The Interplay of Diabetes, Glucose Variability, and Antidiabetic Therapy in Preventing Periprosthetic Joint Infection Following Hip and Knee Arthroplasty: A Review.

» Traditional reliance on preoperative glycated hemoglobin (HbA1c) for surgical eligibility and periprosthetic joint infection (PJI) risk stratification has significant limitations, including surgical delays and poor reflection of short-term metabolic instability. » Perioperative hyperglycemia and glucose variability are stronger and more consistent determinants of PJI risk than static glycemic indices such as HbA1c. » Novel markers, such as fructosamine, and technologies, including continuous glucose monitoring, provide improved assessment of short-term glycemic control and variability and demonstrate superior prognostic utility for PJI compared with HbA1c. » Antidiabetic therapies may differentially influence PJI risk: insulin dependence marks higher risk, whereas oral agents, particularly metformin and glucagon-like peptide-1 receptor agonists, are increasingly associated with reduced short-term PJI risk, especially among diabetic and morbidly obese patients undergoing hip and knee arthroplasty. » Mechanistic evidence implicates effects on inflammation, angiogenesis, immune function, and bacterial biofilm formation in mediating the relationship between glycemic control, antidiabetic therapies, and PJI risk.