HbA1c Recommendation for Rotator Cuff Repair
For patients with diabetes undergoing elective rotator cuff repair, target an HbA1c <8% preoperatively, with optimal control being <7% when safely achievable. 1, 2
Preoperative HbA1c Targets
Measure HbA1c within 3 months before surgery to stratify surgical risk and guide perioperative management 1, 2
The primary target is HbA1c <8% for elective rotator cuff repair, as recommended by the American Diabetes Association for perioperative care 1, 2
Consider delaying surgery if HbA1c is >8% to optimize glycemic control and reduce infection risk, or at minimum obtain consultation from the patient's primary care physician or endocrinologist 2
Evidence-Based Rationale
The recommendation for HbA1c <8% is supported by both general perioperative guidelines and rotator cuff-specific research:
Infection risk increases with higher HbA1c levels in rotator cuff repair patients with diabetes, with infection rates of 0.30% in patients with HbA1c <8% versus 0.84% in those with HbA1c ≥8% (OR 2.0, P=0.014) 3
Retear rates are significantly higher in patients with uncontrolled diabetes: 40.0% retear rate in patients with HbA1c ≥7% compared to 22.7% in well-controlled diabetes (HbA1c <7%) and 14.6% in non-diabetic patients 4
The threshold of HbA1c 8.0 mg/dL emerged from ROC curve analysis as an inflection point for infection risk after rotator cuff repair (AUC 0.648, specificity 61%, sensitivity 59%, P=0.035) 3
Perioperative Glycemic Management
Beyond the preoperative HbA1c target, implement these perioperative strategies:
Target blood glucose 100-180 mg/dL (5.6-10.0 mmol/L) within 4 hours of surgery and throughout the perioperative period 1, 2
Perform preoperative risk assessment for patients at high risk for ischemic heart disease, autonomic neuropathy, or renal failure 1, 2
Adjust diabetes medications perioperatively: hold metformin on day of surgery, discontinue SGLT2 inhibitors 3-4 days before surgery, hold other oral agents the morning of surgery, and reduce NPH insulin to half dose or long-acting basal insulin to 75-80% of usual dose 1
Important Clinical Nuances
The evidence shows some contradictions that warrant discussion:
One recent single-institution study found no association between elevated HbA1c and reoperation rates after rotator cuff repair 5, suggesting HbA1c alone should not be an absolute contraindication
However, this same study found elevated ASA physical status classification was associated with higher reoperation rates (ASA 2.8 vs 2.28, P=0.001) 5, indicating overall medical optimization remains critical
The meta-analysis data clearly demonstrates worse structural outcomes (higher retear rates) with poor glycemic control 4, even if one study didn't find reoperation differences 5
Weighing this evidence for clinical practice: While HbA1c may not predict every adverse outcome, the preponderance of evidence supports optimizing to <8% (ideally <7%) to reduce infection risk and improve healing, consistent with general perioperative diabetes guidelines 1, 2, 3, 4
Common Pitfalls to Avoid
Do not proceed with elective surgery if HbA1c >8% without medical optimization or specialist consultation, as infection risk doubles above this threshold 2, 3
Do not rely solely on perioperative glucose management if preoperative HbA1c is elevated; the 3-month glycemic window reflected by HbA1c matters for tissue healing and infection risk 3, 4
Do not use CGM alone for glucose monitoring during surgery; point-of-care blood glucose testing remains the standard 1
Do not assume HbA1c <7% is always achievable or necessary; balance the benefits of tighter control against hypoglycemia risk, particularly in older patients or those with cardiovascular disease 1