Infection risk increased with perioperative hemoglobin levels after shoulder arthroplasty in patients with diabetes

As perioperative hemoglobin A1c levels increased, risks for wound complications and deep infection increased in patients with diabetes who underwent shoulder arthroplasty, according to a recently published study in the Journal of the American Academy of Orthopaedic Surgeons.

Perspective from Surena Namdari, MD, MSc

Jourdan M. Cancienne

“Patients with diabetes and [hemoglobin A1c] HbA1c levels of 8 and higher should be counseled that proceeding with surgery may place them at higher risk for wound complications and periprosthetic joint infection following shoulder arthroplasty,” Jourdan M. Cancienne, MD, told Healio.com/Orthopedics.

Cancienne and colleagues used a national database to identify 2,537 patients with diabetes who underwent primary shoulder arthroplasty and had HbA1c levels recorded within 3 months of the surgery date. Primary outcomes included a diagnosis of superficial would complication 6-months postoperatively and deep infection that needed surgical intervention 1-year postoperatively. Multivariable binomial logistic regression analysis that controlled for confounding variables was used to compare overall rates of wound complications and deep postoperative infection after shoulder arthroplasty in patients with diabetes vs. without diabetes.

Results showed patients with diabetes had significantly greater wound complication rates and deep infection. Investigators noted as the HbA1c levels increased, wound complication rates and deep postoperative infection rates increased. According to results from the receiver operating characteristics analysis, there was an inflection point at an HbA1c level of 8 mg/dL. – by Monica Jaramillo and Casey Tingle

Disclosures: The authors report no relevant financial disclosures.

Perspective

Surena Namdari, MD, MSc

As shoulder arthroplasty moves into an era of value-based care and bundled reimbursement plans, identifying modifiable risk factors for postoperative complications is critical. Using a large national insurance claim-based database of patient records, Cancienne and colleagues reported increases in HbA1c values were associated with increases in wound and infectious complications. Although imperfect in its accuracy, the authors proposed a perioperative HbA1c level of 8.0 mg/dL as a threshold for increased risk of deep infection after shoulder arthroplasty. Importantly, independent of HbA1c values, the rate of wound and infectious complications after shoulder arthroplasty is low and the level of “acceptable risk” is unknown. For example, if the risk of infection after shoulder arthroplasty is 1%, does doubling the risk to 2% still yield “acceptable risk” for surgery? As the vast majority of shoulder arthroplasty is elective in nature and can be delayed without clinical consequences, I believe the authors should be commended for identifying a tangible parameter by which we can judge our medical optimization of diabetes and a potential strategy for minimizing rates of complications and reoperation after shoulder arthroplasty.

Surena Namdari, MD, MSc

Associate professor of orthopedic surgery

Director of shoulder and elbow research

Rothman Institute – Thomas Jefferson University

Philadelphia

Disclosures: Namdari reports he receives research funding from DePuy Synthes, Zimmer Biomet, Arthrex, Tornier and Integra Life Sciences; is a paid consultant for Don Joy Orthopaedics and Miami Device Solutions; and receives royalties from Don Joy Orthopaedics, Miami Device Solutions and Elsevier.