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Post-operative complications cause suffering and death among patients who have undergone surgery, increase the length of hospital stay, and thus increase costs, moreover, they reduce the quality of life and life expectancy among patients who have left the hospital. The aim of this study was to explore the trend of hospital admission due to intraoperative and post-procedural complications and disorders of the musculoskeletal system in England and Wales during the past 21 years.
Methods
A secular trends study was conducted using hospital admission data extracted from the Hospital Episode Statistics (HES) database in England and the Patient Episode Database for Wales (PEDW) for the period between April 1999 and April 2020. Hospital admissions were identified using the diagnostic code (M96).
Results
Between 1999 and 2020, a total of 95,783 hospital admission episodes were recorded in England and Wales. Hospital admission rates increased by 6.42-fold [from 3.36 (95% CI 3.20–3.52) in 1999 to 24.92 (95% CI 24.52–25.32) in 2020 per 100,000 persons, p < 0.001]. The most prevalent hospital admissions causes were fracture of bone following insertion of orthopaedic implant, joint prosthesis, or bone plate, pseudarthrosis after fusion or arthrodesis, postlaminectomy syndrome, not elsewhere classified, and other post-procedural musculoskeletal disorders which accounted for 64.3%, 13.8%, 12.3%, and 8.5%, respectively. The age group 75 years and older accounted for 49.1% of the total number of hospital admissions. Females contributed to 62.2% of the total number of hospital admission. Female hospital admissions increased 7.63-fold [from 3.58 (95% CI 3.35–3.80) in 1999 to 30.85 (95% CI 30.23–31.48) in 2020 per 100,000 people]. The male hospital admission rate increased by 4.94 times [from 3.13 (95% CI 2.92–3.35) in 1999 to 18.62 (95% CI 18.13–19.11) in 2020 per 100,000 people].
Conclusion
Intraoperative and post-procedural complications and disorders of musculoskeletal system hospital admissions increased in the past 20 years in England and Wales. More efforts should be directed towards reducing the risk of developing intraoperative and post-procedural complications. Elderly patients and females should be given higher emphasis regarding their risk of developing intraoperative and post-procedural complications and disorders of the musculoskeletal system.
The musculoskeletal system consists of skeletal muscles, joints, and bones. The musculoskeletal system supports the body, gives the ability to move, and provides protection for organs.
Razavi M. Chapter 7 - Nanotoxicity and Regulatory Aspects in Musculoskeletal Regeneration. Nanoengineering in Musculoskeletal Regeneration. Academic Press,
2020: 197-235
Razavi M. Chapter 7 - Nanotoxicity and Regulatory Aspects in Musculoskeletal Regeneration. Nanoengineering in Musculoskeletal Regeneration. Academic Press,
2020: 197-235
Global estimates of the need for rehabilitation based on the global burden of disease study 2019: a systematic analysis for the global burden of disease study 2019.
Global estimates of the need for rehabilitation based on the global burden of disease study 2019: a systematic analysis for the global burden of disease study 2019.
MSDs considerably restrict ability and movement, causing early retirement from work, lower well-being levels, and lessened capability to participate in social life.
In England, in 2021, according to admitted patient care statistics, a total of 11,582,866 procedures and interventions were performed for different medical reasons.
European Surgical Outcomes Study (EuSOS) group for the Trials groups of the European Society of Intensive Care Medicine and the European Society of Anaesthesiology Mortality after surgery in Europe: a 7 day cohort study.
The presence of comorbidities, a higher BMI, intraoperative blood loss, emergency and open surgery, palliative surgery, deeper cavity surgery, longer surgical duration, and contaminated surgical wounds were associated with an increased risk of postoperative complications.
Post-operative complications cause suffering and death among patients who have undergone surgery, increase the length of hospital stay, and thus increase costs, moreover, they reduce the quality of life and life expectancy among patients who have left the hospital.
The severity of post-operative complications varies according to the availability of materials and human resources, as well as the quality of care provided in health care facilities.
To provide safe surgical treatment, perioperative and intraoperative care must be done effectively. Therefore, to make sure that the MSDs’ care is carried out effectively, this research aims to study the trend of hospital admission due to intraoperative and post-procedural complications and disorders of musculoskeletal system in England and Wales during the past 21 years.
2. Patients and methods
2.1 Study sources and the population
A secular trends study was conducted using hospital admission data extracted from the Hospital Episode Statistics (HES) database in England and the Patient Episode Database for Wales (PEDW) for the period between April 1999 and April 2020.
The HES and PEDW databases contain hospital admission data related to intraoperative and post-procedural complications and disorders of the musculoskeletal system for patients from all age groups. The primary healthcare databases in England and Wales are HES and PEDW. They document all hospital admissions, outpatients, and Accident and Emergency (A&E) activities at all National Health Service (NHS) trusts and any independent sector organizations financed by NHS trusts (Health and Social Care Information Centre (HSCIC) 2021,.
Patient demographics, clinical diagnoses, procedures, and lengths of stay are among the available data. HES and PEDW statistics are constantly examined to verify their authenticity and precision. There are four age groups in the database; below 15 years, 15–59 years, 60–74 years, and 75 years and more. Intraoperative and post-procedural complications and disorders of the musculoskeletal system hospital admissions were identified using the 10th version of the International Statistical Classification of Diseases (ICD) system. Intraoperative and post-procedural complications and disorders of the musculoskeletal system that required hospital admission were identified using the diagnostic code (M96).
2.2 Statistical analysis
All analyses were performed using SPSS software version 25 (IBM Corp, Armonk, NY, USA). Hospital admissions rates with their 95% confidence intervals (CIs) were calculated using the absolute number of admissions for each age group divided by the mid-year population of the same age group in the same year. The Pearson chi-square test for independence was used to estimate the variation in hospital admission rates between 1999 and 2020. A two-sided p < 0.05 was considered statistically significant.
3. Results
The total annual number for intraoperative and post-procedural complications and disorders of musculoskeletal system hospital admissions for different causes increased by 7.49-fold from 1752 in 1999 to 14,880 in 2020, representing an increase in hospital admission rate of 6.42-fold [from 3.36 (95% CI 3.20–3.52) in 1999 to 24.92 (95% CI 24.52–25.32) in 2020 per 100,000 persons, p < 0.001]. Fig. 1 presents the time series analysis for the admission rates across the study period.
Fig. 1Secular trend analysis for the overall admission rate.
The most common reasons for hospitalization were fracture of bone after insertion of an orthopaedic implant, joint prosthesis, or bone plate; pseudarthrosis after fusion or arthrodesis; postlaminectomy syndrome, not otherwise classified; and other post-procedural musculoskeletal disorders, accounting for 64.3%, 13.8%, 12.3%, and 8.5%, respectively (Fig. 2).
Fig. 2Percentage of intraoperative and postprocedural complications and disorders of musculoskeletal system hospital admission from total number of admissions.
Through the past 21 years, the most notable increase in hospital admissions rate was seen in fracture of bone following insertion of orthopaedic implant, joint prosthesis, or bone plate with 22.1-fold. Besides, the hospital admissions rate for pseudarthrosis after fusion or arthrodesis, postlaminectomy syndrome, postlaminectomy kyphosis, and other post-procedural musculoskeletal disorders increased by 97.7%, 88.4%, 74.6%, and 12.5%, respectively. However, hospital admissions rates for postsurgical lordosis, postradiation kyphosis, and post-procedural musculoskeletal disorder decreased by 70.9%, 12.7%, and 10.9%, respectively (Fig. 3).
Fig. 3Rates of hospital admission for intraoperative and postprocedural complications and disorders of musculoskeletal system in England and Wales stratified by type between 1999 and 2020.
Concerning age group diversity for intraoperative and post-procedural complications and disorders of the musculoskeletal system, hospital admissions, the age group 75 years and above accounted for 49.1% of the total number of hospital admissions, followed by the age group 15–59 years with 26.3%, the age group 60–74 years with 23.9%, and then the age group below 15 years with 0.7%. Rates of hospital admission among patients aged below 15 years increased by 17.9% [from 0.62 (95%CI 0.46–0.77) in 1999 to 0.73 (95%CI 0.56–0.89) in 2020 per 100,000 persons]. Rates of hospital admission among patients aged 15–59 years increased by 1.08-fold [from 2.84 (95%CI 2.65–3.02) in 1999 to 5.90 (95%CI 5.64–6.15) in 2020 per 100,000 persons]. Rates of hospital admission among patients aged 60–74 years increased by 4.85-fold [from 5.59 (95%CI 5.04–6.15) in 1999 to 32.70 (95%CI 31.54–33.86) in 2020 per 100,000 persons]. Rates of hospital admission among patients aged 75 years and above increased by 16.75-fold [from 10.55 (95%CI 9.53–11.57) in 1999 to 187.21 (95%CI 183.48–190.93) in 2020 per 100,000 persons] (Fig. 4).
Fig. 4Rates of hospital admission for intraoperative and postprocedural complications and disorders of musculoskeletal system in England and Wales stratified by age group.
A total of 95,783 hospital admission episodes were recorded in England and Wales during the study period. Females contributed to 62.2% of the total number of hospital admissions accounting for 59,606 hospital admission episodes, or an average of 2838 per year. Hospital admission rate between females increased by 7.63-fold [from 3.58 (95% CI 3.35–3.80) in 1999 to 30.85 (95% CI 30.23–31.48) in 2020 per 100,000 persons]. Hospital admission rate between males increased by 4.94-fold [from 3.13 (95% CI 2.92–3.35) in 1999 to 18.62 (95% CI 18.13–19.11) in 2020 per 100,000 persons] (Fig. 5).
Fig. 5Rates of hospital admission for intraoperative and postprocedural complications and disorders of musculoskeletal system in England and Wales stratified by gender.
Hospital admission rates for pseudarthrosis after fusion or arthrodesis, postlaminectomy syndrome, postradiation scoliosis, fracture of bone following insertion of an orthopaedic implant, joint prosthesis, or bone plate, other post-procedural musculoskeletal disorders, and post-procedural musculoskeletal disorder were higher among females compared to males, while hospital admission rates for postradiation kyphosis, postlaminectomy kyphosis, and postsurgical lordosis were higher among males compared to females (p < 0.05) (Fig. 6).
Fig. 6Hospital admission rates for intraoperative and postprocedural complications and disorders of musculoskeletal system, not elsewhere classified in England and Wales stratified by gender.
Fig. 6Hospital admission rates for intraoperative and postprocedural complications and disorders of musculoskeletal system, not elsewhere classified in England and Wales stratified by gender.
The majority of hospital admissions occurred among people aged 60–74 years. That includes the following: pseudarthrosis after fusion or arthrodesis, postlaminectomy syndrome, postradiation kyphosis, postlaminectomy kyphosis, and other post-procedural musculoskeletal disorders. Besides, hospital admissions due to postsurgical lordosis, postradiation scoliosis, fracture of bone following insertion of an orthopaedic implant, joint prosthesis, or bone plate, and post-procedural musculoskeletal disorder were seen to be directly related to age (more common among the age group of 75 years and above) (Fig. 7).
Fig. 7Hospital admission rates for intraoperative and postprocedural complications and disorders of musculoskeletal system, not elsewhere classified in England and Wales stratified by age group.
Fig. 7Hospital admission rates for intraoperative and postprocedural complications and disorders of musculoskeletal system, not elsewhere classified in England and Wales stratified by age group.
The purpose of this study was to look at the trends in hospital admissions due to intraoperative and post-procedural complications and musculoskeletal disorders in England and Wales over the last 21 years. The main findings are: 1) the annual number for intraoperative and post-procedural complications and disorders of musculoskeletal system hospital admissions for increased by 7.49-fold during the study period, representing an increase in hospital admission rate of 6.42-fold, 2) the most prevalent hospital admissions causes were fracture of bone following insertion of orthopaedic implant, joint prosthesis, or bone plate, pseudarthrosis after fusion or arthrodesis, postlaminectomy syndrome, and other post-procedural musculoskeletal disorders, 3) The most significant increase in hospital admissions rate was seen in bone fractures following the insertion of an orthopaedic implant, joint prosthesis, or bone plate, with a 22.1-fold increase.4) The hospital admissions rate for postsurgical lordosis decreased by 70.9%; 5) the age group 75 years and older accounted for 49.1% of total hospital admissions, followed by the age group 15–59 years, which accounted for 26.3%; 5) Females accounted for more than half of all hospital admissions (62.2%), and 6) the hospital admission rate among females increased 7.63-fold while it increased 4.94-fold among males.
The type of surgery, the patient, the anatomic location, and the operator's skills all have a significant role in the likelihood of complication from any musculoskeletal intervention.
In this study, the hospital admission rate for intraoperative and post-procedural complications and disorders of musculoskeletal system increased by 6.42-fold [from 3.36 (95% CI 3.20–3.52) in 1999 to 24.92 (95% CI 24.52–25.32) in 2020 per 100,000 persons, p < 0.001]. In recent years, a wide range of medical subspecialties have increasingly used musculoskeletal interventions. Although percutaneous technology and imaging guidance have advanced, the danger of complications has not been completely eliminated.
The frequency of musculoskeletal procedures performed for either diagnostic or therapeutic purposes is rising due to technological developments, and correspondingly, so is the risk of complications. When performing an intervention, radiologists and other interventionists may get directly involved in a complication or indirectly implicated when interpreting post-procedure imaging.
The most prevalent hospital admissions causes were fracture of bone following insertion of orthopaedic implant, joint prosthesis, or bone plate, pseudarthrosis after fusion or arthrodesis, and postlaminectomy syndrome, which accounted for 64.3%, 13.8%, and 12.3%, respectively. Previous literature has reported that bleeding, infections, tumour seeding, procedure-related fracture, cement-related complications, unretrieved device fragments, ablation-related complications, steroid-related complications, and biopsy-related complications are the most common complications related to musculoskeletal interventions.
A review of complications associated with vertebroplasty and kyphoplasty as reported to the Food and Drug Administration medical device related web site.
Bleeding is a constant risk in musculoskeletal procedures since they require penetrating the skin and soft tissues. However, most musculoskeletal operations and procedures use needles with relatively modest gauges, which reduces the possibility of significant bleeding.
Orthopedic devices occasionally have life-saving potential. The majority of the time, they greatly improve overall wellbeing by dramatically reducing pain and discomfort, regaining mobility, and enhancing comfort.
Fracture fixation's primary objectives are to stabilize the fractured bone, promote quick healing of the injured bone, and restore early mobility and complete function to the afflicted extremities.
However, regardless of their design or intended application, medical devices can malfunction or cause complications. Every imaging scan should be carefully examined for potential device complications so they may be dealt with in a timely manner, even though they are uncommon and typically recognized promptly (Radiology key 2020). Almost any piece of medical equipment used to monitor or treat patients that is placed on or within the body can experience complications. Among these are improper device installation, device dysfunction, device breakage with displacement into nearby tissues, and device breakage with embolization at distant sites.
Wires, rods, nails, plates, and screws are common fracture fixation devices used in orthopedic surgery, and radiographs frequently show problems from these devices. Fixation screws breaking is the most common.
These are typically unanticipated findings, but their value depends on where they are and what they are used for. To address these complications, significant thought must be given to the material utilized to make the orthopedic implants. If the wrong material is used, the implants themselves may result in fractures or other flaws in the bone, or bone healing may not occur at all.
The design of these implants must take into account the material's biocompatibility, mechanical characteristics, surface characteristics, chemical characteristics, and failure characteristics in order for the implant to closely resemble the biomechanical characteristics of bone, integrate with the native tissue, and maintain its integrity for the necessary amount of time.
This study found that hospital admissions rates for pseudarthrosis after fusion or arthrodesis, postlaminectomy syndrome, postlaminectomy kyphosis, and other post-procedural musculoskeletal disorders increased by 97.7%, 88.4%, 74.6%, and 12.5%, respectively. Any area of the spine where a spinal fusion was attempted is susceptible to pseudoarthrosis. The purpose of fusion surgery, such as anterior cervical discectomy and fusion and anterior lumbar interbody fusion, is to fuse two adjacent vertebrae into a single unit. Movement will nevertheless persist in the afflicted location if the graft material employed to enable the fusion doesn't completely build new solid bone tissue.
Smoking, steroid use, obesity, hunter syndrome and other metabolic disorders, uncontrolled diabetes, malnutrition, and osteoporosis are risk factors that can lead to pseudoarthrosis.
In this study, the hospital admission rate for postlaminectomy kyphosis increased by around 89.0%. This consequence is still frequently observed in a deformity spine surgeon's clinical practice.
Cervical kyphosis (Post-laminectomy) surgery complication.
in: Mummaneni P.V. Park P. Crawford Iii C.H. Kanter A.S. Glassman S.D. Spinal Deformity : A Case-Based Approach to Managing and Avoiding Complications. Springer International Publishing,
Cham2018: 35-42
It is considered a rare but serious side effect of laminectomy, used to treat cervical myelopathy. Knowing the sagittal plane before surgery is the best preventative measure for patients with cervical spondylotic myelopathy.
Both anterior and posterior approaches can be used to treat postlaminectomy instability of the cervical spine. The original decompressive procedure is the ideal time to undergo the posterior procedures.
Concerning the impact of age on the hospital admission rate due to intraoperative and post-procedural complications and disorders of musculoskeletal system, the age group 75 years and older accounted for 49.1% of the total number of hospital admissions, followed by the age group 15–59 years with 26.3%. Rates of hospital admission among patients aged below 15 years, 15–59 years, 60–74 years, and 75 years and above increased by 17.9%, 1.08-fold, 4.85 fold, and 16.75-fold, respectively. Elderly patients are at higher risk of developing complications related to musculoskeletal conditions complications.
Older patients are at higher risk of tissue injury, stasis, and diminished mobility as a result of musculoskeletal disorders, injuries, surgeries, and related care.
In this study, females contributed to 62.2% of the total number of hospital admissions. Hospital admission rate between females increased by 7.63-fold and between males increased by 4.94-fold. In addition, hospital admission rates were higher among females compared to males, except for postradiation kyphosis, postlaminectomy kyphosis, and postsurgical lordosis were higher among males. Osteoporosis, which eventually results in bone fragility, is more likely to develop in female patients, and particularly those going through menopause.
The International Osteoporosis Foundation has released statistics showing that one-third of the female population over the age of 50 years and 20% of the male population may have an osteoporotic fracture during their lifetimes.
According to previous studies, 30% of the females in both Europe and the United States are osteoporotic, and 40% of post-menopausal females and 30% of males are predicted to sustain an osteoporotic fracture during the course of their lifetimes.
Turkish Osteoporosis Society "Incidence of hip fracture and prevalence of osteoporosis in Turkey: the FRACTURK study." Osteoporosis international : a journal established as result of cooperation between the European.
Found Osteoporos Natl Osteoporos Found USA.2012; 23: 949-955
Age, gender, previous fragility fractures, prolonged immobility, and the presence of other comorbidities are all important risk factors that should be considered for the assessment of fracture probability and the development of its associated complications.
National Osteoporosis Guideline Group Diagnosis and management of osteoporosis in postmenopausal women and older men in the UK: National Osteoporosis Guideline Group (NOGG) update 2013.
Practice groups must increasingly place emphasis on minimizing complications by assessing the results of various procedures and putting mitigation measures in place.
This is the first study to examine intra-operative and post-procedural complications and disorders of the musculoskeletal system without restricting the study sample to a specific population, age group, or complication. This will enhance the generalizability of the study findings. This study has limitations. The use of aggregated data (data at the population level) restricted the ability to retrieve information on the patient's comorbidities, medications, and coagulation markers, which is essential before performing a procedure. Certain diseases, like cirrhosis and chronic liver disease, play a significant role in the likelihood of developing post-procedural complications. Moreover, a patient's medical history may include risk factors that raise their likelihood of fractures, fracture non-unions, or bone abnormalities. Therefore, the study findings should be interpreted carefully.
5. Conclusion
Intra-operative and post-procedural complications and disorders of musculoskeletal system hospital admissions increased in the past 20 years in England and Wales. More efforts should be directed towards reducing the risk of developing intraoperative and post-procedural complications. Elderly patients and females should be given higher emphasis regarding their risk of developing intraoperative and post-procedural complications and disorders of the musculoskeletal system.
Funding
No fund was received for this study.
Ethical approval and consent to participate
This study used de-identified data and was considered exempt from human protection oversight by the institutional review board.
Informed consent statement
Informed consent was obtained from all subjects involved in the study.
Razavi M. Chapter 7 - Nanotoxicity and Regulatory Aspects in Musculoskeletal Regeneration. Nanoengineering in Musculoskeletal Regeneration. Academic Press,
2020: 197-235
Global estimates of the need for rehabilitation based on the global burden of disease study 2019: a systematic analysis for the global burden of disease study 2019.
European Surgical Outcomes Study (EuSOS) group for the Trials groups of the European Society of Intensive Care Medicine and the European Society of Anaesthesiology
Mortality after surgery in Europe: a 7 day cohort study.
A review of complications associated with vertebroplasty and kyphoplasty as reported to the Food and Drug Administration medical device related web site.
Cervical kyphosis (Post-laminectomy) surgery complication.
in: Mummaneni P.V. Park P. Crawford Iii C.H. Kanter A.S. Glassman S.D. Spinal Deformity : A Case-Based Approach to Managing and Avoiding Complications. Springer International Publishing,
Cham2018: 35-42
"Incidence of hip fracture and prevalence of osteoporosis in Turkey: the FRACTURK study." Osteoporosis international : a journal established as result of cooperation between the European.
Found Osteoporos Natl Osteoporos Found USA.2012; 23: 949-955
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