Diabetes mellitus: musculoskeletal manifestations and perioperative considerations for the orthopaedic surgeon

Reducing insulin omission errors among patients with diabetes mellitus in general surgical wards: a best practice implementation project

INTRODUCTION AND OBJECTIVES

Omission of insulin, a high-alert medication with one of the highest locally reported errors, could lead to severe hyperglycemia, which could result in coma or death if not treated timeously. This study aimed to identify, evaluate, and implement strategies to reduce the occurrence of insulin omission errors in diabetic adult patients requiring insulin.

METHODS

This project followed the JBI Evidence Implementation Framework and conducted context analysis, strategy implementation, and evaluation of outcomes according to evidence-based quality indicators. The JBI PACES and JBI GRiP situational analysis tools were used to support data collection and implementation planning. There was one evidence-based criterion and five sub-criteria, with a sample size of 22 patients.

RESULTS

There was increased compliance with best practices to reduce interruptions and distractions from baseline audit (50%) to follow-up audits 1 (45.4%) and 2 (31.8%), and no insulin omission incidences during the implementation period. In the post-implementation analysis, there were notable improvements in compliance with strategies related to nurses; however, reduced compliance was observed related to patients. Key barriers to implementation included patients still disturbing nurses despite the nurses wearing the medication vests and patients forgetting instructions not to disturb nurses during medication administration. Strategies to improve compliance included ensuring coverage in each cubicle during insulin preparation and administration, tending to patients' needs prior to insulin administration, and use of posters as reminders.

CONCLUSIONS

There was an overall increase in compliance with best practice to reduce interruptions and distractions and no insulin omission incidences related to interruptions and distractions during the implementation phase.

SPANISH ABSTRACT

http://links.lww.com/IJEBH/A219.

The effect of diabetes mellitus on lumbar disc degeneration: an MRI-based study

PURPOSE

This study aims to analyse the effect of diabetes mellitus (DM) on the radiological changes of Magnetic Resonance Imaging (MRI) on the intervertebral discs and paravertebral muscle to investigate the effect of DM on spinal degeneration.

METHODS

This retrospective study initially included 262 patients who underwent treatment between January 2020 and December 2021 because of lumbar disc herniation. Amongst these patients, 98 patients suffered from type 2 diabetes mellitus (T2DM) for more than five years; this is the poorly controlled group (haemoglobin A1c (HbA1c) ≥ 6.5%; BMI: 26.28 ± 3.60; HbA1c: 7.5, IQR = 1.3). Another 164 patients without T2DM are included in the control group. The data collected and analysed include gender, age, smoking, alcohol use, disease course, Charlson Comorbidity Index, BMI, and radiological parameters including disc height, modified Pfirrmann grading scores, percentage of fat infiltration area of paravertebral muscle, and pathological changes of the endplate.

RESULTS

After propensity score-matched analysis, the difference in general data between the control and T2DM groups was eliminated, and 186 patients were analysed. The modified Pfirrmann grading scores showed statistical differences in every lumbar segment, suggesting that the T2DM group suffered from greater disc degeneration at all L1-S1 segments compared with the control group. The disc height from L1/2 to L5/S1 was not statistically different between the two groups. Compared to the T2DM group, the control group had a lower percentage of fat infiltration areas in L4/5 and L5/S1 paravertebral muscle, whereas L1/2 to L3/4 showed no statistical difference. The T2DM group had more pathological changes of cartilage endplate compared with the control group.

CONCLUSIONS

Prolonged uncontrolled hyperglycaemia may contribute to lumbar disc degeneration, fatty infiltration of the paraspinal muscles in the lower lumbar segments, and increased incidence of endplate cartilage pathological changes in patients with degenerative disc disease.

Clinical effect of kyphoplasty in the treatment of osteoporotic thoracolumbar compression fractures in patients with diabetes

Objective

To study the clinical effect and influencing factors of kyphoplasty in the treatment of osteoporotic thoracolumbar compression fractures (OTCF) complicated with type 2 diabetes mellitus (T2DM).

Methods

A total of 472 patients with OTCF complicated with diabetes who were enrolled in our hospital from January to December 2019 were selected as the study subjects, and all patients were treated with percutaneous kyphoplasty (PKP). The effects of gender, age, smoking, drinking, body mass index (BMI), bone mass density (T score), fasting blood glucose level, fasting C-peptide, glycosylated hemoglobin, course of T2DM, vertebral segment and surgical instrument on postoperative improvement were analyzed. The quality of life was evaluated by visual analog score (VAS) and Oswestry disability index (ODI) before PKP and 7 days, and 6 months after PKP, and the patient satisfaction was assessed by the modified Macnab criteria at 6 months postoperatively.

Results

The overall excellent and good rate of evaluation result was satisfactory. In multivariate regression, independent risk factors for poor patient satisfaction included: age ≥70 years (odds ratio (OR) = 2.298, 95% confidence interval [CI] 1.290-4.245, P = 0.025), fasting blood glucose ≥8 mmol/L [OR = 2.657, 95%(CI) 1.288-4.121, P = 0.016], glycosylated hemoglobin ≥6.5 mmol/L [OR = 3.438, 95%(CI) 2.543-4.628, P = 0.001], duration ≥8 years [OR = 1.732, 95%(CI) 1.471-3.253, P = 0.019] and Kyphon instrument [OR = 1.472, 95%(CI) 1.112-2.228, P = 0.018] were independent influencing factors of OTCF complicated with DM.

Conclusion

Kyphoplasty for patients with osteoporotic thoracolumbar compression fractures complicated with diabetes can achieve a satisfactory clinical effect, the curative effect is affected by many factors, attention to these factors can improve the clinical effect.

Neuropathic (Charcot) Arthropathy of the Knee

Neuropathic arthropathy of the knee (Charcot knee) is a rare pathology defined by progressive destruction of bone and soft tissue in a patient with underlying peripheral neuropathy. Historically, Charcot knee was associated with neurosyphilis, but it has been increasingly described as a late stage of diabetes. The pathophysiology of the disease is not completely understood, but theories include repetitive microtrauma and an abnormal neurovascular response. Patients present with a warm, swollen, and unstable joint and have rapid bone resorption and characteristic findings on pathology. Nonsurgical options for pain and dysfunction include total contact casting and bracing treatment. Pharmacologic management includes diphosphonates, although this use is considered off-label. Surgical management historically included knee fusion. However, recent case series have suggested that newer prostheses allow for successful arthroplasty in this cohort, although complications are higher when compared with joint arthroplasty in patients with normal neurologic function.

Postoperative Glycemic Variability and Adverse Outcomes After Posterior Cervical Fusion

INTRODUCTION

Posterior cervical decompression and fusion (PCDF) is a procedure commonly performed to help alleviate symptoms and improve quality of life in patients experiencing cervical spondylotic myelopathy, multilevel stenosis, and cervical deformity. Although various risk factors have been linked to adverse outcomes in patients after PCDF, this is the first study that specifically explores postoperative glycemic variability and its association with adverse outcomes.

METHODS

A retrospective cohort study was conducted with a total of 264 patients after PCDF procedures that had available postoperative blood glucose measurements. Patients were divided into tertiles based on their coefficient of variation as an indicator of glycemic variability. Outcomes measured included inpatient complications, length of stay (LOS), 90-day readmission, revision, and surgical site infection rates.

RESULTS

Results showed a significant difference in glycemic variability among tertiles with respect to LOS (P = 0.01). The average LOS for the first, second, and third tertiles was 3.90 (3.20, 4.59), 5.73 (4.45, 7.00), and 6.06 (4.89, 7.22), respectively. Logistic regression analysis showed significantly higher odds of readmission (odds ratio: 4.77; P = 0.03) and surgical site infections (odds ratio: 4.35; P = 0.04) in the high glycemic variability group compared with the low glycemic variability group within 90 days of surgery. No significant difference was noted among tertiles with respect to inpatient complications.

DISCUSSION

This study establishes a relationship between postoperative glycemic variability and LOS, as well as 90-day readmission and surgical site infection rates after PCDF. Our results suggest that limiting fluctuations in blood glucose levels may curtail inpatient healthcare costs related to in-hospital stay. Although immediate postoperative glycemic variability is ultimately acceptable, before discharge, proper glucose management plans should be in place to help prevent adverse patient outcomes.

Next-Generation Sequencing for Pathogen Identification in Infected Foot Ulcers

Background:

Accurate identification of primary pathogens in foot infections remains challenging due to the diverse microbiome. Conventional culture may show false-positive or false-negative growth, leading to ineffective postoperative antibiotic treatment. Next-generation sequencing (NGS) has been explored as an alternative to standard culture in orthopedic infections. NGS is highly sensitive and can detect an entire bacterial genome along with genes conferring antibiotic resistance in a given sample. We investigated the potential use of NGS for accurate identification and quantification of microbes in infected diabetic foot ulcer (DFU). We hypothesize that NGS will aid identification of dominant pathogen and provide a more complete profile of microorganisms in infected DFUs compared to the standard culture method.

Methods:

Data were prospectively collected from 30 infected DFU patients who underwent operative treatment by a fellowship-trained orthopedic foot and ankle surgeon from October 2018 to September 2019. The average age of the patient was 60.4 years. Operative procedures performed were irrigation and debridement (12), toe or ray amputation (13), calcanectomies (4), and below-the-knee amputation (1). Infected bone specimens were obtained intraoperatively and processed for standard culture and NGS. Concordance between the standard culture and NGS was assessed.

Results:

In 29 of 30 patients, pathogens were identified by both NGS and culture, with a concordance rate of 70%. In standard culture, Staphylococcus aureus (58.6%) was the most common pathogen, followed by coagulase-negative Staphylococcus (24.1%), Corynebacterium striatum (17.2%), and Enterococcus faecalis (17.2%). In NGS, Finegoldia magna (44.8%) was the most common microorganism followed by S. aureus (41.4%), and Anaerococcus vaginalis (24.1%). On average, NGS revealed 5.1 (range, 1-11) pathogens in a given sample, whereas culture revealed 2.6 (range, 1-6) pathogens.

Conclusion:

NGS is an emerging molecular diagnostic method of microbial identification in orthopedic infection. It frequently provides different profiles of microorganisms along with antibiotic-resistant gene information compared to conventional culture in polymicrobial foot infection. Clinical use of NGS for management of foot and ankle infections warrants further investigation.

Level of Evidence:

Level II, diagnostic study.

Failure to Optimize Before Total Knee Arthroplasty: Which Modifiable Risk Factor is the Most Dangerous?

BACKGROUND

Complications after total knee arthroplasty (TKA) are devastating for patients, and surgeons are held accountable in alternative payment models. Optimization of modifiable risk factors has become a mainstay in the preoperative period. We sought to evaluate the consequence of failure to optimize key risk factors in a modern cohort of patients who underwent TKA.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program database was searched to identify patients who underwent TKA in 2017-2018. Patients were considered optimized if they had a body mass index <40kg/m², had albumin >3.5g/dL, were nonsmokers, and were nondiabetic. Patients were then grouped based on the previous 4 risk factors. Thirty-day readmission, infection, general complications, and mortality were analyzed and compared between the groups.

RESULTS

Overall, 84,315 patients were included in the study. A total of 31.6% of patients were not considered optimized. Body mass index >40kg/m², albumin <3.5, smoking, and insulin-dependent diabetes were all found to be associated with postoperative infection, readmission, mortality, and complication in general (P < .05). When compared, the nonoptimized group was found to have significantly higher risk of readmission (5 vs 3%), infection (2 vs 1%), general complications (8 vs 5%), and mortality (0.35 vs 0.1%) (all P < .001). Logistic regression showed that those with albumin less than 3.5g/dL had 3.7-fold higher odds of infection and 7.2-fold higher odds of 30-day mortality.

CONCLUSION

Despite knowledge that modifiable risk factors significantly influence postoperative outcomes, surgeons continue to operate on patients who are not optimized. Among the modifiable risk factors analyzed, hypoalbuminemia appears to be the strongest risk factor for all complications evaluated. Special attention should be paid to preoperative nutritional optimization.

LEVEL OF EVIDENCE

Retrospective cohort study, level IV.

Two-Year Clinical and Radiological Outcomes in Patients With Diabetes Undergoing Single-Level Anterior Cervical Discectomy and Fusion

STUDY DESIGN

Secondary analysis of data from the multicenter, randomized, parallel-controlled Food and Drug Administration (FDA) investigational device exemption study.

OBJECTIVE

Studies on outcomes following anterior cervical discectomy and fusion (ACDF) in individuals with diabetes are scarce. We compared 24-month radiological and clinical outcomes in individuals with and without diabetes undergoing single-level ACDF with either i-FACTOR or local autologous bone.

METHODS

Between 2006 and 2013, 319 individuals with single-level degenerative disc disease (DDD) and no previous fusion at the index level underwent ACDF. The presence of diabetes determined the 2 cohorts. Data collected included radiological fusion evaluation, neurological outcomes, Neck Disability Index (NDI), Visual Analog Scale (VAS) scores, and the 36-Item Short Form Survey Version 2 (SF-36v2) Physical and Mental component summary scores.

RESULTS

There were 35 individuals with diabetes (11.1%; average body mass index [BMI] = 32.99 kg/m²; SD = 5.72) and 284 without (average BMI = 28.32 kg/m²; SD = 5.67). The number of nondiabetic smokers was significantly higher than diabetic smokers: 73 (25.70%) and 3 (8.57%), respectively. Preoperative scores of NDI, VAS arm pain, and SF-36v2 were similar between the diabetic and nondiabetic participants at baseline; however, VAS neck pain differed significantly between the cohorts at baseline (P = .0089). Maximum improvement for NDI, VAS neck and arm pain, and SF-36v2 PCS and MCS scores was seen at 6 months in both cohorts and remained stable until 24 months.

CONCLUSIONS

ACDF is effective for cervical radiculopathy in patients with diabetes. Diabetes is not a contraindication for patients requiring single-level surgery for cervical DDD.

Factors associated with revision surgery for olecranon bursitis after bursectomy

BACKGROUND

The primary aim of our study was to identify the factors associated with revision surgery after bursal excision in patients with olecranon bursitis. The secondary aims were to describe the revision rate after bursectomy and to assess which factors are associated with flap surgery after bursectomy and describe the most common complications after bursectomy of the olecranon bursa.

METHODS

We included 191 adult patients with olecranon bursitis who underwent olecranon bursa excision between January 2002 and October 2018. Patients who were pregnant, patients with incomplete records of the primary surgical procedure, and patients who underwent bursectomy during elbow arthroplasty were excluded. After manual chart review, we found that 22 patients had undergone revision surgery. Bivariate analysis was performed to assess the association between revision surgery and patient characteristics, comorbidities, and clinical characteristics. Additionally, we collected data regarding postoperative complications and intraoperative variables such as the use of drains, vacuum assisted closure therapy, and flap surgery.

RESULTS

The overall revision rate in our cohort was 11.5% (22 of 191 patients). Bivariate analysis showed that patients who underwent revision surgery were more frequently women (P = .004), more often had a history of ipsilateral (P = .020) or contralateral (P = .012) olecranon bursitis, and more often received a diagnosis of rheumatoid arthritis (P = .001) or diabetes mellitus (P = .019). The most common complications were delayed wound healing (n = 8, 4.2%) and osteomyelitis (n = 8, 4.2%). Flap surgery was performed in 5 patients (2.6%). Bivariate analysis showed that patients with rheumatoid arthritis underwent flap surgery more frequently (P = .011).

CONCLUSION

The revision rate after bursectomy for olecranon bursitis was 11.5% (22 of 191 patients). Patients with rheumatoid arthritis, diabetes mellitus, or a history of ipsilateral and contralateral olecranon bursitis and female patients underwent revision surgery after bursectomy for olecranon bursitis more frequently. In addition, patients with rheumatoid arthritis underwent flap surgery after bursectomy more frequently.

Predicting postoperative complications in patients undergoing lumbar spinal fusion by using the modified five-item frailty index and nutritional status

Aims

As the population ages and the surgical complexity of lumbar spinal surgery increases, the preoperative stratification of risk becomes increasingly important. Understanding the risks is an important factor in decision-making and optimizing the preoperative condition of the patient. Our aim was to determine whether the modified five-item frailty index (mFI-5) and nutritional parameters could be used to predict postoperative complications in patients undergoing simple or complex lumbar spinal fusion.

Methods

We retrospectively reviewed 584 patients who had undergone lumbar spinal fusion for degenerative lumbar spinal disease. The 'simple' group (SG) consisted of patients who had undergone one- or two-level posterior lumbar fusion. The 'complex' group (CG) consisted of patients who had undergone fusion over three or more levels, or combined anterior and posterior surgery. On admission, the mFI-5 was calculated and nutritional parameters collected.

Results

Complications occurred in 9.3% (37/396) of patients in the SG, and 10.1% (19/167) of patients in the CG. In the SG, the important predictors of complications were age (odds ratio (OR) 1.036; p = 0.002); mFI-5 (OR 1.026 to 2.411, as score increased to 1 ≥ 2 respectively; p = 0.023); albumin (OR 11.348; p < 0.001); vitamin D (OR 2.185; p = 0.032); and total lymphocyte count (OR 1.433; p = 0.011) . In the CG, the predictors of complications were albumin (OR 9.532; p = 0.002) and vitamin D (OR 3.815; p = 0.022).

Conclusion

The mFI-5 and nutritional status were effective predictors of postoperative complications in the SG, but only nutritional status was successful in predicting postoperative complications in the CG. The complexity of the surgery, as well as the preoperative frailty and nutritional status of patients, should be considered when determining if it is safe to proceed with lumbar spinal fusion. Cite this article: Bone Joint J 2020;102-B(12):1717–1722.

Ninety-Day Readmission in Elective Revision Lumbar Fusion Surgery in the Inpatient Setting

STUDY DESIGN

Retrospective review.

OBJECTIVES

(1) Identify the 90-day rate of readmission following revision lumbar fusion, (2) identify independent risk factors associated with increased rates of readmission within 90 days, (3) and identify the hospital costs associated with revision lumbar fusion and subsequent readmission within 90 days.

METHODS

Utilizing 2014 data from the Nationwide Readmissions Database, patients undergoing elective revision lumbar fusion were identified. With this sample, multivariate logistic regression was utilized to identify independent predictors of readmission within 90 days. An analysis of total hospital costs was also conducted.

RESULTS

In 2014, an estimated 14 378 patients underwent elective revision lumbar fusion. The readmission rate at 90 days was 3.1% (n = 446). Diabetes with chronic complications was the only comorbidity found to carry significantly increased odds of readmission. Surgical complications such as deep venous thrombosis, surgical wound disruption, hematoma, and pneumonia (experienced during the index admission) were also independent predictors of readmission. Anterior approaches were associated with increased odds of readmission. The most common related diagnoses on readmission were hardware issues, postoperative infection, and disc herniation. Readmissions were associated with an average of $96 152 in increased hospital costs per patient compared with those not readmitted.

CONCLUSION

Relevant patient comorbidities and surgical complications were associated with increased readmission within 90 days. Readmission within 90 days was associated with significant increases in hospital costs.

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.

Combined Malnutrition and Frailty Significantly Increases Complications and Mortality in Patients Undergoing Elective Total Hip Arthroplasty

BACKGROUND

The demand for total hip arthroplasty (THA) continues to rise. While prior work has examined frailty and malnutrition independently, the additive effects of these conditions are unknown. Therefore, the purpose of this study was to evaluate the individual and combined influence of malnutrition and frailty in the elective THA patient.

METHODS

This is a retrospective cohort study. Patients undergoing elective, primary THA were identified from the American College of Surgeons-National Surgery Quality Improvement Program database. Patients with hip fracture were excluded. Preoperative serum albumin levels (malnutrition = albumin <3.5 g/dL) and 5-item modified frailty index scores (≥2 = frail) were collected. Four cohorts were created: (1) Healthy (N), (2) Frail-only (F), (3) Hypoalbuminemia-only (H), and (4) Hypoalbuminemia and frail (HF). Demographic and complication data were collected, and statistical analysis was performed comparing complications between cohorts.

RESULTS

105,997 patients undergoing THA were identified for inclusion. The majority (82%) of patients were healthy (14% F, 3% H, and 1% HF). The HF group was found to have higher odds of complication compared with all other groups (HF vs N; odds ratio [OR] 3.7, 95% confidence interval [CI] 3.07-4.46, P < .001). Notably, patients in the HF cohort had a 1.9% 30-day mortality rate (HF vs N; OR 12.66, 95% CI 7.81-20.83, P < .001). Additionally, HF patients had higher odds of increased resource utilization when compared with all other groups (P < .001).

CONCLUSIONS

Frailty and malnutrition both represent physiologically compromised states but are only weakly correlated. The concurrent presence of frailty and malnutrition in the THA patient has significant detrimental impacts. Further research will be needed to delineate to what degree these risk factors are modifiable.

Diabetes Does Not Increase Complications, Length of Stay, or Hospital Costs After Minimally Invasive Transforaminal Lumbar Interbody Fusion

STUDY DESIGN

Retrospective cohort.

OBJECTIVE

To determine if the presence of diabetes mellitus as comorbidity is associated with complications, inpatient length of stay, or direct hospital costs after minimally invasive transforaminal lumbar interbody fusion (MIS TLIF).

SUMMARY OF BACKGROUND DATA

Very few studies have investigated the effect of diabetes on complications, length of stay, or costs in minimally invasive lumbar surgeries.

METHODS

Patients undergoing primary, single-level MIS TLIF were retrospectively reviewed. Diabetic and nondiabetic patients were propensity matched in a 1:1 manner for age, sex, and comorbidity burden. An association between diabetic status and preoperative demographic or perioperative variables, including inpatient length of stay, was tested for using Student t test or χ analysis. Multivariate linear regression was used to test for an association between diabetic status and direct hospital costs.

RESULTS

After 1:1 propensity matching, 100 patients were included in this analysis. There were no significant differences in age, sex, body mass index, smoking status, or Charlson Comorbidity Index between propensity-matched patients with and without diabetes. In regards to the length of stay, no significant differences existed between diabetic and nondiabetic groups (68.7 vs. 58.3 h, P=0.218). No other significant differences existed in other perioperative variables including operative time, intraoperative blood loss, or complication rate (P≥0.05 for each). Multivariate analysis indicated that diabetic status was not associated with differences in total direct hospital costs (US$20,428 vs. US$20,429, P=0.792) or cost subcategories after MIS TLIF (P≥0.05 for each).

CONCLUSIONS

In this investigation, diabetes was not associated with postoperative complication rates, inpatient length of stay, or direct hospital costs after primary, single-level MIS TLIF. The reduced extent of operative exposure and tissue trauma in MIS TLIF may mitigate the risk of complications in diabetic patients, possibly preventing extensions in hospital stay length and associated hospital costs.

Elevated Preoperative Hemoglobin A1c Associated with Increased Wound Complications in Diabetic Patients Undergoing Primary, Open Carpal Tunnel Release

BACKGROUND

An increased rate of complications has been demonstrated with increasing hemoglobin A1c value for a variety of orthopedic procedures, including arthroplasty and spine surgery. The authors investigated the effects of elevated hemoglobin A1c value on postoperative complications at the time of carpal tunnel release.

METHODS

This retrospective, cohort study evaluated all diabetic patients with a preoperative hemoglobin A1c value within 90 days of primary, open carpal tunnel release at a single academic institution within the past 10 years. Binary hemoglobin A1c thresholds were tested for association with outcomes of superficial or deep infection, delayed wound healing, and persistent symptoms using chi-square analysis. Multivariable models with adjustment for baseline and operative factors were then constructed. Odds ratios and 95 percent confidence intervals were displayed.

RESULTS

Hemoglobin A1c value greater than or equal to 7.8 percent was most strongly associated with an increased risk of all-cause wound healing complications (p = 0.049) at an odds ratio of 4.2 (95 percent CI, 1.0 to 17.7) in adjusted analyses. Six patients (4 percent) experienced delayed wound healing and five patients (4 percent) developed a superficial infection. Six patients (4 percent) reported persistent carpal tunnel syndrome symptoms.

CONCLUSIONS

Diabetic patients undergoing open, primary carpal tunnel release with a hemoglobin A1c value of 7.8 percent or higher had a higher rate of postoperative wound complications compared to diabetic patients with improved preoperative glucose control. Diabetics with poor glycemic control should be counseled that their risk of postoperative complication is higher. Further work is needed to determine whether delaying surgery to optimize glucose control could result in a reduction of wound healing complications.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Influence of Diabetes Mellitus on the Recovery Trajectories of Function, Strength, and Self-Report Measures After Total Knee Arthroplasty

OBJECTIVE

As the proportion of individuals with diabetes mellitus (DM) in the aging population and the number of total knee arthroplasties (TKAs) both continue to grow, understanding the outcomes for these patient populations is critical. The purpose of this study was to determine whether patients with and without DM differed in the recovery of 3 physical performance measures during the first 90 days following a TKA.

METHODS

Data collected at ATI Physical Therapy from 169 patients (37 with DM, and 132 without) were available. Physical performance measures included the 4-meter walk test, the 30-second sit-to-stand test (30STS), and the timed-up-and-go test (TUG). A mixed-effects model was performed to determine differences in the rate of recovery and 90-day postoperative scores for all measures.

RESULTS

Both groups had similar baseline values for all measures. Patients with DM demonstrated a slower rate of recovery for the 4-meter walk test, and worse scores for the 4-meter walk test, 30STS, and TUG at the end of 90 days when accounting for significant covariates.

CONCLUSION

Our findings show a negative relationship between the presence of DM and the recovery trajectories of all physical performance measures. Clinicians should closely monitor patients with DM, knowing that they are at higher risk for sustained functional deficits and early complications.

Frailty and Malnutrition Are Associated With Inpatient Postoperative Complications and Mortality in Hip Fracture Patients

OBJECTIVE

To examine the relationship of nutrition parameters with the modified frailty index (mFI) and postoperative complications in hip fracture patients.

DESIGN

Retrospective observational cohort study.

SETTING

Urban, American College of Surgeons-Verified, Level-1, Trauma Center.

PATIENTS/PARTICIPANTS

Three hundred seventy-seven consecutive patients with isolated hip fractures.

INTERVENTION

N/A.

MAIN OUTCOME MEASURES

On admission, albumin and total lymphocyte count (TLC) levels and complication data were collected. Additionally, mFI scores were calculated. Statistical analysis was then used to analyze the association between frailty, malnutrition, and postoperative complications.

RESULTS

Overall, 62.6% and 17.5% of patients were malnourished as defined by TLC of <1500 cells per cubic millimeter and albumin of <3.5 g/dL, respectively. Both TLC (P = 0.024; r = -0.12) and albumin (P < 0.001; r = -0.23) weakly correlated with frailty. Combining malnutrition and frailty revealed predictive synergy. Albumin of <3.5 g/dL and mFI of ≥0.18 in the same patient resulted in a positive predictive value of 69% and a likelihood ratio of 4 (2.15-7.43) for postoperative complications. Similarly, the combination of hypoalbuminemia and frailty resulted in a positive predictive value of 23.3% and likelihood ratio of 8.52 (P < 0.001) for mortality.

CONCLUSIONS

When patients are frail and malnourished, there is a risk elevation beyond that of frailty or malnutrition in isolation. This high-risk cohort can be easily identified at admission with routine laboratory values and clinical history. There is an opportunity to improve outcomes in frail hip fracture patients because malnutrition represents a potentially modifiable risk factor.

LEVEL OF EVIDENCE

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

Downregulation of long noncoding RNA H19 rescues hippocampal neurons from apoptosis and oxidative stress by inhibiting IGF2 methylation in mice with streptozotocin-induced diabetes mellitus

The diabetes mellitus (DM)-induced reduction of neurogenesis in the hippocampus is consequently accompanied by cognitive decline. The present study set out to define the critical role played by long noncoding RNA H19 (lncRNA H19) in the apoptosis of hippocampal neurons, as well as oxidative stress (OS) in streptozotocin (STZ)-induced DM mice through regulation of insulin-like growth factor 2 (IGF2) methylation. The expression of lncRNA H19 in the hippocampal neurons and surviving neurons were detected. Hippocampal neurons were cultured and transfected with oe-H19, sh-H19, oe-IGF2, or sh-IGF2, followed by detection of the expressions of IGF2 and apoptosis-related genes. Determination of the lipid peroxide and glutathione levels was conducted, while antioxidant enzyme activity was identified. The IGF2 methylation, the binding of lncRNA H19 to DNA methyltransferase, and the binding of lncRNA H19 to IGF2 promoter region were detected. DM mice exhibited high expressions of H19, as well as a decreased hippocampal neurons survival rate. Higher lncRNA H19 expression was found in DM. Upregulated lncRNA H19 significantly increased the expression of Bax and caspase-3 but decreased that of Bcl-2, thus promoting the apoptosis of hippocampal neuron. Besides, upregulation of lncRNA H19 induced OS. LncRNA H19 was observed to bind specifically to the IGF2 gene promoter region and promote IGF2 methylation by enriching DNA methyltransferase, thereby silencing IGF2 expression. Taken together, downregulated lncRNA H19 reduces IGF2 methylation and enhances its expression, thereby suppressing hippocampal neuron apoptosis and OS in STZ-induced (DM) mice.

Diabetes Mellitus as a Risk Factor for Acute Postoperative Complications Following Elective Adult Spinal Deformity Surgery

STUDY DESIGN

Retrospective cohort study.

OBJECTIVES

Diabetes mellitus is a highly prevalent disease in the United States. Adult spinal deformity (ASD) surgery encompasses a wide variety of spinal disorders and is associated with a morbidity rate between 20% and 80%. Considering utilization of spinal surgery will continue to increase, this study investigates the influence of diabetes mellitus on acute postoperative outcomes following elective ASD surgery.

METHODS

The 2010-2014 American College of Surgeon's National Surgical Quality Improvement Program database was queried using Current Procedural Terminology and International Classification of Diseases (9th Revision) diagnosis codes relevant to ASD surgery. Patients were divided into cohorts based on their diabetic status. Bivariate and multivariate logistic regression analyses were employed to identify which 30-day postoperative outcomes patients are at risk for.

RESULTS

A total of 5809 patients met the inclusion criteria for the study of which 4553 (84.2%) patients were nondiabetic, 578 (10.7%) patients had non-insulin-dependent diabetes mellitus (NIDDM), and 275 (5.1%) patients had insulin-dependent diabetes mellitus (IDDM). Diabetes status was significantly associated with length of stay ≥5 days (NIDDM: odds ratio [OR] = 1.27, 95% confidence interval [CI] = 1.02-1.58, P = .034; IDDM: OR = 1.55, 95% CI = 1.15-2.09, P = .004), any complication (NIDDM: OR = 1.26, 95% CI = 1.01-1.58, P = .037), urinary tract infection (NIDDM: OR = 1.87, 95% CI = 1.14-3.05, P = .012), and cardiac complications (IDDM: OR = 4.05, 95% CI = 1.72-9.51, P = .001).

CONCLUSIONS

Given the prevalence of diabetes, surgeons will invariably encounter these patients for ASD surgery. The present study identifies the increased risk NIDDM and IDDM patients experience following ASD surgery. Quantification of this increased risk may improve the selection of appropriate surgical candidates, patient risk stratification, and patient postoperative safety.

Beyond ulcers and osteomyelitis: imaging of less common musculoskeletal complications in diabetes mellitus

Metabolic perturbations in diabetes mellitus affect various organ systems and can lead to end-organ failure. Though most musculoskeletal (MSK) complications of diabetes mellitus are usually not life-threatening, they are often the cause of significant morbidity. While some of the MSK complications have a proven association with diabetes mellitus, others have been loosely associated because of their frequent coexistence, as are the rheumatologic complications. While many of these conditions are well-known, some are overlooked in routine clinical practice. This article focuses on highlighting key imaging features of less common MSK complications and associations of diabetes mellitus.

Quantifying the Effect of Diabetes on Surgical Hand and Forearm Infections

PURPOSE

Diabetes has long been established as a risk factor for hand and forearm infections. The purpose of this study was to review the effect of glycemic factors on outcomes among diabetic patients with surgical upper-extremity infections. We hypothesized that diabetic inpatients may benefit from stronger peri-infection glycemic control.

METHODS

A prospective cohort study enrolled diabetic and nondiabetic surgical hand and forearm infections over 3 years. Glycemic factors included baseline glycosylated hemoglobin, blood glucose (BG) at presentation, and inpatient BG. Poor baseline control was defined as glycosylated hemoglobin of 9.0% or greater and poor inpatient control as average BG of 180 mg/dL or greater. The main outcome of interest was the need for repeat therapeutic drainage. Multivariable logistic regression quantified the association between diabetic factors and this outcome.

RESULTS

The study involved 322 patients: 76 diabetic and 246 nondiabetic. Diabetic infections were more likely than nondiabetic infections to result from idiopathic mechanisms, occur in the forearm, and present as osteomyelitis, septic arthritis, and necrotizing fasciitis. Diabetic microbiology was more likely polymicrobial and fungal. After first drainage, diabetic patients were more likely to require repeat drainage and undergo eventual amputation. Among diabetic patients, poor inpatient control was associated with need for repeat drainage.

CONCLUSIONS

Diabetes exacerbates the burden of surgical upper-extremity infections: specifically, more proximal locations, deeper involved anatomy at presentation, broader pathogenic microbiology, increased need for repeat drainage, and higher risk for amputation. Among diabetic patients, poor inpatient glycemic control is associated with increased need for repeat drainage.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic I.

Increased risk of 30-day postoperative complications for diabetic patients following open reduction-internal fixation of proximal humerus fractures: an analysis of 1391 patients from the American College of Surgeons National Surgical Quality Improvement Program database

Background

Prior database studies have shown that complication rates following surgical treatment of proximal humerus fractures are low. However, diabetes has been shown across orthopedics to have significantly increased risks of postoperative complications. The purpose of our study was to identify complications for which diabetic patients are at increased risk following operative treatment of proximal humerus fractures.

Methods

The National Surgical Quality Improvement Program database from 2005 to 2014 identified patients >18 years undergoing open reduction-internal fixation for proximal humerus fractures. Patients with incomplete perioperative data were excluded. Patients with non–insulin-dependent diabetes mellitus (NIDDM) and insulin-dependent diabetes mellitus (IDDM) were compared with nondiabetic patients using multivariate logistic regression analysis. Odds ratio (OR) was calculated with a 95% confidence interval, and the significance level was held at P < .05.

Results

There were 1391 patients identified; 1147 (82%) were not diabetic, 91 (7%) had IDDM, and 153 (11%) had NIDDM. Of these, 39.68% (550) were obese (body mass index >30.0). Hypertension, dyspnea, and chronic obstructive pulmonary disease were the most frequent concurrent patient factors in diabetic patients. Postoperatively, patients with diabetes had a statistically significant higher risk of pneumonia (OR, 217.80; P = .002) and length of stay >4 days (OR, 2.05; P = .010). Among diabetics, non–insulin-dependent diabetics had a greater risk of sepsis (OR, 25.84; P = .022) and pneumonia (OR, 12.19; P = .013) than insulin-dependent diabetics.

Conclusion

Both NIDDM and IDDM were associated with a number of adverse postoperative events. Importantly, NIDDM was found to be an independent risk factor for postoperative sepsis and pneumonia, whereas IDDM was identified as an independent risk factor for pneumonia and prolonged length of stay (≥4 days).

Investigation of the Comparative Effects of Red and Infrared Laser Therapy on Skeletal Muscle Repair in Diabetic Rats

OBJECTIVE

The aim of this study was to evaluate the in vivo response of 2 different laser wavelengths (red and infrared) on skeletal muscle repair process in diabetic rats.

DESIGN

Forty Wistar rats were randomly divided into 4 experimental groups: basal control-nondiabetic and muscle-injured animals without treatment (BC); diabetic muscle-injured without treatment (DC); diabetic muscle-injured, treated with red laser (DCR) and infrared laser (DCIR). The injured region was irradiated daily for 7 consecutive days, starting immediately after the injury using a red (660 nm) and an infrared (808 nm) laser.

RESULTS

The histological results demonstrated in both treated groups (red and infrared wavelengths) a modulation of the inflammatory process and a better tissue organization located in the site of the injury. However, only infrared light significantly reduced the injured area and increased MyoD and myogenin protein expression. Moreover, both red and infrared light increased the expression of the proangiogenic vascular endothelial growth factor and reduced the cyclooxygenase 2 protein expression.

CONCLUSION

These results suggest that low-level laser therapy was efficient in promoting skeletal muscle repair in diabetic rats. However, the effect of infrared wavelength was more pronounced by reducing the area of the injury and modulating the expression proteins related to the repair.

Impact of Diabetes Mellitus on Surgical Quality Measures After Ankle Fracture Surgery: Implications for "Value-Based" Compensation and "Pay for Performance"

OBJECTIVES

To evaluate the impact of diabetes mellitus (DM) and associated complications on cost, length of stay, and inpatient mortality after open reduction internal fixation (ORIF) of an ankle fracture, and the implications of these variables during a time of health care payment reform.

DESIGN

Retrospective study.

SETTING

The Statewide Planning and Research Cooperative System database, which includes all admissions to New York State hospitals from 2000 to 2011.

PATIENTS/PARTICIPANTS

A total of 58,748 patients were identified as having undergone the primary procedure of ORIF of the ankle (ICD-9-CM procedure code 79.36).

INTERVENTION

ORIF of the ankle.

MAIN OUTCOME MEASURE

Cost, length of stay, and inpatient mortality.

RESULTS

Of the 58,748 patients evaluated, 7501 (12.8%) had DM. Mean length of stay and total hospital charges were significantly greater for the DM cohort compared to the without DM cohort (P < 0.01). Patients with DM had greater Charlson Comorbidity Index scores and greater in-hospital mortality than patients without DM (both P < 0.01). Of the patients with diabetes, 1098/7501 had complicated diabetes mellitus (C-DM). Patients with C-DM stayed 2.4 days longer and were $6895 more costly than those with diabetes alone (both P < 0.01). Patients with C-DM also had a significantly higher in-hospital mortality rate than those with diabetes alone.

CONCLUSIONS

Patients with diabetes admitted to the hospital for ankle ORIF have more expensive hospital stays and higher in-hospital mortality rates than patients without diabetes. The presence of diabetic complications further increases these risks. These data will help provide risk-adjustment for future health care payment reform initiatives.

LEVEL OF EVIDENCE

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

The impact of diabetes mellitus on patients undergoing degenerative cervical spine surgery

STUDY DESIGN

Retrospective administrative database analysis.

OBJECTIVE

To determine the impact of glycemic control on perioperative complications and outcomes in patients undergoing degenerative cervical spine surgery.

SUMMARY OF BACKGROUND DATA

Diabetes mellitus (DM) is a highly prevalent systemic disease that has been shown to increase morbidity and mortality after spine surgery. Few studies have demonstrated negative effects on patients with DM who undergo cervical spine procedures; however, whether glycemic control influences surgical outcome is still unknown.

METHODS

The Nationwide Inpatient Sample was queried from 2002 to 2011. Patients who underwent cervical spine surgery for degenerative conditions were identified using the International Classification of Diseases Ninth Revision, Clinical Modification, codes. Three surgical cohorts were chosen: controlled diabetic, uncontrolled diabetic, and patients without diabetes. Patient demographics, surgical procedures, perioperative complications and postoperative outcomes were assessed.

RESULTS

The prevalence of controlled and uncontrolled diabetic patients undergoing degenerative cervical spine surgery had been increasing significantly from 2002 to 2011. Compared with patients without diabetes, uncontrolled diabetic patients had significantly increased odds of respiratory, cardiac, and genitourinary complications. Uncontrolled diabetic patients also had significantly increased risk of pulmonary embolism and postoperative infection. Uncontrolled diabetic patients had increased risk of inpatient mortality (odds ratio = 6.39, 95% confidence interval = 4.09-10.00, P < 0.0001) and increased mean length of stay (almost 5 d) compared with nondiabetic patients. Similarly, controlled diabetic patients increased the odds of perioperative complications; however not nearly to the same degree. Controlled diabetic patients extended the mean length of stay by almost a day (P < 0.0001) and significantly increased costs compared with nondiabetic patients.

CONCLUSION

Poor glycemic control increases the odds of inpatient mortality and perioperative complications in patients undergoing degenerative cervical spine surgery. Controlling DM before degenerative cervical spine surgery may lead to better outcomes and decreased costs.

LEVEL OF EVIDENCE

Therapeutic Level 3.