Copyright © 2009 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
John C. Clohisy, MD*,
Washington University School of Medicine, St. Louis, Missouri
Posted July 2009
The number of lower-extremity total joint arthroplasty procedures in the United States
is expected to increase markedly over the next twenty years. Kurtz et al. recently
estimated that, by 2030, more than 500,000 total hip arthroplasties and approximately
3.5 million total knee arthroplasties will be performed annually1. While
these procedures provide excellent pain relief, improved function, and enhanced
quality of life for the majority of patients, associated perioperative complications
can result in appreciable morbidity or even mortality and can further burden our
limited healthcare resources2. Therefore, efforts to minimize
perioperative complications and reduce the cost of arthroplasty surgery are
critical.
In their study, "The Impact of Glycemic Control and Diabetes
Mellitus on Perioperative Outcomes After Total Joint Arthroplasty," in this
month's issue of The Journal, Marchant et al. analyzed data from the Nationwide Inpatient Sample (NIS) to determine the effect of preoperative glycemic control on the prevalence of in-hospital
perioperative complications following lower-extremity total joint arthroplasty.
They also evaluated length of hospital stay and cost associated with these
procedures. Patients with uncontrolled diabetes, controlled diabetes, or no
diabetes were studied to determine the impact of glycemic control. More than one
million patients who were treated between 1988 and 2005 were analyzed. Patients
with uncontrolled diabetes had a significantly increased prevalence of perioperative
complications, mortality, length of hospital stay, and inflation-adjusted
charges (p ≤ 0.001 for all). These data
are very notable, and they demonstrate the negative impact of uncontrolled
diabetes on the clinical results and cost associated with total hip and total
knee arthroplasty.
The strengths of this study include the large number of
patients analyzed through the NIS
database. This database includes patients with Medicare, Medicaid, and private
insurance as well as patients without insurance, and therefore provides information
on a diverse and generalizable patient population. The experimental design of
this study was excellent, and the statistical analysis of the data was rigorous,
thus providing us with clinically important information. This study is
particularly timely because the prevalence of both osteoarthritic conditions
and diabetes is increasing.
Despite the importance of this work, there remain
limitations (as acknowledged by the authors in the Discussion). First, the NIS
database is very large, with approximately 1000 participating hospitals. The
accuracy of glycemic control documentation, hospital coding, and data entry can
all be questioned, yet previous investigations have suggested acceptable
accuracy and quality control. Second, the three patient study groups (nondiabetic
patients, patients with controlled diabetes, and patients with uncontrolled
diabetes) had several differences in demographics and hospital characteristics.
This introduces a potential for sampling bias. Third, these data only pertain
to in-hospital complications related to the initial total joint arthroplasty. Complications
after discharge from the hospital were not evaluated in this study. It is
possible that such data could show a more profound effect of uncontrolled
diabetes on the safety and efficacy of total joint replacement surgery.
This study presents important data regarding diabetic
patients who are undergoing total joint replacement surgery. Uncontrolled
diabetes was associated with elevated risks of complications, a longer hospital
stay, and increased cost. These findings underscore the importance of
preoperative screening and medical management prior to surgery. Specifically,
glycemic control should be optimized in diabetic patients to minimize
perioperative complications and to reduce the cost associated with these
procedures.
*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.
References
1. Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007;89:780-5.
2. Kim S. Changes in surgical loads and economic burden of hip and knee replacements in the US: 1997-2004. Arthritis Rheum. 2008;59:481-8.
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