Hb1c May Be Wrong for Surgical Risk in Diabetic Patients

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HbA1c is widely used as a gatekeeping tool to delay or deny elective surgery in diabetic patients. Two new studies suggest it may be a poor indicator of actual surgical outcomes.

 

Study 1: Cervical spine surgery (ACDF)

 

In a study of 75 diabetic and prediabetic patients, HbA1c category had no significant impact on complication or revision rates at 30, 90, or 180 days postoperatively.

 

Study 2: Foot and ankle surgery (the more striking finding)

 

A second study examined 106 diabetic patients undergoing foot and ankle surgery:

 

• 87 achieved union; 19 developed nonunion.

• HbA1c at any level, including >8%, was not associated with nonunion.

• What predicted nonunion were higher BMI and lower vitamin D levels.

 

Traditional risk factors like smoking, neuropathy, and vascular disease showed no significant association.

 

Rethinking preoperative optimization

 

Across both spine and foot/ankle surgery, HbA1c alone appears to be a weak filter for surgical risk. BMI and vitamin D may be more actionable targets for optimizing diabetic patients before surgery.

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Is Subtler Joint Preservation With Total Ankle Arthroplasty (TAA) Overhyped?

by Vince Vacketta, DPM

 

One of the long-proposed advantages of TAA over ankle arthrodesis (AA) has been the preservation of adjacent-joint motion and protection of the subtalar joint. But does that theoretical benefit hold up in practice?

 

Examining the evidence

 

In a recent Level III retrospective matched cohort analysis, researchers examined data from 4,210 patients to compare rates of progression to subtalar arthrodesis after TAA versus AA. The two groups were matched for age, sex, surgical indication, and obesity. Patients with a prior ipsilateral subtalar fusion were excluded from the analysis. 

 

At the five-year mark, the results were striking:

 

• 4.2% of patients who underwent AA progressed to subtalar arthrodesis.

• 1.4% of patients who underwent TAA required the same procedure.

 

That’s roughly three-fold difference in cumulative incidence. 

 

Even after multivariate analysis, AA remained independently associated with 1.9 times greater odds of subsequent subtalar fusion. 

 

Takeaway

 

Maybe subtalar joint preservation with TAA isn’t overhyped after all. While the absolute risk of subtalar fusion remains relatively low in both groups, these findings provide clinical support for one of TAA’s most cited benefits: preserving ankle motion may may meaningfully protect the subtalar joint and reduce the need for future fusions.

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American Academy of Orthopedic Surgeons (AAOS) Approves New Ankle Osteoarthritis Guideline

 

At its June 2026 meeting, the AAOS Board of Directors approved its first-ever clinical practice guideline for ankle arthritis. 

 

Key recommendations

 

• Strongly recommends against intra-articular hyaluronic acid alone, which demonstrated no benefit. However, when combined with corticosteroid, it may offer short-term pain relief.

• Moderate recommendation against intra-articular platelet-rich plasma, as current evidence shows no benefit compared to placebo for ankle osteoarthritis.

• The sole limited-strength recommendation supports group education and exercise programs, including home exercise, for patients with mild to moderate symptomatic ankle osteoarthritis who wish to avoid surgery. These programs may improve satisfaction, pain, and overall perceived outcomes. 

 

In addition, the guideline includes 11 consensus-based statements and one limited-strength option developed for areas where evidence was minimal or absent.

 

What this means for practice

 

Reconciling clinical judgment and evidence-based guidelines is a worthwhile exercise for all of us. Translating the best available evidence into a defensible baseline strengthens how we communicate with patients, insurers, and colleagues alike.