Impact of Preoperative Obstructive Sleep Apnea on Complications, Healthcare Utilization, and Revision Rates Following Primary Total Knee and Total Hip Arthroplasty: A Systematic Review and Meta-Analysis

This systematic review and meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The protocol was registered with PROSPERO (registration number: 420261397468). Obstructive sleep apnea (OSA) affects an estimated 30-40% of patients undergoing total joint arthroplasty (TJA) and is mechanistically linked to systemic inflammation, hypercoagulability, and impaired wound healing. Despite this, OSA has not been comprehensively evaluated as a standalone preoperative predictor of arthroplasty outcomes. This study aimed to quantify the independent effect of preoperative OSA on postoperative complications, healthcare utilization, and implant-related outcomes following primary total knee arthroplasty (TKA) and total hip arthroplasty (THA). A comprehensive search of PubMed, EMBASE, Cochrane Library, and Scopus was conducted from inception to May 1, 2026. Studies comparing postoperative outcomes in patients with and without a preoperative OSA diagnosis undergoing primary TKA or THA were included. Primary outcomes were pulmonary embolism (PE), deep vein thrombosis (DVT), periprosthetic joint infection (PJI), surgical site infection (SSI), and 90-day readmission. Secondary outcomes included length of stay (LOS) and revision rates. Functional outcomes were assessed narratively. Random-effects meta-analysis was performed using the DerSimonian-Laird method; risk of bias was assessed using Risk Of Bias In Non-randomized Studies of Interventions (ROBINS-I). Seventeen studies encompassing approximately 392,000 patients met the inclusion criteria; 15 contributed to at least one pooled analysis. Studies involving spine surgery and shoulder arthroplasty were retained for qualitative synthesis only. OSA diagnosis was independently associated with significantly elevated risk of PE (OR: 1.58, 95% CI: 1.41-1.77; p<0.001; k=7), DVT (OR: 1.45, 95% CI: 1.19-1.76; p<0.001; k=7), PJI (OR: 1.42, 95% CI: 1.24-1.62; p<0.001; k=4), 90-day readmission (OR: 1.57, 95% CI: 1.36-1.82; p<0.001; k=7; sensitivity analysis, excluding CPAP-severity-selection outlier: OR 1.22, 95% CI 1.12-1.33), and revision arthroplasty (OR: 1.26, 95% CI: 1.10-1.45; p=0.001; k=4). SSI data from two TKA/THA studies (OR range 1.23-1.37) were insufficient for formal pooling and are reported narratively. Mean LOS was significantly longer in OSA patients (MD +0.82 days, 95% CI: 0.41-1.23; p<0.001). Preoperative CPAP therapy attenuated thromboembolic but not infectious complication rates. Functional outcome data were insufficient for pooled analysis. Preoperative OSA diagnosis is independently associated with a broad spectrum of complications following primary TKA and THA. These findings support OSA as a target for routine preoperative screening and optimization in arthroplasty candidates, although causal inference is limited by the observational nature of included studies.