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The Impact of Glycemic Control and Diabetes Mellitus on Perioperative Outcomes After Total Joint Arthroplasty

Marchant, Milford H. Jr., MD1; Viens, Nicholas A., MD1; Cook, Chad, PT, PhD, MBA2; Vail, Thomas Parker, MD3; Bolognesi, Michael P., MD1

doi: 10.2106/JBJS.H.00116
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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.

Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

1Division of Orthopaedic Surgery, Duke University Medical Center, Box 3269, Durham, NC 27710. E-mail address for M.H. Marchant Jr.: milfordmarchant@mac.com

2Center for Excellence in Surgical Outcomes, Duke University Medical Center, Box 3094, Durham, NC 27710

3Department of Orthopaedic Surgery, University of California at San Francisco, Box 0728, 500 Parnassus Avenue, MU326W, San Francisco, CA 94143-0728

Copyright © 2009 by The Journal of Bone and Joint Surgery, Incorporated
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