The Impact of Diabetes on Risk of Revision Following Anterior Cruciate Ligament Reconstruction: A Real-World Data Study

INTRODUCTION: Given the increasing prevalence of diabetes mellitus (DM), understanding its impact on anterior cruciate ligament reconstruction (ACLR) revision risk is important for clinical decision-making and patient counselling. This study evaluated whether DM is associated with an increased risk of revision ACLR within 5 years of primary reconstruction. METHODS: We conducted a retrospective observational cohort study using a global federated health research network (TriNetX, Cambridge, USA), including 73,951 patients who underwent primary ACLR across 53 healthcare organisations, of whom 990 had DM (type 1 and 2). Patients undergoing primary ACLR between 5 August 2005 and 4 August 2025 were included. The index event was primary ACLR, and the outcome was subsequent ACLR to the ipsilateral knee. Follow-up was extended until revision surgery or up to 5 years. Patients with DM (type 1 or type 2) were compared with patients without DM following 1:1 propensity score matching for age, sex, and BMI. Following propensity score matching, 988 patients were analysed per cohort. Kaplan-Meier survival analysis and hazard ratios (HRs) were used to assess revision risk. A further sensitivity analysis excluded patients undergoing concomitant soft tissue knee procedures, including meniscectomy, meniscal repair, meniscal transplantation, and additional ligament reconstruction procedures. RESULTS: Of the 73,951 patients included, 990 had DM, corresponding to a prevalence of 1.3% among individuals undergoing ACLR. Following propensity score matching, revision ACLR occurred in 30 of 988 patients with DM and 38 of 988 patients without DM, with no statistically significant difference in revision risk between the cohorts (HR 0.77, 95% CI 0.47-1.26). In the sensitivity analysis excluding patients with concomitant soft tissue knee procedures, between 1 and 10 revision events occurred in each matched cohort (243 patients per cohort), and no statistically significant difference in revision risk was observed (HR 0.45, 95% CI 0.08-2.45). CONCLUSION: DM was not associated with an increased risk of revision ACLR within 5 years of the primary procedure. These findings were consistent in a sensitivity analysis excluding concomitant soft tissue knee procedures. The results should be interpreted in the context of the study's limitations and do not replace individualised clinical risk assessment.