HbA1c Levels >6.6% Linked to Greater Risk of Repeat Surgery After ACL Reconstruction
Key findings
- This study examined associations between preoperative hemoglobin A1c (HbA1c) levels in 19 patients with diabetes and postoperative complications of arthroscopic anterior crucial ligament (ACL) reconstruction
- No patient developed a postoperative medical complication, but one required arthroscopic irrigation and debridement for a septic knee, and three required arthroscopic lysis for arthrofibrosis
- On univariate analysis, HbA1c ≥6.7% was linked to a 25-fold greater risk of developing a complication requiring repeat surgical intervention, and the risk remained significantly higher when adjusted for age, sex, graft type, and diabetes subtype
- On multivariable analysis, HbA1c ≥6.7% was independently associated with a 66% increased risk of experiencing any postoperative complication and a 45% increased risk of localized anterior arthrofibrosis requiring surgical lysis
- When a patient with diabetes is scheduled for elective ACL reconstruction, the surgeon should consider counseling them about preoperative optimization of HbA1c to <6.7% if necessary
Diabetes is known to increase the risk of infection and arthrofibrosis after anterior cruciate ligament (ACL) reconstruction. Now, researchers at Massachusetts General Hospital have determined patients with a diagnosis of diabetes and hemoglobin A1c (HbA1c) levels ≥6.7% are at greater risk of reoperation for surgical complications.
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The study by Ophelie Lavoie-Gagne, MD, a clinical fellow in the Department of Orthopaedic Surgery, Miho J. Tanaka, MD, PhD, sports medicine orthopedic surgeon and co-director of the Mass General Brigham Women's Sports Medicine Program, and colleagues is reported in Arthroscopy, Sports Medicine, and Rehabilitation.
Methods
The team identified 19 patients who underwent elective arthroscopic ACL reconstruction at Mass General between 2000 and 2019, had a preoperative diagnosis of diabetes, and had HbA1c measured at least once within 90 days before the procedure. Their records were evaluated for 90-day medical complications, including infection and subsequent surgery on the ipsilateral knee related to ACL reconstruction.
Characteristics of the Cohort
The 12 male and seven female patients had a median age of 45 (range, 15–60). Four were former smokers, and none were actively smoking at the time of surgery. The minimum follow-up ranged from 13 months to 20 years.
The median preoperative HbA1c was 6.6% (range, 5.5%–10%). The value was <6.7% in 11 patients and ≥6.7% in eight.
Incidence of Complications
No patient experienced a postoperative medical complication. Four experienced a surgical complication:
- One patient developed a septic knee three days postoperatively and required arthroscopic irrigation and debridement
- Three patients developed localized anterior arthrofibrosis with progressive loss of full extension requiring arthroscopic lysis
Complications and HbA1c
On univariate analysis, HbA1c level was associated with 25-fold greater odds of developing any postoperative complication requiring repeat surgery (P=0.04) and nonsignificant 15.9-fold greater odds of developing arthrofibrosis (P=0.08). The risk of any reoperation remained statistically significant even when accounting for age, sex, graft type, and diabetes subtype.
Multivariable analysis showed HbA1c ≥6.7% was independently associated with a greater likelihood of experiencing:
- Any postoperative complication—OR, 1.66 (P=0.007)
- Localized anterior arthrofibrosis requiring surgical lysis—OR, 1.45 (P=0.020)
Preoperative Optimization
The American Diabetes Association and the American College of Physicians recommend HbA1c goals between 7% and 8% for long-term diabetes management. For patients scheduled for elective ACL reconstruction, though, orthopedic surgeons should consider preoperative optimization of HbA1c to <6.7% if necessary.
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