All Patients Should Be Screened for Diabetes Before Total Joint Arthroplasty

Early Versus Late Periprosthetic Joint Infection After Total Knee Arthroplasty: Do Patient Differences Exist?

BACKGROUND

Periprosthetic joint infection (PJI) is a devastating complication following total knee arthroplasty (TKA). Little evidence exists comparing those with early versus late PJI. The purpose of the study was to determine comorbidity profile differences between patients developing early and late PJI.

METHODS

There were 72,659 patients undergoing primary TKA from 2009 to 2021, who were identified from a commercial claims and encounters database. Subjects diagnosed with PJI were categorized as either 'early' (within 90 days of index procedure) or 'late' (> 2 years after index arthroplasty). Non-infected patients within these periods served as control groups following 4:1 propensity score matching on other extraneous variables. Logistic regression analyses were performed comparing comorbidities between groups.

RESULTS

Patients were significantly younger in the late compared to the early infection group (58.1 versus 62.4 years, P < .001). When compared to those with early PJI, patients who had chronic kidney disease (13.3 versus 4.1%; OR [odds ratio] 5.17, P = .002), malignancy (20.4 versus 10.5%; OR 2.53, P = .009), uncomplicated diabetes (40.8 versus 30.6%; OR 2.00, P = .01), rheumatoid arthritis (9.2 versus 3.3%; OR 2.66, P = .046), and hypertension (88.8 versus 81.6%; OR 2.17, P = .04), were all significant predictors of developing a late PJI.

CONCLUSIONS

When compared to patients diagnosed with early PJI following primary TKA, the presence of chronic kidney disease, malignancy, uncomplicated diabetes, rheumatoid arthritis, and hypertension, were independent risk factors for the development of late PJI. Younger patients who have these comorbidities may be targets for preoperative optimization interventions that minimize the risk of PJI.

Preventive strategies to reduce the rate of periprosthetic infections in total joint arthroplasty; a comprehensive review

The increasing frequency of total hip (THA) and knee arthroplasties (TKA) is marred by the rise in periprosthetic joint infections (PJIs) and surgical site infections (SSIs), with PJIs incurring costs over $1.62 billion as of 2020 and individual case management averaging $90,000. SSIs additionally burden the U.S. healthcare economy with billions in expenses annually. PJI prevalence in primary THA and TKA ranges from 0.5% to 2.4%, spiking to 20% in revisions and representing 25% of TKA revision causes. Projections estimate up to 270,000 annual PJI cases by 2030. Often caused by gram-positive bacteria, particularly methicillin-resistant staphylococci, these infections demand preventive measures. This review dissects PJI prevention across preoperative, intraoperative, and perioperative phases, aligning with evidence-based CDC and WHO guidelines. Preoperative measures include managing diabetes, obesity, tobacco use, Staphylococcus aureus screening and nasal decolonization, nutritional optimization, and management of inflammatory arthropathies. Intraoperatively, antibiotic prophylaxis, skin preparation, operative room environmental controls, surgical technique precision, and irrigation options are scrutinized. Perioperative concerns focus on anticoagulation, blood management, and infection risk mitigation. Integrating these strategies promotes a patient-centric care model, aiming to reduce PJI incidence, improve patient outcomes, and increase care cost-effectiveness in joint arthroplasty.

The Creation of Data-Driven Preoperative Hemoglobin A1c and Same-Day Glucose Strata to Stratify Complication Risk Following Total Hip Arthroplasty

BACKGROUND

This study identifies data-driven strata for preoperative Hemoglobin A1c (HbA1c) and same-day glucose levels that maximize differences in the likelihood of complications following total hip arthroplasty (THA).

METHODS

Patients who underwent THA from 2013 to 2022 were identified using a national database. In total, 18,728 patients were identified with a mean age of 67 years (range, 18 to 80). Stratum specific likelihood ratio (SSLR) analysis determined separate strata for HbA1c and same-day glucose levels that minimized the likelihood of 90-day complications following THA. Each stratum was propensity-score matched based on age, sex, hypertension, heart failure, chronic obstructive pulmonary disease, and obesity to the lowest respective stratum. The risk ratio (RR) with respect to the lowest matched stratum was observed.

RESULTS

Our SSLR analysis identified 3 data-driven HbA1c strata (4.5 to 5.9, 6.0 to 6.9, and 7.0+) and two same-day glucose strata (60 to 189 and 190+) that predicted 90-day major complications. For HbA1c, when compared to the lowest strata (4.5 to 5.9), the risk of 90-day major complications sequentially increased as the HbA1c strata increased: 6.0 to 6.9 (RR: 1.21; P = .041), 7+ (RR: 1.82; P < .001). For same-day glucose, when compared to the matched lowest strata (60 to 189), the risk of 90-day major complications was higher for the 190+ strata (RR: 1.5; P < .001).

CONCLUSIONS

Our results support the use of multiple HbA1c strata that can be incorporated into preoperative risk-stratification models. Additionally, we identified a single cut-off level of 190 as a maximum target blood glucose level perioperatively.

Risk factors for surgical site infection after percutaneous endoscopic lumbar discectomy

The objective of this study was to investigate the risk factors associated with surgical site infection (SSI) after percutaneous endoscopic lumbar discectomy (PELD) in patients with lumbar disc herniation (LDH). A retrospective analysis was performed on a cohort of 335 patients who underwent PELD between January 2016 and January 2023. Data were derived from the Hospital Information System (HIS), and a comprehensive statistical assessment was performed using IBM SPSS Statistics version 25.0. Both univariate and multivariate logistic regression analyses assessed a range of risk determinants, such as age, body mass index (BMI), comorbidities, laboratory test parameters and surgery-related variables. The incidence of SSI after PELD was 2.7% (9/335). Univariate analysis highlighted BMI, diabetes mellitus, long-term corticosteroid consumption, surgical time and cerebrospinal fluid leakage as significant predictors of SSI. Multivariate logistic regression identified BMI, diabetes mellitus, long-term corticosteroid consumption, surgical time and cerebrospinal fluid leakage as significant risk factors for SSI after PELD. High BMI, diabetes mellitus, long-term corticosteroid consumption, long surgical time and postoperative cerebrospinal fluid leakage are predisposing factors for SSI in patients undergoing PELD. Precise interventions focused on such risk components, including careful preoperative assessment and strategic postoperative care, are essential to reduce the incidence of SSI and improve surgical efficacy.

Evaluation of risk factors for surgical site infections in osteoarthritis patients undergoing total knee arthroplasty

This research sought to delineate risk factors associated with surgical site infections (SSIs) post-total knee arthroplasty (post-TKA) in elderly osteoarthritis patients, aiming to enhance post-surgical outcomes. A retrospective examination was conducted on a cohort of 650 elderly patients who underwent unilateral TKA between January 2018 and August 2022. Data procurement was from the hospital's Electronic Health Record, and a comprehensive statistical evaluation was performed using IBM SPSS Statistics version 24.0. Both univariate and multivariate techniques assessed a spectrum of risk determinants such as age, body mass index (BMI), coexisting medical conditions and surgical variables. The univariate examination spotlighted age, BMI, diabetes prevalence, chronic corticosteroid consumption and American Society of Anesthesiologists (ASA) physical status classification as notable predictors of SSIs. The multivariate logistic regression pinpointed age, BMI, history of smoking and diabetes diagnosis as salient risk attributors for post-TKA infections. Concurrently, parameters like ASA classification, surgical duration and intraoperative haemorrhage further enriched the risk landscape. Geriatric patients undergoing TKA for knee osteoarthritis manifest a tangible infection susceptibility post-surgery. Precision interventions concentrating on amendable risk components, including meticulous preoperative evaluations and strategic postoperative care, are imperative to attenuate SSI incidence, thereby amplifying surgical efficacy and optimizing patient recuperation trajectories.

Higher Blood Glucose Levels on the Day of Surgery Are Associated with an Increased Risk of Periprosthetic Joint Infection After Total Hip Arthroplasty

BACKGROUND

Hyperglycemia has been identified as a risk factor for periprosthetic joint infection (PJI) after total hip arthroplasty (THA). However, there is no consensus with regard to the preoperative blood glucose level (BGL) on the day of the surgical procedure associated with increased risk. We sought to identify preoperative BGL thresholds associated with an increased risk of PJI.

METHODS

The Premier Healthcare Database was retrospectively queried for adult patients who underwent primary, elective THA and had a measurement of the preoperative BGL recorded on the day of the surgical procedure (preoperative BGL) from January 1, 2016, to December 31, 2021. The association between preoperative BGL and 90-day PJI risk was modeled using multivariable logistic regression with restricted cubic splines. Patients with and without diabetes with a preoperative BGL associated with 1.5 times greater odds of PJI (high preoperative BGL) were then compared with patients with a normal preoperative BGL.

RESULTS

In this study, 90,830 patients who underwent THA and had a recorded preoperative BGL were identified. The preoperative BGL associated with 1.5 times greater odds of PJI was found to be 277 mg/dL in patients with diabetes and 193 mg/dL in patients without diabetes. Compared with the normal preoperative BGL cohort, those with high preoperative BGL had increased odds of PJI (adjusted odds ratio [OR], 2.60 [95% confidence interval (CI), 1.45 to 4.67] for patients with diabetes and 1.66 [95% CI, 1.10 to 2.51] for patients without diabetes) and 90-day readmissions (adjusted OR, 1.92 [95% CI, 1.45 to 2.53] for patients with diabetes and 1.66 [95% CI, 1.37 to 2.00] for patients without diabetes).

CONCLUSIONS

Increased preoperative BGL was found to be associated with an increased risk of PJI following primary THA. Surgeons should be aware of patients with diabetes and a preoperative BGL of >277 mg/dL and patients without diabetes but with a preoperative BGL of >193 mg/dL.

LEVEL OF EVIDENCE

Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Decreased Risk of Periprosthetic Joint Infection with Concurrent Hardware Removal During Conversion Total Hip Arthroplasty Compared to Staged Removal: A Matched Cohort Analysis

INTRODUCTION

Hardware removal before conversion total hip arthroplasty (cTHA) is a challenging task for the orthopaedic surgeon, although there is little consensus on the timing of hardware removal to mitigate risk of surgery-related complication following cTHA.

METHODS

Using a national insurance database, we evaluated patients who underwent hardware removal either on the same day or within 1 year before cTHA, resulting in a total of 7,756 patients. After matching based on demographic factors and comorbidities, both staged and concurrent groups consisted of 2,752 patients. The 90-day and 1-year risk of revision surgery, periprosthetic joint infection (PJI), periprosthetic fracture, and aseptic loosening were calculated and compared. Demographic factors and comorbidities were further evaluated as risk factors for PJI.

RESULTS

The rates of infection were 1.85% and 3.05% at 90 days postoperatively and 2.94% and 4.14% at 1 year postoperatively for concurrent versus staged cohorts, respectively (P = 0.004 and P = 0.02). No difference was observed at 90 days or 1 year between the two cohorts in risk of fracture, revision surgery, or aseptic loosening. Diabetes (P = 0.002 and P < 0.001), tobacco use (P < 0.001 and P < 0.001), and obesity (P = 0.026 and P = 0.025) were identified as risk factors for PJI at both 90 days and 1 year postoperatively.

DISCUSSION

The timing of hardware removal is associated with an increased risk of PJI, although no difference was observed in revision surgery, fracture, or loosening among staged versus concurrent cohorts. These findings are important to consider when surgeons are evaluating patients with periarticular implants surrounding their hip.

Differences Between Patients With Diabetes Mellitus and Obese Patients in Occurrence of Peri-Prosthetic Joint Infection: A Systemic Review and Meta-Analysis

Background: To understand the differences between patients with diabetes mellitus and obese patients with respect to the occurrence of peri-prosthetic joint infection (PJI) after lower-extremity joint arthroplasty as well as to identify differences in PJI occurrence at different time periods. Patients and Methods: The Cochrane Library, CINAHL, MEDLINE, and PubMed were searched for literature published between January 2000 and July 2022. Our targets were studies involving patients with PJI who had already been diagnosed as having diabetes mellitus or being obese before receiving lower-extremity joint arthroplasty. Analysis was performed using Comprehensive Meta-Analysis Software (CMA) Version 3 (Biostat, Inc., Englewood, NJ, USA). Results: A total of 53,522 patients with diabetes mellitus and 360,018 obese patients were included. The forest plot for patients with and without diabetes mellitus indicated that patients with diabetes mellitus were more likely to contract PJIs than were patients without diabetes mellitus (odds ratio, 1.84; 95% confidence interval [CI], 1.56-2.16) and that no differences existed among early, delayed, and late PJI occurrence in patients with diabetes mellitus. The forest plot for obese and non-obese patients indicated that obese patients were more likely to contract PJIs than were non-obese patients (odds ratio, 1.86; 95% CI, 1.53-2.14) and that among obese patients, early PJI occurrence was higher than was late PJI occurrence. In addition, the mixed model indicated that obese patients were more likely to develop early PJIs than were patients with diabetes mellitus. Conclusions: Patients with diabetes mellitus and obese patients were more likely to develop PJIs than were patients without diabetes mellitus and non-obese patients, and that obese patients were more likely to develop early PJIs than late PJIs. Also, obese patients were more likely to develop early PJIs than patients with diabetes mellitus.

Preventing the Impact of Hyperglycemia and Diabetes on Patients Undergoing Total Joint Arthroplasty

Primary and revision total joint arthroplasty (TJA) procedures have become increasingly popular worldwide. At the same time, a growing number of patients undergoing TJA are either known diabetics or exhibit evidence of hyperglycemia preoperatively. Based on extensive data, it is well-established that poor glycemic control in TJA patients is an independent risk factor for several complications, including periprosthetic joint infection and death. This article will serve as an overview of currently available evidence on how to prevent the impact of hyperglycemia and diabetes mellitus on patients undergoing TJA.

Prevention of surgical site infection: a ten-step approach

Surgical site infection (SSI) is a common cause of morbidity and mortality in patients undergoing surgery. Similarly, periprosthetic joint infection (PJI), is a major cause of failure after total joint arthroplasty (TJA). As the annual volume of TJA procedures is projected to rise, so will the rate of subsequent SSI and PJI. Currently, prevention has been identified as the single most important strategy for combating SSI/PJI. Hence, the present article will serve as a summary of an evidence-based ten-step approach for SSI/PJI prevention that may help orthopedic surgeons with their infection prevention strategies.

2022 American Association of Hip and Knee Surgeons Symposium: Periprosthetic Joint Infection

Periprosthetic joint infection (PJI) is the leading cause of failure in patients undergoing total joint arthroplasty. This article is a brief summary of a symposium on PJI that was presented at the annual AAHKS meeting. It will provide an overview of current technqiues in the prevention, diagnosis, and management of PJI. It will also highlight emerging technologies in this setting.

Preoperatively elevated HbA1c levels can meaningfully improve following total joint arthroplasty

BACKGROUND

Prior literature has demonstrated that diabetic (DM) patients undergoing total joint arthroplasty (TJA) with elevated preoperative HbA1c scores have poorer clinical outcomes. However, no literature has reported the effect of undergoing TJA on laboratory markers of glycemic control. This study sought to evaluate effect of undergoing TJA on postoperative glycemic control and outcomes.

METHODS

This retrospective study reviewed all patients with DM who underwent primary, elective TJA at our high volume orthopedic institution. Included patients had at least one HbA1c value 3 months to 2 weeks pre-surgery and 3-6 months after surgery. Changes in HbA1c from before to after surgery were calculated. Change in HbA1c greater than 1.0% was considered clinically meaningful. Change in HbA1c was analyzed and stratified into subgroups.

RESULTS

In total, 770 primary TJA patients were included. Patients with preoperative HbA1c > 7% vs. ≤ 7% were significantly more likely to have clinically meaningful post-TJA decrease in HbA1c (24.5 vs. 2.9%, p < 0.001). Patients with preoperative HbA1c > 8 were significantly more likely to have decrease of > 2.0 compared to those with HbA1c < 8 (p < 0.001). Multivariate regression revealed that preop HbA1c > 7.0, former and current smokers, males, and African-Americans were significantly more likely to achieve clinically meaningful decrease in HbA1c. Additionally, postoperative increase in HbA1c > 1% was associated with significantly higher 90-day ED visits.

DISCUSSION

Patients with higher preoperative HbA1c were more likely to have clinically meaningful decreases in HbA1c postoperatively. A combination of preoperative medical optimization and improvements in mobility after TJA may play a role in these changes. Those with elevated HbA1c can have meaningful improvement in HbA1c after TJA.

Perioperative Identification and Management of Hyperglycemia in Orthopaedic Surgery

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The consequences of undermanaged perioperative hyperglycemia are notable and can have a serious impact on adverse postoperative outcomes, especially surgical site infections and periprosthetic joint infections (PJIs).

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Preoperative screening of hemoglobin A1c with a goal threshold of <7.45% is ideal.

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There are a variety of risk factors that contribute to hyperglycemia that should be considered in the perioperative period, including glucocorticoid use, nutritional factors, patient-specific factors, anesthesia, and surgery.

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There are expected trends in the rise, peak, and fall of postoperative blood glucose levels, and identifying and treating hyperglycemia as swiftly as possible are the fundamental aims of treatment and improved glucose control. Performing frequent postoperative blood glucose monitoring (in the post-anesthesia care unit, on the day of surgery at 1700 and 2100 hours, and in the morning of postoperative day 1) should be considered to allow for the early detection of alterations in glucose metabolism. In addition, instituting a postoperative dietary restriction of carbohydrates should be considered.

➤

The use of insulin as a hypoglycemic agent in orthopaedic patients is relatively safe and is an effective means of controlling fluctuating blood glucose levels. Insulin therapy should be administered to treat hyperglycemia at ≥140 mg/dL when fasting and ≥180 mg/dL postprandially. Insulin therapy should be ceased at blood glucose levels of <110 mg/dL; however, monitoring for glycemic dysregulation should be continued. In all cases of complex diabetes, consultation with diabetes specialty services should be considered.

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The emerging use of technology, including continuous subcutaneous insulin pump therapy and continuous glucose monitoring, is an exciting area of further research and development as such technology can more immediately detect and correct aberrations in blood glucose levels.

Patients with insulin-dependent diabetes are at greater risk for perioperative adverse outcomes following total hip arthroplasty

BACKGROUND

The prevalence of diabetes mellitus (DM) continues to increase among patients undergoing total hip arthroplasty (THA). It is unclear how insulin use is correlated with risk for adverse outcomes.

METHODS

A cohort of 146,526 patients undergoing primary THA were identified in the 2005-2017 National Surgical Quality Improvement Program database. Patients were classified as insulin-dependent diabetic (IDDM), non-insulin-dependent diabetic (NIDDM), or not diabetic. Multivariate analyses were used.

RESULTS

Compared to patients without diabetes, patients with NIDDM were at increased risk for 4 of 17 perioperative adverse outcomes studied. Patients with IDDM were at increased risk for those 4 and 8 additional adverse outcomes (12 of the 17 studied).

CONCLUSION

These findings have important implications for preoperative risk stratification and quality improvement initiatives.

Association between glycosylated hemoglobin, diabetes mellitus, and preoperative deep vein thrombosis in patients undergoing total joint arthroplasty: a retrospective study

Background

To investigate the association between the level of glycosylated hemoglobin (HbA1c) and preoperative deep vein thrombosis (DVT) and that between diabetes mellitus (DM) and preoperative DVT in patient undergoing total joint arthroplasty (TJA).

Methods

A total of 1386 patients were enrolled. We created the receiver operating characteristic (ROC) curve of HbA1c, and based on the cutoff value, patients were divided into two groups. Risk factors were subsequently examined. Chi-square test or Fisher’s exact test was adopted for enumeration data. The results were expressed in percentages (%), and DVT-related variates were analyzed. We included the variates that were statistically significant in the univariate analysis in the multivariate binary logistic regression analysis and calculated the adjusted odds ratio (OR) and 95% confidence interval (95% CI).

Results

Preoperative DVT was 100 cases (7.22%) and DM in 301 cases (21.7%). We determined the cutoff value of HbA1c of 6.15% using the ROC curve as the area under the curve (AUC) was 0.548. Univariate logistic regression revealed that the risk of preoperative DVT in TJA patients with HbA1c ≥ 6.15%, HbA1c between 7 and 7.9%, HbA1c ≥ 8%, DM, female, and major surgery in the last 12 months increased by 1.84 (P = 0.005; 95% CI [1.20–2.80]), 2.22 (P = 0.028, 95% CI [1.09–4.52]), 2.47 (P = 0.013, 95% CI [1.21–5.04]), 2.03 (P = 0.004, 95% CI [1.25–3.30]); 1.85 (P = 0.010, 95% CI [1.16–2.95]); and 2.86 times (P = 0.006, 95% CI [1.35–6.05]), respectively. And multivariate logistic regression revealed that the risk of preoperative DVT in TJA patients with HbA1c ≥ 6.15%, HbA1c between 7 and 7.9%, HbA1c ≥ 8%, DM patients, female patients, and major surgery in the last 12 months increased by 1.77 (P = 0.009, 95% CI [1.16–2.72]); 2.10 (P = 0.043, 95% CI [1.02–4.30]); 2.50 (P = 0.013, 95% CI [1.22–5.14]); 2.01 (P = 0.005, 95% CI [1.23–3.28]); 1.80 (P = 0.014, 95% CI [1.13–2.89]); and 3.04 times (P = 0.004, 95% CI [1.42–6.49]), respectively.

Conclusion

We conclude that HbA1c ≥ 6.15%, DM, female and major surgery in the last 12 months are the independent risk factors for preoperative DVT in patients undergoing TJA. And patients with a higher HbA1c level are at an increased risk of preoperative DVT.

Trial registration: ChiCRT2100054844.

Not So Sweet: Preoperative Diabetes Screening in the Total Joint Population

Clearly identifying patients with prediabetes and diabetes prior to surgery allows the clinical team to target interventions and reduce the risks of complications. Yet, protocols for preoperative diabetes screening vary. The purpose of this article is to present an evidence-based practice project examining the implementation of preoperative diabetes screening in an elective total joint patient population. The American Diabetes Association (ADA) Risk Test was used to assess diabetes risk and guide further testing. A total of 121 patients were screened. Of the sample, 55 were undiagnosed and at risk for diabetes according to the instrument. Twelve patients (21.8%) who screened at risk also revealed elevated fasting blood glucose levels. These patients were identified as potentially having prediabetes. The findings of this project support adoption of the ADA Risk Test in the preoperative setting, emphasize the feasibility of its integration in order to obtain valuable patient information, and assist with optimizing patients for surgery.

Preoperative Patient Optimization in Total Joint Arthroplasty-The Paradigm Shift from Preoperative Clearance: A Narrative Review

Background: Total joint arthroplasty (TJA) is one of the most common procedures performed in the United States. Outcomes of this elective procedure may be improved via preoperative optimization of modifiable risk factors. Purposes: We sought to summarize the literature on the clinical implications of preoperative risk factors in TJA and to develop recommendations regarding preoperative optimization of these risk factors. Methods: We searched PubMed in August 2019 with an update in September 2020 for English-language, peer-reviewed publications assessing the influence on outcomes in total hip and knee replacement of 7 preoperative risk factors-obesity, malnutrition, hypoalbuminemia, diabetes, anemia, smoking, and opioid use-and recommendations to mitigate them. Results: Sixty-nine studies were identified, including 3 randomized controlled trials, 8 prospective cohort studies, 42 retrospective studies, 6 systematic reviews, 3 narrative reviews, and 7 consensus guidelines. These studies described worse outcomes associated with these 7 risk factors, including increased rates of in-hospital complications, transfusions, periprosthetic joint infections, revisions, and deaths. Recommendations for strategies to screen and address these risk factors are provided. Conclusions: Risk factors can be optimized, with evidence suggesting the following thresholds prior to surgery: a body mass index <40 kg/m², serum albumin ≥3.5 g/dL, hemoglobin A1C ≤7.5%, hemoglobin >12.0 g/dL in women and >13.0 g/dL in men, and smoking cessation and ≥50% decrease in opioid use by 4 weeks prior to surgery. Surgery should be delayed until these risk factors are adequately optimized.

Risk factors for complications within 30 days of operatively fixed periprosthetic femur fractures

BACKGROUND

With a rising number of periprosthetic femur fractures (PPFFs) each year, the primary objective of our study was to quantify risk factors that predict complications following operative treatment of PPFFs.

METHODS

A retrospective cohort study of 231 patients with a periprosthetic femur fracture was conducted at an Academic, Level 1 Trauma Center. The main outcome measurement of interest was complications, as defined by the ACS-NSQIP, within 30 days of surgery.

RESULTS

56 patients had 96 complications. Bivariate analyses revealed ASA score, preoperative ambulatory status, length of stay, discharge disposition, time from admission to surgery, length of surgery, perioperative change in hemoglobin, Charlson comorbidity index, cerebral vascular accident/transient ischemic attack, chronic obstructive pulmonary disease, diabetes mellitus, and receipt of a blood transfusion were associated with development of a complication (p < 0.1). Multivariate logistic regression showed length of stay (OR 1.11, 95% CI 1.03-1.19; p = 0.006), receipt of a blood transfusion (OR 2.48, 95% CI 1.14-5.42; p = 0.02), and diabetes mellitus (OR 2.17, 95% CI 1.03-4.56; p = 0.04) remained independently predictive of complication.

CONCLUSIONS

Length of stay, receipt of a blood transfusion, and diabetes were associated with increased perioperative risk for developing a complication following operative treatment of periprosthetic femur fractures. Methods to decrease length of stay or transfusion rates may mitigate complication risk in these patients.

LEVEL OF EVIDENCE

Prognostic, Level III.

Application of Different Doses of Tranexamic Acid Plus Traditional Chinese Medicine in Hip Arthroplasty in Patients with Diabetes and Its Influence on Intraoperative Blood Loss and Postoperative Drainage

Objective

To evaluate the efficacy of different doses of tranexamic acid plus traditional Chinese medicine (TCM) in hip arthroplasty in diabetic patients and the effect on intraoperative hemorrhage and postoperative drainage.

Methods

One hundred patients admitted to our hospital from January 2019 to September 2021 were randomly divided into group B (n = 50) and group A (n = 50), and tranexamic acid was injected intravenously at a dose of 10 mg/kg and 20 mg/kg 30 min before skin incision, and then tranexamic acid 1.0 g was injected into the joint cavity through the drainage after incision closure, followed by 3 h of drainage clamping. The amount of blood loss, coagulation index, postoperative drainage, and incidence of venous thromboembolism (VTE) were compared between the groups.

Results

Group A had significantly less total blood loss, dominant blood loss, and hidden blood loss than group B (P < 0.05). No significant difference in postoperative coagulation indexes and postoperative drainage flow was found between the two groups (P > 0.05). Serological examination results demonstrated no statistical difference in D-dimer (D-D) levels between the two groups. The absence of VTE in both groups was determined by imaging.

Conclusion

Tranexamic acid is effective in reducing intraoperative hemorrhage in diabetic patients undergoing hip arthroplasty. The dose of 20 mg/kg outperforms 10 mg/kg in terms of clinical efficacy with a favorable safety profile, which can be applied according to the patient's actual condition.

Access to hip arthroplasty and rates of complications in different socioeconomic groups : a review of 111,000 patients in a universal healthcare system

AIMS

Total hip arthroplasty (THA) is one of the most successful surgical procedures. The objectives of this study were to define whether there is a correlation between socioeconomic status (SES) and surgical complications after elective primary unilateral THA, and investigate whether access to elective THA differs within SES groups.

METHODS

We conducted a retrospective, population-based cohort study involving 202 hospitals in Ontario, Canada, over a 17-year period. Patients were divided into income quintiles based on postal codes as a proxy for personal economic status. Multivariable logistic regression models were then used to primarily assess the relationship between SES and surgical complications within one year of index THA.

RESULTS

Of 111,359 patients who underwent elective primary THA, those in the lower SES groups had statistically significantly more comorbidities and statistically significantly more postoperative complications. While there was no increase in readmission rates within 90 days, there was a statistically significant difference in the primary and secondary outcomes including all revisions due (with a subset of deep wound infection and dislocation). Results showed that those in the higher SES groups had proportionally more cases performed than those in lower groups. Compared to the highest SES quintile, the lower groups had 61% of the number of hip arthroplasties performed.

CONCLUSION

Patients in lower socioeconomic groups have more comorbidities, fewer absolute number of cases performed, have their procedures performed in lower-volume centres, and ultimately have higher rates of complications. This lack of access and higher rates of complications is a "double hit" to those in lower SES groups, and indicates that we should be concentrating efforts to improve access to surgeons and hospitals where arthroplasty is routinely performed in high numbers. Even in a universal healthcare system where there are no penalties for complications such as readmission, there seems to be an inequality in the access to THA. Cite this article: Bone Joint J 2022;104-B(5):589-597.

The Utility of Preoperative HbA1c as a Standardized Protocol in Elective Carpal Tunnel Release: A Retrospective Review of Clinical Outcomes

Background: In an effort to reduce surgical complications, some institutions have implemented universal hemoglobin A1c (HbA1c) screening for all preoperative patients. However, the value of HbA1c screening for predicting clinically meaningful complications after elective carpal tunnel release (CTR) remains unclear. The purpose of this study was to investigate the clinically meaningful predicative value of HbA1c screening on postoperative complications following elective CTR. Methods: A retrospective cohort study of 790 patients who underwent CTR was performed. All patients had an HbA1c screening performed, regardless of whether they underwent the diagnosis for diabetes or not. Primary outcomes were overall complication rate, rates of major complications (readmission or reoperation), and rates of minor complications (surgical site infection and wound dehiscence). Patients were stratified into 3 groups based on HbA1c: HbA1c <7, HbA1c 7-8, and HbA1c >8. Results: The overall complication rate for all groups was 4.8%. Rates of major complications were 0.4% for readmission and 0.1% for reoperation. For minor complications, the odds ratio (OR) for the HbA1c 7-8 group was 0.6 (95% confidence interval [CI], 0.14-1.77), and for the HbA1c >8 group, the OR was 1.6 (95% CI, 0.66-3.60). All minor complications resolved with outpatient treatment. There were no statistically significant differences between the groups for any comparisons. Conclusions: Elective CTR has a low complication rate. Routine preoperative screening of HbA1c is of little value in predicting clinically meaningful complications.

Spine Surgery and Preoperative Hemoglobin, Hematocrit, and Hemoglobin A1c: A Systematic Review

STUDY DESIGN

Systematic review.

OBJECTIVES

Synthesize previous studies evaluating clinical utility of preoperative Hb/Hct and HbA1c in patients undergoing common spinal procedures: anterior cervical discectomy and fusion (ACDF), posterior cervical fusion (PCF), posterior lumbar fusion (PLF), and lumbar decompression (LD).

METHODS

We queried PubMed, Embase, Cochrane Library, and Web of Science for literature on preoperative Hb/Hct and HbA1c and post-operative outcomes in adult patients undergoing ACDF, PCF, PLF, or LD surgeries.

RESULTS

Total of 4,307 publications were assessed. Twenty-one articles met inclusion criteria.

PCF AND ACDF

Decreased preoperative Hb/Hct were significant predictors of increased postoperative morbidity, including return to operating room, pulmonary complications, transfusions, and increased length of stay (LOS). For increased HbA1c, there was significant increase in risk of postoperative infection and cost of hospital stay.

PLF

Decreased Hb/Hct was reported to be associated with increased risk of postoperative cardiac events, blood transfusion, and increased LOS. Elevated HbA1c was associated with increased risk of infection as well as higher visual analogue scores (VAS) and Oswestry disability index (ODI) scores.

LD

LOS and total episode of care cost were increased in patients with preoperative HbA1c elevation.

CONCLUSION

In adult patients undergoing spine surgery, preoperative Hb/Hct are clinically useful predictors for postoperative complications, transfusion rates, and LOS, and HbA1c is predictive for postoperative infection and functional outcomes. Using Hct values <35-38% and HbA1c >6.5%-6.9% for identifying patients at higher risk of postoperative complications is most supported by the literature. We recommend obtaining these labs as part of routine pre-operative risk stratification.

LEVEL OF EVIDENCE

III.

Team Approach: Preoperative Management of Metabolic Conditions in Total Joint Replacement

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Total joint arthroplasties (TJAs) of the knee and hip have been considered 2 of the most successful surgical procedures performed to date.

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Frailty is defined as increased vulnerability to adverse outcomes with physiologic stress.

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Preoperative optimization of frailty and metabolic bone conditions, including osteoporosis, vitamin D deficiency, and diabetes, through a multidisciplinary approach can help improve outcomes and minimize costs after TJA.

A Novel, Potentially Universal Machine Learning Algorithm to Predict Complications in Total Knee Arthroplasty

BACKGROUND

There remains a lack of accurate and validated outcome-prediction models in total knee arthroplasty (TKA). While machine learning (ML) is a powerful predictive tool, determining the proper algorithm to apply across diverse data sets is challenging. AutoPrognosis (AP) is a novel method that uses automated ML framework to incorporate the best performing stages of prognostic modeling into a single well-calibrated algorithm. We aimed to compare various ML methods to AP in predictive performance of complications after TKA.

METHODS

Thirty-eight preoperative patient demographics and clinical features from all primary TKAs performed at California-licensed hospitals between 2015 and 2017 were evaluated as predictors of major complications after TKA. Traditional logistic regression (LR), various other ML methods (XGBoost, Gradient Boosting, AdaBoost, and Random Forest), and AP were used for model building to determine discriminative power (area under receiver operating curve), calibration (Brier score), and feature importance.

RESULTS

Between 2015 and 2017, there were a total of 156,750 TKAs with 1109 (0.7%) total major complications. AP had the highest discriminative performance with area under receiver operating curve 0.679 compared with LR, XGBoost, Gradient Boosting, AdaBoost, and Random Forest (0.617, 0.601, 0.662, 0.657, and 0.545, respectively). AP (Brier score 0.007) had similar calibration as the other ML methods (0.006, 0.006, 0.022, 0.007, and 0.008, respectively). The variables that are most important for AP differ from those that are most important for LR.

CONCLUSION

Compared to conventional ML algorithms, AP has superior discriminative ability with similar calibration and suggests nonlinear relationships between variables in outcomes of TKA.

Postoperative Morbidity and Mortality in Diabetic Patients After Fast-Track Hip and Knee Arthroplasty: A Prospective Follow-up Cohort of 36,762 Procedures

BACKGROUND

Diabetes increases the risk of adverse outcomes in surgical procedures, including total hip and knee arthroplasty (THA/TKA), and the prevalence of diabetic patients undergoing these procedures is high, ranging from approximately 8% to 20%. However, there is still a need to clarify the role of diabetes and antihyperglycemic treatment in a fast-track THA/TKA setting, which otherwise may decrease morbidity. Consequently, we investigated the association between diabetes and antihyperglycemic treatment on length of stay (LOS) and complications following fast-track THA/TKA within a multicenter fast-track collaboration.

METHODS

We used an observational study design on data from a prospective multicenter fast-track collaboration on unselected elective primary THA/TKA from 2010 to 2017. Complete follow-up (>99%) was achieved through The Danish National Patient Registry, antihyperglycemic treatment established through the Danish National Database of Reimbursed Prescriptions and types of complications leading to LOS >4 days, 90-day readmission or mortality obtained by scrutinizing health records and discharge summaries. Patients were categorized as nondiabetic and if diabetic into insulin-, orally, and dietary-treated diabetic patients.

RESULTS

A total of 36,762 procedures were included, of which 837 (2.3%) had insulin-treated diabetes, 2615 (7.1%) orally treated diabetes, and 566 (1.5%) dietary-treated diabetes. Overall median LOS was 2 (interquartile range [IQR]: 1-3) days, and mean LOS was 2.4 (standard deviation [SD], 2.5) days. The proportion of patients with LOS >4 days was 6.0% for nondiabetic patients, 14.7% for insulin-treated, 9.4% for orally treated, and 9.5% for dietary-treated diabetic patients. Pharmacologically treated diabetes (versus nondiabetes) was independently associated with increased odds of LOS >4 days (insulin-treated: odds ratio [OR], 2.2 [99.6% confidence interval {CI}, 1.3-3.7], P < .001; orally treated: OR, 1.5 [99.6% CI, 1.0-2.1]; P = .002). Insulin-treated diabetes was independently associated with increased odds of "diabetes-related" morbidity (OR, 2.3 [99.6% CI, 1.2-4.2]; P < .001). Diabetic patients had increased renal complications regardless of antihyperglycemic treatment, but only insulin-treated patients suffered significantly more cardiac complications than nondiabetic patients. There was no increase in periprosthetic joint infections or mortality associated with diabetes.

CONCLUSIONS

Patients with pharmacologically treated diabetes undergoing fast-track THA/TKA were at increased odds of LOS >4 days. Although complication rates were low, patients with insulin-treated diabetes were at increased odds of postoperative complications compared to nondiabetic patients and to their orally treated counterparts. Further investigation into the pathogenesis of postoperative complications differentiated by antihyperglycemic treatment is needed.

Association of Preoperative Hemoglobin A1c and Body Mass Index with Wound Infection Rate in Spinal Surgery

BACKGROUND

The deleterious effect of diabetes mellitus on surgical outcomes is well documented for joint replacement surgery. We analyzed the large national US Department of Veterans Affairs (VA) database for patients who had undergone elective spinal surgery.

METHODS

We retrospectively searched the VA database and identified 174 520 spine cases.

RESULTS

There were 7766 (4.5%) wound infections and 49 271 (28%) had hemoglobin A1c (HbA1c) testing (range: 3.0-17.8) prior to surgery. In the preoperative HbA1c-checked group, there were 2941 (6.0% of 49 271) infections and in the without-preoperative HbA1c group, there were 4825 (3.9% of 125 249) infections. The distribution of infections was significantly different (χ² = 372.577, P < .0001) and suggests a 2.12% increase in the absolute risk of infection based on the presence of preoperative HbA1c testing, regardless of the result. Logistic regression revealed a preoperative HbA1c test was associated with an odds ratio of 1.435 for infection (confidence interval 1.367-1.505, P < .0001). In a separate model based on HbA1c levels, we found that HbA1c is a significant predictor of infection with an odds ratio of 1.042 (confidence interval 1.017-1.068, P = .0009) for each 1% increase in the test result. This analysis differs from using a strict cutoff value of HbA1c of 6.5%. Similar testing for body mass index and age yielded an odds ratio of 1.027 for each increase of 1 kg/m² and an odds ratio of 1.009 for each 1-year increase in age respectively.

CONCLUSIONS

Hemoglobin A1c testing, HgA1c value, body mass index, and age all contribute to the risk of wound infection after elective spine surgery in a large national VA population. These data can be used to estimate surgical risks and to aid in patient counseling about proposed spine surgery.

LEVEL OF EVIDENCE

4.

Development and Implementation of Preoperative Optimization for High-Risk Patients With Abdominal Wall Hernia

IMPORTANCE

Real-world surgical practice often lags behind the best scientific evidence. For example, although optimizing comorbidities such as smoking and morbid obesity before ventral and incisional hernia repair improves outcomes, as many as 25% of these patients have a high-risk characteristic at the time of surgery. Implementation strategies may effectively increase use of evidence-based practice.

OBJECTIVE

To describe current trends in preoperative optimization among patients undergoing ventral hernia repair, identify barriers to optimization, develop interventions to address these barriers, and then pilot these interventions.

DESIGN, SETTING, AND PARTICIPANTS

This quality improvement study used a retrospective medical record review to identify hospital-level trends in preoperative optimization among patients undergoing ventral and incisional hernia repair. Semistructured interviews with 21 practicing surgeons were conducted to elicit barriers to optimizing high-risk patients before surgery. Next, a task force of experts was convened to develop pragmatic interventions to increase surgeon use of preoperative optimization. Finally, these interventions were piloted at 2 sites to assess acceptability and feasibility. This study was performed from January 1, 2014, to December 31, 2019.

MAIN OUTCOMES AND MEASURES

The main outcome was rate of referrals for preoperative patient optimization at the 2 pilot sites.

RESULTS

Among 23 000 patients undergoing ventral hernia repair, the mean (SD) age was 53.9 (14.3) years, and 12 315 (53.5%) were men. Of these, 8786 patients (38.2%) had at least 1 high-risk characteristic at the time of surgery, including 7683 with 1, 1079 with 2, and 24 with 3. At the hospital level, the mean proportion of patients with at least 1 of 3 high-risk characteristics at the time of surgery was 38.2% (95% CI, 38.1%-38.3%). This proportion varied widely from 21.5% (95% CI, 17.6%-25.5%) to 52.8% (95% CI, 43.9%-61.8%) across hospitals. Interviews with surgeons identified 3 major barriers to improving this practice: lost financial opportunity by not offering a patient an operation, lack of surgeon awareness of available resources for optimization, and organizational barriers. A task force therefore developed 3 interventions: a financial incentive to optimize high-risk patients, an educational intervention to make surgeons aware of available optimization resources, and on-site facilitation. These strategies were piloted at 2 sites where preoperative risk optimization referrals increased 860%.

CONCLUSIONS AND RELEVANCE

This study demonstrates a stepwise process of identifying a practice gap, eliciting barriers that contribute to this gap, using expert consensus and local resources to develop strategies to address these barriers, and piloting these strategies. This implementation strategy can be adopted to diverse settings given that it relies on developing and implementing strategies based on local practice patterns.

Development and Implementation of Preoperative Optimization for High-Risk Patients With Abdominal Wall Hernia

IMPORTANCE

Real-world surgical practice often lags behind the best scientific evidence. For example, although optimizing comorbidities such as smoking and morbid obesity before ventral and incisional hernia repair improves outcomes, as many as 25% of these patients have a high-risk characteristic at the time of surgery. Implementation strategies may effectively increase use of evidence-based practice.

OBJECTIVE

To describe current trends in preoperative optimization among patients undergoing ventral hernia repair, identify barriers to optimization, develop interventions to address these barriers, and then pilot these interventions.

DESIGN, SETTING, AND PARTICIPANTS

This quality improvement study used a retrospective medical record review to identify hospital-level trends in preoperative optimization among patients undergoing ventral and incisional hernia repair. Semistructured interviews with 21 practicing surgeons were conducted to elicit barriers to optimizing high-risk patients before surgery. Next, a task force of experts was convened to develop pragmatic interventions to increase surgeon use of preoperative optimization. Finally, these interventions were piloted at 2 sites to assess acceptability and feasibility. This study was performed from January 1, 2014, to December 31, 2019.

MAIN OUTCOMES AND MEASURES

The main outcome was rate of referrals for preoperative patient optimization at the 2 pilot sites.

RESULTS

Among 23 000 patients undergoing ventral hernia repair, the mean (SD) age was 53.9 (14.3) years, and 12 315 (53.5%) were men. Of these, 8786 patients (38.2%) had at least 1 high-risk characteristic at the time of surgery, including 7683 with 1, 1079 with 2, and 24 with 3. At the hospital level, the mean proportion of patients with at least 1 of 3 high-risk characteristics at the time of surgery was 38.2% (95% CI, 38.1%-38.3%). This proportion varied widely from 21.5% (95% CI, 17.6%-25.5%) to 52.8% (95% CI, 43.9%-61.8%) across hospitals. Interviews with surgeons identified 3 major barriers to improving this practice: lost financial opportunity by not offering a patient an operation, lack of surgeon awareness of available resources for optimization, and organizational barriers. A task force therefore developed 3 interventions: a financial incentive to optimize high-risk patients, an educational intervention to make surgeons aware of available optimization resources, and on-site facilitation. These strategies were piloted at 2 sites where preoperative risk optimization referrals increased 860%.

CONCLUSIONS AND RELEVANCE

This study demonstrates a stepwise process of identifying a practice gap, eliciting barriers that contribute to this gap, using expert consensus and local resources to develop strategies to address these barriers, and piloting these strategies. This implementation strategy can be adopted to diverse settings given that it relies on developing and implementing strategies based on local practice patterns.

Diabetes is an independent risk factor for infection after non-arthroplasty shoulder surgery: a national database study

OBJECTIVES

Diabetes has been associated with poor healing and prior literature has shown worse functional outcomes in diabetic patients undergoing both open and arthroscopic shoulder surgery. However, the effects of diabetes on perioperative complications for patients undergoing non-arthroplasty type shoulder procedures are not well defined. The purpose of this study was to analyze the effects of diabetes on 30-day complications following non-arthroplasty shoulder surgery.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program was used to identify patients who underwent open and arthroscopic shoulder procedures (excluding arthroplasty) from 2011 to 2018. Diabetic patients were identified and compared to a non-diabetic cohort. Demographic data and postoperative complications within 30 days were analyzed. Multivariable regression was used to determine the effect of diabetes on shoulder surgery.

RESULTS

We identified 99,970 patients who underwent shoulder surgery in our cohort and 13.9% (13,857 patients) of these patients were diabetics. Within the diabetic cohort, 4,394 (31.7%) were insulin dependent. Diabetics were more likely to be older, female, and have a higher body mass index (P < 0.01). Diabetics had a higher rate of associated medial comorbidities (P < 0.05). Diabetics were less likely to be smokers and on average had shorter surgeries (P < 0.05). Univariate analysis showed that diabetes was associated with increased risk for infectious and other major and minor complications; however, multivariate regression revealed that diabetes was only independently associated with infection (OR 1.33, P = 0.38).

CONCLUSION

While diabetes is associated with increased likelihood of infection following shoulder surgery, absent commonly associated comorbidities, they are not at increased risk for other 30-day postoperative complications.

Significance of nutritional status in the development of periprosthetic infections : A retrospective analysis of 194 patients

BACKGROUND

Malnutrition caused by protein and vitamin deficiencies is a significant negative prognostic factor in surgical wound healing disorders and infections. Particularly in elective surgery, preoperative compensation of deficiencies is advisable to avoid negative postoperative consequences. This study examined the nutritional and protein balance of patients with periprosthetic hip and knee joint infections.

MATERIAL AND METHODS

Patients with periprosthetic hip or knee joint infections constituted the study group (SG). Control group I (CG I) included patients with primary implants and CG II included patients who required revision surgery because of aseptic loosening. Relevant nutritional and protein parameters were determined via analysis of peripheral venous blood samples. In addition, a questionnaire was used to evaluate the nutritional and eating patterns of all patients. The nutritional risk screening (NRS) 2002 score and body mass index (BMI) were also calculated for all participants.

RESULTS

Differences were found in the albumin level (SG: 36.23 ± 7.34, CG I: 44.37 ± 3.32, p < 0.001, CG II: 44.06 ± 4.24, p < 0.001) and total protein in serum (SG: 65.42 ± 8.66, CG I: 70.80 ± 5.33, p = 0.004, CG II: 71.22 ± 5.21, p = 0.004). The number of patients with lowered albumin levels (SG 19/61, CG I 1/78, CG II 2/55) and total protein in serum (SG: 12/61, CG I 5/78, CG II 2/55) also showed considerable variation. The number of patients with a NRS 2002 score ≥3 differed significantly between SG and both CGs (SG: 5/61, CG I 1/78, CG II 0/55); however, these differences could not be confirmed using BMI.

CONCLUSION

As expected, lowered albumin and total protein levels were observed in PJI due to the acute phase reaction. The NRS can be performed to exclude nutritional deficiency, which cannot be excluded based on BMI. In cases of periprosthetic joint infection it is reasonable to compensate the nutritional deficiency with dietary supplements.

Fructosamine is a valuable marker for glycemic control and predicting adverse outcomes following total hip arthroplasty: a prospective multi-institutional investigation

Recently, fructosamine has shown promising results in predicting adverse outcomes following total knee arthroplasty. The purpose of this study was to assess the utility of fructosamine to predict adverse outcomes following total hip arthroplasty (THA). A prospective multi-center study involving four institutions was conducted. All primary THA were evaluated for glycemic control using fructosamine levels prior to surgery. Adverse outcomes were assessed at a minimum 1 year from surgery. Primary outcome of interest was periprosthetic joint infection (PJI) based on the International Consensus Meeting (ICM) criteria. Secondary outcomes assessed were superficial infections, readmissions and death. Based on previous studies on the subject, fructosamine levels above 293 µmol/L were used to define inadequate glycemic control. Overall 1212 patients were enrolled in the present study and were available for follow up at a minimum 1 year from surgery. Of those, 54 patients (4.5%) had elevated fructosamine levels (> 293 µmol/L) and these patients were 6.7 times more likely to develop PJI compared to patients with fructosamine levels below 293 µmol/L (p = 0.002). Patients with elevated fructosamine were also associated with more readmissions (16.7% vs. 4.4%, p < 0.007) and a higher mortality rate (3.7% vs. 0.6%, p = 0.057). These associations remained statistically significant in a multi-regression analysis after adjusting for age, comorbidities and length of stay; Adjusted odds ratio were 6.37 (95% confidence interval 1.98–20.49, p = 0.002) for PJI and 2.68 (95% confidence interval 1.14–6.29, p = 0.023) for readmissions. Fructosamine is a good predictor of adverse outcomes in patients undergoing THA and should be used routinely to mitigate morbidity and mortality risk.

A prospective observational prevalence study of elevated HbA1c among elective surgical patients

Type 2 Diabetes Mellitus (DM) is a chronic disease with high prevalence worldwide. Using glycated haemoglobin (HbA1c) as a surrogate for potential pre-DM and DM conditions, our primary objective was to determine the HbA1c epidemiology in non-cardiac elective surgical patients in Singapore. Our secondary aim was to identify risk factors associated with elevated HbA1c. We conducted a prospective, observational single-centre study in adult patients. HbA1c screening was performed. Patient demographics and comorbidities were recorded. Patients were divided into those with HbA1C ≤ 6.0% and HbA1C ≥ 6.1%. Regression analyses were performed to identify associated factors. Subgroup analysis was performed comparing patients with HbA1C ≥ 6.1% and HbA1C ≥ 8.0%. Of the 875 patients recruited, 182 (20.8%) had HbA1c ≥ 6.1%, of which 32 (3.7%) had HbA1c ≥ 8%. HbA1C ≥ 6.1% was associated with Indian ethnicity [1.07 (1.01-1.13), p = 0.023], BMI > 27.5 [1.07 (1.02-1.11), p = 0.002], higher preoperative random serum glucose [1.03 (1.02-1.04), p < 0.001], pre-existing diagnosis of DM [1.85 (1.75-1.96), p < 0.001] and prediabetes [1.44 (1.24-1.67), p < 0.001], and peripheral vascular disease [1.30 (1.10-1.54), p = 0.002]. HbA1c ≥ 8% had an additional association with age > 60 years [0.96 (0.93-0.99), p = 0.017]. The prevalence of elevated HbA1c is high among the surgical population. Targeted preoperative HbA1c screening for at-risk elective surgical patients reduces cost, allowing focused use of healthcare resources.

Analysis of the following Related Surgeries of Unicompartmental Knee Arthroplasty and Total Knee Arthroplasty: A Taiwanese National Health Insurance Research Database Population-Based Study

Background

Current treatment options for both unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA) are still controversial with no consistent results in which one is superior to others. This is the first study to examine and analyze the following related data available in patients receiving either UKA or TKA from the National Health Research Database (NHIRD) in Taiwan.

Methods

The database was searched from NHIRD, pooling one million random patients. Patients' age, gender, and comorbidities were analyzed in either UKA or TKA between January 2005 and December 2013, or up until death. For the patients that had received bilateral surgeries, further subgrouping was divided into TKA to TKA, UKA to UKA, TKA to UKA, and UKA to TKA to analyze the completion rate curve. Additional analysis of the order codes 64202B, 64053B, and 64198B was defined as failures, and the related failure rate curves were analyzed separately within ten years. Finally, infection-related codes were analyzed.

Results

6,179 patients (n = 276 UKA; n = 5903 TKA) were selected. Age (p < 0.0001) and gender (p = 0.037) had significant differences, with more young population and males having UKA than TKA. Most comorbidities had no significant difference. For the bilateral surgery analysis, the UKA to UKA group had the fastest completion rate (p < 0.001) and UKA to TKA was the slowest. There were no significant differences in the failure rates of 64202B, 64053B, and 64198B.

Conclusion

Most UKA and TKA are appropriate solutions to treat patients with osteoarthritis or osteonecrosis. UKA to UKA is the quickest bilateral completion surgery, and UKA has a higher chance of undergoing revision surgery than TKA.

Concomitant Malnutrition and Frailty Are Uncommon, but Significant Risk Factors for Mortality and Complication Following Primary Total Knee Arthroplasty

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.

Dysglycemia and Arthroplasty Outcomes: A Review

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.

Elevated HbA1c is not a risk factor for wound complications following total joint arthroplasty: a prospective study

BACKGROUND

Controversies exist regarding the association of elevated serum glycated haemoglobin (HbA1c) levels and postoperative surgical site infection (SSI) or prosthetic joint infection (PJI) in the setting of total hip and knee arthroplasty (THA and TKA). The purpose of the current study was to determine the prevalence of unknown and uncontrolled diabetes mellitus (DM) in a consecutive series and to investigate the association between postoperative wound complications or SSI/PJI and elevated HbA1c in patients undergoing TJA.

METHODS

In this prospective single-centre study, HbA1c was determined for patients undergoing elective primary, aseptic or septic revision THA and TKA, between September 2017 and March 2018. Prevalence of DM, unknown and uncontrolled diabetes were reported. Occurrence of 90-day wound healing disorders (WHD) as well as SSI or PJI were observed. Considering the HbA1c threshold ⩾6.5%, a comparative analysis between patients with and without WHD and SSI or PJI for the whole study cohort, as well as for each arthroplasty group, was performed. Receiver operating characteristic (ROC) curves were developed to quantify the predictive power of HbA1c with regard to WHD and infection complications. A total of 1488 patients were included for final analysis. There were 1127 primary THA and TKA (75.7%), 272 aseptic revisions (18.3%) and 89 septic revisions (6.0%). The known diabetic patients constituted 9.9% of the whole study cohort.

RESULTS

The majority had uncontrolled DM (67%). Prevalence of unknown DM was 11.1%. The results reveal the prevalence for the German population and might be different in other regions. A total of 57 patients (3.7%) experienced postoperative wound or infectious complications. PJI occurred in only 5 patients (0.03%). There was no significant difference between patients with HbA1c <6.5% and patients with HbA1c ⩾6.5% (p = 0.092).

CONCLUSIONS

We demonstrated that prevalence of unknown and uncontrolled DM in patients undergoing TJA is increasing, however; routine preoperative determination of the HbA1c value to prevent possible postoperative wound or infectious complications remains debatable. Larger studies investigating the optimal HbA1c level, as well as other predictors are required.

Outcomes Following Revision Joint Arthroplasty Among Hemodialysis-Dependent Patients

BACKGROUND

Hemodialysis (HD) dependence is known to impact the integrity of bone and has long been associated with metabolic bone disease and other adverse events postoperatively. The aim of this study is to analyze postoperative outcomes following revision hip and knee arthroplasty in hemodialysis-dependent (HDD) patients and to characterize the common indications for revision procedures among this patient population.

METHODS

A total of 1779 HDD patients who underwent a revision joint arthroplasty (930 revision total knee arthroplasty [TKA] and 849 revision total hip arthroplasty [THA]) between 2005 and 2014 were identified from a retrospective database review. Our resulting study groups of revision TKA and THA HDD patients were compared to their respective matched control groups for hospital length of stay (LOS), 90-day mean total cost, hospital readmission, and other major medical and surgical complications.

RESULTS

HD was significantly associated with increased LOS (7.7 ± 8.3 vs 4.8 ± 4.5; P < .001), mean 90-day total cost ($47,478 ± $33,413 vs $24,286 ± $21,472; P < .001), hospital readmission (odds ratio [OR], 2.25; 95% confidence interval [CI], 1.96-2.58; P < .001), septicemia (OR, 3.18; 95% CI, 2.70-3.74; P < .001), postoperative infection (OR, 1.72; 95% CI, 1.50-1.98; P < .001), and mortality (OR, 3.99; 95% CI, 3.12-5.06; P < .001) following revision TKA. Among revision THA patients, HD was associated with increased LOS (9.4 ± 9.5 vs 5.7 ± 5.7; P < .001), mean 90-day total cost ($40,182 ± $27,082 vs $26,519 ± $22,856; P < .001), hospital readmission (OR, 2.33; 95% CI, 2.02-2.68; P < .001), septicemia (OR, 3.61; 95% CI, 3.05-4.27; P < .001), and mortality (OR, 3.55; 95% CI, 2.86-4.37; P < .001).

CONCLUSION

HD remains a significant risk factor for increased LOS, mean total cost, hospital readmission, septicemia, and mortality following revision joint arthroplasty.

Does Polycythemia Vera Increase Risk of Postoperative Complications Following Primary Total Joint Arthroplasty? A Retrospective Matched Control Cohort Study of 6932 Polycythemia Vera Patients

BACKGROUND

There is sparsity of data on outcomes following joint arthroplasty among polycythemia vera (PV) patients. The aim of this study is to evaluate postoperative outcomes following primary total knee (TKA) and hip (THA) arthroplasty among PV patients.

METHODS

A retrospective Medicare database review identified 6932 PV patients who underwent a primary total joint arthroplasty (4643 TKAs and 2289 THAs) from 2006 to 2013. A comparison of hospital length of stay, mortality, and the diagnosis of surgical site infections (SSIs), stroke, myocardial infarction, acute pulmonary embolism (PE), deep vein thrombosis (DVT), and other postoperative complications was made between PV patients undergoing TKA and THA and their respective matched control groups.

RESULTS

PV was significantly associated with increased rates of acute PE (2.3% vs 1.6%; odds ratio [OR] 1.44, 95% confidence interval [CI] 1.17-1.75), DVT (4.2% vs 3.6%; OR 1.40, 95% CI 1.20-1.61, P < .001), postoperative hematoma (0.6% vs 0.4%; OR 1.57, 95% CI 1.03-2.28), and SSI (4.5% vs 3.6%; OR 1.25, 95% CI 1.08-1.44, P = .002) following TKA. Among PV patients who underwent a primary THA, PV was significantly associated with increased rate of acute PE (1.9% vs 1.4%; OR 1.40, 95% CI 1.01-1.88, P = .035), DVT (3.5% vs 2.6%; OR 1.32, 95% CI 1.04-1.66, P = .035), postoperative hematoma (1.1% vs 0.6%; OR 1.86, 95% CI 1.22-2.80), and 1-year mortality (2.2% vs 1.6%; OR 1.43, 95% CI 1.06-1.89, P = .016).

CONCLUSION

PV was significantly associated with increased risk for DVT, PE, postoperative hematoma, SSI (TKA only), and 1-year mortality (THA only) following primary total joint arthroplasty.

Increased Postoperative Glucose Variability Is Associated With Adverse Outcome Following Two-Stage Exchange Arthroplasty for Periprosthetic Joint Infection

BACKGROUND

Glucose variability in the postoperative period has been associated with increased rates of periprosthetic joint infection (PJI) following primary arthroplasty. It is unknown how postoperative glucose control affects outcome of surgical treatment of PJI patients. We hypothesized that postoperative glucose variability adversely affects the outcome of 2-stage exchange arthroplasty.

METHODS

We retrospectively reviewed records of 665 patients with PJI of the knee and hip who underwent 2-stage exchange arthroplasty from 2000 to 2017. Of them, 341 PJIs with a minimum follow-up of 1 year, and either a minimum of 2 glucose values per day or greater than 3 overall during the reimplantation were included. Glucose variability was assessed by calculating the coefficient of variation. Adverse outcomes included treatment failure according to the Delphi consensuses criteria, reinfection, reoperation, and mortality. A subgroup analysis was performed based on patients with or without diabetes.

RESULTS

Glucose variability following reimplantation was associated with higher treatment failure, reinfection, and reoperation. Adjusted analysis indicated that for every standard deviation (15%) increase in the coefficient of variation, the risks of treatment failure, reinfection, and reoperation increased by 27%, 31%, and 26%. Although stratifying patients with (n = 81) or without diabetes (n = 260), these associations remained robust in nondiabetic patients, but not in diabetic patients.

CONCLUSION

Higher glucose variability is associated with increased risks of treatment failure, reinfection, and reoperation after 2-stage exchange arthroplasty in PJI patients. Compared to diabetic patients, nondiabetic patients have a higher association between glucose variability and poor outcomes. Reducing adverse outcomes may be achieved with close monitoring and strict postoperative glucose control.

[Research progress of two-stage revision for periprosthetic joint infection after hip and knee arthroplasties]

Objective

To summarize the research progress of two-stage revision for periprosthetic joint infection (PJI) after hip and knee arthroplasties.

Methods

The related literature on two-stage revision for PJI was summarized, and the new progress in the choice of spacers, systemic antibiotic therapy, and risk factors were analyzed.

Results

Two-stage revision is a common way to treat infection after hip and knee arthroplasties. The types of spacers used in the one-stage operation are diverse and each has its own advantages and disadvantages. Non-articular spacers are mainly used for the patients with poor soft tissue conditions around the joints and severe bone defects. But the joint mobility is not good after the placement of the spacer. Articular spacers can restore the affected joint movement after operation, which is beneficial to the joint mobility after two-stage operation. The use of antibiotics is an indispensable part of the treatment process, and the effectiveness of short-term antibiotic treatment is similar to long-term treatment. Identifying the relevant risk factors that influence the prognosis of the two-stage revision can help preoperative management and reduce the recurrence rate of infection.

Conclusion

There are still controversies about the choice of spacers and systemic antibiotic therapy during the two-stage revision and treatment of PJI. The factors affecting the prognosis of the two-stage revision need to be explored and the further high-quality research is needed.

Patients with Type-1 Diabetes Are at Greater Risk of Periprosthetic Joint Infection: A Population-Based, Retrospective, Cohort Study

BACKGROUND

The effect of diabetes type on the risk of periprosthetic joint infection is not well documented. We hypothesized that patients with diabetes mellitus type 1 would be at greater risk for periprosthetic joint infection than those with diabetes mellitus type 2 and that a history of diabetic complications would be associated with an increased risk of periprosthetic joint infection.

METHODS

We performed a retrospective cohort study, within a statewide database, on all adult patients who underwent hip or knee arthroplasty, with follow-up of ≥2 years, from 1996 to 2013. Of the 75,478 patients included, 1,668 had type-1 diabetes and 18,186 had type-2 diabetes. Risk factors were calculated using Cox regression, adjusting for siblings and stratified by age. Logistic regression was used to analyze the effect of diabetic complications on the risk of periprosthetic joint infection, controlling for other known risks for periprosthetic joint infection.

RESULTS

There was no difference in age or sex between groups (p > 0.05). The frequency of periprosthetic joint infection in patients without diabetes was 2.6% compared with 4.3% in all patients with diabetes (relative risk, 1.47; p < 0.001). Patients with type-1 diabetes were at a 1.8 times greater risk for periprosthetic joint infection than patients with type-2 diabetes (7% compared with 4%; p < 0.001). The following diabetic complications increased the risk of periprosthetic joint infection: peripheral circulatory disorders (odds ratio [OR], 2.59 [95% confidence interval (CI), 1.70 to 3.94]), ketoacidosis (OR, 2.52 [95% CI, 1.51 to 4.19]), neurological manifestations (OR, 2.33 [95% CI, 1.96 to 2.78]), renal manifestations (OR, 2.15 [95% CI, 1.66 to 2.79]), and ophthalmic manifestations (OR, 1.76 [95% CI, 1.24 to 2.51]). The odds of periprosthetic joint infection increased with each added complication and patients with ≥4 complications were 9 times more likely to have a periprosthetic joint infection than patients with uncomplicated diabetes (OR, 9.47 [95% CI, 4.97 to 18.03]). Overweight and obese patients with type-2 diabetes and underweight patients with type-1 diabetes were at greater risk for periprosthetic joint infection compared with the general population (all p < 0.05).

CONCLUSIONS

Our data showed an increased risk of periprosthetic joint infection in patients with type-1 diabetes compared with those with type-2 diabetes, along with an increasing risk associated with additional diabetic complications. These findings emphasize the need to better understand the medical history of patients with diabetes for more appropriate risk management.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Diabetic Control Predicts Surgical Site Infection Risk in Orthopaedic Trauma Patients

OBJECTIVES

(1) To determine the incidence of surgical site infections (SSIs) in diabetic orthopaedic trauma patients and (2) to establish a protocol for managing diabetes mellitus (DM) in orthopaedic trauma patients.

DESIGN

Retrospective cohort study.

SETTING

Level 1 Trauma Center.

PATIENTS

All diabetic orthopaedic trauma patients who underwent surgical intervention with at least 1 month follow-up. Patients were classified as poorly controlled or controlled diabetic patients based on admission hemoglobin A1c and blood glucose (BG) levels.

INTERVENTIONS

Orthopaedic surgical intervention in accordance with fracture type and a standardized diabetes management protocol with internal medicine comanagement.

MAIN OUTCOME MEASUREMENT

SSI incidence.

RESULTS

There were 260 patients during the study period. Two hundred two (77.7%) were included in the final analysis. Seventy-five (37.1%) patients met the criteria for poorly controlled DM. The overall rate of SSI was 20.8%; 32.0% for poorly controlled diabetic patients, and 14.2% for controlled diabetic patients (P < 0.01). The admission blood glucose level (BG, P = 0.05), but not discharge BG, was associated with SSI incidence.

CONCLUSIONS

Trauma patients with poorly controlled DM have a higher rate of SSIs than patients with controlled DM. Perioperative diabetes control does not seem to decrease infection rates in these patients.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

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

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.

Optimal Timing of Glucose Measurements After Total Joint Arthroplasty

BACKGROUND

Postoperative glucose levels after total joint arthroplasty are important to monitor as hyperglycemia has been linked to complications such as periprosthetic joint infection. The purposes of this study were to identify how postoperative glucose values vary during the perioperative period and determine the optimal time to check glucose levels to best evaluate for hyperglycemia.

METHODS

A retrospective study was conducted from September 2017 to September 2018 on 314 patients who underwent knee and hip arthroplasties. Blood glucose levels were collected immediately preoperatively, immediately postoperatively, at 5 PM on the day of surgery (DOS), at 9 PM on the DOS, and in the morning of postoperative day (POD) 1. The total number of hyperglycemic patients was assessed at 3 glucose thresholds: strict ≥ 126 mg/dL, intermediate ≥ 137 mg/dL, and lenient ≥ 180 mg/dL. Descriptive statistics were performed for each glucose time period, and adjusted comparisons were made between the mean glucose values and number of hyperglycemic patients at all time points.

RESULTS

Mean (±95% confidence interval) glucose values were 105.7 ± 2.1 mg/dL preoperatively, 117.3 ± 2.5 mg/dL immediately postoperatively, 138.6 ± 4.3 mg/dL at 5 PM on the DOS, 142.9 ± 4.3 mg/dL at 9 PM on the DOS, and 116.7 ± 3.1 mg/dL in the morning of POD 1. Values measured at 5 PM and 9 PM were significantly higher than those measured at all other time points in both diabetics and nondiabetics (P < .001 for all). For all 3 hyperglycemia thresholds, the highest number of hyperglycemic patients was observed at 9 PM on the DOS: strict = 205 (65.3%) patients, intermediate = 177 (56.4%) patients; and lenient = 90 (28.7%) patients.

CONCLUSION

Most patients who underwent total joint arthroplasty are hyperglycemic postoperatively, and 9 PM on the night of surgery may be the most sensitive time for detecting hyperglycemia in both diabetic and nondiabetic patients, in contrast to traditional POD 1 levels.