Outcomes of fracture surgery in patients with escalating hemoglobin A1C in the setting of unmanaged diabetes

Abstract

Objective: To determine whether there is a threshold of elevated hemoglobin A1C (HbA1c) above which the complication risk is so high that fracture fixation should be avoided. Design: Retrospective cohort study. Setting: Academic Level I trauma center. Patients/Participants: A cohort of 187 patients with HbA1c values >7 and operatively treated extremity fractures. Intervention: Surgical fixation of extremity fractures. Main Outcome Measurements: Rate of major orthopaedic complication (loss of reduction, nonunion, infection, and need for salvage procedure). Results: 34.8% demonstrated HbA1c > 9% and 12.3% with HbA1c > 11. Major complications occurred in 31.4%; HbA1c values were not predictive. We found no evidence of a clinically or statistically significant relationship between HbA1c and risk of major complication. The odds ratio for a one-point increase in HbA1c was 1.006 (P = 0.9439), and the area under the receiver operating characteristic curve, which reflects the average probability that someone with a major complication will have a higher HbA1c than someone without, was 0.51 (95% confidence interval 0.42–0.61), equivalent to random chance. Conclusion: Diabetic patients with fracture demonstrated an extremely high overall rate of complications, with 30.5% experiencing a major complication. However, patients with extreme diabetic neglect did not have higher complication rates after extremity fracture fixation when compared with patients with controlled and uncontrolled diabetes. There was no correlation between rate of complication and level of HbA1c. In addition, there was no difference in complication rate between upper and lower extremity fractures or between fractures treated with open or percutaneous fixation. This suggests that fracture treatment decision-making should not be altered for patients with poor diabetic control, and that surgery is not contraindicated in patients with an extremely high HbA1c. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.