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Outcomes of total knee arthroplasty in people with diabetes: An overview of systematic reviews and meta-analysis
⁎Corresponding author: Raju Vaishya. raju.vaishya@gmail.com
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Received: ,
Accepted: ,
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.
Abstract
Abstract
Total knee arthroplasty (TKA) in people with diabetes is associated with increased risks of postoperative complications. This review evaluates how diabetes influences complication rates and overall outcomes following TKA.
An overview of systematic reviews and meta-analyses was conducted, with a comprehensive search performed across databases including PubMed, Scopus, Web of Science, and the Cochrane Library. The protocol was registered on PROSPERO on December 12, 2024.
People with diabetes undergoing TKA face a 43 % higher risk of periprosthetic joint infection (PJI) and are 45 % more likely to experience deep vein thrombosis (DVT). The rates of hospital readmissions were significantly higher, showing a 28 % increased likelihood. Subpopulations with insulin-treated diabetes exhibited a 60 % greater incidence of perioperative adverse events. Notably, people with diabetes undergoing TKA had significantly higher odds of developing infection (OR 1.97, 95 % CI 1.48–2.61, p = 0.004) and deep PJI (OR 2.10, 95 % CI 1.49–2.95, p < 0.001). Significantly higher odds of DVT were observed in people with diabetes (OR 1.43, 95 % CI 1.23–1.66, p < 0.0000). Inadequate perioperative glycemic control was identified as a modifiable risk factor, although definitions varied widely across studies.
The presence of diabetes significantly impacts post-TKA outcomes, leading to higher complication rates and negatively affecting physical function and quality of life. Further rigorous studies are needed to establish standardized definitions for glycemic control and to investigate mechanisms contributing to increased risks, facilitating improved preoperative risk stratification and management strategies for diabetic patients undergoing TKA.
Abstract
Graphical abstract
Image 1
Abstract
Key Highlights
•People with diabetes face more complications: infections, thrombosis.•Insulin-treated diabetics face 60% higher perioperative adverse events.•Poor sugar control around TKA surgery worsens outcomes.
Keywords
Total knee arthroplasty
Diabetes mellitus
Postoperative complications
Periprosthetic joint infection
Glycemic control
1 Introduction
Total knee arthroplasty (TKA) is a popular and effective surgery for patients with advanced knee arthritis. Still, it carries with it a risk of complications, particularly for patients with comorbidities, including diabetes mellitus. More than half of people with diabetes have coexisting arthropathy. They may need a hip or knee arthroplasty in the future.1 As the prevalence of diabetes is increasing worldwide, the number of such patients who need joint replacement surgery is also expected to increase correspondingly. It has also been found that up to 50 % of patients undergoing TKA may have diabetes before the operation.2 Diabetes is a significant risk factor for periprosthetic joint infection (PJI) following total joint arthroplasty.1 Deep vein thrombosis (DVT) is another crucial postoperative complication after TKA, which may also cause pulmonary embolism, resulting in increased morbidity and mortality. Diabetes might also be a risk factor for DVT and Pulmonary Embolism (PE) after TKA, but studies are discordant in this regard.3
In general, people with diabetes may have higher complication rates, including infection, vascular disease, myocardial infarction, hospital readmission, and increased death rates after TKA.1–4 The first meta-analysis in this regard, published in 2014, found that people with diabetes undergoing TKA had higher odds of DVT, aseptic loosening, prosthetic joint infection (PJI), and periprosthetic fracture.4 Besides this, diabetes adversely affects physical functions and health-related quality of life after TKA.5
Inadequate perioperative glycemic control has been purported as a modifiable risk factor, and improving the same may reduce complications after TKA. Still, such association has been disputed due to differences in definitions of glycemic control in various studies (based on blood glucose level or glycated haemoglobin - HbA1C) and heterogeneity of study designs. The American Diabetes Association recommended HbA1C for monitoring. Still, its importance in arthroplasty cases is not firmly established, as the association with higher infection risk and the preoperative HbA1C threshold for SSI remain controversial. Arthroplasty surgeons have been using 7 % as a target HbAlC despite a lack of robust evidence.6 Perioperative hyperglycaemia due to surgical stress has also been found to be an independent risk factor for SSI, even in patients without diabetes.7
Type 2 Diabetes (T2D) is increasing in South Asia and India at a rapid pace.8 In addition, obesity is on the rise and remains a significant determinant of T2D.9,10 These conditions are now prevalent in young individuals, making them more susceptible to complications.11 In a new classification of obesity in Asian Indians, it is people with stage 2 obesity who have complications with knee osteoarthritis (OA).12 Although there is a dearth of data, OA likely ascribed to obesity and T2D will increase in Asian Indians.
Amongst people with insulin-treated diabetes (ITD), there was a higher rate of perioperative adverse events, especially cardiac complications after elective noncardiac surgery, including lower limb arthroplasty.13 The relationship between ITD and the rate of adverse events, as per the available literature, is worth exploring, as it may be helpful in inpatient counselling, preoperative risk stratification, and implementing appropriate preventive strategies.13,14
There is no overview of systematic reviews and meta-analyses on the overall effect of TKA on people with diabetes or the effect of diabetes on the outcomes of TKA published. We, therefore, asked how the presence of diabetes affects the outcomes and complication rates after TKA and planned an overview of available systematic reviews and meta-analyses to answer the same.
2 Methods
This overview of systematic reviews and meta-analyses on the outcomes of TKA was conducted per the guidelines provided in the Cochrane Handbook for Systematic Reviews of Interventions (available online, https://training.cochrane.org/handbook/current). The protocol was submitted for pre-registration at PROSPERO (with provisional registration number 593570) and was registered on December 12, 2024, with registration no CRD42024593570.
2.1 Search methods
Several databases, including PubMed, Scopus, Web of Science, and the Cochrane Library, were searched using multiple keywords combined with appropriate Boolean operators (((Diabetes mellitus) OR (Diabetes)) OR (Prediabetes)) OR (metabolic syndrome)) AND ((((((Total knee replacement) OR (total knee arthroplasty)) OR (TKR)) OR (TKA))) (See supplementary file for a complete search strategy).
2.2 Eligibility criteria
Our inclusion criteria covered all systematic reviews and meta-analyses that focused on outcomes in adults (aged over 18 years) with T2D undergoing TKA. The studies included people with diabetes without consistently distinguishing between type 1 diabetes (T1D) and T2D, as most of the reviewed articles did not specify the diabetes type. This broader group, referred to as "people with diabetes," included a subset of individuals requiring insulin—covering both insulin-dependent T1D and insulin-requiring T2D (when specifically defined by authors), now collectively termed "insulin-treated diabetes" (ITD)—who were analyzed separately for complications.
The exclusion criteria included narrative reviews/expert opinions; articles focussed only on the effects of metabolic syndrome (MetS) on arthroplasty surgery; case reports and letters; preclinical and pathophysiological articles and reviews; animal studies and non-English literature.
2.3 Selection of articles
All search results from the individual databases were downloaded in suitable file formats and put on Endnote-web for deduplication and manual selection. Title screening was performed by two authors (initials blinded for review), followed by screening abstracts and full texts according to the inclusion and exclusion criteria mentioned above. The references of the selected papers were also screened for other relevant articles. Discrepancies, if any, were resolved after the involvement of the senior author (initials blinded for review).
2.4 Data extraction, synthesis, and quality assessment
Besides assessing the risk of bias as per AMSTAR 2 criteria, data extraction and qualitative synthesis were performed in the format of the two authors (initials blinded for review). Any disagreements were resolved after discussion with the senior author (initials blinded for review). All relevant data, including mean age, BMI, sex, follow-up periods, and statistical analyses, including summary data (e.g., means, SDs) for outcome measures/patient-reported outcome measures, Pain (Visual Analogue Scale-VAS), stiffness, ROM, strength, complications circulatory, e.g. DVT, PE, urinary tract infections, (UTIs), pulmonary-e.g. pneumonia, gastrointestinal, surgical site infection (SSI)-superficial or deep Prosthetic Joint Infections-PJI, mortality, 30-day readmission), and HRQoL were reviewed, and relevant data was tabulated. Some studies were excluded if they focussed on revision arthroplasty or if data was unavailable in a suitable meta-analysis format. We did not contact the authors of primary studies for clarification regarding data. We explored the primary studies for revised meta-analysis to see if data in a suitable format was unavailable from the available systematic reviews. Glycemic control, as defined by American Diabetes Association (ADA) guidelines as a target HbA1c of below 7 %,15 was used in most studies, though the specific threshold for minimizing surgical risks remains unclear.
AMSTAR 2 criteria assessed study quality/risk of bias of individual systematic reviews and meta-analyses, and the results were depicted as traffic light plots generated using the Robvis tool. AMSTAR 2 criteria are used for evaluating study quality/risk of bias in systematic reviews and meta-analyses and carry 16 domains that assess different aspects of risk of bias in each systematic review. The responses are marked as yes, partial yes or no, and overall scoring is optional.
2.5 Statistics
Meta-analysis performed in individual reviews was reviewed, and a revised meta-analysis was conducted as appropriate. We pooled the results using a random-effects meta-analysis (e.g., the DerSimonian and Laird method) or a fixed-effect meta-analysis, as appropriate (a fixed-effect model was used if I2 <50 %, and a random-effects model was applied if I2 > 50 %) and reported odds ratio/risk ratio for categorical outcomes and mean difference (MD)/Standardized mean difference (SMD) along with 95 % confidence intervals. Heterogeneity between the studies in effect measures was assessed using the Chi2 and I2 statistics. Suitable forest plots and funnel plots (to depict possible publication bias) were generated. Rosenthal Fail-safe N analysis was conducted for each variable for publication Bias using Jamovi software, along with the rank correlation and regression tests, using the standard error of the observed outcomes as a predictor to check for funnel plot asymmetry. The possible reasons responsible for discordance in the results of the published meta-analysis, including the role of confounding factor(s), if any, were explored, and subgroup analysis was performed as necessary. Subgroup analyses were planned based on biological differences, taking guidance from primary systematic reviews of the nature of infection (superficial vs deep), type of arthroplasty (TKA) and native place for DVT/PE. Libre Office for Mac, version 7.3.7.2, was used for data management, and all meta-analysis was conducted using Revman for Mac, version 5.4.1(Nordic Cochrane Center), and Jamovi for Mac, Version 2.3.28 for intel. The overlapping of primary studies in systematic reviews was analyzed as a 'Corrected Covered Area' and depicted in the figure as a 'Graphical Representation of Overlap for Overviews' (Fig. 6). A two-sided p-value <0.05 was considered statistically significant.
3 Results
3.1 Literature search
The search resulted in 1055 documents on PubMed, 1761 on Scopus (all fields search), and 933 on the Web of Science (WoS). The search was then restricted to systematic reviews and meta-analysis, and it left 40 results from PubMed (filters applied-reviews/systematic reviews/meta-analysis), 162 documents on Scopus (reviews), and 80 results on the WoS (review article). Thus, we had 282 papers, and 231 were left after deduplication. After reviewing the titles, 21 papers related to TKA in people with diabetes were isolated. Finally, 11 systematic reviews with meta-analysis1–7,13,14,16,17 were left after the abstract and full-text screening and were considered for the present overview (Fig. 1) (see Fig. 2).
3.2 Characteristics of the studies
All these studies/reviews were published in the years 2014–2024. Details of these reviews have been described in Supplementary Table 1. The first systematic review and meta-analysis by Yang et al. included the effect of diabetes on all relevant postoperative outcomes after TKA.4 However, other reviews have taken a more focused approach by examining specific aspects. For instance, some studies investigated the role of glycemic control and HbA1C levels as predictors of surgical site infections (SSI) and PJI (Yang L et al.,3 Shohat et al.,5 and Ahmad et al.7) ]. One study looked at the effect of diabetes on knee stiffness following TKA (Jump et al.).16 One review specifically analyzed the relationship between diabetes and the risk of DVT (Yang et al.).1 Additionally, two studies examined how insulin resistance influences postoperative complications, outcomes, and mortality (Wu et al.13 and Chalidis et al.14). Other reviews investigated the effect of diabetes on outcomes following lower extremity arthroplasty (Quin et al. 2 and TKA (Na et al.,5 including physical function, ROM, and health-related quality of life. Lastly, one study analyzed the impact of all relevant comorbid conditions, including diabetes, on surgical outcomes (Podmore et al.).16
3.3 Meta-analysis for people with diabetes vs. no diabetes undergoing TKA
3.3.1 Risk of infection
Significantly higher odds of developing infection were found in people with diabetes undergoing TKA as compared to people without diabetes on a meta-analysis of 14 studies, with an odds ratio (OR) 1.97(95 %CI 1.48–2.61), p0.004; I square was 58 % so random effects model was used. Funnel plots indicated no significant publication bias, and neither the rank correlation nor the regression test indicated any funnel plot asymmetry (p- 0.5056 and p-0.5559, respectively), with Rosenthal fail-safe N (241, p < 0.001).
When performing a subgroup analysis by classifying infection as superficial infection, PJI, and unspecified infection, we see that a significantly higher infection rate persisted amongst people with diabetes (as compared to people with no diabetes in the deep PJI subgroup only, with OR 2.10(95 %CI 1.49–2.95), p < 0.001 on a meta-analysis of 11 studies; I square was 63 % so random effects model was used. However, the test for subgroup differences was not significant, Chi Square = 1.52. p-0.47 (Fig. 2 a, 2band 2c).
3.3.2 Glycaemic control and risk of infection
Higher odds of developing infection were found in people undergoing joint replacement surgery with poor glycemic control as compared to those with reasonable glycemic control on a meta-analysis of 11 studies, but it was not significant with OR 1.41(95 %CI 0.94–2.12), Z = 1,64, p-0.10; I square was 80 % so random effects model was used. Furthermore, the basis (blood glucose or HbA1C) and the precise definition of glycemic control were highly variable among studies, further justifying the random effects model. Funnel plots looked symmetric, indicating no significant publication bias, and neither the rank correlation nor the regression test indicated any funnel plot asymmetry (p- 0.5423 and p-0.3012, respectively), with Rosenthal fail-safe N (34, p < 0.001).
When performing a subgroup analysis by considering two studies reporting only TKA as a separate subgroup, we see a trend toward higher infection rate seen amongst people undergoing TKA with poor glycemic control, as compared to those with reasonable glycemic control, but the effect was not statistically significant with OR 2.29(95 %CI 0.16–32.29), Z = 0.62, p = 0.54; I square was 71 % so random effects model was used. However, the test for subgroup differences was not significant, Chi Square = 0.11, df = 1, p-0.74 (Fig. 3A and B)
3.3.3 Risk of deep vein thrombosis (DVT)
Significantly higher odds of developing DVT were observed in people with diabetes as compared to people with no diabetes on a meta-analysis of 12 studies, with OR 1.43(95 %CI 1.23–1.66), Z = 4.62, P < 0.0000 (Fig. 4A). Funnel plots looked symmetric, indicating no significant publication bias, and neither the rank correlation nor the regression test indicated any funnel plot (p-0.1366 and p-0.8484, respectively), with Rosenthal fail-safe N (15, p = 0.011) (Fig. 4B). When analyzing the rates of DVT in patients undergoing TKA, subgroup analysis reveals intriguing differences based on geographic classification. Specifically, the meta-analysis of eight studies conducted in Asian countries indicates that people with diabetes have a significantly higher rate of DVT compared to those without it (with an OR of 1.59 (95 % CI 1.31–1.92). The Z-score of 4.79 and a p < 0.0001 underscore the statistical significance of this finding, suggesting that diabetes poses a considerable risk for DVT in this demographic situation. Furthermore, the I2 statistic of 50 % indicates moderate heterogeneity among the studies included in this meta-analysis. Interestingly, while the significant association between diabetes and increased DVT risk is clear, the test for subgroup differences shows a non-significant result (Chi-Square = 3.40, df = 1, p-0.07) (Fig. 4A and B).
Moreover, significantly higher odds of developing DVT persisted when meta-analyzing seven studies reporting patients receiving chemoprophylaxis for DVT in people with diabetes undergoing TKA as compared to people with no diabetes with OR 1.71(95 %CI 1.25–2.33), Z = 3.38, p-0.0007; random effects model. On subgroup analysis for Asian people with diabetes receiving chemoprophylaxis for DVT, the effect was significant only in the Asian subgroup, with an OR of 1.72 (95 %CI 1.23–2.39), Z = 3.19, p-0.001, I square = 51 %; random effects model; but the test for subgroup differences was not significant (Chi square = 0.09, p-0.76) (Fig. 4C).
3.4 Risk of bias
As per AMSTAR 2 criteria, five studies had a low risk of bias, three had moderate, and three had a high risk of bias (Fig. 5).
The overlapping of primary studies in systematic reviews was analyzed as a Corrected Covered Area, indicating slight overlap. (Fig. 6). Very high or high mutual overlap was seen for systematic reviews by An et al.,3 Ahmad et al.,1 Qin et al.,2 Wu et al.,13 Shohat et al.,6 Yang L et al.4 and Yang Z et al.,7 possibly because they addressed very similar research question (effect of diabetes on the outcomes and complications like PJI, DVT/PE etc. after TKA). Whereas moderate or slight overlap was seen for reviews by Podmore et al.17 and Jump et al.,16 as they studied the effects on outcomes of TKA for other comorbidities besides diabetes (Podmore B et al.17) or analyzed a narrowly focused research question-effect of diabetes on knee stiffness after TKA (Jump et al.16).
4 Discussion
This overview of meta-analyses found that people with diabetes undergoing TKA face a 43 % higher risk of periprosthetic joint infection (PJI) and are 45 % more likely to develop DVT. The rates of hospital readmissions were significantly higher, showing a 28 % increased likelihood. Subpopulations with ITD exhibited a 60 % greater incidence of perioperative adverse events. Notably, people with diabetes undergoing TKA had significantly higher odds of developing infection (OR 1.97, 95 % CI 1.48–2.61, p = 0.004) and PJI (OR 2.10, 95 % CI 1.49–2.95, p < 0.001). Significantly higher odds of DVT were observed in people with diabetes (OR 1.43, 95 % CI 1.23–1.66, p < 0.0000).
Impact of Diabetes on TKA Outcomes: Diabetes can accelerate the joint degenerative process, leading to fast disease progression in knee OA and more need for TKA in such patients. Moreover, the physiological stress due to the operation, compounded with pre-existing diabetes, can worsen glycemic control, thereby leading to an enhanced risk of complications, impaired tissue healing, and affected functional outcomes.1,17 Halabitska et al. (2024) reported that insulin could influence joint health by modulating inflammatory pathways. Metformin, known for its anti-inflammatory effects through AMPK activation, shows potential in slowing OA progression by protecting cartilage and reducing inflammation. GLP-1-based therapies, which improve metabolic profiles in diabetes, also demonstrate anti-inflammatory effects that could benefit OA by suppressing joint inflammation and aiding cartilage repair.18
Postoperative Infections: Diabetes is known to be an independent risk factor for PJI. Hyperglycaemia can adversely affect the immune system in the long run by affecting leukocyte activity, favouring the establishment of superficial and deep infections. Also, diabetes impairs wound healing due to microangiopathic changes, which lead to tissue ischemia, and hypoperfusion may also reduce local tissue antibiotic concentration, thereby favouring the establishment of infection. Besides glycaemic control, several other factors affect the infection rate, including soft tissue handling and surgery duration.19–22 Reasonable perioperative glycemic control may reduce the likelihood of infection in patients undergoing TKA, as per several studies and review by Agos et al..23 The risk of superficial SSI was not significantly different, and more research is necessary. Moreover, Superficial SSI is less severe and usually responds to antibiotics.1
Deep Vein Thrombosis: A recent meta-analysis of 12 studies found that patients with diabetes have significantly higher odds (1.43 times) of DVT compared to those with normal blood sugar levels undergoing TKA. Notably, this increased risk was more pronounced in Asian patients, with an OR of 1.59.24 These findings suggest that ethnicity may influence DVT risk in people with diabetes. The analysis focused on Asian populations, highlighting the importance of considering regional healthcare contexts and practices, such as the diagnostic methods for DVT, which differ from those used in Western countries. The research highlights the need for tailored DVT prevention strategies and emphasizes the importance of managing diabetes preoperatively to mitigate complication risks.2,3
Despite the anticipated improvements in mobility and overall health metrics following TKA, some studies report counterintuitive results regarding MetS and glycemic control. For instance, one study found no reduction in the prevalence of MetS after surgery, although blood pressure and triglyceride levels improved. Interestingly, fasting plasma glucose levels and the prevalence of diabetes increased in the same cohort.25 Another study confirmed significant decreases in blood pressure post-surgery but did not find a significant reduction in fasting blood glucose levels.26 Both studies reported improved knee functional outcomes, which suggests that while TKA may improve physical activity, managing diabetes is a complex issue requiring further investigation.
Knee stiffness: Several factors, including diabetes, may contribute to knee stiffness after TKA.16 People with diabetes are known to be at high risk of frozen shoulders, and it is speculated that they might have greater knee stiffness, even after TKA, than people with no diabetes.27 Higher levels of pro-inflammatory cytokines like TNF-α, IL-6, and IL-1B have been proposed to lead to deposition of greater extracellular matrix and fibrosis. Toll-like receptor 4- 4-activation also leads to synovial hyperplasia, activation of macrophages, chondrocyte damage, and joint degradation.28 Advanced glycation endproducts (AGEs) promote higher collagen crosslinking, thereby affecting tissue biomechanics adversely-leading to stiffness, and it is known that people with diabetes have a higher risk of suffering from knee OA.29,30 Not all joints, however, are affected equally by diabetes - different joints expressing varying receptors for inflammatory cells and structural/anatomical differences between joints and varying quantum of usage in daily life might also affect the risk of developing stiffness at any joint.31 Myofibroblast–mast cell–neuropeptide pathway activation in response to injury may increase stiffness after knee surgery.32,33 Despite these pathophysiological hypotheses and limited clinical data indicating knee stiffness after TKA in people with diabetes, there is no substantial evidence suggesting that these people are at a higher risk of postoperative knee stiffness or unsatisfactory functional outcomes after TKA. Our overview of meta-analyses has supported this (although it has been speculated that this may be due to better/more attentive physiotherapy provided to people with diabetes due to fear of stiffness). Therefore, the fear of postoperative knee stiffness should not deter one from considering TKA.15,16
4.1 Recommendations for clinical practice
The findings of this review carry significant implications for the Indian population, particularly given the rising prevalence of diabetes in the country. With an increasing number of people suffering from diabetes-related complications,34 the heightened risk associated with TKA underscores the necessity for targeted preoperative management strategies. As diabetes is often linked with obesity, which is also on the rise among younger adults in India, healthcare providers must prioritize improving glycemic control and optimizing patient health before surgical interventions. Additionally, awareness campaigns focusing on the risks of TKA for people with diabetes, as well as the importance of proper diabetes management, could enhance surgical outcomes and reduce the incidence of postoperative complications such as PJI and DVT. This proactive approach is crucial in a healthcare landscape where the demand for TKA is expected to grow alongside the diabetes epidemic. Ensuring optimal glycemic management, minimizing soft tissue disruption, and tailoring rehabilitation strategies are vital for improving surgical outcomes in people with diabetes undergoing TKA and other orthopaedic procedures.35–37
Limitations and Future Directions: Despite the valuable insights provided by existing meta-analyses, limitations such as variable definitions of disease states, small sample sizes, inconsistent outcome measures, and heterogeneity restrict the applicability of findings across all patient populations. Moreover, being a review of the previously published systematic reviews, the study does not analyze any new data. The duration of follow-up and the diagnostic criteria for deep and superficial SSI and glycemic control differed across studies. Regarding glycemic control definitions, the studies show substantial heterogeneity in thresholds used to define poor control. Almost all studies, except that of Shohat et al.,6 did not define any threshold levels of HbA1C or blood glucose levels (Table 1). Shohat's data reveals HbA1c cutoffs ranging from 6.5 % to 8.0 %, with 7.0 % being most common across six studies, while glucose thresholds vary from >126 mg/dL to >200 mg/dL for fasting levels and >180 mg/dL to >194 mg/dL for hyperglycaemia.
| Authors, Publication Year, and Reference Number | Type of Diabetes/Glycaemic Control mentioned |
| An J et al. (2024)3 | T1 DM and T2 DM |
| Ahmad MA et al. (2022)1 | Diabetes |
| Chalidis B et al. (2022)14 | IDDM and NIDDM |
| Jump C et al. (2019)16 | DM/Diabetes |
| Na A et al. (2021)5 | Diabetes Mellitus |
| Podmore B et al. (2018)17 | Diabetes |
| Qin W et al. (2020)2 | DM {T1DM, T2DM, and other secondary forms of DM (e.g., insulin-dependent DM and non-insulin-dependent DM) were not analyzed separately)} |
| Shohat N et al. (2018)6 | Definition of Glycemic Control (HbA1C cutoff):6.5 %-Jamsen et al.387.0 %- Six authors-most common definition7.5 %- Cancienne et al.397.7 %-Tarabichi et al.408.0 %- Cancienne et al.41Fasting glucose >200 mg/dL (Hwang et al.,42 Stryker et al.43)Glucose levels >126 mg/dL vs < 110 mg/dL -Jamsen et al.38 |
| Wu LM et al. (2021)13] | IDDM |
| Yang L et al. (2017)7 | Perioperative hyperglycemia (HbAIC and random blood glucose) |
| Yang Z et al. (2014)4 | DM |
The risk for DVT in Asians was found to be significantly different from that in Westerners undergoing TKA. Still, the precise reasons why this happens are unknown and open to speculation and further research. Differentiation between people with diabetes and those without diabetes was not possible in several studies and reviews. Subgroups were chosen arbitrarily (based on the superficial/deep infection, ethnicity, etc.), and tests for subgroup differences were not significant for any variable. There is an urgent need for large multicenter randomized controlled trials to substantiate these findings and refine surgical guidelines. We also acknowledge minimal analysis of the role of diabetes duration on outcomes and the lack of cost-effectiveness analysis.
Additionally, future research should focus on identifying specific thresholds for HbA1c and other metabolic indicators that correlate with improved surgical outcomes. This overview suggests a significant impact of diabetes on the outcomes of TKA. As diabetes becomes increasingly prevalent, an evidence-based approach to managing these patients will be integral to reducing the risks associated with TKA and ensuring optimal patient outcomes. Understanding how these comorbidities interact with surgical outcomes will enhance patient care and refine management strategies in orthopedic surgery.
5 Conclusion
People with diabetes experience significantly higher complication rates following Total Knee Arthroplasty (TKA), including increased risks of periprosthetic joint infection (PJI) and deep vein thrombosis. Individuals with insulin-treated diabetes are particularly susceptible, exhibiting a 60 % greater incidence of perioperative adverse events. Inadequate glycemic control is a modifiable risk factor that may influence surgical outcomes. However, definitions of glycemic control vary widely in the literature. The study found that people with diabetes undergoing TKA had significantly higher odds of developing infection and deep PJI.
CRediT authorship contribution statement
Raju Vaishya: Conceptualization, data collection and analysis, literature search, manuscript writing, editing and final approval. Mohit Kumar Patralekh: Data collection and statistical analysis, literature search, Writing – original draft, editing and final approval. Anoop Misra: Conceptualization, data collection and analysis, literature search, Writing – original draft, editing and final approval. Abhishek Vaish: Data collection and analysis, literature search, Writing – original draft, Writing – review & editing, and final approval.
Ethical approval
Not required for this systematic review of the published literature.
Patients’ consent
This is not applicable for such a systematic review of the published literature.
Statement of ethics
None, since it is not a clinical article.
Use of AI technology
We used Grammarly to improve the English and Readability of the manuscript. However, all the authors have rechecked the manuscript and take the full responsibility of its contents.
Funding statement
The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
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