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A R E C E N T S T U DY i n T h e Journal of the American Medical Association showed that up to 50 percent of the U.S. popula- tion to date have diabetes or prediabetes, and many of these patients don't know it. This dis- ease impacts a disproportionate number of orthopedic patients. Diabetic management is often overlooked in orthopedic prac- tices, but the care of diabetic patients was actually revolutionized by an orthopedic specialists, Frederick Banting, who was awarded the Nobel Prize in 1923 for the discovery of insulin. Although the specific pathogenesis of diabetic complications remains incompletely explicated, hyperglycemia is considered the principle trigger of a broad range of downstream deleterious metabolic results. We see both macrovascular and microvascular complications associated with impaired glucose tolerances in patients often before they are diagnosed as having diabetes. Advanced glycation end products (AGEs) have a negative impact on both tissue function and healing. The process of forming AGEs is a complex two-step process beyond the scope of this article. However, the most important point is that the process is partially reversible when a patient lowers blood glucose levels. Perioperative glucose management plays a significant role in prevention of complications. Preoperative hyperglycemia is a pre- dictive indicator of increased mortality in the year after surgery, even in patients who have not yet been diagnosed with diabetes. This would indicate that all patients should have preoperative screening using HbA1c levels to detect diabetes. Uncontrolled diabetics and undiagnosed diabetics benefit from improved preoperative control prior to elective orthopedic surgery. Preoperative hyperglycemia is associated with increased morbidity costs, increased length of stay, increased readmission rates, increased costs of hospitalization and increased mortality rates. The orthopedic total joint literature indicates that HbA1c greater than 6.8 percent may increase risk of postoperative infection by odds ratio of 9.16. One recent study demonstrated an increased odds ratio of inpatient mortality when uncontrolled diabetics underwent elective cervical surgery for spondylotic myelopathy of 6.4. This population of uncontrolled diabetics had an estimated cost overrun (compared to non-diabetics) of nearly $11,000 more per case. Another group noted an odds ratio of 2.7 for postoperative mortality within 30 days of lumbar fusion for all insulin-dependent diabetics compared with non-diabetics. Tight glycemic control has been shown to improve surgical outcomes. While many hospital systems manage hyperglycemia with a sliding-scale protocol, basal-bolus management and IV insulin infusion in the ICU setting have been shown to provide more ežective glycemic control in postoperative patients. When a patient receives perioperative dose(s) of IV steroids as part of a total joint or postoperative nausea/vomiting protocol, it can result in a subsequent postoperative increase in hyperglycemia by inducing insulin resistance in both diabetic and even non-diabetic patients. Even transient hyperglycemia may negatively impact surgical outcomes. Postoperative blood glucose testing should be considered in patients receiving these medications. More importantly, preoperative normalization of blood glucose in both Type 1 and Type 2 diabetic patients is more than possible in the motivated patient who is guided by a supportive healthcare team. Prescribing low carbohydrate, plant-rich diets that include healthy fats can result in dramatic improvements of glycemic control even without medication in many Type 2 diabetics and can dramatically lower the insulin requirements of Type 1 diabetics. Within the diabetic range, reduction in HbA1c as little as 1 percent significantly decreases the risk of microvascular complications of the disease. For surgical patients, a preoperative HbA1c of less than 7 percent has been shown to decrease the rate of postoperative infections. This is not overly ambitious, nor is achieving "normal" glycemic control, but patients need physician/healthcare partners. In an era of value-based care, increasing burden will be applied to the surgeon for poor outcomes and readmissions. Controlling for known contributors to poor outcomes is part of our dual professional/moral obligation of non-maleficence and beneficence. It is easy to develop tunnel vision in medicine; however, the human body is a complex interconnected web, and we serve our patients better when we take the whole patient into account. Dr. Diulus is a board-certified spine surgeon, fellowship trained at the San Francisco Spine Institute and practicing with Crystal Clinic Spine Wellness Center in Akron, Medina, Hudson and Cuyahoga Falls, Ohio. ■ Requiring Orthopedic Procedures patients was actually revolutionized by an orthopedic specialists, BY CARRIE DIULUS, MD Optimizing Diabetic Patients 2 0S P E C I A L S E C T I O N : O R T H O P E D I C S