Keywords
1. Total joint arthroplasty
2. Dexamethasone and diabetes
3. Postoperative infections
4. Perioperative care
5. Hyperglycemia complications
In the continuously advancing field of orthopedic surgery, total joint arthroplasty (TJA) stands as one of the most commonly performed and clinically significant operative procedures. As surgical techniques and perioperative care improve, the focus increasingly shifts toward the finer points of patient management, particularly the challenge of balancing effective pain control and the risk of complications. A study recently published in The Journal of Arthroplasty on January 12, 2024, addressed a contentious issue in this balance: the safety of administering dexamethasone to diabetic patients undergoing TJA, in the context of postoperative infection risks (DOI: 10.1016/j.arth.2024.01.025).
This groundbreaking retrospective cohort study, spanning over five years from January 2016 to December 2021, utilized a large national database to extract data on adult patients who underwent primary, elective total knee arthroplasty (TKA) or total hip arthroplasty (THA). The analysis included 110,568 TJA cases, of which 34,298 (31.0%) involved patients with diabetes mellitus (DM). The patients who received perioperative dexamethasone were compared with those who did not, with the critical outcomes being the 90-day risk of postoperative periprosthetic joint infection (PJI), surgical site infection (SSI), and non-surgical site infections such as urinary tract infections (UTI), pneumonia, and sepsis.
The concern regarding dexamethasone, a potent corticosteroid known for its anti-inflammatory and pain-reducing properties, primarily lies in its potential to elevate blood glucose levels (BGL). In diabetic patients, this hyperglycemia is feared to increase the risk of infectious complications. However, the study conducted by an interdisciplinary team from the University of Washington and the Keck School of Medicine at the University of Southern California—including Jones Ian A., Wier Julian J., Liu Kevin C., Richardson Mary K., Yoshida Brandon B., Palmer Ryan R., Lieberman Jay R., and Heckmann Nathanael D.—challenges this concern.
Notably, the study concluded that the administration of dexamethasone did not lead to an increased odds of developing PJI or SSI among diabetic patients. On the contrary, dexamethasone was found to have a protective effect against other postoperative infections when factored into the adjusted odds ratio. For TKA patients, this equated to an adjusted odds ratio (aOR) of 0.9 (95% confidence interval [CI] = 0.8 to 1.0, P=0.030), whereas for THA patients, the aOR was positively significant at 0.7 (95% CI = 0.6 to 0.9, P=0.001). Importantly, this reduced infection risk was particularly observed in patients with certain BGL thresholds (110 to 248 mg/dL for TKA and ≤172 mg/dL for THA).
The implications of these findings are considerable. For one, this large-scale study provides persuasive evidence against categorically avoiding dexamethasone in diabetic patients due to fears of postoperative infections. Additionally, the results suggest a potential paradigm shift in perioperative care, emphasizing the tailoring of dexamethasone use to optimize patient outcomes, rather than questioning its suitability in the diabetic population undergoing TJA.
Despite the retrospective nature of the study, the robust patient population and statistically significant findings add weight to the call for reassessing perioperative protocols. Nevertheless, the authors acknowledge the need for prospective studies to further solidify the safety and efficacy of dexamethasone in this context. It is also essential to consider interpatient variability and the potential influence of other perioperative factors, like antibiotic prophylaxis and glycemic control strategies.
The implications of this inquiry into dexamethasone use extend into healthcare economics and patient quality of life, as reducing the incidence of infections post-TJA can significantly decrease healthcare costs and enhance recovery experiences. Furthermore, the findings may have reverberating effects in developing guidelines for other surgeries in diabetic patients, where infection risk and glucose management are paramount concerns.
The study “Dexamethasone-Associated Hyperglycemia is not Associated with Infectious Complications After Total Joint Arthroplasty in Diabetic Patients” offers a turning point in the perception of dexamethasone within the orthopedic surgical setting for diabetic individuals (S0883-5403(24)00025-1). The long-held caution using this anti-inflammatory drug in the face of potential hyperglycemia-induced risks may give way to a more refined, patient-specific analysis that recognizes the benefits without overlooking individual glucose dynamics.
References
1. Jones, I. A., Wier, J. J., Liu, K. C., Richardson, M. K., Yoshida, B. B., Palmer, R. R., … & Heckmann, N. D. (2024). Dexamethasone-Associated Hyperglycemia is not Associated with Infectious Complications After Total Joint Arthroplasty in Diabetic Patients. The Journal of Arthroplasty. https://doi.org/10.1016/j.arth.2024.01.025
2. Horlocker, T. T., Vandermeuelen, E., Kopp, S. L., Gogarten, W., Leffert, L. R., & Benzon, H. T. (2018). Regional anesthesia in the patient receiving antithrombotic or thrombolytic therapy: American Society of Regional Anesthesia and Pain Medicine evidence-based guidelines (Fourth Edition). Regional Anesthesia and Pain Medicine, 43(3), 263-309. https://doi.org/10.1097/AAP.0000000000000763
3. Springer, B. D., Parvizi, J., Austin, M., & McGrory, B. J. (2019). Periprosthetic Joint Infection of the Hip and Knee. Journal of the American Academy of Orthopaedic Surgeons, 27(12), e533-e544. https://doi.org/10.5435/JAAOS-D-18-00041
4. Puar, Y., Singh, S., Damodaram, M. S., & Rowan, F. E. (2021). Impact of perioperative steroid use on outcomes after total hip arthroplasty: a systematic review and meta-analysis. Journal of Orthopaedic Surgery and Research, 16(1), 1-9. https://doi.org/10.1186/s13018-021-02302-0
5. Singh, J. A., Houston, T. K., Ponce, B. A., Maddox, G., Bishop, M. J., Richman, J., … & Wilt, T. J. (2020). Smoking as a risk factor for short-term outcomes following primary total hip and total knee replacement in veterans. Arthritis Care & Research, 72(4), 521-529. https://doi.org/10.1002/acr.23855
Given these promising findings, clinicians and researchers can look forward to further studies and discussions that will likely emerge in the wake of this publication, potentially leading to more nuanced and effective perioperative care strategies for diabetic patients undergoing total joint arthroplasty.