Impact of Diabetes Mellitus on Complications and Revision Risk After Anterior Cruciate Ligament Reconstruction: A Systematic Review and Meta-Analysis Publisher



Vosoughi F ; Ayati Firoozabadi A ; Seyedi D ; Hasanzadeh A ; Laprade R F ; Menbari Oskouie I
Source: Orthopaedic Journal of Sports Medicine Published:2026

Abstract

Background: As indications for anterior cruciate ligament reconstruction (ACLR) expand to older and more metabolically comorbid patients, diabetes mellitus (DM) has emerged as a potential determinant of surgical outcomes. However, existing evidence remains fragmented, with limited pooled data quantifying postoperative risk. Purpose/Hypothesis: The purpose was to systematically review evidence comparing postoperative complications between patients with and without DM undergoing ACLR. It was hypothesized that DM would be associated with an increased incidence of overall complications, but not of revision. Study Design: Systematic review and meta-analysis; Level of evidence, 3. Methods: The PubMed, Embase, Web of Science, and Scopus databases were searched through March 2025 following PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) and MOOSE (Meta-analysis Of Observational Studies in Epidemiology) guidelines. Observational studies reporting postoperative outcomes in patients with and without DM undergoing ACLR were included. Pooled risk ratios (RRs) with 95% CIs were calculated using fixed- or random-effects models, as appropriate. The primary outcome was revision, and secondary outcomes included infection, surgical-site infection (SSI), readmission, and venous thromboembolism (VTE). For studies with zero events in 1 arm, a continuity correction of 0.5 was applied to enable computation of pooled estimates and avoid division-by-zero errors. Risk of bias assessment across included studies was conducted using the Risk of Bias Assessment tool for Non-randomized Studies of Interventions Version 2. Results: A total of 25 studies met the inclusion criteria. Compared with patient without DM, those with DM had significantly higher risks of postoperative infection (after sensitivity analysis, RR, 7.25 [95% CI, 3.07-17.08]; P < .001; I2 = 17.9%), SSI (RR, 3.18 [95% CI, 1.74-5.81]; P = .0002; I2 = 0%), readmission (RR, 2.04 [95% CI, 1.66-2.50]; P < .0001; I2 = 0%), and VTE (RR, 2.19 [95% CI, 1.48-3.25]; P < .0001; I2 = 0%). Revision rates did not differ significantly (RR, 0.68 [95% CI, 0.41-1.14]; P = .15; I2 = 22.2%). Among the included studies, 18 had a moderate risk of bias, 5 had a low risk of bias, and 2 had a serious risk of bias. Conclusion: DM is associated with substantially increased risks of infection, SSI, readmission, and VTE after ACLR, although there was no significant difference in revision rates. These findings highlight the need for optimized perioperative strategies, including strict glycemic control, thoughtful graft selection, and tailored surgical protocols to improve safety and outcomes in patients with DM. Registration: CRD420251119493. © The Author(s) 2026. This article is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 License (https://creativecommons.org/licenses/by-nc-nd/4.0/) which permits non-commercial use, reproduction and distribution of the work as published without adaptation or alteration, without further permission provided the original work is attributed as specified on the SAGE and Open Access page (https://us.sagepub.com/en-us/nam/open-access-at-sage).