Perioperative Glycaemic Control and Orthopaedic Outcomes: A Narrative Review of Evidence and Future Directions

In orthopaedic surgery, diabetes mellitus (DM) is consistently associated with delayed fracture healing, non-union, implant failure, periprosthetic joint infection, and poorer postoperative recovery. Although strict perioperative glycaemic control has been shown to improve outcomes in general surgical populations, current national thresholds are largely extrapolated from non-orthopaedic data and focus primarily on cardiovascular and soft-tissue complications rather than bone biology. Existing recommendations from national guidelines vary and remain non-specific to orthopaedics. No consensus exists on optimal perioperative glucose or glycated haemoglobin (HbA1c) targets for elective orthopaedic interventions. This review evaluates current evidence linking perioperative glycaemic status to orthopaedic outcomes. Relevant literature, particularly focused on total joint arthroplasty (TJA), was identified through a comprehensive search of PubMed, MEDLINE, and Google Scholar. Evidence reviewed in this article suggests that perioperative hyperglycaemia, rather than HbA1c alone, is a stronger predictor of complications. Prospective studies are needed to assess preoperative HbA1c and perioperative glucose trajectories and their relationship with standardised outcomes. The potential harms of intensive control, such as hypoglycaemia and surgical delays, also require careful consideration. Additionally, randomised controlled trials (RCTs) comparing intensified versus standard glucose control protocols are required, with both efficacy and safety as endpoints. Defining evidence-based, orthopaedic-specific glycaemic thresholds is essential to reduce complications, enhance recovery, and improve long-term outcomes.