title: Postoperative morbidity and mortality in type-2 diabetics after fast-track primary total hip and knee arthroplasty.
abstract: BACKGROUND
  Diabetes is a risk factor for postoperative morbidity, which includes total hip and knee arthroplasty. However, no previous studies have been done in a fast-track setting with optimized perioperative care, including spinal anesthesia, multimodal opioid-sparing analgesia, early mobilization, and discharge to home, which improved postoperative outcome.
  
  
  METHODS
  We performed an observational cohort study using prospective data in primary total hip and total knee arthroplasty with a standardized fast-track approach. Eight hundred ninety type 2 diabetics were successfully propensity matched with 7165 nondiabetics. Subanalyses on antihyperglycemic treatment were done using the Danish National Database of Reimbursed Prescriptions for information on dispensed prescriptions 6 months preoperatively. Length of hospital stay (LOS), 90-day readmissions, and mortality were found through the Danish National Health Registry and medical charts. Multiple logistic regression analyses on LOS > 4 days and readmissions were used to further adjust for demographics, comorbidity, and department of surgery. To further evaluate the clinical relevance of type 2 diabetes, we estimated the number of surgical type 2 diabetics needed for 1 more occurrence of LOS > 4 days or readmissions (adjusted number needed to harm [NNH]).
  
  
  RESULTS
  Although more type 2 diabetics (11.3%) than nondiabetics (8.1%) had LOS > 4 days (unadjusted P = 0.001), there was no association between type 2 diabetes and LOS > 4 days when adjusting for covariates (odds ratio: 1.19 [0.93-1.54]; P = 0.172). Correspondingly, the NNH was 78 but ranged between 31 and infinity. Type 2 diabetes was not associated with 30- (1.02 [0.75-1.39]; P = 0.897) or 90-day readmissions (1.22 [0.87-1.71]; P = 0.254), and with an NNH of 957 (59-∞) and 115 (35-∞), respectively. Insulin-treated type 2 diabetes was associated with increased risk of specific "diabetes-related" morbidity (1.95 [1.13-3.35]; P = 0.016).
  
  
  CONCLUSIONS
  Type 2 diabetes per se has limited influence on postoperative morbidity in fast-track total hip and knee arthroplasty.
authors.affiliation: From the Section for Surgical Pathophysiology, Rigshospitalet, Copenhagen University, Copenhagen, Denmark; The Lundbeck Foundation Centre for Fast-track Hip and Knee Replacement, Copenhagen, Denmark; and Department of Endocrinology, Hvidovre University Hospital, Copenhagen University, Copenhagen, Denmark.
authors.forename: Christoffer C
authors.initials: CC
authors.lastname: Jørgensen
authors.forename: Sten
authors.initials: S
authors.lastname: Madsbad
authors.forename: Henrik
authors.initials: H
authors.lastname: Kehlet
mesh_terms: D000368:Aged; D019644:Arthroplasty, Replacement, Hip / Q000009:adverse effects* / Q000401:mortality*; D019645:Arthroplasty, Replacement, Knee / Q000009:adverse effects* / Q000401:mortality*; D003922:Diabetes Mellitus, Type 1 / Q000150:complications / Q000401:mortality; D003924:Diabetes Mellitus, Type 2 / Q000150:complications / Q000453:epidemiology* / Q000401:mortality*; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007004:Hypoglycemic Agents / Q000627:therapeutic use; D015994:Incidence; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D019990:Perioperative Care; D011183:Postoperative Complications / Q000453:epidemiology* / Q000401:mortality*; D011446:Prospective Studies; D016896:Treatment Outcome
chemical_list: D007004:Hypoglycemic Agents