Milford H. Marchant

The Impact of Glycemic Control and Diabetes Mellitus on Perioperative Outcomes After Total Joint Arthroplasty

BACKGROUND As the prevalence of diabetes mellitus in people over the age of sixty years is expected to increase, the number of diabetic patients who undergo total hip and knee arthroplasty should be expected to increase accordingly. In general, patients with diabetes are at increased risk for adverse events following arthroplasty. The goal of the present study was to determine whether the quality of preoperative glycemic control affected the prevalence of in-hospital peri-operative complications following lower extremity total joint arthroplasty. METHODS From 1988 to 2005, the Nationwide Inpatient Sample recorded over 1 million patients who underwent joint replacement surgery. The present retrospective study compared patients with uncontrolled diabetes mellitus (n = 3973), those with controlled diabetes mellitus (n = 105,485), and those without diabetes mellitus (n = 920,555) with regard to common surgical and systemic complications, mortality, and hospital course alterations. Additional stratification compared the effects of glucose control among patients with Type-I and Type-II diabetes. Glycemic control was determined by physician assessments on the basis of the American Diabetes Association guidelines with use of a combination of patient self-monitoring of blood-glucose levels, the hemoglobin A1c level, and related comorbidities. RESULTS Compared with patients with controlled diabetes mellitus, patients with uncontrolled diabetes mellitus had a significantly increased odds of stroke (adjusted odds ratio = 3.42; 95% confidence interval = 1.87 to 6.25; p < 0.001), urinary tract infection (adjusted odds ratio = 1.97; 95% confidence interval = 1.61 to 2.42; p < 0.001), ileus (adjusted odds ratio = 2.47; 95% confidence interval = 1.67 to 3.64; p < 0.001), postoperative hemorrhage (adjusted odds ratio = 1.99; 95% confidence interval = 1.38 to 2.87; p < 0.001), transfusion (adjusted odds ratio = 1.19; 95% confidence interval = 1.04 to 1.36; p = 0.011), wound infection (adjusted odds ratio = 2.28; 95% confidence interval = 1.36 to 3.81; p = 0.002), and death (adjusted odds ratio = 3.23; 95% confidence interval = 1.87 to 5.57; p < 0.001). Patients with uncontrolled diabetes mellitus had a significantly increased length of stay (almost a full day) as compared with patients with controlled diabetes (p < 0.0001). All patients with diabetes had significantly increased inflation-adjusted postoperative charges when compared with nondiabetic patients (p < 0.0001). CONCLUSIONS Regardless of diabetes type, patients with uncontrolled diabetes mellitus exhibited significantly increased odds of surgical and systemic complications, higher mortality, and increased length of stay during the index hospitalization following lower extremity total joint arthroplasty.

The Impact of Diabetes on Perioperative Patient Outcomes After Total Hip and Total Knee Arthroplasty in the United States

The purpose of this study was to determine whether patients with diabetes mellitus (DM) have a higher likelihood of immediate, inpatient complications following primary and revision total hip (THA) and total knee arthroplasty (TKA) than patients without DM. From 1988 to 2003, the Nationwide Inpatient Sample identified 751340 primary or revision THA or TKA patients. 64262 (8.55%) had DM. Comparisons of specific outcome measures between diabetic and nondiabetic cohorts were performed using bivariate and multivariate analyses with logistic regression modeling. Diabetic patients had fewer routine discharges and higher inflation-adjusted hospital charges for all procedures. Although complications were not uniformly increased, diabetic patients had significantly increased odds of pneumonia, stroke, and transfusion (P < .001) after primary arthroplasty. This analysis of a large patient database indicates clinically relevant information for patients and surgeons, suggesting that patients undergoing THA and TKA demonstrate more complications and utilize more resources if they have the comorbidity of DM level II evidence.

Comparison of plain radiography, computed tomography, and magnetic resonance imaging in the evaluation of bone tunnel widening after anterior cruciate ligament reconstruction

Bone tunnel widening poses a problem for graft fixation during revision anterior cruciate ligament (ACL) reconstruction. Large variability exists in the utilization of imaging modalities for evaluating bone tunnels in pre-operative planning for revision ACL reconstruction. The purpose of this study was to identify the most reliable imaging modality for identifying bone tunnels and assessing tunnel widening, and specifically, to validate the reliability of radiographs, MRI, and CT using intra- and inter-observer testing. Data was retrospectively collected from twelve patients presenting for revision ACL surgery. Five observers twice measured femoral and tibial tunnels at their widest point using digital calipers in coronal and sagittal planes. Measurements were corrected for magnification. Tunnel identification, diameter measurements, and cross-sectional area (CSA) calculations were recorded. A categorical classification of tunnel measurements was created to apply clinical significance to the measurements. Using kappa statistics, intra- and inter-observer reliability testing was performed. CT demonstrated excellent intra- and inter-observer reliability for tunnel identification. Intra- and inter-observer reliability was significantly less for MRI and radiographs. CT revealed superior reliability versus either radiographs or MRI for CSA analysis. Intra-observer kappa scores for tibial CSA using CT, radiographs, and MRI were 0.66, 0.5, and 0.37, respectively. Inter-observer kappa scores for tibial CSA using CT, radiographs, and MRI were 0.65, 0.39, and 0.32, respectively. Our results demonstrate CT is the most reliable imaging modality for evaluation of ACL bone tunnels as proven by superior intra- and inter-observer testing results when compared to MRI and radiographs. Radiographs and MRI were not reliable, even for simply identifying the presence of a bone tunnel.

Management of Medial-Sided Knee Injuries, Part 1 Medial Collateral Ligament

The medial collateral ligament complex is a primary stabilizer that combines static and dynamic resistance to direct valgus stress while contributing significant restraints to rotatory motion and anterior-posterior translation. Varying opinions exist among investigators regarding injury classification and treatment algorithms. Whereas most agree that the majority of isolated medial collateral ligament complex injuries can be treated nonoperatively, isolated injuries with chronic instability and multiligament injuries may require operative intervention. Substantial confounding factors are present within published reports, making comparative analyses and systematic review challenging. This review focuses on the anatomy and biomechanics of the medial structures of the knee; it discusses the clinical evaluation of complex injuries; and it reviews nonoperative and operative treatment methods.

Management of medial-sided knee injuries, part 2: posteromedial corner.

Injury to the posteromedial corner (PMC) of the knee differs anatomically and biomechanically from isolated injury to the medial collateral ligament. Newer anatomic and biomechanical studies are refining the field’s understanding of the medial side of the knee, as well as its role in multiple ligament injuries. Valgus instability places additional strain on a reconstructed anterior or posterior cruciate ligament, which can contribute to late graft failure. Injuries to the PMC may not heal without surgical repair or reconstruction, particularly when part of a multiple-ligament injury. Identification of PMC injury before cruciate reconstruction is important so that appropriate repair or reconstruction of the PMC and medial collateral ligament can be undertaken at the same time. This article reviews the relevant literature on the PMC, discusses reasons for selective operative management, and illustrates reconstructive strategies for PMC injuries occurring as part of a medial-sided or multiligament injury to the knee.

Role of diabetes type in perioperative outcomes after hip and knee arthroplasty in the United States.

The objective of this study was to determine whether the type of diabetes mellitus (DM) affected the incidence of immediate perioperative complications following joint replacement. From 1988 to 2003, the Nationwide Inpatient Sample recognized 65,769 patients with DM who underwent total hip and knee arthroplasty in the United States. Bivariate and multivariate analyses compared patients with type 1 (n = 8728) and type 2 (n = 57,041) DM regarding common perioperative complications, mortality, and hospital course alterations. Type 1 DM patients had increased length of stays and inflation-adjusted costs after surgery (p < .001). Type 1 patients also had significant increases in the incidence of myocardial infarction, pneumonia, urinary tract infection, postoperative hemorrhage, wound infection, and death (p < .02). Perhaps because of the differences in the duration of disease and their underlying pathologies, patients with type 1 diabetes carry more significant overall perioperative risks and require more health care resources compared with patients with type 2 diabetes following hip and knee arthroplasty.

The Cortical Ring Sign: Clinical Results of Percutaneous Coracoclavicular Fixation

Background The coracoid cortical ring sign is a radiographical view that targets the coracoid base. We hypothesized that the use of this view to treat acromioclavicular separations would achieve desirable results with a rapid, percutaneous procedure. Methods Percutaneous coracoclavicular screws, guided by the cortical ring sign view, were used to treat acute, Rockwood grade III or greater acromioclavicular separations with instability to cross-body adduction. The anaesthesia database, clinical and radiographical outcomes were retrospectively reviewed for 41 cases (average age 35 years, range 18 years to 78 years). Average follow-up was 4.7 months (range 1 month to 23 months). Results There were six episodes of screw loosening (15%); three of six required an additional surgical procedure. The average residual joint subluxation at final follow-up was approximately 40%, which was significantly improved from the pre-operative displacement (p < 0.01) and not statistically different from the reduction achieved with the screw in place. All patients had full range of motion and, using the modified UCLA score, 98% (40/41) achieved ‘Good to Excellent’ results. The procedure was rapid (average surgical time: 35 minutes), minimally invasive (average blood loss: 15 mL), and the coracoid cortical ring sign view averaged less than 5 minutes to localize. Conclusion When using the coracoid cortical ring sign to target a coracoclavicular screw, the procedure is rapid, minimally invasive, and clinically predictable. There is, however, a high rate of screw loosening and subluxation.