Selecting the right patients for elective surgeries like joint replacement is essential when operating in a system where patient outcomes are linked to payer reimbursement to physician groups and hospitals.
According to Bryan D. Springer, M.D., an orthopedic surgeon with OrthoCarolina Hip and Knee Center in Charlotte, North Carolina, “bundles have led us to have to practice more medicine than we ever had to in the past.”
He added, “I think I am one step away from having to wear a stethoscope around my neck when I go in to see patients.:
“And I think a lot of it is because our medical colleagues don’t read the same literature we read. How many times do you get a morbidly obese patient sent to you by their [primary] doctor with a note saying we will get your knee replaced first and then you’ll lose the weight. And our literature is pretty overwhelming that that doesn’t happen. So, in order to be successful in a bundle we need to take ownership for our patients.”
He explained that while the Centers for Disease Control and Prevention established guidelines for prevention of surgical site infection (SSI) in 2017, 25 out of 43 areas of concern had no definite recommendation on how to manage patients.
Because of this, orthopedic surgeons should be measuring certain risk factors before agreeing to do the surgery in order to reduce the risk for postoperative infection. Springer suggested that the following seven are important modifiable risk factors.
1. Glycemic Management
The stress surgery puts on a patient’s body is known to antagonize insulin, predisposing patients to hyperglycemia. Springer said that hyperglycemia impairs the ability of leukocyte to thwart infection and puts surgical patients at a greater risk for infection than patients with diabetes.
Springer referred to “Relationship of Hyperglycemia and Surgical-Site Infection in Orthopaedic Surgery” published in the Journal of Bone & Joint Surgery on July 3, 2012, which found that hyperglycemia was an independent risk factor for 30-day surgical-site infection in orthopedic trauma patients without a history of diabetes.
He also mentioned, “Elevated Postoperative Blood Glucose and Preoperative Hemoglobin A1C are associated with Increased Wound Complications Following Total Joint Arthroplasty” published on May 1, 2013, in the Journal of Bone & Joint Surgery which confirmed that patients with a mean postoperative hemoglobin A1C level of >6.7% are at increased risk for wound complications following elective primary total joint arthroplasty.
Springer added that one-third of total joint arthroplasty patients are hyperglycemic which puts them at higher risk for complications and infections. The goal is to maintain the blood glucose level at less than 200. He said that this spike in blood glucose happens whether you are diabetic or not, and that if you checked the glucose levels on all your patients after surgery, you’d be amazed at how high they go.
He recommended using the HgbA1c as a marker of long-term glucose control, saying, “The majority of studies show HgbA1c < 7-8 is when the risk wants to go up and it really depends on where you want to set your threshold risk for those patients. Are you going to deny someone at 7.2 and they have a likelihood of success or set your mark at 8 or a little bit higher?”
“One of the interesting things coming down the pike is serum fructosamine, which can show if your patient has tight glucose control a lot quicker,” he added, referring to the study, “Serum Fructosamine: A Simple and Inexpensive Test for Assessing Preoperative Gylcemic Control,” published in the November 2017 issue of the Journal of Bone & Joint Surgery.
