Postoperative glucose control may lower risk of periprosthetic infection

 Is postoperative glucose variability associated with adverse outcomes following shoulder arthroplasty?

These authors investigated the association between postoperative glycemic variability and short-term complications for 1074 patients having total shoulder arthroplasty (TSA) and reverse total shoulder arthroplasty (RTSA).

The mean patient age was 70 years, and 40% (!) of patients had a preoperative diagnosis of diabetes mellitus. 

A postoperative infection developed in 3 of 636 (0.5%) patients without diabetes compared with 9 of 424 (2.1%) patients with diabetes. Younger patient age and a preoperative diagnosis of diabetes mellitus showed statistically significant associations with postoperative infection. 

The first in-hospital glucose measurement beyond the reference tertile of 70-140 mg/dL showed a statistically significant association with postoperative infection,  whereas the second and third glucose measurements showed no association with postoperative infection.

The authors suggest that in-hospital glycemic control, as well as preoperative glycemic control and optimization, may be beneficial for reducing postoperative infections following shoulder arthroplasty.

Comment: Glycemic control before and immediately after shoulder arthroplasty may hold promise as modifiable risk factors for infection.

Interested readers should also view this related post When is a patient with diabetes safe for arthroplasty surgery?

How you can support research in shoulder surgery Click on this link.

Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link).

How to x-ray the shoulder (see this link).

The ream and run procedure (see this link).

The total shoulder arthroplasty (see this link).

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

The smooth and move procedure for irreparable rotator cuff tears (see this link).

Shoulder rehabilitation exercises (see this link).

When is a patient with diabetes safe for arthroplasty surgery?

Fructosamine is a better glycaemic marker compared with glycated haemoglobin (HbA1C) in predicting adverse outcomes following total knee arthroplasty 

Short-term variations in glucose levels have a large impact on inflammatory cytokine levels, cause oxidative stress, and impair host defence against infection. 

Fructosamine reflects the level of glycated serum proteins (mostly albumin) with a half-life of two to three weeks, thus representing a shorter period of preceding blood glucose levels, and a quicker response to treatment compared with HbA1c. It reflects rapid fluctuations of glucose and short-term spikes in glucose levels, thereby providing an early indication of poor glucose control.  

These authors used a prospective multi-institutional study to assess the utility of fructosamine compared with glycated haemoglobin (HbA1c) in predicting early complications following TKA, and to determine the threshold above which the risk of complications increased markedly. 

Patients (both diabetics and non-diabetics) were assessed using fructosamine and HbA1c levels within 30 days of surgery. Complications were assessed for 12 weeks from surgery and included prosthetic joint infection (PJI), wound complication, re-admission, re-operation, and death.

1119 patients (441 men, 678 women) were included in the study. A fructosamine level of 293 μmol/l was identified as the optimal cut-off associated with complications. Patients with high fructosamine (> 293 μmol/l) were 11.2 times more likely to develop PJI compared with patients with low fructosamine (p = 0.001). Re-admission and re-operation rates were 4.2 and 4.5 times higher in patients with fructosamine above the threshold (p = 0.005 and p = 0.019, respectively). These complications remained statistically significant in multiple regression analysis. 

The incidence of each type of complication in patients with fructosamine < 293 μmol/l (high; n = 1059) compared with patients with fructosamine ≥ 293 μmol/l (low; n = 60) is shown in the chart below.

Unlike fructosamine, all three cut-offs for HbA1c failed to show a significant association with complications. 

The authors concluded that fructosamine is a good predictor of complications following TKA. It better reflects the glycaemic control, has greater predictive power for adverse events, and responds quicker to treatment compared with HbA1c. 

How you can support research in shoulder surgery Click on this link.

Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link).

How to x-ray the shoulder (see this link).

The ream and run procedure (see this link).

The total shoulder arthroplasty (see this link).

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

The smooth and move procedure for irreparable rotator cuff tears (see this link).

Shoulder rehabilitation exercises (see this link).

Is diabetes associated with worse shoulder arthroplasty outcomes?

Diabetes Disease Severity Was Not Associated with Risk of Deep Infection or Revision After Shoulder Arthroplasty

These authors used Kaiser Permanente’s Shoulder Arthroplasty Registry (2005-2015) to answer several important questions regarding diabetes and shoulder arthroplasty: 

1) Are diabetes status and glycemic control associated with adverse events, including deep infection, all-cause revision, and 90-day readmission after shoulder arthroplasty? 

(2) Is postoperative HbA1c associated with revision risk? 

(3) Is there a threshold of preoperative HbA1c that best identifies patients with diabetes who are at higher risk of 3-year deep infection, 1-year all-cause revision or 90-day readmission? 

(4) Can the Adapted Diabetes Complications Severity index (aDCSI) be used as an alternative measure of diabetes severity in evaluating the risk of deep infection, all-cause revision, and 90-day readmission and identification of patients with diabetes at higher risk for these events? 

(5) Is there a difference between elective and traumatic shoulder arthroplasty patients?

Their study sample consisted of 8819 patients; 7353 underwent elective shoulder arthroplasty and 1466 underwent shoulder arthroplasty due to trauma. For elective shoulder arthroplasty, 1430 patients (19%) had diabetes, and among the patients who underwent arthroplasty due to trauma, 444 (30%) had diabetes.

Patients with diabetes who underwent elective shoulder arthroplasty and had poor glycemic control had a higher likelihood of 90-day readmission compared with patients without diabetes (OR, 1.5; 95% CI, 1.0–2.1; p =0.032). No association was found for patients with diabetes who underwent shoulder arthroplasty due to trauma. No association was found between postoperative HbA1c and revision risk. 

Patients with severe diabetes (by aDSCI) who underwent both elective and traumatic shoulder arthroplasty had a higher likelihood of 90-day readmission compared with patients without diabetes.

The authors found no difference in the risk of long-term complications (deep infection and revision) for patients with diabetes compared with patients without diabetes, regardless of disease severity or how that severity was measured. Further, they were unable to identify an optimal disease severity threshold, either according to HbA1c or aDCSI, for differentiating risk of adverse events after both elective and shoulder arthroplasty due to trauma.

Comment:  It is commonly held that diabetes, particularly poorly controlled diabetes is a risk factor for adverse outcomes from elective surgery, including arthroplasty. However, such an effect was not evident in this large study from an integrated healthcare system that places great value on preventive care. In this system, patients undergoing elective shoulder arthroplasty have time to use disease management resources preoperatively to try to mitigate the risks of surgery.

In our practice we note that many patients do not have a primary care provider who manages their wellness. By contrast, in the Kaiser system we perceive that primary care providers play a major role in health maintenance and, as such, may minimize the adverse effects of medical conditions such as diabetes.

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We have a new set of shoulder youtubes about the shoulder, check them out at this link.

Be sure to visit "Ream and Run - the state of the art" regarding this radically conservative approach to shoulder arthritis at this link and this link

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How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages  arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Diabetes, HbA1c, infection, and shoulder arthroplasty

Association of Perioperative Glycemic Control With Deep Postoperative Infection After Shoulder Arthroplasty in Patients With Diabetes (J Am Acad Orthop Surg 2018;0:1-8)

These authors queried the  PearlDiver Patient Records Databasefor patients with diabetes who underwent primary shoulder arthroplasty. They assessed the incidence of wound complications within 6 months within 1 year for each perioperative HbA1c level. 

Patients with DM had higher rates of wound complications (1.4% versus 0.9%; odds ratio, 1.22; P = 0.028) and deep infection (0.7% versus 0.4%; odds ratio, 1.47; P = 0.001). 

The rates of wound complications (P = 0.0008) and deep postoperative infection (P = 0.002) increased markedly as the perioperative HbA1c level increased. 

Comment: As the authors point out, the literature on the effects of preoperative optimization of HbA1c values and postoperative infection is lacking. Thus, while it seems compelling to do so, we cannot be sure that requiring our diabetic patients to 'get their HbA1c below 8' will lower their risk of infection.

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Use the "Search" box to the right to find other topics of interest to you.

How you can support progress in shoulder surgery

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

The risks associated with total shoulder in patients with diabetes and others

The impact of insulin dependence on short-term postoperative complications in diabetic patients undergoing total shoulder arthroplasty

These authors sought to determine the impact of insulin dependence on the risk profile of diabetic patients having shoulder arthroplasty. Patients were categorized as non–diabetes mellitus (non-DM), non–insulin dependent diabetes mellitus (NIDDM), or insulin-dependent diabetes mellitus (IDDM). 

In bivariate analysis, NIDDM and IDDM were associated with multiple postoperative complications, including stroke, sepsis, wound complications, blood transfusion, and extended LOS. With multivariable logistic regression, however, NIDDM patients did not have significantly greater odds of any study end point relative to non-DM patients. IDDM patients had significantly greater odds for having any postoperative complication (odds ratio [OR], 1.53), stroke (OR, 13.63), blood transfusion (OR, 1.67), and extended LOS (OR, 1.38).

They concluded that after adjustment for demographics and comorbidity burden, NIDDM patients had risk profiles similar to those of non-DM patients. IDDM was an independent predictor of multiple postoperative complications. 

Comment: While the authors did not have HbA1c levels on the patients in this study, they state that "insulin dependence appears to be a more robust risk factor than glycemic control as measured by the HbA1c level." There is currently a re-examination of the value of using oft-quoted target of an HbA1c level of 7. There is some evidence that (1) some patients may not be able to reach this goal and (2) 'forcing' an HbA1c level of 7 may not be safe for the patient. There seems to be a trend toward accepting the more reachable and perhaps safer target of 8. 

It remains unclear to us how much the well-documented increased risk of surgery in patients with IDDM can be modified. The table above demonstrates that a number of important health factors are co-variates with the severity of diabetes making it a challenge to sort the effect of one from the other. 

At minimum, our responsibility is to inform our patients of the potential risk of surgery. One approach is to use the American College of Surgeons' Surgical risk calculator

Interestingly this calculator classes diabetes as "none", "oral", "insulin".

The reader may like to enter "23472 - Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (eg, total shoulder))" into the procedure box at the top and calculate his/her estimated risk.

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The reader may also be interested in these posts:

Healing through joint replacement

Supporting progress in shoulder surgery

Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book.

Click here to see the new Rotator Cuff Book

Information about shoulder exercises can be found at this link.

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.

Shoulder stiffness and glucose control

The relationship between the incidence of adhesive capsulitis and hemoglobin A1c

These authors determined a "cumulative" HbA1c, that uses HbA1c values over time to estimate the total disease burden that the patient experiences over a period. They evaluated whether a correlation existed between cumulative HbA1c levels in diabetic patients and the prevalence of frozen shoulder using a retrospective review of  patients from a single institution for which HbA1c values were available. The exclusion criteria were age younger than 18 years, HbA1c levels greater than 15, and patients who had 1 year or less of single or consecutively recorded HbA1c levels. A total of 24,417 patients met the inclusion criteria.

They found that cumulative HbA1c was positively associated with adhesive capsulitis.  The effect size of cumulative HbA1c on adhesive capsulitis was significant; for each unit of time that the HbA1c level was greater than 7, there was a 2.77% increase in the risk of adhesive capsulitis.

Comment: The mechanism of joint stiffness in individuals with abnormal sugar metabolism is thought to be non-enzymatic gycosylation, causing abnormal cross links between collagen fibers resulting in increased stiffness. 

Surgeons performing surgical releases for stiff diabetic shoulders often note increased thickness and toughness of the capsular tissue. Surgeons attempting to manage diabetic stiff shoulders with manipulation are often frustrated for the same reason.

This paper would have been stronger if the authors had provided the diagnostic criteria used for making the diagnosis of adhesive capsulitis (if indeed these criteria were standardized across the practice) and if they had performed a multivariate analysis that included all the data they collected: patient age, sex, BMI, length of time over which the HbA1c data were collected (range, 12-207 months), thyroid status, and insulin dosage at the time of diagnosis. 

In any event, this study reminds us that, in addition to its effect on surgical complications, glycemic control may affect the success of procedures designed to improve shoulder motion, including shoulder arthroplasty. 

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Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book.

Click here to see the new Rotator Cuff Book

Information about shoulder exercises can be found at this link.

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

See the countries from which our readers come on this post.

Hyperglycemia may facilitate biofilm formation

Biofilm growth has a threshold response to glucose in vitro.

These authors used an in vitro model of biofilm formation to investigate the relationship between the amount of biofilm formed by Staphylococcus epidermidis and Staphylococcus aureus and the glucose concentration in the clinically important range of 20 to 300 mg/dL.

They found increased biofilm growth by S aureus and S epidermidis in the clinically important range of 20 to 300 mg/dL.

They concluded that postoperative hyperglycemia may increase the risk for implant infection through increased pathogenicity of intraoperative wound contaminants in addition to compromising host immune status.

Comment: This is an example of how a change in the host environment may increase the pathogenicity of bacteria.

Optimizing the blood glucose after shoulder surgery may reduce the chances of biofilm formation.

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Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book

Click here to see the new Rotator Cuff Book

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Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

Diabetes control and wound complications after total joint surgery

Elevated Postoperative Blood Glucose and Preoperative Hemoglobin A1C Are Associated with Increased Wound Complications Following Total Joint Arthroplasty

From among 1702 patients having total joint replacements, those with wound complications within thirty days after the index arthroplasty were identified. A control group matched for exact age, sex, procedure, tourniquet use, surgical approach, and use of antibiotic cement was also created.

Patients with a mean postoperative glucose of >200 mg/dL had an odds ratio for developing a wound complication of 3.75. 

Patients with a maximum postoperative blood glucose of >260 mg/d had an odds ratio for developing a wound complication of 3.0

Patients with a preoperative hemoglobin A1C value of >6.7% had an odds ratio for developing a wound complication of 9.0.

The authors point that this study did not show that good glycemic control resulted in reduced risk. They did demonstrate that poor preoperative and postoperative glucose control is independently associated with wound complications.

These results are in contrast to those of
Surgical outcomes of total knee replacement according to diabetes status and glycemic control, 2001 to 2009, a study of Kaiser enrollees.
The authors found that of 40,491 patients who underwent total knee arthroplasty, 7567 (18.7%) had diabetes, 464 (1.1%) underwent revision arthroplasty, and 287 (0.7%) developed a deep infection. Compared with the patients without diabetes, no association between controlled diabetes (HbA1c < 7%) and the risk of revision (odds ratio [OR], 1.32; 95% confidence interval [CI], 0.99 to 1.76), risk of deep infection (OR, 1.31; 95% CI, 0.92 to 1.86), or risk of deep venous thrombosis or pulmonary embolism (OR, 0.84; 95% CI, 0.60 to 1.17) was observed. Similarly, compared with patients without diabetes, no association between uncontrolled diabetes (HbA1c ≥ 7%) and the risk of revision (OR, 1.03; 95% CI, 0.68 to 1.54), risk of deep infection (OR, 0.55; 95% CI 0.29 to 1.06), or risk of deep venous thrombosis or pulmonary embolism (OR, 0.70; 95% CI, 0.43 to 1.13) was observed.

The authors concluded that no significantly increased risk of revision arthroplasty, deep infection, or deep venous thrombosis was found in patients with diabetes (as defined on the basis of preoperative HbA1c levels and other criteria) compared with patients without diabetes in the study population of patients who underwent elective total knee arthroplasty.

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Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'


See from which cities our patients come.


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Effects of Glycemic Control on Prevalence of Diabetic Frozen Shoulder - JBJS

Effects of Glycemic Control on Prevalence of Diabetic Frozen Shoulder was recently published by JBJS.

It is well known that individuals with diabetes are at increased risk of having a frozen shoulder and that frozen shoulders in these individuals are often more difficult to manage with therapy or with surgery. These authors sought to answer the question of whether control of the diabetes was related to the development of frozen shoulder. They reviewed 201,513 diabetic patients and found 1150 with a diagnosis of frozen shoulder. There was no significant relationship between HbA1c level and the prevalence of frozen shoulder. The frequency of frozen shoulder was almost twice as high in insulin-dependent patients than non-insulin-dependent diabetic patients. The incidence of frozen shoulder was also higher in those taking oral hypoglycemic drugs than those who were not. It was also more common for those who had had diabetes for 10 or more years. The prevalence of end-stage diabetic manifestations was increased in patients with frozen shoulder as compared with those without frozen shoulder.

These data suggest that the severity of the diabetes, but not the degree of diabetic control, and the incidence of frozen shoulder are closely related.

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You may be interested in some of our most visited web pages including: shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, revision surgery for failed shoulder joint replacement, rotator cuff disease, and rotator cuff surgery.You may also be interested in our information about quadriceps sparing or 'mini' total knee replacement or about hip replacement arthroplasty.

Shoulder: arthritic or frozen?

There are three common conditions of the shoulder that are often confused: rotator cuff tear, shoulder arthritis and frozen shoulder. Shoulder stiffness is a common symptom of each of them. Shoulder stiffness is diagnosed as shown here.

A detailed discussion of rotator cuff problems can be found here.

A detailed discussion of shoulder arthritis can be found here. The reasons for stiffness in arthritis are shown here. The photo below shows an arthritic humeral head as seen at surgery.

A frozen shoulder is, like shoulder arthritis, one of the conditions that can result in a stiff shoulder. The difference is that in a frozen shoulder, the joint surfaces are normal and the shoulder motion is limited because the tissue around the joint - the joint capsule - has tightened down. Frozen shoulders are thought to arise from inflammation within the joint. Frozen shoulders can be particularly problematic in individuals with diabetes. It was once believed that frozen shoulder was associated with personality disorders, but recent evidence does not support this contention. We diagnose a frozen shoulder when the shoulder has limited motion, without a history of prior injury or surgery and with AP and Axillary x-rays showing a normal joint space as diagrammed below.



Frozen shoulders usually respond to home exercises.

Our basic approach to rehabilitation of a frozen shoulder is shown in the post on stretching (see this link) and in the post on strengthening (see this link)

If this is not successful, consideration can be given to a gentle manipulation under full muscle relaxation and anesthesia. If this is not successful an arthroscopic or open surgical release of the tight capsule can be considered.

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Here are some videos that are of shoulder interest

Shoulder arthritis - what you need to know (see this link).

How to x-ray the shoulder (see this link).

The ream and run procedure (see this link).

The total shoulder arthroplasty (see this link).

The cuff tear arthropathy arthroplasty (see this link).

The reverse total shoulder arthroplasty (see this link).

The smooth and move procedure for irreparable rotator cuff tears (see this link).

Shoulder rehabilitation exercises (see this link).