DIABETES: ADVERSE EVENTS

There are very few articles in literature comparing diabetic and non-diabetic patients and their outcomes after total hip arthroplasty. Approximately 30 articles were identified on initial literature search; three low quality articles were included (Cancienne 2017, McVey 2020, Na 2020).

McVey (2020) retrospectively compared outcomes after THA between diabetic patients and a control group and found no difference in outcomes between groups. The diabetic group had an average A1c of 6.0% while only 27% patients had A1c more than 7.5%. While Cancienne (2017) found that patients with controlled diabetes had significantly fewer deep infections, McVey (2020) did not report significantly different rates of any adverse events, including deep infection. This cohort of patients had relatively well controlled diabetes which may be the reason for a nonsignificant increase in complication. Na (2020) divided the patients into four groups: uncontrolled diabetes, controlled diabetes with complications, controlled diabetes without complications, and no diabetes. The results show that patients without diabetes or with controlled diabetes without complications had more favorable outcomes than patients with uncontrolled diabetes or controlled diabetes with complications. These outcomes include overall complications, acute myocardial infarction, pulmonary embolism, pneumonia, sepsis/septicemia/shock, surgical site bleeding, and joint/wound infection.

Benefits/Harms of Implementation
There is no consensus on acceptable HbA1c level considered safe for surgery. Patients with uncontrolled diabetes are at an increased risk of adverse events after THA, but there is no consensus on the best determinant of diabetes control and a cutoff by which the risks of surgery outweigh the benefits. The decision to proceed with surgery should be made by each individual patient and surgeon after an informed decision-making process where the risks and benefits of the procedure for that individual patient are discussed.

Outcome Importance
Infection and renal injury could lead to significant morbidity and possibly mortality in patients.

Cost Effectiveness/Resource Utilization
This option would not result in a change in resource utilization.

Acceptability
This option should be widely accepted as it does not mandate a change in clinical practice.

Feasibility
There is no barrier to acceptance of the option.

Future Research
Future research is needed to determine the optimal measure of diabetes control. In addition, more clarity in terms of risks at different severities of diabetes is needed. Future studies should stratify patients based on their A1c level or perioperative blood sugar level with sufficient power to see if there is any unsafe diabetes control for hip arthroplasty.