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Surgical Outcomes of Total Knee Replacement According to Diabetes Status and Glycemic Control, 2001 to 2009

Adams, Annette L., PhD, MPH1; Paxton, Elizabeth W., MA2; Wang, Jean Q., MS1; Johnson, Eric S., PhD3; Bayliss, Elizabeth A., MD, MSPH4; Ferrara, Assiamira, MD, PhD5; Nakasato, Cynthia, MD6; Bini, Stefano A., MD7; Namba, Robert S., MD8

doi: 10.2106/JBJS.L.00109
Scientific Articles

Background: Poor glycemic control in patients with diabetes may be associated with adverse surgical outcomes. We sought to determine the association of diabetes status and preoperative glycemic control with several surgical outcomes, including revision arthroplasty and deep infection.

Methods: We conducted a retrospective cohort study in five regions of a large integrated health-care organization. Eligible subjects, identified from the Kaiser Permanente Total Joint Replacement Registry, underwent an elective first primary total knee arthroplasty during 2001 through 2009. Data on demographics, diabetes status, preoperative hemoglobin A1c (HbA1c) level, and comorbid conditions were obtained from electronic medical records. Subjects were classified as nondiabetic, diabetic with HbA1c < 7% (controlled diabetes), or diabetic with HbA1c ≥ 7% (uncontrolled diabetes). Outcomes were deep venous thrombosis or pulmonary embolism within ninety days after surgery and revision surgery, deep infection, incident myocardial infarction, and all-cause rehospitalization within one year after surgery. Patients without diabetes were the reference group in all analyses. All models were adjusted for age, sex, body mass index, and Charlson Comorbidity Index.

Results: Of 40,491 patients who underwent total knee arthroplasty, 7567 (18.7%) had diabetes, 464 (1.1%) underwent revision arthroplasty, and 287 (0.7%) developed a deep infection. Compared with the patients without diabetes, no association between controlled diabetes (HbA1c < 7%) and the risk of revision (odds ratio [OR], 1.32; 95% confidence interval [CI], 0.99 to 1.76), risk of deep infection (OR, 1.31; 95% CI, 0.92 to 1.86), or risk of deep venous thrombosis or pulmonary embolism (OR, 0.84; 95% CI, 0.60 to 1.17) was observed. Similarly, compared with patients without diabetes, no association between uncontrolled diabetes (HbA1c ≥ 7%) and the risk of revision (OR, 1.03; 95% CI, 0.68 to 1.54), risk of deep infection (OR, 0.55; 95% CI 0.29 to 1.06), or risk of deep venous thrombosis or pulmonary embolism (OR, 0.70; 95% CI, 0.43 to 1.13) was observed.

Conclusions: No significantly increased risk of revision arthroplasty, deep infection, or deep venous thrombosis was found in patients with diabetes (as defined on the basis of preoperative HbA1c levels and other criteria) compared with patients without diabetes in the study population of patients who underwent elective total knee arthroplasty.

Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

1Department of Research and Evaluation, Kaiser Permanente Southern California, 100 South Los Robles Avenue, Pasadena, CA 91101. E-mail address for A.L. Adams:

2Surgical Outcomes and Analysis, SCPMG Clinical Analysis, Kaiser Permanente Southern California, 3033 Bunker Hill Street, San Diego, CA 92109

3The Center for Health Research, Kaiser Permanente Northwest, 3800 North Interstate Avenue, Portland, OR 97227-1099

4Institute for Health Research, Kaiser Permanente Colorado, 10065 East Harvard Avenue, Suite 300, Denver, CO 80231-5968

5Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612

6The Center for Health Research, Kaiser Permanente Hawaii, 501 Alakawa Street, Suite 201, Honolulu, HI 96817

7Department of Orthopedic Surgery, Kaiser Permanente Northern California, 280 West MacArthur Boulevard, Oakland, CA 94611

8Department of Orthopedic Surgery, Kaiser Permanente Southern California, 321 Milford Drive, Corona del Mar, CA 92625

Copyright © 2013 by The Journal of Bone and Joint Surgery, Incorporated
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