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Selemon NA, Gu A, Malahias MA, Fassihi SC, Chen AZ, Adriani M, Sculco TP, Liu J, Cross MB, Sculco PK. Insulin-dependent diabetes mellitus is an independent risk factor for postoperative complications in aseptic revision total hip arthroplasty. Hip Int 2022; 32:213-220. [PMID: 32750266 DOI: 10.1177/1120700020945221] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Revision total hip arthroplasty (rTHA) is becoming a more common procedure due to the increasing volume of primary total hip arthroplasty. Diabetes mellitus (DM) is currently projected to affect 4.4% of the global population by 2030. Diabetes has been associated with poor outcomes for a variety of surgical interventions. However, the impact of insulin dependence has yet to be fully understood. The aim of this study was to determine the impact of insulin dependence on acute postoperative complications following rTHA. METHODS A retrospective cohort study was conducted using the American College of Surgeons National Quality Improvement Program database. All patients who underwent rTHA between 2006 and 2016 were identified and recorded as having non-insulin-dependent DM (NIDDM), insulin-dependent DM (IDDM) or no DM. Univariate and multivariate analysis were used to evaluate the incidence of multiple adverse events within 30 days after rTHA. RESULTS A total of 7685 patients were evaluated (No DM = 6651, NIDDM = 700, IDDM = 334). Univariate analysis revealed that all patients with DM had significantly higher incidences of postoperative complications (NIDDM: p < 0.001; IDDM: p < 0.001) and extended hospital length of stay (NIDDM: p = 0.015; IDDM: p < 0.0001). NIDDM was associated with increased rates of superficial surgical site infection (SSI) (p = 0.001), deep SSI (p = 0.038), and stroke (p = 0.013), while IDDM was associated with increased rates of pneumonia (p < 0.001), renal failure (p < 0.001), and postoperative transfusion (p < 0.001). On multivariate analysis, insulin-dependence was determined to be an independent risk factor for extended hospital length of stay (OR 1.905; 95% CI, 1.410-2.577; p < 0.001), pneumonia (OR 4.016; 95% CI, 1.799-8.929; p = 0.001), renal failure (OR 7.143; 95% CI, 2.203-23.256; p = 0.001) and postoperative transfusion (OR 1.366; 95% CI, 1.076-1.733; p = 0.01). CONCLUSIONS Insulin dependence is an independent risk factor for numerous short-term postoperative complications following rTHA. When assessing risk and planning perioperative management, surgeons should consider insulin-dependent diabetics as a sub-cohort within the diabetic population.
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Affiliation(s)
- Nicolas A Selemon
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, USA
| | - Alex Gu
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, USA.,Department of Orthopaedic Surgery, George Washington School of Medicine and Health Sciences, Washington, USA
| | - Michael-Alexander Malahias
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, USA
| | - Safa Cyrus Fassihi
- Department of Orthopaedic Surgery, George Washington School of Medicine and Health Sciences, Washington, USA
| | | | - Marco Adriani
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, USA
| | - Thomas P Sculco
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, USA
| | - Jiabin Liu
- Department of Anaesthesia, Hospital for Special Surgery, New York, USA
| | - Michael B Cross
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, USA
| | - Peter K Sculco
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, USA
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Diabetes Mellitus Blunts the Symptoms, Physical Function, and Health-Related Quality of Life Benefits of Total Knee Arthroplasty: A Systematic Review With Meta-analysis of Data From More Than 17 000 Patients. J Orthop Sports Phys Ther 2021; 51:269-280. [PMID: 33870736 DOI: 10.2519/jospt.2021.9515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To compare physical function, pain, impairments (stiffness, range of motion, and strength), and health-related quality of life (HRQoL) outcomes between patients with and without diabetes mellitus, before and after a total knee arthroplasty (TKA). DESIGN Prognosis systematic review. LITERATURE SEARCH We searched MEDLINE/PubMed, CINAHL, SPORTDiscus, and Web of Science to August 2019. STUDY SELECTION CRITERIA We included longitudinal studies that examined physical function, pain, impairments, and HRQoL outcomes among patients receiving a TKA and with or without diabetes. DATA SYNTHESIS For quantitative synthesis, we stratified outcomes based on time relative to TKA: preoperative, less than 1 year after a TKA (early postoperative), and 1 year or more after a TKA (late postoperative). We used random-effects meta-analysis to calculate standardized mean differences (SMDs) and 95% confidence intervals (CIs). We used the Grading of Recommendations Assessment, Development and Evaluation system for qualitative synthesis. RESULTS We included 21 studies (n = 17 472 patients). Patients with diabetes mellitus had worse preoperative physical function (SMD, -0.16; 95% CI: -0.24, -0.08) and HRQoL (SMD, -0.16; 95% CI: -0.26, -0.05), worse early postoperative pain (SMD, -0.22; 95% CI: -0.39, -0.05) and strength (SMD, -0.45; 95% CI: -0.77, -0.14), and worse late postoperative physical function (SMD, -0.23; 95% CI: -0.40, -0.06), range of motion (SMD, -0.23; 95% CI: -0.46, 0.00), and HRQoL (SMD, -0.19; 95% CI: -0.29, -0.08) than patients without diabetes mellitus. The overall risk of bias across studies was high, and the certainty of evidence ranged from low to very low. CONCLUSION Patients with diabetes mellitus had worse patient-reported and clinician-assessed outcomes before and after a TKA. Given the limitations of included studies, these results may change with future research. J Orthop Sports Phys Ther 2021;51(6):269-280. Epub 19 Apr 2021. doi:10.2519/jospt.2021.9515.
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Schwartz AM, Wilson JM, Farley KX, Bradbury TL, Guild GN. Concomitant Malnutrition and Frailty Are Uncommon, but Significant Risk Factors for Mortality and Complication Following Primary Total Knee Arthroplasty. J Arthroplasty 2020; 35:2878-2885. [PMID: 32576431 DOI: 10.1016/j.arth.2020.05.062] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 05/12/2020] [Accepted: 05/25/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Total knee arthroplasty (TKA) demand continues to rise, but we are also gaining greater insight into patient risk factors for postoperative complications and excess resource utilization. There has been growing interest in frailty and malnutrition as risk factors, although they are often mistakenly used interchangeably. We aimed at identifying the incidence of their coexistence, and the magnitude of risk they confer to TKA patients. METHODS We queried the American College of Surgeons-National Surgery Quality Improvement Program database to identify 4 patient cohorts: healthy/normal serum albumin, healthy/hypoalbuminemic patients, normoalbuminemic/medically frail patients (defined by modified frailty index), and hypoalbuminemic/frail patients. We performed both univariate and multivariate analyses to quantify the risk conferred by each condition in isolation, and in coexistence. RESULTS Of 179,702 elective TKA cases from 2006 to 2018, 18.6% of patients were frail only, 3.0% were hypoalbuminemic -only, and just 1.2% were both frail and hypoalbuminemic. The raw rate of any complication was highest in frail/hypoalbuminemic patients (8.7%), 5.2% in hypoalbuminemic patients, 4.8% in frail patients, and just 3.4% in healthy patients (P < .001); the multivariate model revealed odds ratio of a complication in frail/hypoalbuminemic group of 2.40 (95% confidence interval = 1.27-1.63; P < .001). Mortality within 30 days was highest in the frail/hypoalbuminemic cohort (1.0%), and just 0.1% in healthy patients, and the multivariate model noted an odds ratio of 9.43 for these patients (95% confidence interval = 5.92-14.93; P < .001). The odds of all studied complications were highest in the frail/hypoalbuminemic group. CONCLUSION Frailty and hypoalbuminemia represent distinct conditions and are independent risk factors for a complication after TKA. Their coexistence imparts a synergistic association with the risk of post-TKA complications.
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Alkindy T. Dysglycemia and Arthroplasty Outcomes: A Review. Cureus 2020; 12:e10239. [PMID: 32923294 PMCID: PMC7478689 DOI: 10.7759/cureus.10239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Arthroplasty (ART) is a common surgery and it is on the rise worldwide due to increasing longevity and osteoarthritis. The effects of perioperative hyperglycemia on the outcomes are largely unknown and the current review aimed to assess the impact of perioperative hyperglycemia on ART outcomes. The literature in PubMed and Google Scholar was searched for relevant articles published in the last ten years up to February 2020. The keywords knee ART, hip ART, diabetes mellitus (DM) impaired fasting glucose (IFG), impaired glucose tolerance (IGT), and impaired glycated hemoglobin (HbA1c)were used. Among the 113 articles retrieved, 34 full-texts were eligible, and only 21 studies (17 from the USA, three from Europe, and two from Asia) met the inclusion criteria for the systematic review. The authors' names, year of publication, country, type of study, number of patients, and duration of the study were reported. The studies reviewed showed high ART complication rates including infections, loosening, increasing severity and depth of infection, more pain, and higher costs with high perioperative hyperglycemia. The cut-off glycated hemoglobin values associated with complications ranged from 6.7 to >8.
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Affiliation(s)
- Talal Alkindy
- Orthopaedics, University of Tabuk, College of Medicine, Tabuk, SAU
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Shang BJ, Yang SW, Lei PC, Ma RJ, He XD, Yuan XL, Jiang L, Li YL, Dong XY, Wang Z, Zhang L, Zhu ZM. [Clinical study on factor Ⅷ inhibitor in children with hemophilia A]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2020; 41:138-142. [PMID: 32135631 PMCID: PMC7357942 DOI: 10.3760/cma.j.issn.0253-2727.2020.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Indexed: 11/30/2022]
Abstract
Objective: To reveal the related factors of inhibitors and differences ofhemorrhage and joint disease before and after the production of inhibitors in children with hemophilia A (HA) . Methods: Retrospective analyses of the clinical data of 381 children with HA under the age of 16 registered in the Registration Management Center of Hemophilia in Henan Provincial from January 2015 to August 2018. Results: A total of the 381 children were enrolled with 116 (30.4%) mild, 196 (51.4%) moderate, and 69 (18.1%) severe cases; 54 patients (14.2%) had inhibitors, including 22 high and 32 low titer inhibitors. Positive family history was positively associated with inhibitors[P<0.001, OR=3.299 (95%CI 1.743-5.983) ], and high-intensity exposure was associated with inhibitors[P=0.002, OR=2.587 (95%CI 1.414-4.731) ]. High-intensity exposure was associated with high titer inhibitor production[P=0.001, OR=8.689 (95%CI 2.464-30.638) ], and high-intensity exposure increased the risk of high titer inhibitors in HA patients. After inhibitors occurred in 54 patients with HA, the rates of overall joint annual bleeding (z=-3.440, P=0.001) and traumatic annual bleeding (z=-2.232, P=0.026) increased, but the rates of the annual joint bleeding (z=-1.342, P=0.180) and spontaneous annual bleeding (z=-1.414, P=0.157) remained to be not statistically significant. The joint ultrasound score did not change significantly after the inhibitor information (z=-0.632, P=0.527) . Conclusions: Positive family history and high-intensity exposure could increase the risk of F Ⅷ inhibitors in HA patients, and high-intensity exposure increased the risk of high titer inhibitors. The rates of the overall joint annual bleeding and traumatic annual bleeding increased after the inhibitor information.
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Affiliation(s)
- B J Shang
- Institute of Hematology of Henan Provincial People's Hospital, 450003, China; Henan Key laboratory of Stem Cell Differentiation and Modification, Zhengzhou 450003, China
| | - S W Yang
- Institute of Hematology of Henan Provincial People's Hospital, 450003, China; Henan Key laboratory of Stem Cell Differentiation and Modification, Zhengzhou 450003, China; Department of Hematology, Henan Provincial People' s Hospital/People's Hospital of Zhengzhou University, Zhengzhou 450003, China
| | - P C Lei
- Department of Hematology, Henan Provincial People' s Hospital/People's Hospital of Zhengzhou University, Zhengzhou 450003, China; Henan Provincial Registration Management Center of Hemophilia, Zhengzhou 450003, China
| | - R J Ma
- Department of Hematology, Henan Provincial People' s Hospital/People's Hospital of Zhengzhou University, Zhengzhou 450003, China
| | - X D He
- Department of Hematology, Henan Provincial People' s Hospital/People's Hospital of Zhengzhou University, Zhengzhou 450003, China; Henan Provincial Registration Management Center of Hemophilia, Zhengzhou 450003, China
| | - X L Yuan
- Department of Hematology, Henan Provincial People' s Hospital/People's Hospital of Zhengzhou University, Zhengzhou 450003, China
| | - L Jiang
- Department of Hematology, Henan Provincial People' s Hospital/People's Hospital of Zhengzhou University, Zhengzhou 450003, China
| | - Y L Li
- Institute of Hematology of Henan Provincial People's Hospital, 450003, China; Henan Key laboratory of Stem Cell Differentiation and Modification, Zhengzhou 450003, China
| | - X Y Dong
- Institute of Hematology of Henan Provincial People's Hospital, 450003, China; Henan Key laboratory of Stem Cell Differentiation and Modification, Zhengzhou 450003, China
| | - Z Wang
- Department of Hematology, Henan Provincial People' s Hospital/People's Hospital of Zhengzhou University, Zhengzhou 450003, China
| | - L Zhang
- Institute of Hematology of Henan Provincial People's Hospital, 450003, China; Henan Key laboratory of Stem Cell Differentiation and Modification, Zhengzhou 450003, China
| | - Z M Zhu
- Institute of Hematology of Henan Provincial People's Hospital, 450003, China; Henan Key laboratory of Stem Cell Differentiation and Modification, Zhengzhou 450003, China
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Dhir S, Dhir A. Cardiovascular Risk Assessment for Noncardiac Surgery: Are We Ready for Biomarkers? J Cardiothorac Vasc Anesth 2019; 34:1914-1924. [PMID: 31866221 DOI: 10.1053/j.jvca.2019.10.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Revised: 09/07/2019] [Accepted: 10/04/2019] [Indexed: 02/07/2023]
Abstract
Biomarkers aided perioperative cardiac assessment is a relatively new concept. Cardiac biomarkers with historical significance (aspartate transaminase, dehydrogenase, creatinine kinase and myoglobin) have paved the way for traditional biomarkers (cardiac troponin, C-reactive protein, lipoprotein). Contemporary biomarkers like natriuretic peptides (BNP and ProBNP) are validated risk markers in both acute and chronic cardiac diseases and are showing remarkable promise in predicting serious cardiovascular complications after non-cardiac surgery. This review is intended to provide a critical overview of traditional and contemporary biomarkers for perioperative cardiovascular assessment and management. This review also discusses the potential utility of newer biomarkers like galectin-3, sST-2, GDF-15, TNF-alpha, MiRNAs and many others that can predict inflammation, cardiac remodeling, injury and endogenous stress and need further investigations to establish their clinical utility. Though promising, biomarker led perioperative care is still in infancy and it has not been determined that it can improve clinical outcomes.
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Affiliation(s)
- Shalini Dhir
- Department of Anesthesia and Perioperative Medicine, Western University, London, Ontario, Canada.
| | - Achal Dhir
- Department of Anesthesia and Perioperative Medicine, Western University, London, Ontario, Canada
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Shohat N, Tarabichi M, Tan TL, Goswami K, Kheir M, Malkani AL, Shah RP, Schwarzkopf R, Parvizi J. 2019 John Insall Award: Fructosamine is a better glycaemic marker compared with glycated haemoglobin (HbA1C) in predicting adverse outcomes following total knee arthroplasty: a prospective multicentre study. Bone Joint J 2019; 101-B:3-9. [PMID: 31256656 DOI: 10.1302/0301-620x.101b7.bjj-2018-1418.r1] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
AIMS The best marker for assessing glycaemic control prior to total knee arthroplasty (TKA) remains unknown. The purpose of this study was to assess the utility of fructosamine compared with glycated haemoglobin (HbA1c) in predicting early complications following TKA, and to determine the threshold above which the risk of complications increased markedly. PATIENTS AND METHODS This prospective multi-institutional study evaluated primary TKA patients from four academic institutions. Patients (both diabetics and non-diabetics) were assessed using fructosamine and HbA1c levels within 30 days of surgery. Complications were assessed for 12 weeks from surgery and included prosthetic joint infection (PJI), wound complication, re-admission, re-operation, and death. The Youden's index was used to determine the cut-off for fructosamine and HbA1c associated with complications. Two additional cut-offs for HbA1c were examined: 7% and 7.5% and compared with fructosamine as a predictor for complications. RESULTS Overall, 1119 patients (441 men, 678 women) were included in the study. Fructosamine level of 293 µmol/l was identified as the optimal cut-off associated with complications. Patients with high fructosamine (> 293 µmol/l) were 11.2 times more likely to develop PJI compared with patients with low fructosamine (p = 0.001). Re-admission and re-operation rates were 4.2 and 4.5 times higher in patients with fructosamine above the threshold (p = 0.005 and p = 0.019, respectively). One patient (1.7%) from the elevated fructosamine group died compared with one patient (0.1%) in the normal fructosamine group (p = 0.10). These complications remained statistically significant in multiple regression analysis. Unlike fructosamine, all three cut-offs for HbA1c failed to show a significant association with complications. CONCLUSION Fructosamine is a valid and an excellent predictor of complications following TKA. It better reflects the glycaemic control, has greater predictive power for adverse events, and responds quicker to treatment compared with HbA1c. These findings support the screening of all patients undergoing TKA using fructosamine and in those with a level above 293 µmol/l, the risk of surgery should be carefully weighed against its benefit. Cite this article: Bone Joint J 2019;101-B(7 Supple C):3-9.
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Affiliation(s)
- N Shohat
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - M Tarabichi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - T L Tan
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - K Goswami
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - M Kheir
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - A L Malkani
- University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - R P Shah
- Columbia University Medical Center, New York, New York, USA
| | - Ran Schwarzkopf
- NYU Langone MC Hospital for Joint Diseases, New York, New York, USA
| | - J Parvizi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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Yan Z, Zhu S, Tian X, Ye Z, Zhai D, Zhu Z, Wei D, Zhu Q, Lu Z, Cao X. Metformin protects bone mass in ultra-high-molecular-weight polyethylene particle-induced osteolysis by regulating osteocyte secretion. J Bone Miner Metab 2019; 37:399-410. [PMID: 30032440 DOI: 10.1007/s00774-018-0939-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Accepted: 06/17/2018] [Indexed: 12/28/2022]
Abstract
Metformin, an anti-hyperglycemic agent used for type 2 diabetes, has recently been found to have more effects apart from glucose regulation. We found that, in ultra-high-molecular-weight polyethylene particle-induced osteolysis mouse models, metformin had bone protect property and reduced the negative regulator of bone formation sclerostin (SOST) and Dickkopf-related protein 1 (DKK1), and increased osteoprotegerin (OPG) secretion and the ratio of OPG/Receptor Activator for Nuclear Factor-κB Ligand (RANKL). In vitro, we established a 3D co-culture system in which metformin affects osteoblasts and osteoclasts through mature osteocytes secretion. Metformin (50 μM) significantly decreased SOST and DKK1 mRNA expression, stimulating alkaline phosphatase activity and proliferation of osteoblast, and increased OPG secretion and the ratio of OPG/RANKL, inhibiting osteoclastogenesis. Moreover, the effect on OPG was reversed by adenosine 5'-monophosphate-activated protein kinase inhibitor, Compound C. Our finding suggests that metformin induces differentiation and mineralization of osteoblasts, while inhibits osteoclastogenesis via mature osteocytes secretion. Therefore, the drug might be beneficial for not only diabetes but also in other bone disorders by acting on mature osteocytes.
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Affiliation(s)
- Zhao Yan
- Department of Orthopaedics, Xijing Hospital, Fourth Military Medical University, Xi'an, 710032, People's Republic of China
| | - Shu Zhu
- Department of Orthopaedics, Xijing Hospital, Fourth Military Medical University, Xi'an, 710032, People's Republic of China
| | - Xiaoxi Tian
- Emergency Department of Tangdu Hospital, Fourth Military Medical University, Xi'an, 710032, People's Republic of China
| | - Zichen Ye
- State Key Laboratory of Cancer Biology, Department of Pharmacogenomics, Fourth Military Medical University, Xi'an, 710032, People's Republic of China
| | - Dongsheng Zhai
- State Key Laboratory of Cancer Biology, Department of Pharmacogenomics, Fourth Military Medical University, Xi'an, 710032, People's Republic of China
| | - Zheng Zhu
- Department of Urinary Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, 710032, People's Republic of China
| | - Di Wei
- Department of Urinary Surgery, Xijing Hospital, Fourth Military Medical University, Xi'an, 710032, People's Republic of China
| | - Qingsheng Zhu
- Department of Orthopaedics, Xijing Hospital, Fourth Military Medical University, Xi'an, 710032, People's Republic of China
| | - Zifan Lu
- State Key Laboratory of Cancer Biology, Department of Pharmacogenomics, Fourth Military Medical University, Xi'an, 710032, People's Republic of China.
| | - Xiaorui Cao
- Department of Orthopaedics, Xijing Hospital, Fourth Military Medical University, Xi'an, 710032, People's Republic of China.
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Shohat N, Muhsen K, Gilat R, Rondon AJ, Chen AF, Parvizi J. Inadequate Glycemic Control Is Associated With Increased Surgical Site Infection in Total Joint Arthroplasty: A Systematic Review and Meta-Analysis. J Arthroplasty 2018; 33:2312-2321.e3. [PMID: 29605149 DOI: 10.1016/j.arth.2018.02.020] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 02/05/2018] [Accepted: 02/07/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The association between inadequate glycemic control and surgical site infection (SSI) following total joint arthroplasty (TJA) remains unclear. The aim of this study is to assess the relationship between perioperative glycemic control and the risk for SSI, mainly periprosthetic joint infection. METHODS We searched OVID-MEDLINE, Embase, and Web of Science from inception up to June 2017. The main independent variable was glycemic control as defined by glycated hemoglobin (HbA1C) or perioperative glucose values. The main outcome was SSI. Publication year, location, study design, sample population (size, age, gender), procedure, glycemic control assessment, infection outcome, results, confounders, and limitations were assessed. Studies included in the meta-analysis had stratified glycemic control using a distinct HbA1C cut-off. RESULTS Seventeen studies were included in this study. Meta-analysis of 10 studies suggested that elevated HbA1C levels were associated with a higher risk of SSI after TJA (pooled odds ratio 1.49, 95% confidence interval 0.94-2.37, P = .09) with significant heterogeneity between studies (I2 = 81.32%, P < .0001). In a subgroup analysis of studies considering HbA1C with a cut-off of 7% as uncontrolled, this association was no longer noticed (P = .50). All 5 studies that specifically assessed for SSI and perioperative hyperglycemia showed a significant association, which was usually attenuated after adjusting for covariates. CONCLUSION Inadequate glycemic control was associated with increased risk for SSI after TJA. However, the optimal HbA1C threshold remains contentious. Pooled data does not support the conventional 7% cut-off for risk stratification. Future studies should examine new markers for determining adequate glycemic control.
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Affiliation(s)
- Noam Shohat
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, PA
| | - Khitam Muhsen
- Department of Epidemiology and Preventive Medicine, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ron Gilat
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Alexander J Rondon
- Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, PA
| | - Antonia F Chen
- Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, PA
| | - Javad Parvizi
- Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, PA
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Kurowicki J, Rosas S, Khlopas A, Newman JM, Law TY, Roche MW, Higuera CA, Mont MA. Impact of Perioperative HbA1c on Reimbursements in Diabetes Mellitus Patients Undergoing Total Hip Arthroplasty: A Nationwide Analysis. J Arthroplasty 2018; 33:2038-2042. [PMID: 29891083 PMCID: PMC6383765 DOI: 10.1016/j.arth.2018.01.062] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2017] [Revised: 01/22/2018] [Accepted: 01/29/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Patients who have diabetes mellitus (DM) are at an increased risk of postoperative complications following total hip arthroplasty (THA). Therefore, much interest has been paid to perioperative glycemic control. However, no prior studies have evaluated the patient variation of HbA1c levels on costs. Therefore, the purpose of this study was to evaluate the impact of obtaining preoperative HbA1c levels on (1) day of surgery (DOS) cost; (2) subsequent 89-day costs; and (3) global 90-day cost. METHODS A retrospective query of the Humana insurance claims database was performed from 2007 to 2015 for all DM patients undergoing THA. Only patients with HbA1c (%) levels within 3 months before or after the THA were included. Patients were stratified into 6 groups based on HbA1c starting at 5.5% and increasing by 1% increments to 11.5%; one additional group (11.5%-20%) for extreme cases was analyzed. Correlations between HbA1c level and reimbursements for DOS, subsequent 89-day, and global 90-day period were performed. RESULTS HbA1c level demonstrated a significant correlation to DOS (correlation coefficient = 0.664), subsequent 89-day (correlation coefficient = 0.789), and global 90-day period (correlation coefficient = 0.747) costs. DOS, 89-day, and global 90-day costs significantly increased with increasing HbA1c levels (P < .0001). CONCLUSION Higher perioperative HbA1c levels increase the DOS, subsequent 89-day, and global 90-day costs of THA. This was expected as these patients require multidisciplinary care, have longer LOS, and develop more complications. Further investigation into postoperative complications based on glycemic control is warranted.
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Affiliation(s)
- Jennifer Kurowicki
- Department of Orthopaedic Surgery, School of Health and Medical Sciences, Seton Hall University, South Orange, NJ,Department of Orthopaedic Surgery, Holy Cross Orthopedic Institute, Fort Lauderdale, FL
| | - Samuel Rosas
- Department of Orthopaedic Surgery, Holy Cross Orthopedic Institute, Fort Lauderdale, FL,Department of Orthopaedic Surgery, Wake Forest School of Medicine, Winston-Salem, NC
| | - Anton Khlopas
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Jared M. Newman
- Department of Orthopaedic Surgery, SUNY Downstate Medical Center, Brooklyn, NY
| | - Tsun yee Law
- Department of Orthopaedic Surgery, Holy Cross Orthopedic Institute, Fort Lauderdale, FL
| | - Martin W. Roche
- Department of Orthopaedic Surgery, Holy Cross Orthopedic Institute, Fort Lauderdale, FL
| | | | - Michael A. Mont
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH,Reprint requests: Michael A. Mont, MD, Department of Orthopaedic Surgery, Cleveland Clinic, 9500 Euclid Avenue/A40, Cleveland, OH 44195
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Rudy MD, Ahuja NK, Aaronson AJ. Diabetes and Hyperglycemia in Lower-Extremity Total Joint Arthroplasty. JBJS Rev 2018; 6:e10. [DOI: 10.2106/jbjs.rvw.17.00146] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Abstract
Purpose of Review The central question of preoperative assessment is not “What can be done?” but “What should be done and how?” Predicting a patient’s risk of unwanted outcomes is vital to answering this question. This review discusses risk prediction tools currently available and anticipates future developments. Recent Findings Simple, parsimonious risk scales and scores are being replaced by complex risk prediction models as high-capacity information systems become ubiquitous. The accuracy of risk estimation will be further increased by improved assessment of physical fitness, frailty, and incorporation of existing and novel biomarkers. However, the limitations of risk prediction for individual patient care must be recognized. Summary Risk prediction is transforming from clinical estimation to statistical science. Predictions should be used within the context of a patient’s baseline risk (life expectancy independent of surgery), personal circumstances, quality of life, their expectations and values, and consideration of outcomes that are meaningful for the patient.
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Affiliation(s)
- Pragya Ajitsaria
- 1Department of Anaesthesia & Perioperative Medicine, John Hunter Hospital, Locked Bag 1 HRMC, Newcastle, NSW 2310 Australia.,2University of Newcastle, Newcastle, NSW Australia
| | - Sabry Z Eissa
- 1Department of Anaesthesia & Perioperative Medicine, John Hunter Hospital, Locked Bag 1 HRMC, Newcastle, NSW 2310 Australia.,2University of Newcastle, Newcastle, NSW Australia
| | - Ross K Kerridge
- 1Department of Anaesthesia & Perioperative Medicine, John Hunter Hospital, Locked Bag 1 HRMC, Newcastle, NSW 2310 Australia.,2University of Newcastle, Newcastle, NSW Australia
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Shohat N, Tarabichi M, Tischler EH, Jabbour S, Parvizi J. Serum Fructosamine: A Simple and Inexpensive Test for Assessing Preoperative Glycemic Control. J Bone Joint Surg Am 2017; 99:1900-1907. [PMID: 29135663 DOI: 10.2106/jbjs.17.00075] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Although the medical community acknowledges the importance of preoperative glycemic control, the literature is inconclusive and the proper metric for assessment of glycemic control remains unclear. Serum fructosamine reflects the mean glycemic control in a shorter time period compared with glycated hemoglobin (HbA1c). Our aim was to examine its role in predicting adverse outcomes following total joint arthroplasty. METHODS Between 2012 and 2013, we screened all patients undergoing total joint arthroplasty preoperatively using serum HbA1c, fructosamine, and blood glucose levels. On the basis of the recommendations of the American Diabetes Association, 7% was chosen as the cutoff for HbA1c being indicative of poor glycemic control. This threshold correlated with a fructosamine level of 292 μmol/L. All patients were followed and total joint arthroplasty complications were evaluated. We were particularly interested in retrieving details on surgical-site infection (superficial and deep). Patients with fructosamine levels of ≥292 μmol/L were compared with those with fructosamine levels of <292 μmol/L. Complications were evaluated in a univariate analysis followed by a stepwise logistic regression analysis. RESULTS A total of 829 patients undergoing primary total joint arthroplasty were included in the present study. There were 119 patients (14.4%) with a history of diabetes and 308 patients (37.2%) with HbA1c levels in the prediabetic range. Overall, 51 patients had fructosamine levels of ≥292 μmol/L. Twenty patients (39.2%) had a fructosamine level of ≥292 μmol/L but did not have an HbA1c level of ≥7%. Patients with fructosamine levels of ≥292 μmol/L had a significantly higher risk for deep infection (adjusted odds ratio [OR], 6.2 [95% confidence interval (CI), 1.6 to 24.0]; p = 0.009), readmission (adjusted OR, 3.0 [95% CI, 1.1 to 8.1]; p = 0.03), and reoperation (adjusted OR, 3.4 [95% CI, 1.2 to 9.2]; p = 0.02). In the current study with the given sample size, HbA1c levels of ≥7% failed to show any significant correlation with deep infection (p = 0.14), readmission (p = 1.0), or reoperation (p = 0.7). CONCLUSIONS Serum fructosamine is a simple and inexpensive test that appears to be a good predictor of adverse outcome in patients with known diabetes and those with unrecognized diabetes or hyperglycemia. Our findings suggest that fructosamine can serve as an alternative to HbA1c in the setting of preoperative glycemic assessment. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Noam Shohat
- 1The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania 2Tel Aviv University, Tel Aviv, Israel 3Department of Endocrinology, Thomas Jefferson University, Philadelphia, Pennsylvania
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Determining the Threshold for HbA1c as a Predictor for Adverse Outcomes After Total Joint Arthroplasty: A Multicenter, Retrospective Study. J Arthroplasty 2017; 32:S263-S267.e1. [PMID: 28662955 DOI: 10.1016/j.arth.2017.04.065] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 04/26/2017] [Accepted: 04/30/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Although HbA1c is commonly used for assessing glycemic control before surgery, there is no consensus regarding its role and the appropriate threshold in predicting adverse outcomes. This study was designed to evaluate the potential link between HbA1c and subsequent periprosthetic joint infection (PJI), with the intention of determining the optimal threshold for HbA1c. METHODS This is a multicenter retrospective study, which identified 1645 diabetic patients who underwent primary total joint arthroplasty (1004 knees and 641 hips) between 2001 and 2015. All patients had an HbA1c measured within 3 months of surgery. The primary outcome of interest was a PJI at 1 year based on the Musculoskeletal Infection Society criteria. Secondary outcomes included orthopedic (wound and mechanical complications) and nonorthopedic complications (sepsis, thromboembolism, genitourinary, and cardiovascular complications). A regression analysis was performed to determine the independent influence of HbA1c for predicting PJI. RESULTS Overall 22 cases of PJI occurred at 1 year (1.3%). HbA1c at a threshold of 7.7 was distinct for predicting PJI (area under the curve, 0.65; 95% confidence interval, 0.51-0.78). Using this threshold, PJI rates increased from 0.8% (11 of 1441) to 5.4% (11 of 204). In the stepwise logistic regression analysis, PJI remained the only variable associated with higher HbA1c (odds ratio, 1.5; confidence interval, 1.2-2.0; P = .0001). There was no association between high HbA1c levels and other complications assessed. CONCLUSION High HbA1c levels are associated with an increased risk for PJI. A threshold of 7.7% seems to be more indicative of infection than the commonly used 7% and should perhaps be the goal in preoperative patient optimization.
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