These authors used Kaiser Permanente’s Shoulder Arthroplasty Registry (2005-2015) to answer several important questions regarding diabetes and shoulder arthroplasty:
1) Are diabetes status and glycemic control associated with adverse events, including deep infection, all-cause revision, and 90-day readmission after shoulder arthroplasty?
(2) Is postoperative HbA1c associated with revision risk?
(3) Is there a threshold of preoperative HbA1c that best identifies patients with diabetes who are at higher risk of 3-year deep infection, 1-year all-cause revision or 90-day readmission?
(4) Can the Adapted Diabetes Complications Severity index (aDCSI) be used as an alternative measure of diabetes severity in evaluating the risk of deep infection, all-cause revision, and 90-day readmission and identification of patients with diabetes at higher risk for these events?
(5) Is there a difference between elective and traumatic shoulder arthroplasty patients?
Their study sample consisted of 8819 patients; 7353 underwent elective shoulder arthroplasty and 1466 underwent shoulder arthroplasty due to trauma. For elective shoulder arthroplasty, 1430 patients (19%) had diabetes, and among the patients who underwent arthroplasty due to trauma, 444 (30%) had diabetes.
Patients with diabetes who underwent elective shoulder arthroplasty and had poor glycemic control had a higher likelihood of 90-day readmission compared with patients without diabetes (OR, 1.5; 95% CI, 1.0–2.1; p =0.032). No association was found for patients with diabetes who underwent shoulder arthroplasty due to trauma. No association was found between postoperative HbA1c and revision risk.
Their study sample consisted of 8819 patients; 7353 underwent elective shoulder arthroplasty and 1466 underwent shoulder arthroplasty due to trauma. For elective shoulder arthroplasty, 1430 patients (19%) had diabetes, and among the patients who underwent arthroplasty due to trauma, 444 (30%) had diabetes.
Patients with diabetes who underwent elective shoulder arthroplasty and had poor glycemic control had a higher likelihood of 90-day readmission compared with patients without diabetes (OR, 1.5; 95% CI, 1.0–2.1; p =0.032). No association was found for patients with diabetes who underwent shoulder arthroplasty due to trauma. No association was found between postoperative HbA1c and revision risk.
Patients with severe diabetes (by aDSCI) who underwent both elective and traumatic shoulder arthroplasty had a higher likelihood of 90-day readmission compared with patients without diabetes.
The authors found no difference in the risk of long-term complications (deep infection and revision) for patients with diabetes compared with patients without diabetes, regardless of disease severity or how that severity was measured. Further, they were unable to identify an optimal disease severity threshold, either according to HbA1c or aDCSI, for differentiating risk of adverse events after both elective and shoulder arthroplasty due to trauma.
Comment: It is commonly held that diabetes, particularly poorly controlled diabetes is a risk factor for adverse outcomes from elective surgery, including arthroplasty. However, such an effect was not evident in this large study from an integrated healthcare system that places great value on preventive care. In this system, patients undergoing elective shoulder arthroplasty have time to use disease management resources preoperatively to try to mitigate the risks of surgery.
The authors found no difference in the risk of long-term complications (deep infection and revision) for patients with diabetes compared with patients without diabetes, regardless of disease severity or how that severity was measured. Further, they were unable to identify an optimal disease severity threshold, either according to HbA1c or aDCSI, for differentiating risk of adverse events after both elective and shoulder arthroplasty due to trauma.
Comment: It is commonly held that diabetes, particularly poorly controlled diabetes is a risk factor for adverse outcomes from elective surgery, including arthroplasty. However, such an effect was not evident in this large study from an integrated healthcare system that places great value on preventive care. In this system, patients undergoing elective shoulder arthroplasty have time to use disease management resources preoperatively to try to mitigate the risks of surgery.
In our practice we note that many patients do not have a primary care provider who manages their wellness. By contrast, in the Kaiser system we perceive that primary care providers play a major role in health maintenance and, as such, may minimize the adverse effects of medical conditions such as diabetes.
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