Thursday, July 27, 2017

The risks associated with total shoulder in patients with diabetes and others

The impact of insulin dependence on short-term postoperative complications in diabetic patients undergoing total shoulder arthroplasty

These authors sought to determine the impact of insulin dependence on the risk profile of diabetic patients having shoulder arthroplasty. Patients were categorized as non–diabetes mellitus (non-DM), non–insulin dependent diabetes mellitus (NIDDM), or insulin-dependent diabetes mellitus (IDDM). 

In bivariate analysis, NIDDM and IDDM were associated with multiple postoperative complications, including stroke, sepsis, wound complications, blood transfusion, and extended LOS. With multivariable logistic regression, however, NIDDM patients did not have significantly greater odds of any study end point relative to non-DM patients. IDDM patients had significantly greater odds for having any postoperative complication (odds ratio [OR], 1.53), stroke (OR, 13.63), blood transfusion (OR, 1.67), and extended LOS (OR, 1.38).

They concluded that after adjustment for demographics and comorbidity burden, NIDDM patients had risk profiles similar to those of non-DM patients. IDDM was an independent predictor of multiple postoperative complications. 

Comment: While the authors did not have HbA1c levels on the patients in this study, they state that "insulin dependence appears to be a more robust risk factor than glycemic control as measured by the HbA1c level." There is currently a re-examination of the value of using oft-quoted target of an HbA1c level of 7. There is some evidence that (1) some patients may not be able to reach this goal and (2) 'forcing' an HbA1c level of 7 may not be safe for the patient. There seems to be a trend toward accepting the more reachable and perhaps safer target of 8. 

It remains unclear to us how much the well-documented increased risk of surgery in patients with IDDM can be modified. The table above demonstrates that a number of important health factors are co-variates with the severity of diabetes making it a challenge to sort the effect of one from the other. 

At minimum, our responsibility is to inform our patients of the potential risk of surgery. One approach is to use the American College of Surgeons' Surgical risk calculator

Interestingly this calculator classes diabetes as "none", "oral", "insulin".

The reader may like to enter "23472 - Arthroplasty, glenohumeral joint; total shoulder (glenoid and proximal humeral replacement (eg, total shoulder))" into the procedure box at the top and calculate his/her estimated risk.

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Information about shoulder exercises can be found at this link.

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