|Year : 2017 | Volume
| Issue : 2 | Page : 450-455
Comparison of results of primary total hip replacement in diabetic and nondiabetic patients
Elsayed M Zaky, Osama G Ahmed, Hossam M Abdella
Department of Orthopedic Surgery, Karmouz Health Insurance Hospital, Faculty of Medicine, Menoufia University, Alexandria, Egypt
|Date of Submission||02-Aug-2016|
|Date of Acceptance||02-Dec-2016|
|Date of Web Publication||25-Sep-2017|
Hossam M Abdella
Damanhur, Al-Behira 22611, 22511
Source of Support: None, Conflict of Interest: None
The aim of this study was to compare the results of total hip arthroplasty in diabetic and nondiabetic patients.
Total hip arthroplasty is considered one of the most successful and effective surgical procedures performed in the world. The increase in the numbers of patients undergoing hip arthroplasty coincides with the incidence of increased prevalence of diabetes over the last two decades. The diabetic population undergoing arthroplasty is very poorly reported in comparison with the nondiabetic population due to the adverse outcomes of diabetes.
Materials and methods
All 40 patients received cemented primary total hip replacement for the treatment of osteoarthritis and were divided into two groups: a diabetic group, which included 20 patients, and the nondiabetic group, which included 20 patients. The functional outcome was evaluated according to the modified Harris Hip Score in all patients, and complications (e.g., superficial wound problems, deep infection, periprosthetic fracture, loosening, and osteolysis) were recorded in both groups.
Patients with diabetes mellitus required longer hospital stay and increased overall cost. Moreover, the need for postoperative blood transfusion was higher in the diabetic group. The diabetic group showed a higher number of complications in comparison with the nondiabetic group, although it was statistically nonsignificant. The study showed the negative impact of body weight on the functional outcome in both groups.
Diabetic patients undergoing arthroplasty are the high-risk group and they required close monitoring of blood glucose level during the perioperative period, as diabetic patients had a higher rate of postoperative complications and required longer hospital stay and had increased total cost in comparison with the nondiabetic group.
Keywords: diabetes mellitus, functional outcome, hip arthroplasty, periprosthetic infection
|How to cite this article:|
Zaky EM, Ahmed OG, Abdella HM. Comparison of results of primary total hip replacement in diabetic and nondiabetic patients. Menoufia Med J 2017;30:450-5
|How to cite this URL:|
Zaky EM, Ahmed OG, Abdella HM. Comparison of results of primary total hip replacement in diabetic and nondiabetic patients. Menoufia Med J [serial online] 2017 [cited 2019 Apr 19];30:450-5. Available from: http://www.mmj.eg.net/text.asp?2017/30/2/450/215457
| Introduction|| |
Total hip arthroplasty (THA) became one of the most effective procedures performed in orthopedic surgery as it improves mobility and allows pain relief in the vast majority of patients with end-stage arthritis .
The increase in the numbers of THA being performed coincides with the incidence of diabetes increasing over the last two decades. The diabetic population undergoing arthroplasty is very poorly reported in comparison with the nondiabetic population .
Diabetes results in complications affecting multiple organ systems, potentially resulting in adverse outcomes after orthopedic surgery; significant alterations in glucose metabolism occur during periods of heightened stress such as major surgery, trauma, and sepsis. It has been reported that diabetic patients undergoing surgery are at risk for increased morbidity and longer hospital stay .
As changes in the blood sugar concentration in a patient with diabetes mellitus can acutely affect physiologic stability, serum glucose concentration at the time of admission has been shown to be an important predictor of outcomes in hospitalized patients as hyperglycemia results in the inhibition of interleukin 1 release from macrophages, impaired phagocytosis, and diminished production of oxygen radicals from neutrophils, all of which contribute to a relative immunodeficiency .
Glycemic control has been shown to affect the outcomes in acute medical, general surgical, and trauma environments; studies have demonstrated that elective surgery is associated with physiologic stress that can alter the ability of both diabetic and nondiabetic patients to regulate glucose metabolism .
Although THA became a highly successful procedure and has become a conventional method for improving the quality of life and reducing pain in patients with joint diseases, periprosthetic joint infection (PJI) can have catastrophic consequences. It can reach as high as 3% following primary THA .
The risk for deep joint infection and postoperative infection in general has been reported to be similar or higher in patients with diabetes than in nondiabetic patients. Uncontrolled diabetes mellitus demonstrated significantly more PJI when compared with patients with controlled diabetes and those without diabetes .
The aim of the present work was to compare the results of THA in diabetic and nondiabetic patients and to evaluate the impact of diabetes on postoperative functional outcome and postoperative complication rate.
| Materials and Methods|| |
This prospective study was conducted on 40 patients. They were divided into two groups: a diabetic group, which included 20 patients, and a nondiabetic group, which included 20 patients. All patients received primary cemented total hip replacement as a treatment for hip osteoarthritis through lateral approach at Karmuz Health Insurance Hospital in Alexandria between May 2015 and January 2016. The follow-up period ranged between 6 and 14 months with a mean follow-up period of 10 months.
Full preoperative assessment including clinical and radiological examination with routine investigations was carried out for every patient and postoperative clinical and radiological evaluation was carried out.
All patients were subjected to the following:
- Personal history taking including name, age, sex, occupation, and past history of previous fractures, especially of the lower limb, and medical diseases such as diabetes mellitus, hypertension, and cardiac, renal, or chest problems
- General examination for the evaluation of the general condition of the patient, systemic examination to investigate for any associated deformity, and local examination of the hip, including skin condition, leveling, range of motion, and leg-length discrepancy
- Preoperative plain radiography in the form of anteroposterior and lateral views of the hip joint and proximal femur and postoperative radiographs for the evaluation of cup position, inclination, and anteversion, position of the stem in the femur, bone cement, size and fitting of the head in the cup, and any complications (e.g., osteolysis and loosening)
- Routine laboratory investigations were carried out for every patient, including: complete blood picture, fasting and 2 h postprandial blood glucose level, HbA1c, erythrocyte sedimentation rate, C-reactive protein, bleeding and clotting time, prothrombin time and concentration, liver enzymes blood urea, and creatinine level.
Methods of assessment
Evaluation of outcome was carried out at 2 weeks postoperatively using the Harris Hip Score to detect the functional ability of every patient, and then the final evaluation was carried out after 6 months to reach the final functional ability for every patient using the same score. Scores more than 90 were considered excellent, scores between 81 and 90 were considered good, scores between 71 and 80 were considered fair, and scores less than 70 were considered poor.
Data were fed to the computer and analyzed using IBM SPSS software package version 20.0 (SPSS Inc., Chicago, Illinois, USA). Qualitative data were described using number and percent. Quantitative data were described using range (minimum and maximum), mean, SD, and median. Significance of the obtained results was judged at the 5% level.
| Results|| |
All patients in the diabetic group had type II diabetes mellitus and were controlled on oral hypoglycemic medication at home. Their HbA1c level was less than 7% on admission; they were controlled during hospital stay on insulin scale.
The patients' ages ranged between 40 and 70 years and the body weight ranged between 60 and 100 kg in both groups. Patients in this study underwent THA for primary osteoarthritis of the hip, fracture of the femoral neck and secondary osteoarthritis on top of avascular necrosis of the femoral head, and fracture of the acetabulum.
A significant difference was found in the two groups between preoperative and postoperative Harris Hip Score. The diabetic patients had a preoperative Harris Hip Score that ranged between 27 and 55 points with a mean of 50.90 points, and the postoperative Harris Hip Score ranged between 56 and 97 points with a mean of 85.25 points. However, the nondiabetic preoperative Harris Hip Score ranged from 27 to 54 points with a mean of 47.95 points, and the postoperative Harris Hip Score ranged between 57 and 96 points with a mean of 86.90 points [Table 1].
|Table 1: Comparison between two groups according to total of Harris Hip Score|
Click here to view
This study showed a significant increase in the total days of hospital stay in the diabetic group with a mean of 12.15 days in the diabetic group and 6.05 days in the nondiabetic group (P = 0.047) [Table 2].
|Table 2: Comparison between the two groups according to total hospital stay (days)|
Click here to view
Although it was statistically nonsignificant, the diabetic group manifested a higher incidence of complications in comparison with the nondiabetic group: the rate of superficial wound complications was 10% in the diabetic group and 5% in the nondiabetic group; deep infection rate was 10% in the diabetic group and 5% in the nondiabetic group; and one patient in the diabetic group had periprosthetic fracture, whereas no patients in the nondiabetic showed periprosthetic fracture. The number of patients who experienced complications related to the procedure in the diabetic group represented 25% compared with only 5% of patients in the nondiabetic group [Table 3].
|Table 3: Comparison between the two groups according to total complications|
Click here to view
The need for postoperative blood transfusion was significantly higher in the diabetic group as 13 (65%) patients in the diabetic group needed blood transfusion postoperatively and only four (20%) patients in the nondiabetic group required blood transfusion (P = 0.004).
In this study, there was a significant relation between functional outcome and the patient's weight in both groups. In the diabetic group, the mean weight was 78.69 ± 7.91 kg for those who achieved satisfactory results, whereas it was 89.25 ± 6.60 kg for patients who achieved unsatisfactory results (P = 0.025). In the nondiabetic group, the mean weight for the patients who achieved satisfactory results was 80.22 ± 5.60 kg, whereas it was 96.0 ± 2.83 kg in patients who achieved unsatisfactory results (P = 0.001). Moreover, there was a significant relationship between periprosthetic infection and the functional outcome, as patients who had infective complications achieved unsatisfactory outcome (P = 0.010) [Table 4].
|Table 4: Relation between functional results (postoperative) and infective complications in the diabetic group|
Click here to view
| Discussion|| |
Diabetes mellitus is a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both. The chronic hyperglycemia of diabetes is associated with long-term damage, dysfunction, and failure of various organs, especially the eyes, kidneys, nerves, heart, and blood vessels .
Diabetes contributes to poor orthopedic surgical outcomes, including infection, increased pain and stiffness, decreased joint function, decreased range of motion, no homebound discharge status, and reduction in implant survivorship requiring subsequent revision surgery .
In this study, the patients' ages in this study ranged from 42 to 69 years with a mean age of 54.75 years. The average age for THA as reported by Marchant et al. in 2009 was 68.1 years, whereas Ravi et al.  reported that the mean age for THA has been decreased mainly due to the increased prevalence of obesity, which increased osteoarthritis incidence at an younger age.
All diabetic patients in this study had their blood glucose level controlled on subcutaneous insulin during the period of hospital stay, and on discharge they were back to oral medication. Patients who developed infective complications were shifted to insulin treatment even after discharge for better control of blood glucose.
Moeckel et al. reviewed the results of 93 hip replacements in 78 diabetic patients. They noted that previously non-insulin-dependent patients required insulin during the perioperative period. The authors concluded that the insulin dependence during the perioperative period was due to deterioration of the diabetic condition. Therefore, stress-induced hyperglycemia occurs even in patients undergoing elective arthroplasty surgery and can potentially affect systemic outcomes in both the short term and the long term.
In the diabetic group, the mean preoperative Harris Hip Score was 50.90 ± 5.77 in comparison with the mean postoperative score of 85.25 ± 10.59. In the nondiabetic group, the mean was 47.95 ± 8.54 preoperatively and 86.90 ± 8.74 postoperatively. This shows a significant improvement in the score 6 months postoperatively in both groups (P < 0.001).
This is in agreement with the results reported by Ng et al. in their study in 2007 as they reported a significant improvement in Harris Hip Score 6 months after the procedure (P < 0.001).
The total Harris Hip Score showed no significant difference between the two groups as the mean total Harris Hip Score was 85.25 ± 10.59 in the diabetic group and 86.90 ± 8.74 in the nondiabetic group.
Our results showed similarity to the results reported by Chun et al.  as they stated that the Harris Hip Score s for the diabetes mellitus group and the nondiabetes mellitus group before the operations were 63 and 65 (P = 0.295), respectively, and, by the final follow-up, it was found to be 92 and 94 (P = 0.3), respectively, which was not significantly different.
Factors affecting the final outcome
In this study, there was no significant relationship between the final outcome and the patient's age and sex in both groups. This shows similarity to the results published by Chan et al.  in their prospective study on 1220 nondiabetic and 77 diabetic patients, which reported no significant difference between the two groups with regard to age and sex.
In both groups, the functional outcome was significantly affected by the patient's weight, as poorer functional outcome was found in patients with higher weight (P = 0.025) in the diabetic group and (P = 0.001) the nondiabetic group. This is consistent with the results reported by Murgatroyd et al.  in their cohort study that evaluated 5357 hip arthroplasty in 2014, which showed that poorer functional outcome was achieved with increased weight of the patients receiving THA (P > 0.05).
In this series, periprosthetic deep joint infection was found to be higher in the diabetic group as 2/20 (10%) patients were diagnosed with infection, whereas in the nondiabetic group only 1/20 (5%) patient had periprosthetic infection. However, this was statistically nonsignificant. This is consistent with the results reported by Chan et al. .
In two earlier case–control studies, Menon et al.  and Vannini et al.  found that diabetes mellitus patients were associated with a five-time greater risk for PJI compared with nondiabetic patients. These studies were conducted before the widespread use of laminar flow and prophylactic antibiotic therapy.
Bolognesi et al.  in their case–control study reported that patients with diabetes demonstrated more frequent complications and nonroutine discharge as compared with nondiabetic patients.
Pedersen et al.  performed a population-based assessment of all-cause revision risk, including periprosthetic infection, in diabetic patients compared with patients without diabetes; they found that diabetes mellitus was associated with an increased risk for any-time-revision owing to deep infection.
In this study, established periprosthetic infection significantly affected functional outcome (P = 0.032) in the diabetic group with infected patients who achieved unsatisfactory results. This is in agreement with the results reported by Mittag et al.  in their publication, which stated that patients with PJI had lower Harris Hip Score s compared with those without infection, as patients under the study with established infection had a lower score with an average of 70 points.
In this study, the total hospital stay ranged from 6 to 52 days in the diabetic group with a mean of 12.15 ± 12.69 days, and it ranged from 5 to 23 days with a mean of 6.05 ± 4.01 days in the nondiabetic group (P = 0.047); this shows a significant increase in total days of hospital stay in the diabetic group. This is consistent with the results noticed by Chan et al. . This increase in total hospital stay and cost was attributed to a higher complication rate in the diabetic group, which needed longer index hospital stay for the control of blood sugar and hospital readmission for complication management.
Vannini et al. reported shorter hospital stay in diabetic patients undergoing arthroplasty; this finding was initially unexpected. The result could be attributed to a significantly higher rate of nonroutine discharge to secondary facilities for the diabetic patients. A nonroutine discharge may increase overall costs over time. This is in agreement with our results as patients received all care related to postoperative complications in our hospital with increased hospital stay and total cost in the diabetic group.
| Conclusion|| |
The present case series, although small in number, shows that the procedure achieved great benefit in the functional outcome in both diabetic and nondiabetic patients, but extra care should be given for glycemic control in the diabetic group.
We were able to confirm that preoperative diagnosis of diabetes mellitus significantly increased the total days of hospital stay and the need for postoperative blood transfusion for patients undergoing primary THA. We also found that the risk for orthopedic complications, in particular infection, was higher in diabetic patients (although statistically nonsignificant), which negatively affected the functional outcome.
Moreover, this study confirmed the negative impact of body weight on the functional outcome of THA.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Dixon T, Shaw M, Ebrahim S, Dieppe P. Trends in hip and knee joint replacement: socioeconomic inequalitiesand projections of need. Ann Rheum Dis 2004; 63:825–830.
Chan P, Brenkel I, Aderinto J. The outcome of total hip arthroplasty in diabetes mellitus. Br J Diabetes Vasc Dis 2005; 5:146–149.
Wukich DK. Diabetes and its negative impact on outcomes in orthopaedic surgery. World J Orthop 2015; 6:331–339.
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; 91:1621–1629.
Chuanlong WU. Risk factors for periprosthetic joint infection after total hip arthroplasty and total knee arthroplasty in Chinese patients. PLoS One 2014;9:e95300.
Shaaban MA, Dawod AA, Nasr MA. Role of iron in diabetes mellitus and its complications. Menoufia Med J 2016; 29:11–16. [Full text]
King B, Findley W, Williams E, Bucknell L. Veterans with diabetes receive arthroplasty more frequently and at a younger age. Clin Orthop Relat Res 2013; 471:3049–3054.
Ravi B, Croxford R, Reichmann WM, Losina E, Katz JN, Hawker GA. The changing demographics of total joint arthroplasty recipients in the United States and Ontario from 2001 to 2007. Best Pract Res Clin Rheumatol 2012; 26:637–647.
Moeckel B, Huo MH, Salvati EA, Pellicci PM Total hip arthroplasty in patients with diabetes mellitus. J Arthroplasty 1993; 8:279–284.
Ng Y, Ballantyne A, Brenkel J. Quality of life and functional outcome after primary total hip replacement. A five-year follow up J Bone Joint Surg Br 2007; 89:868–873.
Chun YS, Lee SH, Cho YJ, Rhyu KH. Clinical implication of diabetes mellitus in primary total hip arthroplasty. Hip Pelvis. 2014; 26:136–142.
Murgatroyd SE, Frampton CM, Wright MS. The effect of body mass index on outcome in total hip arthroplasty: early analysis from the New Zealand Joint Registry. J Arthroplasty 2014; 29:1884–1888.
Menon TJ, Thjellesen D, Wroblewski BM. Charnley low-friction arthroplasty in diabetic patients. J Bone Joint Surg Br 1983; 65:580–581.
Vannini P, Ciavarella A, Olmi R, Flammini M, Moroni A, Galuppi V, et al.
Diabetes as pro-infective risk factor in total hip replacement. Acta Diabetol Lat 1984; 21:275–280.
Bolognesi MP, Marchant MH Jr, Viens NA, Cook C, Pietrobon R, Vail TP. 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.
Pedersen AB, Mehnert F, Johnsen SP, Sørensen HT. 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.
Mittag F, Leichtle CI, Schlumberger M, Leichtle UG, Wünschel M. Clinical outcome after infected total knee and total hip arthroplasty. Acta Ortop Bras 2016; 24:43–47.
[Table 1], [Table 2], [Table 3], [Table 4]