Abstract
Background
Diabetic patients are known to have poor wound healing and worse outcomes following surgeries. The purpose of this study is to evaluate diabetes status and complications for patients receiving open rotator cuff repair.
Methods
Patients undergoing open rotator cuff repair from 2006 to 2018 were identified in a national database. Patients were stratified into 3 cohorts: no diabetes mellitus, non-insulin dependent diabetes mellitus (NIDDM), and insulin dependent diabetes mellitus (IDDM). Differences in demographics, comorbidities, and complications were assessed with the use of bivariate and multivariate analyses.
Results
Of 7678 total patients undergoing open rotator cuff repair, 6256 patients (81.5%) had no diabetes, 975 (12.7%) had NIDDM, and 447 (5.8%) had IDDM. Bivariate analyses revealed that IDDM patients had increased risk of mortality, extended length of stay, and readmission compared to non-diabetic patients (p < 0.05 for all). IDDM patients had higher risks of major complications and readmission relative to NIDDM patients (p < 0.05 for both). On multivariate analysis, there were no differences in any postoperative complications between the non-diabetic, NIDDM, and IDDM groups.
Discussion
Diabetes does not affect postoperative complications following open rotator cuff repairs. Physicians should be aware of this finding and counsel their patients appropriately.
Level of Evidence: III
Keywords: open rotator cuff repair, diabetes mellitus, non-insulin dependent, insulin dependent, postoperative complications
Introduction
The number of rotator cuff repair procedures performed has increased steadily over the past 20 years. 1 Individuals with diabetes mellitus (DM) have been shown to have worse postoperative outcomes and more complications after a variety of surgical procedures.2–4 The impact of DM status on postoperative complication rates following open rotator cuff repair has not been fully elucidated.
Diabetic status and postoperative complications have been investigated for other orthopedic surgeries. In foot and ankle surgery, each one-percent increase in HbA1c increases the odds of infection by a factor of 1.59 and increases the odds of postoperative wound complications by a factor of 1.25. 5 In joint replacement surgery, hyperglycemia is believed to increase the risk of infections, impaired wound healing, cardiovascular events, venous thromboembolism, and mortality. 6 In primary total hip arthroplasty, an HbA1c level of 7.5 mg/dL or greater is associated with an increased risk of deep infection compared to patients below this threshold (OR: 2.6). 7
However, beyond examining differences between patients with diabetes and patients without diabetes, there are important distinctions with respect to the etiology and pathophysiology of the disease. insulin dependent diabetes mellitus (IDDM) and non-insulin-dependent diabetes mellitus (NIDDM) differ with respect to the average age, race, ethnicity, geography, and socioeconomic status of the populations they preferentially affect.8–11 They also differ with respect to genetic factors and environmental modifiers, including obesity.8–10
While short term complications following rotator cuff repair procedures are uncommon, they are more prevalent following open repairs than arthroscopic repairs (OR: 1.6). 12 Unplanned surgical interventions and deep wound infections are two of the most common complications following open rotator cuff repairs.12,13 Several risk factors for complications following open surgery have been identified, including smoking, which increases the risk of venous thromboembolic events and pulmonary embolism. 13 It has also been postulated that the indications for surgery are influential in determining postoperative outcomes: as arthroscopy continues to become more widely available and used, open surgery may yet yield better outcomes in cases of compromised bone and tendon tissue quality or massive tear size. 14
The purpose of this study was to investigate DM status and postoperative complications for patients receiving open rotator cuff repair. Based on previous reports of increased postoperative complications in patients with DM in other procedure types, it was hypothesized that patients with DM would have higher rates of postoperative complications following open rotator cuff repair. In addition, based on the pathophysiological differences between IDDM and NIDDM, it was hypothesized that there would be differences in postoperative complications between the two subcategories of patients with diabetes.
Materials and methods
A retrospective cohort study was performed with the utilization of data collected from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database for the years 2006 to 2018. The ACS-NSQIP is a national registry that includes de-identified patient-level data on surgical procedures from more than 700 participating institutions. Rigorous data collection by trained clinical reviewers has led to high inter-rater reliability when using this database.15,16 This database includes preoperative demographic and comorbidity information, perioperative events, and postoperative complications for patients undergoing orthopedic and non-orthopedic surgical procedures.17–19
Patient selection
Patients who underwent open rotator cuff repair were identified using Current Procedural Terminology codes 23,410 and 23,412. Patients were excluded from this study if they had missing baseline demographics data, including gender, race, or American Society of Anesthesiologists (ASA) class was unknown. Patients with disseminated cancer, wound infection, and sepsis on admission were also excluded from our study. Three subgroups were used to assess the impact of diabetes on complications following surgery: patients without diabetes mellitus (non-DM), patients with NIDDM, and patients with IDDM.
Patient characteristics
Data regarding patients’ baseline demographics and clinical characteristics included age, gender, race, body mass index (BMI), ASA class, smoking status, and functional status. Functional status focused on the patient's abilities to perform activities of daily living, including bathing, dressing, feeding, toileting, and mobility. Patients who were defined as having an independent functional status did not require assistance from another person for any activities of daily living. Dependent functional status was defined as those who required some assistance or total assistance for activities of daily living. Patient medical comorbidities and anesthesia type were identified.
Postoperative outcomes
The primary outcomes were the rate of complications and unplanned hospital readmission within 30 days of open rotator cuff repair. Based on the type of complication, thirty-day postoperative complications were classified into clinically relevant domains. These domains included wound (superficial surgical site infection, deep surgical site infection, organ or space infections, or wound disruption), cardiac (cardiac arrest or myocardial infarction), pulmonary (pneumonia, reintubation, or failure to wean off ventilator for more than 48 h), renal (renal failure or renal insufficiency), thromboembolic (deep vein thrombosis, pulmonary embolism, or stroke), and sepsis (sepsis or septic shock). Based on previous studies, major complications (cardiac arrest, pulmonary embolism, intubation, myocardial infarction, sepsis, septic shock, renal failure, deep surgical site infection or mortality) and minor complications (urinary tract infection, deep vein thrombosis, pneumonia, or superficial surgical site infection) were also categorized.20,21 In addition, postoperative transfusion requirement, postoperative admission, extended length of stay, reoperation and readmission were recorded. Based on the existing literature, postoperative admission was defined as at least one overnight stay in the hospital immediately after the surgery.22,23 Extended length of stay was defined as > 3 days, or one standard deviation above the mean length of stay for the patients in this study.
Statistical analysis
Statistical Package for the Social Sciences (SPSS; Version 26; Armonk, NY) software was used to conduct the statistical analyses in this study. Using bivariate analyses, data on patient demographics, comorbidities, and postoperative complications were analyzed using Pearson's Chi-squared test and analysis of variance where appropriate. Logistic regressions were performed for multivariate analyses to determine the risk factors that are independently associated with postoperative complications. Demographic and comorbidity variables that achieved significance at p < 0.20 were included in the multivariable logistic regression.24,25 Postoperative complication variables with a p-value <0.05 were selected for multivariate analyses. A p-value of < 0.05 was the cut-off value for statistical significance in this study.
Results
In total, 7678 patients who underwent open rotator cuff repair were included in the analysis after application of the exclusion criteria. There were 6256 patients (81.5%) in the non-DM group. Among the patients with diabetes, 975 (12.7%) were in the NIDDM group and 447 (5.8%) were in the IDDM group. Compared to patients without diabetes, patients with NIDDM were more likely to be older, female, non-Caucasian, have a higher BMI, and have an ASA class of III or IV (p < 0.05 for all). Similar demographics were seen when comparing patients with IDDM to patients without diabetes, except that patients with IDDM were more likely to have a dependent functional status (p < 0.01 for all). Compared to NIDDM patients, patients with IDDM were more likely to be younger (p = 0.014), Caucasian or Black (p = 0.022), have an ASA class of III or IV (p < 0.001), and have a dependent functional status (p = 0.036) (Table 1).
Table 1.
Demographics and clinical characteristics Among patients undergoing open rotator cuff repair.
| Demographics | No DM | NIDDM | IDDM | p-value: NIDDM vs No DM | p-value: IDDM vs No DM | p-value: IDDM vs NIDDM |
|---|---|---|---|---|---|---|
| Total patients, n | 6256 | 975 | 447 | |||
| Sex, n (%) | 0.029 a | 0.001 a | 0.149 a | |||
| Female | 2687 (43.0) | 455 (46.7) | 227 (50.8) | |||
| Male | 3569 (57.0) | 520 (53.3) | 220 (49.2) | |||
| Ethnicity, n (%) | < 0.001 a | < 0.001 a | 0.022 a | |||
| Caucasian | 5065 (81.0) | 715 (73.3) | 340 (76.1) | |||
| Black or African American | 394 (6.3) | 84 (8.6) | 49 (11.0) | |||
| Hispanic | 503 (8.0) | 111 (11.4) | 46 (10.3) | |||
| American Indian or Alaska Native | 78 (1.2) | 13 (1.3) | 5 (1.1) | |||
| Asian | 175 (2.8) | 41 (4.2) | 5 (1.1) | |||
| Native Hawaiian or Pacific Islander | 41 (0.7) | 11 (1.1) | 2 (0.4) | |||
| ASA, n (%) | < 0.001 a | < 0.001 a | < 0.001 a | |||
| I | 490 (7.8) | 2 (0.2) | 2 (0.4) | |||
| II | 3713 (59.4) | 335 (34.4) | 92 (20.6) | |||
| III | 1996 (31.9) | 611 (62.7) | 322 (72.0) | |||
| IV | 57 (0.9) | 27 (2.8) | 31 (6.9) | |||
| Smoker, n (%) | 1188 (19.0) | 163 (16.7) | 86 (19.2) | 0.090 a | 0.897 a | 0.245 a |
| Functional status, n (%) | 0.071 a | < 0.001 a | 0.036 a | |||
| Independent | 6138 (99.6) | 949 (99.1) | 429 (97.3) | |||
| Partially dependent | 26 (0.4) | 8 (0.8) | 10 (2.3) | |||
| Totally dependent | 1 (0.0) | 1 (0.1) | 2 (0.5) | |||
| Mean age, yrs (SD) | 59.09 (11.11) | 62.46 (9.82) | 61.08 (9.72) | < 0.001 b | < 0.001 b | 0.014 b |
| Mean BMI (SD) | 30.76 (6.72) | 34.26 (7.60) | 34.98 (7.51) | < 0.001 b | < 0.001 b | 0.097 b |
Pearson's chi-squared test.
Analysis of variance.
DM, diabetes mellitus; NIDDM, non-insulin dependent diabetes mellitus; IDDM, insulin dependent diabetes mellitus; ASA, American Society of Anesthesiologists; SD, standard deviation; BMI, body mass index.
Bolding indicates that the p-value is significant, which means that it is less than 0.05.
Relative to patients without diabetes, patients with NIDDM were more likely to have comorbidities, including chronic obstructive pulmonary disease (COPD) (p < 0.001), hypertension (p < 0.001), renal failure (p < 0.001), and dyspnea (p = 0.010). Similar comorbidity findings were seen between non-diabetic and patients with IDDM, except that patients with IDDM were more likely to have congestive heart failure (CHF), dialysis, and bleeding disorders (p < 0.001 for all). Compared to patients with NIDDM, patients with IDDM were more likely to have COPD (p = 0.006), CHF (p = 0.006), dialysis (p = 0.019), bleeding disorders (p = 0.018), and dyspnea (p = 0.004) (Table 2).
Table 2.
Comorbidities and intraoperative variables Among patients undergoing open rotator cuff repair.
| Comorbidities | No DM | NIDDM | IDDM | p-value: NIDDM vs No DM a | p-value: IDDM vs No DM a | p-value: IDDM vs NIDDM a |
|---|---|---|---|---|---|---|
| Total patients, n | 6256 | 975 | 447 | |||
| COPD, n (%) | 251 (4.0) | 65 (6.7) | 49 (11.0) | < 0.001 | < 0.001 | 0.006 |
| CHF, n (%) | 2 (0.0) | 1 (0.1) | 5 (1.1) | 0.314 | < 0.001 | 0.006 |
| Hypertension, n (%) | 2878 (46.0) | 795 (81.5) | 377 (84.3) | < 0.001 | < 0.001 | 0.198 |
| Dialysis, n (%) | 6 (0.1) | 1 (0.1) | 4 (0.9) | 0.950 | < 0.001 | 0.019 |
| Renal failure, n (%) | 0 (0.0) | 2 (0.2) | 1 (0.2) | < 0.001 | < 0.001 | 0.943 |
| Steroid use, n (%) | 131 (2.1) | 14 (1.4) | 6 (1.3) | 0.173 | 0.278 | 0.889 |
| Bleeding disorder, n (%) | 106 (1.7) | 20 (2.1) | 19 (4.3) | 0.428 | < 0.001 | 0.018 |
| Dyspnea, n (%) | 0.010 | < 0.001 | 0.004 | |||
| No dyspnea | 5945 (95.0) | 906 (92.9) | 393 (87.9) | |||
| Moderate exertion | 285 (4.6) | 66 (6.8) | 49 (11.0) | |||
| At rest | 26 (0.4) | 3 (0.3) | 5 (1.1) | |||
| Anesthesia type, n (%) | 0.622 | 0.832 | 0.663 | |||
| General | 5980 (95.7) | 937 (96.2) | 433 (96.9) | |||
| Neuraxial | 7 (0.1) | 0 (0.0) | 0 (0.0) | |||
| Regional | 197 (3.2) | 32 (3.3) | 11 (2.5) | |||
| MAC | 52 (0.8) | 4 (0.4) | 3 (0.7) |
Pearson's chi-squared test.
DM, diabetes mellitus; NIDDM, non-insulin dependent diabetes mellitus; IDDM, insulin dependent diabetes mellitus; COPD, chronic obstructive pulmonary disease; CHF, congestive heart failure; MAC, monitored anesthetic care.
Bolding indicates that the p-value is significant, which means that it is less than 0.05.
On bivariate analysis, patients with NIDDM had no significant difference in developing postoperative complications compared to non-diabetic patients (p > 0.05 for all). Compared to patients without diabetes, patients with IDDM were at increased risk of mortality (p = 0.014), extended length of stay (p = 0.014), and readmission (p = 0.005). Relative to patients with NIDDM, patients with IDDM were at increased risk of major complications (p = 0.019) and readmission (p = 0.025) (Table 3). Following adjustment for covariates on multivariate analyses, there were no differences in any postoperative complications between the non-diabetic, NIDDM, and IDDM groups (p > 0.05 for all) (Table 4).
Table 3.
Bivariate analysis of postoperative complications of patients following open rotator cuff repair.
| Complications | No DM | NIDDM | p-value: NIDDM vs No DM a | IDDM | p-value: IDDM vs No DM a | p-value: IDDM vs NIDDM a |
|---|---|---|---|---|---|---|
| Total patients, n | 6256 | 975 | 447 | |||
| Any complication, n (%) | 93 (1.5) | 12 (1.2) | 0.535 | 11 (2.5) | 0.107 | 0.088 |
| Major complication, n (%) b | 22 (0.4) | 1 (0.1) | 0.199 | 4 (0.9) | 0.074 | 0.019 |
| Minor complication, n (%) c | 62 (1.0) | 10 (1.0) | 0.919 | 7 (1.6) | 0.245 | 0.384 |
| Death, n (%) | 1 (0.0) | 0 (0.0) | 0.693 | 1 (0.2) | 0.014 | 0.140 |
| Wound complication, n (%) | 34 (0.5) | 5 (0.5) | 0.903 | 5 (1.1) | 0.122 | 0.204 |
| Cardiac complication, n (%) | 4 (0.1) | 1 (0.1) | 0.670 | 1 (0.2) | 0.232 | 0.571 |
| Pulmonary complication, n (%) | 10 (0.2) | 3 (0.3) | 0.311 | 2 (0.4) | 0.165 | 0.679 |
| Renal complication, n (%) | 0 (0.0) | 0 (0.0) | - | 0 (0.0) | - | - |
| Thromboembolic complication, n (%) | 21 (0.3) | 1 (0.1) | 0.219 | 2 (0.4) | 0.696 | 0.188 |
| Sepsis complication, n (%) | 1 (0.0) | 0 (0.0) | 0.693 | 0 (0.0) | 0.789 | - |
| Urinary tract infection, n (%) | 19 (0.3) | 2 (0.2) | 0.595 | 1 (0.2) | 0.765 | 0.943 |
| Postoperative transfusion, n (%) | 6 (0.1) | 1 (0.1) | 0.950 | 0 (0.0) | 0.512 | 0.498 |
| Postoperative admission, n (%) | 1441 (23.0) | 234 (24.0) | 0.506 | 114 (25.5) | 0.232 | 0.540 |
| Extended length of stay, n (%) | 62 (1.0) | 12 (1.2) | 0.489 | 10 (2.2) | 0.014 | 0.153 |
| Reoperation, n (%) | 40 (0.6) | 9 (0.9) | 0.315 | 6 (1.3) | 0.082 | 0.473 |
| Readmission, n (%) | 78 (1.8) | 12 (1.7) | 0.864 | 13 (4.0) | 0.005 | 0.025 |
Pearson's chi-squared test.
Includes cardiac arrest, pulmonary embolism, myocardial infarction, unplanned intubation, sepsis, septic shock, acute renal failure, or mortality.
Includes urinary tract infection, pneumonia, deep venous thrombosis, superficial surgical site infection, or deep surgical site infection.
DM, diabetes mellitus; NIDDM, non-insulin dependent diabetes mellitus; IDDM, insulin dependent diabetes mellitus.
Bolding indicates that the p-value is significant, which means that it is less than 0.05.
Table 4.
Multivariate analysis of postoperative complications of patients following open rotator cuff repair.
| Complications | NIDDM | IDDM | IDDM | |||
|---|---|---|---|---|---|---|
| p-value | Odds ratio (NIDDM/No DM) (95% CI) | p-value | Odds ratio (IDDM/No DM) (95% CI) | p-value | Odds ratio (IDDM/NIDDM) (95% CI) | |
| Major complication a | 0.216 | 0.275 (0.036 to 2.121) | 0.140 | 2.415 (0.749 to 7.791) | 0.177 | 4.983 (0.484 to 51.254) |
| Death | 0.263 | 0.921 (0.799 to 1.063) | 0.185 | 6.618 (0.404 to 108.417) | 0.500 | 1.099 (0.835 to 1.446) |
| Extended length of stay | 0.861 | 0.942 (0.482 to 1.840) | 0.297 | 1.493 (0.703 to 3.172) | 0.335 | 1.553 (0.635 to 3.802) |
| Readmission | 0.527 | 0.811 (0.423 to 1.553) | 0.303 | 1.445 (0.717 to 2.914) | 0.110 | 2.014 (0.853 to 4.754) |
Includes cardiac arrest, pulmonary embolism, myocardial infarction, unplanned intubation, sepsis, septic shock, acute renal failure, or mortality.
DM, diabetes mellitus; NIDDM, non-insulin dependent diabetes mellitus; IDDM, insulin dependent diabetes mellitus; CI, confidence interval.
Discussion
Multivariate analyses demonstrated no significant differences in postoperative complication rates between the three groups. This is contrary to both hypotheses of this study: there was no increase in complication rates in patients with IDDM or patients with NIDDM compared to patients without diabetes, and there was no difference in complication rates between patients with IDDM and patients with NIDDM. However, the analyses show statistically insignificant trends towards increased rates of major complications and death in the IDDM group compared to the non-diabetic group and increased rates of major complications and readmission in the IDDM group compared to the NIDDM group.
Major complications included cardiac arrest, pulmonary embolism, myocardial infarction, unplanned intubation, sepsis, septic shock, acute renal failure, or mortality. The trend towards an increase in these complications in patients with IDDM is likely due to the metabolic consequences of the disease, which have been quantified.26–32 The trend towards increased readmission rates in the IDDM group compared to the NIDDM group could be, at least in part, due to acute episodes of diabetic ketoacidosis, a common cause of hospital readmissions in patients with IDDM. 33 There is also evidence that postpartum women with pregnancies complicated by pregestational IDDM are at increased risk of readmission in the 60 days following childbirth, potentially due to increases in hypertensive diseases of pregnancy. 34
This study has several limitations. One limitation is that we did not compare A1C levels for diabetic patients and were unable to investigate if poorly controlled DM patients did worse. 35 In addition, there were several potentially confounding demographic and comorbidities variable between the patients with NIDDM and IDDM. Given that diabetes is associated with many disparate medical conditions, we are unable to conclude if diabetic status alone contributes to postoperative complications even when adjusting for these confounders. This is because diabetes is a systemic disease that affects all organ systems. Another limitation is that while we did not find associations between diabetes and postoperative complications for open rotator cuff repair within our 30-day postoperative window, they could have experienced complications at a later time point. Future studies should examine complications of diabetic patients following open rotator cuff repair beyond the 30-day follow-up period. We were also unable to confirm if patients were at increased risk of rotator cuff retears, which has been reported with Yang et al.'s meta-analysis in 2020. 36
Future work could investigate additional subsets of patients with DM.37–40 Bloomgarden and Drexler established four subcategories of DM: severe insulin deficiency diabetes, severe insulin resistance diabetes, mild obesity-related diabetes, and mild age-related diabetes. 41 There are differences across the four groups with respect to HbA1c levels, BMI, and age of diagnosis—all of which are factors that may play into the postoperative complication rate.
In conclusion, in this large national database study, we found that diabetes status does not affect postoperative complications for patients undergoing open rotator cuff repairs when adjusting for demographic and comorbidity variables.
Contributorship: TQ, JM, FC, RR, NR, CM, and MR researched literature and conceived the study. TQ, JM, FC, and RR wrote the first draft of the manuscript. ZZ reviewed and provided corrections to the manuscript. All authors reviewed and edited the manuscript and approved the final version of the manuscript
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The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Ethical approval (include full name of committee approving the research and if available mention reference number of that approval): Informed consent was not sought for this article because this study utilizes a national database and all of the patient data is de-identified.
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Guarantor: *TQ
ORCID iDs: Theodore Quan https://orcid.org/0000-0001-8730-0804
Joseph Emanuele Manzi https://orcid.org/0000-0002-8825-0105
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