Effects of obstructive sleep apnea on postoperative outcomes following total shoulder arthroplasty: A matched cohort analysis

Abstract

Introduction

Obstructive sleep apnea (OSA), marked by recurrent airway obstruction and disrupted sleep, is linked to increased perioperative risk in major surgeries. However, its impact on total shoulder arthroplasty (TSA) remains unclear. This study investigates the association between OSA and postoperative outcomes.

Methods

This retrospective cohort study used the PearlDiver Mariner Database to identify patients who underwent TSA from 2010 to 2021. Patients with OSA were compared to a matched control group without OSA, with matching based on demographics and comorbidities. Postoperative complications, including deep vein thrombosis (DVT), pulmonary embolism (PE), surgical site infection (SSI), transfusions, and revision TSA, were identified using ICD and CPT codes. Multivariate logistic regression was used to adjust for confounders.

Results

A total of 57,118 TSA patients were included, with 50 % (n = 28,559) having a documented diagnosis of OSA. Patients with OSA had a significantly higher prevalence of comorbidities, including hypertension (65.0 % vs. 62.1 %, p < 0.001), obesity (27.3 % vs. 18.8 %, p < 0.001), asthma (8.7 % vs. 4.9 %, p < 0.001), and COPD (17.8 % vs. 14.4 %, p < 0.001). The incidence of DVT, PE, SSI, and wound disruption was not significantly different between groups. However, OSA was associated with a significantly higher risk of revision TSA within two years (0.3 % vs. 0.2 %; OR: 1.43, 95 % CI: 1.04–2.00; p = 0.028). Additionally, OSA patients had a significantly lower rate of blood transfusion (0.6 % vs. 0.8 %; OR: 0.68, 95 % CI: 0.55–0.83; p < 0.001).

Conclusion

OSA does not significantly raise the risk of acute complications after TSA but is linked to a higher rate of revision surgeries, suggesting a role in long-term failure, possibly from poor wound healing, systemic inflammation, or obesity-related stress. Preoperative screening and postoperative optimization may help reduce these risks. Further research is needed to assess the effects of OSA severity and CPAP adherence on TSA outcomes.

1. Introduction

Obstructive sleep apnea (OSA) is a common disorder, impacting around 15–20 % of females and 20–30 % of males, characterized by recurrent upper airway obstruction during sleep, resulting in intermittent hypoxia, hypercapnia, and sleep fragmentation.^1,2 This condition is linked to a variety of systemic complications, including cardiovascular disease, pulmonary hypertension, and metabolic dysfunction, all of which can negatively impact surgical outcomes.2, 3, 4 In patients undergoing major surgeries, particularly cardiac and general procedures, OSA has been identified as a significant risk factor for postoperative complications such as respiratory distress, thromboembolic events, and extended hospital stays.⁵ However, its specific impact on orthopedic procedures, especially total joint arthroplasty, remains underexamined.6, 7

Total shoulder arthroplasty (TSA) is a frequently performed orthopedic procedure that carries well-documented risks for postoperative complications, including surgical site infections, deep vein thrombosis (DVT), pulmonary embolism (PE), and impaired wound healing.^6,8 Given the systemic effects of OSA, it is plausible that patients with this condition may face an elevated risk of adverse outcomes following TSA compared to those without OSA.⁹ Despite this, current literature lacks comprehensive analyses assessing the association between OSA and postoperative complications in orthopedic surgery, particularly across multiple joint arthroplasties.^10,11

The PearlDiver database provides a unique opportunity to assess the perioperative risks of OSA in large, real-world patient cohorts undergoing TSA. This national database integrates de-identified patient records from private insurance claims, Medicare, and Medicaid, enabling the identification of comorbidities and postoperative complications using standardized ICD-9, ICD-10, and CPT coding systems.^1,12 Leveraging this resource allows for a direct comparison of surgical outcomes between patients with and without OSA, offering valuable insights into the influence of OSA on joint arthroplasty procedures.

This study aims to evaluate the effect of OSA on postoperative outcomes in patients undergoing TSA, with a focus on key complications such as acute kidney injury (AKI), DVT, surgical site infections, wound disruption, transfusion requirements, reoperation rates, and hospital readmissions. The key postoperative outcomes analyzed in this study included significant complications such as acute kidney injury (AKI), deep vein thrombosis (DVT), pulmonary embolism (PE), pneumonia, surgical site infection (SSI), wound dehiscence, transfusion needs, and the likelihood of requiring reoperation. Additionally, secondary outcomes encompassed overall readmission rates and the incidence of any postoperative complication within the first year after surgery. We seek to determine whether OSA is associated with an increased risk of periprosthetic joint infection (PJI) and revision TSA.² We anticipated that individuals with OSA would experience increased rates of perioperative complications, including a heightened risk of periprosthetic joint infection (PJI). By controlling for baseline comorbidities and employing rigorous statistical analyses, this study addresses existing gaps in the literature and aims to inform perioperative risk stratification and management strategies for patients with OSA undergoing TSA.^1,8

2. Methods

2.1. Data source and study design

This retrospective cohort study was conducted using the PearlDiver Mariner Database, a large national repository of de-identified patient records compiled from private insurance claims, Medicare, and Medicaid. The database provided access to patient-level data, enabling the identification of individuals who underwent TSA between 2010 and 2021. Patients were identified using relevant ICD-9, ICD-10, and CPT procedure codes, allowing for a comprehensive analysis of demographic characteristics, comorbidities, and postoperative outcomes. This study aimed to assess the impact of OSA on perioperative and long-term surgical complications following TSA.

2.2. Cohort selection and matching

A total of 57,118 patients who underwent TSA were included in the study, with 50 % (n = 28,559) carrying a documented diagnosis of OSA. Patients were stratified into two cohorts: (1) the OSA group, consisting of individuals diagnosed with OSA before surgery, and (2) the control group, composed of patients without a history of OSA.

To control for potential demographic confounders, a matched cohort design was implemented, ensuring that control patients were selected to closely resemble the OSA group in terms of age, sex. Patients were matched for: age, sex, coronary artery disease, coagulopathy, alcohol abuse, tobacco use, obesity, osteoarthritis, diabetes, and CCI. Age was stratified into two categories (<55 years and ≥55 years) to account for age-related variations in surgical risk and comorbidity burden. Sex was matched categorically to achieve a balanced comparison. This approach minimized baseline demographic discrepancies, allowing for a more precise evaluation of OSA's impact on postoperative outcomes, further enhancing the validity.

2.3. Baseline characteristics and comorbidity assessment

Patient demographic data and medical histories were systematically extracted from the database. Comorbidities known to influence surgical outcomes, including asthma, chronic obstructive pulmonary disease (COPD), coronary artery disease (CAD), diabetes mellitus, hypertension (HTN), obesity, and ischemic heart disease, were identified using ICD diagnosis codes.

Comparative analysis of baseline characteristics demonstrated that patients with OSA exhibited significantly higher rates of comorbid conditions such as asthma, COPD, CAD, HTN, and obesity, suggesting an overall greater burden of chronic disease in this group. However, there were no significant differences between cohorts in terms of congestive heart failure (CHF), diabetes mellitus, or liver disease. Notably, OSA patients had a higher prevalence of deficiency anemia and tobacco use, necessitating statistical adjustments in subsequent analyses to account for these confounding variables.

2.4. Baseline characteristics

A total of 57,118 patients undergoing TSA were included, with 50 % (n = 28,559) having a documented diagnosis of OSA. The age and sex distributions were identical between groups. Patients with OSA had significantly higher rates of several comorbidities, including asthma (OSA: 2496 [8.7 %] vs. control: 1411 [4.9 %]; p < 0.001), COPD (OSA: 5085 [17.8 %] vs. control: 4114 [14.4 %]; p < 0.001), and coronary artery disease (OSA: 5618 [19.7 %] vs. control: 5143 [18.0 %]; p < 0.001). OSA patients were also significantly more likely to have HTN (OSA: 18,571 [65.0 %] vs. control: 17,744 [62.1 %]; p < 0.001) and obesity (OSA: 7788 [27.3 %] vs. control: 5369 [18.8 %]; p < 0.001).

There were no significant differences between the groups in congestive heart failure (CHF) (p = 0.921), diabetes mellitus (p = 0.921), or liver disease (p = 0.094). However, OSA patients had significantly higher rates of deficiency anemia (p = 0.014) and tobacco use (p = 0.038) (Table 1).

Table 1.

Matched cohort patient demographics. Bold = statistically significant.

Total Shoulder Arthroplasty
Variable	Control	OSA	p-value
Age <55	1384	1384
Age >55	28555	28555
Male	14132	14132
Female	14427	14427
Asthma	1411	2496	< 0.001
COPD	4114	5085	< 0.001
CKD	2665	2350	< 0.001
CHF	840	835	0.921
CAD	5143	5618	< 0.001
Diabetes Mellitus	8873	8885	0.921
HTN	17744	18571	< 0.001
IHD (ischemic heart)	2868	2349	< 0.001
Obesity	5369	7788	< 0.001
Osteo	14059	11807	< 0.001
PHD	569	1174	< 0.001
RheumArthritis	1054	819	< 0.001
TobaccoUse	4372	4553	0.038
Alcohol Abuse	391	328	0.020
Liver Disease	1171	1092	0.094
Cancer	4125	4002	0.144
Coagulopathy	748	808	0.130
Deficiency Anemia	1428	1560	0.014

2.5. Outcome measures and adverse events

The primary outcomes assessed included major postoperative complications, such as acute kidney injury (AKI), deep vein thrombosis (DVT), pulmonary embolism (PE), pneumonia, surgical site infection (SSI), wound disruption, transfusion requirements, and reoperation. Secondary outcomes included all-cause readmission rates and the incidence of any complication within one year postoperatively. Additionally, long-term complications such as periprosthetic joint infection (PJI) and revision TSA were evaluated.

Postoperative complications were identified using validated sets of ICD-9, ICD-10, and CPT codes, ensuring a standardized methodology for outcome assessment. Incidence rates of complications were compared between the OSA and control groups to determine whether OSA was associated with increased perioperative morbidity and long-term surgical risks following TSA.

2.6. Statistical analysis

Chi square and student t-tests were used to summarize baseline characteristics, comorbid conditions, and postoperative outcomes. Continuous variables were reported as means with standard deviations, while categorical variables were expressed as frequencies and percentages. Comparisons between groups were conducted using chi-square tests for categorical variables and t-tests for continuous variables, with statistical significance set at p < 0.05.

To adjust for potential confounders, multivariate logistic regression models were constructed for each primary and secondary outcome. Covariates included age, sex, and key comorbidities, with the Charlson Comorbidity Index (CCI) incorporated to quantify the overall comorbidity burden. Adjusted odds ratios (OR) with 95 % confidence intervals (CI) were calculated to quantify the relationship between OSA and postoperative complications.

All statistical analyses were performed within the PearlDiver platform using its built-in analytical tools, which are specifically designed for large-scale claims data research. This approach provided a rigorous framework for evaluating the association between OSA and postoperative outcomes in TSA patients.

2.7. Ethical considerations

This study was exempt from institutional review board (IRB) approval, as it was conducted using de-identified patient data from the PearlDiver database. The study adhered to all relevant Health Insurance Portability and Accountability Act (HIPAA) regulations to ensure patient privacy and data security.

3. Results

3.1. Postoperative outcomes

The incidence of adverse events following TSA varied between the OSA and control groups. Notably, OSA patients were significantly less likely to require manipulation under anesthesia (OSA: 106 [0.4 %] vs. control: 151 [0.5 %]; OR: 0.70, 95 % CI: 0.54–0.90; p = 0.006). Conversely, OSA was associated with a higher rate of revision TSA within two years (OSA: 96 [0.3 %] vs. control: 67 [0.2 %]; OR: 1.43, 95 % CI: 1.04–2.00; p = 0.028).

There was no significant difference in rates of surgical site infection (p = 0.183), DVT (p = 0.137), or pulmonary embolism (p = 0.164). Acute kidney injury (p = 0.658), arrhythmia (p = 0.571), wound disruption (p = 0.610), and nerve injury (p = 0.665) were also similar between groups.

However, the need for blood transfusion was significantly lower in the OSA cohort (OSA: 160 [0.6 %] vs. control: 235 [0.8 %]; OR: 0.68, 95 % CI: 0.55–0.83; p < 0.001). There were no significant differences in rates of urinary tract infection (UTI) (p = 0.369) or pneumonia (p = 0.174) (Table 2).

Table 2.

Complications within 90 days following shoulder arthroplasty All other outcomes are 90-day outcomes Bold = statistically significant.

Total Shoulder Arthroplasty
Adverse Eventsa	Control	OSA	p-value	OR (95 % CI)	Adjusted p-value
Manipulation Under Anesthesiab	151	106	0.006	0.70 (0.54–0.90)	0.005
Any Revisionb	67	96	0.028	1.43 (1.04–2.00)	0.024
Surgical Site Infection	92	112	0.183	0.22 (0.92–1.60)	0.161
DVT	164	193	0.137	1.12 (0.95–1.45)	0.124
Pulmonary Embolism	103	125	0.164	1.21 (0.93–1.58)	0.145
Acute Kidney Injury	502	517	0.658	1.03 (0.91–1.17)	0.630
Arrhythmia	16	12	0.571	0.75 (0.35–1.59)	0.451
Wound Disruption	66	73	0.610	1.11 (0.79–1.54)	0.552
Hematoma	117	90	0.070	0.77 (0.58–1.01)	0.061
Nerve Injury	22	27	0.665	1.18 (0.66–2.09)	0.564
Pneumonia	442	484	0.174	1.09 (0.96–1.24)	0.162
Transfusion	235	160	< 0.001	0.68 (0.55–0.83)	< 0.001
UTI	895	857	0.369	0.96 (0.86–1.05)	0.352
Readmission	558	583	0.473	1.04 (0.93–1.18)	0.453
Any Complication	2580	2654	0.290	1.03 (0.97–1.09)	0.276
PJI	19	28	0.243	1.47 (0.82–2.64)	0.192

^aAdjusted for: age, gender, CCI.

^bTwo-year outcomes.

3.2. Complications and reoperations

While any complication was not significantly different between the groups (OSA: 2654 [9.3 %] vs. control: 2580 [9.0 %]; OR: 1.03, 95 % CI: 0.97–1.09; p = 0.290), OSA patients demonstrated a higher likelihood of revision TSA (p = 0.024). The incidence of periprosthetic joint infection (PJI) was not significantly different (OSA: 28 [0.1 %] vs. control: 19 [0.1 %]; OR: 1.47, 95 % CI: 0.82–2.64; p = 0.243) (Table 2).

4. Discussion

This study provides a closer perspective of the relationship between OSA and postoperative outcomes in TSA. The principal findings of the present investigation are: (1) patients with obstructive sleep apnea (OSA) undergoing total shoulder arthroplasty (TSA) had a significantly higher prevalence of comorbidities, including hypertension, obesity, asthma, and chronic obstructive pulmonary disease (COPD), compared to matched controls; (2) while OSA was not associated with increased rates of major perioperative complications such as deep vein thrombosis (DVT), pulmonary embolism (PE), or surgical site infections (SSI), it was significantly linked to an increased risk of revision TSA within two years; and (3) patients with OSA had a lower likelihood of requiring perioperative blood transfusion, a finding that contrasts with prior studies in lower extremity arthroplasty. These results suggest that while OSA may not substantially increase the risk of acute surgical complications, it may contribute to long-term surgical failure, possibly due to impaired wound healing, systemic inflammation, or mechanical stress from obesity.

The findings demonstrate that patients with OSA exhibit distinct perioperative risks, particularly in relation to comorbid burden, transfusion requirements, and revision surgery. While some complications did not show significant differences, the association between OSA and increased revision rates underscores the need for heightened perioperative management in this patient population.

4.1. Impact of OSA on postoperative outcomes in TSA

OSA has been well-documented as a risk factor for adverse perioperative outcomes due to its systemic effects, including intermittent hypoxia, sympathetic nervous system activation, and chronic inflammation.^1,2 In previous studies on cardiac and general surgery, OSA has been linked to an increased risk of respiratory failure, cardiovascular complications, and extended hospital stays.^3,4 Similarly, in orthopedic surgery, prior research on total joint arthroplasty has suggested that OSA may contribute to greater rates of thromboembolic events, infections, and readmissions.^5,6 However, limited data exist specifically evaluating the impact of OSA in TSA.

Our results align with prior findings in total knee arthroplasty (TKA) and total hip arthroplasty (THA), reinforcing that patients with OSA often present with a higher burden of comorbid conditions such as asthma, COPD, CAD, HTN, and obesity.7, 8, 9 The increased prevalence of these conditions may partially explain the differences in postoperative outcomes observed in this study. While rates of major complications such as DVT, PE, and SSI were not significantly different between groups, patients with OSA had a notably higher risk of requiring revision TSA within two years.

4.2. OSA and revision surgery in TSA

One of the most significant findings in this study is the increased rate of revision TSA among patients with OSA. Prior literature on lower extremity arthroplasty has similarly demonstrated an association between OSA and increased rates of revision procedures, potentially linked to impaired wound healing and chronic inflammation.^10,11 The physiological disturbances caused by OSA, including oxidative stress and endothelial dysfunction, may contribute to compromised soft tissue and bone healing following arthroplasty.^12,13 Additionally, the higher prevalence of obesity in the OSA cohort may exacerbate mechanical stress on the implanted prosthesis, increasing the likelihood of early failure.^14,15

4.3. Transfusion requirements and perioperative management considerations

Interestingly, our study found that patients with OSA had significantly lower rates of blood transfusion compared to the control group. This contrasts with prior studies in lower extremity arthroplasty, where OSA has been linked to increased transfusion rates.¹⁶ One possible explanation is that TSA generally involves less intraoperative blood loss compared to TKA and THA, which may minimize the impact of OSA-related coagulopathies on transfusion needs.^17,18 However, this finding warrants further investigation to determine whether differences in perioperative hemodynamic management strategies between upper and lower extremity arthroplasty procedures contribute to this discrepancy.¹⁹

4.4. Comparison with prior orthopedic studies

While prior studies have examined the role of OSA in lower extremity arthroplasty, few have evaluated its impact in shoulder arthroplasty. Given the differences in biomechanical demands and surgical considerations between TSA and lower extremity joint replacement, our findings contribute valuable insights into the nuanced ways in which OSA may influence outcomes based on anatomical site.^20,21 Our study builds upon existing body of literature by providing TSA-specific data, highlighting that while OSA does not necessarily increase the risk of acute complications such as DVT or PE, it does contribute to a higher rate of revision surgery. This distinction is critical in guiding perioperative risk stratification and long-term surveillance strategies for TSA patients.

4.5. Clinical implications and future directions

The findings of this study emphasize the importance of preoperative screening for OSA in TSA patients. Given the observed association between OSA and revision TSA, optimizing perioperative management strategies, such as ensuring adequate OSA treatment adherence, perioperative oxygenation, and hemodynamic stability, may help mitigate long-term complications.^22,23 The role of CPAP therapy in reducing perioperative risk remains an area of active investigation. Some studies suggest that adherence to CPAP therapy may reduce postoperative complications in OSA patients undergoing major surgery.²⁴ However, the impact of CPAP use on TSA outcomes specifically remains unclear and warrants further study.^25,26

Additionally, future research should incorporate granular clinical data, including OSA severity, CPAP adherence, and intraoperative anesthetic management, to refine risk stratification models. Prospective studies with longer follow-up periods will be necessary to confirm the observed association between OSA and revision TSA and to elucidate the underlying mechanisms driving this relationship.²⁷

4.6. Limitations

While this study's utilization of a large sample size and the inclusion of a broad, diverse patient population can improve the generalizability of the findings of the impact of OSA on postoperative outcomes following TSA, several limitations must be acknowledged. As a retrospective analysis utilizing an administrative claims database, the study is inherently limited by the accuracy and completeness of coding. Errors in diagnosis or procedural coding, including underreporting or misclassification of complications, may affect data reliability. Additionally, the PearlDiver database depends on institutional coding practices, and inconsistencies in documentation across healthcare systems could introduce variability in the dataset.

Despite statistical adjustments for key confounders, the presence of unmeasured variables remains a potential source of bias. The retrospective design also carries an inherent risk of selection bias, as inclusion in the study was restricted to patients with documented TSA procedures and OSA diagnoses. Furthermore, the dataset primarily captures inpatient and coded postoperative complications, potentially overlooking adverse events that develop after hospital discharge or are managed in outpatient settings. This limitation is particularly relevant for complications such as delayed wound healing, functional impairments, and chronic postoperative pain, which may not be fully captured within claims data.

A limitation of this study is the lack of detailed clinical data on OSA severity, patient adherence to continuous positive airway pressure (CPAP) therapy, and perioperative anesthetic management. These factors likely play a crucial role in modulating perioperative risk but could not be accounted for in the current analysis. Without access to granular patient-level data, this study is unable to assess how variations in OSA severity or treatment compliance influence postoperative complications in TSA patients. Given these constraints, prospective studies incorporating detailed clinical data are necessary to validate these findings and better characterize the relationship between OSA and TSA outcomes.

5. Conclusion

This study evaluates of the impact of OSA on postoperative outcomes following TSA. Our findings indicate that while OSA does not significantly increase the risk of acute postoperative complications such as deep vein thrombosis, pulmonary embolism, surgical site infections, or wound disruption, it is associated with a higher likelihood of revision TSA. This suggests that OSA may influence long-term surgical outcomes, potentially due to factors such as impaired wound healing, systemic inflammation, and increased mechanical stress related to comorbid obesity.

The observed differences in transfusion rates between OSA and non-OSA cohorts further underscore the complex perioperative effects of OSA. While prior studies in lower extremity arthroplasty have linked OSA to increased transfusion requirements, our study found a lower transfusion rate among TSA patients with OSA, suggesting that site-specific factors and intraoperative management strategies may play a role in mitigating certain OSA-related risks in upper extremity procedures.

Given the increased risk of revision surgery among OSA patients, preoperative screening and optimization strategies should be considered to mitigate potential adverse outcomes. The role of CPAP therapy in improving TSA surgical outcomes remains an area of active investigation, and future research should focus on the impact of OSA severity, adherence to CPAP therapy, and perioperative anesthetic management on TSA-related complications.

While this study provides valuable insights, it is limited by its retrospective design and reliance on administrative claims data, which may not capture all relevant clinical details, such as OSA severity and patient compliance with therapy. Future prospective studies with detailed clinical data collection and longer follow-up periods are warranted to further elucidate the mechanisms underlying the relationship between OSA and TSA outcomes.

Ultimately, our findings emphasize the importance of individualized perioperative planning for TSA patients with OSA. By identifying high-risk patients and implementing targeted management strategies, orthopedic surgeons and anesthesiologists can optimize patient outcomes and reduce the risk of long-term complications.

CRediT authorship contribution statement

Catherine Hand: Writing – review & editing. Camden Bohn: Writing – review & editing. Morgan Angotti: Conceptualization, Methodology, Data curation. Henry Eilen: Software, Validation, Data curation. Matthew Varano: Data curation. Brian Forsythe: Supervision, Project administration, Writing – Review.

Guardian/patients consent

The study utilized the PearlDiver Database, a national insurance claims database run through Humana Health Insurance (PearlDiver Inc, Fort Wayne, IN, USA). All data available in the database is anonymized and de-identified and was queried only using ICD-9, ICD-10, and Current Procedural Terminology (CPT) codes. Thus, no human subjects were directly involved nor any protected health information collected and no guardian/patient consent was necessary.

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Funding source declaration

This research was supported by internal department funds. No external funding was received for this project.

Declaration of interests

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.