Diabetes Mellitus, Hemoglobin A1C, and the Incidence of Total Joint Arthroplasty Infection

107

Background Patients with diabetes have increased risk of infections and wound complications after total knee arthroplasty (TKA). Glycemic markers identifying patients at risk for complications after TKA have not yet been elucidated. Questions/purposes We aimed to determine the correlations among four commonly used glycemic markers and to identify the glycemic markers most strongly associated with the occurrence of surgical site infections and postoperative wound complications in patients with diabetes mellitus after undergoing TKA. Methods Our retrospective study included 462 patients with diabetes, who underwent a total of 714 TKAs. Blood levels of glycemic markers, including preoperative fasting blood glucose (FBG), postprandial glucose (PPG2), glycated hemoglobin (HbA 1c ), and levels obtained from random glucose testing on postoperative days 2, 5, and 14, were collected on all patients as part of a medical clearance program and an established clinical pathway for patients with diabetes at our center. Complete followup was available on 93% (462 of 495) of the patients. Correlations among markers were assessed. Associations between the markers and patient development of complications were analyzed using multivariate regression analyses of relevant cutoff values. We considered any of the following as complications potentially related to diabetes, and these were considered study endpoints: surgical site infection (superficial and deep) and wound complications (drainage, hemarthrosis, skin necrosis, and dehiscence). During the period of study, there were no fixed criteria applied to what levels of glycemic control patients with diabetes needed to achieve before undergoing arthroplasty, and there were wide ranges in the levels of all glycemic markers; for example, whereas the mean HbA 1c level was 7%, the range was 5% to 11.3%.Each author certifies that he or she, or a member of his or her immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research 1 editors and board members are on file with the publication and can be viewed on request. Each author certifies that his or her institution has approved the human protocol for this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent was obtained. This work was performed at the Joint Reconstruction Center, Seoul National University Bundang Hospital, Seoul, Republic of Korea. Results There were positive correlations among the levels of the four glycemic markers; the strongest correlation was found between the preoperative HbA 1c and PPG2 levels (R = 0.502, p \ 0.001). After controlling for potential confounding variables using multivariate analysis, the HbA 1c cutoff level of 8 (odds ratio [OR], 6.1; 95% confidence interval...

Section: Discussionsupporting

confidence: 91%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Do Glycemic Markers Predict Occurrence of Complications After Total Knee Arthroplasty in Patients With Diabetes?

Hwang

Kim

Bamne

et al. 2015

107

“…Several studies found diabetes mellitus to be a risk factor for infection [1,14,15]; however, hemoglobin A1c level has not been found to be predictive of infection [10]. In our study, however, ASA score [ 2, diabetes complications, caseload, and hemiarthroplasty were identified in the univariate analysis as significant predictors; multivariate analysis did not confirm these findings as predictive of infection risk.…”

Section: Staphylococcus Aureus 15contrasting

confidence: 55%

The Otto Aufranc Award: Modifiable versus Nonmodifiable Risk Factors for Infection After Hip Arthroplasty

Maoz

Phillips

Bosco

et al. 2015

Self Cite

159

Background Periprosthetic joint infections (PJIs) are associated with increased morbidity and cost. It would be important to identify any modifiable patient-and surgicalrelated factors that could be modified before surgery to decrease the risk of PJI. Questions/purposes We sought to identify and quantify the magnitude of modifiable risk factors for deep PJIs after primary hip arthroplasty. Methods A series of 3672 primary and 406 revision hip arthroplasties performed at a single specialty hospital over a 3-year period were reviewed. All deep PJIs were identified using the Centers for Disease Control and Prevention case definitions (ie, occurs within 30-90 days postoperatively, involves deep soft tissues of the incision, purulent drainage, dehiscence and fever, localized pain or tenderness). Univariate and multivariate analyses determined the association between patient and surgical risk factors and PJIs. For the elective patients, the procedure was performed on the day of admission (''same-day procedure''), whereas for the fracture and nonelective patients, the procedure was performed 1 or more days postadmission (''nonsame-day procedure''). Staphylococcus aureus colonization, tobacco use, and body mass index (BMI) were defined as patient-related modifiable risk factors. Results Forty-seven (1.3%) deep PJIs were identified. Infection developed in 20 of 363 hips of nonsame-day procedures and 27 of 3309 same-day procedures (p = 0.006). There were eight (2%) infections in the revision group. After controlling for confounding variables, our multivariate analysis showed that BMI 3 40 kg/m 2 (odds ratio [OR], 4.13; 95% confidence interval [CI], 1.3-12.88; p = 0.01), operating time [ 115 minutes (OR, 3.38; 95% CI, 1.23-9.28; p = 0.018), nonsame-day surgery (OR, 4.16; 95% CI, 1.44-12.02; p = 0.008), and revision surgery (OR, 4.23; 95% CI, 1.67-10.72; p \ 0.001) are significant risk factors for PJIs. Tobacco use and S aureus colonization were additive risk factors when combined with other significant risk factors (OR, 12.76; 95% CI,; p = 0.017). Conclusions Nonsame-day hip and revision arthroplasties have higher infection rates than same-day primary surgeries. These characteristics are not modifiable and should be categorized as a separate cohort for complication-reporting purposes. Potentially modifiable risk factors in our patient population include operating time, elevated BMI, tobacco use, and S aureus colonization. Modifying risk factors may

“…Patients with a BMI greater than 50 kg/m 2 reportedly have an 18.3 times higher odds of infection compared with BMI lower than 50 kg/m 2 [21]. Diabetes mellitus is also associated with SSI in patients undergoing arthroplasty [12,13], although the degree of attributable risk for infection independent of obesity is difficult to establish [6,30]. These risks may increase morbidity and mortality while also adding the burden of increased cost [15,18].…”

Section: Introductionmentioning

confidence: 99%

Medical Comorbidities Are Independent Preoperative Risk Factors for Surgical Infection After Total Joint Arthroplasty

Everhart

Altneu

Calhoun

2013

135

Background Surgical site infection (SSI) after total joint arthroplasty (TJA) is a major cause of morbidity. Multiple patient comorbidities have been identified as SSI risk factors including obesity, tobacco use, diabetes, immunosuppression, malnutrition, and coagulopathy. However, the independent effect of multiple individual patient factors on risk of subsequent periprosthetic infection is unclear. Questions/purposes The purposes of this study are (1) to collect data on several preestablished infection risk factors in addition to SSI-related data on a large TJA cohort; and (2) to use multivariate modeling on previously established patient risk factors to determine independent preoperative predictors of SSI.Methods We reviewed records of patients undergoing TJA from January 1, 2010, to July 30, 2012. Confirmation of SSI followed published guidelines for superficial, deep, and periprosthetic. A total of 29 culture-positive SSIs (1.5% total) and 1846 controls were identified. The prevalence of known patient-specific infection risk factors was determined for both infected cases and healthy control subjects followed by multiple regression analysis to determine independent risk. Results Isolated organisms consisted of methicillinresistant Staphylococcus aureus (MRSA; 34.5%) followed by gram-negative rods (31.0%). After adjusting for anatomic site, independent risk factors for infection include: revision surgery (odds ratio [OR]