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The Impact of Glycemic Control and Diabetes Mellitus on Perioperative Outcomes After Total Joint Arthroplasty
Milford H. MarchantJr., MD1; Nicholas A. Viens, MD1; Chad Cook, PT, PhD, MBA2; Thomas Parker Vail, MD3; Michael P. Bolognesi, MD1
1 Division of Orthopaedic Surgery, Duke University Medical Center, Box 3269, Durham, NC 27710. E-mail address for M.H. Marchant Jr.: milfordmarchant@mac.com
2 Center for Excellence in Surgical Outcomes, Duke University Medical Center, Box 3094, Durham, NC 27710
3 Department of Orthopaedic Surgery, University of California at San Francisco, Box 0728, 500 Parnassus Avenue, MU326W, San Francisco, CA 94143-0728
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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. Commercial entities (Zimmer and DePuy) paid or directed in any one year, or agreed to pay or direct, benefits in excess of $10,000 to a research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which one or more of the authors, or a member of his or her immediate family, is affiliated or associated.
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Investigation performed at Duke University Medical Center, Durham, North Carolina

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2009 Jul 01;91(7):1621-1629. doi: 10.2106/JBJS.H.00116
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Abstract

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.

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    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    N. Wah Cheung
    Posted on August 19, 2009
    Glycemic Control and Outcomes after Joint Arthroplasty
    Westmead Hospital, University of Sydney, NSW, Australia

    To the Editor:

    Marchant et al. have found that patients with uncontrolled diabetes have worse perioperative outcomes after joint arthroplasty than patients with controlled diabetes who, in turn, have worse outcomes than those without diabetes (1). The classification of diabetes control was determined from ICD-9 codes. While this reflects glycemic control to a degree, a better determinant would be a biochemical measure such as serum glucose at the time of hospital admission.

    We have previously found a relationship between admission blood glucose levels, hospital mortality, and length of stay (LOS) in patients admitted through our Emergency Department (2). In light of the publication by Marchant et al., we analyzed our data for the subset of 489 patients who had a Diagnosis Related Group and ICD-10 code indicating their admission was related to a bone and joint disorder. As there were no deaths in this cohort, we used LOS as the outcome of interest.

    Using linear regression, the relative LOS per unit increase in blood glucose level was 1.07 (95%CI 1.03-1.10, p<0.001), after adjustment for age and sex; i.e., for every one mmol/L increase in blood glucose level, LOS increased by 7%. The relative LOS for those with a blood glucose level over 8 mmol/L compared to those with a level under 8 mmol/L was 1.31 (95%CI 1.03-1.65), after adjustment; i.e., their average length of stay was 31% longer.

    It seems likely that increased LOS in our study was related to increased hospital complications. Our data therefore support the finding that glucose control influences outcomes of patients admitted to hospital for acute musculoskeletal conditions. In addition to increased morbidity, this has significant cost implications to the health system. Further research needs to be conducted to determine if interventions for hyperglycemia result in better outcomes for these patients.

    The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated.

    References

    1. Marchant MH Jr, Viens NA, Cook C, Vail TP, Bolognesi MP. The impact of glycemic control and diabetes mellitus on perioperative outcomes after total joint arthroplasty. J Bone Joint Surg Am. 2009;91:1621-9.

    2. Cheung NW, Li S, Ma G, Crampton R. The relationship between admission blood glucose levels and hospital mortality. Diabetologia. 2008;51:952-5.

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