Patients with Diabetes More Likely to Develop Hyperglycemia after TJA

    Total joint arthroplasty patients with insulin-dependent diabetes mellitus (IDDM) are at a sharply higher risk of experiencing an elevated blood glucose level after surgery than patients with non-insulin-dependent diabetes mellitus (NIDDM), potentially putting them at greater risk for developing periprosthetic joint infection (PJI) and other complications, according to a new study from researchers at Hospital for Special Surgery in New York and The Ochsner Health System in New Orleans.

    These findings were presented at the 2019 Annual Meeting of the American Academy of Orthopaedic Surgeons.

    Previous research has shown that in general, hyperglycemia (blood glucose level above 200 mg/dL) is a risk factor for infection in patients undergoing total joint arthroplasty. The new study has a narrower focus: It compares outcomes between patients with IDDM and those with NIDDM. Patients who need insulin to control diabetes can be considered to have a more-severe disease and a greater chance of developing hyperglycemia in the perioperative period, said senior study author Bradford S. Waddell, MD, from Hospital for Special Surgery.

    Dr. Waddell and his colleagues retrospectively reviewed the medical charts of patients who had undergone total joint arthroplasty between January 1, 2011, and December 31, 2016, identifying 437 patients with IDDM and 336 patients with NIDDM. Patients were included in the study only if they had a recorded preoperative hemoglobin A1c level and a minimum of 1 year of follow-up. The researchers found that:

    • Patients with IDDM had a higher average preoperative A1c level than patients with NIDDM, 6.97% vs 6.28% (P<0.0001)
    • Patients with IDDM had a higher mean postoperative blood glucose level than patients with NIDDM, 235.2 mg/dL vs 163.5 mg/dL (P<0.0001)
    • Patients with IDDM were 5.2 times more likely than patients with NIDDM to develop hyperglycemia after surgery (odds ratio 5.2; P<0.0001)
    • Patients with IDDM who had a preoperative A1c level above 6.59% and patients with NIDDM who had a preoperative A1c level above 6.6% had an elevated risk for postoperative hyperglycemia (P<0.0001)

    Despite the increased risk for hyperglycemia after surgery, the incidence of PJI did not differ between the 2 groups (2.52% for IDDM vs 2.38% for NIDDM; P=0.9034). However, Dr. Waddell noted that a limitation of the study was that it was underpowered to detect the risk of infection.

    The bottom line for clinicians, Dr. Waddell said, is “if your patient comes in with diabetes and is dependent on insulin, you need to be more cognizant of controlling their blood [glucose level] in the perioperative period because they’re at higher risk [for infection].”


    Godshaw BM, Warren MS, Chimento GF, Mohammed AE, Waddell BS. Insulin-Dependent Diabetic Patients Undergoing Total Joint Arthroplasty are at Increased Risk of Postoperative Hyperglycemia (Paper 759). Presented at the 2019 Annual Meeting of the American Academy of Orthopaedic Surgeons, March 12-16, Las Vegas, Nevada.