Diabetes and Osteoarthritis Disability: An Important Underrepresented Topic in the Related Literature

Review Article

Austin J Endocrinol Diabetes. 2016; 3(1): 1039.

Diabetes and Osteoarthritis Disability: An Important Underrepresented Topic in the Related Literature

Marks R*

Department of Health and Behavior Studies, Columbia University, USA

*Corresponding author: Marks R, Department of Health, Physical Education, Gerontological Studies and Services, Columbia University, School of Health & Behavioral Sciences, City University of New York, Box 114, 525W 120th Street, NY 10027, USA

Received: December December 15, 2015; Accepted: February 26, 2016; Published: April 01, 2016


Diabetes prevalence, increasing rapidly among older populations, has several orthopedic consequences. This brief specifically examines whether adults with type 2 diabetes are at increased risk for developing osteoarthritis, and if so, whether this adversely impacts health outcomes, in general, and hip arthroplasty surgery outcomes, in particular. The possibility that osteoarthritis is a contributing factor to diabetes type 2 is also discussed. To examine these issues, relevant literature located in key databases and published over the last 5 years using key words: hip arthroplasty outcomes, diabetes and osteoarthritis, diabetes and falls injuries, among others, were sought and carefully examined. These data revealed: 1) There is a possible increased risk of developing osteoarthritis, as well as more complications and delayed healing after surgery among cases with type 2 diabetes compared to non diabetic cases. 2) Osteoarthritis may be a possible risk factor for diabetes 2. These observations suggest further exploration of the linkages between diabetes type 2 and osteoarthritis may be highly valuable in efforts to promote healthy aging and reduce health costs attributable to diabetes type 2 and osteoarthritis among the elderly.

Keywords: Diabetes; Hip joint, Osteoarthritis; Surgical outcomes; Type 1 and Type 2


Diabetes, a leading cause of comorbidity in the United States and around the world, can lead to many complications, including, but not limited to blood vessel damage, including blood vessels that supply the heart and brain [1]. Other well-established complications include eye problems, kidney disease, and neuropathy or nerve damage [2]. Less well documented are musculoskeletal impairments, an increased fracture and falls risk, possible increased rates of osteoarthritis, and adverse health outcomes after surgery to repair a fracture or replace a diseased joint, along with impaired bone health and gait [3,4]. Indeed, in our view, diabetes, a frequent co-occurring disease in people with osteoarthritis [5,6], is often overlooked as a highly significant risk factor for osteoarthritis, and consequently for its impact on the person with this condition, as well as on any surgery that is undertaken to treat this disabling health condition. This is disappointing in light of a fair number of early studies describing an association between diabetes and osteoarthritis, and recent findings that show the immense negative impact of diabetes on life quality, and other data that reveal osteoarthritis is often as disabling and painful as far as life quality goes, as the impact of hypertension. In fact, although Stürmer et al. [7] hypothesized that type 2 diabetes might be a potentially important systemic risk factor for knee and hip osteoarthritis, approximately 15 years ago, it seems little has been done to embed this message in public health education programs and others designed to maximize type 2 diabetes outcomes.

In light of the increasing numbers of people anticipated to acquire type 2 diabetes in the next few decades, along with an increasingly older population, prone to painful disabling osteoarthritis, this brief specifically aims to highlight what is currently known about the possible linkage between diabetes and osteoarthritis, the most common chronic disease disabler of older adults. To this end, this brief details some recent literature dealing with evidence linking diabetes and osteoarthritis in general, and the suffering that accompanies this. Information on the impact of diabetes on outcomes of surgery for hip joint osteoarthritis was also sought to examine if function after this form of surgery is likely to be more compromised than not in the case of a patient with type 2 diabetes based on studies of the outcomes of knee joint surgery for osteoarthritis among type 2 diabetes sufferers [8]. The goal was to identify selected facts that might have future implications for reducing the extent of the disability suffered by older adults with type 2 diabetes.

To attain the goal of the brief, a systematic search using key data bases including, Academic Search Complete, PubMed, Scopus, and Web of Science was implemented. Key terms used were: Diabetes and osteoarthritis, hip arthroplasty outcomes and diabetes, falls and diabetes, bone and diabetes, and motor dysfunction in diabetes. Only full length English language clinical reports and empirical papers published in the last five years were deemed acceptable for this narrative review, the method adopted for organizing these data, given the scarcity of publications on this topic, as well as their immense heterogeneity.


Employing the term: diabetes and osteoarthritis there were 305 articles listed in Academic Search Complete, 469 in PubMed and 461 in Scopus. Employing the term: hip arthroplasty outcomes and diabetes, there were 15 listing on PubMed, 10 of which focused on hip joint replacement, rather than knee, shoulder, ankle, or other forms of joint replacement, and 67 in total in Scopus. Key themes that emerged are discussed below.

Evidence linking diabetes and osteoarthritis

In terms of a possible cause effect relationship between diabetes and osteoarthritis, several studies and a recent review by Louati et al. [5] and by King et al. [9] affirm diabetes is a possible risk factor for osteoarthritis or for heightening osteoarthritis disability. Schett et al. [10] too, found that type 2 diabetes was a significant predictor of the need for joint surgery due to osteoarthritis, and that this association was more profound relative to the duration of the condition. Moreover, this group found more severe clinical symptoms of osteoarthritis existed in cases examined over 20 years in those patients with type 2 diabetes, when compared to those with no diabetic condition (Table 1). Wang et al. [11] also noted that the prevalence of osteoarthritis in middle-aged Mongolian and senior residents was affected negatively by diabetes, as did Fadhil et al. [12] who also noted type 2 diabetes not only predicted the presence of knee osteoarthritis in a group ages 40-50 years of age, but the development of severe knee osteoarthritis independent of age and other known risk factors for the condition.

Diabetes and osteoarthritis progression

Several studies have examined the impact of type 2 diabetes on osteoarthritis outcomes [9]. In their related study, Eymard et al. [13] concluded diabetes is an independent risk factor for progression of osteoarthritis of the knee joint. Diabetes type 2 also appeared associated with increased hand pain in a population based study of cases with hand osteoarthritis [14], and among a variety of comorbid health conditions, Zullig et al. [15] who examined patient reported outcomes in veterans with hip and knee osteoarthritis were worse in this subgroup even when adjusting for demographic and clinical factors. The presence of diabetes and other comorbidities was associated with pain, depressive symptoms, fatigue and insomnia, as well as more limited functioning.

Miksch et al. [16] concluded that the impact of osteoarthritis in those with type 2 diabetes was higher than the impact of hypertension, and patients assessed for quality of life who had both diabetes and osteoarthritis were said to have remarkably lower scores than other subgroups on all the Medical Outcome Study Short form subscales examined. The impact of self-reported diabetes on increasing mortality rates of adults over age 35 with either hip or knee osteoarthritis has been observed in a population based cohort study [17].

Diabetes and arthroplasty outcomes

Several studies have examined outcomes such as death rates, functional outcomes and complications, as well as revision rates following knee or hip joint replacement or arthroplasty surgery for disabling end stage osteoarthritis [8,9]. In the systematic review by Wang et al. [11], patients with type 2 diabetes or 12.2 percent of cases had increased risks of deep infection, deep vein thrombosis, aseptic loosening, periprosthetic fractures, and a poorer overall functional score than non diabetic cases. Tsang et al. [18] who conducted a systematic review and meta-analysis of cohort studies found the prevalence of type 2 diabetes increased the risk of infection after hip joint replacement surgery. In addition, Rajmaki et al. [19] found diabetes to be associated with the presence of persistent pain after hip and knee replacement surgery, even if the diabetic patients’ baseline pre operative pain scores were lower than those with no diabetes as a whole. This, the authors conjectured was possibly attributed to their chronic systemic inflammatory state, and/or possible state of neuropathy.

Impact of type 2 diabetes on joint structures

The term joint structures refers to the elements that comprise the joints affected by osteoarthritis, namely, the articular cartilage lining the joint and its structural backbone comprised of collagen and proteoglycan molecules, the synovial membrane lining the joint capsule, the subjacent bones forming the joint, and the ligaments providing stability to the joint. In terms of impacting one or more of these structures, a study by Laiguillon et al. [20] revealed that osteoarthritic cartilage extracted from cases with type 2 diabetes tends to show a heightened responsiveness to inflammation induced by the inflammatory agent Interleukin (IL-1B) –that could increase the extent to which the patient experiences pain and joint destruction processes. Ribeiro et al. [21] found that the metabolic process known as autophagy, which is defective in osteoarthritis is a possible mechanism whereby diabetes impairs articular cartilage integrity. Other data imply that alterations in lipid metabolism, including changes in the level of adipokines associated with obesity can produce inflammatory joint changes that might be destructive to a joint, as well as hyperglycemia that can alter cartilage metabolism negatively in people with diabetes [22]. Although it is not known with any certainty if diabetes is predictive of osteoarthritic joint changes in the area of the knee joint and others, Onur et al. [23] found type 2 diabetes associated with degeneration of the lateral and medial femoral condyles of the knees, along with altered articular cartilage at the medial condyles, and cysts within the articular cartilage and at the junction between the articular cartilage and subchondral bone in a rat model of the disease.

Umpierrez et al. [24] who examined incubated rat articular cartilage showed collagen content decreased to 49% in mildly diabetic rats and 16% in severely diabetic rats, suggesting a possible effect of diabetes on collagen, a key component of articular cartilage. Based on results of an animal study in the rat, Rosa et al. [25] concluded that the exposure of human chondrocytes to high glucose, favors degenerative chondrocyte changes that may promote articular cartilage degradation, and ultimately, the development and/or progression of osteoarthritis.

Berenbaum [26] has drawn attention to the fact that hyperglycemia can induce an inflammatory state, and that an inflammatory state might predispose cartilage to damage that leads to osteoarthritis due to its systemic effect. Hyperglycemia could also have a negative impact on chondrocyte function and viability according to this author. The author also noted that other joint structures that could be affected by type 2 diabetes are nerves, muscles, and ligaments that may reduce joint protection mechanisms, thus fostering the risk of further joint destruction. This claim is supported by research by Atayde et al. [27] who found the joint ligaments, synovia, and cartilage were compromised in the presence of diabetes due to abnormal collagen production, which predisposed to weakening the cartilage matrix and joint function [26] (Figure 1 and Box 1).