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Magruder ML, Miskiewicz MJ, Rodriguez AN, Mont MA. Semaglutide Use Prior to Total Hip Arthroplasty Results in Fewer Postoperative Prosthetic Joint Infections and Readmissions. J Arthroplasty 2024; 39:716-720. [PMID: 38122837 DOI: 10.1016/j.arth.2023.12.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 12/03/2023] [Accepted: 12/13/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Semaglutide, a novel diabetes management medication, is known for its efficacy in inducing weight loss. Despite this, its impact on outcomes after total hip arthroplasty (THA) remains unclear. The aim of this study was to evaluate if THA patients on semaglutide demonstrate: (1) fewer medical complications; (2) fewer implant-related complications; (3) fewer readmissions; and (4) lower costs. METHODS Using a national claims database from 2010 to 2021, we retrospectively examined diabetic patients prescribed semaglutide who underwent primary THA. This yielded 9,465 patients (Semaglutide = 1,653; Control = 7,812). Multivariable logistic regression was used to evaluate the following outcomes: 90-day postoperative medical complications, 2-year implant-related complications, 90-day readmissions, in-hospital lengths of stay, and day-of-surgery and 90-day episode of care costs. RESULTS Semaglutide users exhibited lower 90-day readmission rates (6.2 versus 8.8%; odds ratio 0.68; P < .01) and reduced prosthetic joint infections (1.6 versus 2.9%; odds ratio 0.56; P < .01). However, medical complication rates, hospital stays, same-day surgical costs, and 90-day episode costs showed no significant differences. CONCLUSIONS This study highlights semaglutide users undergoing THA with fewer 90-day readmissions and 2-year prosthetic joint infections. Although no variance appeared in medical complications, hospital stays, or costs, the medication's notable glycemic control and weight loss benefits could prompt pre-surgery consideration. Further research is essential for a comprehensive understanding of semaglutide's impact on post-THA outcomes.
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Affiliation(s)
- Matthew L Magruder
- Department of Orthopaedic Surgery, Maimonides Medical Center, Brooklyn, New York
| | - Michael J Miskiewicz
- Renaissance School of Medicine at Stony Brook University Medical Center, Stony Brook, New York
| | - Ariel N Rodriguez
- Department of Orthopaedic Surgery, Maimonides Medical Center, Brooklyn, New York
| | - Michael A Mont
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
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Leal J, Wellman SS, Jiranek WA, Seyler TM, Bolognesi MP, Ryan SP. Continuation of Oral Antidiabetic Medications Was Associated With Better Early Postoperative Blood Glucose Control Compared to Sliding Scale Insulin After Total Knee Arthroplasty. J Arthroplasty 2024:S0883-5403(24)00189-X. [PMID: 38428690 DOI: 10.1016/j.arth.2024.02.069] [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] [Received: 09/10/2023] [Revised: 02/19/2024] [Accepted: 02/20/2024] [Indexed: 03/03/2024] Open
Abstract
BACKGROUND This study evaluated blood glucose (BG), creatinine levels, metabolic issues, length of stay (LOS), and early postoperative complications in diabetic primary total knee arthroplasty (TKA) patients. It examined those who continued home oral antidiabetic medications and those who switched to insulin postoperatively. The hypothesis was that continuing home medications would lead to lower BG levels without metabolic abnormalities. METHODS Patients who had diabetes who underwent primary TKA from 2013 to 2022 were evaluated retrospectively. Diabetic patients who were not on home oral antidiabetic medications or who were not managed as an inpatient postoperatively were excluded. Patient demographics and laboratory tests collected preoperatively and postoperatively as well as 90-day emergency department visits and 90-day readmissions, were pulled from electronic records. Patients were grouped based on inpatient diabetes management: continuation of home medications versus new insulin coverage. Acute postoperative BG control, creatinine levels, metabolic abnormalities, LOS, and early postoperative complications were compared between groups. Multivariable regression analyses were performed to measure associations. RESULTS A total of 867 primary TKAs were assessed; 703 (81.1%) patients continued their home oral antidiabetic medications. Continuing home antidiabetic medications demonstrated lower median maximum inpatient BG (180.0 mg/dL versus 250.0 mg/dL; P < .001) and median average inpatient BG (136.7 mg/dL versus 173.7 mg/dL; P < .001). Logistic regression analyses supported the presence of an association (odds ratio = 17.88 [8.66, 43.43]; P < .001). Proportions of acute kidney injury (13.5 versus 26.7%; P < .001) were also lower. There was no difference in relative proportions of metabolic acidosis (4.4 versus 3.7%; P = .831), LOS (2.0 versus 2.0 days; P = .259), or early postoperative complications. CONCLUSIONS Continuing home oral antidiabetic medications after primary TKA was associated with lower BG levels without an associated worsening creatinine or increase in metabolic acidosis. LEVEL III EVIDENCE Retrospective Cohort Study.
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Affiliation(s)
- Justin Leal
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | - Samuel S Wellman
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | - William A Jiranek
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | - Thorsten M Seyler
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | | | - Sean P Ryan
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
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Mou P, Zhao XD, Cai XY, Liu ZH, He CQ. The effect of preoperative different dexamethasone regimens on postoperative glycemic control in patients with type 2 diabetes mellitus undergoing total joint arthroplasty: a retrospective cohort study. J Orthop Surg Res 2024; 19:14. [PMID: 38167107 PMCID: PMC10763206 DOI: 10.1186/s13018-023-04485-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 12/16/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Concerns have been raised regarding the impact of preoperative intravenous dexamethasone on postoperative glycemic control in diabetic patients undergoing total joint arthroplasty (TJA). This study aimed to determine relationships between preoperative different dexamethasone regimens and postoperative fasting blood glucose (FBG), as well as to identify risk factors for postoperative FBG ≥ 200 mg/dl in diabetic patients undergoing TJA. METHODS This retrospective study included 1216 diabetic patients undergoing TJA and categorized into group A (dexamethasone = 0 mg), group B (dexamethasone = 5 mg), and group C (dexamethasone = 10 mg). All dexamethasone was administered before skin incision. FBG levels were monitored until postoperative day (POD) 3. Analyses were conducted for periprosthetic joint infection (PJI) and wound complications during 90 days postoperatively. And the risk factors for postoperative FBG ≥ 200 mg/dl were identified. RESULTS Preoperative dexamethasone administration resulted in a transiently higher FBG on POD 0 and POD 1 (all P < 0.001). However, no differences were observed on POD 2 (P = 0.583) and POD 3 (P = 0.131) among three groups. While preoperative dexamethasone led to an increase in postoperative mean FBG and postoperative maximum FBG (all P < 0.001), no differences were found in wound complications (P = 0.548) and PJI (P = 1.000). Increased HbA1c and preoperative high FBG, but not preoperative dexamethasone, were identified as risk factors for postoperative FBG ≥ 200 mg/dl. Preoperative HbA1c level of ≥ 7.15% was associated with an elevated risk of postoperative FBG ≥ 200 mg/dl. CONCLUSIONS Although preoperative intravenous administration of 5 mg or 10 mg dexamethasone in diabetic patients showed transient effects on postoperative FBG after TJA, no differences were found in the rates of PJI and wound complications during 90 days postoperatively. Notably, patients with a preoperative HbA1c level of ≥ 7.15% and elevated preoperative FBG may encountered postoperative FBG ≥ 200 mg/dl.
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Affiliation(s)
- Ping Mou
- Department of Rehabilitation Medicine, West China Hospital, Sichuan University, #37 Guoxue Road, Chengdu, 610041, People's Republic of China
- Key Laboratory of Rehabilitation Medicine in Sichuan Province, West China Hospital, Sichuan University, #37 Guoxue Road, Chengdu, 610041, People's Republic of China
- Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, #37 Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Xiao-Dan Zhao
- Department of Orthopaedic Surgery, Trauma Medical Center, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Xin-Yu Cai
- Rehabilitation Medicine Department, Medical Technology Institute, West China Clinical Medical College, Sichuan University, #37 Guoxue Road, Chengdu, 610041, People's Republic of China
| | - Zun-Han Liu
- Department of Sports Medicine Center, State Key Laboratory of Trauma, Burn and Combined Injury, Southwest Hospital of the Army Military Medical University, Chongqing, 400038, People's Republic of China
| | - Cheng-Qi He
- Department of Rehabilitation Medicine, West China Hospital, Sichuan University, #37 Guoxue Road, Chengdu, 610041, People's Republic of China.
- Key Laboratory of Rehabilitation Medicine in Sichuan Province, West China Hospital, Sichuan University, #37 Guoxue Road, Chengdu, 610041, People's Republic of China.
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Magruder ML, Yao VJH, Rodriguez AN, Ng MK, Sasson V, Erez O. Does Semaglutide Use Decrease Complications and Costs Following Total Knee Arthroplasty? J Arthroplasty 2023; 38:2311-2315.e1. [PMID: 37279843 DOI: 10.1016/j.arth.2023.05.071] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 05/20/2023] [Accepted: 05/24/2023] [Indexed: 06/08/2023] Open
Abstract
BACKGROUND Diabetes mellitus (DM) and obesity are associated with total knee arthroplasty (TKA) complications. Semaglutide, a medication for DM and weight loss, can potentially affect TKA outcomes. This study investigated whether semaglutide use during TKA demonstrates fewer: (1) medical complications; (2) implant-related complications; (3) readmissions; and (4) costs. METHODS A retrospective query was performed using a National database to 2021. Patients undergoing TKA for osteoarthritis with DM and semaglutide use were successfully propensity score-matched to controls semaglutide = 7,051; control = 34,524. Outcomes included 90-day postoperative medical complications, 2-year implant-related complications, 90-day readmissions, in-hospital lengths of stay, and costs. Multivariate logistical regressions calculated odds ratios (ORs), 95% confidence intervals, and P values (P < .003 as significance threshold after Bonferroni correction). RESULTS Semaglutide cohorts had higher incidence and odds of myocardial infarction (1.0 versus 0.7%; OR 1.49; P = .003), acute kidney injury (4.9 versus 3.9%; OR 1.28; P < .001), pneumonia (2.8 versus 1.7%; OR 1.67; P < .001), and hypoglycemic events (1.9 versus 1.2%; OR 1.55; P < .001), but lower odds of sepsis (0 versus 0.4%; OR 0.23; P < .001). Semaglutide cohorts also had lower odds of prosthetic joint infections (2.1 versus 3.0%; OR 0.70; P < .001) and readmission (7.0 versus 9.4%; OR 0.71; P < .001), and trended toward lower odds of revisions (4.0 versus 4.5%; OR 0.86; P = .02) and 90-day costs ($15,291.66 versus $16,798.46; P = .012). CONCLUSION Semaglutide use during TKA decreased risk for sepsis, prosthetic joint infections, and readmissions, but also increased risk for myocardial infarction, acute kidney injury, pneumonia, and hypoglycemic events.
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Affiliation(s)
- Matthew L Magruder
- Department of Orthopaedic Surgery, Maimonidies Medical Center, Brooklyn, New York
| | - Vincent J H Yao
- Sophie Davis Biomedical Education Program at the CUNY School of Medicine, New York, New York
| | - Ariel N Rodriguez
- Department of Orthopaedic Surgery, Maimonidies Medical Center, Brooklyn, New York
| | - Mitchell K Ng
- Department of Orthopaedic Surgery, Maimonidies Medical Center, Brooklyn, New York
| | - Victor Sasson
- Department of Orthopaedic Surgery, Maimonidies Medical Center, Brooklyn, New York
| | - Orry Erez
- Department of Orthopaedic Surgery, Maimonidies Medical Center, Brooklyn, New York
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Osorio P, Amenábar D, Salineros M, Zylberberg A. Limiting Factors for Indication of Hip and Knee Arthroplasty in Chile: The International Perception of Risk Initiative. J Arthroplasty 2023; 38:2242-2246.e2. [PMID: 37295626 DOI: 10.1016/j.arth.2023.05.096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 05/30/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND An aging population with a resultant higher incidence of osteoarthritis have increased the need for total hip (THA) and knee arthroplasty (TKA) worldwide. The purpose of this study was to explore what medical and social risk factors are considered relevant by Chilean orthopaedic surgeons in decisions regarding indications for THA or TKA. METHODS An anonymous survey was sent to 165 hip and knee arthroplasty surgeons who were members of the Chilean Orthopedics and Traumatology Society. From a total of 165 surgeons, 128 (78%) completed the survey. The questionnaire included demographic data, place of work, and inquired about medical and socioeconomic factors that could affect surgical indications. RESULTS Factors that limited indications for elective THA/TKA included body mass index (81%), elevated hemoglobin A1c (92%), lack of social support network (58%), and low socioeconomic status (40%). Most respondents made decisions based on personal experience or literature review rather than hospital or departmental pressures. Of the respondents, 64% believe that some patient populations would benefit from better care if payment systems adjusted for their socioeconomic risk factors. CONCLUSION In Chile, limitations regarding the indication for THA/TKA are most influenced by the presence of modifiable medical risk factors such as obesity, uncompensated diabetes, or malnutrition. We believe that the reason surgeons limit surgeries for such individuals is to promote better clinical outcomes, and not in response to pressure from paying entities. However, low socioeconomic status was perceived to impair the ability to achieve good clinical outcomes by 40% of the surgeons.
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Affiliation(s)
- Pedro Osorio
- Department of Orthopaedic Surgery, Clínica Universidad de los Andes, Santiago, Chile
| | - Diego Amenábar
- Department of Orthopaedic Surgery, Clínica Universidad de los Andes, Santiago, Chile
| | - Matías Salineros
- Department of Orthopaedic Surgery, Clínica Universidad de los Andes, Santiago, Chile
| | - Alejandro Zylberberg
- Department of Orthopaedic Surgery, Clínica Universidad de los Andes, Santiago, Chile
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Total Hip and Knee Arthroplasty in Solid Organ Transplant Patients: Perioperative Optimization and Outcomes. J Am Acad Orthop Surg 2022; 30:1157-1164. [PMID: 36476461 DOI: 10.5435/jaaos-d-22-00370] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 08/15/2022] [Indexed: 12/13/2022] Open
Abstract
The success of renal, liver, cardiac, pulmonary, and other solid organ transplantation (SOT) has resulted in increasing volume of transplant procedures and recipient survivorship. Subsequently, many SOT patients develop end-stage degenerative joint disease and are presenting for total hip or total knee arthroplasty more frequently. Surgeons must be aware of the medical complexities and prepare for the perioperative risks associated with these immunocompromised patients. Preoperative evaluation should be conducted in coordination with transplant specialists to ensure optimization, including appropriate surgical timing and advanced, organ-specific medical assessments. Although often unable to be modified, the transplant patient's antirejection medication regimens should be reviewed with understanding of inherent risks of poor wound healing or acute infection. Despite higher rates of complications, revision surgeries, and mortality compared with the general population, SOT recipients continue to demonstrate markedly improved pain relief, function, and quality of life. An ongoing multidisciplinary approach is required throughout the perioperative process and beyond to deliver successful outcomes after total joint arthroplasty in the SOT population.
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Modernizing Total Hip Arthroplasty Perioperative Pathways: The Implementation of ERAS-Outpatient Protocol. J Clin Med 2022; 11:jcm11123293. [PMID: 35743363 PMCID: PMC9224899 DOI: 10.3390/jcm11123293] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 05/26/2022] [Accepted: 06/06/2022] [Indexed: 12/28/2022] Open
Abstract
Pressure to reduce healthcare costs, limited hospital availability along with improvements in surgical technique and perioperative care motivated many centers to focus on outpatient pathway implementation. However, in many short-stay protocols, the focus has shifted away from aiming to reduce complications and improved rehabilitation, to using length of stay as the main factor of success. To improve patient outcomes and maintain safety, the best way to implement a successful outpatient program would be to combine it with the principles of enhanced recovery after surgery (ERAS), and to improve patient recovery to a level where the patient is able to leave the hospital sooner. This article delivers a case for modernizing total hip arthroplasty perioperative pathways by implementing ERAS-outpatient protocols.
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The Role of Dexmedetomidine in the Structure of Anesthesia for Hip and Knee Arthroplastyс Surgery in Patients with Diabetes. Fam Med 2022. [DOI: 10.30841/2307-5112.1-2.2022.260504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Hip and knee arthroplasty (HKA) is a surgical procedure when damaged parts of the joint are replaced with artificial ones that replicate the shape of a normal joint and restore its function.
Every year more than 1.5 million endoprosthetic operations are performed in the world. Replacement of a damaged joint allows patients to return to the normal life, freeing from pain and limited mobility. However, one of the common diseases that negatively affect the results of these operations is diabetes mellitus (DM).
The aim of the study: to determine the efficacy and safety of the combined multimodal low opioid anesthesia with dexmedetomidine sedation in patients with diabetes undergoing HKA surgery.
Materials and methods. The study included 45 patients who underwent HKA surgery. Patients were divided into three groups according to the scheme of anesthesia. In patients of the 1st group (n = 15) multicomponent low-flow anesthesia with artificial lung ventilation was performed, in the patients of the 2nd group (n = 15) spinal anesthesia was used, in the 3rd group (n = 15) – combined spinal – epidural anesthesia with dexmedetomidine sedation.
The groups of patients were identical in anthropometric and gender characteristics, duration of surgery and anesthesia, baseline somatic status.
Statistical analysis was performed using the IBM SPSS Statistics suite (SPSS v.16.0).
Results. The course of anesthesia in patients in all groups was satisfactory, but patients in group 3 were less likely to experience hyperdynamic reactions (tachycardia and hypotension), postoperative nausea and vomiting (PONV). Only one patient from group 3 required ondansetron for the treatment of PONV against 3 and 2 patients from groups 1 and 2, respectively (p <0.05).
Conclusions. Any of the proposed techniques can be used for anesthesia during hip and knee arthroplasty, but the best results have been obtained with combined spinal-epidural anesthesia with dexmedetomidine sedation. In addition, the use of dexmedetomidine can significantly reduce the use of opioids diring the intraoperative and postoperative period.
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Ortved M, Petersen PB, Jørgensen CC, Kehlet H. Postoperative Morbidity and Mortality in Diabetic Patients After Fast-Track Hip and Knee Arthroplasty: A Prospective Follow-up Cohort of 36,762 Procedures. Anesth Analg 2021; 133:115-122. [PMID: 33234944 DOI: 10.1213/ane.0000000000005248] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
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.
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Affiliation(s)
- Milla Ortved
- From the Section for Surgical Pathophysiology, Rigshospitalet, Copenhagen University, Copenhagen, Denmark
| | - Pelle B Petersen
- From the Section for Surgical Pathophysiology, Rigshospitalet, Copenhagen University, Copenhagen, Denmark
| | - Christoffer C Jørgensen
- From the Section for Surgical Pathophysiology, Rigshospitalet, Copenhagen University, Copenhagen, Denmark.,The Lundbeck Foundation Centre for Fast-track Hip and Knee Replacement, Copenhagen, Denmark
| | - Henrik Kehlet
- From the Section for Surgical Pathophysiology, Rigshospitalet, Copenhagen University, Copenhagen, Denmark.,The Lundbeck Foundation Centre for Fast-track Hip and Knee Replacement, Copenhagen, Denmark
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Wilson JM, Farley KX, Broida SE, Bradbury TL, Guild GN. Metformin Use Is Associated with Fewer Complications in Patients with Type-2 Diabetes Undergoing Total Knee Arthroplasty: A Propensity Score-Matched Analysis. J Bone Joint Surg Am 2021; 103:601-608. [PMID: 33787554 DOI: 10.2106/jbjs.20.01535] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Diabetes is a well-established risk factor for complications following total knee arthroplasty (TKA), and the incidence of type-2 diabetes is increasing. Metformin is considered first-line therapy for type-2 diabetes and has been shown to reduce all-cause mortality and to possess anti-inflammatory properties. The impact of metformin use as it relates to outcomes following TKA is unknown. The purpose of this study was to investigate this relationship. METHODS This is a retrospective cohort study using the Truven MarketScan database. Adult patients undergoing unilateral, primary TKA were identified. We included only patients with a preoperative diagnosis of type-2 diabetes and established 2 cohorts based on metformin status. Propensity score matching was performed to match patients who used metformin to those who did not (1-to-1). Patients were matched on factors including age, sex, insulin status, other diabetic medications, comorbidities, complexity of diabetes, and smoking status. Regression analysis was then performed on matched cohorts to examine 90-day outcomes. A subgroup analysis was performed on 1-year revision rates. RESULTS After matching, there were 32,186 patients in both the metformin group and the no-metformin group, resulting in a total of 64,372 included patients. Baseline characteristics were similar between groups. Regression analysis, performed on matched cohorts, demonstrated that the no-metformin group had increased odds of readmission (odds ratio [OR], 1.09 [95% confidence interval (CI), 1.04 to 1.15]; p < 0.001), emergency department presentation (OR, 1.09 [95% CI, 1.04 to 1.14]; p < 0.001), extended length of stay (OR, 1.12 [95% CI, 1.06 to 1.15]; p < 0.001), periprosthetic joint infection (OR, 1.30 [95% CI, 1.13 to 1.50]; p < 0.001), deep vein thrombosis (OR, 1.17 [95% CI, 1.09 to 1.26]; p < 0.001), acute kidney injury (OR, 1.21 [95% CI, 1.09 to 1.33]; p < 0.001), hypoglycemic events (OR, 1.25 [95% CI, 1.01 to 1.54]; p = 0.039), and 1-year revision (OR, 1.16 [95% CI, 1.01 to 1.33]; p = 0.033). CONCLUSIONS Metformin use in patients with type-2 diabetes undergoing TKA appears to be associated with lower odds of multiple complications and resource utilization parameters, including periprosthetic joint infection and 1-year revision rates. Given the frequency with which TKA is performed in patients with type-2 diabetes, this knowledge has the potential to improve optimization protocols and outcomes in this group of patients. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Jacob M Wilson
- Department of Orthopaedic Surgery, Emory University , Atlanta , Georgia
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Citak M, Toussaint B, Abdelaziz H, Klebig F, Dobinsky A, Gebauer M, Gehrke T. Elevated HbA1c is not a risk factor for wound complications following total joint arthroplasty: a prospective study. Hip Int 2020; 30:19-25. [PMID: 32907422 DOI: 10.1177/1120700020926986] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- Mustafa Citak
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Bastian Toussaint
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Hussein Abdelaziz
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Felix Klebig
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Alexandra Dobinsky
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Matthias Gebauer
- Department of Orthopaedic Surgery, Roland-Klinik Bremen, Germany
| | - Thorsten Gehrke
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
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Lin CA, Behrens PH, Paiement G, Hardy WD, Mirocha J, Rettig RL, Kiziah HL, Rudikoff AG, Hernandez Conte A. Metabolic factors and post-traumatic arthritis may influence the increased rate of surgical site infection in patients with human immunodeficiency virus following total hip arthroplasty. J Orthop Surg Res 2020; 15:316. [PMID: 32787972 PMCID: PMC7425402 DOI: 10.1186/s13018-020-01827-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 07/29/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The impact of CD4+ T-cell count and highly active antiretroviral therapy (HAART) on the rate of surgical site infection (SSI) in patients with human immunodeficiency virus (HIV) undergoing total hip arthroplasty is still unclear. The goals of this study were to assess the rate of perioperative infection at a large tertiary care referral center and to identify risk factors in HIV+ patients undergoing total hip arthroplasty (THA). METHODS This study was a prospective, observational study at a single medical center from 2000-2017. Patients who were HIV+ and underwent THA were followed from the preoperative assessment period, through surgery and for a 2-year follow-up period. RESULTS Sixteen of 144 HIV+ patients (11%) undergoing THA developed perioperative surgical site infections. Fourteen patients (10%) required revision THA within a range of 12 to 97 days after the initial surgery. The patients' mean age was 49.6 ± 4.5 years, and the most common diagnosis prompting THA was osteonecrosis (96%). Patients who developed SSI had a lower waist-hip ratio (0.86 vs. 0.93, p = 0.047), lower high density lipoprotein cholesterol (45.8 vs. 52.5, p = 0.015) and were more likely to have post-traumatic arthritis (12.5% vs. 0%, p = 0.008). Logistic regression analysis demonstrated that current alcohol use and higher waist-hip ratio were significant protectors against infection (p < 0.05). No other demographic, medical, immunologic parameters, or specific HAART regimens were associated with perioperative infection. CONCLUSIONS Immunologic status as measured by CD4+ cell count, HIV viral load, and medical therapy do not appear to influence the development of SSI in HIV+ patients undergoing THA. Metabolic factors and post-traumatic arthritis may influence the increased rate of infection in HIV+ patients following THA.
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Affiliation(s)
- Carol A Lin
- Department of Orthopedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Phillip H Behrens
- Department of Orthopedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Guy Paiement
- Department of Orthopedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - W David Hardy
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - James Mirocha
- Division of Biostatistics & Bioinformatics, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Robert L Rettig
- Department of Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, USA
| | - Heidi L Kiziah
- Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd, 3rd Floor, Suite 3017, Los Angeles, CA, 90027, USA
| | - Andrew G Rudikoff
- Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd, 3rd Floor, Suite 3017, Los Angeles, CA, 90027, USA
| | - Antonio Hernandez Conte
- Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd, 3rd Floor, Suite 3017, Los Angeles, CA, 90027, USA.
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Varady NH, Schwab PE, Jones T, Collins JE, Fitz W, Chen AF. Optimal Timing of Glucose Measurements After Total Joint Arthroplasty. J Arthroplasty 2019; 34:S152-S158. [PMID: 30704771 DOI: 10.1016/j.arth.2019.01.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 12/27/2018] [Accepted: 01/02/2019] [Indexed: 02/01/2023] Open
Abstract
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.
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Affiliation(s)
- Nathan H Varady
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Pierre-Emmanuel Schwab
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Todd Jones
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Jamie E Collins
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Wolfgang Fitz
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Antonia F Chen
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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