Accepted Manuscript All Patients Should be Screened for Diabetes Prior to Total Joint Arthroplasty Noam Shohat, MD, Karan Goswami, MD, Majd Tarabichi, MD, Emily Sterbis, MD, Timothy L. Tan, MD, Javad Parvizi, MD, FRCS PII:
S0883-5403(18)30178-5
DOI:
10.1016/j.arth.2018.02.047
Reference:
YARTH 56443
To appear in:
The Journal of Arthroplasty
Received Date: 21 December 2017 Revised Date:
15 January 2018
Accepted Date: 8 February 2018
Please cite this article as: Shohat N, Goswami K, Tarabichi M, Sterbis E, Tan TL, Parvizi J, All Patients Should be Screened for Diabetes Prior to Total Joint Arthroplasty, The Journal of Arthroplasty (2018), doi: 10.1016/j.arth.2018.02.047. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
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All Patients Should be Screened for Diabetes Prior to Total Joint Arthroplasty
The Rothman Institute at Thomas Jefferson University, Philadelphia, PA
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Noam Shohat MD1 Karan Goswami MD1 Majd Tarabichi MD1 Emily Sterbis MD1 Timothy L Tan MD1 Javad Parvizi MD, FRCS
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Running Title: TJA Patients Should be screened for Diabetes
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Corresponding Author Javad Parvizi MD, FRCS The Rothman Institute 125 S 9th St. Ste 1000 Philadelphia, PA 19107 P: 267-339-7813 F: 215-503-5651
[email protected]
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All Patients Should be Screened for Diabetes Prior to Total Joint Arthroplasty
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Running Title: TJA Patients Should be screened for Diabetes
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ABSTRACT
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Background: Diabetes is highly prevalent in patients with osteoarthritis prior to total joint
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arthroplasty (TJA) and confers a higher risk of adverse postoperative outcomes. However, the
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rate of diabetes in this population and optimal screening strategies remain unknown.
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Methods: We prospectively screened patients undergoing elective TJA for diabetes using
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glycated hemoglobin (HbA1c) levels and fasting blood glucose (FBG). Screening was conducted
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within two discrete time periods between 2012 and 2017. The prevalence of diabetes was
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assessed using a previous diagnosis of diabetes, or in the absence of diagnosed diabetes, by
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HbA1c ≥6.5%, or FBG ≥126mg/dL. Pre-diabetes was defined as 5.7%≤ HbA1c ≤6.4%, or
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100mg/dL≤ FBG ≤125mg/dL. Occurrence of 90-day periprosthetic joint infection (PJI) and
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wound complications were noted.
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Results: A total of 1461 patients were included in the study. The overall prevalence of diabetes
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was 20.6%; 178 patients (59.1%) had diagnosed diabetes and 123 patients (40.9%) had
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undiagnosed diabetes. Pre-diabetes was identified in 559 patients (38.3%), resulting in a
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combined total of 860 (58.9%) diabetics and pre-diabetics. Total diabetic rates were significantly
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higher (p’s65 years, non-whites, undergoing total knee arthroplasty. No
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significant differences in PJI and wound complications were observed comparing diagnosed and
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undiagnosed diabetics (p’s=1.0).
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Conclusion: A significant proportion of undiagnosed diabetics and prediabetics were identified.
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Preadmission testing provide an ideal opportunity to identify and address this systemic condition,
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thereby potentially reducing both short term arthroplasty-related complications, as well as
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avoiding long term systemic diabetic complications. We strongly recommend universal glycemic
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screening of all elective arthroplasty patients.
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Keywords: Total Joint Arthroplasty; Hip; Knee; Diabetes; Glycemic Screening
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INTRODUCTION
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Diabetes mellitus is amongst the most prevalent and morbid ailments, affecting the wellbeing of
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millions of people worldwide. The burden of diabetes is rising and it is projected that in the next
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20 years, the number of diabetics in the United States will reach 44 million, about two times the
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present prevalence [1,2]. In addition, the prevalence of prediabetes, which may ultimately lead to
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diabetes, has also been increasing [3,4]. Diabetes is an established risk factor for severe
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osteoarthritis,[5] and a higher prevalence has been reported in patients undergoing total joint
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arthroplasty (TJA) [6,7].
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Patients with diabetes, especially those with inadequate glycemic control, are at increased risk
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for both joint-related and systemic adverse outcomes following TJA [8–11], of which
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periprosthetic joint infection (PJI) has been the most studied. Diabetic patients are also more
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likely to incur higher costs of treatment and achieve poorer functional outcomes. A recent study
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showed that one third of patients undergoing TJA had undiagnosed dysglycemia detected on
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routine screening [7]. This could explain why numerous studies show that perioperative
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hyperglycemia and elevated glycated hemoglobin (HbA1c) are associated with postoperative
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complications even without a diagnosis of diabetes, as these patients are simply unaware of their
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diabetic status [12–14].
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Diabetes is frequently asymptomatic during the initial stages and can remain undiagnosed for a
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prolonged period of time. Aside from the aforementioned postoperative complications,
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individuals with undiagnosed diabetes are at significantly higher risk for stroke, heart disease,
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and peripheral vascular disease [15–17]. Screening TJA patients for diabetes could allow early
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detection and rapid treatment, which may reduce the burden of diabetes and both its surgical and
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non-surgical complications. Furthermore, patients with inadequate glycemic control and
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undiagnosed diabetes may be treated and appropriately optimized in the perioperative, which
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could improve their outcomes. Furthermore, lifestyle changes and pharmacologic interventions
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may reduce progression and delay development in undiagnosed diabetics and pre-diabetics [18–
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20].
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Multiple professional organizations have published screening recommendations for diabetes
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[19,21–23]. While there are slight differences between them, they all agree that patients with an
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increased risk for diabetes should be screened. Since patients undergoing TJA are at increased
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risk for diabetes, it is reasonable to provide screening recommendations for this patient
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population. The fact that individuals approaching TJA undergo preadmission testing provides an
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ideal screening setting, for both patient and physician. The aim of this study was to assess the
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role of diabetic screening in all patients undergoing TJA. We were interested in determining the
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true incidence of diabetes and prediabetes in a large prospective cohort of patients undergoing
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TJA. More specifically, we sought to identify the rate of undiagnosed diabetes and pre-diabetes,
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ascertain these patients’ characteristics and provide screening recommendations for patients
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undergoing elective joint replacement.
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MATERIALS AND METHODS
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Following Institutional Review Board approval, patients undergoing elective total hip (THA) and
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knee (TKA) arthroplasty were prospectively screened for diabetes using HbA1c levels and
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fasting blood glucose (FBG) levels. Screening was conducted within two discrete 3-month time
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periods between 2012 and 2017. All blood samples were obtained at preadmission testing 1-3
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weeks prior to surgery. We excluded all cases of revision arthroplasty with a diagnosis of PJI.
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Data Collection:
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A standardized questionnaire was used to collect information on age, sex, race and patient co-
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morbidities. Participants were also asked to confirm if they had prior or current diagnosis of
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diabetes, as well as all prescribed medications. During preadmission testing, weight and height
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were measured and body mass index (BMI) was calculated.
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Postoperative outcome data was collected by nurse navigators. Further information was collated
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from phone call logs, and postoperative follow up encounters. All patients were examined by
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their surgeon at 4-6 weeks after surgery. Patients were also contacted for a phone interview at 90
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days to ascertain any complications or hospital readmissions. Occurrence of periprosthetic joint
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infection (PJI) and wound complications were noted. PJI was diagnosed using the
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Musculoskeletal Infection Society (MSIS) criteria [24]. Wound complications were defined as
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superficial infections necessitating further treatment (irrigation and debridement or antibiotics),
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erythema or cellulitis treated with antibiotics, or prolonged wound drainage.
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Definitions of Diabetes:
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Patients were classified as: 1) Diagnosed diabetics if they had a previous diagnosis of diabetes
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based on medical records and self-reported questionnaire, 2) Undiagnosed diabetics if their
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HbA1c level was 6.5% or greater or FBG level was 126 mg/dL or greater, but without a prior
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existing diagnosis of diabetes or 3) Prediabetics in the context of no preceding diabetes
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diagnosis, but HbA1c levels between 5.7% and 6.4%, or FBG levels between 100 mg/dL and
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125 mg/dL. The total number of diabetics was deemed to include all patients with diagnosed and
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undiagnosed diabetes based on the aforementioned criteria.
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Statistical analysis:
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The prevalence of total diabetics, diagnosed diabetics, and undiagnosed diabetics, as well as the
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prevalence of prediabetics in the overall population was calculated and presented as number (%).
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Diabetes status was stratified by age (20-44 years, 45-64 years and ≥65 years), sex, race (white,
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black, other) and BMI (normal, overweight and obese class 1, obese class 2, obese class 3).
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Categorical variables were analyzed using the Chi-square test and continuous variables by the
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Student's t-test if they were normally distributed or Mann–Whitney test if not normally
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distributed. A p-value
