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Budin M, Sandiford NA, Gehrke T, Citak M. Body mass index matters: morbid obese patients have different microorganism profiles in the setting of periprosthetic hip joint infections. INTERNATIONAL ORTHOPAEDICS 2025; 49:1309-1317. [PMID: 40183945 DOI: 10.1007/s00264-025-06513-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/10/2025] [Accepted: 03/20/2025] [Indexed: 04/05/2025]
Abstract
PURPOSE This study investigated the relationship between BMI and microorganism profiles, with a particular focus on gut microorganisms in patients with PJI following total hip arthroplasty (THA). It also explored comorbidities, that may contribute to these variations. METHODS This study included all patients treated at our institution for a PJI of a THA between 1996 and 2021. Patients were categorized into four distinct BMI groups: <30; 30-34.9; 35-39.9; ≥ 40. Bivariate and logistic regression analysis were conducted, with presentation of odds ratio (OR) and 95% confidence interval (CI). RESULTS A total of 3645 hip PJI cases were recruited for the final analysis. Patients with a BMI ≥ 40 had approximately a ten fold higher risk for Streptococcus dysgalactiae (p < 0.001; OR = 9.92; 95% CI 3.87-25.44) and a seven fold higher risk for Proteus mirabilis (p < 0.001; OR = 7.43; 95% CI 3.13-17.67) and Klebsiella pneumoniae (p < 0.001; OR = 6.9; 95% CI 2.47-19.31). Furthermore, polymicrobial infections (p < 0.001; OR = 2.17; 95% CI 1.50-3.15) were found to be significantly more prevalent in patients with a BMI ≥ 40. CONCLUSION Obese patients (BMI ≥ 30) displayed a distinct microorganism profile in hip PJIs, mainly dominated by Firmicutes and Proteobacteria. Comorbidities such as diabetes, hypertension, and hyperlipidaemia may contribute to a leaky gut syndrome, increasing PJI risk caused by gut microorganisms. Optimizing comorbidities may help reduce the risk of hip PJI. Further research is needed to clarify the relationship between obesity, gut microbiome alterations and hip PJI development.
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Berkovich Y, Nissan EC, Maman D, Hirschmann MT, Yonai Y, Steinfeld Y, Berkovich Y. Diabetes and total knee arthroplasty: A nationwide analysis of complications, hospitalization outcomes and revision burden. Knee Surg Sports Traumatol Arthrosc 2025. [PMID: 40351235 DOI: 10.1002/ksa.12696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2025] [Revised: 04/04/2025] [Accepted: 04/04/2025] [Indexed: 05/14/2025]
Abstract
PURPOSE Total knee arthroplasty (TKA) is a frequently performed surgical procedure aimed at reducing pain, improving mobility, and restoring function in patients with advanced knee osteoarthritis. As patients undergoing TKA age, the prevalence of comorbidities, particularly diabetes, continues to rise. This study assesses post-operative complications, healthcare costs and hospital length of stay (LOS) among diabetic patients undergoing primary and revision TKA using nationwide data from the NIS database, employing propensity score matching (PSM) to minimize confounding variables. We hypothesized that diabetic patients undergoing TKA would experience higher complication rates, greater healthcare costs and longer hospital stays compared to non-diabetic controls. METHODS This retrospective cohort analysis utilized data from the Nationwide Inpatient Sample from 2016 to 2019, including a total of 2,602,484 TKA patients: 561,340 with type 2 diabetes and 2,041,144 without diabetes. PSM was applied to create balanced cohorts, adjusting for baseline demographic and clinical differences. Outcomes analyzed included LOS, total hospitalization charges, post-operative complications and revision surgery rates. Statistical significance was set at p < 0.05. RESULTS Following PSM, diabetic patients exhibited significantly higher risks for post-operative complications, including sepsis, heart failure and surgical site infections, compared to matched non-diabetic controls. Diabetic patients also incurred significantly greater hospital charges ($64,694 vs. $59,952, p < 0.001). In revision TKA cases, diabetic patients demonstrated slightly longer LOS (3.5 days vs. 3.0 days, p < 0.001) and higher total hospital charges ($101,457 vs. $96,614, p = 0.015). CONCLUSIONS Diabetic patients undergoing TKA experience significantly higher complication rates, hospital charges and revision surgery burden. Orthopaedic surgeons and perioperative teams should implement personalized perioperative management strategies, including optimized glycaemic control, cardiovascular risk assessment and infection prevention measures, to mitigate these risks and improve clinical outcomes. LEVELS OF EVIDENCE Level III.
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Affiliation(s)
| | | | - David Maman
- Technion Israel Institute of Technology, Haifa, Israel
- Department of Orthopedics, Carmel Medical Center, Haifa, Israel
| | - Michael Tobias Hirschmann
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), Bruderholz, Switzerland
| | - Yaniv Yonai
- Technion Israel Institute of Technology, Haifa, Israel
- Department of Orthopedics, Carmel Medical Center, Haifa, Israel
| | - Yaniv Steinfeld
- Technion Israel Institute of Technology, Haifa, Israel
- Department of Orthopedics, Carmel Medical Center, Haifa, Israel
| | - Yaron Berkovich
- Technion Israel Institute of Technology, Haifa, Israel
- Department of Orthopedics, Carmel Medical Center, Haifa, Israel
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Levidy MF, Vatsia S, Gohel N, Rowe N, Kirchner GJ, Demedal S, Mason M. The Effects of Glucagon-Like Peptide-1 Agonist Therapy on Risk of Infection, Fracture, and Early Revision in Primary Total Joint Arthroplasty. J Am Acad Orthop Surg 2025:00124635-990000000-01327. [PMID: 40397943 DOI: 10.5435/jaaos-d-24-01284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2024] [Accepted: 03/26/2025] [Indexed: 05/23/2025] Open
Abstract
INTRODUCTION The purpose of this study was to examine rates of infection, revision, and periprosthetic fracture following total joint arthroplasty in diabetic patients treated with and without glucagon-like peptide-1 (GLP-1) agonist therapy. METHODS The TriNetX Global Collaborative Network was queried for patients with diabetes mellitus undergoing primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) from 2005 to 2024. Patients taking GLP-1 agonists within 1 year of surgery were matched to patients without. Cohort matching was done according to race, sex, body mass index nicotine dependence, hemoglobin A1c, and estimated glomerular filtration rate A total of 9,400 TKA procedures and 4,488 THA procedures constituted evenly divided cohorts. Outcomes included infection, revision surgery, and periprosthetic fractures at 3 months and 1 year. Bonferroni correction applied with threshold P < 0.0041. RESULTS TKA: periprosthetic infection following TKA was lower in the GLP-1 group compared with the non-GLP-1 group at both 3 months (0.94% vs. 1.45%; P < 0.001) and 1-year (1.21% vs. 2.04%; P < 0.001). Rates of periprosthetic fracture following TKA were higher albeit not markedly in patients prescribed GLP-1 agonists versus patients not receiving GLP-1 agonists at 3-months (0.47% vs. 0.21%; P = 0.034, respectively) and at 1-year (0.70% vs. 0.34%; P = 0.015) postoperatively. THA: No notable differences were observed in rates of infection, revision, or periprosthetic fracture in patients undergoing THA between those prescribed GLP-1s versus patients not receiving GLP-1 agonists at 3-months and 1-year. CONCLUSION In this retrospective study of both TKA and THA among diabetic patients, we found that patients using GLP-1 agonists had a lower rate of periprosthetic infection following TKA. The benefits of GLP-1 therapy might limit infection risk, however additional research is needed to understand the effect these medications make on patient nutrition and bone metabolism.
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Affiliation(s)
- Michael F Levidy
- From the Department of Orthopaedics and Rehabilitation, Penn State Milton S. Hershey Medical Center, Hershey, PA
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Tarabichi S, Abe EA, Olin B, Lizcano JD, Goh GS, Mu W, Hozack WJ, Cao L, Parvizi J, Courtney PM. Glycated Albumin as a Predictor of Adverse Outcomes in Patients Undergoing Primary Total Hip and Knee Arthroplasty: A Multicenter Prospective Study. J Arthroplasty 2025:S0883-5403(25)00454-1. [PMID: 40339933 DOI: 10.1016/j.arth.2025.04.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2025] [Revised: 04/22/2025] [Accepted: 04/24/2025] [Indexed: 05/10/2025] Open
Abstract
BACKGROUND Hemoglobin A1c (HbA1c) has long been the standard for measuring glycemic control; however, it may not be the ideal test to predict complications following total hip arthroplasty (THA) and total knee arthroplasty (TKA). While HbA1c measures glycemic control over three months, other markers such as fructosamine (seven to 21 days) and glycated albumin (GA) (14 to 21 days) may be more accurate predictors. The purpose of this study was to assess the utility of GA in predicting complications in patients undergoing primary THA and TKA. METHODS This prospective study enrolled 1,020 patients (633 TKA, 387 THA) at two institutions. The mean age of our cohort was 64 years, and 631 (61.8%) patients were women. There were 131 (12.8%) patients who had a history of type 2 diabetes mellitus. The HbA1c, fructosamine, and GA were measured preoperatively using standardized assays. The HbA1c cutoff of 7.7%, fructosamine cutoff of 270 mmol/L, and GA cutoff of 17.1% were used to define poor glycemic control. The 90-day complications in patients above the threshold for each marker were identified and compared with those below it. Multivariate regressions were utilized to assess the predictive value of each test. RESULTS The HbA1c and GA were found to have the strongest correlation with one another (r = 0.63), followed by fructosamine/GA (r = 0.41) and ractopamine/HbA1c (r = 0.23). Upon regression analysis, GA ≥ 17.1% (odds ratio [OR], 4.8 [95% CI (confidence interval), 1.4 to 15.7]; P = 0.011) was identified as an independent risk factor for 90-day complications, while fructosamine (OR, 0.63 [95% CI, 0.13 to 2.13]; P = 0.51), and HbA1c (OR, 1.18 [95% CI, 0.24 to 4.97]; P = 0.83) were not. CONCLUSIONS The results of our prospective study suggest that GA may more accurately predict short-term (90-day) complications in patients undergoing THA and TKA, when compared to fructosamine and HbA1c. Longer follow-up time is necessary in order to identify the optimal GA cutoff for use in this setting and to determine whether any correlation exists between elevated GA levels and periprosthetic joint infection.
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Affiliation(s)
- Saad Tarabichi
- Department of Orthopaedic Surgery, Mayo Clinic Arizona, Phoenix, Arizona
| | - Elizabeth A Abe
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Brooke Olin
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Juan D Lizcano
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Graham S Goh
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania; Department of Orthopaedic Surgery, Boston Medical Center, Boston, Massachusetts
| | - Wenbo Mu
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania; Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Xinjian, China
| | - William J Hozack
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Li Cao
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Xinjian, China
| | - Javad Parvizi
- International Joint Center, Acibadem University Hospital, Istanbul, Turkey
| | - P Maxwell Courtney
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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Kheir MM, Anderson CG, Chiu YF, Carli A. Perioperative Glycemic Variability Influences Infection Rates Differently Following Revision Hip and Knee Arthroplasty. J Arthroplasty 2025; 40:1005-1013. [PMID: 39368718 DOI: 10.1016/j.arth.2024.09.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2024] [Revised: 09/27/2024] [Accepted: 09/30/2024] [Indexed: 10/07/2024] Open
Abstract
BACKGROUND Recent investigations have determined that abnormal postoperative glycemia following primary total joint arthroplasty is associated with adverse events. Our study aimed to determine if hyperglycemia and glycemic variability following aseptic revision total joint arthroplasty were associated with periprosthetic joint infection (PJI) within two years postoperatively. METHODS A retrospective review was performed of 2,208 patients within a single institution undergoing aseptic revision total joint arthroplasty from 2012 to 2019. Postoperative glucose values were recorded. Glycemic variability was measured via three parameters: coefficient of variation, mean amplitude of glycemic excursions, and J-index. Logistic regression analyses were performed to examine associations with PJI at 90-day, 1-, and 2-year follow-up. RESULTS In revision hips, all glycemic measures were not associated with PJI at any time point in logistic regression analyses, except for the mean amplitude of glycemic excursions, which predicted PJI at one year (P = 0.045); body mass index was the only factor associated with PJI at all timepoints in all models. In revision knees, all glycemic measures were not associated with PJI at any timepoint in logistic regression analyses; however, PJI rates differed between diabetics and nondiabetics at all time points (P < 0.05). CONCLUSIONS Our findings illustrate that decreasing preoperative body mass index and postoperative glycemic variability may be critical in reducing PJI rates in revision hips. Furthermore, patients who have diabetes should be counseled that they remain at higher risk of PJI regardless of perioperative glucose control after revision knee surgery.
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Affiliation(s)
- Michael M Kheir
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan
| | | | - Yu-Fen Chiu
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - Alberto Carli
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
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Chen J, Wang C, Li F, Wang X, Li Y, Feng H, Zhao M, Tian H. Impact of Dexamethasone on Blood Glucose After Total Knee Arthroplasty in Patients With Type 2 Diabetes. Orthop Surg 2025; 17:814-821. [PMID: 39871680 PMCID: PMC11872363 DOI: 10.1111/os.14333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2024] [Revised: 12/02/2024] [Accepted: 12/03/2024] [Indexed: 01/29/2025] Open
Abstract
OBJECTIVE With the global aging population, the incidence of OA is rising annually, and the number of TKA surgeries is rapidly increasing, placing a heavy economic and healthcare burden on society. As one of the key medications in the ERAS protocol, DXM can significantly reduce postoperative pain, suppress nausea and vomiting, and accelerate patient recovery. However, the safety of perioperative DXM use in patients with diabetes remains unclear. This study aims to clarify the safety of perioperative DXM application in diabetic patients. METHODS This retrospective analysis involved 285 patients with type 2 diabetes and late-stage knee osteoarthritis who underwent unilateral TKA at the Joint Surgery Center of Peking University Third Hospital from January 2019 to November 2022. After application of the inclusion and exclusion criteria, 161 patients were included in the study. The patients were divided into two groups according to whether they had received continuous intravenous administration of DXM for 3 days postoperatively: the DXM group (n = 66) and the non-DXM group (n = 95). All other treatments and medications were the same in both groups. The patients' PBG, incidence of PONV, length of hospital stay, pain scores, and clinical data were collected and compared between the two groups. RESULTS There were no significant differences in the general preoperative data between the DXM and non-DXM groups. The average PBG and the proportion of patients with levels exceeding 200 mg/dL were not significantly different between the two groups (10.84 mg/dL vs. 11.05 mg/dL and 43.2% vs. 43.9%). The postoperative visual analog scale scores (3.67 vs. 2.48) and the incidence of PONV were significantly lower in the DXM than non-DXM group (40% vs. 16%). The preoperative level of glycated hemoglobin accurately predicted PBG. Furthermore, there were no statistically significant differences in the incidence of early postoperative complications between the groups. CONCLUSIONS The administration of DXM after unilateral TKA can effectively reduce postoperative pain and suppress the occurrence of PONV without affecting PBG in patients with type 2 diabetes. In addition, the preoperative level of glycated hemoglobin can accurately predict PBG.
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Affiliation(s)
- Jiazheng Chen
- Department of Orthopaedics/Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education/Beijing Key Laboratory of Spinal Disease ResearchPeking University Third HospitalBeijingChina
| | - Cheng Wang
- Department of Orthopaedics/Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education/Beijing Key Laboratory of Spinal Disease ResearchPeking University Third HospitalBeijingChina
| | - Feng Li
- Department of Orthopaedics/Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education/Beijing Key Laboratory of Spinal Disease ResearchPeking University Third HospitalBeijingChina
| | - Xinguang Wang
- Department of Orthopaedics/Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education/Beijing Key Laboratory of Spinal Disease ResearchPeking University Third HospitalBeijingChina
| | - Yang Li
- Department of Orthopaedics/Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education/Beijing Key Laboratory of Spinal Disease ResearchPeking University Third HospitalBeijingChina
| | - Hui Feng
- Department of Orthopaedics/Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education/Beijing Key Laboratory of Spinal Disease ResearchPeking University Third HospitalBeijingChina
| | - Minwei Zhao
- Department of Orthopaedics/Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education/Beijing Key Laboratory of Spinal Disease ResearchPeking University Third HospitalBeijingChina
| | - Hua Tian
- Department of Orthopaedics/Engineering Research Center of Bone and Joint Precision Medicine, Ministry of Education/Beijing Key Laboratory of Spinal Disease ResearchPeking University Third HospitalBeijingChina
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Müller M, Weber P. [Diabetes mellitus and total joint arthroplasty-What should be considered?]. ORTHOPADIE (HEIDELBERG, GERMANY) 2025; 54:129-134. [PMID: 39774718 DOI: 10.1007/s00132-024-04598-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 12/06/2024] [Indexed: 01/11/2025]
Abstract
Diabetes mellitus (DM) is on the rise in the population. Approximately 10% of adults suffer from DM. Over two-thirds of patients are over 60 years old, and thus it particularly affects patients who have to undergo total joint arthroplasty. Patients with DM have an increased risk of surgical site infection and periprosthetic infections. The risk particularly affects patients with inadequately controlled DM. Diabetes control can be monitored using HbA1c, which correlates with both the adjustment and the risk of infection. HbA1c should therefore be determined in all patients with DM before a prosthesis is implanted. Patients with HbA1c over 8% should be seen by a diabetologist and have their blood sugar control optimized.
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Affiliation(s)
- Michael Müller
- Klinik für Orthopädie und Unfallchirurgie, Zentralklinik Bad Berka, Robert-Koch-Allee 9, 99438, Bad Berka, Deutschland.
| | - Patrick Weber
- ECOM - Praxis für Orthopädie, Sportmedizin und Unfallchirurgie, München, Deutschland
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Choe H, Indelli PF, Ricciardi B, Kim TY, Homma Y, Kigera J, Veloso Duran M, Khan T. What Are the Absolute Contraindications for Elective Total Knee or Hip Arthroplasty? J Arthroplasty 2025; 40:S45-S47. [PMID: 39426446 DOI: 10.1016/j.arth.2024.10.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2024] [Revised: 10/04/2024] [Accepted: 10/08/2024] [Indexed: 10/21/2024] Open
Affiliation(s)
- Hyonmin Choe
- Department of Orthopaedic Surgery, Yokohama City University, Yokohama, Japan
| | - Pier Francesco Indelli
- Knee Robotics and PJI Unit, Südtiroler Sanitätsbetrieb, Brixen, Italy; The Breyer Center for Overseas Studies, Stanford University in Florence, Italy
| | - Benjamin Ricciardi
- Department of Orthopaedic Surgery, University of Rochester, Rochester, New York
| | - Tae-Young Kim
- Department of Orthopaedic Surgery, Konkuk University Medical Center, School of Medicine, Konkuk University, Seoul, Korea
| | - Yasuhiro Homma
- Department of Medicine for Orthopaedics and Motor Organ, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - James Kigera
- Faculty of Health Sciences, University of Nairobi, Nairobi, Kenya
| | - Margarita Veloso Duran
- Department of Orthopaedic Surgery, Hospital Universitari MútuaTerrassa, Terrassa, Catalunya, ES
| | - Tahir Khan
- Caterall Unit, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore, UK
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Palmer RC, Telang SS, Ball JR, Wier J, Lieberman JR, Heckmann ND. The Limited Utility of Hemoglobin A1c as a Predictor for Periprosthetic Joint Infection Following Total Joint Arthroplasty: A Continuous Variable Analysis. J Arthroplasty 2025:S0883-5403(25)00019-1. [PMID: 39814114 DOI: 10.1016/j.arth.2025.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Revised: 01/03/2025] [Accepted: 01/07/2025] [Indexed: 01/18/2025] Open
Abstract
BACKGROUND Patients who have poorly controlled diabetes mellitus are at increased risk of periprosthetic joint infection (PJI). Nevertheless, an optimal preoperative hemoglobin A1c (HbA1c) threshold has not been established. This study sought to identify preoperative HbA1c thresholds that were predictive of adverse outcomes for total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients. METHODS A healthcare database was used to identify primary THAs or TKAs performed from 2016 to 2021 with a preoperative HbA1c value within 28 days of surgery. The primary outcome was PJI within 90 days postoperatively. Secondary outcomes included aggregate medical and surgical complications. Restricted cubic splines were generated using logistic regression to quantify the impact of HbA1c as a continuous variable on the risk of PJI. Between HbA1c values of 5 and 12%, relevant sensitivity and specificity measurements were calculated at intervals of 0.5%. A Youden's J statistic identified clinically relevant preoperative HbA1c thresholds. RESULTS In total, 17,481 elective arthroplasty patients who had a preoperative HbA1c were identified. The mean preoperative HbA1c was 6.5%. The previous two sentences should be placed at the end of the Methods section For TKA, a PJI threshold of 9.7% was identified (sensitivity: 19.4%, specificity: 99.1%), while for THA, a PJI threshold of 7.8% was identified (sensitivity: 22.7%, specificity: 89.9%). The threshold for aggregate medical complications was 6.8% for TKA (sensitivity: 53.7%, specificity: 59.1%) and 6.5% for THA (sensitivity: 45.5%, specificity: 66.5%). No association was observed between HbA1c and aggregate surgical complications for either THA or TKA. CONCLUSIONS This study identified PJI and medical complication HbA1c thresholds above which patients were at a significantly increased risk of early postoperative complications. While our findings suggest that HbA1c has limited predictive utility for postoperative complications, it remains an accessible biomarker that can aid in preoperative risk stratification. Future studies should explore other promising or complementary biomarkers that may be more effective for preoperative risk stratification. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Ryan C Palmer
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Sagar S Telang
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Jacob R Ball
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Julian Wier
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Jay R Lieberman
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Nathanael D Heckmann
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
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Akram F, Tseng J, Behery O, Levine BR. Comorbidities in Total Hip and Knee Arthroplasty Patients: When Is It Okay to Say No? Orthop Clin North Am 2025; 56:1-12. [PMID: 39581640 DOI: 10.1016/j.ocl.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2024]
Abstract
Preoperative optimization of modifiable risk factors for total hip and knee arthroplasty remains a foundational cornerstone in reducing postoperative complications and enhancing patient outcomes. With an increasing prevalence of high-risk comorbidities among total joint arthroplasty patients with morbid obesity (body mass index ≥40 kg/m2), uncontrolled diabetes (hemoglobin A1c ≥ 7.5%), and active smoking and tobacco use, many joint arthroplasty surgeons face complex ethical decisions when surgical intervention poses a higher risk for potential harm. Creating definitive numerical cutoffs may lead to access-to-care issues with a difficult balance between helping and harming patients.
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Affiliation(s)
- Faisal Akram
- Department of Orthopaedic Surgery, Corewell Health and Michigan State University, Grand Rapids, MI, USA.
| | - Joyee Tseng
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Omar Behery
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Brett R Levine
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
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Hong SH, Kwon SC, Lee JH, Moon S, Kim JI. Influence of Diabetes Mellitus on Postoperative Complications After Total Knee Arthroplasty: A Systematic Review and Meta-Analysis. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:1757. [PMID: 39596942 PMCID: PMC11595993 DOI: 10.3390/medicina60111757] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/09/2024] [Revised: 10/19/2024] [Accepted: 10/24/2024] [Indexed: 11/29/2024]
Abstract
Background and Objectives: Total knee arthroplasty (TKA) is an effective treatment option for severe knee osteoarthritis. Understanding the impact of diabetes mellitus (DM) on postoperative outcomes is crucial for improving patient satisfaction after TKA. This study aimed to investigate the influence of DM on postoperative complications and mortality after TKA. Materials and Methods: We conducted a systematic review and meta-analysis by searching relevant studies published before December 2023 in the PubMed, EMBASE, Cochrane Library, Medline, and Web of Science databases. The assessment included demographic data, comorbidities, and postoperative complications after primary TKA for both DM and non-DM patients. The odds ratio (OR) was used to represent the estimate of risk of a specific outcome. Results: Thirty-nine studies were finally included in this meta-analysis. Patients with DM had higher rates of periprosthetic joint infection (OR: 1.71, 95% confidence interval [CI]: 1.46-2.00, p < 0.01) and prosthesis revision (OR: 1.37, 95% CI: 1.23-1.52, p < 0.01). Moreover, patients with DM showed an elevated incidence of pneumonia (OR: 1.54, 95% CI: 1.15-2.07, p < 0.01), urinary tract infection (OR: 1.86, 95% CI: 1.07-3.26, p = 0.02), and sepsis (OR: 1.61, 95% CI: 1.46-1.78, p < 0.01). Additionally, the postoperative risk of cardiovascular (OR: 2.49, 95% CI: 1.50-4.17, p < 0.01) and cerebrovascular (OR: 2.38, 95% CI: 1.48-3.81, p < 0.01) events was notably higher in patients with DM. The presence of DM increased the risk of deep vein thrombosis (OR: 1.58, 95% CI: 1.22-2.04, p < 0.01), but did not lead to an increased risk of pulmonary embolism. Most importantly, DM was associated with a higher mortality rate within 30 days after TKA (OR: 1.27, 95% CI: 1.02-1.60, p = 0.03). Conclusions: Patients with DM exhibited a higher rate of postoperative complications after TKA, and DM was associated with a higher mortality rate within 30 days after TKA. It is crucial to educate patients about the perioperative risk and develop evidence-based guidelines to prevent complications after TKA.
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Affiliation(s)
- Seok Ho Hong
- Department of Orthopaedic Surgery, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul 07441, Republic of Korea; (S.H.H.); (S.C.K.); (J.H.L.)
| | - Seung Cheol Kwon
- Department of Orthopaedic Surgery, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul 07441, Republic of Korea; (S.H.H.); (S.C.K.); (J.H.L.)
| | - Jong Hwa Lee
- Department of Orthopaedic Surgery, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul 07441, Republic of Korea; (S.H.H.); (S.C.K.); (J.H.L.)
| | - Shinje Moon
- Department of Internal Medicine, Hanyang University Seoul Hospital, Hanyang University College of Medicine, Seoul 04763, Republic of Korea
| | - Joong Il Kim
- Department of Orthopaedic Surgery, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul 07441, Republic of Korea; (S.H.H.); (S.C.K.); (J.H.L.)
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12
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Tischler EH, Lizcano JD, Shohat N, Tarabichi M, Restrepo C, Parvizi J. The Association of Glycemic Control Medication Regimens and Preoperative Fructosamine Among Total Joint Artrhoplasty Patients. J Am Acad Orthop Surg 2024:00124635-990000000-01127. [PMID: 39467277 DOI: 10.5435/jaaos-d-23-01189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Accepted: 09/04/2024] [Indexed: 10/30/2024] Open
Abstract
BACKGROUND Although glycated hemoglobin A1C (HbA1c) has classically been used for glycemic control screening before surgery, fructosamine, a short-term glucose variability indicator, has been reported to be a more accurate predictor of postoperative periprosthetic joint infection among patients with diabetes mellitus (DM). Given the variability of diabetic medication management, this study aims to identify the associated effect of glycemic control medication regimen (GCMR) on the incidence rate and associated odds of abnormal preoperative fructosamine levels among diabetic primary total knee arthroplasty or total hip arthroplasty patients. METHODS Between 2017 and 2018, consecutive series of total hip arthroplasty and total knee arthroplasty patients were identified, and the final cohort included only diabetic patients. All patients reported preoperative HbA1c and fructosamine levels. GCMR categories included insulin, metformin, and other. Independent risk of GCMR and abnormal fructosamine levels (>293 µmol/L) were identified using multivariable logistic regression, while controlling for preoperative baseline factors including HbA1C. RESULTS Among 420 patients, 15.7% (66/420) were diabetic, of whom 22.7% (15/66) reported an abnormal fructosamine level. Among patients requiring GCMR, 24.0% (18/75), 56.0% (42/75), and 77.7% (58/75) reported using insulin, other, and metformin, respectively. Multivariable logistic regressions demonstrated that insulin-dependent patients with DM reported a 1.71 (95% confidence interval [CI], 0.096 to 30.213, P = 0.716) increased odds of abnormal fructosamine levels compared with nonactive GCMR patients, whereas patients managed with metformin and other glycemic control medications reported a protective 0.48 (95% CI, 0.418 to 5.407, P = 0.549) and 0.32 (95% CI, 0.216 to 4.508, P = 0.393) decreased odds of abnormal fructosamine levels, respectively. CONCLUSION In this study, insulin and other GCMR medications exhibited a trend for increased and decreased odds of having abnormal preoperative fructosamine levels while controlling for baseline HbA1c level compared with patients with DM without active GCMR. This association may be explained by multifactorial short-term glucose variability in insulin users, indicating the continued need and optimization of short-term glycemic variations instead of HbA1c.
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Affiliation(s)
- Eric H Tischler
- Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, PA (Tischler, Lizcano, Shohat, Tarabichi, and Restrepo), and International Joint Center, Acibadem University Hospital, Istanbul, Turkey (Parvizi)
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13
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Wu KA, Anastasio AT, Krez AN, O'Neill C, Adams SB, DeOrio JK, Easley ME, Nunley JA. Diabetic management and infection risk in total ankle arthroplasty. Foot Ankle Surg 2024; 30:552-556. [PMID: 38637171 DOI: 10.1016/j.fas.2024.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 03/11/2024] [Accepted: 04/15/2024] [Indexed: 04/20/2024]
Abstract
BACKGROUND As total ankle arthroplasty (TAA) increases in popularity nationwide for the management of end-stage arthritis, it is essential to understand ways to mitigate the risk of infection. Diabetes increases the risk of infection due to compromised immunity and impaired wound-healing mechanisms. However, there is limited research on how diabetic management, inclusive of medications and glucose control, may impact infection risks post-TAA. This study aims to demonstrate the impact of diabetic management on the occurrence of periprosthetic joint infection (PJI) following TAA. METHODS This was a retrospective study of patients who underwent a TAA at a single academic institution from March 2002 to May 2022. Patients with diabetes who developed an intraarticular infection following TAA were propensity score matched (1:3) to diabetic patients who did not. Data collection included demographics, implant types, diabetic medications, and preoperative hemoglobin A1c. PJI was diagnosed based on Musculoskeletal Infection Society (MSIS) criteria. Statistical analyses assessed differences in medication use, glucose control, and infection rates between groups. RESULTS Of the 1863 patients who underwent TAA, 177 patients had a diagnosis of diabetes. The infection rate in patients with diabetes (2.8%) was higher than the total cohort rate (0.8%). Five patients with diabetes developed a PJI at an average of 2.2 months postoperatively. This cohort (n = 5) was compared to propensity score-matched controls (n = 15). There was no significant difference in diabetic medication use. Patients who developed PJI had higher rates of uncontrolled diabetes (60.0% vs. 6.7%) and average A1c levels (7.02% vs. 6.29%) compared to controls. CONCLUSION Our findings suggest that the elevated risk of PJI observed in individuals with diabetes subsequent to TAA may be attributed not solely to the presence of diabetes, but to inadequate glycemic control. Effectively managing blood glucose levels is imperative for achieving favorable outcomes following TAA. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Kevin A Wu
- Division of Foot and Ankle, Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC 27710, USA.
| | - Albert T Anastasio
- Division of Foot and Ankle, Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC 27710, USA.
| | - Alexandra N Krez
- Division of Foot and Ankle, Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC 27710, USA.
| | - Conor O'Neill
- Division of Foot and Ankle, Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC 27710, USA.
| | - Samuel B Adams
- Division of Foot and Ankle, Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC 27710, USA.
| | - James K DeOrio
- Division of Foot and Ankle, Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC 27710, USA.
| | - Mark E Easley
- Division of Foot and Ankle, Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC 27710, USA.
| | - James A Nunley
- Division of Foot and Ankle, Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, NC 27710, USA.
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14
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Ergin M, Budin M, Canbaz SB, Ciloglu O, Gehrke T, Citak M. Microbiological profiles in periprosthetic joint infections after total knee arthroplasty: a comparative analysis of diabetic and non-diabetic patients. INTERNATIONAL ORTHOPAEDICS 2024; 48:2633-2640. [PMID: 39180538 DOI: 10.1007/s00264-024-06275-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Accepted: 08/10/2024] [Indexed: 08/26/2024]
Abstract
AIM OF THE STUDY The purpose of this study is to conduct a comparative analysis of the microbiological profiles in periprosthetic joint infections (PJIs) after total knee arthroplasty (TKA) between diabetic and non-diabetic patients. The study aims to address what are the variations in microbial colonization and infection patterns between diabetic and non-diabetic patients undergoing total knee arthroplasty. METHODS A retrospective analysis of 2,569 culture-positive cases of PJIs post-TKA was conducted, comparing outcomes between diabetic (n = 321) and non-diabetic (n = 2,248) patients. Demographic, clinical, and microbiological data were collected and analyzed using descriptive statistics, chi-squared tests, logistic regression, and other statistical tests. RESULTS Diabetic patients exhibited distinct microbial colonization patterns, with a higher prevalence of pathogens such as Staphylococcus aureus (p = 0.033), Pseudomonas aeruginosa (p < 0.001), Streptococcus spp. (Streptococcus agalactiae and Streptococcus dysgalactiae; p = 0.010, 0.016 respectively), Candida spp. (p = 0.010), and Corynebacterium spp. (p = 0.024). Additionally, diabetic patients were at increased risk of polymicrobial infections. Comorbidities associated with diabetes, including chronic pulmonary disease, renal insufficiency, and peripheral artery disease, were significantly more prevalent in diabetic patients and further complicated PJI outcomes. CONCLUSION This study underscores the importance of tailored perioperative antimicrobial strategies and vigilant infection control measures in diabetic patients undergoing TKA. Understanding the differential microbial profiles and associated comorbidities can inform targeted interventions to mitigate the risk of PJIs and improve outcomes in this high-risk population. Further research is warranted to elucidate the underlying mechanisms and optimize management strategies for diabetic patients undergoing TKA.
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Affiliation(s)
- Musa Ergin
- Department of Orthopaedic Surgery, ENDO-Klinik Hamburg, Holstenstr. 2, 22767, Hamburg, Germany
- Department of Orthopedics and Traumatology, Cihanbeyli State Hospital, Konya, Turkey
| | - Maximilian Budin
- Department of Orthopaedic Surgery, ENDO-Klinik Hamburg, Holstenstr. 2, 22767, Hamburg, Germany
| | - Sebati Başer Canbaz
- Department of Orthopaedic Surgery, ENDO-Klinik Hamburg, Holstenstr. 2, 22767, Hamburg, Germany
| | - Osman Ciloglu
- Department of Orthopaedic Surgery, ENDO-Klinik Hamburg, Holstenstr. 2, 22767, Hamburg, Germany
| | - Thorsten Gehrke
- Department of Orthopaedic Surgery, ENDO-Klinik Hamburg, Holstenstr. 2, 22767, Hamburg, Germany
| | - Mustafa Citak
- Department of Orthopaedic Surgery, ENDO-Klinik Hamburg, Holstenstr. 2, 22767, Hamburg, Germany.
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Leal J, Wellman SS, Jiranek WA, Seyler TM, Bolognesi MP, Ryan SP. Continuing Home Oral Hypoglycemic Medications Was Associated With Superior Postoperative Glycemic Control Versus Initiating Sliding Scale Insulin After Total Hip Arthroplasty. Orthopedics 2024; 47:276-282. [PMID: 38935846 DOI: 10.3928/01477447-20240619-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
Abstract
BACKGROUND This retrospective study investigated the impact of continuing vs discontinuing home oral hypoglycemic medications for patients with diabetes undergoing total hip arthroplasty. MATERIALS AND METHODS Patients who were not exclusively receiving home oral hypoglycemic regimens were excluded. Additionally, patients whose diabetes was not managed inpatient postoperatively were excluded. Included patients were retrospectively evaluated for early postoperative glycemic control, renal function, and metabolic abnormalities. Patients were then compared based on whether their home oral hypoglycemic regimen was continued vs discontinued in favor of initiating insulin while inpatient and analyzed using multivariable regression analysis. RESULTS A total of 532 patients undergoing total hip arthroplasty met inclusion criteria, with 78.6% continuing their home oral hypoglycemic regimen. Those who continued showed significantly lower median maximum inpatient blood glucose (178.5 mg/dL vs 249.5 mg/dL; P<.001) and median average inpatient blood glucose (138.4 mg/dL vs 178.6 mg/dL; P<.001). Linear regression analysis, adjusting for various potential confounding factors, revealed a positive correlation between discontinuation of home hypoglycemic medications and higher maximum in-patient blood glucose (β=70.15 [95% CI, 59.27-81.03]; P<.001). Patients in the continuation group had lower proportions of acute kidney injury (18.7% vs 41.2%; P<.001) and metabolic acidosis (4.3% vs 17.5%; P<.001), along with a shorter length of stay (1.0 vs 2.0 days; P<.001). CONCLUSION These findings suggest that continuing a home oral hypoglycemic regimen for patients with diabetes after total hip arthroplasty is associated with superior glycemic control without exacerbating renal abnormalities or increasing metabolic complications. [Orthopedics. 2024;47(5):276-282.].
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16
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Leal J, Wellman SS, Jiranek WA, Seyler TM, Bolognesi MP, Ryan SP. Continuation of Oral Antidiabetic Medications Was Associated With Better Early Postoperative Blood Glucose Control Compared to Sliding Scale Insulin After Total Knee Arthroplasty. J Arthroplasty 2024; 39:2047-2054.e1. [PMID: 38428690 DOI: 10.1016/j.arth.2024.02.069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 02/19/2024] [Accepted: 02/20/2024] [Indexed: 03/03/2024] Open
Abstract
BACKGROUND This study evaluated blood glucose (BG), creatinine levels, metabolic issues, length of stay (LOS), and early postoperative complications in diabetic primary total knee arthroplasty (TKA) patients. It examined those who continued home oral antidiabetic medications and those who switched to insulin postoperatively. The hypothesis was that continuing home medications would lead to lower BG levels without metabolic abnormalities. METHODS Patients who had diabetes who underwent primary TKA from 2013 to 2022 were evaluated retrospectively. Diabetic patients who were not on home oral antidiabetic medications or who were not managed as an inpatient postoperatively were excluded. Patient demographics and laboratory tests collected preoperatively and postoperatively as well as 90-day emergency department visits and 90-day readmissions, were pulled from electronic records. Patients were grouped based on inpatient diabetes management: continuation of home medications versus new insulin coverage. Acute postoperative BG control, creatinine levels, metabolic abnormalities, LOS, and early postoperative complications were compared between groups. Multivariable regression analyses were performed to measure associations. RESULTS A total of 867 primary TKAs were assessed; 703 (81.1%) patients continued their home oral antidiabetic medications. Continuing home antidiabetic medications demonstrated lower median maximum inpatient BG (180.0 mg/dL versus 250.0 mg/dL; P < .001) and median average inpatient BG (136.7 mg/dL versus 173.7 mg/dL; P < .001). Logistic regression analyses supported the presence of an association (odds ratio = 17.88 [8.66, 43.43]; P < .001). Proportions of acute kidney injury (13.5 versus 26.7%; P < .001) were also lower. There was no difference in relative proportions of metabolic acidosis (4.4 versus 3.7%; P = .831), LOS (2.0 versus 2.0 days; P = .259), or early postoperative complications. CONCLUSIONS Continuing home oral antidiabetic medications after primary TKA was associated with lower BG levels without an associated worsening creatinine or increase in metabolic acidosis. LEVEL III EVIDENCE Retrospective Cohort Study.
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Affiliation(s)
- Justin Leal
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | - Samuel S Wellman
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | - William A Jiranek
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | - Thorsten M Seyler
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
| | | | - Sean P Ryan
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina
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Gauthier CW, Bakaes YC, Kern EM, Kung JE, Hopkins JS, Hamilton CA, Bishop BC, March KA, Jackson JB. Total Joint Arthroplasty Outcomes in Eligible Patients Versus Patients Who Failed to Meet at Least 1 Eligibility Criterion: A Single-Center Retrospective Analysis. J Arthroplasty 2024; 39:1974-1981.e2. [PMID: 38403078 DOI: 10.1016/j.arth.2024.02.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 02/14/2024] [Accepted: 02/19/2024] [Indexed: 02/27/2024] Open
Abstract
BACKGROUND This study looks to investigate how not meeting eligibility criteria affects postoperative outcomes following total joint arthroplasty surgery. METHODS A retrospective review was conducted of total joint arthroplasty patients at a single academic institution. Demographics, laboratory values, and complications were recorded. Continuous and categorical variables were compared using the Student's T-test and the Chi-Square test, respectively. Multivariable analysis was used to control for confounding variables. RESULTS Our study included 915 total hip and 1,579 total knee arthroplasty patients. For total hip and total knee arthroplasty, there were no significant differences in complications (P = .11 and .87), readmissions (P = .83 and .2), or revision surgeries (P = .3 and 1) when comparing those who met all criteria to those who did not. Total hip arthroplasty patients who did not meet two criteria had 16.1 higher odds (P = .02) of suffering a complication. There were no differences in complications (P = .34 and .41), readmissions (P = 1 and .55), or revision surgeries (P = 1 and .36) between ineligible patients treated by total joint arthroplasty surgeons and those who were not. Multivariable analysis demonstrated no eligibility factors were associated with outcomes for both total hip and knee arthroplasty. CONCLUSIONS There was no significant difference in outcomes between those who met all eligibility criteria and those who did not. Not meeting two criteria conferred significantly higher odds of suffering a complication for total hip arthroplasty patients. Total joint arthroplasty surgeons had similar outcomes to non-total joint surgeons, although their patient population was more complex. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Chase W Gauthier
- Prisma Health Department of Orthopedic Surgery, Columbia, South Carolina
| | - Yianni C Bakaes
- Prisma Health Department of Orthopedic Surgery, Columbia, South Carolina
| | - Elizabeth M Kern
- Prisma Health Department of Orthopedic Surgery, Columbia, South Carolina
| | - Justin E Kung
- Prisma Health Department of Orthopedic Surgery, Columbia, South Carolina
| | - Jeffrey S Hopkins
- Prisma Health Department of Orthopedic Surgery, Columbia, South Carolina
| | - Corey A Hamilton
- Prisma Health Department of Orthopedic Surgery, Columbia, South Carolina
| | - Braxton C Bishop
- Prisma Health Department of Orthopedic Surgery, Columbia, South Carolina
| | - Kyle A March
- Prisma Health Department of Orthopedic Surgery, Columbia, South Carolina
| | - J Benjamin Jackson
- Prisma Health Department of Orthopedic Surgery, Columbia, South Carolina
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Telang S, Mayfield CK, Palmer R, Liu KC, Wier J, Hong K, Lieberman JR, Heckmann ND. Preoperative Laboratory Values Predicting Periprosthetic Joint Infection in Morbidly Obese Patients Undergoing Total Hip or Knee Arthroplasty. J Bone Joint Surg Am 2024; 106:1317-1327. [PMID: 38941451 DOI: 10.2106/jbjs.23.01360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/30/2024]
Abstract
BACKGROUND Morbidly obese patients are an ever-growing high-risk population undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA) for end-stage osteoarthritis. This study sought to identify preoperative laboratory values that may serve as predictors of periprosthetic joint infection (PJI) in morbidly obese patients undergoing THA or TKA. METHODS All morbidly obese patients with preoperative laboratory data before undergoing primary elective TKA or THA were identified using the Premier Healthcare Database. Patients who developed PJI within 90 days after surgery were compared with patients without PJI. Laboratory value thresholds were defined by clinical guidelines or primary literature. Univariate and multivariable regression analyses were utilized to assess the association between PJI and preoperative laboratory values, including total lymphocyte count, neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), monocyte-lymphocyte ratio (MLR), systemic immune-inflammation index (SII), albumin level, platelet count, albumin-globulin ratio, hemoglobin level, and hemoglobin A1c. RESULTS Of the 6,780 patients identified (TKA: 76.67%; THA: 23.33%), 47 (0.69%) developed PJI within 90 days after surgery. The rate of PJI was 1.69% for patients with a hemoglobin level of <12 g/dL (for females) or <13 g/dL (for males), 2.14% for those with a platelet count of <142,000/µL or >417,000/µL, 1.11% for those with an NLR of >3.31, 1.69% for those with a PLR of >182.3, and 1.05% for those with an SII of >776.2. After accounting for potential confounding factors, we observed an association between PJI and an abnormal preoperative NLR (adjusted odds ratio [aOR]: 2.38, 95% confidence interval [CI]: 1.04 to 5.44, p = 0.039), PLR (aOR: 4.86, 95% CI: 2.15 to 10.95, p < 0.001), SII (aOR: 2.44, 95% CI: 1.09 to 5.44, p = 0.029), platelet count (aOR: 3.50, 95% CI: 1.11 to 10.99, p = 0.032), and hemoglobin level (aOR: 2.62, 95% CI: 1.06 to 6.50, p = 0.038). CONCLUSIONS This study identified preoperative anemia, abnormal platelet count, and elevated NLR, PLR, and SII to be associated with an increased risk of PJI among patients with a body mass index of ≥40 kg/m 2 . These findings may help surgeons risk-stratify this high-risk patient population. LEVEL OF EVIDENCE Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Sagar Telang
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Cory K Mayfield
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Ryan Palmer
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Kevin C Liu
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Julian Wier
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Kurt Hong
- Department of Medicine, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Jay R Lieberman
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Nathanael D Heckmann
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
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Schmidt-Braekling T, Sabri E, Kim PR, Gofton WT, Beaulé PE, Grammatopoulos G. Prevalence of anemia and association with outcome in joint arthroplasty - is there a difference between primary and revision cases? Arch Orthop Trauma Surg 2024; 144:2337-2346. [PMID: 38416136 DOI: 10.1007/s00402-024-05247-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 02/17/2024] [Indexed: 02/29/2024]
Abstract
PURPOSE Anemia has been shown to be a modifiable pre-operative, patient factor associated with outcome following arthroplasty. The aims of this retrospective study were to (1) ascertain the prevalence of preoperative anemia in patients undergoing primary and revision hip and knee arthroplasty at a tertiary referral center and (2) to test the association with outcome and whether it differs between primary and revision cases. METHODS All hip and knee primary and revision arthroplasties performed at a Canadian academic, tertiary-care, arthroplasty center between 2012 and 2017 were included in this study. The study group consisted of 5944 patients, of which 5251 were primary Total Hip and Knee Arthroplasties or Hip Resurfacings and 693 were revision arthroplasties (65% hip revisions/35% knee revisions). Anemia was classified as per WHO definition (hemoglobin < 130 g/L for men and < 120 g/L for women). All anemic patients were grouped into mild, moderate or severe anemia. Length-of-stay, perioperative transfusion-rate, 90-day readmission, overall complication rate and reoperation rates were recorded. The effect of preoperative anemia and the effect of severity of the anemia was evaluated through multivariable regression analysis controlling for relevant covariates. RESULTS Preoperatively, 15% (786/5251) of the primary patients and 47% (322/693) of the revision arthroplasty patients were anemic preoperatively. Anemic revision patients were 3.1 times more likely (95% CI: 1.47-6.33) to obtain blood transfusions during the hospital stay, compared to a 4.9 times higher risk in primary patients. The odds ratio to sustain any postoperative complication if anemic was 1.5 times higher (95% CI: 0.73-3.16) in revision patients and 1.7 in primary cases. In addition, the 90-day readmission rate among both groups was 1.6 times higher in anemic patients. Furthermore, anemic revision patients had a 5.3 days longer length of stay (95% CI: 2.63-7.91), compared to only 1 additional day in anemic primary patients (95% CI: 0.69-1.34). CONCLUSION In this study cohort, the prevalence of anemia in patients awaiting revision arthroplasty was 3 times higher (46.6%) than in primary arthroplasty patients (18.7%). Preoperative anemia was associated with similarly, inferior outcomes in both groups. To reduce postoperative complications and the "burden" associated with anemia, these findings strongly recommend optimizing the preoperative hemoglobin in all arthroplasty patients. However, revision patients are affected more frequently, and particular attention must therefore be taken to this growing group in the future. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Tom Schmidt-Braekling
- Division of Orthopaedic Surgery, The Ottawa Hospital, 501 Smyth Road, CCW 1638, Ottawa, ON, K1H 8L6, Canada
- Department of General Orthopedics and Tumor Orthopedics, University Hospital Muenster, Muenster, Germany
| | - Elham Sabri
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Paul R Kim
- Division of Orthopaedic Surgery, The Ottawa Hospital, 501 Smyth Road, CCW 1638, Ottawa, ON, K1H 8L6, Canada
| | - Wade T Gofton
- Division of Orthopaedic Surgery, The Ottawa Hospital, 501 Smyth Road, CCW 1638, Ottawa, ON, K1H 8L6, Canada
| | - Paul E Beaulé
- Division of Orthopaedic Surgery, The Ottawa Hospital, 501 Smyth Road, CCW 1638, Ottawa, ON, K1H 8L6, Canada
| | - George Grammatopoulos
- Division of Orthopaedic Surgery, The Ottawa Hospital, 501 Smyth Road, CCW 1638, Ottawa, ON, K1H 8L6, Canada.
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Lucenti L, Testa G, Caldaci A, Sammartino F, Cicio C, Ilardo M, Sapienza M, Pavone V. Preoperative Risk Factors for Periprosthetic Joint Infection: A Narrative Review of the Literature. Healthcare (Basel) 2024; 12:666. [PMID: 38540630 PMCID: PMC10970643 DOI: 10.3390/healthcare12060666] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 03/10/2024] [Accepted: 03/12/2024] [Indexed: 01/03/2025] Open
Abstract
Periprosthetic joint infection (PJI) poses a challenging complication for many patients undergoing arthroplasty, and the literature identifies numerous risk factors. A comprehensive understanding of the primary risk and protective factors for PJI is valuable for surgeons. This article aims to compile and summarize the key risk factors for PJI documented in the literature. Some risk factors are related to the nutritional status of patients, with obesity, weight loss, hypovitaminosis, and malnutrition being frequently reported. Pathologies affecting patients also contribute to PJI risk, including septic arthritis, hepatitis, diabetes, urinary tract infections, anemia, hypothyroidism, osteoporosis, and dental pathologies. Unhealthy habits, such as tobacco and drug abuse, are significant factors. Previous corticosteroid injections may also play a role in infection development. A few protective factors are also reported in the literature (use of statins, preoperative decolonization, and preadmission skin preparation). The identification of risk factors and the implementation of evidence-based preoperative protocols are essential steps in reducing the incidence of PJI.
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Affiliation(s)
| | | | | | | | | | | | | | - Vito Pavone
- Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, Policlinico Rodolico-San Marco, University of Catania, 95123 Catania, Italy; (L.L.); (G.T.); (A.C.); (F.S.); (C.C.); (M.I.); (M.S.)
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21
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Dannaway J, Sharma G, Raniga S, Graham P, Bokor D. Is preoperative elevated glycated hemoglobin (HbA1c) a risk factor for postoperative shoulder stiffness after posterior-superior rotator cuff repair? JSES Int 2024; 8:47-52. [PMID: 38312295 PMCID: PMC10837722 DOI: 10.1016/j.jseint.2023.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2024] Open
Abstract
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.
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Affiliation(s)
- Jasan Dannaway
- Faculty of Medicine, Health & Human Sciences, Macquarie University, Sydney, NSW, Australia
| | - Gaurav Sharma
- Faculty of Medicine, Health & Human Sciences, Macquarie University, Sydney, NSW, Australia
| | - Sumit Raniga
- Faculty of Medicine, Health & Human Sciences, Macquarie University, Sydney, NSW, Australia
| | - Petra Graham
- Faculty of Medicine, Health & Human Sciences, Macquarie University, Sydney, NSW, Australia
| | - Desmond Bokor
- Faculty of Medicine, Health & Human Sciences, Macquarie University, Sydney, NSW, Australia
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Osorio P, Amenábar D, Salineros M, Zylberberg A. Limiting Factors for Indication of Hip and Knee Arthroplasty in Chile: The International Perception of Risk Initiative. J Arthroplasty 2023; 38:2242-2246.e2. [PMID: 37295626 DOI: 10.1016/j.arth.2023.05.096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 05/30/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND An aging population with a resultant higher incidence of osteoarthritis have increased the need for total hip (THA) and knee arthroplasty (TKA) worldwide. The purpose of this study was to explore what medical and social risk factors are considered relevant by Chilean orthopaedic surgeons in decisions regarding indications for THA or TKA. METHODS An anonymous survey was sent to 165 hip and knee arthroplasty surgeons who were members of the Chilean Orthopedics and Traumatology Society. From a total of 165 surgeons, 128 (78%) completed the survey. The questionnaire included demographic data, place of work, and inquired about medical and socioeconomic factors that could affect surgical indications. RESULTS Factors that limited indications for elective THA/TKA included body mass index (81%), elevated hemoglobin A1c (92%), lack of social support network (58%), and low socioeconomic status (40%). Most respondents made decisions based on personal experience or literature review rather than hospital or departmental pressures. Of the respondents, 64% believe that some patient populations would benefit from better care if payment systems adjusted for their socioeconomic risk factors. CONCLUSION In Chile, limitations regarding the indication for THA/TKA are most influenced by the presence of modifiable medical risk factors such as obesity, uncompensated diabetes, or malnutrition. We believe that the reason surgeons limit surgeries for such individuals is to promote better clinical outcomes, and not in response to pressure from paying entities. However, low socioeconomic status was perceived to impair the ability to achieve good clinical outcomes by 40% of the surgeons.
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Affiliation(s)
- Pedro Osorio
- Department of Orthopaedic Surgery, Clínica Universidad de los Andes, Santiago, Chile
| | - Diego Amenábar
- Department of Orthopaedic Surgery, Clínica Universidad de los Andes, Santiago, Chile
| | - Matías Salineros
- Department of Orthopaedic Surgery, Clínica Universidad de los Andes, Santiago, Chile
| | - Alejandro Zylberberg
- Department of Orthopaedic Surgery, Clínica Universidad de los Andes, Santiago, Chile
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23
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Coady-Fariborzian L, Anstead C. HbA1c and Infection in Diabetic Elective Hand Surgery: A Veterans Affair Medical Center Experience 2012-2018. Hand (N Y) 2023; 18:994-998. [PMID: 35253503 PMCID: PMC10470238 DOI: 10.1177/1558944720937363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
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.
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Affiliation(s)
- Loretta Coady-Fariborzian
- Malcom Randall VA Medical Center, Gainesville, FL, USA
- University of Florida, Department of Surgery, Plastic Surgery Division, Gainesville, USA
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24
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Martinez R, Chen AF. Outcomes in revision knee arthroplasty: Preventing reoperation for infection Keynote lecture - BASK annual congress 2023. Knee 2023; 43:A5-A10. [PMID: 37524637 DOI: 10.1016/j.knee.2023.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/02/2023]
Abstract
Revision total knee arthroplasty (TKA) patients have a lower survival rate and lower post-surgical outcomes compared to primary TKA patients. Infection and aseptic loosening are the most common reasons for revision and re-revision TKAs, with infection accounting for nearly half of re-revision cases. To prevent infection, patient optimization addressing obesity, diabetes, malnutrition, and smoking cessation is crucial. Advancements in irrigation solutions, antibiotic-impregnated bone fillers, bacteriophage therapy, and electrochemical therapy hold promise for preventing infection. Technical strategies such as obtaining sufficient component fixation, joint line restoration, and using robot assistance may improve revision TKA outcomes. As the burden of revision TKA continues to rise, substantial efforts remain for mitigating future revision TKAs and their associated complications.
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Affiliation(s)
- Roxana Martinez
- Department of Orthopaedic Surgery & Rehabilitation, Howard University Hospital, Howard University College of Medicine, Washington, DC, USA
| | - Antonia F Chen
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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25
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Tarabichi S, Parvizi J. Preventing the Impact of Hyperglycemia and Diabetes on Patients Undergoing Total Joint Arthroplasty. Orthop Clin North Am 2023; 54:247-250. [PMID: 37271552 DOI: 10.1016/j.ocl.2023.02.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
Primary and revision total joint arthroplasty (TJA) procedures have become increasingly popular worldwide. At the same time, a growing number of patients undergoing TJA are either known diabetics or exhibit evidence of hyperglycemia preoperatively. Based on extensive data, it is well-established that poor glycemic control in TJA patients is an independent risk factor for several complications, including periprosthetic joint infection and death. This article will serve as an overview of currently available evidence on how to prevent the impact of hyperglycemia and diabetes mellitus on patients undergoing TJA.
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Affiliation(s)
- Saad Tarabichi
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Javad Parvizi
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA.
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26
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Ege E, Briggi D, Javed S, Huh A, Huh BK. Risk factors for surgical site infection in advanced neuromodulation pain procedures: a retrospective study. Pain Manag 2023; 13:397-404. [PMID: 37503743 DOI: 10.2217/pmt-2023-0051] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/29/2023] Open
Abstract
Aim: To assess the effects of diabetes mellitus (DM) and related variables on surgical site infection (SSI) risk in neuromodulation. Methods: This retrospective study followed patients who underwent neuromodulation procedures for at least 9 months to identify postoperative infections. Demographics, clinical characteristics and surgical outcomes were compared. Results: Of 195 cases included, 5 (2.6%) resulted in SSIs. Median HbA1c was significantly higher for the cases with SSIs (8.2 vs 5.6%; p = 0.0044). The rate of SSI was significantly higher among patients with DM (17.9 vs 0%; p = 0.0005), HbA1c≥7% (37.5 vs 0%; p = 0.0009), and perioperative glucose ≥200 mg/dl (40 vs 2.3%; p = 0.0101). Conclusion: DM, elevated HbA1c and perioperative hyperglycemia may all contribute to increased risk of SSIs with neuromodulation procedures.
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Affiliation(s)
- Eliana Ege
- Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX 77030, USA
| | - Daniel Briggi
- Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, TX 77030, USA
| | - Saba Javed
- Department of Pain Medicine, MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Albert Huh
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Billy K Huh
- Department of Pain Medicine, MD Anderson Cancer Center, Houston, TX 77030, USA
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27
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Tarabichi S, Parvizi J. Prevention of surgical site infection: a ten-step approach. ARTHROPLASTY 2023; 5:21. [PMID: 37029444 PMCID: PMC10082525 DOI: 10.1186/s42836-023-00174-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 02/20/2023] [Indexed: 04/09/2023] Open
Abstract
Surgical site infection (SSI) is a common cause of morbidity and mortality in patients undergoing surgery. Similarly, periprosthetic joint infection (PJI), is a major cause of failure after total joint arthroplasty (TJA). As the annual volume of TJA procedures is projected to rise, so will the rate of subsequent SSI and PJI. Currently, prevention has been identified as the single most important strategy for combating SSI/PJI. Hence, the present article will serve as a summary of an evidence-based ten-step approach for SSI/PJI prevention that may help orthopedic surgeons with their infection prevention strategies.
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Affiliation(s)
- Saad Tarabichi
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, 19107, USA.
| | - Javad Parvizi
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, PA, 19107, USA
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Early Experience With an Endocrinology Preoperative Fast-Track Program for Optimizing Spine Surgery Candidates With Poorly Controlled Diabetes Mellitus. J Am Acad Orthop Surg 2023; 31:458-462. [PMID: 36827207 DOI: 10.5435/jaaos-d-22-00653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 01/20/2023] [Indexed: 02/25/2023] Open
Abstract
INTRODUCTION Previous studies demonstrated an increase in adverse outcomes for patients undergoing elective surgeries with poorly controlled diabetes mellitus. At a large, tertiary-care spine center with a notable population of patients with poorly controlled diabetes, an Endocrinology Fast-Track (EFT) program was developed to improve patient optimization before elective spine surgery. The purpose of this study was to report our early experience. METHODS Seventy-five patients who were scheduled for elective spine surgery were noted to have Hgb A1c > 7 on preoperative evaluation. Thirty-two patients accepted referral to the EFT program and 43 declined (non-EFT). Mean preoperative Hgb A1c was similar between groups (EFT: 8.79 versus non-EFT: 9.26, P = 0.221). The Fast-Track program included counseling, education, and medical management. RESULTS Patients in the two groups were similar in number of females (EFT: 17 versus non-EFT: 17, P = 0.348), age (EFT: 57.7 versus non-EFT: 60.6, P = 0.280), and body mass index (EFT: 34.6 versus non-EFT: 33.0, P = 0.341). A smaller number of smokers were there in the EFT group (1) compared with the non-EFT group (15, P = 0.003). The proportion of patients on insulin (EFT: 19 versus non-EFT: 23, P = 0.814) and oral hypoglycemics (EFT: 29 versus non-EFT: 39, P = 0.983) was similar between the two groups. Surgical clearance for patients with a documented preoperative Hgb A1c of < 7 or equivalent fructosamine level was significantly better in the Fast-Track group compared with the non-Fast-Track group (91% versus 42%, P = 0.000). Although most patients who declined the Fast-Track program did not obtain clearance for surgery, mean Hgb A1c was improved at the latest follow-up in both groups for those who obtained surgical clearance (7.10 versus 6.78, P = 0.470). DISCUSSION A novel EFT program was successful in obtaining acceptable blood glucose control in patients recommended for spine surgery who had poorly controlled diabetes mellitus on preoperative evaluation. The improved blood glucose control was maintained at the latest follow-up.
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Tarabichi S, Chen AF, Higuera CA, Parvizi J, Polkowski GG. 2022 American Association of Hip and Knee Surgeons Symposium: Periprosthetic Joint Infection. J Arthroplasty 2023:S0883-5403(23)00065-7. [PMID: 36738863 DOI: 10.1016/j.arth.2023.01.045] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 01/23/2023] [Accepted: 01/24/2023] [Indexed: 02/06/2023] Open
Abstract
Periprosthetic joint infection (PJI) is the leading cause of failure in patients undergoing total joint arthroplasty. This article is a brief summary of a symposium on PJI that was presented at the annual AAHKS meeting. It will provide an overview of current technqiues in the prevention, diagnosis, and management of PJI. It will also highlight emerging technologies in this setting.
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Affiliation(s)
- Saad Tarabichi
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Antonia F Chen
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Carlos A Higuera
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, Florida
| | - Javad Parvizi
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Gregory G Polkowski
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Shichman I, Oakley CT, Konopka JA, Rozell JC, Schwarzkopf R, Lajam CM. Preoperatively elevated HbA1c levels can meaningfully improve following total joint arthroplasty. Arch Orthop Trauma Surg 2023:10.1007/s00402-023-04765-6. [PMID: 36703084 DOI: 10.1007/s00402-023-04765-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 01/03/2023] [Indexed: 01/28/2023]
Abstract
BACKGROUND Prior literature has demonstrated that diabetic (DM) patients undergoing total joint arthroplasty (TJA) with elevated preoperative HbA1c scores have poorer clinical outcomes. However, no literature has reported the effect of undergoing TJA on laboratory markers of glycemic control. This study sought to evaluate effect of undergoing TJA on postoperative glycemic control and outcomes. METHODS This retrospective study reviewed all patients with DM who underwent primary, elective TJA at our high volume orthopedic institution. Included patients had at least one HbA1c value 3 months to 2 weeks pre-surgery and 3-6 months after surgery. Changes in HbA1c from before to after surgery were calculated. Change in HbA1c greater than 1.0% was considered clinically meaningful. Change in HbA1c was analyzed and stratified into subgroups. RESULTS In total, 770 primary TJA patients were included. Patients with preoperative HbA1c > 7% vs. ≤ 7% were significantly more likely to have clinically meaningful post-TJA decrease in HbA1c (24.5 vs. 2.9%, p < 0.001). Patients with preoperative HbA1c > 8 were significantly more likely to have decrease of > 2.0 compared to those with HbA1c < 8 (p < 0.001). Multivariate regression revealed that preop HbA1c > 7.0, former and current smokers, males, and African-Americans were significantly more likely to achieve clinically meaningful decrease in HbA1c. Additionally, postoperative increase in HbA1c > 1% was associated with significantly higher 90-day ED visits. DISCUSSION Patients with higher preoperative HbA1c were more likely to have clinically meaningful decreases in HbA1c postoperatively. A combination of preoperative medical optimization and improvements in mobility after TJA may play a role in these changes. Those with elevated HbA1c can have meaningful improvement in HbA1c after TJA.
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Affiliation(s)
- Ittai Shichman
- Department of Orthopedic Surgery, Hospital of Joint Diseases, NYU Langone Health, NYU Langone Orthopedic Hospital, 301 East 17th Street, New York, NY, 10003, USA
- Division of Orthopedic Surgery, Tel-Aviv Sourasky Medical Center, Sackler School of Medicine, Tel-Aviv, Israel
| | - Christian T Oakley
- Department of Orthopedic Surgery, Hospital of Joint Diseases, NYU Langone Health, NYU Langone Orthopedic Hospital, 301 East 17th Street, New York, NY, 10003, USA
| | - Jaclyn A Konopka
- Department of Orthopedic Surgery, Hospital of Joint Diseases, NYU Langone Health, NYU Langone Orthopedic Hospital, 301 East 17th Street, New York, NY, 10003, USA
| | - Joshua C Rozell
- Department of Orthopedic Surgery, Hospital of Joint Diseases, NYU Langone Health, NYU Langone Orthopedic Hospital, 301 East 17th Street, New York, NY, 10003, USA
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, Hospital of Joint Diseases, NYU Langone Health, NYU Langone Orthopedic Hospital, 301 East 17th Street, New York, NY, 10003, USA
| | - Claudette M Lajam
- Department of Orthopedic Surgery, Hospital of Joint Diseases, NYU Langone Health, NYU Langone Orthopedic Hospital, 301 East 17th Street, New York, NY, 10003, USA.
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Lamanna DL, McDonnell ME, Chen AF, Gallagher JM. Perioperative Identification and Management of Hyperglycemia in Orthopaedic Surgery. J Bone Joint Surg Am 2022; 104:2117-2126. [PMID: 36005390 DOI: 10.2106/jbjs.22.00149] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
➤ The consequences of undermanaged perioperative hyperglycemia are notable and can have a serious impact on adverse postoperative outcomes, especially surgical site infections and periprosthetic joint infections (PJIs). ➤ Preoperative screening of hemoglobin A1c with a goal threshold of <7.45% is ideal. ➤ There are a variety of risk factors that contribute to hyperglycemia that should be considered in the perioperative period, including glucocorticoid use, nutritional factors, patient-specific factors, anesthesia, and surgery. ➤ There are expected trends in the rise, peak, and fall of postoperative blood glucose levels, and identifying and treating hyperglycemia as swiftly as possible are the fundamental aims of treatment and improved glucose control. Performing frequent postoperative blood glucose monitoring (in the post-anesthesia care unit, on the day of surgery at 1700 and 2100 hours, and in the morning of postoperative day 1) should be considered to allow for the early detection of alterations in glucose metabolism. In addition, instituting a postoperative dietary restriction of carbohydrates should be considered. ➤ The use of insulin as a hypoglycemic agent in orthopaedic patients is relatively safe and is an effective means of controlling fluctuating blood glucose levels. Insulin therapy should be administered to treat hyperglycemia at ≥140 mg/dL when fasting and ≥180 mg/dL postprandially. Insulin therapy should be ceased at blood glucose levels of <110 mg/dL; however, monitoring for glycemic dysregulation should be continued. In all cases of complex diabetes, consultation with diabetes specialty services should be considered. ➤ The emerging use of technology, including continuous subcutaneous insulin pump therapy and continuous glucose monitoring, is an exciting area of further research and development as such technology can more immediately detect and correct aberrations in blood glucose levels.
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Affiliation(s)
- Daniel L Lamanna
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Marie E McDonnell
- Division of Endocrinology, Diabetes and Hypertension, Brigham and Women's Hospital, Boston, Massachusetts
| | - Antonia F Chen
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
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"Recommendations for periprosthetic joint infections (PJI) prevention: the European Knee Associates (EKA)-International Committee American Association of Hip and Knee Surgeons (AAHKS)-Arthroplasty Society in Asia (ASIA) survey of members". Knee Surg Sports Traumatol Arthrosc 2022; 30:3932-3943. [PMID: 34518895 DOI: 10.1007/s00167-021-06742-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Accepted: 09/02/2021] [Indexed: 12/16/2022]
Abstract
PURPOSE Periprosthetic joint infections (PJIs) represent a devastating consequence of total joint arthroplasty. The European Knee Associates (EKA), the American Association of Hip and Knee Surgeons (AAHKS) International Committee, and the Arthroplasty Society in Asia (ASIA) board members were interested in quantifying differences in arthroplasty surgeons' use of various PJI prevention measures to provide clinical recommendations to reduce PJI incidence. METHODS A prospective Microsoft Forms online survey was distributed among EKA, AAHKS International Committee, and ASIA members and their affiliated arthroplasty surgeons. The survey consisted of 20 single and multiple response questions focused on PJI prevention strategies at three perioperative periods: preoperatively, intraoperatively, and postoperatively. RESULTS Three hundred and ninety-four arthroplasty surgeons from 6 different continents completed the survey. Preoperative: (A) PJI Risk Stratification: 40.6% routinely set thresholds (e.g., BMI, HgbA1C) to be met to qualify for surgery, 36.5% only review past medical history; 9.1% use machine learning to personalize PJI risk; (B) BMI limit: 36% no limit; 15.4% BMI < 35; 30.9% BMI < 40; 17.2% BMI < 45; (C) Nutritional status: 55.3% do not screen; among those who screen their patients (44.7%), albumin is the single most used marker (86.3%); (D) Hyperglycemia/Diabetes: 83.3% check this comorbidity; 88.1% use HgbA1C as single best screening test; (E) MRSA nasal colonization: 63.7% do not test; 28.9% test all patients; 7.4% test selectively. Intraoperative: (A) Antibiotic prophylaxis in high-risk patients: 43.4% use single antibiotic for 24 h; 21.3% use double antibiotic for 24 h; 14.2% use single/double antibiotic for 7 days postoperatively; (B) Skin-cleansing: 68.7% at home (45.6% chlorhexidine sponge; 11.9% clippers); (C) Intraoperative skin disinfection: 46.9% single chlorhexidine; 25% double chlorhexidine-povidone-iodine;15.4% single povidone-iodine; (D) Tranexamic acid (TXA) to reduce bleeding/SSI: 96% yes (51% double IV dose, 35.2% single IV dose, 23.6% intra-articular injection); (E) Surgical suction drain: 52% do not use drains; 19.7% use a drain < 24 h; (F) Intra-articular lavage: 64.9% use only saline; 28.1% use dilute povidone-iodine; (G) Antibiotic local delivery to prevent PJI: 82.4% use antibiotic-added cement. Postoperative: (A) Routine monitoring of PJI serologic markers: 42% only in symptomatic patients; 34.2% do not; 20.8% in all patients; (B) Serologic markers to rule in/out PJI: 95.9% CRP; 71% SEDRATE; 60.6% WBC; (C) Synovial fluid test to rule in/out PJI: 79.6% culture/sensitivity; 69.5% WBC count; 31.4% CRP. CONCLUSIONS This survey demonstrated that notable differences still exist in the application of PJI preventive measures across different geographic areas: Optimizing the patient preoperatively and applying multimodal intraoperative strategies represent newer, clinically relevant steps in the effort to reduce the burden of PJI. More uniform guidelines still need to be produced from international scientific societies in order facilitate a more comprehensive approach to this devastating complication. LEVEL OF EVIDENCE IV.
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Lin YC, Lin YH, Chou JH, Lo YT, Chang CH, Lee SH, Lin SH. Higher reinfection rate after two-stage revision arthroplasty in patients with refractory diabetes mellitus: a retrospective analysis with a minimum ten-year follow up. BMC Musculoskelet Disord 2022; 23:990. [PMID: 36397029 PMCID: PMC9670390 DOI: 10.1186/s12891-022-05964-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 11/07/2022] [Indexed: 11/18/2022] Open
Abstract
Background Treatment protocols for two-stage revision arthroplasty with diabetes mellitus (DM) have not yet been established. The control of glycated hemoglobin (HbA1c) in two-stage revision arthroplasty is still debated. This study aimed to clarify the importance of preoperative HbA1c levels before each stage of revision arthroplasty and to analyze the risk factors for reinfection. Methods Five hundred eighty-eight patients suffered from first-time PJI and was treated in our institute from January 1994 to December 2010 were reviewed. The mean follow-up time was 13.8 (range, 10.2–24.8) years. Patients underwent two-stage revision arthroplasty with DM at presentation were included. The endpoint of the study was reinfection of the revision arthroplasty. Demographic, survivorship, and surgical variables were also analyzed. Results Eighty-eight patients were identified and grouped by HbA1c level before the first stage surgery: Groups 1 and 2 had HbA1c levels < 7% and ≥ 7%, respectively. Reinfection was identified in 4.55% (2/44) and 18.18% (8/44) of the patients in Groups 1 and 2, respectively. Survivorship analysis revealed correction of the HbA1c before the final stage of revision arthroplasty as an independent factor (p < 0.001). The identified risks for reinfection were HbA1c levels ≥ 7% before final-stage surgery, ≥ 3 stages of revision arthroplasty, and extended-spectrum beta-lactamase (ESBL)-Escherichia coli PJI. Conclusion The HbA1c level before the final stage of revision arthroplasty could affect staged revision arthroplasty outcomes. Therefore, the necessity of postponing the elective final-stage revision arthroplasty procedure for HbA1c control should be further investigated in the future.
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Movement Is Life-Optimizing Patient Access to Total Joint Arthroplasty: Diabetes Mellitus Disparities. J Am Acad Orthop Surg 2022; 30:1017-1022. [PMID: 34534181 DOI: 10.5435/jaaos-d-21-00425] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 08/23/2021] [Indexed: 02/01/2023] Open
Abstract
This is one of a series of articles that focuses on maximizing access to total joint arthroplasty by providing preoperative optimization pathways to all patients to promote the best results and minimize postoperative complications. Because of inequities in health care, an optimization process that is not equipped to support the underserved can potentially worsen disparities in the utilization of arthroplasty. A staggering 10.5% of the American population lives with diabetes mellitus. Diabetes prevalence is 17% higher in rural communities compared with urban communities. Rates of diabetes are higher in African American, Hispanic, and American Indian populations. Barriers to health care are higher in rural areas and for vulnerable communities, positioning the management of diabetes at the intersection of risk. Poor glycemic control is a predictor of periprosthetic joint infection. Optimization tools include assessing for food security, knowledge of a social safety net and community resources, patient diabetic literacy, and relationships with primary care providers to ensure continuous check-ins as well as partnering with specialty endocrine diabetic clinics. Several strategic recommendations, such as healthcare navigators and promotores (Latinx population), are made to enable and empower, such as continuous glucose monitoring, the preoperative patient to reach a safe preoperative optimization goal for their TJA surgery.
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Webb ML, Justen MA, Kerbel YE, Scanlon CM, Nelson CL, Grauer JN. Patients with insulin-dependent diabetes are at greater risk for perioperative adverse outcomes following total hip arthroplasty. Hip Int 2022; 32:730-736. [PMID: 33566714 DOI: 10.1177/1120700020988834] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND The prevalence of diabetes mellitus (DM) continues to increase among patients undergoing total hip arthroplasty (THA). It is unclear how insulin use is correlated with risk for adverse outcomes. METHODS A cohort of 146,526 patients undergoing primary THA were identified in the 2005-2017 National Surgical Quality Improvement Program database. Patients were classified as insulin-dependent diabetic (IDDM), non-insulin-dependent diabetic (NIDDM), or not diabetic. Multivariate analyses were used. RESULTS Compared to patients without diabetes, patients with NIDDM were at increased risk for 4 of 17 perioperative adverse outcomes studied. Patients with IDDM were at increased risk for those 4 and 8 additional adverse outcomes (12 of the 17 studied). CONCLUSION These findings have important implications for preoperative risk stratification and quality improvement initiatives.
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Affiliation(s)
- Matthew L Webb
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Marissa A Justen
- Department of Orthopaedics and Rehbailitation, Yale School of Medicine, New Haven, CT, USA
| | - Yehuda E Kerbel
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Christopher M Scanlon
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Charles L Nelson
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Jonathan N Grauer
- Department of Orthopaedics and Rehbailitation, Yale School of Medicine, New Haven, CT, USA
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Hunter CW, Deer TR, Jones MR, Chang Chien GC, D’Souza RS, Davis T, Eldon ER, Esposito MF, Goree JH, Hewan-Lowe L, Maloney JA, Mazzola AJ, Michels JS, Layno-Moses A, Patel S, Tari J, Weisbein JS, Goulding KA, Chhabra A, Hassebrock J, Wie C, Beall D, Sayed D, Strand N. Consensus Guidelines on Interventional Therapies for Knee Pain (STEP Guidelines) from the American Society of Pain and Neuroscience. J Pain Res 2022; 15:2683-2745. [PMID: 36132996 PMCID: PMC9484571 DOI: 10.2147/jpr.s370469] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 08/12/2022] [Indexed: 11/23/2022] Open
Abstract
Knee pain is second only to the back as the most commonly reported area of pain in the human body. With an overall prevalence of 46.2%, its impact on disability, lost productivity, and cost on healthcare cannot be overlooked. Due to the pervasiveness of knee pain in the general population, there are no shortages of treatment options available for addressing the symptoms. Ranging from physical therapy and pharmacologic agents to interventional pain procedures to surgical options, practitioners have a wide array of options to choose from - unfortunately, there is no consensus on which treatments are "better" and when they should be offered in comparison to others. While it is generally accepted that less invasive treatments should be offered before more invasive ones, there is a lack of agreement on the order in which the less invasive are to be presented. In an effort to standardize the treatment of this extremely prevalent pathology, the authors present an all-encompassing set of guidelines on the treatment of knee pain based on an extensive literature search and data grading for each of the available alternative that will allow practitioners the ability to compare and contrast each option.
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Affiliation(s)
- Corey W Hunter
- Ainsworth Institute of Pain Management, New York, NY, USA
- Department of Rehabilitation & Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Timothy R Deer
- The Spine and Nerve Center of the Virginias, Charleston, WV, USA
| | | | | | - Ryan S D’Souza
- Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA
| | | | - Erica R Eldon
- Department of Rehabilitation & Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Johnathan H Goree
- Department of Anesthesiology, University of Arkansas for Medical Sciences, Little Rock, AR, USA
| | - Lissa Hewan-Lowe
- Department of Rehabilitation & Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jillian A Maloney
- Department of Anesthesiology, Division of Pain Medicine, Mayo Clinic, Phoenix, AZ, USA
| | - Anthony J Mazzola
- Department of Rehabilitation & Human Performance, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | | | - Jeanmarie Tari
- Ainsworth Institute of Pain Management, New York, NY, USA
| | | | | | - Anikar Chhabra
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, AZ, USA
| | | | - Chris Wie
- Interventional Spine and Pain, Dallas, TX, USA
| | - Douglas Beall
- Comprehensive Specialty Care, Oklahoma City, OK, USA
| | - Dawood Sayed
- Department of Anesthesiology, Division of Pain Medicine, University of Kansas Medical Center, Kansas City, KS, USA
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MacMahon A, Rao SS, Chaudhry YP, Hasan SA, Epstein JA, Hegde V, Valaik DJ, Oni JK, Sterling RS, Khanuja HS. Preoperative Patient Optimization in Total Joint Arthroplasty-The Paradigm Shift from Preoperative Clearance: A Narrative Review. HSS J 2022; 18:418-427. [PMID: 35846267 PMCID: PMC9247589 DOI: 10.1177/15563316211030923] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background: Total joint arthroplasty (TJA) is one of the most common procedures performed in the United States. Outcomes of this elective procedure may be improved via preoperative optimization of modifiable risk factors. Purposes: We sought to summarize the literature on the clinical implications of preoperative risk factors in TJA and to develop recommendations regarding preoperative optimization of these risk factors. Methods: We searched PubMed in August 2019 with an update in September 2020 for English-language, peer-reviewed publications assessing the influence on outcomes in total hip and knee replacement of 7 preoperative risk factors-obesity, malnutrition, hypoalbuminemia, diabetes, anemia, smoking, and opioid use-and recommendations to mitigate them. Results: Sixty-nine studies were identified, including 3 randomized controlled trials, 8 prospective cohort studies, 42 retrospective studies, 6 systematic reviews, 3 narrative reviews, and 7 consensus guidelines. These studies described worse outcomes associated with these 7 risk factors, including increased rates of in-hospital complications, transfusions, periprosthetic joint infections, revisions, and deaths. Recommendations for strategies to screen and address these risk factors are provided. Conclusions: Risk factors can be optimized, with evidence suggesting the following thresholds prior to surgery: a body mass index <40 kg/m2, serum albumin ≥3.5 g/dL, hemoglobin A1C ≤7.5%, hemoglobin >12.0 g/dL in women and >13.0 g/dL in men, and smoking cessation and ≥50% decrease in opioid use by 4 weeks prior to surgery. Surgery should be delayed until these risk factors are adequately optimized.
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Affiliation(s)
- Aoife MacMahon
- Department of Orthopedic Surgery, Johns
Hopkins University School of Medicine, Baltimore, MD, USA
| | - Sandesh S. Rao
- Department of Orthopedic Surgery, Johns
Hopkins University School of Medicine, Baltimore, MD, USA
| | - Yash P. Chaudhry
- Department of Orthopedic Surgery, Johns
Hopkins University School of Medicine, Baltimore, MD, USA
| | - Syed A. Hasan
- Department of Orthopedic Surgery, Johns
Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jeremy A. Epstein
- Department of Medicine, Johns Hopkins
University School of Medicine, Baltimore, MD, USA
| | - Vishal Hegde
- Department of Orthopedic Surgery, Johns
Hopkins University School of Medicine, Baltimore, MD, USA
| | - Daniel J. Valaik
- Department of Orthopedic Surgery, Johns
Hopkins University School of Medicine, Baltimore, MD, USA
| | - Julius K. Oni
- Department of Orthopedic Surgery, Johns
Hopkins University School of Medicine, Baltimore, MD, USA
| | - Robert S. Sterling
- Department of Orthopedic Surgery, Johns
Hopkins University School of Medicine, Baltimore, MD, USA
| | - Harpal S. Khanuja
- Department of Orthopedic Surgery, Johns
Hopkins University School of Medicine, Baltimore, MD, USA,Department of Orthopaedic Surgery,
Johns Hopkins Bayview Medical Center, Baltimore, MD, USA,Harpal S. Khanuja, MD, Department of
Orthopaedic Surgery, Johns Hopkins Bayview Medical Center, 4940 Eastern Ave.,
Baltimore, MD 21224-2780, USA.
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Ashkenazi I, Morgan S, Graif N, Shaked O, Shohat N, Khoury A, Snir N, Warschawski Y. Increased postoperative glycemic variability is associated with increased mortality in diabetic patients undergoing hip arthroplasty for hip fracture. Arch Orthop Trauma Surg 2022; 143:2773-2779. [PMID: 35900587 DOI: 10.1007/s00402-022-04558-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 07/17/2022] [Indexed: 11/02/2022]
Abstract
BACKGROUND Increased glycemic variability (GV) during hospitalization has been associated with increased rates of surgical site and periprosthetic joint infections (PJI) following elective total joint arthroplasty. Uncertainty exists surrounding GV as a predictor for complications in urgent arthroplasty cases following hip fractures. In this study, we evaluated the association between GV and postoperative complications in diabetic patients undergoing total hip arthroplasty (THA) and hemiarthroplasty (HA) for hip fractures. METHODS We analyzed data on 2421 consecutive patients who underwent THA or HA at our institution from 2011 to 2020. Patients with a known diagnosis of diabetes mellitus who had a minimum of three postoperative glucose values taken within the first week after surgery were included. GV was assessed using a coefficient of variation. Outcomes included short- and long-term mortality, reoperations, prosthetic joint infection (PJI) requiring revision and readmissions for any cause. RESULTS The final cohort consisted of 482 patients (294 females, 188 males). Higher GV was associated with an increased 90-day mortality (p = 0.017). GV was not associated with 30-day mortality (p = 0.45), readmissions of any cause at 30 or 90 days (p = 0.99, p = 0.91, respectively), reoperation of any cause (p = 0.91) or PJI requiring revision surgery (p = 0.42). CONCLUSIONS Higher GV in the postoperative period is associated with increased rates of mortality in diabetic patients following THA and HA for hip fractures. Efforts should be made to monitor and control glucose variability in the postoperative period.
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Affiliation(s)
- Itay Ashkenazi
- Division of Orthopedics, Tel Aviv Sourasky Medical Center, Tel-Aviv, Affiliated to the Sackler Faculty of Medicine Tel Aviv University, 6 Weizman Street, 6423906, Tel Aviv, Israel
| | - Samuel Morgan
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nadav Graif
- Division of Orthopedics, Tel Aviv Sourasky Medical Center, Tel-Aviv, Affiliated to the Sackler Faculty of Medicine Tel Aviv University, 6 Weizman Street, 6423906, Tel Aviv, Israel
| | - Or Shaked
- Division of Orthopedics, Tel Aviv Sourasky Medical Center, Tel-Aviv, Affiliated to the Sackler Faculty of Medicine Tel Aviv University, 6 Weizman Street, 6423906, Tel Aviv, Israel
| | - Noam Shohat
- Department of Orthopedics, Shamir Medical Center, Beer-Yaakov, Affiliated to the Sackler Faculty of Medicine Tel Aviv University, Tel Aviv, Israel
| | - Amal Khoury
- Division of Orthopedics, Tel Aviv Sourasky Medical Center, Tel-Aviv, Affiliated to the Sackler Faculty of Medicine Tel Aviv University, 6 Weizman Street, 6423906, Tel Aviv, Israel
| | - Nimrod Snir
- Division of Orthopedics, Tel Aviv Sourasky Medical Center, Tel-Aviv, Affiliated to the Sackler Faculty of Medicine Tel Aviv University, 6 Weizman Street, 6423906, Tel Aviv, Israel
| | - Yaniv Warschawski
- Division of Orthopedics, Tel Aviv Sourasky Medical Center, Tel-Aviv, Affiliated to the Sackler Faculty of Medicine Tel Aviv University, 6 Weizman Street, 6423906, Tel Aviv, Israel.
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Richard RD, Gaski GE, Farooq H, Wagner DJ, McKinley TO, Natoli RM. Risk factors for complications within 30 days of operatively fixed periprosthetic femur fractures. J Clin Orthop Trauma 2022; 31:101925. [PMID: 35799883 PMCID: PMC9253917 DOI: 10.1016/j.jcot.2022.101925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 04/25/2022] [Accepted: 06/17/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND With a rising number of periprosthetic femur fractures (PPFFs) each year, the primary objective of our study was to quantify risk factors that predict complications following operative treatment of PPFFs. METHODS A retrospective cohort study of 231 patients with a periprosthetic femur fracture was conducted at an Academic, Level 1 Trauma Center. The main outcome measurement of interest was complications, as defined by the ACS-NSQIP, within 30 days of surgery. RESULTS 56 patients had 96 complications. Bivariate analyses revealed ASA score, preoperative ambulatory status, length of stay, discharge disposition, time from admission to surgery, length of surgery, perioperative change in hemoglobin, Charlson comorbidity index, cerebral vascular accident/transient ischemic attack, chronic obstructive pulmonary disease, diabetes mellitus, and receipt of a blood transfusion were associated with development of a complication (p < 0.1). Multivariate logistic regression showed length of stay (OR 1.11, 95% CI 1.03-1.19; p = 0.006), receipt of a blood transfusion (OR 2.48, 95% CI 1.14-5.42; p = 0.02), and diabetes mellitus (OR 2.17, 95% CI 1.03-4.56; p = 0.04) remained independently predictive of complication. CONCLUSIONS Length of stay, receipt of a blood transfusion, and diabetes were associated with increased perioperative risk for developing a complication following operative treatment of periprosthetic femur fractures. Methods to decrease length of stay or transfusion rates may mitigate complication risk in these patients. LEVEL OF EVIDENCE Prognostic, Level III.
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Affiliation(s)
- Raveesh D. Richard
- Centura Orthopaedics & Spine, 9949 South Oswego Stree, Suite 200 Parker, CO, 80134, USA
| | - Greg E. Gaski
- Inova Fairfax Medical Campus, 3300 Gallows Road, Falls Church, VA, 22042, USA
| | - Hassan Farooq
- Indiana University School of Medicine, Department of Orthopaedic Surgery, 1801 North Senate Blvd, MPC 1, Suite 535, Indianapolis, IN, 46202, USA
| | - Daniel J. Wagner
- Indiana University School of Medicine, Department of Orthopaedic Surgery, 1801 North Senate Blvd, MPC 1, Suite 535, Indianapolis, IN, 46202, USA
| | - Todd O. McKinley
- Indiana University School of Medicine, Department of Orthopaedic Surgery, 1801 North Senate Blvd, MPC 1, Suite 535, Indianapolis, IN, 46202, USA
| | - Roman M. Natoli
- Indiana University School of Medicine, Department of Orthopaedic Surgery, 1801 North Senate Blvd, MPC 1, Suite 535, Indianapolis, IN, 46202, USA,Corresponding author. Department of Orthopaedic Surgery Indiana University School of Medicine, 1801 North Senate Blvd, MPC 1, Suite 535, Indianapolis, IN, 46202, USA.
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Costs and benefits of routine hemoglobin A1c screening prior to total joint arthroplasty: a cost-benefit analysis. CURRENT ORTHOPAEDIC PRACTICE 2022; 33:338-346. [DOI: 10.1097/bco.0000000000001131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Fan EY, Crawford AS, Nguyen T, Judelson D, Learned A, Chan J, Schanzer A, Simons JP, Jones DW. Hemoglobin A1C Monitoring Practices Prior to Lower Extremity Bypass in Patients with Diabetes Vary Broadly and Do Not Predict Outcomes. J Vasc Surg 2022; 76:255-264. [DOI: 10.1016/j.jvs.2022.02.052] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 02/14/2022] [Indexed: 02/07/2023]
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Zhuang T, Feng AY, Shapiro LM, Hu SS, Gardner M, Kamal RN. Is Uncontrolled Diabetes Mellitus Associated with Incidence of Complications After Posterior Instrumented Lumbar Fusion? A National Claims Database Analysis. Clin Orthop Relat Res 2021; 479:2726-2733. [PMID: 34014844 PMCID: PMC8726562 DOI: 10.1097/corr.0000000000001823] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Accepted: 04/23/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Previous research has shown that diabetes mellitus (DM) is associated with postoperative complications, including surgical site infections (SSIs). However, evidence for the association between diabetes control and postoperative complications in patients with DM is mixed. Prior studies relied on a single metric for defining uncontrolled DM, which does not account for glycemic variability, and it is unknown whether a more comprehensive assessment of diabetes control is associated with postoperative complications. QUESTIONS/PURPOSES (1) Is there a difference in the incidence of SSI after lumbar spine fusion in patients with uncontrolled DM, defined with a comprehensive assessment of glycemic control, compared with patients with controlled DM? (2) Is there a difference in the incidence of other select postoperative complications after lumbar spine fusion in patients with uncontrolled DM compared with patients with controlled DM? (3) Is there a difference in total reimbursements between these groups? METHODS We used the PearlDiver Patient Records Database, a national administrative claims database that provides access to the full continuum of perioperative care. We included 46,490 patients with DM undergoing posterior lumbar fusion with instrumentation. Patients were required to be continuously enrolled in the database for at least 1 year before and 90 days after the index procedure. Patients were divided into uncontrolled and controlled DM cohorts, as defined by ICD-9 diagnostic codes. These are based on a comprehensive assessment of glycemic control, including consideration of patient self-monitoring of blood glucose levels, hemoglobin A1c, and the presence/severity of diabetes-related comorbidities. The cohorts differed only by age, insurance type, and Elixhauser comorbidity score. The primary outcome was the incidence of SSI, divided into superficial and deep, within 90 days postoperatively. Secondary complications included the incidence of cerebrovascular events, acute kidney injury, pulmonary embolism, pneumonia, urinary tract infection, blood transfusion, and total reimbursements. These are the sum of reimbursements occurring within 90 days of surgery, which capture the total professional and facility cost burden to the health payer (such as the insurer). We constructed multivariable logistic regression models to adjust for the effects of age, insurance type, and comorbidities. RESULTS After adjusting for potentially confounding variables including age, insurance type, and comorbidities, we found that patients with uncontrolled DM had an odds ratio for deep SSI of 1.52 (95% confidence interval 1.16 to 1.95; p = 0.002). Similarly, patients with uncontrolled DM had adjusted odds ratios of 1.25 (95% CI 1.01 to 1.53; p = 0.03) for cerebrovascular events, 1.36 (95% CI 1.18 to 1.57; p < 0.001) for acute kidney injury, 1.55 (95% CI 1.16 to 2.04; p = 0.002) for pulmonary embolism, 1.30 (95% CI 1.08 to 1.54; p = 0.004) for pneumonia, 1.33 (95% CI 1.19 to 1.49; p < 0.001) for urinary tract infection, and 1.27 (95% CI 1.04 to 1.53; p = 0.02) for perioperative transfusion. Patients with uncontrolled DM had higher median 90-day total reimbursements than patients with controlled DM: USD 27,915 (interquartile range 5472 to 63,400) versus USD 10,263 (IQR 4101 to 49,748; p < 0.001). CONCLUSION Our findings encourage surgeons to take a full diabetic history beyond the HbA1c value, including any self-monitoring of glucose measurements, time in acceptable range for continuous glucose monitors, and/or consideration of the presence/severity of diabetes-related complications before lumbar spine fusion, as HbA1c does not fully capture glycemic control or variability. We emphasize that uncontrolled DM is a clinical, rather than laboratory, diagnosis. Comprehensive diabetes histories should be incorporated into existing preoperative diabetes care pathways and elective surgery could be deferred to improve glycemic control. Future development of an index measure incorporating multidimensional measures of diabetes control (such as continuous or self-glucose monitoring, diabetes-related comorbidities) is warranted. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Thompson Zhuang
- Department of Orthopaedic Surgery, Stanford University, VOICES Health Policy Research Center, Redwood City, CA, USA
| | - Austin Y. Feng
- Stanford University School of Medicine, Stanford, CA, USA
| | - Lauren M. Shapiro
- Department of Orthopaedic Surgery, Stanford University, VOICES Health Policy Research Center, Redwood City, CA, USA
| | - Serena S. Hu
- Department of Orthopaedic Surgery, Stanford University, VOICES Health Policy Research Center, Redwood City, CA, USA
| | - Michael Gardner
- Department of Orthopaedic Surgery, Stanford University, VOICES Health Policy Research Center, Redwood City, CA, USA
| | - Robin N. Kamal
- Department of Orthopaedic Surgery, Stanford University, VOICES Health Policy Research Center, Redwood City, CA, USA
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Dick BP, Yousif A, Raheem O, Hellstrom WJG. Does Lowering Hemoglobin A1c Reduce Penile Prosthesis Infection: A Systematic Review. Sex Med Rev 2021; 9:628-635. [PMID: 32768358 DOI: 10.1016/j.sxmr.2020.06.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 06/10/2020] [Accepted: 06/14/2020] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Hemoglobin A1c (HbA1c), a glycated form of hemoglobin, develops when glucose is elevated in the blood. It is used as a marker of how well a diabetic patient has been controlling their blood sugar over the previous 3-4 months. Some use HbA1c as a predictor of infection risk during prosthetic surgery, and many surgeons require patients to lower it preoperatively. OBJECTIVE This study was designed to comprehensively review the literature relating HbA1c and penile prosthesis (PP). METHODS A PubMed search of English-language articles identified studies that investigate the relationship between HbA1c levels and PP infection. Studies were only included if they reported the mean HbA1c of all PP patients and compared patients who did/did not develop a prosthetic infection. References from relevant articles are included. RESULTS A total of 6 studies, 1992-2020, were identified. 2 studies occurred before the advent of antibiotic-enhanced devices in the early 2000s and have limited applicability to the modern era. Of the 4 studies published after, 2 reported a significant difference in mean HbA1c when comparing patients who developed a prosthetic infection and those who did not (9.1% vs 7.5%, P = .000 and 9.5% vs 7.8%, P < .001). The other 2 studies reported no significant difference in mean HbA1c when comparing patients who developed a prosthetic infection and those who did not (7.0% vs 7.6%, P > .05; and 7.6% vs 7.5%, P = .598). CONCLUSION Current data regarding HbA1c as a predictor of PP infection are inconclusive, with no consensus. HbA1c is increasingly used as a predictor of postsurgical prosthetic infection, with some urologists requiring patients with elevated HbA1c to acutely lower it before elective surgery. While there are a number of established health benefits of controlling elevated blood sugar, larger randomized controlled trials need to validate whether acutely lowering perioperative HbA1c decreases risk of prosthetic infection. Dick BP, Yousif A, Raheem O, et al. Does Lowering Hemoglobin A1c Reduce Penile Prosthesis Infection: A Systematic Review. Sex Med Rev 2021;9:628-635.
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Affiliation(s)
- Brian P Dick
- Department of Urology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Ayad Yousif
- Department of Urology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Omer Raheem
- Department of Urology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Wayne J G Hellstrom
- Department of Urology, Tulane University School of Medicine, New Orleans, LA, USA.
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Sherman WF, Patel AH. Letter to the Editor: "Failure to Medically Optimize Before Total Hip Arthroplasty: Which Modifiable Risk Factor Is the Most Dangerous?". Arthroplast Today 2021; 11:54-55. [PMID: 34466638 PMCID: PMC8387730 DOI: 10.1016/j.artd.2021.07.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Accepted: 07/25/2021] [Indexed: 12/01/2022] Open
Affiliation(s)
- William F. Sherman
- Corresponding author. 1430 Tulane Avenue #8632, New Orleans, LA 70112, USA. Tel.: +1-504-889-2663.
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Haller JM, Working ZM, Ross HL, Gililland JM, Kubiak EN. Fewer Hip Dislocations With Anterior Total Hip Arthroplasty for Displaced Femoral Neck Fracture. Orthopedics 2021; 44:e248-e252. [PMID: 33416894 DOI: 10.3928/01477447-20210104-02] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The primary goal of this study was to compare dislocation rates with an anterior approach vs a posterior approach for patients who underwent total hip arthroplasty (THA) for displaced femoral neck fracture. A retrospective review was conducted of patients who underwent THA for acute femoral neck fracture at the authors' level I trauma center. All patients had at least 1 year of follow-up. Modified Harris Hip Score (mHHS) and EuroQol 5D-5L score were obtained to assess hip function and overall quality of life at a minimum of 12 months postoperatively. The study population included 76 patients (posterior, 22; anterior, 54), with mean follow-up of 39 months (range, 12-125 months). Significantly more postoperative complications occurred in the posterior group compared with the anterior group (7 vs 4, respectively; P=.006). In addition, significantly more hip dislocations occurred in the posterior group compared with the anterior group (3 vs 1, respectively; P=.037). The study did not show a difference in mHHS (anterior, 82; posterior, 77; P=.411). The findings suggest that an anterior-based approach to THA may result in fewer complications than a posterior-based approach for patients who have displaced femoral neck fracture. Patients should be counseled on the higher perioperative risk after surgery compared with patients undergoing elective THA. Patients undergoing THA with an anterior approach for femoral neck fracture can expect to achieve good hip functional outcome and good quality of life 12 months after surgery. [Orthopedics. 2021;44(2):e248-e252.].
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Statz JM, Odum SM, Johnson NR, Otero JE. Failure to Medically Optimize Before Total Hip Arthroplasty: Which Modifiable Risk Factor Is the Most Dangerous? Arthroplast Today 2021; 10:18-23. [PMID: 34277906 PMCID: PMC8267488 DOI: 10.1016/j.artd.2021.05.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 05/24/2021] [Accepted: 05/26/2021] [Indexed: 12/18/2022] Open
Abstract
Background There is mounting evidence that smoking, abnormal body mass index (BMI), uncontrolled diabetes, and poor nutritional status are associated with complications after total hip arthroplasty (THA). The goal of the present study was to evaluate the consequences of failure to medically optimize Medicare-eligible patients with respect to these key modifiable health targets by assessing complications in the early postoperative period after THA. Methods The National Surgical Quality Improvement Program database was queried for all primary THAs performed in 2018. Data were collected on preoperative serum albumin, BMI, diabetes, and tobacco use as well as postoperative infections, readmissions, complications, and mortality. We identified 47,924 THA patients with a median BMI of 29 kg/m2 and age of 72 years, and 60% of whom were female. Results We found that preoperative albumin <3.5 g/dL, BMI ≥40 kg/m2, tobacco use, and diabetes were all individually associated with increased risk of postoperative complications. Serum albumin <3.5 g/dL was the greatest overall risk factor for infection (odds ratio [OR]: 3.1, 95% confidence interval [CI]: 2.3-4.4, P < .0001), readmission (OR: 2.2, 95% CI: 1.9-2.5, P < .0001), any complication (OR: 4.2, 95% CI: 3.8-4.6, P < .0001), and mortality (OR: 7.5, 95% CI: 5.3-10.6, P < .0001). Conclusions Low albumin, elevated BMI, tobacco use, and diabetes are associated with increased risk of postoperative infection, readmission, any complication, and mortality after primary THA. Low albumin poses the greatest risk of these. Preoperative optimization should be obtained in all patients before elective surgery, and the final decision for surgery should be individually made between a surgeon and patient. Level of Evidence IV.
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Affiliation(s)
| | - Susan M Odum
- OrthoCarolina Research Institute, Charlotte, NC, USA.,Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC, USA
| | - Nicholas R Johnson
- Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC, USA
| | - Jesse E Otero
- OrthoCarolina Research Institute, Charlotte, NC, USA.,Department of Orthopaedic Surgery, Atrium Health Musculoskeletal Institute, Charlotte, NC, USA.,OrthoCarolina Hip and Knee Center, Charlotte, NC, USA
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Fillingham YA, Hanson TM, Leinweber KA, Lucas AP, Jevsevar DS. Generalized Anxiety Disorder: A Modifiable Risk Factor for Pain Catastrophizing After Total Joint Arthroplasty. J Arthroplasty 2021; 36:S179-S183. [PMID: 33648840 DOI: 10.1016/j.arth.2021.02.023] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Revised: 01/26/2021] [Accepted: 02/08/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Patients with mood disorders undergoing total joint arthroplasty (TJA) are at increased risk for poor outcomes. This study seeks to examine the effect of anxiety disorders on pain following TJA and evaluate if anxiety disorders are a modifiable risk factor. METHODS Between March 2019 and July 2020, 319 TJA patients had preoperative anxiety screening using the Generalized Anxiety Disorder 2-item screening tool (GAD-2) and 6-week postoperative Pain Catastrophizing Scale scores. Patients were organized into 4 cohorts based on preoperative selective serotonin reuptake inhibitor/serotonin-norepinephrine reuptake inhibitor (SSRI/SNRI) use and GAD-2 scores: Group 1: no SSRI/SNRI use and GAD-2 score <3 (control patients); Group 2: SSRI/SNRI use and GAD-2 score <3 (appropriately treated GAD patients); Group 3: no SSRI/SNRI use and GAD-2 score ≥3 (untreated GAD patients); and Group 4: SSRI/SNRI use and GAD-2 score ≥3 (poorly treated GAD patients). The cohorts underwent multivariate linear regression analysis and equivalence testing. RESULTS Patients with preoperative GAD-2 scores ≥3 had worse postoperative pain with significantly higher average 6-week postoperative Pain Catastrophizing Scale score than patients with GAD-2 scores <3 (9.90 vs 5.19, P < .001). Patients with appropriately treated GAD and the control group had statistically equivalent postoperative pain, while patients with poorly treated or untreated GAD had worse postoperative pain. CONCLUSION Preoperative GAD is a risk factor for poor postoperative pain control but is a modifiable risk factor when patients are appropriately treated. Screening for preoperative GAD with GAD-2 and referral for treatment may improve patient outcomes and reduce opioid consumption following TJA.
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Affiliation(s)
- Yale A Fillingham
- Department of Orthopaedic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Thomas M Hanson
- Department of Orthopaedic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Kathleen A Leinweber
- Department of Orthopaedic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Adriana P Lucas
- Department of Orthopaedic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - David S Jevsevar
- Department of Orthopaedic Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
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Zhang S, Chong M, Lau BPH, Ng YH, Wang X, Chua W. Do Patients With Diabetes Have Poorer Improvements in Patient-Reported Outcomes After Total Knee Arthroplasty? J Arthroplasty 2021; 36:2486-2491. [PMID: 33775468 DOI: 10.1016/j.arth.2021.02.070] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 02/21/2021] [Accepted: 02/24/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Diabetes is one of the most common comorbidities in patients undergoing total knee arthroplasty (TKA) for osteoarthritis. However, the evidence remains unclear on how it affects patient-reported outcome measures after TKA. METHODS We reviewed prospectively collected data of 2840 patients who underwent primary unilateral TKA between 2008 and 2018, of which 716 (25.2%) had diabetes. All patients had their HbA1c measured within 1 month before surgery, and only well-controlled diabetics (HbA1c <8.0%) were allowed to proceed with surgery. Patient demographics and comorbidities were recorded, and multiple regression was performed to evaluate the impact of diabetes on improvements in patient-reported outcome measures (Short Form 36 (SF-36), Western Ontario and McMaster University Osteoarthritis Index (WOMAC), Knee Society Score (KSS)) and knee range of motion (ROM). RESULTS Compared with nondiabetics, patients with diabetes were more likely to possess a higher body mass index (P-value <.001), more comorbidities (P-value <.001), and poorer preoperative SF-36 Physical Component Summary (PCS) (P-value <.001), WOMAC (P-value = .002), KSS-function (P-value <.001), and knee ROM (P-value <.001). Multiple regression showed that diabetic patients experienced marginally poorer improvements in KSS-knee (-1.22 points, P-value = .025) and knee ROM (-1.67°, P-value = .013) than nondiabetics. However, there were no significant differences in improvements for SF-36 PCS (P-value = .163), Mental Component Summary (P-value = .954), WOMAC (P-value = .815), and KSS-function (P-value = .866). CONCLUSION Patients with well-controlled diabetes (HbA1c <8.0%) can expect similar improvements in general health and osteoarthritis outcomes (SF-36 PCS and Mental Component Summary, WOMAC, and KSS-function) compared with nondiabetics after TKA. Despite having marginally poorer improvements in knee-specific outcomes (KSS-knee and knee ROM), these differences are unlikely to be clinically significant.
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Affiliation(s)
- Siyuan Zhang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Mark Chong
- Department of Orthopaedic Surgery, National University Hospital, Singapore, Singapore
| | - Bernard Puang Huh Lau
- Department of Orthopaedic Surgery, National University Hospital, Singapore, Singapore
| | - Yau Hong Ng
- Department of Orthopaedic Surgery, National University Hospital, Singapore, Singapore
| | - Xinyu Wang
- Department of Orthopaedic Surgery, National University Hospital, Singapore, Singapore
| | - Weiliang Chua
- Department of Orthopaedic Surgery, National University Hospital, Singapore, Singapore
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Chen JP, Chang CH, Lin YC, Lee SH, Shih HN, Chang Y. Two-stage exchange Arthroplasty for knee Periprosthetic joint infection exhibit high infection recurrence rate in patients with chronic viral hepatitis. BMC Musculoskelet Disord 2021; 22:538. [PMID: 34118906 PMCID: PMC8199816 DOI: 10.1186/s12891-021-04416-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 05/31/2021] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Currently, there is little evidence about the outcome of two-stage exchange arthroplasty for the treatment of knee periprosthetic joint infection (PJI) in patients with chronic viral hepatitis. To evaluate it, we set the primary outcome as infection recurrence, and the secondary outcome as the difference between patients diagnosed with hepatitis B virus or hepatitis C virus. PATIENTS AND METHODS Between June, 2010 and December, 2016, 172 patients with knee PJIs were treated with two-stage exchange arthroplasty at our institute. Treatment success was defined using Delphi-based consensus. These patients were further divided into groups with or without chronic hepatitis. Variables were analyzed, including age, sex, comorbidities, microbiology, and operative methods. Minimum follow-up was 12 months (mean, 35 months; range, 12-85 months). RESULTS Of the 172 knee PJI patients, 25 were identified with chronic hepatitis. The infection recurrence rate in the hepatitis group (28%, 7 in 25) was significantly higher than that in the non-hepatitis group (9.5%, 14 in 147), p = 0.017. However, there was no significant difference in the infection recurrence rates between patients with HBV (24%, 4 in 16) and HCV (33.3%, 3 in 9). Regarding the outcomes of patients with infection recurrence, 4 of the non-hepatitis patients were treated with the debridement, antibiotic treatment, irrigation, and retention of prosthesis (DAIR) procedure, with a success rate of 75%. The other 17 patients (7 with hepatitis and 10 without) were treated with repeated two-stage exchange arthroplasty with 100% infection elimination rate until the final follow-up. CONCLUSIONS Knee PJI patients with chronic hepatitis have higher infection recurrence rate after two-stage exchange arthroplasty (28%).
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Affiliation(s)
- Jui-Ping Chen
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chih-Hsiang Chang
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Yu-Chih Lin
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan.,Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Sheng-Hsun Lee
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan.,College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Hsin-Nung Shih
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan.,Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Yuhan Chang
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Linkou, Taiwan. .,College of Medicine, Chang Gung University, Taoyuan, Taiwan. .,Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan. .,Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, 5, Fu-Hsin St., Kweishan, Taoyuan, Taiwan.
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Howard R, Delaney L, Kilbourne AM, Kidwell KM, Smith S, Englesbe M, Dimick J, Telem D. Development and Implementation of Preoperative Optimization for High-Risk Patients With Abdominal Wall Hernia. JAMA Netw Open 2021; 4:e216836. [PMID: 33978723 PMCID: PMC8116983 DOI: 10.1001/jamanetworkopen.2021.6836] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
IMPORTANCE Real-world surgical practice often lags behind the best scientific evidence. For example, although optimizing comorbidities such as smoking and morbid obesity before ventral and incisional hernia repair improves outcomes, as many as 25% of these patients have a high-risk characteristic at the time of surgery. Implementation strategies may effectively increase use of evidence-based practice. OBJECTIVE To describe current trends in preoperative optimization among patients undergoing ventral hernia repair, identify barriers to optimization, develop interventions to address these barriers, and then pilot these interventions. DESIGN, SETTING, AND PARTICIPANTS This quality improvement study used a retrospective medical record review to identify hospital-level trends in preoperative optimization among patients undergoing ventral and incisional hernia repair. Semistructured interviews with 21 practicing surgeons were conducted to elicit barriers to optimizing high-risk patients before surgery. Next, a task force of experts was convened to develop pragmatic interventions to increase surgeon use of preoperative optimization. Finally, these interventions were piloted at 2 sites to assess acceptability and feasibility. This study was performed from January 1, 2014, to December 31, 2019. MAIN OUTCOMES AND MEASURES The main outcome was rate of referrals for preoperative patient optimization at the 2 pilot sites. RESULTS Among 23 000 patients undergoing ventral hernia repair, the mean (SD) age was 53.9 (14.3) years, and 12 315 (53.5%) were men. Of these, 8786 patients (38.2%) had at least 1 high-risk characteristic at the time of surgery, including 7683 with 1, 1079 with 2, and 24 with 3. At the hospital level, the mean proportion of patients with at least 1 of 3 high-risk characteristics at the time of surgery was 38.2% (95% CI, 38.1%-38.3%). This proportion varied widely from 21.5% (95% CI, 17.6%-25.5%) to 52.8% (95% CI, 43.9%-61.8%) across hospitals. Interviews with surgeons identified 3 major barriers to improving this practice: lost financial opportunity by not offering a patient an operation, lack of surgeon awareness of available resources for optimization, and organizational barriers. A task force therefore developed 3 interventions: a financial incentive to optimize high-risk patients, an educational intervention to make surgeons aware of available optimization resources, and on-site facilitation. These strategies were piloted at 2 sites where preoperative risk optimization referrals increased 860%. CONCLUSIONS AND RELEVANCE This study demonstrates a stepwise process of identifying a practice gap, eliciting barriers that contribute to this gap, using expert consensus and local resources to develop strategies to address these barriers, and piloting these strategies. This implementation strategy can be adopted to diverse settings given that it relies on developing and implementing strategies based on local practice patterns.
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Affiliation(s)
- Ryan Howard
- Division of Minimally Invasive Surgery, Department of Surgery, University of Michigan, Ann Arbor
| | - Lia Delaney
- University of Michigan Medical School, Ann Arbor
| | - Amy M. Kilbourne
- University of Michigan Medical School, Ann Arbor
- Health Services Research and Development, Office of Research and Development, US Department of Veterans Affairs, Washington, DC
| | | | - Shawna Smith
- Health Services Research and Development, Office of Research and Development, US Department of Veterans Affairs, Washington, DC
| | - Michael Englesbe
- Division of Minimally Invasive Surgery, Department of Surgery, University of Michigan, Ann Arbor
| | - Justin Dimick
- Division of Minimally Invasive Surgery, Department of Surgery, University of Michigan, Ann Arbor
| | - Dana Telem
- Division of Minimally Invasive Surgery, Department of Surgery, University of Michigan, Ann Arbor
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