RISK FACTORS: DIABETES/HYPERGLYCEMIA

There is one high quality study (Reategui 2017) concluding that postoperative hyperglycemia control reduces the postoperative complications in patients who have undergone TKA. Patients were classified as non-diabetic patients (group 1), diabetic patients (group 2) and patients with stress hyperglycemia (group 3). The last two groups were recommended assessments by a primary care physician (PCP). After one year follow up the groups were compared with respect to incidence of postoperative complications. The groups were also compared regarding the decrease or increase of HbA1c levels with the incidence of complications. Patients that consulted their PCP presented lower medical complication rates than those who did not. Surgical site infection and mechanical complication were increased. A decrease of HbA1c value was related to less medical systemic complications. There are two high quality studies (Ojemolon 2020, Teo 2018) and one low quality study (Zhang 2021) assessing patients with diabetes and outcomes after TKA. Zhang (2021) shows patients with uncontrolled diabetes HGB A1C >8 having a lower KSS and WOMAC score, however, there is no difference between their mental component scores and patient satisfaction. Additionally, they also reported lower ROM and SF-36 scores. In Teo (2018), patients with diabetes have a lower Oxford, KSS, and SF-36 score. There was no difference in range of motion, length of hospitalization stay, infection risk, and patient satisfaction. Diabetic patients also had a 50% reduction in body mass index after TKA compared to 36% in nondiabetic patients. Ojemolon (2018) reviewed NSQIP data of diabetic patients and non-diabetic patients which showed lower complication rates in diabetic patients in areas such as infection, DVT, PE, sepsis, pneumonia, and MI.

Benefits/ Harms of Implementation

The risks associated with performing total knee arthroplasty on patients with poorly controlled diabetes may include higher surgical complications such as SSIs and mechanical complications. These patients also tend to have lower functional scores. These increased complications may require further financial resources to treat them.

Outcome Importance

Patients with uncontrolled diabetes may have a higher rate of complications after total knee arthroplasty.

Cost Effectiveness / Resource Utilization

Several high-quality studies show that there is an increased risk of SSIs in patients with uncontrolled diabetes after TKA. Several studies also highlighted increased use of resources such as antibiotics and the need for consulting services which may increase the cost.

Acceptability

The recommendation comes with varying acceptability.

Feasibility

Since there have been a number of studies showing increase complications in patients with uncontrolled diabetes, it is reasonable to better optimize this patient before surgery to decrease risk.

Future Research

Additional prospective studies are needed to evaluate functional outcomes in patients with controlled and uncontrolled diabetes.