Advanced knee osteoarthritis can be effectively managed with total knee arthroplasty (TKA), a surgical technique that greatly improves joint function, alleviates pain, and overall quality of life. More and more people with diabetes are receiving total knee arthroplasty (TKA) procedures due to the increasing global prevalence of diabetes mellitus [1, 2]. But diabetes slows wound healing, changes the immune response, and makes you more likely to get SSIs and other postoperative complications. SSIs continue to be a major concern after TKA, since they can extend the time a patient spends in the hospital, drive up healthcare expenses, necessitate additional procedures, and ultimately lead to less than ideal clinical results [3, 4].

An important modifiable risk factor impacting surgery outcomes in diabetic patients is perioperative glucose management. Researchers have discovered that hyperglycemia during the perioperative period increases the risk of infection by impairing leukocyte function, reducing chemotaxis and phagocytosis, and promoting bacterial proliferation. Acute perioperative glucose fluctuations and chronic glycemic management, both evaluated with glycated hemoglobin (HbA1c), are significant factors in surgical outcome [5, 6].

There is currently no agreed-upon standard for ideal glycemic objectives in patients having orthopedic surgeries like TKA, despite developments in perioperative care and surgical methods. The exact association between glycemic fluctuation and the risk of surgical site infections (SSIs) is not well understood, particularly in resource-limited clinical settings, while numerous studies have shown that blood glucose levels below 180 mg/dL should be maintained during the perioperative period [7-9].

This study was conducted to assess how glycemic control before surgery affects the risk of surgical site infections in individuals with diabetes who are having total knee replacement surgery. This study intends to enhance surgical outcomes in this high-risk population by gaining clinically useful evidence to guide perioperative glucose management regimens through assessing both preoperative and perioperative glycemic indices.

An observational study was undertaken in the Department of General Medicine at tertiary care hospital over a duration of 12 months. This study was conducted between  February 2020 to January 2021 at Department of General Medicine, Mahavir institute of Medical sciences, Shivareddyguda, Vikarabad, Telangana. The study comprised 40 patients diagnosed with diabetes mellitus (Type 1 or Type 2) who were scheduled for primary unilateral total knee arthroplasty. The research sought to assess the effect of perioperative glycemic regulation on the occurrence of surgical site infections (SSIs) in diabetic individuals having total knee arthroplasty (TKA).

Inclusion Criteria:

• Patients aged between 50 and 75 years
• Diagnosed cases of diabetes mellitus (on oral hypoglycemic agents or insulin)
• Patients undergoing elective primary total knee arthroplasty
• Patients who provided written informed consent

Exclusion Criteria:

• Patients with active infection at any site
• Revision knee arthroplasty cases
• Patients with immunocompromised conditions (e.g., HIV, malignancy, long-term steroid therapy)
• Patients with severe renal or hepatic dysfunction
• Non-compliant patients or those lost to follow-up

Preoperative Assessment:

Glycated hemoglobin (HbA1c), fasting blood glucose (FBG), and postprandial blood glucose (PPBG) were among the laboratory tests and clinical assessments that were administered to all patients. We took note of basic demographic information including age, gender, BMI, and length of diabetes.

Surgical Procedure:

Using a medial parapatellar technique and aseptic circumstances, every patient had a typical primary total knee arthroplasty. The patient was prescribed antibiotics before surgery and continued to take them after the procedure in accordance with the hospital's policy.

Postoperative Care and Follow-Up:

For the first 30 days after surgery, patients were monitored for the occurrence of surgical site infections. While in the hospital and again on days 14 and 30 after surgery, the wound was examined often.

Statistical Analysis:

Categorical data were represented as percentages, whereas continuous variables were shown as mean ± standard deviation (SD). The statistical analysis was conducted with the help of SPSS software, namely version 25. For categorical data, we utilized a chi-square test, and for continuous variables, we utilized an independent t-test to compare the groups. We utilized Pearson correlation analysis to find out how glycemic levels relate to the risk of SSI. For statistical purposes, a p-value less than 0.05 was deemed significant.

The research comprised 40 individuals with diabetes who were having total knee arthroplasty. Demographic variables, glycemic indices, and the frequency of infections at the surgery site were considered in the analysis.

Table 1: Demographic and Baseline Clinical Characteristics of Patients (n = 40)

Table 1 displays the patients' demographic and clinical details. When comparing the two groups according to age, gender distribution, and body mass index (BMI), no statistically significant difference was found (p > 0.05). The controlled group had a shorter duration of diabetes (6.8 ± 2.5 years) compared to the uncontrolled group (9.2 ± 3.1 years) (p = 0.01), suggesting that patients with poor glycemic control had a longer duration of disease.

Table 2: Preoperative Glycemic Parameters

The patients' preoperative glycemic status is shown in Table 2. Poor long-term and short-term glycemic control was confirmed by the considerably higher fasting blood glucose (FBG), postprandial blood glucose (PPBG), and HbA1c levels in the uncontrolled group compared to the controlled group (p < 0.001).

Table 3: Perioperative Blood Glucose Levels

Blood glucose levels throughout the perioperative period are displayed in Table 3. Throughout the perioperative period, the glucose levels of the uncontrolled group remained consistently higher (p < 0.001). This points to the possibility of these patients experiencing persistent hyperglycemia, which could worsen their surgical complications.

Table 4: Incidence of Surgical Site Infection (SSI)

Infections at the surgical site were recorded in Table 4 for all research groups. Patients in the uncontrolled group were 33.3% more likely to acquire SSIs than those in the controlled group, which had a rate of 4.5% (p = 0.02). This discovery emphasizes the robust correlation between elevated risk of surgical infections and inadequate glycemic management during the perioperative period.

Table 5: Comparison of Glycemic Parameters in Patients With and Without SSI

The glycemic parameters of individuals with and without surgical site infections are compared in Table 5. The HbA1c levels, perioperative glucose levels, and duration of diabetes were all noticeably higher in patients who acquired SSIs (p < 0.05). These results point to the importance of hyperglycemia as a predictor of postoperative infection risk, whether it's chronic or acute.

Patients with diabetes who were due to get total knee arthroplasty (TKA) had their risk of surgical site infections (SSIs) measured in this study. The results show that there is a strong correlation between postoperative infections and inadequate glycemic management, whether it's chronic (as shown by HbA1c) or acute (as shown by perioperative blood glucose levels [10-12].

In this study, the levels of fasting blood glucose (FBG), postprandial blood glucose (PPBG), and hemoglobin A1c were considerably higher in the uncontrolled group compared to the controlled group. Consistent with previous research, these results show that persistent hyperglycemia hinders immunological function via lowering neutrophil activity, chemotaxis, and phagocytic efficiency. As a result, infections and slow wound healing are more common in diabetic patients with high HbA1c values [13-15].

The study found that SSIs were more common in patients whose mean perioperative blood glucose levels were higher than 180 mg/dL (33.3% vs. 4.5%), which is an important finding. Consistent with earlier clinical data, this lends credence to the idea that surgical infections are significantly facilitated by perioperative hyperglycemia. High blood sugar levels promote the growth of microbes and hinder the production of collagen, both of which weaken the healing process [16-18].

In addition, the study showed that compared to patients without infections, those with SSIs had considerably higher mean HbA1c levels (9.5 ± 1.2%) and perioperative glucose levels (225.3 ± 18.7 mg/dL). A longer duration of diabetes was also found in SSI patients, suggesting that microvascular and immunological dysfunctions may be worsened by extended exposure to hyperglycemia. These results stress the need for both preoperative glucose treatment and long-term glycemic control [19, 20].

Consistently elevated blood glucose levels throughout all perioperative time periods in the uncontrolled group was another notable observation. The risk of problems may be significantly increased during the postoperative time if this chronic hyperglycemic condition indicates insufficient glycemic management. So, to keep glucose levels acceptable, stringent preoperative monitoring and suitable insulin treatment regimens are required [21, 22].

This study's findings corroborate those of other studies that have found that reducing the incidence of surgical site infections (SSIs) after surgery requires keeping blood glucose levels below 180 mg/dL. However, patient results can be negatively impacted by an increase in the risk of hypoglycemia due to excessively strict glycemic control. Consequently, glycemic management must be approached with a balanced and personalized strategy [23].

The study has certain drawbacks, but it does have some merits, such as a prospective design and systematic glucose monitoring. Results may not be applicable outside of the specific study location due to the limited sample size (n = 40) and the fact that the research only used data from one facility. Furthermore, there was a lack of thorough analysis of other possible confounding factors, including dietary status, timing of perioperative antibiotics, and surgical duration [24, 25].,

This study found that diabetic individuals having total knee arthroplasty were more likely to get surgical site infections if they did not have good perioperative glycemic control. Infection rates were significantly greater in patients with higher levels of both preoperative hemoglobin A1c and perioperative blood glucose. Compared to patients with well-controlled glycemic status, the incidence of surgical site infections (SSIs) was significantly higher in patients whose mean perioperative glucose levels were greater than 180 mg/dL. The significance of maintaining excellent glycemic control prior to and during the perioperative phase is emphasized by these findings. Strict monitoring of blood glucose levels throughout the perioperative phase and optimization of HbA1c levels before surgery can greatly enhance surgical results by reducing postoperative problems. Individualized insulin therapy and regular glucose monitoring are standardized glycemic control measures that should be strongly implemented for diabetic patients having total knee arthroplasty. In order to formulate firm glycemic objectives and fortify clinical guidelines for better patient care, additional large-scale, multicentric trials are necessary.

Funding

None

Conflict of Interest:

None

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