Simple Treatment Can Lessen Infection Risk for Joint Replacement Patients

Mercy Health - Cincinnati, which provides advanced, quality, compassionate care in your neighborhood through its care network, announces that research findings from Mercy Health Physician and orthopaedic surgeon John Gallagher, MD could help joint replacement patients – or any patients undergoing major surgery - regain their infection-fighting edge and lower their rate of complications following surgery.

In times of stress, hormones in our bodies trigger the release of extra glucose for energy. That energy is meant to power a fight or flight response. But what if you are in the hospital on bed rest recuperating from hip or knee joint replacement surgery or other surgery? With no muscles to power into movement and nowhere to go, that glucose travels the bloodstream, starving white blood cells and depriving them of their ability to fight infection. That weakened immune response is a problem for people who’ve just had major surgery and can lead to infections and other complications.

“We have known since the 1970s that extra glucose inhibits the function of white blood cells. We also know that treating heart patients for extra glucose lowered their rate of complications. That got me wondering if the same would be true for joint replacement patients,” says Dr. Gallagher.

Dr. Gallagher and his team studied a total of 489 total hip and total knee replacement patients (including revisions) performed by a single surgeon between January 2008 and April 2013. Dr. Gallagher included all total joint patients, regardless of their diabetic status, with the exception of joint replacements performed for fractures, in the study.

To lower the risk of infection, Dr. Gallagher developed and tested the following simple insulin protocol for the patients who had elevated glucose, a condition called hyperglycemia, after undergoing joint replacement surgery:

“We evaluated each patient for hyperglycemia starting in the recovery room and then over the first 24 hours following surgery. We started any patient who had elevated glucose values of more than 140 fasting or more than 180 following a meal on four doses of insulin a day until the glucose fell below 110.”

During the course of his study, 301 patients, or 62% of the total number of patients, had elevated glucose levels triggering the insulin protocol. Among the patients who triggered the protocol, 17.5% were diabetic, 45% were pre-diabetic and 37.5% had normal blood sugar levels.

“You cannot tell simply by looking at someone whether or not he or she will suffer stress-induced hyperglycemia, or excess glucose,” says Dr. Gallagher, who notes that this issue does not disproportionately affect diabetics. “It’s important to test every patient’s glucose level right after the operation and at least two more times in the first 24 hours after surgery.”

Not one of the patients on the protocol developed an infection or needed hospital readmission for wound complications. That compares with the national average infection rate of 1-1.5%, which, based on the number of total joint replacements surgeons perform, would see about 15,000+ total joint replacement patients annually develop an infection. And infection in these patients is a serious matter.

When orthopaedic surgeons catch an infection early, they return the patient to the operating room and wash out the joint, a procedure that can cost $40,000. If the infection persists, the doctor needs to remove the joint, replace it with a temporary one while the patient recovers and then replace the joint for a total of three major surgeries at great personal and financial cost to the patient.

Dr. Gallagher’s findings could mean that no major surgery patient faces that nightmare scenario again.

“During the study, the use of a Mercy Health’s standard insulin protocol proved safe and effective in the treatment of post-operative hyperglycemia,” says Dr. Gallagher. “The study produces the first data available to support more effective glycemic control in major orthopaedic surgery.”

The Journal of Bone and Joint Surgery published Dr. Gallagher’s research, titled Postoperative Hyperglycemia Can Be Safely and Effectively Controlled in Both Diabetic and Nondiabetic Patients with Use of a Subcutaneous Insulin Protocol, on March 13, 2017: http://journals.lww.com/jbjsoa/Pages/default.aspx