Orthopedics · Medical Literature
Glucagon-like peptide-1 receptor agonists are associated with improved 90-day outcomes after total hip and knee arthroplasty : a systematic review and meta-analysis.
Abstract
Obesity and diabetes are risk factors for developing osteoarthritis and associated with worse outcomes following total hip (THA) and total knee arthroplasty (TKA). Glucagon-like peptide-1 receptor agonists (GLP-1as) improve glycaemic control and promote weight loss. The aim of this study was to assess the impact of GLP-1a treatment on 90-day surgical complications following THA and TKA. A systematic review was undertaken according to PRISMA guidelines. Studies were included if they reported at least one outcome of interest following primary THA or TKA. In all the studies which were included, a GLP-1a was prescribed for the management of type 2 diabetes mellitus or for weight loss in obese patients. The primary outcome was the 90-day surgical complication rate in the combined THA and TKA cohort. The 90-day surgical complications were defined as: periprosthetic joint infection (PJI), wound dehiscence, periprosthetic fracture (PPF), haematoma, nerve injury, or surgical site infection (SSI). Secondary outcomes included 90-day medical complications and readmission rates, all-cause revision, healthcare costs, and length of stay. A total of 78 studies were reviewed, and ten matched cohort studies with a total of 96,356 patients (30,350 THAs and 66,606 TKAs) were included. The mean age of the patients was 61.9 years; 60.1% female (n = 57,939). Two studies had a serious risk of overall bias and eight had a moderate risk. The confidence of evidence according to the GRADE assessment was very low for all but one outcome measure (healthcare cost: moderate). The rate of 90-day surgical complications was lower in the GLP-1a cohort (pooled risk ratio (RR) 0.73). The use of a GLP-1a lowered the 90-day medical complications and readmission rates (RR 0.78 and RR 0.79 (I2 = 61.6%), respectively). At two years, the revision rate ranged from 1.7% to 3.3% for the GLP-1a cohort and 1.7% to 4.5% for the controls. Sub-group analysis showed a stronger association in the THA group, in which the use of a GLP-1a was associated with significantly lower rates of 90-day surgical complications (RR 0.63), 90-day medical complications (RR 0.55), and 90-day readmissions (RR 0.82). In contrast, the use of a GLP-1a in the TKA group was only sigificantly associated with a lower 90-day readmission rate (RR 0.77). GLP-1a treatment before THA and TKA potentially reduces the 90-day surgical and medical complications and 90-day readmission rates in high-risk diabetic and obese patients. The use of a GLP-1a may also be associated with substantial cost savings.
Clinical relevance
Obesity and type 2 diabetes mellitus are independent risk factors for osteoarthritis progression and are associated with elevated perioperative complication rates following total hip arthroplasty (THA) and total knee arthroplasty (TKA). GLP-1 receptor agonists (GLP-1as), increasingly prescribed for glycaemic control and weight reduction, represent a potentially modifiable perioperative intervention in this high-risk surgical cohort. Given the rising prevalence of metabolic comorbidities among arthroplasty candidates, clarifying the perioperative risk-benefit profile of GLP-1as is of immediate clinical importance.
Key findings
1. In a pooled meta-analysis of 10 matched cohort studies (N = 96,356 patients; 30,350 THAs and 66,606 TKAs), GLP-1a use was associated with a 27% relative reduction in 90-day surgical complications (pooled RR 0.73) compared to controls. 2. GLP-1a use was associated with a 22% reduction in 90-day medical complications (RR 0.78) and a 21% reduction in 90-day readmission rates (RR 0.79; I² = 61.6%), indicating moderate heterogeneity in the readmission outcome. 3. Subgroup analysis demonstrated a stronger protective association in THA specifically: GLP-1a use was associated with significantly lower rates of 90-day surgical complications (RR 0.63), 90-day medical complications (RR 0.55), and 90-day readmissions (RR 0.82). 4. In the TKA subgroup, GLP-1a use reached statistical significance only for 90-day readmission rate reduction (RR 0.77); 90-day surgical and medical complication reductions in TKA did not achieve significance. 5. At two-year follow-up, all-cause revision rates ranged from 1.7%–3.3% in the GLP-1a cohort versus 1.7%–4.5% in controls, suggesting a potential longer-term durability benefit, though formal pooled statistics were not reported for this endpoint. 6. GRADE assessment of evidence confidence was very low for all outcomes except healthcare costs, which was rated moderate; two of the ten included studies carried a serious risk of bias and eight a moderate risk, limiting the strength of causal inference.
Practice implications
Orthopedic surgeons and perioperative medicine teams should consider identifying obese and type 2 diabetic arthroplasty candidates who are not yet on a GLP-1a and engaging endocrinology or primary care colleagues for pre-surgical initiation, particularly for patients planned for THA where the risk reduction signal is strongest (RR 0.63 for surgical complications). Given that the TKA subgroup showed a more attenuated and largely non-significant benefit for surgical and medical complications, patient selection and shared decision-making should account for procedure type, baseline metabolic control, and individual risk profile. The association with healthcare cost savings (moderate GRADE evidence) further supports institutional protocols that incorporate GLP-1a optimization as part of a structured arthroplasty prehabilitation pathway, while prospective randomized trials are needed to establish causality and define optimal drug class, dosing, and treatment duration prior to surgery.