The impact of glycemic control and diabetes mellitus on perioperative outcomes after total joint arthroplasty.
BACKGROUND
As the prevalence of diabetes mellitus in people over the age of sixty years is expected to increase, the number of diabetic patients who undergo total hip and knee arthroplasty should be expected to increase accordingly. In general, patients with diabetes are at increased risk for adverse events following arthroplasty. The goal of the present study was to determine whether the quality of preoperative glycemic control affected the prevalence of in-hospital peri-operative complications following lower extremity total joint arthroplasty.


METHODS
From 1988 to 2005, the Nationwide Inpatient Sample recorded over 1 million patients who underwent joint replacement surgery. The present retrospective study compared patients with uncontrolled diabetes mellitus (n = 3973), those with controlled diabetes mellitus (n = 105,485), and those without diabetes mellitus (n = 920,555) with regard to common surgical and systemic complications, mortality, and hospital course alterations. Additional stratification compared the effects of glucose control among patients with Type-I and Type-II diabetes. Glycemic control was determined by physician assessments on the basis of the American Diabetes Association guidelines with use of a combination of patient self-monitoring of blood-glucose levels, the hemoglobin A1c level, and related comorbidities.


RESULTS
Compared with patients with controlled diabetes mellitus, patients with uncontrolled diabetes mellitus had a significantly increased odds of stroke (adjusted odds ratio = 3.42; 95% confidence interval = 1.87 to 6.25; p < 0.001), urinary tract infection (adjusted odds ratio = 1.97; 95% confidence interval = 1.61 to 2.42; p < 0.001), ileus (adjusted odds ratio = 2.47; 95% confidence interval = 1.67 to 3.64; p < 0.001), postoperative hemorrhage (adjusted odds ratio = 1.99; 95% confidence interval = 1.38 to 2.87; p < 0.001), transfusion (adjusted odds ratio = 1.19; 95% confidence interval = 1.04 to 1.36; p = 0.011), wound infection (adjusted odds ratio = 2.28; 95% confidence interval = 1.36 to 3.81; p = 0.002), and death (adjusted odds ratio = 3.23; 95% confidence interval = 1.87 to 5.57; p < 0.001). Patients with uncontrolled diabetes mellitus had a significantly increased length of stay (almost a full day) as compared with patients with controlled diabetes (p < 0.0001). All patients with diabetes had significantly increased inflation-adjusted postoperative charges when compared with nondiabetic patients (p < 0.0001).


CONCLUSIONS
Regardless of diabetes type, patients with uncontrolled diabetes mellitus exhibited significantly increased odds of surgical and systemic complications, higher mortality, and increased length of stay during the index hospitalization following lower extremity total joint arthroplasty.
Marchant
Milford H
MH
Division of Orthopaedic Surgery, Duke University Medical Center, Durham, NC 27710, USA. milfordmarchant@mac.com
Viens
Nicholas A
NA
Cook
Chad
C
Vail
Thomas Parker
TP
Bolognesi
Michael P
MP
D000368:Aged; D019644:Arthroplasty, Replacement, Hip / Q000009:adverse effects / Q000401:mortality; D019645:Arthroplasty, Replacement, Knee / Q000009:adverse effects / Q000401:mortality; D001786:Blood Glucose / Q000032:analysis*; D003920:Diabetes Mellitus / Q000097:blood*; D005260:Female; D006442:Glycated Hemoglobin / Q000032:analysis; D017722:Hospital Charges; D006801:Humans; D007902:Length of Stay; D008297:Male; D010351:Patient Discharge; D011183:Postoperative Complications; D012086:Reoperation; D020521:Stroke / Q000209:etiology; D014552:Urinary Tract Infections / Q000209:etiology
D001786:Blood Glucose; D006442:Glycated Hemoglobin