The Impact of Diabetes on Patient Outcomes After Total Knee Arthroplasty in an Asian Population

Do Overall Weight, Body Mass Index, or Clinically Meaningful Weight Changes Occur After Total Joint Arthroplasty? A Meta-Analysis of 60,837 Patients

BACKGROUND

Total joint arthroplasty (TJA) is well-recognized for improving quality of life and functional outcomes of patients with osteoarthritis; however, TJA's impact on body weight remains unclear. Recent trends have demonstrated a shift among TJA patients, such that patients who have higher body mass indices (BMIs) are undergoing this common surgery. Given this trend, it is critical to characterize the impact TJA has on body weight or BMI. This meta-analysis aimed to quantitatively assess whether patients lose, gain, or maintain body weight or BMI after TJA.

METHODS

This study followed the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Ovid MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials databases were queried from inception through July 2022. The included studies: (1) reported on weight or BMI after elective, primary total hip arthroplasty (THA) or total knee arthroplasty (TKA); and (2) weight or BMI change was deemed to be associated with THA or TKA. The excluded studies: (1) included weight or BMI interventions; and (2) reported on unicompartmental, partial, or revision arthroplasty or joint arthroscopy. Meta-analyses for weight change, BMI change, and proportion of patients achieving clinically significant change were performed using random-effects models. Factors associated with clinically significant change were systematically reported. A total of 60,837 patients from 39 studies were included.

RESULTS

No significant differences existed between preoperative and postoperative weights (P = 1.0; P = 0.28) or BMIs (P = 1.0; P = 1.0) after THA or TKA, respectively. Overall, 66% of THA patients (P < 0.01) and 65% of TKA patients (P < 0.01) did not experience clinically significant weight change.

CONCLUSIONS

Among a TJA cohort, two-thirds of the patients maintained their preoperative body weight or BMI after surgery. With these results, orthopaedic surgeons can better manage patient expectations of TJA.

The impact of diabetes on physical and mental health status and patient satisfaction after total hip and knee arthroplasty

OBJECTIVE

To assess the impact of diabetes on physical and mental health status, as well as patient satisfaction, one-year following knee and hip total joint arthroplasty (TJA) for osteoarthritis (OA).

METHODS

Participants were 626 hip and 754 knee TJA patients. Pre-surgery data were collected on socio-demographics and health status. The 12-item Short Form Health Survey (SF-12) was collected pre- and one year post-surgery, and physical (PCS) and mental component (MCS) summary scores computed. One-year patient satisfaction was also recorded. Four regression models tested the effect of diabetes on: 1) PCS change score; 2) MCS change score; 3) achieving minimal clinically important improvement (MCII) on PCS; and 4) patient satisfaction ('Somewhat or Very Satisfied' vs. 'Somewhat or Very Dissatisfied'). An interaction between surgical joint and diabetes was tested in each model.

RESULTS

Self-reported diabetes prevalence was 13.0% (95% CI: 11.2%-14.7%) and was more common in knee 16.1% (95% CI: 13.4%-18.7%) than hip 9.3% (95% CI: 7.0%-11.5%) patients. In adjusted analyses, change scores were 2.3 units less on the PCS for those with diabetes compared to those without (p = 0.005). Patients with diabetes were about half as likely to achieve MCII as patients without diabetes (p = 0.004). Diabetes was not significantly associated with satisfaction or changes in MCS scores. Diabetes effects did not differ by surgical joint.

CONCLUSIONS

Findings support that diabetes has a negative impact on improvements in physical health after TJA. Considering the growing prevalence of OA and diabetes in the population, our findings support the importance of perioperative screening and management of diabetes in patients undergoing TJA.

American Academy of Orthopaedic Surgeons Clinical Practice Guideline Summary of Surgical Management of Osteoarthritis of the Knee

The Surgical Management of Osteoarthritis of the Knee Evidence-Based Clinical Practice Guideline is based on a systematic review of published studies for surgical management of osteoarthritis of the knee in skeletally mature patients. This guideline contains 16 recommendations and seven options to assist orthopaedic surgeons and all qualified physicians with the surgical management of patients with osteoarthritis of the knee based on the best current available evidence. It is also intended to serve as an information resource for professional healthcare practitioners and developers of practice guidelines and recommendations. In addition to providing pragmatic practice recommendations, this guideline also highlights gaps in the literature and informs areas for future research and quality measure development.

Identification of Metabolic Factors and Inflammatory Markers Predictive of Outcome after Total Knee Arthroplasty in Patients with Knee Osteoarthritis: A Systematic Review

OBJECTIVE

To identify metabolic factors and inflammatory markers that are predictive of postoperative total knee arthroplasty (TKA) outcome.

METHOD

A systematic search of the existing literature was performed using the electronic databases PubMed, Web of Science and Embase until the 1^st of August 2022. Studies that evaluated the influence of metabolic or inflammatory markers (I) on postsurgical outcome (O) in end-stage knee osteoarthritis patients awaiting primary TKA (P) were included in this review.

RESULTS

In total, 49 studies were included. Risk of bias of the included studies was low for one study, moderate for 10 studies and high for the remaining 38 studies. Conflicting evidence was found for the influence of body mass index, diabetes, cytokine levels and dyslipidaemia on pain, function, satisfaction and quality of life at more than six months after TKA.

CONCLUSIONS

Several limitations such as not taking into account known confounding factors, the use of many different outcome measures and a widely varying follow-up period made it challenging to draw firm conclusions and clinical implications. Therefore large-scaled longitudinal studies assessing the predictive value of metabolic and inflammatory factors pre-surgery in addition to the already evidenced risk factors with follow-up of one year after TKA are warranted.

Do Patients With Diabetes Have Poorer Improvements in Patient-Reported Outcomes After Total Knee Arthroplasty?

BACKGROUND

Diabetes is one of the most common comorbidities in patients undergoing total knee arthroplasty (TKA) for osteoarthritis. However, the evidence remains unclear on how it affects patient-reported outcome measures after TKA.

METHODS

We reviewed prospectively collected data of 2840 patients who underwent primary unilateral TKA between 2008 and 2018, of which 716 (25.2%) had diabetes. All patients had their HbA1c measured within 1 month before surgery, and only well-controlled diabetics (HbA1c <8.0%) were allowed to proceed with surgery. Patient demographics and comorbidities were recorded, and multiple regression was performed to evaluate the impact of diabetes on improvements in patient-reported outcome measures (Short Form 36 (SF-36), Western Ontario and McMaster University Osteoarthritis Index (WOMAC), Knee Society Score (KSS)) and knee range of motion (ROM).

RESULTS

Compared with nondiabetics, patients with diabetes were more likely to possess a higher body mass index (P-value <.001), more comorbidities (P-value <.001), and poorer preoperative SF-36 Physical Component Summary (PCS) (P-value <.001), WOMAC (P-value = .002), KSS-function (P-value <.001), and knee ROM (P-value <.001). Multiple regression showed that diabetic patients experienced marginally poorer improvements in KSS-knee (-1.22 points, P-value = .025) and knee ROM (-1.67°, P-value = .013) than nondiabetics. However, there were no significant differences in improvements for SF-36 PCS (P-value = .163), Mental Component Summary (P-value = .954), WOMAC (P-value = .815), and KSS-function (P-value = .866).

CONCLUSION

Patients with well-controlled diabetes (HbA1c <8.0%) can expect similar improvements in general health and osteoarthritis outcomes (SF-36 PCS and Mental Component Summary, WOMAC, and KSS-function) compared with nondiabetics after TKA. Despite having marginally poorer improvements in knee-specific outcomes (KSS-knee and knee ROM), these differences are unlikely to be clinically significant.

Diabetes Mellitus Blunts the Symptoms, Physical Function, and Health-Related Quality of Life Benefits of Total Knee Arthroplasty: A Systematic Review With Meta-analysis of Data From More Than 17 000 Patients

OBJECTIVE

To compare physical function, pain, impairments (stiffness, range of motion, and strength), and health-related quality of life (HRQoL) outcomes between patients with and without diabetes mellitus, before and after a total knee arthroplasty (TKA).

DESIGN

Prognosis systematic review.

LITERATURE SEARCH

We searched MEDLINE/PubMed, CINAHL, SPORTDiscus, and Web of Science to August 2019.

STUDY SELECTION CRITERIA

We included longitudinal studies that examined physical function, pain, impairments, and HRQoL outcomes among patients receiving a TKA and with or without diabetes.

DATA SYNTHESIS

For quantitative synthesis, we stratified outcomes based on time relative to TKA: preoperative, less than 1 year after a TKA (early postoperative), and 1 year or more after a TKA (late postoperative). We used random-effects meta-analysis to calculate standardized mean differences (SMDs) and 95% confidence intervals (CIs). We used the Grading of Recommendations Assessment, Development and Evaluation system for qualitative synthesis.

RESULTS

We included 21 studies (n = 17 472 patients). Patients with diabetes mellitus had worse preoperative physical function (SMD, -0.16; 95% CI: -0.24, -0.08) and HRQoL (SMD, -0.16; 95% CI: -0.26, -0.05), worse early postoperative pain (SMD, -0.22; 95% CI: -0.39, -0.05) and strength (SMD, -0.45; 95% CI: -0.77, -0.14), and worse late postoperative physical function (SMD, -0.23; 95% CI: -0.40, -0.06), range of motion (SMD, -0.23; 95% CI: -0.46, 0.00), and HRQoL (SMD, -0.19; 95% CI: -0.29, -0.08) than patients without diabetes mellitus. The overall risk of bias across studies was high, and the certainty of evidence ranged from low to very low.

CONCLUSION

Patients with diabetes mellitus had worse patient-reported and clinician-assessed outcomes before and after a TKA. Given the limitations of included studies, these results may change with future research. J Orthop Sports Phys Ther 2021;51(6):269-280. Epub 19 Apr 2021. doi:10.2519/jospt.2021.9515.

Perfil epidemiológico e clínico dos pacientes submetidos a artroplastia total do joelho

Objective  To define the epidemiological profile and the associated comorbidities of patients submitted to total knee arthroplasty (TKA) in two reference hospitals.

Materials and Methods  During the present cross-sectional observational study, 294 patients submitted to TKA were evaluated in 2 tertiary care hospitals. The diagnosis of self-reported comorbidities was collected by direct interview. The Functional Comorbidity Index (FCI) and the 5-Factor Modified Frailty Index (mFI-5) were calculated. The incidence of comorbidities and their relationship with the calculated indexes were evaluated.

Results  Most of the patients in the sample were women ( p  = 0.000) between the seventh and eighth decades of life. Systemic arterial hypertension was the most common pathology, followed by obesity and diabetes mellitus. The FCI presented a direct relationship with females ( p  = 0.038) and obesity ( p  < 0.001). The mFI-5 was only associated to obesity ( p  = 0.022), demonstrating a higher chance of complications in this group.

Conclusion  Patients undergoing TKA are essentially carriers of clinical comorbidities that can negatively influence functional results and compromise the safety of the procedure. The identification of risk factors can contribute to the safety and better selection of TKA candidates.

The Influence of Diabetes Mellitus on Patients Undergoing Primary Total Lower Extremity Arthroplasty: A Systematic Review and Meta-Analysis

Background

Diabetes mellitus (DM) is a common disease that has an adverse impact on most orthopedic surgeries, and its prevalence has gradually increased in recent years. We aim to investigate the influence of DM on comorbidities and complications of patients undergoing primary total lower extremity arthroplasty.

Methods

PubMed, Embase, Cochrane Library, Medline, and Web of Science were systematically searched for relevant studies published before December 2019. Demographic data, comorbidities, and postoperative complications after primary total hip arthroplasties (THA) or primary total knee arthroplasties (TKA) were assessed between DM and non-DM patients. Meta-analysis was conducted using Review Manager 5.3, and forest plots were drawn for each variable.

Results

A total of 1,560,461 patients (215,916 patients with DM and 1,344,545 patients without DM) from 23 studies were included in this meta-analysis. The incidences of several preoperative comorbidities (hypertension (HTN), kidney disease, cardiac and cerebrovascular disease) were generally higher in patients with DM. Moreover, DM patients had a higher rate of postoperative complications (superficial and deep infection, deep vein thrombosis (DVT), and in-hospital mortality) compared to non-DM patients.

Conclusions

DM patients were more likely to suffer from comorbidities and had a higher risk of complications in total lower extremity arthroplasty compared to non-DM patients. It is necessary to identify DM and control hyperglycemia in the perioperative period to prevent postoperative complications in patients with DM.

Predictive value of common serum glycaemic markers on periprosthetic joint infection following Total Joint Arthroplasty: A review of the literature

It is well established that diabetes mellitus and osteoarthritis commonly exist together and among various treatment modalities for osteoarthritis, Total Joint Arthroplasty (TJA) has been effective. Prosthetic Joint Infection (PJI) is a serious complication of TJA with high costs and morbidity associated with it. The aim of this study is to provide background information and relevance of diabetes on PJI, and to conduct a review on existing literature, to find out if common serum glycaemic markers in diabetes could be used as predictors for PJI after TJA. These markers include measuring pre-operative glucose levels with glycated haemoglobin (HbA1c) or capillary blood glucose, peri-operative or post-operative blood glucose levels. We have found that existing literature studying these markers as predictors of PJI after TJA has been largely contentious. Despite not being used widely in clinical practice, serum fructosamine has been shown to be more reliable and accurate than the above-mentioned markers. Future studies should be carried out to confirm and better understand this association.

Tobacco Smoking Independently Predicts Lower Patient-Reported Outcomes: New Insights on a Forgotten Epidemic

BACKGROUND

Although smoking is a well-accepted risk factor for surgical complications, the effect of smoking on patient-reported outcomes (PROs) has not been previously investigated. Prompted by an increasingly value-conscious healthcare environment, the purpose of this study is to investigate the association between smoking and PROs in total joint arthroplasty (TJA).

METHODS

A retrospective review of 713 primary total hip and knee replacements was performed. Two cohorts were compared: (1) current smokers and (2) previous/never smokers at the time of TJA. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and the Short Form-12 Physical Composite Summary (SF-12 PCS) and Short Form-12 Mental Composite Summary were assessed preoperatively and again at 6 and 12 months postoperatively. The primary outcomes were the net changes and absolute outcome scores at final follow-up. Postoperative patient satisfaction was also assessed as a secondary outcome. Linear mixed-effects regression analysis was performed.

RESULTS

There were significant demographic and preoperative health disparities as measured by PROs among smokers. After adjusting for baseline differences, smokers achieved significantly lower improvements in WOMAC (P = .002) and SF-12 PCS (P = .03) compared to nonsmokers. For each unit increase in packs per day smoked, the WOMAC scores increased (worsened) by 7.7 points (P = .003) and SF-12 PCS decreased by 4.8 points (P = .001). At final follow up, nonsmokers had significantly better absolute scores for all outcomes (except for mental health) and were more likely to be satisfied with surgery (89% vs 82%, P = .052).

CONCLUSION

Tobacco smoking is an independent predictor for lower PROs after TJA and this relationship is dose-dependent. The negative impact of smoking does not appear to be related to impaired psychological health. As we transition to value-based care delivery models, this study provides further evidence that smoking cessation should be strongly recommended as a modifiable risk factor before embarking on elective TJA. Studies are still needed to define the optimal window for smoking cessation.