Association of Perioperative Glycemic Control With Deep Postoperative Infection After Shoulder Arthroplasty in Patients With Diabetes

A Systematic Review of Patient Selection Criteria for Outpatient Total Shoulder Arthroplasty

The utilization of total shoulder arthroplasty (TSA) is increasing, driving associated annual health care costs higher. Opting for outpatient over inpatient TSA may provide a solution by reducing costs. However, there is no single set of accepted patient selection criteria for outpatient TSA. Here, the authors identify and systematically review 14 articles to propose evidence-based criteria that merit postoperative admission. Together, the studies suggest that patients with limited ability to abmluate independently or a history of congestive heart failure may benefit from postoperative at least one night of hospital based monitoring and treatment.

The 100 Most Impactful Articles on Total Shoulder Arthroplasty: An Altmetric Analysis

Background

To use the top 100 articles pertaining to total shoulder arthroplasty (TSA) to understand the impact that social media platforms have on the dissemination of shoulder research while highlighting bibliometric factors associated with Altmetric Attention Score (AAS) to offer insight into the impact that social media platforms have on the dissemination, attention, and citation of shoulder research publications.

Methods

In June 2023, the Altmetric database was searched using the following PubMed MeSH terms: "total shoulder arthroplasty" or "TSA." Articles with the highest AAS were screened to exclude other topics unrelated to TSA. The top 100 articles that met inclusion criteria were used in the final analysis. Bibliometric factors pertaining to each study were collected for further analysis of article characteristics in accordance with prior studies.

Results

The Altmetric Database query yielded 1,283 studies. After applying our inclusion criteria, the top 118 articles with the highest AAS were identified. The mean AAS was 29.14 ± 42.35, with a range of 13 to 402. The included articles represented 27 journals, with 70 articles attributed to 2 journals: Journal of Shoulder and Elbow Surgery (JSES; 43%) and the Journal of Bone and Joint Surgery (JBJS; 16%). There was a significant increase in AAS for the presence of a conflict of interest (p = 0.042) and open access status (p < 0.01), but no association between the score and citation rate (p > 0.05).

Conclusions

Top articles on TSA, as defined by high AAS, mostly comprise original clinical research performed in the United States or Europe. The presence of a conflict of interest and open access status is associated with an increase in AAS, but there was no association between AAS score and citation rate.

Normothermia to Decrease Surgical Site Infection Risk: Silver Bullet or Fool's Gold? A Retrospective Cohort Study

PURPOSE

Surgical site infection (SSI) is the leading cause of nosocomial infections among surgical patients in the United States. Currently, there is compelling evidence suggesting that temperature dysregulation in surgical patients may be a risk factor for the development of SSI. We examined the relationship between perioperative hypothermia (PH) and SSI in a population of surgical patients with diabetes mellitus (DM).

METHODS

This retrospective cohort review was conducted on patients with a history of DM undergoing orthopaedic surgery at our institution between May 1, 2018, and April 1, 2022. Inclusion criteria were age older than 15 years, a history of DM or recent hemoglobin A1c concentration of ≥6.5%, and operation of at least 60 minutes under general anesthesia. Perioperative hypothermia was defined as an intraoperative temperature ≤ 35.5°C. Continuous variables were compared using the t-test and Wilcoxon rank-sum test. Categorical variables were compared using the chi-squared test. We constructed a multivariable logistic regression model to estimate SSI risk while controlling for demographic variables.

RESULTS

A total of 236 patients were included in the final analysis. The overall incidence of SSI was 5.93%. 99 patients (42%) experienced PH. No difference was observed in the risk of SSI between the normothermic and hypothermic cohorts. Among the 99 patients who experienced PH, increasing HbA1c was associated with increasing risk of SSI (OR = 2.39, 95% CI = 1.12 to 5.32, P-value = 0.0222). The multivariable logistic regression model had good discriminatory ability (c-statistic 0.74, 95% CI: 0.61 to 0.89) and good predictive accuracy (sensitivity 64%, specificity 73%).

DISCUSSION

PH is not an independent risk factor of SSI. However, in the presence of elevated HbA1c, PH may more than double the risk of SSI. Perioperative hypothermia may be an additive risk factor in the setting of poor glycemic control and potentially in the setting of other known risk factors.

Factors affecting risk of recurrence with periprosthetic infection in shoulder arthroplasty

BACKGROUND

The goal of treating periprosthetic infection, besides its eradication, is to avoid recurrence. The purpose of this study was to evaluate the impact of increasing Infection Severity (IS) score (based on the 2018 International Consensus Meeting on Orthopedic Infections statement), single-stage revision, and pathogenicity of the infective organism on the risk of infection recurrence.

METHODS

A database of 790 revisions performed by a single surgeon from 2004-2020 was reviewed for patients with minimum 2-year follow-up and ≥1 positive culture finding and/or pathology result from the revision surgical procedure. In total, 157 cases performed in 144 patients met the inclusion criteria. These cases were then categorized by infection probability (IS score) according to the 2018 consensus statement. Of 157 cases, 46 (29%) were classified as definitely or probably infected; 25 (16%), possibly infected; and 86 (55%), unlikely to be infected. Additionally, patients were grouped by single-stage surgery and pathogenicity of the infective organism.

RESULTS

A recurrence in this study was classified as the growth of the same organism in any patient requiring revision surgery. The 86 cases in the group with unlikely infection showed a recurrence rate of 2.3%. The 25 cases in the group with possible infection showed a recurrence rate of 12%. The 46 cases in the group with definite or probable infection showed a recurrence rate of 17.4%. Patients in the definite/probable infection group had a higher rate of recurrence than those in the groups with possible infection and unlikely infection (P = .009). The IS score was higher in the recurrence group than the non-recurrence group (7.5 ± 4.3 vs. 3.9 ± 3.4, P < .001). Overall, patients who underwent 1-stage revision had a 5.0% recurrence rate, but among the 34 patients with an infection classification of definite or probable who underwent 1-stage revision, the recurrence rate was 5.9%. Cases of highly virulent methicillin-resistant Staphylococcus aureus also showed a recurrence rate of 30.8% compared with 4.0% and 5.9% for Cutibacterium acnes and coagulase-negative staphylococci, respectively (P = .005).

CONCLUSION

Recurrent infection after treatment of a periprosthetic infection is associated with increasing severity scores, as defined in the 2018 consensus statement, and more aggressive microorganisms. However, a single-stage surgical procedure, even in patients with higher IS scores, did not impart a significantly increased risk of recurrence.

Risk factors for infection in patients undergoing shoulder arthroscopy: a systematic review and meta-analysis

We conducted a meta-analysis to determine the risk of infection following shoulder arthroscopy and to identify risk factors for infection. We systematically searched the PubMed/Medline, Embase and Cochrane Library databases, as well as the reference lists of previous systematic reviews and meta-analyses; manual searches were also performed. A random-effects model was employed to estimate pooled odds ratios (ORs), based on sample size, the P-value of Egger's test and heterogeneity among studies. Of the 29,342 articles screened, 16 retrospective studies comprising 74,759 patients were included. High-quality evidence showed that patients with diabetes (OR, 1.30; 95% confidence interval (CI), 1.20-1.41) or hypertension (OR, 1.26; 95% CI, 1.10-1.44) had a higher risk of infection, while moderate quality evidence showed that patients with obesity (body mass index ≥30 kg/m2) (OR, 1.42; 95% CI, 1.28-1.57), those who were male (OR, 1.65; 95% CI, 1.12-2.44), those who had an American Society of Anesthesiologists (ASA) class ≥3 (OR, 2.02; 95% CI, 1.02-3.99) and those who had a history of smoking (OR, 2.44; 95% CI, 1.39-4.28) had a higher risk of infection. The meta-analysis revealed that there was no association between age, time of surgery, or alcohol consumption and infection. This meta-analysis identified six significant risk factors for infection following shoulder arthroscopy including diabetes, obesity, hypertension, male sex, ASA class, history of smoking. These patient-related risk factors may help identify postoperative patients at higher risk for infection following shoulder arthroscopy.

Patient-selection algorithm for outpatient shoulder arthroplasty in ambulatory surgery center: a retrospective update

BACKGROUND

Outpatient total shoulder arthroplasty (TSA) presents a safe alternative to inpatient arthroplasty, while helping meet the rapidly rising volume of shoulder arthroplasty needs and minimizing health care costs. Identifying the correct patient for outpatient surgery is critical to maintaining the safety standards with TSA. This study sought to update an ambulatory surgery center (ASC) TSA patient-selection algorithm previously published by our institution.

METHODS

A retrospective chart review of TSAs was performed in an ASC at a single institution to collect patient demographics, perioperative risk factors, and postoperative outcomes with regard to reoperations, hospital admissions, and complications. The existing ASC algorithm for outpatient TSA was altered based on collected perioperative information, review of pertinent literature, and anesthesiology recommendations.

RESULTS

A total of 319 TSAs were performed in an ASC in 298 patients over 7 years. Medically related complications occurred in 3 patients (0.9%) within 90 days of surgery, 2 of whom required hospital admission (0.6%) for acute kidney injury and pulmonary embolus. There were no instances of major cardiac events. Orthopedic-related complications occurred in 11 patients (3.4%), with hematoma development requiring evacuation and instability requiring revision being the most common causes.

CONCLUSIONS

There was a low rate of perioperative complications and hospital admissions, confirming the safety of TSAs in an ASC setting. Based on prior literature and the population included, a pre-existing patient-selection algorithm was updated to better reflect increased comfort, knowledge, and data regarding safe patient selection for TSA in an ASC.

Is preoperative elevated glycated hemoglobin (HbA1c) a risk factor for postoperative shoulder stiffness after posterior-superior rotator cuff repair?

Background

Postoperative shoulder stiffness (POSS) affects a large number of patients undergoing rotator cuff repair (RCR). Diabetes may increase the risk of POSS. Preoperative glycated hemoglobin (HbA1c) is a convenient measure of glucose control in this group. The aim of the present study was to determine a relationship between preoperative HbA1c and POSS in patients undergoing postero-superior RCR.

Methods

Two hundred fifty patients with full-thickness postero-superior rotator cuffs who underwent RCR were followed for 6 months. Pre- and post-operative external rotation with arm by the side at 3 and 6 months were measured. Patient demographics, tear characteristics, preoperative HbA1c level, and surgical details were recorded. Patients with subscapularis tears, concomitant instability, partial thickness tears, arthritis, and irreparable rotator cuff tears were excluded. Univariate and multivariate logistic regression were used to determine the association between patient characteristics and POSS at 6 months.

Results

At the end of 6 months, 16% (41/250) of patients had POSS. Multivariate analysis demonstrated an elevated preoperative HbA1c level was a statistically significant predictor of POSS at 6 months (odds ratio 7.04, P < .01) after posterior superior RCR. Lower preoperative external rotation (P = .02) and female sex (P < .01) were also risk factors associated with POSS. Age, hand dominance, worker's compensation claim status, etiology, and size of the tear, surgical technique, and additional treatments were not statistically significant predictors.

Conclusion

Elevated preoperative HbA1c level is associated with POSS after RCR. Measuring HbA1c preoperatively may assist clinicians to identify patients at risk of POSS. HbA1c is a modifiable parameter that could then be optimized preoperatively in order to improve outcomes.

HbA1c and Infection in Diabetic Elective Hand Surgery: A Veterans Affair Medical Center Experience 2012-2018

BACKGROUND

Hemoglobin A1c (HbA1c) is an indicator of glucose control over a 3-month period. The plastic surgery service began screening HbA1c levels prior to surgery when a trend in infectious complications was noted in diabetics. We made a cutoff value of < 8% for elective hand surgery.

METHODS

The institutional review board approved a 7-year retrospective chart review (#201900402) 2012 through 2018 of our elective diabetic hand surgery cases. Data collected included: surgery, HbA1c levels within 3 months before surgery, glucose finger sticks day of surgery, and infectious complications up to 30 days after surgery. A Fisher exact test using a P value of < .05 and a logistic regression analysis using a P value of < .05 were used to determine statistical significance between infectious complications and screening.

RESULTS

In all, 848 cases were recorded in the data base. Infection complication rates before and after screening were not statistically significant (P = .44). All major complications (3) requiring a return to the operating room involved surgery within the flexor sheath before screening was enforced. This was not statistically significant (P = .25). The relative risk of an infectious complication involving the flexor sheath in unscreened patients was 3.66. A logistic regression analysis found no correlation with infectious complications based on the 3 variables of screening time (P = .99), preoperative finger stick values (P = .12), or HbA1c levels (P = .29).

CONCLUSION

The data did not support our guidelines for enforcing HbA1c cutoff levels prior to elective hand surgery. Consider enforcing levels < 8% when the flexor sheath may be violated.

Modifiable and Nonmodifiable Risk Factors Associated with the Development of Recurrent Rotator Cuff Tears

Nonoperative and operative strategies exist to manage rotator cuff pathology. Although surgical repair is successful for most patients, others may experience retear or nonhealing of the rotator cuff. Several modifiable and nonmodifiable risk factors are associated with an increased retear rate. The literature shows consistency and agreement regarding many of these risk factors, most notably, patient age, tear size, and rotator cuff muscular atrophy, whereas others remain controversial. It is important that shoulder surgeons are familiar with modifiable and nonmodifiable risk factors associated with retear, to better advise patients and optimize their chances of success following rotator cuff repair surgery.

Understanding Medical Optimization for Patients Undergoing Shoulder Arthroplasty

Many surgeons seek to optimize their patients' comorbid conditions preoperatively to reduce postoperative complications. To effectively optimize patients before total shoulder arthroplasty, the surgeon should be familiar with recognizing and treating common medical comorbidities found in an orthopedic patient including anemia, diabetes, malnutrition, cardiovascular conditions, and history of deep venous thrombosis. Screening for depression or other mental illness should also be conducted preoperatively and managed accordingly before surgery. Preoperative opioid use and smoking have significant effects on postoperative outcomes and should be addressed before surgery.

Preventing and Treating Infection in Reverse Total Shoulder Arthroplasty

PURPOSE OF REVIEW

Periprosthetic infection after shoulder arthroplasty is relatively uncommon though associated with severe long-term morbidity when encountered. The purpose of the review is to summarize the recent literature regarding the definition, clinical evaluation, prevention, and management of prosthetic joint infection after reverse shoulder arthroplasty.

RECENT FINDINGS

The landmark report generated at the 2018 International Consensus Meeting on Musculoskeletal Infection has provided a framework for diagnosis, prevention, and management of periprosthetic infections after shoulder arthroplasty. Shoulder specific literature with validated interventions to reduce prosthetic joint infection is limited; however existing literature from retrospective studies and from total hip and knee arthroplasty allows us to make relative guidelines. One and two-stage revisions seem to demonstrate similar outcomes; however, no controlled comparative studies exist limiting the ability to make definitive recommendations between the two options. We report on recent literature regarding the current diagnostic, preventative, and treatment options for periprosthetic infection after shoulder arthroplasty. Much of the literature does not distinguish between anatomic and reverse shoulder arthroplasty, and further high-level shoulder specific studies are needed to answer questions generated from this review.

Diabetes increases risk for readmission and infection after shoulder arthroplasty: A national readmissions study of 113,713 patients

Background

The recent increasing popularity of shoulder arthroplasty has been paralleled by a rise in prevalence of diabetes in the United States. We aimed to evaluate the impact of diabetes status on readmission and short-term complications among patients undergoing shoulder arthroplasty.

Methods

We analyzed the Healthcare Cost and Utilization Project National Readmissions Database (NRD) between the years 2016-2018. Patients were included in the study if they underwent anatomic total shoulder arthroplasty (aTSA) or reverse total shoulder arthroplasty (rTSA) according to ICD-10 procedure codes. Postoperative complications including surgical site/joint infection, dislocation, prosthetic complications, hardware-related complications, non-infectious wound complications, 30-day, and 90-day readmission were collected.

Results

A total of 113,713 shoulder arthroplasty patients were included. 23,749 (20.9%) had a diagnosis of diabetes and 89,964 (79.1%) did not. On multivariate analysis, a diagnosis of diabetes led to an increased risk of 30-day (OR: 1.24; 95% CI: [1.14, 1.34]; p < 0.001) and 90-day (OR: 1.18; 95% CI: [1.12, 1.25]; p < 0.001) readmission, surgical site/joint infection (OR: 1.21; 95% CI: [1.06, 1.38]; p = 0.005), respiratory complication (OR: 1.34; 95% CI: [1.09, 1.64]; p = 0.005), postoperative infection (OR: 1.22; 95% CI [1.07, 1.39]; p = 0.003), and deep vein thrombosis (OR: 1.38; 95% CI: [1.09, 1.74]; p = 0.007).

Conclusions

Our findings suggest that patients with diabetes may be at an increased risk of readmission, infection, respiratory complication, and deep vein thrombosis following shoulder arthroplasty. Shoulder surgeons should consider these potential adverse events when planning postoperative care for patients with diabetes.

The Association of Benign Prostatic Hyperplasia on Postoperative Complications and Periprosthetic Joint Infections Following Total Shoulder Arthroplasty

Background

A recently proposed risk factor for periprosthetic joint infections (PJI) in men is benign prostatic hyperplasia (BPH). The objective was to explore the association of BPH on 1) 90-day complications, 2) length of stay (LOS), 3) readmission rates, and 4) healthcare expenditures following total shoulder arthroplasty (TSA).

Methods

A retrospective query was performed using a nationwide claims database from January 2005 to March 2014 for male patients undergoing primary TSA. The study cohort included 5067 patients with BPH while 50,720 patients served as the comparison cohort. Logistic regression determined the association of BPH on complications and readmissions. A p value less than 0.001 was significant.

Results

Patients with BPH had higher incidence and odds (36.8 vs. 6.2%; OR: 2.73, p < 0.0001) of all ninety-day medical complications including PJIs (0.49 vs. 0.32%; OR: 1.54, p < 0.001). BPH patients had longer in-hospital LOS (3- vs. 2-days, p < 0.0001). Study group patients had higher 90-day episode of care reimbursements ($13,653 vs. $12,688), p < 0.0001).

Conclusions

BPH is associated with increased complications and healthcare expenditures following total shoulder arthroplasty. The investigation can be used to educate BPH patients of the possible adverse events which may occur within ninety-days following primary TSA for the treatment of glenohumeral osteoarthritis.

The role of pathogens in diabetes pathogenesis and the potential of immunoproteomics as a diagnostic and prognostic tool

Diabetes mellitus (DM) is a group of metabolic diseases marked by hyperglycemia, which increases the risk of systemic infections. DM patients are at greater risk of hospitalization and mortality from bacterial, viral, and fungal infections. Poor glycemic control can result in skin, blood, bone, urinary, gastrointestinal, and respiratory tract infections and recurrent infections. Therefore, the evidence that infections play a critical role in DM progression and the hazard ratio for a person with DM dying from any infection is higher. Early diagnosis and better glycemic control can help prevent infections and improve treatment outcomes. Perhaps, half (49.7%) of the people living with DM are undiagnosed, resulting in a higher frequency of infections induced by the hyperglycemic milieu that favors immune dysfunction. Novel diagnostic and therapeutic markers for glycemic control and infection prevention are desirable. High-throughput blood-based immunoassays that screen infections and hyperglycemia are required to guide timely interventions and efficiently monitor treatment responses. The present review aims to collect information on the most common infections associated with DM, their origin, pathogenesis, and the potential of immunoproteomics assays in the early diagnosis of the infections. While infections are common in DM, their role in glycemic control and disease pathogenesis is poorly described. Nevertheless, more research is required to identify novel diagnostic and prognostic markers to understand DM pathogenesis and management of infections. Precise monitoring of diabetic infections by immunoproteomics may provide novel insights into disease pathogenesis and healthy prognosis.

Benign prostatic hyperplasia is associated with increased 90-day medical complications but not peri-prosthetic joint infections following reverse shoulder arthroplasty

INTRODUCTION

Studies have shown male sex to be a predisposing factor for peri-prosthetic joint infections (PJIs). Symptomatic benign prostatic hyperplasia (BPH) has been suggested as an additional risk for PJI. This study aimed to assess the impact of BPH on (1) lengths of stay (LOS), (2) complications (medical and implant-related), (3) readmission rates, and (4) healthcare expenditures after reverse shoulder arthroplasty (RSA).

METHODS

Utilizing a nationwide sample from the 2010-2020 PearlDiver insurance database, an analysis was performed retrospectively for all males who underwent primary RSA. Males with BPH (n = 2,184) represented the study group and were ratio-matched with men without a history of BPH (n = 10,832) in a 1:5 manner by medical comorbidities. T-tests compared LOS and healthcare expenditures. Multivariate logistic regression models were used to determine the effect of BPH on 90-day medical complications, 2-year implant complications, and readmissions. A p value less than 0.001 was statistically significant.

RESULTS

In-hospital LOS (1.96 days vs. 1.99 days, p = 0.683) did not significantly differ between cohorts. Males with BPH had significantly greater occurrence and odds (34.3% vs. 21.2%, odds ratio (OR):1.84, p < 0.0001) of all 90-day medical complications, including urinary tract infections (9.3% vs. 3.1%, OR:3.23, p < 0.0001), pneumonias (6.0% vs. 3.9%, OR:1.61, p < 0.0001), and acute kidney injuries (7.7% vs. 5.0%, OR:1.60, p < 0.0001). Two-year implant-related complications were comparable between study and control groups (12.2% vs 10.9%, OR:1.14, p = 0.073), including PJIs (2.3% vs. 2.2%, OR:1.02, p = 0.874). Readmission rates (1.88% vs. 2.11%, p = 0.482) and average global 90-day reimbursements ($26,301 vs. $24,399), p = 0.535) were similar between men with and without BPH.

DISCUSSION

Males with a history of BPH have greater rates of medical complications, including UTIs and acute kidney injuries, within 90 days following RSA. BPH does not appear to be a risk factor for 2-year implant-related complications including PJIs.

LEVEL OF EVIDENCE

III.

Association between diabetes mellitus and risk of infection after trigger finger release: a systematic review and meta-analysis

PURPOSE

To investigate the association between diabetes mellitus and risk of infection after trigger finger release.

METHODS

Reports of adult trigger finger patients who had undergone trigger finger release that included details of patient diabetic status and post-surgery infections were included in the study. Reports of congenital trigger finger release and incomplete data on either diabetic status or infection after surgery were excluded. Search engines were PubMed, Scopus, the Cochrane Central Register of Controlled Trials, and Web of Science from inception to third December 2021. The risk of infection after trigger finger release was compared between diabetic and non-diabetic patients by evaluating the pooled risk ratio (RR) with a 95% confident interval (CI) under random effects modeling. Risk of bias in each study was assessed using Newcastle-Ottawa Scale (NOS).

RESULTS

A total of 213,071 trigger finger patients described in seven studies were identified. Overall, patients with diabetes mellitus had a 65% higher risk of infection after trigger finger release compared to non-diabetic patients (RR 1.65; 95% CI, 1.39-1.95). Diabetes mellitus increased the risk of infection following trigger finger surgery in both young and old age groups as well as obese and non-obese patients who underwent open release surgery. The risk of bias in each of the included studies was estimated as moderate to high.

CONCLUSION

Meta-analysis results demonstrated that diabetes mellitus increases the risk of infection after trigger finger release. Glycemic control and percutaneous rather than open surgery might be strategies to the reduce risk of infection after trigger finger release in diabetic patients.

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.

Is postoperative glucose variability associated with adverse outcomes following shoulder arthroplasty?

BACKGROUND

Postoperative infection after shoulder arthroplasty is a devastating complication. Multiple patient risk factors have been associated with postoperative infection, including increased body mass index and diabetes. Although the association between preoperative glucose control and infection has been established, little is known about the effect of perioperative glycemic control on outcomes following shoulder arthroplasty. The purpose of this study was to investigate the association between postoperative glycemic variability and short-term complications after total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RTSA).

METHODS

A retrospective study was performed at a large, single-specialty center from January 2015 to December 2018. Patients were included if they underwent primary TSA or RTSA with a minimum of 90 days' follow-up and had a minimum of 1 serum glucose value obtained per day of the hospital stay or had ≥3 measurements obtained during the hospital admission period. The primary outcome variable was postoperative infection per accepted definitions of surgical-site infection or periprosthetic joint infection. Secondary outcome variables included stiffness, periprosthetic fracture, periprosthetic dislocation, and reoperation.

RESULTS

In total, 1074 TSAs or RTSAs (in 1032 patients) met the eligibility criteria. The mean patient age was 69.9 ± 8.4 years, and 40.3% of patients had a preoperative diagnosis of diabetes mellitus. Of the patients, 670 (62%) had a calculable coefficient of variation. A younger patient age (median, 65 years [interquartile range (IQR), 13.5 years] vs. 71 years [IQR, 11.0 years]; P = .02) and a preoperative diagnosis of diabetes mellitus (P = .01) showed statistically significant associations with postoperative infection. The first in-hospital glucose measurement beyond the reference tertile of 70-140 mg/dL showed a statistically significant association with postoperative infection, with a median of 128.0 mg/dL (IQR, 43 mg/dL) vs. 167.5 mg/dL (IQR, 37.0 mg/dL; P = .01), whereas the second and third glucose measurements showed no association with postoperative infection. We found no associations between the coefficient of variation and reoperations or complications including surgical-site infection, periprosthetic joint infection, death, postoperative infection, periprosthetic fracture, or stiffness.

CONCLUSION

We found an association between a preoperative diagnosis of diabetes mellitus and postoperative infection following shoulder arthroplasty. We also found that an elevated first glucose measurement is associated with the development of postoperative infection. In-hospital glycemic control, as well as preoperative glycemic control and optimization, may be beneficial for reducing postoperative infections following shoulder arthroplasty.

Limited improvement and high rate of complication in patients undergoing reverse total shoulder arthroplasty for previous native shoulder infection

BACKGROUND

The outcomes of reverse total shoulder arthroplasty (RTSA) surgery for the sequelae of former septic native joint shoulder arthritis are unknown but might be inferior to patients without prior bacterial arthritis.

METHODS

We performed a single-center case-control study embedded in our prospective RTSA cohort. We matched all patients with prior infections in a 1:1 ratio with patients who underwent RTSA for other indications. The matching variables were indication for surgery, age, sex, dominant/nondominant shoulder, and body mass index. We evaluated outcomes by Constant score and active function.

RESULTS

Among 1249 patients in the RTSA cohort, 14 were operated for sequelae of previous native shoulder joint infections. Although both groups significantly improved from preoperative to postoperative values, the outcome of postinfectious patients was clearly inferior in comparison with the control group (absolute [38 ± 17 vs. 75 ± 8, P < .01], relative Constant score [47 ± 19 vs. 88 ± 9, P < .01], Constant pain score [11.0 ± 3.1 vs. 14.3 ± 1.3, P < .01], subjective shoulder value [43 ± 26 vs. 85 ± 10, P < .01], abduction [70 ± 43 vs. 148 ± 29°, P = .001], and elevation [82 ± 49° to 131 ± 16°, P = .02]). Moreover, in the postinfectious group, overall surgical complications occurred in 36%, with the need for revision in 21%. There was, however, no recurrence of infection in any of the patients' shoulders.

CONCLUSION

RTSA for end-stage postinfectious joint disease is associated with a high number of complications and reoperations. Clinical outcomes are inferior to those without past infection.

Periprosthetic Infection After Reverse Shoulder Arthroplasty: a Review

PURPOSE OF REVIEW

Periprosthetic infection is a relatively rare but potentially devastating complication after shoulder arthroplasty. The purpose of this article is to review the incidence, diagnosis, prevention, and management of periprosthetic infections after reverse shoulder arthroplasty, with a focus on literature published within the last 5 years.

RECENT FINDINGS

The 2018 International Consensus Meeting on Musculoskeletal Infection provides us with a framework for the diagnosis and management of periprosthetic infections after shoulder arthroplasty. Reverse shoulder arthroplasty has a higher reported rate of infection compared with anatomic total shoulder arthroplasty. Our current diagnostic tests do not appear to be as sensitive when compared with the hip and knee literature. Similar success has been reported with single and two-stage revision protocols, although prospective comparative data are lacking. The significance of unexpected positive cultures during revision arthroplasty remains unclear. We report current diagnostic and therapeutic options for periprosthetic infection after reverse shoulder arthroplasty. Much of the current literature does not distinguish between anatomic and reverse shoulder arthroplasty. Further high-level studies are warranted to refine these definitions and guide management.

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.

Diabetes Disease Severity Was Not Associated with Risk of Deep Infection or Revision After Shoulder Arthroplasty

BACKGROUND

Prior studies have identified diabetes and disease severity (defined using hemoglobin A1c [HbA1c]) as potential risk factors for complications after shoulder arthroplasty. Evaluations of diabetes status and risk of adverse outcomes beyond the 30-day window either are limited or have not accounted for disease severity. Further, measures of diabetes severity other than HbA1c have yet to be investigated in a shoulder arthroplasty population.

QUESTIONS/PURPOSES

(1) Are diabetes status and glycemic control associated with adverse events, including deep infection, all-cause revision, and 90-day readmission after shoulder arthroplasty? (2) Is postoperative HbA1c associated with revision risk? (3) Is there a threshold of preoperative HbA1c that best identifies patients with diabetes who are at higher risk of 3-year deep infection, 1-year all-cause revision, or 90-day readmission? (4) Can the Adapted Diabetes Complications Severity index (aDCSI) be used as an alternative measure of diabetes severity in evaluating the risk of deep infection, all-cause revision, and 90-day readmission and identification of patients with diabetes at higher risk for these events? (5) Is there a difference between elective and traumatic shoulder arthroplasty patients?

METHODS

We conducted a retrospective registry-based cohort study using Kaiser Permanente's Shoulder Arthroplasty Registry (2005-2015). Primary shoulder arthroplasties were classified as patients with and without diabetes. Patients with diabetes were further evaluated using two disease severity measures (1) HbA1c, with good glycemic control classified as preoperative HbA1c < 7.0% and poor control defined as HbA1c ≥ 7.0%; and (2) aDCSI, classified as mild (score of 0-2) or severe (score ≥ 3) diabetes. Cox regression was used to evaluate the risk of deep infection and revision according to diabetes status and disease severity; conditional logistic regression was used for 90-day readmission. Time-dependent 1-year postoperative HbA1c was used to evaluate revision risk in Cox regression. All models were adjusted for covariates and stratified by elective versus trauma shoulder arthroplasty. Receiver operating characteristic curves were generated for HbA1c and aDCSI to determine whether a threshold exists to identify patients at higher risk of deep infection, all-cause revision, or 90-day readmission. The study sample consisted of 8819 patients; 7353 underwent elective shoulder arthroplasty and 1466 underwent shoulder arthroplasty due to trauma. For elective shoulder arthroplasty, 1430 patients (19%) had diabetes, and among the patients who underwent arthroplasty due to trauma, 444 (30%) had diabetes.

RESULTS

Patients with diabetes who underwent elective shoulder arthroplasty and had poor glycemic control had a higher likelihood of 90-day readmission compared with patients without diabetes (OR, 1.5; 95% CI, 1.0-2.1; p = 0.032). No association was found for patients with diabetes who underwent shoulder arthroplasty due to trauma. No association was found between postoperative HbA1c and revision risk. Receiver operating characteristic curve analysis suggested preoperative HbA1c performed poorly at differentiating adverse events. When using aDCSI, patients with severe diabetes who underwent both elective and traumatic shoulder arthroplasty had a higher likelihood of 90-day readmission compared with patients without diabetes (OR, 1.6; 95% CI, 1.2-2.2; p = 0.001 and OR, 1.8; 95% CI, 1.2-2.7; p = 0.005, respectively). Similar to HbA1c, the aDCSI was a poor classifier in differentiating adverse events.

CONCLUSIONS

Of the longer-term outcomes evaluated, more-severe diabetes was only found to be associated with an increase in 90-day readmissions after shoulder arthroplasty; a stronger association was found when using the aDCSI in identifying diabetes severity. Arbitrary cutoffs in HbA1c may not be the best method for determining risk of postoperative outcomes. Future work investigating perioperative diabetes management should work to identify and validate measures, such as the aDCSI, that better identify patients at higher risk for postoperative outcomes and, more importantly, whether outcomes can be improved by modifying these measures with targeted interventions.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Evaluation and Perioperative Management of the Diabetic Patient

Diabetes mellitus is a devastating disease that has reached epidemic proportions. The surgical patient with diabetes is at increased risk for developing complications when compared with patients without diabetes. A comprehensive preoperative work-up must be performed, including ancillary studies, with optimization of the patient's glucose levels during the perioperative period to decrease the chance of developing surgical complications. A multispecialty team approach for the care of patients with diabetes should be used to produce successful surgical outcomes.