Pre-operative Hypoalbuminemia is Associated with Complications following Proximal Humerus Fracture Surgery: An Analysis of 919 Patients

Abstract

Background

Proximal humerus fractures are among the most common presenting fractures to orthopedic surgeons in the USA. Hypoalbuminemia is accepted as a nutrition marker associated with post-operative complications following common orthopedic interventions.

Questions/Purposes

Thus, the authors sought to (1) describe the national demographic trends of patients undergoing surgical fixation for proximal humerus fracture and (2) investigate the association between pre-operative hypoalbuminemia, a malnutrition marker, and post-operative complications within 1 year of surgical intervention.

Methods

The PearlDiver Humana Claims Database was queried to identify a nationally representative cohort of patients who underwent surgical intervention for proximal humerus fractures from 2008 to 2015. Demographic and comorbid characteristics were collected. Pearson's χ-squared analysis was used to compare rates of 90-day and 1-year outcomes between hypoalbuminemia (albumin ≤ 3.5 mg/dL) and control groups. Multivariate logistic regression was then used to determine the isolated effect that hypoalbuminemia had on post-operative outcomes.

Results

Of the 3337 patients identified, 919 (27.5%) had available serum albumin data. Seventy (7.6%) patients had hypoalbuminemia. Hypoalbuminemia was more likely to be associated with post-operative sepsis (7.1% vs. 1.5%, respectively) and pneumonia (15.7% vs. 4.6) compared with controls. Additionally, hypoalbuminemia was associated with increased 90-day rates of discharge to extended care (4.3% vs. 0.8), emergency room visits (38.6% vs. 21.7), and total cost ($24,051.96 ± 24,972.74 vs. $15,429.74 ± 24,492.30).

Conclusion

Our study suggests hypoalbuminemia is associated with an increased risk of complications, specifically pneumonia and sepsis, and total health care costs in patients undergoing surgery for proximal humerus fractures. These findings provide insight for individualized patient care that will aid in evaluating the potential risk of surgical complications in an effort to improve outcomes and reduce costs.

Keywords

albumin complication proximal humerus fracture hypoalbuminemia cost

Introduction

Proximal humerus fractures are the third most common fracture in the USA, accounting for about 5% of fractures referred to orthopedic surgeons [12, 13, 19]. Previously identified risk factors for these fractures commonly include female gender, age over 65 years, and poor bone density [6].

Operative or non-operative interventions may be pursued in patients presenting with a proximal humerus fracture. Radiographic parameters, patient-specific functional status, and desires can help guide management decisions, especially in elderly individuals [4, 18, 22]. The goals of operative fixation include increased functional range of motion and decreased pain. Common surgical interventions include open-reduction internal fixation (ORIF), hemiarthroplasty, or reverse total shoulder arthroplasty (rTSA) [10, 16].

Although many patient-related demographic risk factors for post-operative complications are non-modifiable upon presentation, nutrition status may be a modifiable risk factor in the peri-operative period. An accepted serum marker of nutrition status is albumin, with hypoalbuminemia defined as serum albumin < 3.5 g/dL [5]. Database studies have previously evaluated the association between pre-operative albumin and post-operative complications in total joint arthroplasty, distal radius fracture fixation, and geriatric hip fracture surgery [1, 2, 27]. Few studies have evaluated the association between hypoalbuminemia and post-operative complications following surgical intervention for proximal humerus fractures. As increased scrutiny is placed on post-operative complications with regard to re-imbursement, it is imperative to identify modifiable patient-related risk factors in an effort to reduce adverse outcomes.

Thus, the purpose of the present study is to (1) determine the incidence of hypoalbuminemia, as measured by serum albumin, in individuals undergoing proximal humerus fracture open reduction and internal fixation and (2) identify the incidence of post-operative complications in patients with objective evidence of hypoalbuminemia compared to those with normal serum albumin levels.

Methods

The PearlDiver Humana Claims Database (private/commercial and Medicare payers) was queried to identify a nationally representative cohort of patients who underwent surgical intervention following a proximal humerus fracture from 2008 to 2015Q3. The database (www.pearldiverinc.com; PearlDiver Inc., Fort Wayne, IN, USA) is an insurance claims-based database, containing anonymous patient information such as demographics, procedure data, and patient outcome and event-related comorbidity information. Records are searchable by International Classification of Diseases (ICD) coding, Current Procedural Terminology (CPT) codes, and Logical Observation Identifiers Names and Codes (LOINC) for all laboratory data. The nationally representative database was deemed appropriate as many patients undergoing surgical fixation for proximal humerus fractures are within the Humana provider demographic.

The study population included all private, commercial, and Medicare patients from 2008 through the third quarter of 2015 between the ages of 20 and 84 years who underwent surgical fixation of proximal humerus fracture (CPT-23615). Consistent with prior literature, patients with concurrent or prior history of sepsis, upper extremity infective arthritis, pathologic fracture, and distal humeral trauma were excluded from the population using CPT and ICD-9-CM diagnostic codes (Appendix Table 6) [1]. The cohort was then subdivided into patients who had pre-operative hypoalbuminemia as defined as documented hypoalbuminemia (albumin < 3.5 g/dL) within 90 days of index surgery and those with a recorded albumin value ≥ 3.5 g/dL within 90 days of surgery (controls).

Patient demographics including age and sex were compared between hypoalbuminemia patients and controls, in addition to comorbidities including obesity (body mass index 30–40 kg/m2), peripheral vascular disease (PVD), chronic kidney disease (CKD), congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), diabetes mellitus (DM), coronary artery disease (CAD), hypertension (HTN), hyperlipidemia (HLD), and pre-operative tobacco and alcohol abuse.

Post-operative outcomes were measured using a combination of CPT, ICD-9-CM and ICD-10-CM codes (Appendix Table 7). Outcomes of interest between hypoalbuminemia patients and controls included 90-day complications, ER (emergency room) visits, readmissions, discharge to extended care facilities, physician reimbursement, 90-day total cost, and 1-year nonunion or reoperation. Reoperation included conversion to subsequent arthroplasty, hemiarthroplasty, repeat open reduction internal fixation, and repair of nonunion or malunion. Among 90-day complications compared were surgical site complications, deep vein thrombosis (DVT), pneumonia (PNA), sepsis, and death.

Statistical Analysis

Both groups’ baseline demographics, pre-operative substance use, and preexisting comorbidities were compared using Pearson's χ-square analysis. Pearson's χ-square analysis was also used to compare rates of 90-day and 1-year outcomes between patients with pre-operative hypoalbuminemia and controls. Multivariate logistic regression was then used to determine the isolated effect hypoalbuminemia had on post-operative outcomes following repair of proximal humerus fracture. This was adjusted for age, pre-operative substance use, and preexisting comorbidities as covariates. The analysis performed was a binomial logistic regression analysis that evaluated the independent effects of hypoalbuminemia while controlling for other covariates. Physician reimbursement and 90-day total cost between cohorts were compared using Welch's t test. A linear regression was then used to determine the independent effect of hypoalbuminemia on physician reimbursement and 90-day total cost using previously mentioned covariates. All statistical analysis was performed using R Project for Statistical Computing. Significance was determined by a p value < 0.05.

Results

Between 2008 and 2015, 3337 patients underwent surgical fixation of proximal humerus fractures. From this cohort, 919 (27.5%) had available serum albumin concentrations. In those with recorded serum albumin concentrations, there were more women (n = 739, 80.4%) than men (n = 180, 19.6%) and 79.1% (n = 727) of patients were > 65 years old (range, 20–84 years old) (Table 1).

Table 1

Patient demographics

		Hypoalbuminemia n = 70		Control n = 849		p value
Age, years	< 65	19	27.1%	173	20.4%	0.059
	65–69	18	25.7%	174	20.5%
	70–74	11	15.7%	207	24.4%
	75–79	13	18.6%	175	20.6%
	80–84	9	12.9%	120	14.1%
Female sex		56	80.0%	683	80.4%	1
Male sex		14	20.0%	166	19.6%
Comorbidities Obesity		18	25.7%	174	20.5%	0.379
(BMI 30–40 kg/m²)
PVD		12	17.1%	151	17.8%	1
Chronic kidney disease		27	38.6%	229	27.0%	0.052
Congestive heart failure		17	24.3%	135	15.9%	0.099
COPD		33	47.1%	321	37.8%	0.157
Diabetes mellitus		38	54.3%	386	45.5%	0.194
Coronary artery disease		25	35.7%	257	30.3%	0.416
Hypertension		62	88.6%	707	83.3%	0.325
Hyperlipidemia		51	72.9%	707	83.3%	0.041
Substance use
Smoking		10	14.3%	57	6.7%	0.035
Alcohol		26	37.1%	217	25.6%	0.049

BMI, Body Mass Index; PVD, Peripheral Vascular Disease; COPD, Chronic Obstructive Pulmonary Disease

Seventy (7.6%) patients had hypoalbuminemia (albumin ≤ 3.5 mg/dL) within 90 days of index surgical intervention. Patients with hypoalbuminemia more commonly were smokers ([n = 10, 14.3%] vs. [n = 57, 6.7%], p = 0.035) and had recorded alcohol use ([n = 26, 37.1%] vs. [n = 217, 25.6%], p = 0.049). Additionally, patients with hypoalbuminemia had a lower incidence of hyperlipidemia than the control group ([n = 51, 72.9%] vs. [n = 707, 83.3%], p = 0.041) (Table 1).

Patients with hypoalbuminemia had higher rates of post-operative pneumonia compared with the control group ([n = 11, 15.7%] vs. [n = 39, 4.6%]) (AOR = 3.18, CI = 1.37–6.93, p = 0.005). Furthermore, patients with hypoalbuminemia had higher rates of sepsis ([n = 5, 7.1%] vs. [n = 13, 1.5%], respectively) (AOR = 5.71, CI = 1.67–17.34, p = 0.003). The hypoalbuminemia group displayed higher rates of discharge to extended care ([n = 3, 4.3%] vs. [n = 7, 0.8%], respectively) (AOR = 10.38, CI = 1.71–54.88, p = 0.006). The hypoalbuminemia group also presented with a higher rate of emergency room visits within 90 days post-operatively (n = 27, 38.6%) compared with the control group (n = 184, 21.7%) (AOR = 2.16, CI = 1.24–3.72, p = 0.006) (Table 4). There was no difference between groups in the rate of death ([n = 0, 0.0%] vs. [n = 3, 0.4%], respectively, p = 1) and 1-year post-operative outcomes of nonunion ([n = 7, 10.0%] vs. [n = 46, 5.4%], p = 0.189) (AOR = 2.18, CI = 0.84–5.04, p = 0.084), reoperation ([n = 3, 4.3%] vs. [n = 51, 6.0%], p = 0.746) (AOR = 0.78, CI = 0.18–2.27, p = 0.684), or subsequent conversion to arthroplasty ([n = 2, 2.9%] vs. [n = 21, 2.5%], p = 1) (AOR = 1.59, CI = 0.24–6.25, p = 0.558) (Tables 2, 3 and 4).

Table 2

90-day post-operative outcomes between hypoalbuminemia patients and controls

	Hypoalbuminemia n = 70	Control n = 849	p value	Hypoalbuminemia vs. control Adjusted OR (95% CI)	p value
Death	0 (0%)	3 (0.4%)	1	–	–
Sepsis	5 (7.1%)	13 (1.5%)	0.005	5.71 (1.67–17.34)	0.003
Pneumonia	11 (15.7%)	39 (4.6%)	< 0.001	3.18 (1.37–6.93)	0.005
DVT	2 (2.9%)	17 (2.0%)	0.963	1.58 (0.24–6.11)	0.563
SS Complications	5 (7.1%)	26 (3.1%)	0.141	2.49 (0.73–7.08)	0.109

DVT deep vein thrombosis, SS surgical site

Values in bold denote significance determined as p < 0.05

Table 3

1-year post-operative outcomes between hypoalbuminemia patients and controls

	Hypoalbuminemia n = 70	Control n = 849	p value	Hypoalbuminemia vs. control Adjusted OR (95% CI)	p value
Nonunion	7 (10.0%)	46 (5.4%)	0.189	2.18 (0.84–5.04)	0.084
Reoperation	3 (4.3%)	51 (6.0%)	0.746	0.78 (0.18–2.27)	0.684
Arthroplasty	2 (2.9%)	21 (2.5%)	1	1.59 (0.24–6.25)	0.558

Table 4

Discharge status, ER visits, and readmissions

	Hypoalbuminemia n = 70	Control n = 849	p value	Hypoalbuminemia vs. control Adjusted OR (95% CI)	p value
Discharge to extended care	3 (4.3%)	7 (0.8%)	0.037	10.38 (1.71–54.88)	0.006
90-day ER visit	27 (38.6%)	184 (21.7%)	0.002	2.16 (1.24–3.72)	0.006
90-day readmission	17 (24.3%)	136 (16.0%)	0.106	1.55 (0.82–2.80)	0.162

ER emergency room

Values in bold denote significance determined as p < 0.05

Table 5

Reimbursement and total cost

	Hypoalbuminemia n = 70	Control n = 849	p value	Hypoalbuminemia vs. control Adjusted β (95% CI)	p value
Physician reimbursement	$590.04 ± 391.63	$594.43 ± 389.44	0.930	$180.28 (74.46 ≤ β ≤ 286.12)	0.001
90-day total cost	$24,051.96 ± 24,972.74	$15,429.74 ± 24,492.30	0.005	$9195.48 (3309.45 ≤ β ≤ 15,081.51)	0.002

β standardized beta coefficient

Values in bold denote significance determined as p < 0.05

The 90-day total cost for the hypoalbuminemia group ($24,051.96 ± 24,972.74) was greater than the control group ($15,429.74 ± 24,492.30) (AβC = $9195.48, CI = $3309.45–$15,081.51, p = 0.002). After adjustments for covariates, linear regression determined that hypoalbuminemia significantly increased physician reimbursement rate (AβC = $180.28, CI = $74.46–$286.12, p = 0.001). Welch's t test results displayed no significant difference when comparing physician reimbursement rate between hypoalbuminemia ($590.04 ± 391.63) and control groups ($594.43 ± 389.44, p = 0.930) (Table 5).

Discussion

Few studies have evaluated the relationship between hypoalbuminemia and post-operative outcomes of proximal humerus fractures, a common injury that accounts for approximately 5% of fractures referred to orthopedic surgeons. The current study characterizes the demographic trends and identifies the incidence of post-operative complications in patients undergoing surgical fixation. Hypoalbuminemia, marked by serum albumin less than 3.5 g/dL, was identified in 7.6% of patients and was found to be associated with an increased risk of post-operative complications of pneumonia and sepsis following surgical intervention. Additionally, malnutrition was associated with an increase in extended care discharges, 90-day emergency room visits, physician reimbursement, and 90-day total cost for patients.

The current study is not without limitations. Inherent limitations associated with all surgical database studies, such as electronic miscoding errors, may have affected reported malnutrition or complication rates. Additionally, only 27.5% of patients who met inclusion criteria had available serum albumin, most likely excluding a number of malnourished patients from our data. Another limitation includes the study endpoint of 1 year after surgical intervention. This may exclude a small cohort of post-operative complications, but a time period longer than 1 year was not deemed appropriate as post-operative complications could be due to a subsequent procedure or secondary cause. The categorical nature of malnutrition status hinging on single value of 3.5 g/dL also has limitations. Patients with levels just above and below that value were categorical placed in separate groups, whereas in practice, these patients potentially present with similar risk of post-operative complications. Serum albumin levels present during surgery and post-operatively were unknown, but we required the documented serum albumin to be within 90 days pre-operatively to reduce the time between documentation and surgery. Serum albumin, although a widely accepted marker of malnutrition, also has its own inherent limitations [8]. Out of the 3337 total patients undergoing proximal humerus fracture surgery in the included time period, 919 had serum albumin available. It may be hypothesized that patients with albumin data available may have been more likely to be tested for serum albumin due to a confounding variable, or clinical decision, noted by treating physicians. This limitation was evaluated by comparing demographic and comorbid variables between the two cohorts, demonstrating that there were few statistically significant differences in cohort comorbidities (Table 1).

Of the demographic and comorbid variables included, patients with hypoalbuminemia were more commonly smokers (14.3% vs. 6.7%, respectively) and alcohol users (37.1% vs. 25.6%, respectively) compared with the control cohort. While less is known about concomitant alcohol use, the association of complications following orthopedic procedures with smoking is well-studied. Increased post-operative complications in smokers is consistent with previous literature demonstrating that there are higher risks of surgical complications in tobacco users following orthopedic procedures [17, 23]. As such, these risk factors were adjusted for in latter multivariate analysis to identify independent effects of hypoalbuminemia on post-operative complications.

Our findings present similar associations as those described in previous literature with regard to the relationship of pre-operative malnutrition and post-operative complications [9, 14]. Similarly, previous literature in arthroplasty demonstrated that patients with hypoalbuminemia had a higher risk for surgical site infection, pneumonia, extended length of stay, and readmission [2].

Orthopedic literature focused on geriatric hip and distal radius fracture outcomes found that hypoalbuminemia increased risk of surgical complications and mortality rate [1, 27]. In comparison, our findings present similar post-operative complications in the setting of hypoalbuminemia with the exception of no significant increase in mortality. Although post-operative complications were similar, the incidence of hypoalbuminemia differed between proximal humerus (7.6%), distal radius (14.7%), and hip fractures (45.9%). This reduced incidence of malnutrition in the peri-operative period may be explained by the fact that a portion of presenting fractures may be treated non-operatively, with the possibility that malnourished patients were less likely to undergo surgical intervention [11].

Our findings, in agreement with previous studies, have described the association between malnutrition and post-operative complications. Hypoalbuminemia has the potential to serve as a modifiable risk factor in an effort to provide improvement in surgical outcomes [7, 15]. Fortunately, the treatment of proximal humerus fractures consists of an individualized pre-operative period that provides opportunity for nutrition optimization, further emphasizing the significance of identifying hypoalbuminemia as a pre-operative risk factor [3, 11, 15]. Hypoalbuminemia suggests, but does not confirm, malnutrition. Thus it should trigger a work-up for nutritional status. The potential pre-operative optimization period is in contrast to hip fractures which often require urgent care within 24 h [20, 25]. In consideration of our findings and the flexible pre-operative period of proximal humerus fractures, there may be future studies to evaluate the effect of pre-operative nutrition modification on post-operative complications.

Heightened scrutiny on post-operative complications with regard to re-imbursement has created a greater demand for the prevention of adverse outcomes through modifiable patient-related risk factors such as nutrition. Our study characterized the effect of hypoalbuminemia on proximal humerus fracture costs and found it increased 90-day total cost. This is presumably through the increased rates of discharge to extended care and 90-day emergency room visits. These fractures represent a significant financial burden in health care, amassing similar costs of care as other osteoporotic fractures such as distal radius, hip and vertebral compression fractures [25]. Overall incidence and cost is likely to increase in the current at risk aging demographic [21, 26]. These considerations further reinforce the desire to risk-stratify individuals, paying particular attention to post-operative complications and health care costs. Our cost analysis expands the findings of hypoalbuminemia in proximal humerus fractures from individualized patient treatment to potential utilization in health care system practices to reduce health care costs.

In conclusion our study demonstrated that pre-operative malnutrition was associated with increased post-operative complications of pneumonia and sepsis in patients undergoing surgical fixation of proximal humerus fractures. Additionally, malnutrition, as defined by low albumin, was associated with increased extended care discharges, 90-day emergency room visits, physician reimbursement, and 90-day total cost for patients. These findings have implications on both individualized patient care and health care system expenditures. This is especially relevant as there is currently an aging population that will likely bear higher numbers of fractures and health care costs. Fortunately, the treatment of proximal humerus fractures provides the opportunity to utilize nutrition as a modifiable risk factor that can be carefully considered in patient care. Further studies are necessary to evaluate this opportunity and assess the effect of pre-operative nutrition modification on post-operative complications.

Electronic supplementary material

Electronic supplementary material, 11420_2020_9804_MOESM1_ESM - Pre-operative Hypoalbuminemia is Associated with Complications following Proximal Humerus Fracture Surgery: An Analysis of 919 Patients

Electronic supplementary material, 11420_2020_9804_MOESM1_ESM for Pre-operative Hypoalbuminemia is Associated with Complications following Proximal Humerus Fracture Surgery: An Analysis of 919 Patients by, Alyssa D. Althoff, MD, Anthony J. Ignozzi, BS, Joshua E. Bell, MD, Brian C. Werner, MD, in HSS Journal: The Musculoskeletal Journal of Hospital for Special Surgery

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Electronic supplementary material, 11420_2020_9804_MOESM2_ESM for Pre-operative Hypoalbuminemia is Associated with Complications following Proximal Humerus Fracture Surgery: An Analysis of 919 Patients by, Alyssa D. Althoff, MD, Anthony J. Ignozzi, BS, Joshua E. Bell, MD, Brian C. Werner, MD, in HSS Journal: The Musculoskeletal Journal of Hospital for Special Surgery

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Electronic supplementary material, 11420_2020_9804_MOESM3_ESM for Pre-operative Hypoalbuminemia is Associated with Complications following Proximal Humerus Fracture Surgery: An Analysis of 919 Patients by, Alyssa D. Althoff, MD, Anthony J. Ignozzi, BS, Joshua E. Bell, MD, Brian C. Werner, MD, in HSS Journal: The Musculoskeletal Journal of Hospital for Special Surgery

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Electronic supplementary material, 11420_2020_9804_MOESM4_ESM for Pre-operative Hypoalbuminemia is Associated with Complications following Proximal Humerus Fracture Surgery: An Analysis of 919 Patients by, Alyssa D. Althoff, MD, Anthony J. Ignozzi, BS, Joshua E. Bell, MD, Brian C. Werner, MD, in HSS Journal: The Musculoskeletal Journal of Hospital for Special Surgery

Footnotes

Electronic supplementary material

The online version of this article () contains supplementary material, which is available to authorized users.

Compliance with Ethical Standards

Conflict of Interest:

Alyssa D. Althoff, MD, Anthony J. Ignozzi, BS, and Joshua Bell declare no conflict of interest. Brian C. Werner, MD, declares personal fees from Arthrex, Inc., board or committee membership from the American Orthopaedic Society for Sports Medicine and American Shoulder and Elbow Surgeons, and research support from Biomet and Integra LifeScience.

Human/Animal Rights:

All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1975, as revised in 2013.

Informed Consent:

Informed consent was waived from all patients for being included in this study.

Required Author Forms

Disclosure forms provided by the authors are available with the online version of this article.

Appendix

Table 6

Exclusion codes

Upper extremity trauma	ICD-9-CM: 996.41-45
Upper extremity trauma	CPT: 24566, 24575, 24582, 24586, 24587, 25607, 25608
Upper extremity neoplasm	ICD-9-CM: 733.10-11
Upper extremity infection	ICD-9-CM: 995.91-92, 711.90-92

Table 7

Post-operative outcome codes

Sepsis	ICD-9-CM: 995.91-92
Sepsis	ICD-10-CM: A0.21, A2.27, A2.67, A3.27, A4.00-01, A4.03, A4.08, A4.09, A4.101-102, A4.11-14, A4.150-153, A4.159, A4.181, A4.189, A4.19, A4.27, A5.486, B3.77, R6.520-521
Pneumonia	ICD-9-CM: 480.0-3, 480.8-9, 481, 482.0-2, 482.30-32, 482.39-42, 482.49, 482.81-84, 482.89, 482.9, 483.0-1, 483.8, 485, 486, 997.31-32
Pneumonia	ICD-10-CM: A01.03, A02.22, A37.01, A37.11, A37.81, A37.91, A54.84, B01.2, B06.81, J12.0-3, J12.81, J12.89-9, J13-14, J15.0-212, J15.29-9, J16.0, J16.8, J17, J18.0-9, J84.111, J84.116, J84.117, J84.2, J85.1, J95.851
Deep vein thrombosis	ICD-9-CM: 453.40-42
Deep vein thrombosis	ICD-10-CM: I82.401-403, I82.409, I82.491-493, I82.499, I82.4Y1-4Y3, I82.4Y9, I82.4Z1-4Z3, I82.4Z9
Wound complications	ICD-9-CM: 998.12-13, 996.67, 998.30-32, 998.51, 998.59, 998.83
Wound complications	ICD-10-CM: M96.840, M96.842, T81.30XA-32XS, T81.4XXA-4XXS, T84.610A-611S
Nonunion/malunion	ICD-9-CM: 733.81-82
	ICD-10-CM: S42.201K-201P, S42.202K-202P, S42.209K-209P, S42.211K-211P, S42.212K-212P, S42.214K-214P, S42.215K-215P, S42.221K-221P, S42.222K-222P, S42.223K-223P, S42.224K-224P, S42.225K-225P, S42.226P, S42.231K-231P, S42.232K-232P, S42.239P, S42.241K-241P, S42.242K-242P, S42.251K-251P, S42.252K-252P, S42.253K-253P, S42.254K-254P, S42.255K-255P, S42.256K, S42.261K, S42.272K, S42.291K-291P, S42.292K-292P, S42.293P, S42.294K-294P, S42.295K-295P, S42.296P
	CPT: 24430, 24435
Reoperation	CPT: 23470, 23472, 23615, 24430, 24435
Emergency room visit	CPT: 99281, 99282, 99283, 99284, 99285

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