Diabetes and Total Joint

Replacement
Overview
• The American Diabetes Association:
• The recommended value of HbA1c prior elective surgery should be lower
than 7%.

• Many orthopaedic surgeon (94%) accept the value of 7% for joint

replacement without solid evidence dedicated to arthroplasty.

Aggarwal VK, Tischler EH, Lautenbach C, Williams GR, Abboud JA, Altena M, et al. Mitigation and
education. J Arthroplasty 2014;29:19–25. doi:10.1016/j.arth.2013.09.028.
• It is unknown whether HbA1c < 7% is ideal for total joint replacement.

• A large multi-center published in (JBJS 2013) proved no relation of HbA1c

> 7% or > 7% with deep infection or revision replacement.

• Another large study on 20,171 THA and TKA primary and revisions (Journal
of Arthroplasty 2016) found that HbA1c is an inconsistent indicator of
post-operative infection.

• Adams AL et al. Surgical outcomes of total knee replacement according to diabetes status
and glycemic control, 2001 to 2009. J Bone Joint Surg Am 2013;95:481–7.
• Maradit Kremers H et al. Diabetes mellitus, hyperglycemia, hemoglobin A1C and the risk of
prosthetic joint infections in total hip and knee arthroplasty. J Arthroplasty 2015;30:439–
43.
• Both of the previous studies have shown the following:

• That joint infection in patients with high HbA1c values

can be explain with other factors such
• Prolonged operative time
• Obesity
• High ASA scores.
 However, 7.7 might be the threshold
• A multi center retrospective study by Parvizi and his group at the Rothman
Institute

• 1645 underwent primary joint arthroplasty (1004 knees and 641 hips)

• A threshold of HbA1c >= 7.7% seems to be more indicative of infection than

the commonly used 7%.

• HbA1c < 7.7% should perhaps be the goal in preoperative patient optimization
Arabichi, Majd et al. Determining the Threshold for HbA1c as a Predictor for Adverse Outcomes After Total
Joint Arthroplasty: A Multicenter, Retrospective Study The Journal of Arthroplasty , Volume 32 , Issue 9 ,
S263 - S267.e1
 Another standpoint
• The American Academy of Orthopedic Surgeons published in a
2013 review article:

• Perioperative hyperglycemia may be a more accurate predictor of

complication risk, specifically of postoperative infection.

• Hyperglycemia levels 200 mg/dL evident on postoperative day one result

in a twofold increased risk of infection

• Yu S, Garin K, William H, et al. Preventing Hospital Readmissions and Limiting

the Complications Associated With Total Joint Arthroplasty J Am Acad Ortho
Surg 2015