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Surgical Outcomes of Total Knee Replacement According to Diabetes Status and Glycemic Control, 2001 to 2009
Annette L. Adams, PhD, MPH1; Elizabeth W. Paxton, MA2; Jean Q. Wang, MS1; Eric S. Johnson, PhD3; Elizabeth A. Bayliss, MD, MSPH4; Assiamira Ferrara, MD, PhD5; Cynthia Nakasato, MD6; Stefano A. Bini, MD7; Robert S. Namba, MD8
1 Department of Research and Evaluation, Kaiser Permanente Southern California, 100 South Los Robles Avenue, Pasadena, CA 91101. E-mail address for A.L. Adams: Annette.L.Adams@kp.org
2 Surgical Outcomes and Analysis, SCPMG Clinical Analysis, Kaiser Permanente Southern California, 3033 Bunker Hill Street, San Diego, CA 92109
3 The Center for Health Research, Kaiser Permanente Northwest, 3800 North Interstate Avenue, Portland, OR 97227-1099
4 Institute for Health Research, Kaiser Permanente Colorado, 10065 East Harvard Avenue, Suite 300, Denver, CO 80231-5968
5 Division of Research, Kaiser Permanente Northern California, 2000 Broadway, Oakland, CA 94612
6 The Center for Health Research, Kaiser Permanente Hawaii, 501 Alakawa Street, Suite 201, Honolulu, HI 96817
7 Department of Orthopedic Surgery, Kaiser Permanente Northern California, 280 West MacArthur Boulevard, Oakland, CA 94611
8 Department of Orthopedic Surgery, Kaiser Permanente Southern California, 321 Milford Drive, Corona del Mar, CA 92625
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Investigation performed at Kaiser Permanente

This article was chosen to appear electronically on February 27, 2013, in advance of publication in a regularly scheduled issue.

A commentary by Paul Manner, MD, is linked to the online version of this article at jbjs.org.

Disclosure: One or more of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of an aspect of this work. In addition, one or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2013 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2013 Mar 20;95(6):481-487. doi: 10.2106/JBJS.L.00109
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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.


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.


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.


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.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Stefano Bini, MD(1), Annette Adams, PhD, MPH(2), Robert Namba, MD(2)
    Posted on April 22, 2013
    Authors respond to “What about peri-operative blood glucose levels?”
    (1) Kaiser Permanente Northern California, (2) Kaiser Permanente Southern California

    Thank you for taking an interest in our paper. As eloquently noted, we did not look at perioperative glycemia as this was not the aim of our paper, though perioperative glycemic control has indeed been shown to increase complication rates following total joint surgery. We have also recently reported diabetic status as a risk factor for complications from our own registry.1 The aim of the present paper, though, was to evaluate whether long-term glycemic control as measured by HgA1c - as opposed to acute hyperglycemia in the perioperative period - is associated with an increased risk of complications. Our finding is that it is not. Simply stated, just because a diabetic patient has been poorly controlled in the months and possibly years prior to surgery does not automatically mean that they are at higher risk for poorer surgical outcomes and need not be counseled that they are. As you have correctly noted, current evidence suggests that it is the perioperative management of a patient's blood glucose that has the highest impact on surgical risk.

    1. Namba R, Inacio M, Paxton E. Risk factors associated with deep surgical site infections in primary total knee arthroplasty. In press, J Bone Joint Surg Am 2013.

    Cemal Kazimoglu, Serkan Akcay
    Posted on April 04, 2013
    What about peri-operative blood glucose levels?
    Cemal Kazimoglu (Ass. Prof), Serkan Akcay (MD), Katip Celebi Üniversity, Atatürk Training and Research Hospital Department of Orthopaedics, İzmir, Turkey

    We read this article with great interest. We think that a major shortcoming of this article is the failure of the authors to measure peri-operative blood glucose levels. Indeed, postoperative hyperglycemia increases the risk for postoperative infection independent of preoperative blood glucose levels and diabetes mellitus status. Short-term hyperglycemia impairs immunity via reduced neutrophil activity and diminishes the ability of the host to combat infection1,2.

    Diabetes mellitus as a risk factor for infection is controversial. The controversy might exist because the diagnosis of diabetes mellitus was used from the discharge summaries or because the studies were not powered enough to show the difference as the authors stated. Additionally, the study didn’t investigate the duration of diabetes. Microvascular complications of diabetes mellitus are related to  the duration of the disease. It can be speculated that longer duration of diabetes but not of glucose control is associated with higher deep vein thrombosis prevalence.

    1. Ramos M, Khalpey Z, Lipsitz S, Steinberg J, Panizales MT, Zinner M, Rogers SO. Relationship of perioperative hyperglycemia and post-operative infections in patients who undergo general and vascular surgery. Ann Surg. 2008;248(4):585–91.
    2. Turina M, Fry DE, Polk HC Jr. Acute hyperglycemia and the innate immune system: clinical, cellular, and molecular aspects. Crit Care Med. 2005;33(7):1624–33.

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