Diabetes Mellitus—What to Consider for Total Hip and Knee Arthroplasty

Diabetes mellitus (DM) represents an important risk factor after total joint arthroplasty (TJA) for both perioperative and long-term complications, in particular periprosthetic joint infection (PJI). The risk of complications appears to be correlated to uncontrolled perioperative hyperglycemia (blood glucose level >180 mg/dL). In diabetic patients waiting for TJA, we need to optimize the DM control. Glycosylated hemoglobin (HbA1c) is an objective, reliable marker of glycemic control. HbA1c 7% was defined as the recommended cutoff to delay surgery in diabetic patients being a candidate for TJA (American Academy of Orthopaedic Surgeons. Surgical management of osteoarthritis of the knee evidencebased clinical practice guideline; 2022. http://www.aaos.org/smoak2cpg . Accessed 05 Feb 2023 [Online]; Schwarz et al., J Orthop Res 37:997–1006, 2019). However, the risk to delay surgery is about 20–50%. Moreover, HbA1c count has some limitations and cannot be safe for elderly and frail patients. Diabetes itself does not exclude patients from accessing to fast-track surgery. The orthopedic surgeon should check Hb1Ac before surgery in all patients at risk for DM and affected by DM and consider delaying surgery if the cutoff of Hb1Ac <7% is safe and realistic (Kallio et al., Anesth Pain Med 5:e24376, 2015). On the contrary, the cutoff accepted can be 8% but one must prepare for more strict glycemic control in the perioperative period. These patients are not candidates for fast-track surgery.