Insulin Dependence Increases the Risk of Complications and Death in Total Joint Arthroplasty: A Systematic Review and Meta-(Regression) Analysis

Insulin dependence as an independent predictor of complications following surgical treatment of distal radius fracture

PURPOSE

Diabetes mellitus (DM) is a well-established risk factor for postoperative complications. Distal radius fractures (DRFs) are a common orthopedic injury and often require open reduction and internal fixation (ORIF). The rise of ORIF utilization warrants investigation into factors that may expose patients to postoperative complications following DRF ORIF.

METHODS

We queried the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database for cases of DRF ORIF between 2015 and 2021. Cases were stratified into cohorts based on diabetes mellitus (DM) status. The DM cohort was further stratified into non-insulin-dependent DM (NIDDM) and insulin-dependent DM (IDDM) groups. Bivariate logistic regression was performed to compare patient demographics, comorbidities, and 30-day postoperative complications. Multivariate logistic regressions were performed to identify associations between diabetes mellitus status and postoperative complications.

RESULTS

A total of 27,761 cases of DRF ORIF were identified from 2015 to 2021. After exclusion criteria were applied, 25,971 cases remained, of which 2169 (8.4%) cases had DM and 23,802 (91.6%) cases were free of DM. Within the DM cohort, there were 1392 cases in the NIDDM subgroup and 777 cases in the IDDM subgroup. Relative to the cohort without diabetes, the IDDM cohort was independently associated with sepsis, septic shock, reintubation, myocardial infarction, blood transfusion, failure to wean off mechanical ventilation, readmission, and nonhome discharge.

CONCLUSION

Having IDDM was independently associated with higher rates of postoperative sepsis, septic shock, reintubation, myocardial infarction, blood transfusion, failure to wean off ventilation, readmission, and nonhome discharge when compared to the cohort without diabetes following DRF ORIF.

LEVEL OF EVIDENCE

Level III; Retrospective cohort comparison; Prognosis study.

Safety Considerations for Outpatient Arthroplasty

Since 2018, the number of total joint arthroplasties (TJAs) performed on an outpatient basis has dramatically increased. Both surgeon and anesthesiologist should be aware of the implications for the safety of outpatient TJAs and potential patient risk factors that could alter this safety profile. Although smaller studies suggest that the risk of negative outcomes is equivalent when comparing outpatient and inpatient arthroplasty, larger database analyses suggest that, even when matched for comorbidities, patients undergoing outpatient arthroplasty may be at increased risk of surgical or medical complications. Appropriate patient selection is critical for the success of any outpatient arthroplasty program. Potential exclusion criteria for outpatient TJA may include age greater than 75 years, bleeding disorder, history of deep vein thrombosis, uncontrolled diabetes mellitus, and hypoalbuminemia, among others. Patient optimization before surgery is also warranted. The potential risks of same-day versus next-day discharge have yet to be elicited in a large-scale manner.

Effective Surgical Site Infection Prevention Strategies for Diabetic Patients Undergoing Surgery: A Systematic Review

Surgical site infections (SSIs) pose a significant clinical challenge, with heightened risks and severe consequences for diabetic patients undergoing surgical procedures. This systematic review aims to synthesize the current evidence on effective prevention strategies for mitigating SSI risk in this vulnerable population. From inception to March 2024, we comprehensively searched multiple electronic databases (PubMed, Medline, Embase, Cochrane Library, CINAHL) to identify relevant studies evaluating SSI prevention strategies in diabetic surgical patients. Our search strategy followed Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, utilizing a combination of keywords and Medical Subject Headings (MeSH) terms related to diabetes, surgical site infections, prevention strategies, and surgical procedures. Inclusion criteria focused on peer-reviewed clinical trials, randomized controlled trials, and meta-analyses published in English. The search yielded three studies meeting the eligibility criteria, subject to data extraction and qualitative synthesis. Key findings highlighted the efficacy of interventions such as optimized perioperative glycemic control, timely prophylactic antibiotic administration, and meticulous preoperative skin antisepsis in reducing SSI rates among diabetic surgical patients. The potential for personalized prevention approaches based on individual patient factors, such as diabetes type and surgical complexity, was explored. This systematic review underscores the importance of a multifaceted, evidence-based approach to SSI prevention in diabetic surgical patients, integrating strategies like glycemic control, antibiotic prophylaxis, and preoperative skin antisepsis. Furthermore, our findings suggest the potential benefits of personalized care pathways tailored to individual patient characteristics. Implementing these interventions requires interdisciplinary collaboration, adaptation to diverse healthcare settings, and patient engagement through culturally sensitive education initiatives. This comprehensive analysis informs clinical practice, fosters patient safety, and contributes to the global efforts to enhance surgical outcomes for this high-risk population.

Preliminary investigation of the effect of non-cardiac surgery on intraoperative islet and renal function: a single-center prospective cohort study

Background

The effect of different non-cardiac surgical methods on islet and renal function remains unclear. We conducted a preliminary investigation to determine whether different surgical methods affect islet function or cause further damage to renal function.

Methods

In this prospective cohort study, the clinical data of 63 adult patients who underwent non-cardiac surgery under general anesthesia were evaluated from February 2019 to January 2020. Patients were divided into the abdominal surgery group, the laparoscopic surgery group, and the breast cancer surgery group. The primary outcome was the difference between the effects of different surgical methods on renal function.

Results

Islet and renal function were not significantly different between the groups. The correlation analysis showed that hematocrit (HCT) and hemoglobin (HB) were negatively correlated with fasting plasma glucose (FPG) (p < 0.05), MAP was positively correlated with C-peptide (p < 0.05), and HCT and Hb were positively correlated with serum creatinine (SCr) (p < 0.05). Fasting insulin (FINS) and C-peptide were negatively correlated with SCr (p < 0.05), and the homeostatic model assessment of insulin resistance (HOMA-IR) was positively correlated with SCr (p < 0.05). FINS, C-peptide, HOMA-IR, and the homeostatic model assessment of β-cell function (HOMA-β) were positively correlated with cystatin C (Cys C) (p < 0.05).

Conclusion

FINS, C-peptide, and HOMA-IR had positive effects on beta-2-microglobulin (β2-MG). FINS, C-peptide, and HOMA-IR were positively correlated with Cys C and β2-Mg. While FINS and C-peptide were negatively correlated with SCr, HOMA-IR was positively correlated with SCr.

[Patient optimization before hip revision arthroplasty: : How to handle comorbidities]

Preoperative optimization of the therapeutic regime of comorbidities can lead to an improvement of the postoperative outcome and has the potential to reduce the financial burden on the health care system in revision hip arthroplasty. Patient-related factors and an increasing incidence of comorbidities lead to a higher risk of implant failure and revision for all causes. Important and potentially modifiable risk factors like preoperative anemia, coagulopathy, infectious disease (dental status, urinary tract infections, colonization with staphylococcus), metabolic conditions (obesity, malnutrition, diabetes mellitus, osteoporosis), and smoking need to be addressed. To achieve an optimal preoperative condition a multidisciplinary approach should be applied.

Effect of Diabetes Mellitus on Implant Osseointegration of Titanium Screws: An Animal Experimental Study

Objective

To explore the effect of diabetes mellitus (DM) on implant osseointegration of titanium screws.

Methods

Sixty rats were randomly divided into a DM group and a control group (each group, n = 30). DM group rats were injected with 1% Streptozotocin solution at 65 mg/kg to establish a DM model. Titanium screws were implanted into the rats' distal femurs in both groups. The rats were sacrificed for micro‐CT scanning, micro‐indentation, biomechanical detection, confocal Raman microspectroscopy, and histological and histomorphometric analysis at 4, 8, and 12 weeks post‐implantation, respectively. Messenger RNA (mRNA) expression and protein expression of the related growth factors around the implant were analyzed using real‐time polymerase chain reaction and Western blots.

Results

At 4, 8 and 12 weeks, micro‐CT scanning, hematoxylin‐eosin (HE) staining, Gieson's acid‐magenta staining, and fluorescent labeled staining showed disorder in the bone tissue arrangement, a lack of new bone tissue, poor maturity and continuity, and poor trabecular bone parameters around the implant in the DM group. At 4, 8, and 12 weeks, the interfacial bone binding rate in the DM group was significantly lower (16.2% ± 4.8%, 25.7% ± 5.7%, 42.5% ± 5.8%, respectively) than that in the control group (23.6% ± 5.2%, 40.8% ± 6.3%, 64.2% ± 7.3%, respectively; P < 0.05). At 8 and 12 weeks, the elastic modulus (17.0 ± 1.8 and 15.1 ± 1.5 GPa, respectively) and trabecular bone hardness (571 ± 39 and 401 ± 37 MPa, respectively) in the DM group were significantly lower than the elastic modulus (23.4 ± 2.3 and 23.8 ± 1.8 GPa, respectively) and trabecular bone hardness (711 ± 45 and 719 ± 46 MPa, respectively) in the control group (P < 0.05). The maximum load required for the prosthesis pull‐out experiment in the DM group at 4, 8, and 12 weeks (55.14 ± 6.74 N, 73.34 ± 8.43 N, and 83.45 ± 8.32 N, respectively) was significantly lower than that in the control group (77.45 ± 7.48 N, 93.28 ± 8.29 N, and 123.62 ± 9.43 N, respectively, P < 0.05). At 8 and 12 weeks, the mineral‐to‐collagen ratio in the DM group (6.56 % ± 1.35% and 4.45%± 1.25%, respectively) was significantly higher than that in the control group (5.31% ± 1.42% and 3.62% ± 1.33%, respectively, P < 0.05). At 12 weeks, mRNA and protein expression levels of bone morphogenetic protein 2, transforming growth factor‐β1, vascular endothelial growth factor, osteopontin, osteocalcin, and runt‐related transcription factor 2 in the DM group were significantly lower than that in the control group.

Conclusions

DM can negatively affect bone osseointegration, manifesting as disorder in bone tissue arrangement around the implant, a lack of new bone tissue, poor maturity and continuity, poor trabecular bone parameters and lower expression of the related growth factors.

Safety Considerations for Outpatient Arthroplasty

Since 2018, the number of total joint arthroplasties (TJAs) performed on an outpatient basis has dramatically increased. Both surgeon and anesthesiologist should be aware of the implications for the safety of outpatient TJAs and potential patient risk factors that could alter this safety profile. Although smaller studies suggest that the risk of negative outcomes is equivalent when comparing outpatient and inpatient arthroplasty, larger database analyses suggest that, even when matched for comorbidities, patients undergoing outpatient arthroplasty may be at increased risk of surgical or medical complications. Appropriate patient selection is critical for the success of any outpatient arthroplasty program. Potential exclusion criteria for outpatient TJA may include age greater than 75 years, bleeding disorder, history of deep vein thrombosis, uncontrolled diabetes mellitus, and hypoalbuminemia, among others. Patient optimization before surgery is also warranted. The potential risks of same-day versus next-day discharge have yet to be elicited in a large-scale manner.