Diabetes and its negative impact on outcomes in orthopaedic surgery

Table 1 Complications of diabetes potentially affecting orthopaedic surgery patients

Retinopathy

Visual impairment leading to falls

Peripheral neuropathy

Balance issues

Gait abnormalities

Lack of protective sensation

Increased risk of surgical site infection

Increased risk of nonunion

Peripheral artery disease

Impaired lower extremity blood supply leading to faulty healing

End stage renal disease

Metabolic bone disease

Anemia of chronic disease

Poorly controlled diabetes (hyperglycemia)

Increased risk of surgical site infection

Impaired bone and soft tissue healing

Table 2 Impact of diabetes on orthopaedic surgical subspecialties

Foot and ankle surgery

Increased risk of surgical site infection

Increased risk of nonunion, malunion and hardward failure

Increased risk of neuropathic ulcers

Spine surgery

Increased risk of surgical site infection

Increased risk of nonroutine discharges

Sports medicine

Impaired healing of soft tissues (ligaments and tendons)

Spontaneous necrosis of muscle

Total joint arthroplasty

Increased risk of surgical site infection

Increased risk of nonroutine discharges

Upper extremity

Increased risk of nerve compression syndromes

Increased risk of overuse syndromes

Inferior outcomes in rotator cuff repair and frozen shoulder

Table 3 Take home messages for orthopaedic surgeons treating diabetic patients

Optimize the patient’s medical care preoperatively

Strive for long term glycemic control of HbgA1c ≤ 8%

Thorough preoperative workup for cardiovascular disease

Identify anemia if present and treat accordingly if major blood loss is anticipated (i.e., spine surgery or total joint surgery)

Thorough assessment of the vascular system preoperatively

If an abnormal examination is present proceed with non-invasive testing and vascular consultation

Perioperative care

Strive for inpatient glycemic control as recommended by major societies

Pre-meal glucose of < 140 mg/dL

Random glucose of < 180 mg/dL

Avoid hypoglycemia!!

Glucose levels of > 200 mg/dL have been associated with increased rates of complications in orthopaedic patients

Recognize that patients with poorly controlled diabetes and comorbidities are at increased for postoperative complications

Cardiovascular complications

Myocardial infarction

Stroke

Deep vein thrombosis and pulmonary embolism

Infection

Surgical site

Urinary tract

Pneumonia

Iatrogenic pressure ulcers

Pad bony prominences such as the sacrum and heels

Noninfectious complications

Hardward failure

Nonunion or malunion

Impaired wound healing

Inform patients that local injections of corticosteroids (trigger point injections, epidural steroid injections, etc.) will cause a temporary elevation in serum glucose for 24-48 h