Abstract
Purpose
The purpose of this study was to assess complications, reoperations, and their risk factors at 90 days and 2 years after high tibial osteotomy (HTO) and distal femoral osteotomy (DFO) in a national cohort.
Methods
The PearlDiver Mariner Dataset was queried using International Classification of Diseases (ICD) and Current Procedural Terminology (CPT) codes for HTO and DFO, complications, and subsequent surgery. Minimum follow-up was 2 years and complications were assessed at 90 days and 2 years. Hospital readmission in the first 90 days was also assessed. Univariate and multiple logistic regression were utilized to identify risk factors for complications and re-operation.
Results
The 90-day and 2-year complication rates after HTO (n = 1780) were 11.6% and 31.7%, compared to 21.5% (p < 0.0001) and 41.5% (p = 0.0001) after DFO (n = 446). Infection was the most frequent early (90-day) complication for both HTO and DFO cohorts, while hardware problems were most common at 2 years. Increasing Elixhauser Comorbidity Index (ECI) was associated with increased odds of infection, readmission, and hardware-associated complications in both cohorts. Gender and tobacco use were also associated with various complications after HTO. At 2 years, 23.7% of HTO patients and 26.2% of DFO patients had undergone subsequent surgery. Hardware removal occurred in 16.4% of HTO and 18.4% of DFO patients (n.s.), while 4.5% of HTO and 5.2% of DFO patients underwent total knee arthroplasty (TKA) within 2 years (n.s.).
Conclusion
HTO and DFO have substantial complication rates in the short and mid term, with a higher rate of overall complications observed after DFO as compared to the HTO cohort. After both procedures, roughly one quarter of patients will undergo subsequent surgery within 2 years. Patients with tobacco use and numerous medical co-morbidities may not be optimal candidates due to increased complication rates. Elixhauser Comorbidity Index (ECI) may be an useful tool for risk assessment prior to surgery.
Level of evidence
Retrospective cohort study, III.
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Acknowledgements
We acknowledge Scott Ellison for his assistance with the PearlDiver database.
Funding
This research did not receive any specific grant from funding.
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Authors and Affiliations
Contributions
NKK designed the study, collected data, performed statistical analysis, and drafted the manuscript; CA contributed to writing of manuscript; ALZ, CBM, BTF critically revised the manuscript; DAL conceived of and designed the study and critically revised the manuscript.
Ethics declarations
Conflict of interest
DAL consults for Vericel, Inc., receives educational support from Arthrex/Evolution Surgical, receives research support from AOSSM, AANA, and Arthritis Foundation, and is a committee member of AOSSM, AANA, and ORS; BTF serves on the editorial board of JSES and CRMM, holds stock options with Bioniks and Kaliber.ai, and receives research support from NIH, VA, Orthofix, and Stryker; ALZ is a consultant for Stryker and Depuy-Mitek; CBM is a consultant for Stryker, Conmed, and Tornier, receives research support from Aesculap, Samumed, Zimmer, and Conmed and receives royalties from Conmed.
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Appendices
Appendix A
Codes used to define HTO and DFO cohorts
Procedure | Code |
|---|---|
HTO | CPT-27455, CPT-27457, CPT-27705, CPT-27709, ICD-9-P-7727, ICD-10-P-0Q8G0ZZ, ICD-10-P-0Q8G3ZZ, ICD-10-P-0Q8G4ZZ, ICD-10-P-0Q8H0ZZ, ICD-10-P-0Q8H3ZZ, ICD-10-P-0Q8H4Z |
DFO | CPT-27448, CPT-27450, ICD-9-P-7725, ICD-10-P-0Q8B0ZZ, ICD-10-P-0Q8C0ZZ, ICD-10-P-0Q8C3ZZ, ICD-10-P-0Q8C4ZZ, ICD-10-P-0Q8B3ZZ, ICD-10-P-0Q8B4ZZ |
Associated diagnosis | Code |
|---|---|
Knee osteoarthritis | ICD-9-D-71516, ICD-9-D-71526, ICD-9-D-71536, ICD-9-D-71596, ICD-10-D-M1710, ICD-10-D-M175, ICD-10-D-M179, ICD-10-DM170, ICD-10-D-M1711, ICD-10-D-M1712, ICD-10-D-M172, ICD-10-D-M1730, ICD-10-D-M1731, ICD-10-D-M1732, ICD-10-D-M174, ICD-10-D-M175 |
Meniscus tear | ICD-9-D-7170, ICD-9-D-7171, ICD-9-D-7172, ICD-9-D-7173, ICD-9-D-71740, ICD-9-D-71741, ICD-9-D-71742, ICD-9-D-71743, ICD-9-D-71749, ICD-9-D-7175, ICD-9-D-8360, ICD-9-D-8361, ICD-9-D-8362, ICD-10-D-S83252A, ICD-10-D-S83252S, ICD-10-D-S83252D, ICD-10-D-S83251A, ICD-10-D-S83251S, ICD-10-D-S83251D, ICD-10-D-S83259A, ICD-10-D-S83259S, ICD-10-D-S83259D, ICD-10-D-S83212A, ICD-10-D-S83212S, ICD-10-D-S83212D, ICD-10-D-S83211A, ICD-10-D-S83211S, ICD-10-D-S83211D, ICD-10-D-S83219A, ICD-10-D-S83219S, ICD-10-D-S83219D, ICD-10-D-S83201A, ICD-10-D-S83201S, ICD-10-D-S83201D, ICD-10-D-S83200A, ICD-10-D-S83200S, ICD-10-D-S83200D, ICD-10-D-S83202A, ICD-10-D-S83202S, ICD-10-D-S83202D, ICD-10-D-S83272A, ICD-10-D-S83272S, ICD-10-D-S83272D, ICD-10-D-S83271A, ICD-10-D-S83271S, ICD-10-D-S83271D, ICD-10-D-S83279A, ICD-10-D-S83279S, ICD-10-D-S83279D, ICD-10-D-S83232A, ICD-10-D-S83232S, ICD-10-D-S83232D, ICD-10-D-S83231A, ICD-10-D-S83231S, ICD-10-D-S83231D, ICD-10-D-S83239A, ICD-10-D-S83239S, ICD-10-D-S83239D, ICD-10-D-M23242, ICD-10-D-M23241, ICD-10-D-M23249, ICD-10-D-M23212, ICD-10-D-M23211, ICD-10-D-M23219, ICD-10-D-M23262, ICD-10-D-M23261, ICD-10-D-M23269, ICD-10-D-M23232, ICD-10-D-M23231, ICD-10-D-M23239, ICD-10-D-M23252, ICD-10-D-M23251, ICD-10-D-M23259, ICD-10-D-M23222, ICD-10-D-M23221, ICD-10-D-M23229, ICD-10-D-M23201, ICD-10-D-M23200, ICD-10-D-M23202, ICD-10-D-M23204, ICD-10-D-M23203, ICD-10-D-M23205, ICD-10-D-M23207, ICD-10-D-M23206, ICD-10-D-M23209, ICD-10-D-S83282A, ICD-10-D-S83282S, ICD-10-D-S83282D, ICD-10-D-S83281A, ICD-10-D-S83281S, ICD-10-D-S83281D, ICD-10-D-S83289A, ICD-10-D-S83289S, ICD-10-D-S83289D, ICD-10-D-S83242A, ICD-10-D-S83242S, ICD-10-D-S83242D, ICD-10-D-S83241A, ICD-10-D-S83241S, ICD-10-D-S83241D, ICD-10-D-S83249A, ICD-10-D-S83249S, ICD-10-D-S83249D, ICD-10-D-S83204A, ICD-10-D-S83204S, ICD-10-D-S83204D, ICD-10-D-S83203A, ICD-10-D-S83203S, ICD-10-D-S83203D, ICD-10-D-S83205A, ICD-10-D-S83205S, ICD-10-D-S83205D, ICD-10-D-S83262A, ICD-10-D-S83262S, ICD-10-D-S83262D, ICD-10-D-S83261A, ICD-10-D-S83261S, ICD-10-D-S83261D, ICD-10-D-S83269A, ICD-10-D-S83269S, ICD-10-D-S83269D, ICD-10-D-S83222A, ICD-10-D-S83222S, ICD-10-D-S83222D, ICD-10-D-S83221A, ICD-10-D-S83221S, ICD-10-D-S83221D, ICD-10-D-S83229A, ICD-10-D-S83229S, ICD-10-D-S83229D, ICD-10-D-S83207A, ICD-10-D-S83207S, ICD-10-D-S83207D, ICD-10-D-S83206A, ICD-10-D-S83206S, ICD-10-D-S83206D, ICD-10-D-S83209A, ICD-10-D-S83209S, ICD-10-D-S83209D |
Cartilage injury | ICD-9-D-71800, ICD-9-D-71808, ICD-9-D-73390, ICD-9-D-73399, ICD-9-D-8360, ICD-9-D-8361, ICD-9-D-8362, ICD-10-D-S8330XA, ICD-10-D-S8330XD, ICD-10-D-S8330XS, ICD-10-D-S8331XA, ICD-10-D-S8331XD, ICD-10-D-S8331XS, ICD-10-D-S8332XA, ICD-10-D-S8332XD, ICD-10-D-S8332XS, ICD-10-D-M93261, ICD-10-D-M93262, ICD-10-D-M93269, ICD-9-D-7327, ICD-9-D-73392, ICD-9-D-7324, ICD-10-D-M9251, ICD-10-D-M9252, ICD-10-D-M9250, ICD-10-D-M9240, ICD-10-D-M9241, ICD-10-D-M9242, ICD-9-D-7177, ICD-10-D-M2240, ICD-10-D-M2241, ICD-10-D-M2242, ICD-10-D-M94261, ICD-10-D-M94262, ICD-10-D-M94269 |
Ligament injury | ICD-9-D-71781, ICD-9-D-71782, ICD-9-D-71783, ICD-9-D-71784, ICD-9-D-71785, ICD-10-D-M23601, ICD-10-D-M23602, ICD-10-D-M23609, ICD-10-D-M23611, ICD-10-D-M23612, ICD-10-D-M23619, ICD-10-D-M23621, ICD-10-D-M23622, ICD-10-D-M23629, ICD-10-D-M23631, ICD-10-D-M23632, ICD-10-D-M23639, ICD-10-D-M23641, ICD-10-D-M23642, ICD-10-D-M23649 |
Appendix B
Codes used to define complications and subsequent surgery
Complication | Codes |
|---|---|
Pulmonary embolism | ICD-9-D-4151:ICD-9-D-4159,ICD-10-D-I26:ICD-10-D-I269 |
Deep venous thrombosis | ICD-9-D-4532,ICD-9-D-4533,ICD-9-D-4534,ICD-9-D-45382,ICD-9-D-45384,ICD-9-D-45385,ICD-9-D 45386,ICD-10-D-I26:ICD-10-D-I2699 |
Pneumonia | ICD-9-D-4800:ICD-9-D-4809,ICD-9-D-481,ICD-9-D-4820,ICD-9-D-4821,ICD-9-D- 48230,ICD-9-D-48231,ICD-9-D-48232,ICD-9-D-48239,ICD-9-D-48240,ICD-9-D-48241,ICD-9-D-48242,ICD-9- D-48249,ICD-9-D-48281,ICD-9-D-48282,ICD-9-D-48283,ICD-9-D-48284,ICD-9-D-48289,ICD-9-D-4829,ICD-9- D-4830,ICD-9-D-4831,ICD-9-D-4838,ICD-9-D-4841,ICD-9-D-4843,ICD-9-D-4845,ICD-9-D-4846,ICD-9-D- 4847,ICD-9-D-4848,ICD-9-D-485,ICD-9-D-486,ICD-10-D-J12:ICD-10-D-J189 |
Acute kidney injury | ICD-9-D-5845,ICD-9-D-5846,ICD-9-D-5847,ICD-9-D-5848,ICD-9-D-5849,ICD-10D-N17:ICD-10-D-N179 |
Hematoma | ICD-9-D-99811,ICD-9-D-99812,ICD-9-D-99813,ICD-10-D-D7801, ICD-10-D-D7802, ICD-10-D-D7821, ICD-10-D-D7822, ICD-10-D-E3601, ICD-10-D-E3602, ICD-10-D-E89810, ICD-10-D-E89811, ICD-10-D-G9731, ICD-10-D-G9732, ICD-10-D-G9751, ICD-10-D-G9752, ICD-10-D-H59111, ICD-10-D- H59112, ICD-10-D-H59113, ICD-10-D-H59119, ICD-10-D-H59121, ICD-10-D-H59122, ICD-10-D-H59123, ICD-10-D-H59129, ICD-10-D-H59311, ICD-10-D-H59312, ICD-10-D-H59313, ICD-10-D-H59319, ICD-10-D- H59321, ICD-10-D-H59322, ICD-10-D-H59323, ICD-10-D-H59329, ICD-10-D-H9521, ICD-10-D-H9522, ICD-10-D-H9541, ICD-10-D-H9542, ICD-10-D-I97410, ICD-10-D-I97411, ICD-10-D-I97418, ICD-10-D-I9742, ICD-10-D-I97610, ICD-10-D-I97611, ICD-10-D-I97618, ICD-10-D-I97620, ICD-10-D-J9561, ICD-10-D-J9562, ICD- 10-D-J95830, ICD-10-D-J95831, ICD-10-D-K9161, ICD-10-D-K9162, ICD-10-D-K91840, ICD-10-D-K91841, ICD-10-D-L7601, ICD-10-D-L7602, ICD-10-D-L7621, ICD-10-D-L7622, ICD-10-D-M96810, ICD-10-D- M96811, ICD-10-D-M96830, ICD-10-D-M96831, ICD-10-D-N9961, ICD-10-D-N9962, ICD-10-D-N99820, ICD- 10-D-N99821, ICD-10-D-T888XXA |
Sepsis or septic shock | ICD-9-D-99591, ICD-9-D-99592, ICD-9-D-99802, ICD-9-D-99809, ICD-9-D-99800, ICD-10-D-A419, ICD-10-D-R6521, ICD-10-D-R6520, ICD-10-D-T8144XA, ICD-10-D-A400, ICD-10-D-A401, ICD-10-D-A4101, ICD-10-D-A4102, ICD-10-D-A411 |
Peroneal nerve injury | ICD-9-D-9563, ICD-10-D-S8410XA, ICD-10-D-S8411XA, ICD-10-D-S8412XA |
Popliteal artery injury | ICD-10-D-S85001A, ICD-10-D-85002A, ICD-10-D-85009A, ICD-9-D-9044, ICD-9-D-90441, ICD-9-D-90440, ICD-10-D-S85011A, ICD-10-D-S85012A, ICD-10-D-S85091A, ICD-10-D-S85092A |
Compartment syndrome | ICD-9-D-95890, ICD-9-D-72972, ICD-10-D-M79A21, ICD-10-D-M79A22, ICD-10-D-M79A29, ICD-10-D-T79A0XA |
Infection or drainage | ICD-9-D-71106, ICD-9-D-71146, ICD-9-D-71186, ICD-9-D-71196, ICD-9-D-99851, ICD-10-D-M01X61, ICD-10-D-M01X62, ICD-10-D-M01X69, CPT-10180, CPT-20005, CPT-27310, CPT-29871, ICD-9-D-99859, ICD-10-D-M00869, ICD-10-D-M00069, ICD-10-D-M00162, ICD-10-D-M00169, ICD-10-D-M00061, ICD-10-D-M00062, ICD-10-D-M00161, ICD-10-D-M00261, ICD-10-D-M00262, ICD-10-D-M00861, ICD-10-D-M00862, ICD-10-D-T847XXA, ICD-10-D-T84620A, ICD-10-D-T84621A, ICD-10-D-T84622A, ICD-10-D-T84623A, ICD-10-D-T84629A, ICD-9-D-99667 |
Wound disruption | ICD-9-D-99830,ICD-9-D-99831,ICD-9-D-99832,ICD-9-D-99833,ICD-10-D-T8130XA,ICD-10-D-T8130XD,ICD-10-D-T8130XS,ICD-10-D-T8131XA,ICD-10-D-T8131XD,ICD-10-D-T8131XS,ICD-10-D-T8132XA,ICD-10-D-T8132XD,ICD-10-D-T8132XS,ICD-10-D-T8133XA,ICD-10-D-T8133XD,ICD-10-D-T8133XS |
Any hardware-related complication | ICD-9-D-99640, ICD-9-D-99649, ICD-10-D-T84114A, ICD-10-D-T84115A, ICD-10-D-T84116A, ICD-10-D-T84117A, ICD-10-D-T84119A, ICD-10-D-T85698A, ICD-9-D-99678, ICD-10-D-T84124A, ICD-10-D-T84125A, ICD-10-D-T84126A, ICD-10-D-T84127A, ICD-10-D-T8481XA, ICD-10-D-T8486XA, ICD-10-D-T84418A, ICD-10-D-T84428A, ICD-10-D-T84498A, ICD-10-D-T847XXA, ICD-10-D-T84620A, ICD-10-D-T84621A, ICD-10-D-T84622A, ICD-10-D-T84623A, ICD-10-D-T84629A, ICD-9-D-99667 |
Hardware complications (mechanical or other) | ICD-9-D-99640, ICD-9-D-99649, ICD-10-D-T84114A, ICD-10-D-T84115A, ICD-10-D-T84116A, ICD-10-D-T84117A, ICD-10-D-T84119A, ICD-10-D-T85698A, ICD-9-D-99678, ICD-10-D-T84124A, ICD-10-D-T84125A, ICD-10-D-T84126A, ICD-10-D-T84127A, ICD-10-D-T8481XA, ICD-10-D-T8486XA, ICD-10-D-T84418A, ICD-10-D-T84428A, ICD-10-D-T84498A |
Hardware-related infection | ICD-10-D-T847XXA, ICD-10-D-T84620A, ICD-10-D-T84621A, ICD-10-D-T84622A, ICD-10-D-T84623A, ICD-10-D-T84629A, ICD-9-D-99667 |
Nonunion or malunion | ICD-9-D-73382, ICD-10-D-S8290XK, ICD-10-D-S72401K, ICD-10-D-S72402K, ICD-10-D-S72409K, ICD-10-D-S7290XK, ICD-10-D-S7291XK, ICD-10-D-S7292XK, ICD-10-D-S82101K, ICD-10-D-S82102K, ICD-9-D-73381, ICD-10-D-S72401P, ICD-10-D-S72402P, ICD-10-D-S72409P, ICD-10-D-S7290XP, ICD-10-D-S82101P, ICD-10-D-S82102P, ICD-10-D-S82109P |
Subsequent surgery | Codes |
|---|---|
Total knee arthroplasty | CPT-27445, CPT-27447, ICD-9-P-8154, ICD-10-P-0SRD0J9, ICD-10-P-0SRC0J9, ICD-10-P-0SRC0JA, ICD-10-P-0SRD0JA, ICD-10-P-0SRC069, ICD-10-P-0SRC06A, ICD-10-P-0SRC06Z, ICD-10-P-0SRC0JZ, ICD-10-P-0SRD069, ICD-10-P-0SRD06A, ICD-10-P-0SRD06Z, ICD-10-P-0SRD0JZ |
Unicompartmental knee arthroplasty | CPT-27446, ICD-10-P-0SRC0L9, ICD-10-P-0SRC0LA, ICD-10-P-0SRC0LZ, ICD-10-P-0SRD0L9, ICD-10-P-0SRD0LA, ICD-10-P-0SRD0LZ, ICD-10-P-0SRC0M9, ICD-10-P-0SRC0MA, ICD-10-P-0SRC0MZ, ICD-10-P-0SRD0M9, ICD-10-P-0SRD0MA, ICD-10-P-0SRD0MZ |
Manipulation under anesthesia | CPT-27570 |
Any arthroscopic procedure | CPT-29884, ICD-9-P-8026, ICD-10-P-0SJC4ZZ, ICD-10-P-0SJD4ZZ, CPT-29866, CPT-29867, CPT-29874, CPT-29877, CPT-29879, CPT-29885, CPT-29886, CPT-29887, CPT-G0289 |
Arthroscopy with cartilage procedure | CPT-29866, CPT-29867, CPT-29874, CPT-29877, CPT-29879, CPT-29885, CPT-29886, CPT-29887, CPT-G0289 |
Hardware removal | CPT-20680, ICD-9-P-7865, ICD-9-P-7867, ICD-10-P-0QPB04Z, ICD-10-P-0QPB34Z, ICD-10-P-0QPB44Z, ICD-10-P-0QPC04Z, ICD-10-P-0QPC34Z, ICD-10-P-0QPC44Z, ICD-10-P-0QPG04Z, ICD-10-P-0QPG34Z, ICD-10-P-0QPG44Z, ICD-10-P-0QPH04Z, ICD-10-P-0QPH34Z, ICD-10-P-0QPH44Z |
Co-morbidity | Codes |
|---|---|
Diabetes mellitus | ICD-9-D-24900:ICD-9-D-25099,ICD-9-D-7902,ICD-9-D-79021,ICD-9-D-79022,ICD-9-D-79029,ICD-9-D-7915,ICD-9-D-7916,ICD-10-D-E090:ICD-10-D-E139 |
Tobacco use | ICD-9-D-3051, ICD-9-D-V1582, ICD-10-D-F17220, ICD-10-D-F17221, ICD-10-D-F17223, ICD-10-D-F17228, ICD-10-D-F17229, ICD-10-D-F17290, ICD-10-D-F17291, ICD-10-D-F17293, ICD-10-D-F17298, ICD-10-D-F17299, ICD-10-D-Z720 |
Obesity | ICD-9-D-2780,ICD-9-D-27800,ICD-9-D-27801,ICD-9-D-27802,ICD-9-D-27803,ICD-10-D-E660:ICD-10-D-E669 |
Appendix C
Variables included in multiple logistic regression.
HTO 90-day complications
Complication | Variables included |
|---|---|
Wound disruption | Obesity, ECI, diabetes |
Infection | Obesity, gender, ECI |
Readmission | ECI, obesity, diabetes |
All hardware-related complications | ECI, age, diabetes, tobacco |
Mechanical or “other” hardware complications | Tobacco, ECI, gender |
Hardware-related infections | ECI, obesity, diabetes |
DFO 90-day complications
Complication | Variables included |
|---|---|
Wound disruption | None, n < 20 per group |
Infection | ECI, obesity, diabetes |
Readmission | ECI, age > 40 |
All hardware-related complications | ECI, age > 40 |
Mechanical or “other” hardware complications | None, n < 20 per group |
Hardware-related infections | None, n < 20 per group |
HTO 2-year complication
Complication | Variables included |
|---|---|
Wound disruption | Obesity, diabetes, ECI, age |
Infection | Obesity, diabetes, ECI, age |
All hardware-related complications | Gender, ECI, age, tobacco |
Mechanical or “other” hardware complications | Age, gender, tobacco |
Hardware-related infections | Obesity, diabetes, ECI |
Nonunion or malunion | Obesity, ECI, tobacco |
DFO 2 year complication
Complication | Variables included |
|---|---|
Wound disruption | None, n < 20 per group |
Infection | ECI, obesity, diabetes |
All hardware-related complications | None, no factors identified in univariate analysis |
Mechanical or “other” hardware complications | None, no factors identified in univariate analysis |
Hardware-related infections | ECI, age > 40 |
Nonunion or malunion | None, no factors identified in univariate analysis |
DFO re-operation
Operation | Variables included |
|---|---|
TKA | ECI, age |
MUA | None, no factors identified in univariate analysis |
Any arthroscopic procedure | Age < 40, gender |
Arthroscopy with cartilage procedure | Age < 40, gender |
Hardware removal | Age < 40, gender, obesity |
HTO re-operation
Operation | Variables included |
|---|---|
TKA | Diabetes, ECI, age > 40 |
MUA | Age, gender |
Any arthroscopic procedure | Age < 40, gender |
Arthroscopy with cartilage procedure | Age, gender |
Hardware removal | Age < 40, gender, obesity |
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Kucirek, N.K., Anigwe, C., Zhang, A.L. et al. Complications after high tibial osteotomy and distal femoral osteotomy are associated with increasing medical comorbidities and tobacco use. Knee Surg Sports Traumatol Arthrosc 30, 4029–4045 (2022). https://doi.org/10.1007/s00167-022-06865-z
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DOI: https://doi.org/10.1007/s00167-022-06865-z