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Preoperatively elevated HbA1c levels can meaningfully improve following total joint arthroplasty

  • Hip Arthroplasty
  • Published:
Archives of Orthopaedic and Trauma Surgery Aims and scope Submit manuscript

Abstract

Background

Prior literature has demonstrated that diabetic (DM) patients undergoing total joint arthroplasty (TJA) with elevated preoperative HbA1c scores have poorer clinical outcomes. However, no literature has reported the effect of undergoing TJA on laboratory markers of glycemic control. This study sought to evaluate effect of undergoing TJA on postoperative glycemic control and outcomes.

Methods

This retrospective study reviewed all patients with DM who underwent primary, elective TJA at our high volume orthopedic institution. Included patients had at least one HbA1c value 3 months to 2 weeks pre-surgery and 3–6 months after surgery. Changes in HbA1c from before to after surgery were calculated. Change in HbA1c greater than 1.0% was considered clinically meaningful. Change in HbA1c was analyzed and stratified into subgroups.

Results

In total, 770 primary TJA patients were included. Patients with preoperative HbA1c > 7% vs. ≤ 7% were significantly more likely to have clinically meaningful post-TJA decrease in HbA1c (24.5 vs. 2.9%, p < 0.001). Patients with preoperative HbA1c > 8 were significantly more likely to have decrease of > 2.0 compared to those with HbA1c < 8 (p < 0.001). Multivariate regression revealed that preop HbA1c > 7.0, former and current smokers, males, and African-Americans were significantly more likely to achieve clinically meaningful decrease in HbA1c. Additionally, postoperative increase in HbA1c > 1% was associated with significantly higher 90-day ED visits.

Discussion

Patients with higher preoperative HbA1c were more likely to have clinically meaningful decreases in HbA1c postoperatively. A combination of preoperative medical optimization and improvements in mobility after TJA may play a role in these changes. Those with elevated HbA1c can have meaningful improvement in HbA1c after TJA.

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Data Availability

The authors confirm that the data supporting the findings of this study are available within the article [and/or] its supplementarymaterials.

References

  1. Qin W, Huang X, Yang H, Shen M (2020) The influence of diabetes mellitus on patients undergoing primary total lower extremity arthroplasty: a systematic review and meta-analysis. BioMed Res Int. https://doi.org/10.1155/2020/6661691

    Article  PubMed  PubMed Central  Google Scholar 

  2. Bolognesi MP, Marchant MH, Viens NA et al (2008) The impact of diabetes on perioperative patient outcomes after total hip and total knee arthroplasty in the United States. J Arthroplasty 23:92–98. https://doi.org/10.1016/j.arth.2008.05.012

    Article  PubMed  Google Scholar 

  3. Martinez-Huedo MA, Villanueva M, de Andres AL et al (2013) Trends 2001 to 2008 in incidence and immediate postoperative outcomes for major joint replacement among Spanish adults suffering diabetes. Eur J Orthop Surg Traumatol 23:53–59. https://doi.org/10.1007/s00590-011-0915-6

    Article  PubMed  Google Scholar 

  4. Namba RS, Inacio MCS, Paxton EW (2013) Risk factors associated with deep surgical site infections after primary total knee arthroplasty. J Bone Joint Surg 95:775–782. https://doi.org/10.2106/JBJS.L.00211

    Article  PubMed  Google Scholar 

  5. Shohat N, Goswami K, Tarabichi M et al (2018) All patients should be screened for diabetes before total joint arthroplasty. J Arthroplasty 33:2057–2061. https://doi.org/10.1016/j.arth.2018.02.047

    Article  PubMed  Google Scholar 

  6. Koenig RJ, Peterson CM, Jones RL et al (1976) Correlation of glucose regulation and hemoglobin A Ic in diabetes mellitus. N Engl J Med 295:417–420. https://doi.org/10.1056/NEJM197608192950804

    Article  CAS  PubMed  Google Scholar 

  7. Peterson KP, Pavlovich JG, Goldstein D et al (1998) What is hemoglobin A1c? An analysis of glycated hemoglobins by electrospray ionization mass spectrometry. Clin Chem 44:1951–1958. https://doi.org/10.1093/clinchem/44.9.1951

    Article  CAS  PubMed  Google Scholar 

  8. Na A, Middleton A, Haas A et al (2020) Impact of diabetes on 90-day episodes of care after elective total joint arthroplasty among medicare beneficiaries. J Bone Joint Surg 102:2157–2165. https://doi.org/10.2106/JBJS.20.00203

    Article  PubMed  Google Scholar 

  9. Antonelli B, Chen AF (2019) Reducing the risk of infection after total joint arthroplasty: preoperative optimization. Arthroplasty 1:1–13. https://doi.org/10.1186/s42836-019-0003-7

    Article  Google Scholar 

  10. Jämsen E, Nevalainen P, Kalliovalkama J, Moilanen T (2010) Preoperative hyperglycemia predicts infected total knee replacement. Eur J Intern Med 21:196–201. https://doi.org/10.1016/j.ejim.2010.02.006

    Article  CAS  PubMed  Google Scholar 

  11. Lovie J, Clement ND, MacDonald D, Ahmed I (2022) Diabesity: a superadded effect contributing to worse total primary hip replacement operative outcomes for patients with diabetes and obesity. Arch Orthop Trauma Surg. https://doi.org/10.1007/s00402-022-04563-6

    Article  PubMed  Google Scholar 

  12. Ashkenazi I, Morgan S, Graif N et al (2022) Increased postoperative glycemic variability is associated with increased mortality in diabetic patients undergoing hip arthroplasty for hip fracture. Arch Orthop Trauma Surg. https://doi.org/10.1007/s00402-022-04558-3

    Article  PubMed  Google Scholar 

  13. Giori NJ, Ellerbe LS, Bowe T et al (2014) Many diabetic total joint arthroplasty candidates are unable to achieve a preoperative hemoglobin A1c goal of 7% or less. J Bone Joint Surg 96:500–504. https://doi.org/10.2106/JBJS.L.01631

    Article  PubMed  Google Scholar 

  14. Lenguerrand E, Beswick AD, Whitehouse MR et al (2018) Outcomes following hip and knee replacement in diabetic versus nondiabetic patients and well versus poorly controlled diabetic patients: a prospective cohort study. Acta Orthop 89:399–405. https://doi.org/10.1080/17453674.2018.1473327

    Article  PubMed  PubMed Central  Google Scholar 

  15. Lenters-Westra E, Schindhelm RK, Bilo HJG et al (2014) Differences in interpretation of haemoglobin A1c values among diabetes care professionals. Neth J Med 72:462–466

    CAS  PubMed  Google Scholar 

  16. (1998) Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33). UK Prospective Diabetes Study (UKPDS) Group. Lancet (London, England) 352:837–853

  17. (2003) Implications of the United Kingdom Prospective Diabetes Study. Diabetes Care 26:s28–s32. https://doi.org/10.2337/diacare.26.2007.S28

  18. Marchant MH, Viens NA, Cook C et al (2009) The impact of glycemic control and diabetes mellitus on perioperative outcomes after total joint arthroplasty. J Bone Joint Surg-Am 91:1621–1629. https://doi.org/10.2106/JBJS.H.00116

    Article  PubMed  Google Scholar 

  19. (2021) 6. Glycemic targets: standards of medical care in diabetes—2021. Diabetes Care 44:S73–S84. https://doi.org/10.2337/dc21-S006

  20. Parvizi J, Tan TL, Goswami K et al (2018) The 2018 definition of periprosthetic hip and knee infection: an evidence-based and validated criteria. J Arthroplasty 33:1309-1314.e2. https://doi.org/10.1016/j.arth.2018.02.078

    Article  PubMed  Google Scholar 

  21. Iorio R, Williams KM, Marcantonio AJ et al (2012) Diabetes mellitus, hemoglobin A1C, and the incidence of total joint arthroplasty infection. J Arthroplasty 27:726-729.e1. https://doi.org/10.1016/j.arth.2011.09.013

    Article  PubMed  Google Scholar 

  22. Adams AL, Paxton EW, Wang JQ et al (2013) Surgical outcomes of total knee replacement according to diabetes status and glycemic control, 2001 to 2009. J Bone Joint Surg 95:481–487. https://doi.org/10.2106/JBJS.L.00109

    Article  PubMed  Google Scholar 

  23. Harris AHS, Bowe TR, Gupta S et al (2013) Hemoglobin A1C as a marker for surgical risk in diabetic patients undergoing total joint arthroplasty. J Arthroplasty 28:25–29. https://doi.org/10.1016/j.arth.2013.03.033

    Article  PubMed  Google Scholar 

  24. Quinlan ND, Werner BC, Brown TE, Browne JA (2020) Risk of prosthetic joint infection increases following early aseptic revision surgery of total hip and knee arthroplasty. J Arthroplasty 35:3661–3667. https://doi.org/10.1016/j.arth.2020.06.089

    Article  PubMed  Google Scholar 

  25. Schairer WW, Sing DC, Vail TP, Bozic KJ (2014) Causes and frequency of unplanned hospital readmission after total hip arthroplasty. Clin Orthopaedics Related Res® 472:464–470. https://doi.org/10.1007/s11999-013-3121-5

    Article  Google Scholar 

  26. Tarabichi M, Shohat N, Kheir MM et al (2017) Determining the threshold for HbA1c as a predictor for adverse outcomes after total joint arthroplasty: a multicenter, retrospective study. J Arthroplasty 32:S263–S267. https://doi.org/10.1016/j.arth.2017.04.065

    Article  PubMed  Google Scholar 

  27. Gold RS, Unkart JT, McClelland RL et al (2021) Health insurance status and type associated with varying levels of glycemic control in the US: The multi-ethnic study of atherosclerosis (MESA). Prim Care Diabetes 15:378–384. https://doi.org/10.1016/j.pcd.2020.11.011

    Article  PubMed  Google Scholar 

  28. Hu R, Shi L, Rane S et al (2014) Insurance, racial/ethnic, SES-related disparities in quality of care among US Adults with diabetes. J Immigr Minor Health 16:565–575. https://doi.org/10.1007/s10903-013-9966-6

    Article  PubMed  Google Scholar 

  29. Dall TM, Yang W, Halder P et al (2016) Type 2 diabetes detection and management among insured adults. Popul Health Metrics 14:43. https://doi.org/10.1186/s12963-016-0110-4

    Article  Google Scholar 

  30. Maciejewski ML, Hammill BG, Bayliss EA et al (2017) Prescriber continuity and disease control of older adults. Med Care 55:405–410. https://doi.org/10.1097/MLR.0000000000000658

    Article  PubMed  PubMed Central  Google Scholar 

  31. Hansen RA, Voils CI, Farley JF et al (2015) Prescriber continuity and medication adherence for complex patients. Ann Pharmacother 49:293–302. https://doi.org/10.1177/1060028014563266

    Article  PubMed  Google Scholar 

  32. Glantz NM, Duncan I, Ahmed T et al (2019) Racial and ethnic disparities in the burden and cost of diabetes for US medicare beneficiaries. Health Equity 3:211–218. https://doi.org/10.1089/heq.2019.0004

    Article  PubMed  PubMed Central  Google Scholar 

  33. Cheng YJ, Kanaya AM, Araneta MRG et al (2019) Prevalence of diabetes by race and ethnicity in the United States, 2011–2016. JAMA 322:2389. https://doi.org/10.1001/jama.2019.19365

    Article  PubMed  PubMed Central  Google Scholar 

  34. Quandt SA, Bell RA, Snively BM et al (2005) Ethnic disparities in glycemic control among rural older adults with type 2 diabetes. Ethn Dis 15:656–663

    PubMed  Google Scholar 

  35. Warren GW, Alberg AJ, Kraft AS, Cummings KM (2014) The 2014 Surgeon General’s report: “The Health Consequences of Smoking-50 Years of Progress”: A paradigm shift in cancer care. Cancer 120:1914–1916. https://doi.org/10.1002/cncr.28695

    Article  PubMed  Google Scholar 

  36. Kulak JA, Cornelius ME, Fong GT, Giovino GA (2016) Differences in quit attempts and cigarette smoking abstinence between Whites and African Americans in the United States: Literature review and results from the International Tobacco Control US Survey. Nicotine Tob Res 18:S79–S87. https://doi.org/10.1093/ntr/ntv228

    Article  PubMed  PubMed Central  Google Scholar 

  37. Nguyen-Grozavu FT, Pierce JP, Sakuma K-LK et al (2020) Widening disparities in cigarette smoking by race/ethnicity across education level in the United States. Preventive Med 139:106220

    Article  Google Scholar 

  38. Ueki K, Sasako T, Okazaki Y et al (2021) Multifactorial intervention has a significant effect on diabetic kidney disease in patients with type 2 diabetes. Kidney Int 99:256–266. https://doi.org/10.1016/j.kint.2020.08.012

    Article  CAS  PubMed  Google Scholar 

  39. Ueki K, Sasako T, Okazaki Y et al (2017) Effect of an intensified multifactorial intervention on cardiovascular outcomes and mortality in type 2 diabetes (J-DOIT3): an open-label, randomised controlled trial. Lancet Diabetes Endocrinol 5:951–964. https://doi.org/10.1016/S2213-8587(17)30327-3

    Article  PubMed  Google Scholar 

  40. Raz I, Riddle MC, Rosenstock J et al (2013) Personalized management of hyperglycemia in Type 2 diabetes. Diabetes Care 36:1779–1788. https://doi.org/10.2337/dc13-0512

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  41. Kim KY, Anoushiravani AA, Chen KK et al (2019) Perioperative orthopedic surgical home: optimizing total joint arthroplasty candidates and preventing readmission. J Arthroplasty 34:S91–S96. https://doi.org/10.1016/j.arth.2019.01.020

    Article  PubMed  Google Scholar 

  42. Kuhn M, Harris-Hayes M, Steger-May K et al (2013) Total hip arthroplasty in patients 50 years or less. J Arthroplasty 28:872–876. https://doi.org/10.1016/j.arth.2012.10.009

    Article  PubMed  PubMed Central  Google Scholar 

  43. Dahm DL, Barnes SA, Harrington JR et al (2008) Patient-reported activity level after total knee arthroplasty. J Arthroplasty 23:401–407. https://doi.org/10.1016/j.arth.2007.05.051

    Article  PubMed  Google Scholar 

  44. Plassard J, Masson JB, Malatray M et al (2020) Factors lead to return to sports and recreational activity after total knee replacement. SICOT-J 6:11. https://doi.org/10.1051/sicotj/2020009

    Article  PubMed  PubMed Central  Google Scholar 

  45. Macdonald AL, Philp A, Harrison M et al (2006) Monitoring exercise-induced changes in glycemic control in type 2 diabetes. Med Sci Sports Exerc 38:201–207. https://doi.org/10.1249/01.mss.0000183852.31164.5a

    Article  CAS  PubMed  Google Scholar 

  46. Sarnowski C, Hivert M-F (2018) Impact of genetic determinants of HbA1c on Type 2 diabetes risk and diagnosis. Curr Diab Rep 18:52. https://doi.org/10.1007/s11892-018-1022-4

    Article  CAS  PubMed  Google Scholar 

  47. Fang F, Li Z, Cheng X et al (2013) Influencing factors of glycemic variability in elderly patients with type 2 diabetes. Zhonghua Yi Xue Za Zhi 93:3202–3206

    CAS  PubMed  Google Scholar 

  48. Xie K, Han X, Jiang X et al (2019) The effect of varus knee deformities on the ankle alignment in patients with knee osteoarthritis. J Orthop Surg Res 14:1–7. https://doi.org/10.1186/s13018-019-1191-0

    Article  Google Scholar 

  49. Schwarzkopf R, Ho J, Quinn JR et al (2016) Factors influencing discharge destination after total knee arthroplasty. Geriatric Orthopaedic Surg Rehab 7:95–99. https://doi.org/10.1177/2151458516645635

    Article  Google Scholar 

  50. Tarity TD, Swall MM (2017) Current trends in discharge disposition and post-discharge care after total joint arthroplasty. Curr Rev Musculoskelet Med 10:397–403. https://doi.org/10.1007/s12178-017-9422-7

    Article  PubMed  PubMed Central  Google Scholar 

  51. Godshaw BM, Ojard CA, Adams TM et al (2018) Preoperative glycemic control predicts perioperative serum glucose levels in patients undergoing total joint arthroplasty. J Arthroplasty 33:S76–S80. https://doi.org/10.1016/j.arth.2018.02.071

    Article  PubMed  Google Scholar 

  52. Mraovic B, Suh D, Jacovides C, Parvizi J (2011) Perioperative hyperglycemia and postoperative infection after lower limb arthroplasty. J Diabetes Sci Technol 5:412–418. https://doi.org/10.1177/193229681100500231

    Article  PubMed  PubMed Central  Google Scholar 

  53. Hoenig JM, Heisey DM (2001) The abuse of power. Am Stat 55:19–24. https://doi.org/10.1198/000313001300339897

    Article  Google Scholar 

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Funding

The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.

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Authors and Affiliations

  1. Department of Orthopedic Surgery, Hospital of Joint Diseases, NYU Langone Health, NYU Langone Orthopedic Hospital, 301 East 17th Street, New York, NY, 10003, USA

    Ittai Shichman, Christian T. Oakley, Jaclyn A. Konopka, Joshua C. Rozell, Ran Schwarzkopf & Claudette M. Lajam

  2. Division of Orthopedic Surgery, Tel-Aviv Sourasky Medical Center, Sackler School of Medicine, Tel-Aviv, Israel

    Ittai Shichman

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  1. Ittai Shichman
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  2. Christian T. Oakley
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Contributions

This study’s conceptualization and conception were made by CL. Methodology and study design were suggested and supervised by RS. Material preparation, data collection, and analysis were performed by IS, CO, and JK. The first draft of the manuscript was written by IS and JR and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Claudette M. Lajam.

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Conflict of interest

Dr. RS is a paid consultant for Smith&Nephew and InteliJoint and has stock options in Intelijoint and Gauss Surgical. Dr. CL is a paid employee for Pfizer. Drs. IS, CO, JK, and JR have no financial disclosures.

Ethical approval

This study was performed in line with the principles of the Declaration of Helsinki. Approval was granted by the Ethics Committee of NYU University and informed consent was waived: i17-01223.

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Appendix 1

Appendix 1

See Tables 5 and 6.

Table 5 Baseline characteristics for patients stratified by inclusion or exclusion in our analysis
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Table 6 Baseline characteristics for patients stratified by THA and TKA analysis
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Shichman, I., Oakley, C.T., Konopka, J.A. et al. Preoperatively elevated HbA1c levels can meaningfully improve following total joint arthroplasty. Arch Orthop Trauma Surg 143, 5425–5435 (2023). https://doi.org/10.1007/s00402-023-04765-6

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