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72 (); 111-116
doi:
10.1016/j.jor.2025.11.008

Outcomes after total joint arthroplasty in patients with and without diabetes mellitus: A TriNetX database study

, , ,
a Department of Rehabilitation Medicine, The University of Washington, USA
b Department of Physical Therapy and Rehabilitation Science, University of Texas Medical Branch, USA
c Department of Pharmacy, University of Texas Medical Branch, USA

⁎Corresponding author: Kathleen Cummer. kcummer@uw.edu

Received: , Accepted: ,
Professor P K Surendran Memorial Education Foundation
Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

Abstract

Up to 25 % of people who undergo total hip arthroplasty (THA) or total knee arthroplasty (TKA) in the United States live with diabetes. Due to variability in complication rates reported between those with and without diabetes who undergo total joint arthroplasty, this study aimed to compare postoperative outcomes up to 5 years after THA or TKA for patients with and without diabetes.

Using the TriNetX database, patients who underwent THA or TKA were categorized into three cohorts: type 2 diabetes mellitus (T2DM), type 1 diabetes mellitus (T1DM), and no diabetes (controls). Propensity matching based on age, race, and ethnicity created comparable cohorts for analysis at 90 days, 2 years, and 5 years, with outcomes assessed using odds ratios and confidence intervals.

After propensity matching, 97,404 T2DM patients were compared to controls, and T2DM patients showed consistently worse outcomes. At 90 days, T2DM patients had 25.7 % higher readmission odds, 12.5 % higher manipulation under anesthesia rates, and 33 % higher rates of infections. At 2 years, individuals with T2DM were more likely to experience episodes of readmission (17 %), revision arthroplasty (13 %), and resection arthroplasty (31 %), escalating to 32 % higher readmissions, and 57 % higher distal femur fracture plating (57 %) at 5 years. The 298 T1DM showed no statistically significant differences compared to controls for any complication.

These findings confirm that patients with T2DM undergoing THA or TKA had significantly greater odds of complications compared to no diabetes controls and indicate the need for close postoperative monitoring to minimize complication risk.

Keywords

Type 1 diabetes mellitus
Type 2 diabetes mellitus
Total knee arthroplasty
Total hip arthroplasty
Diabetes post-operative outcomes
1

1 Introduction

Diabetes mellitus represents a significant comorbidity in orthopedic surgery, affecting approximately 17 % of patients undergoing total hip arthroplasty (THA) and 25 % of those receiving total knee arthroplasty (TKA).1,2 With over 42 million Americans living with either type 2 diabetes mellitus (T2DM) or type 1 diabetes mellitus (T1DM),3 understanding the impact of this metabolic disorder on total joint arthroplasty outcomes has become increasingly critical for optimizing patient care and surgical planning.

The relationship between diabetes and orthopedic surgical outcomes remains complex and multifaceted. Diabetes-related complications including impaired wound healing, compromised immune function, and altered bone metabolism can potentially influence recovery trajectories following major joint reconstruction.4–6 However, existing literature demonstrates considerable variability in reported outcomes between those with and without diabetes undergoing total joint arthroplasty. For example, Marchant and colleagues1 reported a greater risk of post-operative infection for individuals with diabetes after TKA, while Bolognesi and colleagues7 reported no increased risk of infection. The same contradiction has been reported for stiffness. Fisher and colleagues8 reported at 2.8 higher odds of stiffness one year after TKA for individuals with diabetes, while a meta-analysis by Jump and colleagues9 reported no evidence that diabetes increases the risk for stiffness after TKA. Qin and colleagues10 identified possible regional differences with no significant difference between patients with diabetes and those without diabetes for risk for deep vein thrombosis (DVT) in a subset of European studies. This variability of outcomes creates uncertainty for clinicians regarding risk stratification and perioperative management strategies.11–15

Current evidence gaps limit our ability to provide evidence-based counseling to those with diabetes considering joint replacement surgery. While some studies suggest increased complication rates in the diabetes population such as increased length of hospital stay and hospital re-admission rates, the magnitude and temporal distribution of these risks across different outcome measures and is often only examined during the first 90-days after surgery due to the bundled payment programs within the US healthcare system.16–19 Studies evaluating diabetes and TKA focus on individuals with T2DM, excluding individuals with T1DM, or simply failing to clearly report the classification of diabetes of the cohort studied.11,13,16,20–22 Ortved and colleagues assessed the use of insulin in T2DM management and found worse outcomes for individuals with diabetes who are managed with insulin compared to those managed with oral medication or through diet and lifestyle approaches.23 However it is unknown if insulin use by those with T1DM negatively impacts outcomes after TKA. This suggests the importance of evaluating outcomes for individuals with both T2DM and T1DM. Finally, most existing analyses have been limited by relatively small sample sizes or single-institution experiences, potentially limiting the generalizability of findings to broader patient populations.4,18,20,24

The TriNetX research network provides a unique opportunity to examine these questions using real-world data from a large, diverse patient population across multiple healthcare organizations. This federated health research platform enables analysis of electronic medical records offering unprecedented statistical power for comparative effectiveness research. The purpose of this study was to comprehensively compare postoperative outcomes between patients with and without diabetes (either T1DM or T2DM) undergoing THA or TKA using propensity score matched cohorts from the TriNetX database. We hypothesized that patients with diabetes (either T1DM or T2DM) would demonstrate increased rates of complications including surgical revision, infection, and hospital readmission across multiple time horizons. By examining outcomes at 90 days, 2 years, and 5 years postoperatively, this study aims to provide clinicians with evidence-based data to guide perioperative counseling, risk stratification, and long-term monitoring strategies for patients with diabetes undergoing major joint reconstruction.

2

2 Methods

2.1

2.1 Study population

This retrospective cohort study was exempted by Institutional Review board # 20–0085. The TriNetX research database was retrospectively queried as of July 9, 2025. TriNetX is the global federated health research network providing access to electronic medical records (diagnoses, procedures, medications, laboratory values, genomic information) across large healthcare organizations (HCOs). This report was run on the set of HCOs grouped into a network called Research. This network included 106 HCO(s). A total of 54 providers responded with patients. All queries were developed using current procedural terminology (CPT) and International Classification of Disease 10th edition (ICD-10) codes. This query was run on the network Research with 106 HCO(s) queried and 106 HCO(s) responded.

The TriNetX database was retrospectively queried for all patients undergoing THA (CPT:27130) and TKA (CPT:27447). Individuals with T2DM were evaluated first by creating two cohorts. Cohort one included patients diagnosed with T2DM (ICD10CM:E11) at least one year before the index event, which is either hip or knee arthroplasty. Cohort two had patients with either a total knee or hip arthroplasty without any type of diabetes (T1DM or T2DM). Both groups were matched using the propensity score matching for the demographics categories of age at index event, race, and ethnicity. Propensity score matching was also done for the other diagnostic categories such as Overweight, obesity and other hyperalimentation (ICD10CM:E65-E68), Atrial fibrillation and flutter (ICD10CM:I48), Chronic kidney disease (ICD10CM:N18), Other chronic obstructive pulmonary disease (ICD10CM:J44), Essential (primary) hypertension (ICD10CM:I10), and Chronic ischemic heart disease characteristics (ICD10CM:I25). Next, a second analysis was completed specifically looking at patients with T1DM (ICD10:E10) using the same approach. Two cohorts were created, one for individuals diagnosed with T1DM at least one year before the index event and undergoing either hip or knee arthroplasty and a second cohort of patients who had either a total knee or hip arthroplasty with no diabetes. Again, both groups were propensity matched, using the same criteria as the T2DM group.

2.2

2.2 Outcomes

The following outcomes were evaluated between groups (T2DM and no diabetes; T1DM and no diabetes) at 90 days, 2 years, and 5 years postoperatively: revision (CPT:27486), resection arthroplasty (CPT:27488), closed reduction (THA only), femur fracture plating (CPT:27511, CPT:27513, CPT:27514), and prosthetic joint infection (ICD10CM:T84.53, ICD10CM:T84.54). Readmission (CPT:1013659) and manipulation under anesthesia (TKA only)(CPT:27570) were evaluated at 90 days postoperatively.

2.3

2.3 Statistical analysis

Cohorts were propensity score matched based on the criteria listed above. Differences in cohort demographics and comorbidities were assessed. Differences in outcomes of the matched cohorts were assessed using odds ratios (ORs) and 95 % confidence intervals (CIs). This was assessed twice, once for individuals with T2DM and their matched cohorts and again for individuals with T1DM and their matched cohort. Statistical significance was assessed at p ≤ 0.05. All statistical analysis was performed within the TriNetX platform.

3

3 Results

3.1

3.1 Type 2 diabetes mellitus

A query of TriNetX identified a total of 99,762 participants with T2DM and 352,329 without diabetes who underwent either THA or TKA. Prior to matching, there were significant differences in age at index event, race, ethnicity, and comorbidities among participants(Table 1). After propensity score matching, 194,808 patients who underwent either THA or TKA (97,404 with T2DM and 97,404 without diabetes) were included for analysis. There were significant differences between the groups for age, sex, chronic kidney disease and chronic obstructive pulmonary disease (p < 0.01) (Table 1). No other significant differences existed between the groups.

Table 1 Participants characteristics for individuals with and without T2DM.
Before matching After matching
Surgery + T2DMN = 99, 762 Surgery onlyN = 352,329 P-value Surgery + T2DMN = 97,404 Surgery onlyN = 97,404 P-value
Age at index 68.6 (7.3) 67.9 (7.5) <0.001 68.6 (7.3) 68.7 (7.4) 0.007
White 71,342 (71.5) 282,995 (80.3) <0.001 70,343 (72.2) 70,239 (72.1) 0.599
Hispanic or Latino 6477 (6.5) 11,249 (3.2) <0.001 5947 (6.1) 6120 (6.3) 0.104
Black or African American 13,093 (13.1) 25,742 (7.3) <0.001 12,297 (12.6) 12,366 (12.7) 0.638
Asian 3996 (4.0) 7791 (2.2) <0.001 3789 (3.9) 3794 (3.9) 0.953
Male 42,365 (42.5) 136,155 (38.6) <0.001 41, 301 (42.4) 37,905 (38.9) <0.001
Comorbidities
Overweight, obesity and other hyperalimentation 30,959 (31.0) 50,910 (14.4) <0.001 28,948 (29.7) 28,802 (29.6) 0.469
Atrial fibrillation and flutter 9356 (9.4) 19,920 (5.7) <0.001 8796 (9.0) 8583 (8.8) 0.090
Chronic kidney disease 13,196 (13.2) 15,641 (4.4) <0.001 11,410 (11.7) 11,051 (11.3) 0.011
Other chronic obstructive pulmonary disease 6925 (6.9) 12,737 (3.6) <0.001 6374 (6.5) 6083 (6.2) 0.007
Essential hypertension 65,349 (65.5) 140,226 (39.8) <0.001 63,016 (64.7) 63,347 (65.0) 0.116
Chronic ischemic heart disease 17,854 (17.9) 28,936 (8.2) <0.001 16,390 (16.8) 16,240 (16.7) 0.363

The odds of readmission in the first 90-days after surgery were 25.7 % higher in the T2DM group compared to the individuals without diabetes [(OR = 1.257 CI (1.230, 1.285)]. Individuals with T2DM were 12.5 % more likely undergo manipulation under anesthesia [(OR = 1.195, CI (1.106, 1.292)], and experience periprosthetic joint infection compared to those with no diabetes [(OR = 1.334, CI (1.185, 1.502)] (Table 3). At 2 years after surgery, individuals with T2DM were more likely to experience episodes of readmission (17 %) [OR = 1.170, CI (1.150, 1.190)], revision arthroplasty (13 %) [OR = 1.138, CI (1.024, 1.264)], and resection arthroplasty (31 %) [OR = 1.314, (1.062, 1.625)] compared to those with no diabetes. At 5 years after surgery, individuals with T2DM were more likely to experience episodes of readmission (32 %) [OR = 1.321, CI (1.296, 1.347)], revision arthroplasty (18 %) [OR = 1.181, CI (1.076, 1.296)], resection arthroplasty (29 %) [OR = 1.292,CI (1.077, 1.550)], and more likely to experience distal femur fracture plating (57 %) [OR = 1.571, CI (1.198, 2.059)] (Table 3).

Table 2 Participants characteristics for individuals with and without T1DM.
Before matching After matching
Surgery + T1DMN = 301 Surgery onlyN = 354,541 P-value Surgery + T1DMN = 298 Surgery onlyN = 298 P-value
Age at index 68.2 (7.6) 67.9 (7.5) 0.491 68.2 (7.6) 68.4 (7.5) 0.774
White 241(80.9) 282,995 (80.3) 0.811 241 (80.9) 240 (80.5) 0.917
Hispanic or latino 10 (3.4) 11,249 (3.2) 0.873 10 (3.4) 10 (3.4) 1.00
Black or African American 29 (9.7) 25,742 (7.3) 0.108 29 (9.7) 28 (9.4) 0.638
Asian 10 (3.4) 7791 (2.2) 0.179 10 (3.4) 10 (3.4) 0.953
Male 115 (38.6) 136,155 (38.6) 0.985 115 (38.6) 123 (41.3) <0.001
Comorbidities
Overweight, obesity and other hyperalimentation 55 (18.5) 50,910 (14.4) 0.049 55 (18.5) 55 (18.5) 1.00
Atrial fibrillation and flutter 28 (9.4) 19,920 (5.7) 0.005 28 (9.4) 27 (9.1) 0.887
Chronic kidney disease 32 (10.7) 15,641 (4.4) <0.001 32 (10.7) 30 (10.1) 0.788
Other chronic obstructive pulmonary disease 17 (5.7) 12,737 (3.6) 0.053 17 (5.7) 16 (5.4) 0.858
Essential hypertension 157 (52.7) 140,226 (39.8) <0.001 157 (52.7) 162 (54.4) 0.681
Chronic ischemic heart disease 32 (10.7) 28,936 (8.2) 0.113 32 (10.7) 31 (10.4) 0.894
Table 3 Outcomes after knee or hip arthroplasty in people with and without T2DM.
Outcomes Surgery + T2DM Surgery only Odds ratio
Patients in cohort (97,404)Patients with outcome Patients in cohort (97,404)Patients with outcome T2DM vs Surgery only
90-d outcomes
Readmission 22,713 18,972 1.257 (1.230, 1.285)
Revision arthroplasty 302 258 1.171 (0.992, 1.383)
Resection arthroplasty 50 39 1.282 (0.843, 1.949)
Distal femur fracture plating 19 25 0.760 (0.418, 1.380)
Manipulation under anesthesia 1418 1189 1.195 (1.106, 1.292)
Periprosthetic joint infection 642 482 1.334 (1.185, 1.502)
2-y outcomes
Readmission 29,668 24,564 1.170 (1.150, 1.190)
Revision arthroplasty 749 659 1.138 (1.024, 1.264)
Resection arthroplasty 197 150 1.314 (1.062, 1.625)
Distal femur fracture plating 79 66 1.197 (0.863, 1.660)
5-y outcomes
Readmission 34,646 28,706 1.321 (1.296, 1.347)
Revision arthroplasty 975 827 1.181 (1.076, 1.296)
Resection arthroplasty 266 206 1.292 (1.077, 1.550)
Distal femur fracture plating 135 86 1.571 (1.198, 2.059)
3.2

3.2 Type 1 diabetes mellitus

Three hundred and one participants with T1DM and 354,541 without diabetes underwent either TKA or THA (Table 2). After matching propensity scores, 596 patients were included for analysis (298 with T1DM and 298 without diabetes). There were significantly more males in the T1D group (p < 0.01), but no other demographic differences were noted between the groups (Table 2).

The odds of readmission in the first 90-days after surgery were similar between those with T1DM and those without diabetes (63 vs 60 patients), with an OR = 1.063, 95 % CI: 0.715–1.581, indicating no statistically significant difference (Table 4). T1DM patients required manipulation under anesthesia more frequently than those without diabetes (10 vs 1 patient), suggesting possible stiffness or healing complications. However, results were not statistically significant [OR = 1.00, CI (0.410, 2.439)] (Table 4). No notable differences were found between the two groups for periprosthetic joint infection. At 2 years after surgery, no significant differences were found for any outcomes such as readmission, revision, resection arthroplasty, and distal femur fracture plating (Table 4), with no differences at 5-years.

Table 4 Outcomes after knee or hip arthroplasty in people with and without T1DM.
Outcomes Surgery + T1DM Surgery only Odds ratio
Patients in cohort (298)Patients with outcome Patients in cohort (298)Patients with outcome
90-d outcomes
Readmission 63 60 1.063 (0.715, 1.581)
Revision arthroplasty 10 0 NA
Resection arthroplasty 0 0 NA
Distal femur fracture plating 0 10 NA
Manipulation under anesthesia 10 1 1.00 (0.410, 2.439)
Periprosthetic joint infection 10 10 1.00 (0.410, 2.439)
2-y outcomes
Readmission 76 79 0.949 (0.658,1.369)
Revision arthroplasty 10 10 1.00 (0.410, 2.439)
Resection arthroplasty 10 10 1.00 (0.410, 2.439)
Distal femur fracture plating 0 10 NA
4

4 Discussion

This large-scale analysis of nearly 200,000 propensity-matched patients represents one of the most comprehensive examinations of the impact of diabetes (T1DM or T2DM) on total joint arthroplasty outcomes to date. Our findings demonstrate consistently elevated complication rates across multiple outcome measures and time horizons for individuals with T2DM, yet no increase in complications for those with T1DM. Our results corroborate and extend previous smaller-scale studies demonstrating increased complication rates in those with T2DM after total joint arthroplasty.25–27 The consistency of our findings across multiple outcome measures strengthens the evidence base for T2DM as a significant risk factor in total joint arthroplasty. The large sample size and propensity matching methodology employed in this analysis help address limitations of previous investigations, providing more robust estimates of risk magnitude.

The temporal pattern of complications observed—with risks persisting and in some cases increasing to the 5-year follow-up period—suggests that diabetes-related complications in joint replacement extend beyond the acute perioperative phase.17 This finding has important implications for long-term surveillance protocols and patient education regarding ongoing risk awareness. Interestingly, we found no increase in complication risk for individuals with T1DM compared to those without diabetes, regardless of time period. This contradicts evidence from Duensing and colleagues,28 who reported increased periprosthetic joint infection rates for those with T1DM (7 %) compared to those with T2DM (4 %) and those with no diabetes (2.6 %). A systematic review and meta-analysis by Wu and colleagues29 reported similar findings with increased risk of complications in individuals with insulin dependent diabetes mellitus. However, individuals with T1DM and T2DM can be medically managed using insulin, yet based on our findings, can have different outcomes. Including patients with T1DM or T2DM, as diagnosed by a physician, is a strength of our study.

The substantially increased readmission and infection rates in those with T2DM observed across time points have significant implications for healthcare resources. The 26 % increased odds of readmission in the first 90-days and 32 % increased odds at 5 years suggest that patients with T2DM require more intensive postoperative support systems and monitoring protocols.30,31 The 33 % increased risk of periprosthetic joint infection at 90 days aligns with established understanding of diabetes-related immune dysfunction and wound healing impairment.7,32 However, the persistence and amplification of these risks over time—with 57 % higher odds of distal femur fracture plating at 5 years—suggests that patients with T2DM require extended surveillance beyond the immediate perioperative period. Postoperative glucose monitoring and management protocols should be standardized to minimize hyperglycemia-related complications during the critical healing period.33 Additionally, cost-effectiveness analyses of enhanced monitoring and intervention protocols in those with diabetes undergoing THA or TKA could inform healthcare policy decisions.

Our findings underscore the critical importance of comprehensive preoperative diabetes management. Optimal glycemic control should be achieved prior to elective surgery when possible34,35; however, the inconsistency of studies and outcomes makes recommendations unclear. While optimal diabetes control recommends a hemoglobin A1c (A1C) < 7 %,36 surgical guidelines range from 7 to 9 %.37 An A1C goal of <8 % has been widely accepted; however, surgical preference may vary.38 Multidisciplinary care coordination involving endocrinology, orthopedic surgery, and perioperative medicine teams may help optimize outcomes through a systematic approach to metabolic management.33

The increased manipulation under anesthesia rates (20 % higher odds) in T2DM patients suggests potential differences in postoperative stiffness and range of motion recovery. Physical therapy protocols may require modification to account for potentially slower healing trajectories and increased risk of joint stiffness in this cohort.39,40 This is consistent with findings of worse post-operative ROM for up to 5 years after TKA in those with T2DM, compared to those without diabetes.11 Early mobilization strategies, while maintaining appropriate precautions for wound healing, may be particularly important in this population. Despite this, recent physical therapy guidelines after TKA do not recommend modifications in rehab specifically for individuals with diabetes, however, they report that more research is required for this subgroup.41

The elevated revision rates (13 % at 2 years, 18 % at 5 years) and resection arthroplasty requirements (31 % at 2 years, 29 % at 5 years) in T2DM patients likely reflect the complex interplay between metabolic dysfunction, bone quality, and implant integration.24,42 The burden of additional surgery not only impacts patients' function and quality of life, but will also impact them financially.13 Our findings support the need for enhanced preoperative and post-operative optimization protocols, including glycemic control assessment and multidisciplinary diabetes management consultation prior to elective joint replacement.

Several limitations warrant consideration. The retrospective nature of this analysis limits our ability to assess causality or control for unmeasured confounders such as diabetes severity, glycemic control quality, or specific diabetes management strategies. Additionally, the database structure does not permit detailed analysis of surgical technique variations, implant selection, or institutional practice differences that may influence outcomes. Furthermore, the analysis does not differentiate between hip and knee arthroplasty outcomes, which may have distinct risk profiles in patients with diabetes.

5

5 Conclusion

This comprehensive analysis provides compelling evidence that T2DM significantly increases the risk of complications following total joint arthroplasty across multiple outcome measures and time horizons. The consistency and magnitude of these findings support the implementation of enhanced perioperative optimization protocols, extended postoperative monitoring strategies, and modified rehabilitation approaches for diabetic patients undergoing joint replacement surgery. Our unique findings for T1DM report no increased risk for complications after THA or TKA, which warrants further investigation, as there is limited research in this cohort. The complexity of diabetes management demands that future investigations should focus on identifying specific diabetes-related factors that most strongly predict adverse outcomes, including A1C levels, diabetes classification (T1DM or T2DM), diabetes duration, and presence of diabetic complications.43,44 Overall, our study findings emphasize the critical need for enhanced postoperative monitoring, specifically for T2DM patients to minimize complications and optimize long-term outcomes.

Author contributions

Dr. Kaur completed the data extraction and data analysis. All authors reviewed the findings and participated equally in manuscript development. All authors have read and approved the final submitted manuscript.

Ethical statement

This retrospective cohort study was exempted by Institutional Review board # 20–0085.

Funding

There was no funding received for this study.

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