Vascular Complications Following Total Knee Arthroplasty in Patients with Diabetes: Anesthesia-Related Insights from a Nationwide Database Study with Meta-Analysis and Comprehensive Narrative Review

Abstract

Background: Total knee arthroplasty (TKA) is among the most frequently performed orthopedic procedures globally. With the rising prevalence of diabetes mellitus, an increasing proportion of surgical candidates present with metabolic, vascular, and inflammatory comorbidities that predispose them to postoperative complications. Diabetes is associated with endothelial dysfunction, platelet hyperreactivity, impaired fibrinolysis, and chronic systemic inflammation, all of which contribute to elevated vascular risk. The interaction between diabetes, anesthetic technique, and perioperative management in determining vascular outcomes remains incompletely defined.

Objective: To evaluate vascular complications following TKA in patients with diabetes using a nationwide inpatient database and to examine anesthesia-related modifiers through meta-analysis and mechanistic narrative review.

Methods: A retrospective cohort analysis was conducted using a nationally representative inpatient database (2010–2022). Adult patients undergoing primary TKA were identified and stratified by diabetes status. Primary outcomes included deep vein thrombosis (DVT), pulmonary embolism (PE), acute limb ischemia, arterial thrombosis, and in-hospital mortality. Multivariate regression and propensity matching were performed. A PRISMA-compliant meta-analysis of published studies was conducted to synthesize existing evidence. A narrative review explored internal medicine and anesthetic mechanisms influencing vascular risk.

Results: Among 412,638 TKA patients, 128,944 (31.2%) had diabetes. Diabetic patients demonstrated higher rates of DVT (1.9% vs 1.2%, adjusted OR 1.42), PE (0.8% vs 0.5%, OR 1.36), arterial complications (0.4% vs 0.2%, OR 1.78), and transfusion requirement (6.3% vs 4.7%). Neuraxial anesthesia was associated with reduced thromboembolic risk (adjusted OR 0.74). Meta-analysis of 18 studies (n=1.2 million) confirmed increased pooled thromboembolic risk in diabetics (OR 1.38). Mechanistic analysis suggests sympathetic blockade, improved limb perfusion, and attenuated stress response as potential protective factors under neuraxial techniques.

Conclusion: Diabetes independently increases vascular risk following TKA. Anesthetic strategy, particularly neuraxial approaches, appears to modify this risk. Integrated perioperative management involving anesthesia and internal medicine optimization is critical for improving outcomes.