Insulin-dependent diabetes mellitus is an independent risk factor for postoperative complications in aseptic revision total hip arthroplasty

Abstract

Introduction:

Revision total hip arthroplasty (rTHA) is becoming a more common procedure due to the increasing volume of primary total hip arthroplasty. Diabetes mellitus (DM) is currently projected to affect 4.4% of the global population by 2030. Diabetes has been associated with poor outcomes for a variety of surgical interventions. However, the impact of insulin dependence has yet to be fully understood. The aim of this study was to determine the impact of insulin dependence on acute postoperative complications following rTHA.

Methods:

A retrospective cohort study was conducted using the American College of Surgeons National Quality Improvement Program database. All patients who underwent rTHA between 2006 and 2016 were identified and recorded as having non-insulin-dependent DM (NIDDM), insulin-dependent DM (IDDM) or no DM. Univariate and multivariate analysis were used to evaluate the incidence of multiple adverse events within 30 days after rTHA.

Results:

A total of 7685 patients were evaluated (No DM = 6651, NIDDM = 700, IDDM = 334). Univariate analysis revealed that all patients with DM had significantly higher incidences of postoperative complications (NIDDM: p < 0.001; IDDM: p < 0.001) and extended hospital length of stay (NIDDM: p = 0.015; IDDM: p < 0.0001). NIDDM was associated with increased rates of superficial surgical site infection (SSI) (p = 0.001), deep SSI (p = 0.038), and stroke (p = 0.013), while IDDM was associated with increased rates of pneumonia (p < 0.001), renal failure (p < 0.001), and postoperative transfusion (p < 0.001). On multivariate analysis, insulin-dependence was determined to be an independent risk factor for extended hospital length of stay (OR 1.905; 95% CI, 1.410–2.577; p < 0.001), pneumonia (OR 4.016; 95% CI, 1.799–8.929; p = 0.001), renal failure (OR 7.143; 95% CI, 2.203–23.256; p = 0.001) and postoperative transfusion (OR 1.366; 95% CI, 1.076–1.733; p = 0.01).

Conclusions:

Insulin dependence is an independent risk factor for numerous short-term postoperative complications following rTHA. When assessing risk and planning perioperative management, surgeons should consider insulin-dependent diabetics as a sub-cohort within the diabetic population.

Keywords

Diabetes insulin dependency NSQIP postoperative complications revision total hip arthroplasty

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References

Kurtz

Lau

Ong

, et al. Future young patient demand for primary and revision joint replacement: national projections from 2010 to 2030. Clin Orthop Relat Res 2009; 467: 2606–2612.

Bozic

Kamath

Ong

, et al. Comparative epidemiology of revision arthroplasty: failed THA poses greater clinical and economic burdens than failed TKA. Clin Orthop Relat Res 2015; 473: 2131–2138.

Nichols

Vose

. Clinical outcomes and costs within 90 days of primary or revision total joint arthroplasty. J Arthroplasty 2016; 31: 1400–1406.e3.

Centers for Disease Control and Prevention. At a glance 2016. Diabetes: working to reverse the US epidemic, https://lionsofillinoisfoundation.org/images/Diabetes%20CDC.pdf (2017, accessed 4 January 2019).

Caspard

Jabbour

Hammar

, et al. Recent trends in the prevalence of type 2 diabetes and the association with abdominal obesity lead to growing health disparities in the USA: an analysis of the NHANES surveys from 1999 to 2014. Diabetes Obes Metab 2018; 20: 667–671.

Cho

Shaw

Karuranga

, et al. Diabetes atlas: global estimates of diabetes prevalence for 2017 and projections for 2045. Diabetes Res Clin Pract 2018; 138: 271–281.

Boddapati

Dines

, et al. The impact of insulin dependence on short-term postoperative complications in diabetic patients undergoing total shoulder arthroplasty. J Shoulder Elbow Surg 2017; 26: 2091–2096.

Chrastil

Anderson

Stevens

, et al. Is hemoglobin A1c or perioperative hyperglycemia predictive of periprosthetic joint infection or death following primary total joint arthroplasty? J Arthroplasty 2015; 30: 1197–1202.

Lavernia

Heiner

Villa

, et al. Preoperative glycemic control on total joint arthroplasty patient-perceived outcomes and hospital costs. J Arthroplasty 2017; 32: 6–10.

10.

Pugely

Martin

Gao

, et al. The incidence of and risk factors for 30-day surgical site infections following primary and revision total joint arthroplasty. J Arthroplasty 2015; 30(Suppl. 9): 47–50.

11.

López-de-Andrés

Hernández-Barrera

Martínez-Huedo

, et al. Type 2 diabetes and in-hospital complications after revision of total hip and knee arthroplasty. PLoS One 2017; 12: e0183796.

12.

Bolognesi

Marchant

Viens

Jr , et al. The impact of diabetes on perioperative patient outcomes after total hip and total knee arthroplasty in the United States. J Arthroplasty 2008; 23(Suppl. 1): 92–98.

13.

Han

Kang

. Relations between long-term glycemic control and postoperative wound and infectious complications after total knee arthroplasty in type 2 diabetics. Clin Orthop Surg 2013; 5: 118–123.

14.

Dowsey

Choong

. Obese diabetic patients are at substantial risk for deep infection after primary TKA. Clin Orthop Relat Res 2009; 467: 1577–1581.

15.

Stepan

Boddapati

Sacks

, et al. Insulin dependence is associated with increased risk of complications after upper extremity surgery in diabetic patients. J Hand Surg 2018; 43: 745–754.e4.

16.

Webb

Golinvaux

Ibe

, et al. Comparison of perioperative adverse event rates after total knee arthroplasty in patients with diabetes: insulin dependence makes a difference. J Arthroplasty 2017; 32: 2947–2951.

17.

Kee

Mears

Edwards

, et al. Modifiable risk factors are common in early revision hip and knee arthroplasty. J Arthroplasty 2017; 32: 3689–3692.

18.

Kremers

Lewallen

Mabry

, et al. Diabetes mellitus, hyperglycemia, hemoglobin A1C and the risk of prosthetic joint infections in total hip and knee arthroplasty. J Arthroplasty 2015; 30: 439–443.

19.

Lovecchio

Beal

Kwasny

, et al. Do patients with insulin-dependent and noninsulin-dependent diabetes have different risks for complications after arthroplasty? Clin Orthop Relat Res 2014; 472: 3570–3575.

20.

Badarudeen

Shu

Ong

, et al. Complications following revision total hip arthroplasty in the Medicare population. J Arthroplasty 2017; 32: 1954–1958.

21.

Lie

Havelin

Furnes

, et al. Failure rate for 4762 revision total hip arthroplasties in the Norwegian Arthroplasty Register. J Bone Joint Surg Br 2004; 86: 504–509.

22.

Mahomed

Barrett

Katz

, et al. Rates and outcomes of primary and revision total hip replacement in the United States Medicare population. J Bone Joint Surg Am 2003; 85: 27–32.

23.

Bozic

Kurtz

Lau

, et al. The epidemiology of revision total hip arthroplasty in the United States. J Bone Joint Surg Am 2009; 91: 128–133.

24.

Gwam

Mistry

Mohamed

, et al. Current epidemiology of revision total hip arthroplasty in the United States: national inpatient sample 2009 to 2013. J Arthroplasty 2017; 32: 2088–2092.

25.

Tornero

García-Oltra

García-Ramiro

, et al. Prosthetic joint infections due to Staphyloccocus aureus and coagulase-negative staphylococci. Int J Artif Organs 2012; 35: 884–892.

26.

Trickey

Wright

Donovan

, et al. Interrater reliability of hospital readmission evaluations for surgical patients. Am J Med Qual 2017; 32: 201–207.

27.

Maoz

Phillips

Bosco

, et al. The Otto Aufranc Award: modifiable versus nonmodifiable risk factors for infection after hip arthroplasty. Clin Orthop Relat Res 2015; 473: 453–459.

28.

Pedersen

Mehnert

Johnsen

, et al. Risk of revision of a total hip replacement in patients with diabetes mellitus: a population-based follow up study. J Bone Joint Surg Br 2010; 92: 929–934.

29.

Iorio

Williams

Marcantonio

, et al. Diabetes mellitus, hemoglobin A1C, and the incidence of total joint arthroplasty infection. J Arthroplasty 2012; 27: 726–729.e1.

30.

Kremers

Schleck

Lewallen

, et al. Diabetes mellitus and hyperglycemia and the risk of aseptic loosening in total joint arthroplasty. J Arthroplasty 2017; 32: S251–S253.

31.

Stryker

Abdel

Morrey

, et al. Elevated postoperative blood glucose and preoperative hemoglobin A1C are associated with increased wound complications following total joint arthroplasty. J Bone Joint Surg Am 2013; 95: 808–814.

32.

Fontes-Carvalho

Ladeiras-Lopes

Bettencourt

, et al. Diastolic dysfunction in the diabetic continuum: association with insulin resistance, metabolic syndrome and type 2 diabetes. Cardiovasc Diabetol 2015; 14: 4.

33.

Leslie

Palmer

Schloot

, et al. Diabetes at the crossroads: relevance of disease classification to pathophysiology and treatment. Diabetologia 2016; 59: 13–20.