Should Insulin-dependent Diabetic Patients be Screened for Malnutrition Before Total Joint Arthroplasty?

A Cohort at Risk

Andrew M. Schneider, MD; Nicholas M. Brown, MD


J Am Acad Orthop Surg. 2021;29(15):673-680. 

In This Article

Abstract and Introduction


Introduction: The association of malnutrition in the morbidly obese cohort has led to recommendations for preoperative screening before total joint arthroplasty (TJA). However, despite the connection between diabetes and poor nutrition, preoperative screening in the diabetic cohort has not been closely examined. This study compared malnutrition risk between diabetic patients and morbidly obese patients undergoing TJA and investigated the association of malnutrition on 30-day postoperative TJA outcomes in the diabetic cohort.

Methods: The National Surgical Quality Improvement Program database was queried, and primary TJA patients were identified for inclusion. Patients were stratified by body mass index and diabetes, and outcomes were reported as two composite groups: complications and infections in the 30-day postoperative period. Univariate and multivariate regressions were used for the analysis.

Results: Patients with insulin-dependent diabetes mellitus (IDDM) were at a high risk of being malnourished in both the morbidly obese and nonmorbidly obese populations (frequencies of 11.9% and 9.9%, respectively). Patients with IDDM, but without morbid obesity, were 1.5x more often malnourished than morbidly obese patients without diabetes mellitus (9.9% versus 6.4%, respectively, P < 0.001). In a multivariate analysis among patients with co-occurring diabetes and malnutrition, patients with IDDM were at greatest risk for postoperative complications and infection (odds ratio 2.081 [1.652, 2.621]; P < 0.001 and odds ratio 1.894 [1.231, 2.913]; P = 0.004, respectively).

Discussion: Patients with IDDM are at high risk for malnutrition, and increased vigilance should be maintained in this cohort before TJA to optimize outcomes. Future studies should further investigate the utility of preoperative malnutrition screening in this cohort.


The number of patients with diabetes mellitus (DM) in the United States is expected to double over the next 20 years, totaling 44 million people, and evidence exists that increasing numbers of patients with DM are undergoing total joint arthroplasty (TJA).[1] Diabetes has been associated with an increased risk of complications after TJA, and recent reports have demonstrated that insulin-dependent diabetic patients are at particularly high risk of adverse outcomes.[1–5]

Similar to DM, malnutrition has also been implicated as an independent risk factor for complications after TJA.[6–9] Preivous reports have shown that patients with an albumin <3.5 mg/dL, often used as a surrogate for malnourishment, had a seven times greater risk of major wound complication as compared to those with a normal albumin.[10] Paradoxically, morbid obesity (body mass index [BMI] ≥ 40 kg/m2) and malnutrition are frequently co-occurring conditions, thought to be a product of a high caloric but nutritionally poor diet.[11] Because of this correlation, preoperative serum albumin screening before TJA has been advocated for morbidly obese patients so that nutritional intake can be optimized before surgical intervention.[12] The American Association of Hip and Knee Surgeons evidence-based committee found sufficient data to support delaying TJA in morbidly obese patients with concomitant malnutrition because of the notably increased complication risk.[13] However, although the association of malnutrition in the morbidly obese is well established, less clarity exists in the diabetic cohort despite the inextricable linkage between diabetes and poor nutrition.[14–17] At present, there remains a paucity of data on the frequency of malnutrition in the diabetic cohort undergoing TJA, and the postoperative complication risk in patients with co-occurring diabetes and malnutrition is not well described.[18,19] Hence, recommendations regarding preoperative malnutrition screening in this cohort are lacking.

Using a large nationwide sample, we compared the risk of malnutrition between diabetics and morbidly obese patients undergoing TJA. Furthermore, we investigated the association of malnutrition on postoperative TJA complication risk in the diabetic cohort. We hypothesized that insulin-dependent diabetic patients would have a similar risk of malnutrition as morbidly obese patients, and malnourished diabetic patients undergoing TJA would be at notable risk for postoperative complications.