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Hba1c And Joint Replacement

Delaying Joint Replacement Surgery Until Hemoglobin A1c Is Less Than 7%

Delaying Joint Replacement Surgery Until Hemoglobin A1c Is Less Than 7%

Delaying Joint Replacement Surgery Until Hemoglobin A1c is Less Than 7% Allan S. Brett, MD reviewing Giori NJ et al. J Bone Joint Surg Am 2014 Mar 19 The benefit of this practice, which delays or prevents surgery for some diabetic patients, is unclear. Increasingly, orthopedists are insisting that diabetic patients lower their glycosylated hemoglobin (HbA1c) levels to less than 7% before they undergo total joint arthroplasty. But this is far easier said than done, particularly in older patients, in whom tight control increases risk for potentially dangerous hypoglycemia. A study from the orthopedic clinic at a U.S. Veterans Affairs hospital illustrates this problem. During a 5-year period, 59 diabetic patients who were deemed otherwise suitable for total hip or knee arthroplasty were not scheduled for surgery because their HbA1c levels were >7%. The patients were referred back to their primary care physicians to intensify glycemic control. After an average of 8 months, 35 (59%) achieved HbA1c levels 7%, but the remaining 24 patients (41%) were unable to do so. Only 5 of those 24 patients ultimately had surgery. Reluctance to perform total hip or knee arthroplasty on diabetic patients with HbA1c levels >7% is based on assumptions that this threshold is a good predictor of risk for postoperative complications (especially deep infection) and that preoperative lowering of HbA1c reduces that risk. But observational studies do not uniformly support the first assumption ( NEJM JW Gen Med Mar 28 2013 ), and no randomized trials have tested the second one. Indeed, it might be that glycemic control immediately after surgery is more important for preventing complications than control during the months before surgery. EDITOR DISCLOSURES AT TIME OF PUBLICATION Disclosures for Allan Continue reading >>

Management Of Hyperglycemia And Diabetes In Orthopedic Surgery

Management Of Hyperglycemia And Diabetes In Orthopedic Surgery

Go to: An increasing number of orthopedic operations are being carried out in an older population in whom the prevalence of diabetes is dramatically increasing. People having surgery with diabetes and hyperglycemia are at increased risk of post-operative complications. The peri-operative risks have been well demonstrated for cardiac surgery and, more recently, for orthopedic surgery. This paper considers the issues surrounding orthopaedic surgery in patients with diabetes and the significance and management of hyperglycemia in the peri-operative period. Keywords: Diabetes mellitus, Hyperglycemia, Peri-operative glucose, Orthopedic surgery, Arthroplasty Go to: Introduction The global prevalence and incidence of diabetes is steadily rising in all populations and at the current rate the International Diabetes Foundation (IDF) estimates a prevalence of 9.9% worldwide by 2030. With population growth, this represents a 50.7% increase in people affected over a 19-year period [1]. A person with diabetes is more likely to require surgery than a person without and this is particularly notable for orthopedic surgery, which has seen an overall increase in procedures in this population as a whole [2]. Observational studies show that in the surgical patient, diabetes is associated with a higher rate of peri-operative complications such as need for transfusion, pneumonia, delayed discharge, surgical site infections, and in-hospital mortality [3]. These poorer outcomes are in part due to higher rates of co-morbid conditions such as ischemic heart disease, renal impairment, and hypertension in patients with diabetes [4]. Dysglycemia, which encompasses hyperglycemia, hypoglycemia, stress-induced hyperglycemia, and excessive glucose variability, is increasingly observed and associated wit Continue reading >>

Diabetes Mellitus, Hemoglobin A1c, And The Incidence Of Total Joint Arthroplasty Infection.

Diabetes Mellitus, Hemoglobin A1c, And The Incidence Of Total Joint Arthroplasty Infection.

1. J Arthroplasty. 2012 May;27(5):726-9.e1. doi: 10.1016/j.arth.2011.09.013. Epub2011 Nov 4. Diabetes mellitus, hemoglobin A1C, and the incidence of total joint arthroplasty infection. Iorio R(1), Williams KM, Marcantonio AJ, Specht LM, Tilzey JF, Healy WL. (1)Department of Orthopaedic Surgery, Lahey Clinic Medical Center, Burlington, Massachusetts 01805, USA. Patients with diabetes have a higher incidence of infection after total jointarthroplasty (TJA) than patients without diabetes. Hemoglobin A1c (HbA1c) levels are a marker for blood glucose control in diabetic patients. A total of 3468patients underwent 4241 primary or revision total hip arthroplasty or total knee arthroplasty at one institution. Hemoglobin A1c levels were examined to evaluate if there was a correlation between the control of HbA1c and infection after TJA. There were a total of 46 infections (28 deep and 18 superficial [9 cellulitis and9 operative abscesses]). Twelve (3.43%) occurred in diabetic patients (n = 350;8.3%) and 34 (0.87%) in nondiabetic patients (n = 3891; 91.7%) (P < .001). There were 9 deep (2.6%) infections in diabetic patients and 19 (0.49%) in nondiabetic patients. In noninfected, diabetic patients, HbA1c level ranged from 4.7% to15.1% (mean, 6.92%). In infected diabetic patients, HbA1c level ranged from 5.1% to 11.7% (mean, 7.2%) (P < .445). The average HbA1c level in patients withdiabetes was 6.93%. Diabetic patients have a significantly higher risk forinfection after TJA. Hemoglobin A1c levels are not reliable for predicting therisk of infection after TJA.Copyright 2012 Elsevier Inc. All rights reserved. Arthroplasty, Replacement, Hip/statistics & numerical data* Arthroplasty, Replacement, Knee/statistics & numerical data* Continue reading >>

Many Diabetic Total Joint Arthroplasty Candidates Are Unable To Achieve A Preoperative Hemoglobin A1c Goal Of 7% Or Less.

Many Diabetic Total Joint Arthroplasty Candidates Are Unable To Achieve A Preoperative Hemoglobin A1c Goal Of 7% Or Less.

Abstract BACKGROUND: Patients with poorly controlled diabetes have an elevated risk of complications and death following total joint arthroplasty. Some centers set a threshold hemoglobin A1c (HbA1c) value above which surgery is delayed pending better glycemic control. The purpose of this study was to examine how many diabetic patients scheduled for primary total joint arthroplasty underwent a delay because of an HbA1c value of >7.0%, how many subsequently achieved this goal, and how much time was necessary to achieve this goal. METHODS: The study involved a retrospective chart review at one Veterans Affairs medical center. Patients with an HbA1c of >7.0% were referred to their primary care provider for better diabetic control. Unless reduction of the HbA1c to ≤7.0% was deemed medically inadvisable, surgery proceeded only after the patient returned with an HbA1c of ≤7.0%. RESULTS: A total of 404 diabetic patients were scheduled for total joint arthroplasty. In fifty-nine cases, the surgery was delayed because of an HbA1c of >7.0%. Thirty-five of these patients were able to reduce the HbA1c level to ≤7.0% after a median of 141 days (range, seven to 1043 days), and twenty-four failed to achieve this goal. If an HbA1c goal of ≤8.0% had been used, the surgery would have been delayed in thirty cases, and twenty-one of these patients would have subsequently achieved the goal. CONCLUSIONS: When establishing a goal designed to reduce perioperative risks, there should be an expectation that the goal is achievable. Overall, an HbA1c of ≤7.0% was achieved by 380 of the 404 diabetic patients (94%; 95% confidence interval [CI], 91% to 96%), but it was achieved by only thirty-five (59%; 95% CI, 46% to 72%) of the fifty-nine patients presenting with an HbA1c of >7.0%. An HbA1 Continue reading >>

Diabetes Mellitus, Hemoglobin A1c, And The Incidence Of Total Joint Arthroplasty Infection

Diabetes Mellitus, Hemoglobin A1c, And The Incidence Of Total Joint Arthroplasty Infection

Patients with diabetes have a higher incidence of infection after total joint arthroplasty (TJA) than patients without diabetes. Hemoglobin A1c (HbA1c) levels are a marker for blood glucose control in diabetic patients. A total of 3468 patients underwent 4241 primary or revision total hip arthroplasty or total knee arthroplasty at one institution. Hemoglobin A1c levels were examined to evaluate if there was a correlation between the control of HbA1c and infection after TJA. There were a total of 46 infections (28 deep and 18 superficial [9 cellulitis and 9 operative abscesses]). Twelve (3.43%) occurred in diabetic patients (n = 350; 8.3%) and 34 (0.87%) in nondiabetic patients (n = 3891; 91.7%) (P < .001). There were 9 deep (2.6%) infections in diabetic patients and 19 (0.49%) in nondiabetic patients. In noninfected, diabetic patients, HbA1c level ranged from 4.7% to 15.1% (mean, 6.92%). In infected diabetic patients, HbA1c level ranged from 5.1% to 11.7% (mean, 7.2%) (P < .445). The average HbA1c level in patients with diabetes was 6.93%. Diabetic patients have a significantly higher risk for infection after TJA. Hemoglobin A1c levels are not reliable for predicting the risk of infection after TJA. Do you want to read the rest of this article? ... The number of DM patients who need to undergo THA or TKA have been increasing [9]. As many literatures have stated the associations between the postoperative infections and DM or a high level of HbA1c in the fi eld of cardiothoracic surgery [4][5][6][7], it was also reported that the patients that underwent total joint arthroplasty with DM had a signifi cantly higher risk of postoperative PJI than that of the patients without DM [10][11][12][13][14][15]. For example, Hwang et al. reported that the patients with the preoperat Continue reading >>

Hba1c, Joint Replacement Complications Linked

Hba1c, Joint Replacement Complications Linked

HbA1c, Joint Replacement Complications Linked SAN FRANCISCO Complications after total knee or hip arthroplasty in patients with diabetes were significantly more common in those with higher hemoglobin A1c levels, a retrospective study of 119 patients found. The overall rate of medical and surgical complications was more than 50% in patients with a hemoglobin A1c (HbA1c) level greater than 7%, and less than 40% in those with an HbA1c level below 7%, study investigators reported. We believe that the HbA1c test should be a routine preoperative test ordered for diabetes patients prior to total joint arthroplasty, Dr. Yossef C. Blum said during a poster session at the annual meeting of the American Academy of Orthopaedic Surgeons. Patients with significantly elevated HbA1c levels should have their glycemic control better optimized prior to undergoing total hip arthroplasty or total knee arthroplasty, as well as in the perioperative period. In a review of inpatient and outpatient charts of total knee or hip arthroplasty performed by a single surgeon at one institution from 2000 to 2007, Dr. Blum and his associates found 199 patients whose HbA1c level had been measured in the year before surgery or within 3 months after the surgery. Patients were excluded from the study if they had conditions other than diabetes that led to an immunosuppressed state, such as HIV or rheumatoid arthritis. Patients did not have to have a diagnosis of diabetes to be included in the studyjust an HbA1c measurementbecause up to a third of people with diabetes do not have a formal diagnosis, he and his associates reported. In all, 73% of the patients underwent total knee arthroplasty and 27% had total hip arthroplasty. Patients had a mean age of 68 years. The cohort was 76% male, 34% white, 34% black, Continue reading >>

Deep Perioperative Infection Risk After Tha Was Greater With Higher Hba1c Levels

Deep Perioperative Infection Risk After Tha Was Greater With Higher Hba1c Levels

Deep perioperative infection risk after THA was greater with higher HbA1c levels HbA1c values correlate with the risk of infection, but it is a poor predictor of who will develop an infection. Patients with diabetes who underwent total hip arthroplasty had an increased risk of deep perioperative infection that required surgical intervention as their perioperative hemoglobin A1c levels increased, based on results presented at the American Association of Hip and Knee Surgeons Annual Meeting. In patients with diabetes, a perioperative hemoglobin A1c value does correlate with the risk of infection following total hip arthroplasty, James A. Browne, MD, associate professor of orthopedic surgery and division head of adult reconstruction at the University of Virginia, told Orthopedics Today. Using a national administrative database, Browne and his colleagues stratified 7,736 patients with diabetes who underwent total hip arthroplasty (THA) between 2007 and 2015 into mutually exclusive groups with hemoglobin A1c (HbA1c) values in increments of 0.5 mg/dL. They were most interested in deep periprosthetic joint infection (PJI) within 1 year of surgery as an outcome, Browne noted. Results showed at 1 year postoperatively, patients with low HbA1c levels at or below 5.49 mg/dL had an incidence of PJI that was as low as 0.7% vs. 5.9% for patients with HbA1c levels of 11.5 or greater. This difference was statistically significant (P<.0001). When we developed our [receiver operating characteristic] ROC curve, we found the inflection point is around 7.0 [mg/dL] to 7.5 mg/dL, Browne said in his presentation. He noted statistically significant differences in the PJI rate when patients were divided into two groups: patients with a HbA1c level below 7.5 mg/dL and patients with a HbA1c level Continue reading >>

Determining The Threshold For Hba1c As A Predictor For Adverse Outcomes After Total Joint Arthroplasty: A Multicenter, Retrospective Study.

Determining The Threshold For Hba1c As A Predictor For Adverse Outcomes After Total Joint Arthroplasty: A Multicenter, Retrospective Study.

Determining the Threshold for HbA1c as a Predictor for Adverse Outcomes After Total Joint Arthroplasty: A Multicenter, Retrospective Study. Tarabichi M, et al. J Arthroplasty. 2017. Department of Orthopaedic Surgery, Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania. Department of Orthopaedic Surgery, Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania; Department of Orthopaedic Surgery, Tel Aviv University, Tel Aviv, Israel. Department of Orthopaedic Surgery, Washington University School of Medicine, St. Louis, Missouri. Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio. Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois. Department of Orthopaedic Surgery, NYU Langone Medical Center, New York, New York. Department of Orthopaedic Surgery, Duke University School of Medicine, Durham, North Carolina. J Arthroplasty. 2017 Sep;32(9S):S263-S267.e1. doi: 10.1016/j.arth.2017.04.065. Epub 2017 May 11. BACKGROUND: Although HbA1c is commonly used for assessing glycemic control before surgery, there is no consensus regarding its role and the appropriate threshold in predicting adverse outcomes. This study was designed to evaluate the potential link between HbA1c and subsequent periprosthetic joint infection (PJI), with the intention of determining the optimal threshold for HbA1c. METHODS: This is a multicenter retrospective study, which identified 1645 diabetic patients who underwent primary total joint arthroplasty (1004 knees and 641 hips) between 2001 and 2015. All patients had an HbA1c measured within 3 months of surgery. The primary outcome of interest was a PJI at 1 year based on the Musculoskeletal Infection Society criteria. Secondary outcomes included orthopedic (wound Continue reading >>

More Than Half Of Diabetic Patients With High Preop Hba1c Levels Were Able To Achieve Threshold Level For Tja

More Than Half Of Diabetic Patients With High Preop Hba1c Levels Were Able To Achieve Threshold Level For Tja

More than half of diabetic patients with high preop HbA1c levels were able to achieve threshold level for TJA Please provide your email address to receive an email when new articles are posted on this topic. Receive an email when new articles are posted on this topic. While the authors of this study found that most diabetic patients scheduled for total joint arthroplasty achieved a threshold hemoglobin A1c value of 7% or less, 59% of patients who had levels greater than this value and were delayed surgery were able to achieve this hemoglobin goal at a mean of approximately 4.5 months. Through a retrospective chart review at a Veterans Affairs medical center, researchers referred patients with a hemoglobin A1c (HbA1c) of greater than 7% to their primary care provider for better diabetic control. Unless reduction of HbA1c to 7% or less was deemed medically inadvisable, patients underwent surgery only after they returned with an HbA1c of 7% or less. Overall, 404 diabetic patients were scheduled for total joint arthroplasty. Researchers delayed surgery in 59 cases because of an HbA1c of greater than 7%. After a median of 141 days, 35 of these patients were able to reduce the HbA1c level to 7% or less while 24 failed to achieve this goal, according to study results. If researchers used an HbA1c goal of 8% or lower, the surgery would have been delayed in 30 cases and 21 patients would have achieved the goal. The increased risk of complications in patients with elevated HbA1c must be balanced against the fact that access to surgery can potentially alter the quality of life of diabetic patients, the researchers wrote in their study. Ultimately, surgeons must work with their diabetic patients to weigh the data becoming available on this important topic and decide how to balance Continue reading >>

Study: Hba1c Risk Threshold For Infection Identified For Diabetes Patients Undergoing Shoulder Replacement

Study: Hba1c Risk Threshold For Infection Identified For Diabetes Patients Undergoing Shoulder Replacement

Study: HbA1c Risk Threshold for Infection Identified for Diabetes Patients Undergoing Shoulder Replacement A study, presented at the AAOS Annual Meeting in San Diego, reported, that, in patients with diabetes mellitus undergoing shoulder arthroplasty, the risk of deep postoperative infection rises with increasing hemoglobin A1c (HbA1c) levels. The data also suggested a perioperative HbA1c greater than 8.0 mg/dL might serve as a threshold for a significantly increased risks of postoperative infection. Although diabetes has been strongly associated with an increased risk of postoperative wound complications and deep postoperative infection after total hip arthroplasty (THA) and total knee arthroplasty (TKA), it has not been routinely associated with higher rates of infection after shoulder arthroplasty, said Brian C. Werner, MD, of the University of Virginia, who presented the study. The likely explanation is that lower infection rates and lower numbers of shoulder arthroplasty procedures challenge investigators to achieve adequate statistical power to investigate any association. The study reviewed outcomes for 2,257 patients with diabetes and with a perioperative HbA1c recorded in the PearlDiver Patient Records Database who underwent shoulder reconstruction, including anatomic total shoulder arthroplasty, reverse total shoulder arthroplasty, and shoulder hemiarthroplasty. Patients with a history of prior or concomitant diagnoses of periprosthetic infection were excluded from the analysis. These patients were identified from an overall group of 18,729 patients who underwent shoulder arthroplasty. Patients then grouped into 13 groups based on 1 mg/dL increments of their HbA1c level , A low group started with patients with a level between 0.00 and 5.9 mg/dL. The highest g Continue reading >>

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