“I Love My Camel Cigarettes” and Other Red Flags

What are the four most important red flags that a patient can present?

This talk, which is moderated by Giles R. Scuderi, M.D., was part of this past December’s 2018 Orthopaedic Summit in Las Vegas and the four participants, Michael A. Kelly, M.D., Peter K. Sculco, M.D., Edward MacPherson, M.D., and Adolph V. Lombardi, Jr., M.D., F.A.C.S., each identified the four top red flags that all orthopedic physicians should pay attention to.

Check them out and see if you agree.

RED FLAG #1: “My Patient’s HgbA1c is 8.6 but Trying to Get it Under Control.”

Michael A. Kelly, M.D.: Diabetes mellitus is an established risk factor for osteoarthritis. When you screen for it, you find that a large percentage of your patients are undiagnosed with diabetes or pre-diabetic.

About 96% of 500 surgeons from around the world attending International Consensus Meeting-Periprosthetic Joint Infection agreed that routine screening has the potential to reduce the risk of SSI or PJI. This allows early detection and optimization. It’s the only way we can risk-stratify the Medicare bundles and the various commercial bundles we’re going to be involved in. It’s crucial for successful CMS [Centers for Medicare and Medicaid Services] bundles, particularly now as we get to regional payments.

Laboratory markers assessing diabetes mellitus or glycemic peri-operative control.

Hemoglobin A1c levels lack consensus. Is there a number where above this number you have a high risk, below it you’re a little bit less risk, but at the same time you’re not just disallowing patients who would really have a successful total knee replacement change their life? That number is somewhere 7.5-8%. If you get too low you’re really keeping people away from an operation that may be very beneficial to them.

Random glucose—greater than or equal to 200 mg/dL. Fasting glucose is around 126 mg/dL.

Increased post-operative glucose variability is associated with adverse outcomes. If there is an increased risk of post-operative infection, there is an increased length of stay, as well as increased mortality. It is a benefit of maintaining glucose control within a narrow range in these total joint patients. Suggested range from 70-140 on random glucose variations.

1. Parvizi published papers in the last year suggesting that this fluctuation in rapid variations in glucose is probably more important either than maintaining a level of glucose as well as higher levels of standard glucose and/or hemoglobin A1c and they look at a level of fructosamine—a preoperative marker that goes out over a longer period of time. It may be better for fluctuations in rapid variations and the value is 292 mmol/L.

Careful perioperative monitoring and glucose control using your endocrine service where indicated and manage your co-morbid issues.

RED FLAG #2: “I Love My Camel Cigarettes, I’m 82-Years-Old & I’m Healthier Than You”

Peter K. Sculco, M.D.: A patient who comes in for total joint arthroplasty may have some non-modifiable risk factors. We can’t change an 82-year-old male patient’s age or gender. Smoking is probably one of the easiest, best, targeted modifiable risk factors.

The overall the rate of smoking has decreased. In 2018, the number is 16%. About 10% of your practice—1 out of 10 patients who come to you for joint replacement will be active smokers.

Smoking causes vasoconstriction, decreased oxygenation, and several cellular problems in regards to inflammatory response in the healing process, delayed wound healing issues because we can’t produce collagen. Every part of the body is affected. Creates free radicals that cause cellular damage.

What happens when you stop? If you stop, your blood flow and tissue oxygenation improves within a few hours. But it takes four weeks for your wound healing response to repair. There are issues with endothelial vasculature, with airway repair, and healing processes that can go on for decades, so really there is some permanent damage in these patients that we can’t control.

One study looked at 33,000 patients in the VA who are current smokers and former smokers. Current smokers had a number of medical complications, surgical site infections, pneumonia, stroke, and increase in one-year mortality. Former smokers also had an increase. Prior smoking is an underlying risk factor that actually becomes non-modifiable.

If a patient is going to do joint replacement, they have to stop smoking. We’re all talking to our patients, but really not doing much about it. Only 20% of us actually use a smoking-cessation program and very few of us actually test our patients for nicotine.

Intensive interventions where you go to a course eight weeks prior to surgery and put them on a nicotine patch are effective. Patients who completely stop smoking had a marked reduction of complications. If you just reduce smoking, really no difference, so really you can’t do it half-assed.

Testing is a powerful method. Do a cotinine test, which is urine, saliva, or blood test. Test them in the office with carbon monoxide exhalation. The carbon dioxide actually tests just the last 24 hours. The cotinine is about two weeks.

If you give a one-page handout on why they should stop smoking and test them prior to surgery, 70% pass the test, 13 stopped cold turkey and 64% continued to abstain from smoking, showing I think we have an opportunity change patients’ lives.

So, current smoking is bad: increase risk of revision and overall complications. Former smokers have increased risk. You should stop four weeks prior to surgery. It’s cost-effective and you have to stop you can’t just reduce it.

And we need to do a better job because only 6% of surgeons are currently testing patients.

Moderator: One other thing to mention is that cigars have about 10 times the amount of nicotine as cigarettes so be aware of that.

Another challenge is those who are culture negative and you’re really concerned about that knee and what to do after the patient may or may not have been on some antibiotics. Ed McPherson is going to talk to us about that issue.

RED FLAG #3: “Painful TKA: The Culture Negative Case, ‘The Difficult Decision.’”

Ed McPherson, M.D.: I’m going talk about that difficult decision of what you do with culture negative total knee revision.

I’ve taken care of 1,200 infected total knee cases. The economic aspects of care are significant. We are trying to find better and more efficient ways to treat these infections and what I’m going to speak to you about today is the diagnosis.

I want to emphasize that all bacteria make biofilm and it’s the biofilm on implants that causes chronic disease and sometimes these can be very indolent. We do not have a direct biofilm test. Based on the International Consensus this year, a biofilm state is inferred when known infection is greater than three weeks of known symptoms and duration.

If you have a painful knee at three months, the game is over.

If it’s a peri-prosthetic infection, that’s a biofilm state and the implants need to be removed in a single or two-stage arthroplasty. What we really want right now is clarity; there’s more confusion now than ever.

Some feel that all joint implants are colonized from bacteria and therefore in the Consensus the definition of colonization which is presence of bacteria possibly in biofilm without interaction with the immune system. In contrast a PJI, a peri-prosthetic infection, has an interplay with the immune system creating an inflammatory response which you can measure with biomarkers.

We have this issue over biomarkers over about the culture are not reliable. My solution is a direct DNA analysis of joint fluid. Not a PCR [polymerase chain reaction] set, but direct DNA and you would now have a DNA library of over 30,000 organisms of which only 1% can be cultured.

In summary, remember that infection is the most likely diagnosis within the first two years of implantation. The diagnosis of PJI is evolving. We have a state of a biofilm without any reaction by the immune system, which is colonization. We do now acknowledge this condition of colonization while without overt clinical infection. The concept of diagnosis is inflammatory markers plus the presence of microorganism. Since cultures only pick up 1% of what we can get with the DNA Library we’re going to be moving to DNA.

Direct DNA analysis will be helpful. In five years, I predict that none of us will be using cultures anymore. For me, a 100% negative predictive value is what I want. That comes with a negative DNA, normal CRP [C-reactive protein], a normal alpha defensin, and green light to go forward with the surgery.

RED FLAG #4: “I’m 87-Years-Old, Live Alone, & Have 3 Flights of Stairs – You Are Not Making Me Go Home, Sonny”

Adolph V. Lombardi, Jr., M.D., F.A.C.S.: I started practice in 1988. We were keeping patients in the hospital 10 to 14 days. We then started transferring patients to skilled facilities associated with the hospital, then transferring to outside facilities, then the whole rapid-recovery minimally invasive surgery craze, building my own hospital, and getting length of stay down to 2.5 days and now about 40% of my patients are done the same day.

In 2001, I published paper on simultaneous bilateral knees and in that group there were 897 unilateral knees. We then broke them down into age less than or greater than 80. Of course, there were more complications in our older age group even in the unilateral as more so than in the bilateral. Then we looked at discharge disposition: 57% of those patients greater than age of 80 were going to a skilled facility back in that day and only 21% for those less than 80.

From 2013 through 2018, I’m crazy enough to have done 27 patients that were 80 to 90 in an outpatient facility and 284 that were between the age of 70 and 80.

Looking at length of stay, 228 or 3.8% stayed overnight and you do see that for those 228 or greater than the age of 80 for 1.8%

In 2016-2018, discharge to skilled facilities goes down to 12.8% from that initial high number of almost 50%.

The average length of stay for our patients is 19 days. Cost per day is anywhere between $500 and $525. Average cost is about $9,500 per patient.

If you look at the discharge size for adults greater than age 65, in 2010, primary knee, 50% are going home, 8.7% were discharged transfer to skilled or short-term facility, and 29% to a long-term care facility.

It starts with the surgeon evaluating the patient, setting the stage, and understanding the home situation. To decide, “is the patient a candidate for the operation?” we need to know where is that patient going to be operated on, do they have adequate support at home, what’s their home environment? We want to minimize risk when optimizing patient’s medical condition and have the appropriate support systems available by patient’s preference.

A medical consultant evaluates every patient to correct the correctable and let us know what is uncorrectable. I’m not looking for “clearance,” I’m looking for them to optimize the patient so that the patient undergoes this operation with minimal risk. We have to start talking about the patient about discharge planning right from the get-go. When we see the patient, they are called by a pre-op nurse to make sure they have a plan for when they’re going home.

Skilled facility cost can be anywhere from $6,000 to $11,000, so you have to be able to partner with the skilled facility you’re sending the patient to if you’re in a bundle situation.

Can patients living alone safely be discharged to home? Yes, if the patient is medically optimized and has somebody that’s going to look after them on occasion. Even octogenarians can safely be discharged, but you need to make sure that they are pre-operatively optimized.

Please visit orthosummit.com for more information at this year’s upcoming event on December 11-14, 2019 at the Bellagio in Las Vegas, Nevada.