Perioperative management of diabetes and hyperglycemia in patients undergoing orthopaedic surgery

Perioperative hyperglycaemia and incidence of post-operative complications in patients undergoing total knee arthroplasty

PURPOSE

The aim of this study was to assess whether hyperglycaemia in the post-operative period of total knee arthroplasty (TKA) affects post-operative complications regardless of diabetes mellitus (DM) diagnosis.

METHODS

All patients who had undergone primary TKA were included in the study. The following data were recorded: DM diagnosis, and pre- (BGL1), intra- (BGL2) and post-operative blood glucose levels (BGL3). After 1-year follow-up, medical, infectious and mechanical or surgery-related complications were recorded.

RESULTS

Of the 833 patients included, 130 (15.6 %) were diabetic. Median BGL1, BGL2 and BGL3 were 106.13, 93.49 and 134.16 mg/dl, respectively. After follow-up, 173 (20.8 %) patients presented complications, including 48 (5.76 %) medical complications and 94 (11.28 %) infections. Surgery-related complications presented in 31 (3.72 %) patients. A statistically significant association was found between BGL3 ≥ 126 mg/dl and complications (OR 1.95, p < 0.001), medical complications (OR 3.98, p < 0.001), and infections (OR 1.76, p < 0.006).

CONCLUSIONS

Hyperglycaemia during the post-operative period in diabetic and non-diabetic patients undergoing TKA increases post-operative medical and infectious complications. Glycemic control during this period must be performed in order to reduce these complications.

LEVEL OF EVIDENCE

Retrospective case series, Level IV.

Patient, Surgery, and Hospital Related Risk Factors for Surgical Site Infections following Total Hip Arthroplasty

Surgical site infections (SSI) following total hip arthroplasty (THA) have a significantly adverse impact on patient outcomes and pose a great challenge to the treating surgeon. Therefore, timely recognition of those patients at risk for this complication is very important, as it allows for adopting measures to reduce this risk. This review discusses literature reported risk factors for SSI after THA. These can be classified into patient-related factors (age, gender, obesity, comorbidities, history of infection, primary diagnosis, and socioeconomic profile), surgery-related factors (allogeneic blood transfusion, DVT prophylaxis and coagulopathy, duration of surgery, antibiotic prophylaxis, bearing surface and fixation, bilateral procedures, NNIS index score, and anesthesia type), and hospital-related factors (duration of hospitalization, institution and surgeon volume, and admission from a healthcare facility). All these factors are discussed with respect to potential measures that can be taken to reduce their effect and consequently the overall risk for infection.

Risk factors for perioperative hyperglycemia in primary hip and knee replacements

BACKGROUND AND PURPOSE

Perioperative hyperglycemia has been associated with adverse outcomes in several fields of surgery. In this observational study, we identified factors associated with an increased risk of hyperglycemia following hip and knee replacement.

PATIENTS AND METHODS

We prospectively monitored changes in glucose following primary hip and knee replacements in 191 patients with osteoarthritis. Possible associations of patient characteristics and operation-related factors with hyperglycemia (defined as glucose > 7.8 mmol/L in 2 consecutive measurements) and severe hyperglycemia (glucose > 10 mmol/L) were analyzed using binary logistic regression with adjustment for age, sex, operated joint, and anesthesiological risk score.

RESULTS

76 patients (40%) developed hyperglycemia, and 48 of them (25% of the whole cohort) had severe hyperglycemia. Glycemic responses were similar following hip replacement and knee replacement. Previously diagnosed diabetes was associated with an increased risk of hyperglycemia and severe hyperglycemia, compared to patients with normal glucose metabolism, whereas newly diagnosed diabetes and milder glucose metabolism disorders had no effect. In patients without previously diagnosed diabetes, increased values of preoperative glycosylated hemoglobin (HbA1c) and fasting glucose on the day of operation were associated with hyperglycemia. Higher anesthesiological risk score-but none of the operation-related factors analyzed-was associated with an increased risk of hyperglycemia.

INTERPRETATION

Perioperative hyperglycemia is common in primary hip and knee replacements. Previously diagnosed diabetes is the strongest risk factor for hyperglycemia. In patients with no history of diabetes, preoperative HbA1c and fasting glucose on the day of operation can be used to stratify the risk of hyperglycemia.

Best practices for centers of excellence in addressing periprosthetic joint infection

Periprosthetic joint infection is a rare and devastating complication. Management of this complication often requires a multidisciplinary approach similar to that used for the care of patients with cancer. Several studies have reported better outcomes following total joint arthroplasties performed at specialized hospitals than those performed at general hospitals. Specialized institutions use care pathways that aid the multidisciplinary team in decision making. During the recent Musculoskeletal Infection symposium, specific issues were discussed with regard to the treatment of periprosthetic joint infection, including medical optimization, systematic approaches to infection management, and the importance of establishing registries to aid in the creation of Centers of Excellence. A Center of Excellence in periprosthetic infection could provide better overall outcomes with lower financial, physical, and emotional costs to patients.

Part II: managing perioperative hyperglycemia in total hip and knee replacement surgeries

Perioperative hyperglycemia management is an important factor in reducing the risk of surgical site infections (SSIs) in all patients regardless of existing history of diabetes. Reduction of SSIs is one of the quality indicators reported by the National Healthcare Safety Networks of the Centers for Disease Control and Prevention (CDC). In 2009 and 2010, the orthopedic surgical unit had an increased number of SSIs above the CDC benchmark. This article describes the impact of an evidence-based practice standard for perioperative hyperglycemia management in the reduction of SSIs in patients having total hip and knee replacement surgery.

Clinical Implication of Diabetes Mellitus in Primary Total Hip Arthroplasty

Purpose

The purpose of this study was to investigate the effect of diabetes mellitus on primary total hip arthroplasty by comparing the clinical outcomes of patients diagnosed to have diabetes mellitus before the operation with those without diabetes.

Materials and Methods

A total 413 patients who underwent unilateral cementless total hip arthroplasty from June 2006 to May 2009 were recruited and divided into diabetic and non-diabetic groups. The comparative analysis between the two groups was made. We evaluated Harris hip score, postoperative complications such as wound problem, surgical site infection, other medical complication and length of stay in hospital as clinical parameters. Radiographic evaluations were also included to determine loosening, dislocation and osteolysis.

Results

Patients with diabetes had an increased incidence of orthopaedic complications including surgical site infection and mortality, but other medical complications were not increased in diabetic patients. All complications after primary total hip arthroplasty were associated with diabetes mellitus, but the degree of diabetes was not associated with complications.

Conclusion

Diabetes mellitus increases incidence of orthopaedic complications, particularly deep infection, after cementless primary total hip arthroplasty.

Characterisation of osteoarthritis in a small animal model of type 2 diabetes mellitus

Objectives

Our objective in this article is to test the hypothesis that type 2 diabetes mellitus (T2DM) is a factor in the onset and progression of osteoarthritis, and to characterise the quality of the articular cartilage in an appropriate rat model.

Methods

T2DM rats were obtained from the UC Davis group and compared with control Lewis rats. The diabetic rats were sacrificed at ages from six to 12 months, while control rats were sacrificed at six months only. Osteoarthritis severity was determined via histology in four knee quadrants using the OARSI scoring guide. Immunohistochemical staining was also performed as a secondary form of osteoarthritic analysis.

Results

T2DM rats had higher mean osteoarthritis scores than the control rats in each of the four areas that were analysed. However, only the results at the medial and lateral femur and medial tibia were significant. Cysts were also found in T2DM rats at the junction of the articular cartilage and subchondral bone. Immunohistochemical analysis does not show an increase in collagen II between control and T2DM rats. Mass comparisons also showed a significant relationship between mass and osteoarthritis score.

Conclusions

T2DM was found to cause global degeneration in the UCD rat knee joints, suggesting that diabetes itself is a factor in the onset and progression of osteoarthritis. The immunohistochemistry stains showed little to no change in collagen II degeneration between T2DM and control rats. Overall, it seems that the animal model used is pertinent to future studies of T2DM in the development and progression of osteoarthritis.

Cite this article: Bone Joint Res 2014;3:203–11

Stress hyperglycemia and surgical site infection in stable nondiabetic adults with orthopedic injuries

BACKGROUND

Hyperglycemia in nondiabetic patients outside the intensive care unit is not well defined. We evaluated the relationship of hyperglycemia and surgical site infection (SSI) in stable nondiabetic patients with orthopedic injuries.

METHODS

We conducted a prospective observational cohort study at a single academic Level 1 trauma center over 9 months (Level II evidence for therapeutic/care management). We included patients 18 years or older with operative orthopedic injuries and excluded patients with diabetes, corticosteroid use, multisystem injuries, or critical illness. Demographics, medical comorbidities (American Society of Anesthesiologists class), body mass index, open fractures, and number of operations were recorded. Fingerstick glucose values were obtained twice daily. Hyperglycemia was defined as a fasting glucose value greater than or equal to 125 mg/dL or a random value greater than or equal to 200 mg/dL on more than one occasion before the diagnosis of SSI. Glycosylated hemoglobin level was obtained from hyperglycemic patients; those with glycosylated hemoglobin level of 6.0 or greater were considered occult diabetic patients and were excluded. SSI was defined by a positive intraoperative culture at reoperation within 30 days of the index case.

RESULTS

We enrolled 171 patients. Of these 171, 40 (23.4%) were hyperglycemic; 7 of them were excluded for occult diabetes. Of the 164 remaining patients, 33 were hyperglycemic (20.1%), 50 had open fractures (6 Type I, 22 Type II, 22 Type III), and 12 (7.3%) had SSI. Hyperglycemic patients were more likely to develop SSI (7 of 33 [21.2%] vs. 5 of 131 [3.8%], p = 0.003). Open fractures were associated with SSI (7 of 50 [14%] vs. 5 of 114 [4.4%], p = 0.047) but not hyperglycemia (10 of 50 [20.0%] vs. 23 of 114 [20.2%], p = 0.98). There was no significant difference between infected and noninfected patients in terms of age, sex, race, American Society of Anesthesiologists class, obesity (body mass index > 29), tobacco use, or number of operations.

CONCLUSION

Stress hyperglycemia was associated with SSI in this prospective observational cohort of stable nondiabetic patients with orthopedic injuries. Further prospective randomized studies are necessary to identify optimal treatment of hyperglycemia in the noncritically ill trauma population.

LEVEL OF EVIDENCE

Therapeutic study, level III.

Preoperative asymptomatic leucocyturia and early prosthetic joint infections in patients undergoing joint arthroplasty

Prosthetic joint infection (PJI) is associated with a higher mortality, morbidity and economic costs. Although it is well known that the presence of urinary tract infection (UTI) is associated with PJI, few investigations evaluated the preoperative asymptomatic leukocyturia (ASL) and the possible relationship with early PJI. We reviewed the records of 739 patients performed primary joint arthroplasty. A total of 131 patients had preoperative ASL (17.7%) and 7 of 739 patients (0.9%) had early PJI. Preoperative ASL was not confirmed as a risk factor for early PJI on the multivariate regression analysis with an adjusted OR of 1.04 (P>0.05). Therefore, it should not be considered as a reason for postponement of total joint arthroplasty.

Perioperative Glucose Control and Infection Risk in Older Surgical Patients

The aging of the U.S. population is leading to an increasing number of surgical procedures performed on older adults. At the same time, the quality of medical care is being more closely scrutinized. Surgical site infection is a widely-assessed outcome. Evidence suggests that strict perioperative serum glucose control among patients with or without diabetes can lower the risk of these infections, but it is unclear whether this control should be applied to older surgical patients. In this clinical review, we discuss current research on perioperative serum glucose management for cardiothoracic, orthopedic, and general/colorectal surgery. In addition, we summarize clinical recommendations and quality-of-care process indicators provided by surgical, diabetes, and geriatric medical organizations.

Impact of diabetes mellitus on surgical outcomes in sports medicine

Diabetes mellitus (DM) affects a significant proportion of the patients evaluated and treated by orthopedic surgeons who specialize in sports medicine. Sports-medicine-related conditions associated with DM include tendinopathy, adhesive capsulitis of the shoulder, and articular cartilage disease. This article reviews the current literature adressing the effect of DM on surgical outcomes in sports medicine. In general, patients with DM undergo operations more frequently and experience inferior surgical outcomes compared with patients without DM. Diabetes mellitus is associated with increased rates of complications from sports medicine procedures, such as infection, delayed healing, and failure of the operation. However, additional research is needed to determine the full impact of DM on patient outcomes in sports medicine. Surgeons should be cognizant of special considerations in the population of patients with DM and aim to tailor the surgical management of this growing patient population.

Medical comorbidities are independent preoperative risk factors for surgical infection after total joint arthroplasty

BACKGROUND

Surgical site infection (SSI) after total joint arthroplasty (TJA) is a major cause of morbidity. Multiple patient comorbidities have been identified as SSI risk factors including obesity, tobacco use, diabetes, immunosuppression, malnutrition, and coagulopathy. However, the independent effect of multiple individual patient factors on risk of subsequent periprosthetic infection is unclear.

QUESTIONS/PURPOSES

The purposes of this study are (1) to collect data on several preestablished infection risk factors in addition to SSI-related data on a large TJA cohort; and (2) to use multivariate modeling on previously established patient risk factors to determine independent preoperative predictors of SSI.

METHODS

We reviewed records of patients undergoing TJA from January 1, 2010, to July 30, 2012. Confirmation of SSI followed published guidelines for superficial, deep, and periprosthetic. A total of 29 culture-positive SSIs (1.5% total) and 1846 controls were identified. The prevalence of known patient-specific infection risk factors was determined for both infected cases and healthy control subjects followed by multiple regression analysis to determine independent risk.

RESULTS

Isolated organisms consisted of methicillin-resistant Staphylococcus aureus (MRSA; 34.5%) followed by gram-negative rods (31.0%). After adjusting for anatomic site, independent risk factors for infection include: revision surgery (odds ratio [OR], 2.28; confidence interval [CI], 1.26-3.98), super obesity (body mass index>50 kg/m2; OR, 5.28; CI, 1.38-17.1), diabetes mellitus (OR, 1.83; CI, 1.02-3.27), tobacco abuse (OR, 2.96; CI, 1.65-5.11), MRSA colonization or infection (OR, 4.17; CI, 1.63-9.66), and current or prior bone cancer (OR, 3.86; CI, 1.21-12.79).

CONCLUSIONS

Multiple patient comorbidities independently contribute to infection risk after TJA. Preoperative TJA infection risk stratification may be feasible and should be investigated further.

LEVEL OF EVIDENCE

Level II, prognostic study. See Guidelines for Authors for a complete description of levels of evidence.

Hemoglobin A1C as a marker for surgical risk in diabetic patients undergoing total joint arthroplasty

Diabetes is a risk factor for complications following total joint arthroplasty (TJA). This retrospective cohort study of 6088 diabetic patients from the Veterans Health Administration (VHA) undergoing TJA sought to determine if hemoglobin A1c, an accessible and objective lab value, has utility as a predictor of risk of complications in TJA after controlling for demographic, surgical, and medical center effects, and to evaluate the benefits and risks of alternative thresholds. Analysis of the functional relationship between hemoglobin A1c and complications revealed that the risk linearly increases through, rather than surging at, the threshold of 7%. Before delaying surgery to achieve better diabetic control, surgeons and patients should weigh the estimated risks of TJA against the potential benefits.

Risk factors for early mortality following modern total hip arthroplasty

The aim of this study was to evaluate the incidence of early mortality and identify risk factors for early death following modern uncemented THA. Between 2000 and 2006, we identified patients who died within 90days of THA. Demographics, comorbidities, laboratory studies, and complications were analyzed as risk factors for mortality. 38 of 8261 patients undergoing THA (0.46%) died within 90days postoperatively. Of these, 26% were due to myocardial infarction. Multivariate analysis revealed Charlson index >3, peripheral vascular disease, elevated postoperative glucose, and abnormal postoperative cardiac studies as independent predictors of early mortality following THA. Caution should be taken in patients with increased comorbidities, PVD, perioperative hyperglycemia, and impaired renal function in order to reduce mortality following THA.

Relationship of hyperglycemia and surgical-site infection in orthopaedic surgery

BACKGROUND

The impact of perioperative hyperglycemia in orthopaedic surgery is not well defined. We hypothesized that hyperglycemia is an independent risk factor for thirty-day surgical-site infection in orthopaedic trauma patients without a history of diabetes at hospital admission.

METHODS

Patients eighteen years of age or older with isolated orthopaedic injuries requiring acute operative intervention were studied. Patients with diabetes, injuries to other body systems, a history of corticosteroid use, or admission to the intensive care unit were excluded. Blood glucose values were obtained, and hyperglycemia was defined in two ways. First, patients with two or more blood glucose levels of ≥200 mg/dL were identified. Second, the hyperglycemic index, a validated measure of overall glucose control during hospitalization, was calculated for each patient. A hyperglycemic index of ≥1.76 (equivalent to ≥140 mg/dL) was considered to indicate hyperglycemia. The primary outcome was thirty-day surgical-site infection. Multivariable logistic regression models evaluating the effect of the markers of hyperglycemia, after controlling for open fractures, were constructed.

RESULTS

Seven hundred and ninety patients were identified. There were 268 open fractures (33.9%). Twenty-one thirty-day surgical-site infections (2.7%) were recorded. Age, race, comorbidities, injury severity, and blood transfusion were not associated with the primary outcome. Of the 790 patients, 294 (37.2%) had more than one glucose value of ≥200 mg/dL. This factor was associated with thirty-day surgical-site infection, with thirteen (4.4%) of the 294 patients with that indication of hyperglycemia having a surgical-site infection versus eight (1.6%) of the 496 patients without more than one glucose value of ≥200 mg/dL (p = 0.02). One hundred and thirty-four (17.0%) of the 790 patients had a hyperglycemic index of ≥1.76, and this was also associated was thirty-day surgical-site infection (ten [7.5%] of 134 versus eleven [1.7%] of 656; p < 0.001). Multivariable logistic regression models demonstrated that two or more blood glucose levels of ≥200 mg/dL was a risk factor for thirty-day surgical-site infection (odds ratio [OR]: 2.7, 95% confidence interval [CI]: 1.1 to 6.7) after adjustment for open fractures (OR: 3.2, 95% CI: 1.3 to 7.8). A second model demonstrated that a hyperglycemic index of ≥1.76 was an independent risk factor for surgical-site infection (OR: 4.9, 95% CI: 2.0 to 11.8) after controlling for open fractures (OR: 3.3, 95% CI: 1.4 to 8.3).

CONCLUSIONS

Hyperglycemia was an independent risk factor for thirty-day surgical-site infection in orthopaedic trauma patients without a history of diabetes.

Diabetes Among Recipients of Home Health Services in the United States

The 2007 National Home and Hospice Care Survey was used to generate representative data on diabetic home health patients in the United States. Approximately 30% of home health patients have diabetes (11% have diabetes as the primary diagnosis), 28% were <65, 62% were women, and diabetic patients were more likely to be non-White. Nearly 75% received services immediately following a hospital or emergency room stay, 32% lived alone and nearly 20% did not have a primary caregiver. More than 40% of these patients needed assistance with ≥4 activities of daily living, 38% needed assistance with medication management and more than two thirds of families of diabetic patients received services from the agency that was serving the patient. The cost of services for home health patients with a primary diagnosis of diabetes is US$17.9 million/day.

Management of the hyperglycemic inpatient: tips, tools, and protocols for the clinician

Inpatient hyperglycemia is increasingly recognized as a contributor to in-hospital complications and prolonged hospital stays. Protocols to assist in management of hyperglycemia are becoming more widely used and have been shown to improve outcomes for hyperglycemic patients. In this article, several evidence-based protocols are reviewed for use by hospital-based clinicians, both for subcutaneous and intravenous insulin. Clinicians should consider implementing protocols for hyperglycemia management in the inpatient setting.

Prevalence of comorbid obstructive sleep apnea and metabolic syndrome: syndrome Z and maxillofacial surgery implications

PURPOSE

To determine the prevalence of the recently identified syndrome Z (SZ), which is the co-occurrence of obstructive sleep apnea (OSA; hypoxia, systemic and pulmonary hypertension, nocturnal arrhythmias) and metabolic syndrome (MetS; increased abdominal girth, hypertriglyceridemia, decreased high-density lipoprotein, hypertension, increased fasting glucose), which places the surgical patient at heightened risk of perioperative complications (myocardial infarction, stroke, pneumonia, wound infection).

MATERIALS AND METHODS

Electronic medical records of 296 male veterans were assessed for the presence of SZ using the American Academy of Sleep Medicine definition of OSA and a modified Adult Treatment Panel III definition of MetS, where obesity was defined by a body mass index of at least 30 kg/m(2) rather than by waist circumference.

RESULTS

SZ was diagnosed in 59% of patients. These individuals commonly exhibited severe OSA and least commonly mild OSA. The more severe the OSA, the more likely (60%) that patients manifested moderate (4 risk markers) or severe (5 risk markers) MetS. Furthermore, with increasing apnea-hypopnea index values, the more severe were the MetS elements.

CONCLUSIONS

The results of this study demonstrate the high prevalence rate of MetS in patients with OSA seeking treatment. Given the risk of perioperative complications, it is suggested that all patients scheduled for maxillofacial surgical procedures to treat OSA be evaluated for SZ.