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


Of the 203,277 patients included in our TJA analysis, 78,656 patients (38.7%) underwent total hip arthroplasty and 124,621 patients (61.3%) underwent TKA. The average age of the cohort was 66.0 years, with a standard deviation of 10.4 years.

Patients with 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). In addition, patients with IDDM, but without morbid obesity, were 1.5x more often malnourished than morbidly obese patients without DM, a cohort that is routinely screened for malnutrition before TJA (9.9% versus 6.4%, respectively, P < 0.001). A frequency summary of malnutrition among the diabetic subgroups with and without morbid obesity can be found in Figure 2.

Figure 2.

The bar graph demonstrates the relative frequency of malnutrition (serum albumin level <3.5 mg/dL) among the diabetic subgroups with and without morbid obesity. BMI = body mass index, DM = diabetes mellitus, IDDM = insulin-dependent diabetes mellitus, NIDDM = noninsulin-dependent diabetes mellitus

On univariate analysis (Table, Supplemental Digital Content 1,, men were more likely than women to have a postoperative infection. BMI ≥40, smoking, increasing ASA class, IDDM, and albumin <3.5 mg/dL were all statistically notable risk factors for both complications and infection. When grouping based on the co-occurring conditions of diabetes and malnutrition, the combination of IDDM and albumin <3.5 mg/dL represented the greatest risk for both complications and infection (P < 0.001).

On multivariate analysis (Table, Supplemental Digital Content 2,, increasing age, BMI ≥40, smoking, and ASA class 3 or 4 all had significantly increased OR for complication and infection (all P < 0.001). When grouping based on the co-occurring conditions of diabetes and malnutrition, all groups with albumin <3.5 mg/dL were at notably increased risk of complications and infection, regardless of diabetes status. Of the groups with albumin ≥3.5 mg/dL, only the comorbid condition of IDDM led to a statistically notbaly increased risk of complications. Of note, although the statistically notably increased OR's were similar, the most marked increases for risk of complications and infection occurred in the group with co-occurring IDDM and malnutrition (OR 2.081 [1.652, 2.621]; P < 0.001 and OR 1.894 [1.231, 2.913]; P = 0.004 for complications and infection, respectively).

Table, Supplemental Digital Content 3, shows the comparison of patients with recorded albumin levels to patients with missing albumin levels. In the cohort with missing albumin levels, fewer patients existed with high ASA scores and less smokers than in the cohort with recorded albumin. No clinically meaningful difference was noted in mean age or sex between the groups.