

ICD-9:

International classification of disease, ninth revision

I&D:

Incision and drainage

OR:

Odds ratio

CI:

Confidence interval

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Acknowledgements

All individuals who have contributed to this article are listed as authors.

Funding

No external funding was used.

Author information

Authors and Affiliations

  1. Foot and Ankle Injury Research [F.A.I.R.] group, Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, 3471 Fifth Ave., Pittsburgh, PA, 15213, USA

    Malcolm Dombrowski, Christopher D. Murawski, Samuel O. Ewalefo, Mitchell S. Fourman & MaCalus V. Hogan

  2. Department of Orthopaedic Surgery, Teikyo University School of Medicine, Tokyo, Japan

    Youichi Yasui

  3. Department of Foot and Ankle Surgery, Hospital for Special Surgery, New York, NY, USA

    Youichi Yasui & John G. Kennedy

  4. Department of Orthopaedic Surgery, Harvard Medical School, Brigham and Women’s Hospital, Boston, MA, USA

    Antonia F. Chen

Authors
  1. Malcolm Dombrowski
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  2. Christopher D. Murawski
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  3. Youichi Yasui
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  4. Antonia F. Chen
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  5. Samuel O. Ewalefo
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  6. Mitchell S. Fourman
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  7. John G. Kennedy
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  8. MaCalus V. Hogan
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Contributions

MD, CM, and MH contributed to the design, data acquisition, analysis and interpretation of data for this article. YY and AC contributed to the data acquisition, analysis, and interpretation of data for this article. SE and JK contributed to the analysis and interpretation of data, drafting, and critical revision of the manuscript.

Corresponding author

Correspondence to MaCalus V. Hogan.

Ethics declarations

Conflict of interest

The author declares that they have no conflict of interest.

Ethical approval

All procedures performed in the studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

For this type of database, formal consent is not required.

Appendix: List of comorbidities and ICD-9 codes included in study (alphabetical order)

Appendix: List of comorbidities and ICD-9 codes included in study (alphabetical order)

Comorbidities

ICD-9 code

ICD-9 code name

Alcohol abuse

D-30390

Other and unspecified alcohol dependence unspecified

D-30391

Other and unspecified alcohol dependence continuous

D-30393

Other and unspecified alcohol dependence in remission

D-30500

Alcohol abuse unspecified

D-30501

Alcohol abuse continuous

D-30503

Alcohol abuse in remission

D-V113

Personal history of alcoholism

Anemia

D-2800

Iron deficiency anemia secondary to blood loss (chronic)

Cancer

D-1960

Secondary and unspecified malignant neoplasm of lymph nodes of head face and neck

D-1962

Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes

D-1963

Secondary and unspecified malignant neoplasm of lymph nodes of axilla and upper limb

D-1965

Secondary and unspecified malignant neoplasm of lymph nodes of inguinal region and lower limb

D-1969

Secondary and unspecified malignant neoplasm of lymph node site unspecified

D-1970

Secondary malignant neoplasm of lung

D-1971

Secondary malignant neoplasm of mediastinum

D-1976

Secondary malignant neoplasm of retroperitoneum and peritoneum

D-1980

Secondary malignant neoplasm of kidney

D-1982

Secondary malignant neoplasm of skin

D-1985

Secondary malignant neoplasm of bone and bone marrow

D-1987

Secondary malignant neoplasm of adrenal gland

D-19882

Secondary malignant neoplasm of genital organs

D-19889

Secondary malignant neoplasm of other specified sites

D-1991

Other malignant neoplasm without specification of site

Cardiac arrhythmia

D-42610

Atrioventricular block unspecified

D-42611

First degree atrioventricular block

D-42613

Other second degree atrioventricular block

D-42650

Bundle branch block unspecified

D-42651

Right bundle branch block and left posterior fascicular block

D-42652

Right bundle branch block and left anterior fascicular block

D-42653

Other bilateral bundle branch block

D-4270

Paroxysmal supraventricular tachycardia

D-42731

Atrial fibrillation

D-42760

Premature beats unspecified

D-4279

Cardiac dysrhythmia unspecified

D-7850

Tachycardia unspecified

Coagulopathy

D-2863

Congenital deficiency of other clotting factors

D-2864

Von Willebrand disease

D-28659

Other hemorrhagic disorder due to intrinsic circulating anticoagulant antibodies or inhibitors

D-2866

Defibrination syndrome

D-2867

Acquired coagulation factor deficiency

D-2869

Other and unspecified coagulation defects

D-2874

Secondary thrombocytopenia

D-2873

Primary thrombocytopenia

D-28730

Primary thrombocytopenia unspecified

D-28731

Immune thrombocytopenic purpura

D-2874

Unknown

D-28749

Other secondary thrombocytopenia

D-2875

Thrombocytopenia unspecified

CHF

D-4280

Congestive heart failure unspecified

COPD

D-496

Chronic airway obstruction not elsewhere classified

Deficiency anemia

D-2859

Anemia unspecified

Depression

D-311

Depressive disorder not elsewhere classified

Diabetes circulatory

D-25070

Diabetes with peripheral circulatory disorders type II or unspecified type not stated as uncontrolled

D-25071

Diabetes with peripheral circulatory disorders type I (juvenile type) not stated as uncontrolled

D-25072

Diabetes with peripheral circulatory disorders type II or unspecified type uncontrolled

D-25073

Diabetes with peripheral circulatory disorders type I (juvenile type) uncontrolled

Diabetes (ocular complications)

D-25050

Diabetes with ophthalmic manifestations type II or unspecified type not stated as uncontrolled

D-25051

Diabetes with ophthalmic manifestations type I [juvenile type] not stated as uncontrolled

D-25052

Diabetes with ophthalmic manifestations type II or unspecified type uncontrolled

D-25053

Diabetes with ophthalmic manifestations type I (juvenile type) uncontrolled

D-25060

Diabetes with neurological manifestations type II or unspecified type not stated as uncontrolled

D-25061

Diabetes with neurological manifestations type I (juvenile type) not stated as uncontrolled

D-25062

Diabetes with neurological manifestations type II or unspecified type uncontrolled

D-25063

Diabetes with neurological manifestations type I (juvenile type) uncontrolled

Diabetes renal manifestations

D-25040

Diabetes with renal manifestations type II or unspecified type not stated as uncontrolled

D-25041

Diabetes with renal manifestations type I (juvenile type) not stated as uncontrolled

D-25042

Diabetes with renal manifestations type II or unspecified type uncontrolled

D-25043

Diabetes with renal manifestations type I (juvenile type) uncontrolled

Diabetes (uncomplicated)

D-25000

Diabetes mellitus without mention of complication type II or unspecified type not stated as uncontrolled

D-25001

Diabetes mellitus without mention of complication type I (juvenile type) not stated as uncontrolled

D-25002

Diabetes mellitus without mention of complication type II or unspecified type uncontrolled

D-25003

Diabetes mellitus without mention of complication type I (juvenile type) uncontrolled

Drug abuse

D-2920

Drug withdrawal

D-29285

Drug-induced sleep disorders

D-2929

Unspecified drug-induced mental disorder

D-30400

Opioid-type dependence unspecified

D-30401

Opioid-type dependence continuous

D-30403

Opioid-type dependence in remission

D-30410

Sedative hypnotic or anxiolytic dependence unspecified

D-30411

Sedative hypnotic or anxiolytic dependence continuous

D-30412

Sedative hypnotic or anxiolytic dependence episodic

D-30413

Sedative hypnotic or anxiolytic dependence in remission

D-30420

Cocaine dependence unspecified

D-30421

Cocaine dependence continuous

D-30422

Cocaine dependence episodic

D-30430

Cannabis dependence unspecified

D-30431

Cannabis dependence continuous

D-30432

Cannabis dependence episodic

D-30441

Amphetamine and other psychostimulant dependence continuous

D-30462

Other specified drug dependence episodic

D-30471

Combinations of opioid-type drug with any other drug dependence continuous

D-30480

Combinations of drug dependence excluding opioid-type drug unspecified

D-30490

Unspecified drug dependence unspecified

D-30491

Unspecified drug dependence continuous

D-30520

Cannabis abuse unspecified

D-30521

Cannabis abuse continuous

D-30522

Cannabis abuse episodic

D-30523

Cannabis abuse in remission

D-30540

Sedative hypnotic or anxiolytic abuse unspecified

D-30550

Opioid abuse unspecified

D-30551

Opioid abuse continuous

D-30560

Cocaine abuse unspecified

D-30561

Cocaine abuse continuous

D-30563

Cocaine abuse in remission

D-30570

Amphetamine or related acting sympathomimetic abuse unspecified

D-30590

Other mixed or unspecified drug abuse unspecified

D-30591

Other mixed or unspecified drug abuse continuous

D-30593

Other mixed or unspecified drug abuse in remission

Fluid and electrolyte abnormalities

D-2761

Hyposmolality and/or hyponatremia

D-2762

Acidosis

D-2763

Alkalosis

D-2765

Hypovolemia

D-27651

Dehydration

D-2766

Fluid retention

D-2767

Hyperpotassemia

D-2768

Hypopotassemia

Hypertension (uncomplicated)

D-4019

Unspecified essential hypertension

Hypothyroidism

D-2449

Unspecified acquired hypothyroidism

Liver disease

D-07032

Chronic viral hepatitis B without mention of hepatic coma without mention of hepatitis delta

D-07033

Chronic viral hepatitis B without mention of hepatic coma with hepatitis delta

D-07054

Chronic hepatitis C without mention of hepatic coma

D-4560

Esophageal varices with bleeding

D-4561

Esophageal varices without mention of bleeding

D-45620

Esophageal varices in diseases classified elsewhere with bleeding

D-45621

Esophageal varices in diseases classified elsewhere without mention of bleeding

D-5710

Alcoholic fatty liver

D-5713

Alcoholic liver damage unspecified

D-57140

Chronic hepatitis unspecified

D-57149

Other chronic hepatitis

D-5715

Cirrhosis of liver without mention of alcohol

D-5718

Other chronic nonalcoholic liver disease

D-5719

Unspecified chronic liver disease without mention of alcohol

D-5723

Portal hypertension

D-5728

Other sequelae of chronic liver disease

Lymphoma

D-20000

Reticulosarcoma unspecified site extranodal and solid organ sites

D-20030

Marginal zone lymphoma unspecified site extranodal and solid organ sites

D-20037

Marginal zone lymphoma spleen

D-20270

Peripheral T-cell lymphoma unspecified site extranodal and solid organ sites

D-20280

Other malignant lymphomas unspecified site extranodal and solid organ sites

D-20281

Other malignant lymphomas lymph nodes of head face and neck

D-20283

Other malignant lymphomas intra-abdominal lymph nodes

D-20287

Other malignant lymphoma spleen

D-20290

Other and unspecified malignant neoplasms of lymphoid and histiocytic tissue unspecified site extranodal and solid organ sites

D-20300

Multiple myeloma without mention of having achieved remission

Obesity

D-27800

Obesity unspecified

D-27801

Morbid obesity

Other neurologic disorders

D-3319

Cerebral degeneration unspecified

D-3320

Paralysis agitans

D-3334

Huntington’s chorea

D-3335

Other choreas

D-3343

Other cerebellar ataxia

D-3344

Cerebellar ataxia in diseases classified elsewhere

D-3348

Other spinocerebellar diseases

D-3350

Werdnig–Hoffmann disease

D-33521

Progressive muscular atrophy

D-33524

Primary lateral sclerosis

D-3358

Other anterior horn cell diseases

D-34500

Generalized nonconvulsive epilepsy without mention of intractable epilepsy

D-34510

Generalized convulsive epilepsy without mention of intractable epilepsy

D-34580

Other forms of epilepsy and recurrent seizures without mention of intractable epilepsy

D-34590

Epilepsy unspecified without mention of intractable epilepsy

D-7843

Aphasia

Peptic ulcer disease

D-V1271

Personal history of peptic ulcer disease

Peripheral vascular disease

D-4439

Peripheral vascular disease unspecified

Psychoses

D-29500

Simple-type schizophrenia unspecified

D-29530

Paranoid-type schizophrenia unspecified

D-29532

Paranoid-type schizophrenia chronic

D-29534

Paranoid-type schizophrenia chronic with acute exacerbation

D-29540

Schizophreniform disorder unspecified

D-29550

Latent schizophrenia unspecified

D-29570

Schizoaffective disorder unspecified

D-29572

Schizoaffective disorder chronic

D-29574

Schizoaffective disorder chronic with acute exacerbation

D-29580

Other specified types of schizophrenia unspecified

D-29590

Unspecified schizophrenia unspecified

D-29592

Unspecified schizophrenia chronic

D-29600

Bipolar I disorder single manic episode unspecified

D-29602

Bipolar I disorder single manic episode moderate

D-29604

Bipolar I disorder single manic episode severe specified as with psychotic behaviour

D-29610

Manic affective disorder recurrent episode unspecified

D-29620

Major depressive affective disorder single episode unspecified

D-29621

Major depressive affective disorder single episode mild

D-29622

Major depressive affective disorder single episode moderate

D-29623

Major depressive affective disorder single episode severe without mention of psychotic behaviour

D-29624

Major depressive affective disorder single episode severe specified as with psychotic behaviour

D-29625

Major depressive affective disorder single episode in partial or unspecified remission

D-29626

Major depressive affective disorder single episode in full remission

D-29630

Major depressive affective disorder recurrent episode unspecified

D-29631

Major depressive affective disorder recurrent episode mild

D-29632

Major depressive affective disorder recurrent episode moderate

D-29633

Major depressive affective disorder recurrent episode severe without mention of psychotic behaviour

D-29634

Major depressive affective disorder recurrent episode severe specified as with psychotic behaviour

D-29635

Major depressive affective disorder recurrent episode in partial or unspecified remission

D-29640

Bipolar I disorder most recent episode (or current) manic unspecified

D-29644

Bipolar I disorder most recent episode (or current) manic severe specified as with psychotic behaviour

D-29650

Bipolar I disorder most recent episode (or current) depressed unspecified

D-29651

Bipolar I disorder most recent episode (or current) depressed mild

D-29652

Bipolar I disorder most recent episode (or current) depressed moderate

D-29653

Bipolar I disorder most recent episode (or current) depressed severe without mention of psychotic behaviour

D-29655

Bipolar I disorder most recent episode (or current) depressed in partial or unspecified remission

D-29660

Bipolar I disorder most recent episode (or current) mixed unspecified

D-29662

Bipolar I disorder most recent episode (or current) mixed moderate

D-29663

Bipolar I disorder most recent episode (or current) mixed severe without mention of psychotic behaviour

D-29664

Bipolar I disorder most recent episode (or current) mixed severe specified as with psychotic behaviour

D-2967

Bipolar I disorder most recent episode (or current) unspecified

D-29680

Bipolar disorder unspecified

D-29681

Atypical manic disorder

D-29682

Atypical depressive disorder

D-29689

Other bipolar disorders

D-29690

Unspecified episodic mood disorder

D-29699

Other specified episodic mood disorder

D-2970

Paranoid state simple

D-2971

Delusional disorder

D-2972

Paraphrenia

D-2980

Depressive-type psychosis

D-2982

Reactive confusion

D-2984

Psychogenic paranoid psychosis

D-2988

Other and unspecified reactive psychosis

D-2989

Unspecified psychosis

Pulmonary circulation disorders

D-4168

Other chronic pulmonary heart diseases

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Dombrowski, M., Murawski, C.D., Yasui, Y. et al. Medical comorbidities increase the rate of surgical site infection in primary Achilles tendon repair. Knee Surg Sports Traumatol Arthrosc 27, 2840–2851 (2019). https://doi.org/10.1007/s00167-018-5295-6

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