SLR - February 2024 - Currey
Title: Higher Blood Glucose Levels on the Day of Surgery Are Associated with an Increased Risk of Periprosthetic Joint Infection After Total Hip ArthroplastyReference: Wier, J., Liu, K. C., Richardson, M. K., Gettleman, B. S., Kistler, N. M., Heckmann, N. D., & Lieberman, J. R. (2023). Higher Blood Glucose Levels on the Day of Surgery Are Associated with an Increased Risk of Periprosthetic Joint Infection After Total Hip Arthroplasty. Journal of Bone and Joint Surgery. American Volume. https://doi.org/10.2106/JBJS.23.00546
Level of Evidence: Level III (Prognostic)
Reviewed By: Suzanne Currey, DPM, PGY-1
Residency Program: Mount Auburn Hospital, Cambridge, MA
Podiatric Relevance: Though this article discusses periprosthetic joint infection (PJI) s/p total hip arthroplasty (THA), it has an influential implication for foot and ankle surgery, especially for TARs. The conclusion discusses how crucial it is for surgeons performing total joint arthroplasties to identify patients with elevated preoperative glucose levels given the increased risk for infection. Furthermore, it is well established that the infection risk is increased in diabetic patients which is relevant in podiatric surgery as many patients are diabetic.
Methods: The authors utilized the Premier Healthcare Database to identify patients undergoing THA from 1/1/2016 through 12/31/2021 with recorded preoperative blood glucose levels (BGL). Patients were excluded from the study if <18 years of age, admitted for >24 hours prior to surgery and undergoing nonelective THA. Then, multivariable logistic regression with restricted cubic splines was used to determine the association between the preoperative BGL and the 90-day PJI risk. Of note, BGL within normal limits was 70-100 mg/dL in non-diabetics and 80-130 mg/dL in diabetics.
Results: There was a total of 90,830 patients included in the study, 22.5% of these patients had a documented history of diabetes. Patients were divided into two groups, diabetic versus nondiabetic then further split based on preoperative glucose status. The mean preoperative BGL in the diabetic group was found to be 143.0 mg/dL and 44.42% of these patients had a normal BGL, whereas 1.67% had a high preoperative BGL (mean of 328.25 mg/dL)—more of these patients were found to be male, admitted for 0.35 fewer days, and admitting hospitals were more commonly rural. Similar results were found in the non-diabetic group, the mean preoperative BGL was found to be 119.8 mg/dL and 2.08% of these patients had high BGL. It was also found that the high preoperative glucose groups had higher rates of concomitant systemic illness (examples: CHF and renal failure) compared to the normal preoperative glucose groups. In the high glucose diabetic group, it was determined there were significantly greater adjusted odds of PJI, hyperglycemic complications, other infectious complications, medical complications, and higher 90-day readmission. As for the high glucose nondiabetic group, it was determined that there were significantly greater adjusted odds of PJI, hyperglycemic complications, and higher 90-day readmission.
Conclusions: The authors concluded that increased preoperative BGL was found to be associated with increased risk of PJI following primary THA. They further stated patients with diabetes and high preoperative glucose had 2.60 times greater odds of PJI, compared to nondiabetic patients with high preoperative BGL have 1.66 times greater odds of PJI. Given the high preoperative BGL groups also had higher rates of 90-day readmission and other complications (especially in diabetic group), the authors suggest that surgeons be conscious of high preoperative BGL in their patients ( >277 mg/dL in nondiabetics and >193 mg/dL in diabetics). Despite study limitations, such as risk of data entry errors and limited generalizability, this article is helpful raising awareness for the potential negative outcomes in total joint arthroplasty patients with high preoperative glucose levels, especially in diabetic patients.