Common modifiable risk factors in total joint arthroplasty: a 2021 update—diabetes
The role of glycemic control before total joint arthroplasty (TJA) has received intense scrutiny in the past 20 years. Patients with diabetes mellitus (DM), especially those with inadequate glycemic control, have been associated with increased risk for both joint-related and systemic adverse outcomes following TJA [1–3]. This observation, however, has been disputed by others, who showed that diabetic patients did not have increased odds of complications [4, 5]. What is the current evidence for supporting perioperative glycemic control? What is a proper glycemic control? In this article, Matthew P Abdel, Andrew A. and Mary S. Sugg Professor of Orthopedic Surgery and Chair of Division of Orthopedic Surgery Research at the Mayo Clinic, Rochester, Minnesota, US, reviews the current evidence of what tools are available for glycemic control at the chronic, subacute, and acute levels in managing (potential) TJA patients.
Matthew P Abdel
Rochester, United States
Population-based studies demonstrating the influence of uncontrolled hyperglycemia
The incidence of diabetes is increasing. Current literature estimates that 8.5–20.7% of patients undergoing TJA in the US were diabetic; in a local population, the percentage can be even higher [3, 6].
The effect of diabetes or uncontrolled hyperglycemia on health and outcomes of medical treatments has been well established. Quoting a publication showing intensive insulin therapy in diabetic patients with acute myocardial infarction led to better long-term outcomes, Van den Berghe et al  published in 2001 a randomized controlled study on 1,548 critically ill patients and demonstrated that an intensive insulin therapy resulted in, for example, lower mortality, shorter stay in the intensive care unit, lower rate of bloodstream infection, and lower rate of acute renal failure.
Does diabetes or uncontrolled hyperglycemia have similar influence on the outcomes after TJA? In the past two decades, many have attempted to answer this question.
In their 2008 publication, Bolognesi et al  demonstrated that diabetic patients had substantially increased odds of pneumonia, stroke, and transfusion after primary total hip arthroplasty (THA) or total knee arthroplasty (TKA). Using the data from the Nationwide Inpatient Sample, the study included 751,340 primary or revision THA or TKA patients, and the results can be considered generally applicable to the American population. In their subsequent publication, Marchant et al  used the data from the same database to further examine over one million patients to evaluate the effect of glycemic control. In their investigation, patients were divided into three cohorts: 3,937 patients with uncontrolled DM, 105,485 patients with controlled DM, and 920,555 patients without DM. After adjusting for a long list of potentially confounding factors such as sex, age, race, comorbidity, household income, and surgeon volume, the authors showed that patients with uncontrolled DM had significantly higher risk (than patients without DM) of cerebrovascular accidents, infections, and mortality, the list of adverse results goes on.
These two studies provided valuable information, but they have limitations that are typically associated with retrospective studies, ie, the uncertainty of the data quality and the unavailability of crucial information. For example, in the Marchant et al  study, uncontrolled factors such as different perioperative screening protocols may have skewed the patient population, causing unexpected results such as higher odds of experiencing a postoperative myocardial infarction in the nondiabetic than in the diabetic patients. Other limitations include, for example, relying on the database coding (performed in accordance with the International Classification of Diseases codes, ninth revision, ICD-9) that was not directly validated against the clinical data and using subjective criteria to determine the glycemic control status for the grouping of cohorts [2, 4, 9].
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- Putting numbers to glycemic control
- In the name of better outcomes after arthroplasty
- Is there a better marker for glycemic control than HbA1c?
- Consistency may be more important
- Glycemic control should be part of a multimodal optimization
This series of articles was created with the support of the following specialists (in alphabetical order):
Matthew P Abdel
Rochester, United States
University of Western Ontario
Michael A Mont
Rubin Institute for Advanced Orthopedics
Baltimore, United States
This article was compiled by Maio Chen, Senior Project Manager Medical Writing, AO Foundation, Switzerland.
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