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ORIGINAL ARTICLE
Year : 2017  |  Volume : 30  |  Issue : 2  |  Page : 450-455

Comparison of results of primary total hip replacement in diabetic and nondiabetic patients


Department of Orthopedic Surgery, Karmouz Health Insurance Hospital, Faculty of Medicine, Menoufia University, Alexandria, Egypt

Date of Submission02-Aug-2016
Date of Acceptance02-Dec-2016
Date of Web Publication25-Sep-2017

Correspondence Address:
Hossam M Abdella
Damanhur, Al-Behira 22611, 22511
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-2098.215457

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  Abstract 

Objective
The aim of this study was to compare the results of total hip arthroplasty in diabetic and nondiabetic patients.
Background
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 40patients received cemented primary total hip replacement for the treatment of osteoarthritis and were divided into two groups: a diabetic group, which included 20patients, and the nondiabetic group, which included 20patients. 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.
Results
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.
Conclusion
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 Aug 25];30:450-5. Available from: http://www.mmj.eg.net/text.asp?2017/30/2/450/215457


  Introduction Top


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[1].

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[2].

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[3].

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[2].

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[4].

Although THAbecame 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[5].

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[4].

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 Top


Thisprospective study was conducted on 40patients. They were divided into two groups: a diabetic group, which included 20patients, and a nondiabetic group, which included 20patients. 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 14months with a mean follow-up period of 10months.

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:

  1. 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
  2. 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
  3. 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)
  4. Routine laboratory investigations were carried out for every patient, including: complete blood picture, fasting and 2h 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 2weeks postoperatively using the Harris Hip Score to detect the functional ability of every patient, and then the final evaluation was carried out after 6months 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 version20.0 (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 Top


All patients in the diabetic group had typeII 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 70years and the body weight ranged between 60 and 100kg in both groups. Patientsin 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[Table1].
Table 1: Comparison between two groups according to total of Harris Hip Score

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This study showed a significant increase in the total days of hospital stay in the diabetic group with a mean of 12.15days in the diabetic group and 6.05days in the nondiabetic group(P=0.047)[Table2].
Table 2: Comparison between the two groups according to total hospital stay (days)

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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[Table3].
Table 3: Comparison between the two groups according to total complications

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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±7.91kg for those who achieved satisfactory results, whereas it was 89.25±6.60kg 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±5.60kg, whereas it was 96.0±2.83kg 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)[Table4].
Table 4: Relation between functional results (postoperative) and infective complications in the diabetic group

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  Discussion Top


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[6].

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[7].

In this study, the patients' ages in this study ranged from 42 to 69years with a mean age of 54.75years. The average age for THA as reported by Marchant etal. [4]in 2009 was 68.1years, whereas Ravi etal. [8] 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 etal. [9]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 6months postoperatively in both groups(P<0.001).

This is in agreement with the results reported by Ng etal. [10]in their study in 2007 as they reported a significant improvement in Harris Hip Score 6months 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 etal. [11] 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 etal. [2] 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 etal. [12] 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 etal.[2].

In two earlier case–control studies, Menon etal. [13] and Vannini etal. [14] 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 etal. [15] in their case–control study reported that patients with diabetes demonstrated more frequent complications and nonroutine discharge as compared with nondiabetic patients.

Pedersen etal. [16] 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 etal. [17] 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 52days in the diabetic group with a mean of 12.15±12.69days, and it ranged from 5 to 23days with a mean of 6.05±4.01days 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 etal.[2]. 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. [14]reported shorter hospital stay in diabetic patients undergoing arthroplasty; this finding was initially unexpected. Theresult could be attributed to a significantly higher rate of nonroutine discharge to secondary facilities for the diabetic patients. Anonroutine 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 Top


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

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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