Search

Aims: The diagnosis of periprosthetic joint infection (PJI) can be challenging as the symptoms are similar to other conditions, and the markers used for diagnosis have limited sensitivity and specificity. Recent research has suggested using blood cell ratios, such as platelet-to-volume ratio (PVR) and platelet-to-lymphocyte ratio (PLR), to improve diagnostic accuracy. The aim of the study was to further validate the effectiveness of PVR and PLR in diagnosing PJI. Methods: A retrospective review was conducted to assess the accuracy of different marker combinations for diagnosing chronic PJI. A total of 573 patients were included in the study, of which 124 knees and 122 hips had a diagnosis of chronic PJI. Complete blood count and synovial fluid analysis were collected. Recently published blood cell ratio cut-off points were applied to receiver operating characteristic curves for all markers and combinations. The area under the curve (AUC), sensitivity, specificity, and positive and negative predictive values were calculated. Results: The results of the analysis showed that the combination of ESR, CRP, synovial white blood cell count (Syn. WBC), and polymorphonuclear neutrophil percentage (PMN%) with PVR had the highest AUC of 0.99 for knees, with sensitivity of 97.73% and specificity of 100%. Similarly, for hips, this combination had an AUC of 0.98, sensitivity of 96.15%, and specificity of 100.00%. Conclusion: This study supports the use of PVR calculated from readily available complete blood counts, combined with established markers, to improve the accuracy in diagnosing chronic PJI in both total hip and knee arthroplasties. Cite this article: Bone Jt Open 2023;4(11):881–888.

Introduction/Purpose: Rotational ankle fractures in diabetics have long posed difficult clinical challenges, with several observational studies noting increased risk of complications and amputation following treatment of unstable ankle fractures in diabetics. Several treatment options exist, including non-operative management, external fixation, open reduction internal fixation, staged fixation, and fusion. Hemoglobin A1C produces a mean blood glucose level over a three-month period. There is mounting evidence that glucose variability may be an alternative predictor of complication profile in non-orthopedic procedures, as well as in the total joint arthroplasty literature. The purpose of this investigation is to retrospectively analyze complication rates for diabetics with rotational ankle fractures at a single institution and assess their association with both the hemoglobin A1C and glucose variability. Methods: After obtaining Institutional Review Board approval, all patients from 2015-2022 with a diagnosis of diabetes and ankle fracture were retrospectively identified based on ICD-9/ICD-10 codes. These charts were manually reviewed to determine fracture classification and treatment. For operatively and non-operatively managed ankle fractures, the patient’s hemoglobin A1C was recorded when available within 3 months of the date of injury. Glucose variability was calculated using a coefficient of variation. Results: Two-hundred patients were included for analysis, of which 29% (n=58) were treated non-operatively. The majority of surgically treated patients underwent acute ORIF (58%, n=116). 8.5% were treated with staged fixation, 3.5% with acute hindfoot fusion, and 1% with external fixation alone. The overall complication rate was 27.5% (n=55). There were no statistically significant differences in both A1C (7.81 +/- 1.89 vs 7.73 +/- 1.96) and glucose variability, as measured by the covariance of variation (0.23 +/- 0.15 vs 0.20 +/- 0.13) in patients who did and did not experience postoperative complications. Higher glucose variability did trend towards predicting complications, though not in a statistically significant fashion (OR=1.57, p=0.35). Conclusion: Ankle fractures in patients with diabetes pose a challenge for orthopedic surgeons, as evidenced by the high medical and surgical complication rate observed in this study and others. No statistical significance was found between higher A1C and complication rate or between glucose variability and complication rate. Further investigation on the impact of glucose variability on complication rates in a larger cohort of this patient population is warranted. Univariable logistic Regression Results for the association of the odds of post-operative complication with patient characteristics.

Background: Dexamethasone is a commonly used perioperative medication for the management of postoperative nausea and vomiting following total joint arthroplasty (TJA). However, concerns have been raised about its potential to cause hyperglycemia. This study aimed to investigate the impact of dexamethasone administration on glucose levels and complications in both diabetic and nondiabetic patients undergoing TJA. Methods: We performed a retrospective review of 1928 patients who underwent primary total knee and hip arthroplasty procedures at a large tertiary medical institution. Patients were divided into 2 groups based on whether they received preoperative dexamethasone. Postoperative blood glucose values and variability were measured, and data on complications were collected. We performed statistical analysis using descriptive analysis, multivariate logistic regression models, negative binomial regression, and a subset analysis to assess the impact of dexamethasone dose on postoperative glycemic control. Results: Preoperative dexamethasone did not significantly increase the mean glucose, fasting glucose, glucose variability, or 90-day complications in both the diabetic and nondiabetic groups. Nondiabetic patients who received dexamethasone had a significantly lower rate of intensive care unit admission (P < .01). Additionally, patients who received dexamethasone had a significantly shorter length of hospital stay compared to those who did not (P < .001). Conclusions: Preoperative dexamethasone administration is a safe and effective method for preventing postoperative nausea and vomiting in patients undergoing TJA without significant adverse effects on glucose levels, glucose variability, or infection rates in both diabetics and nondiabetics. Preoperative dexamethasone decreases postoperative length of stay.

Background: Periprosthetic joint infection (PJI) is a serious complication following joint replacement surgery, and its diagnosis can be challenging due to the similarity of symptoms to other conditions and the lack of confirmatory imaging tests. Platelet/mean platelet volume ratio (PVR), platelet/lymphocyte ratio, monocyte/lymphocyte ratio, and neutrophil/lymphocyte ratio have been proposed as potential markers to aid in the diagnosis of PJI. This study aimed to further assess the utility of these blood cell ratio combinations for the diagnosis of PJI. Methods: A retrospective chart review was conducted on patients who presented to a university hospital for evaluation for PJI or underwent aseptic revision surgery. All patients were reviewed for inclusion in the study. Data were collected on several markers, including complete blood counts, synovial fluid white blood cell count, and polymorphonuclear percentage. Receiver operator characteristic curve analysis was used to evaluate the diagnostic capabilities of the markers and marker combinations. Results: The combination of erythrocyte sedimentation rate, C-reactive protein, synovial white blood cell count, and synovial polymorphonuclear percentage, with PVR, had the highest area under the curve of 0.97, with a sensitivity of 94.3% and a specificity of 88.9%, and a positive predictive value of 97.1% and a negative predictive value of 80.0%. Conclusions: This study further supports the use of PVR calculated from complete blood count commonly ordered laboratory values obtained during routine complete blood counts when combined with established serum and synovial markers to increase the diagnostic accuracy for diagnosing PJI.