Dataset Information

Do glycemic markers predict occurrence of complications after total knee arthroplasty in patients with diabetes?

ABSTRACT:

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 (HbA1c), 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 HbA1c level was 7%, the range was 5% to 11.3%.

Results

There were positive correlations among the levels of the four glycemic markers; the strongest correlation was found between the preoperative HbA1c and PPG2 levels (R = 0.502, p < 0.001). After controlling for potential confounding variables using multivariate analysis, the HbA1c cutoff level of 8 (odds ratio [OR], 6.1; 95% confidence interval [CI], 1.6-23.4; p = 0.008) and FBG 200 mg/dL or higher (OR, 9.2; 95% CI, 2.2-38.2; p = 0.038) were associated with superficial surgical site infection after TKA.

Conclusions

In general, there is a positive correlation among the various available glycemic markers among patients with diabetes undergoing TKA, and patients undergoing surgery with HbA1c ? 8 and/or FBG ? 200 mg/dL were associated with superficial surgical site infection. These findings should be considered in patient selection and preoperative counseling for patients with diabetes undergoing TKA.

Level of evidence

Level III, prognostic study.

SUBMITTER: Hwang JS

PROVIDER: S-EPMC4385343 | biostudies-literature | 2015 May

REPOSITORIES: biostudies-literature

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Publications

Do glycemic markers predict occurrence of complications after total knee arthroplasty in patients with diabetes?

Hwang Ji Sup JS Kim Seok Jin SJ Bamne Ankur B AB Na Young Gon YG Kim Tae Kyun TK

Clinical orthopaedics and related research 20141118 5

<h4>Background</h4>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.<h4>Questions/purposes</h4>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 p ...[more]

PMID: 25404402

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Project description:BACKGROUND:The study of localized immune-related factors has proven beneficial for a variety of conditions, and one area of interest in the field of orthopaedics is the impact of implants and localized infections on immune response. Several cytokines have shown increased systemic concentrations (in serum/plasma) in response to implants and infection, but tissue-level cytokines have not been investigated as thoroughly. METHODS:This exploratory study investigated tissue-level cytokines in a cohort of patients (N?=?17) in response to total knee arthroplasty and total knee revision to better understand the immune response to implants and localized infection (e.g., prosthetic joint infection). The overall goal of this study was to provide insight into the localized cytokine response of tissues and identify tissue-level markers specific to inflammation caused by implants vs. inflammation caused by infection. Tissues were collected across several anatomical locations and assayed with a panel of 20 human inflammatory cytokines to understand spatial differences in cytokine levels. RESULTS:In this study, six cytokines were elevated in implanted joints, as compared to native joints: IL-10, IL-12p70, IL-13, IL-17A, IL-4, and TNF-? (p?<?0.05). Seven cytokines showed infection-dependent increases in localized tissues: IL-1?, IL-1?, IL-6, IL-8, MCP-1, MIP-1?, and MIP-1? (p?<?0.05). CONCLUSIONS:This study demonstrated that differences exist in tissue-level cytokines in response to presence of implant, and some cytokines were specifically elevated for infection; these responses may be informative of overall tissue health. These results highlight the utility of investigating localized cytokine concentrations to offer novel insights for total knee arthroplasty and total knee revision procedures, as well as their complications. Ultimately, this information could provide additional, quantitative measurements of tissue to aid clinical decision making and patient treatment options.

Project description:ObjectivesAssessing the effects of diabetes mellitus (DM), non-insulin-dependent diabetes mellitus (NIDDM), and insulin-dependent diabetes mellitus (IDDM) on revision TKA (rTKA) has become increasingly imperative due to the increased rates of revisions associated with DM. This study sought to identify complications in rTKA that were independently associated with NIDDM/IDDM compared to non-diabetic (Non-DM) patients and whether IDDM was associated with specific postoperative complications compared to NIDDM.Methods and materials16,428 rTKA patients were identified from the ACS-NSQIP database from 2005 to 2016 and stratified into three separate cohorts. 12,922 (78.66%) were Non-DM, 2335 (14.21%) had NIDDM, and 1171 (7.13%) had IDDM. Univariate analyses were utilized to assess for differences in demographics, preoperative comorbidities, and postoperative complication rates. Multivariate logistic regression analyses were then employed to control for significant differences in patients characteristics to assess NIDDM and IDDM as independent risk factors for complications in comparison to Non-DM. IDDM was further analyzed as a risk factor in comparison to NIDDM for the purpose of elucidating the impact of insulin dependence on risk for postoperative complications.ResultsNIDDM was an independent risk factor for deep incisional surgical site infections (Odds Ratio (OR): 2.477) and urinary tract infections (UTI) (OR 1.862) (p?<?0.05). Compared to NIDDM, IDDM was independently associated with greater risk for pneumonia (OR 2.603), septic shock (OR 6.597), blood transfusions (OR 1.326), and an extended length of stay (OR: 1.331) (p?<?0.05). IDDM additionally increased the risk for acute renal failure (OR 3.269) and cardiac arrest (OR 3.268) (p?<?0.05) when compared to Non-DM. DM patients overall had increased rates of worse outcomes and infectious complications.ConclusionAlthough differences between diabetes and non-diabetes rTKA patients were seen, differences in complication rates between diabetes patients further divided based on insulin dependence status were also noted. Future work examining whether targeting perioperative glucose levels <200?mg/dL in DM rTKA patients decreases infectious complications is warranted. Future work analyzing the role of tranexamic acid administration and 24-h postoperative antibiotics in rTKA IDDM patients may be warranted given the elevated risk of pneumonia, septic shock, and blood transfusions.

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Dataset Information

Do glycemic markers predict occurrence of complications after total knee arthroplasty in patients with diabetes?

Background

Questions/purposes

Methods

Results

Conclusions

Level of evidence

Publications

Do glycemic markers predict occurrence of complications after total knee arthroplasty in patients with diabetes?

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