Elevated Preoperative Hemoglobin A1c Increases Complications in Diabetic Patients undergoing Carpal Tunnel Release
Rita E Baumgartner, MD1; Andrew E Federer, MD2; Daniel Cunningham, MD, MHSc1; Marc J Richard, MD3; Suhail K. Mithani, MD4; (1)Duke University, Durham, NC, (2)Duke University Health System, Durham, NC, (3)Department of Orthopaedic Surgery, DUKE UNIVERSITY, Durham, NC, (4)Plastics and Reconstructive Surgery, Duke University Medical Center, Durham, NC
Introduction: An increased rate of complications has been demonstrated with increasing hemoglobin A1c (HbA1c) for a variety of orthopaedic procedures, including arthroplasty and spine surgery. We investigated the effects of elevated HbA1c on postoperative complications at the time of carpal tunnel release (CTR).
Materials & Methods: This retrospective, cohort study evaluated all diabetic patients with a pre-operative HbA1c within 90 days of open CTR at a single academic institution within the past 10 years. Exclusion criteria included hypothyroidism, rheumatoid arthritis, malignancy, HIV/AIDS, and systemic steroid use at the time of the procedure. One hundred thirty-five patients were included in the study. Incidence of superficial or deep infection, delayed wound healing, limited wrist range of motion (ROM) at 6 weeks, pain requiring medication at 6 weeks, and return to operating room (OR) were noted. In order to determine any potential binary HbA1c threshold associated with poor outcomes, patients were sequentially grouped based on HbA1c level in 0.1-unit increments to determine association with complication rate using Chi-square analysis. Relative risk ratios and 95% confidence intervals (CI) are also displayed.
Results: In this study, 15 of the 135 patients experienced a complication (11%). Six patients (4%) experienced delayed wound healing, 5 patients (4%) developed a superficial infection, 3 patients (2%) had persistent pain requiring medication after 6 weeks, and 2 patients (1%) had limited wrist range of motion at 6 weeks. In this series, no patients developed deep infection or required return to OR. When evaluating the binary HbA1c thresholds, HbA1c greater than or equal to 7.8 was most strongly correlated with an increased risk of complications (p=0.004) at a relative risk ratio of 4.3 (95% CI 1.6 – 11.8). Ten of 43 patients (23.3%) with HbA1c greater than or equal to 7.8 had a complication compared with 5 of 92 patients (5.4%) with HbA1c less than 7.8.
Conclusion: Diabetic patients undergoing open CTR with a HbA1c greater than or equal to 7.8 had a higher rate of post-operative complications relative to diabetic patients with improved pre-operative glucose control. This study suggests that patients with diabetes and a HbA1c greater than or equal to 7.8 should be counseled that their risk of postoperative complication is higher. Further work is needed to determine if delaying surgery to optimize glucose control could result in a reduction of poor postoperative outcomes.
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