Identifying Risk Groups in 73,000 Patients with Diabetes Receiving Total Hip Replacement: A Machine Learning Clustering Analysis

<b>Background/Objective</b>: Diabetes mellitus (DM) is a highly prevalent condition that contributes to adverse outcomes in patients undergoing total hip arthroplasty (THA). This study applied machine learning clustering algorithms to identify comorbidity profiles among diabetic THA patients and evaluate their association with postoperative outcomes. <b>Methods</b>: The 2015-2021 National Inpatient Sample was queried using ICD-10 CM/PCS codes to identify DM patients undergoing THA. Forty-nine comorbidities, complications, and clinical covariates were incorporated into clustering analysis. The Davies-Bouldin and Calinski-Harabasz indices determined the optimal number of clusters. Multivariate logistic regression assessed risk of non-routine discharge (NRD), and Kruskal-Wallis H testing evaluated length-of-stay (LOS) differences. <b>Results</b>: A total of 73,606 patients were included. Six clusters were identified, ranging from 107 to 61,505 patients. Cluster 6, enriched for urinary tract infection and sepsis, had the highest risk of NRD (OR 7.83, <i>p</i> < 0.001) and the longest median LOS (9.0 days). Clusters 1-4 had shorter recoveries with median LOS of 2.0 days and narrow variability, while Cluster 5 showed intermediate outcomes. Kruskal-Wallis and post hoc testing confirmed significant differences across clusters (<i>p</i> < 0.001). <b>Conclusions</b>: Machine learning clustering of diabetic THA patients revealed six distinct groups with varied comorbidity profiles. Infection-driven clusters carried the highest risk for non-routine discharge and prolonged hospitalization. This approach provides a novel framework for risk stratification and may inform targeted perioperative management strategies.