madman
Super Moderator
ABSTRACT
Testosterone replacement therapy (TRT) is an indicated treatment of several medical conditions including late-onset hypogonadism,congenital syndromes, and gender affirmation hormonal therapy.Increasing population age, medical benefits, and public awareness of TRT have resulted in increased prevalence of its utilization. However,TRT is not without concern for adverse risks including venous thromboembolic complications, cardiovascular events, and prostate issues. In the field of orthopaedic surgery, research is beginning to delineate the complex relationship between TRT and the development of orthopaedic conditions and potential effects on surgical interventions and outcomes. In this review, we discuss current literature surrounding TRT and subsequent development of osteoarthritis, incidence of total joint arthroplasty, musculotendinous pathology, postoperative infection risk, improvements in postoperativere habilitation metrics, enhancement of osseous healing, and increased bone-implant integration. The authors suggest future areas of investigation that may provide guidance on how surgeons can mitigate adverse risks while optimizing benefits of TRT in the orthopaedic patient.
Hormone replacement therapy
(HRT) is a domain of endocrinology with a goal of hormonal normalization and optimization of the individual’s overall health. HRT encompasses numerous organ systems including hypothalamic, pituitary, and thyroid-related dysfunction, but may be most recognized for its role in sex steroid hormone regulation. HRT is commonly used for estrogen replacement therapy in perimenopausal women, and HRT with testosterone is becoming increasingly common formen during age-related androgen decline, as well as individuals undergoing gender-affirming hormone therapy. Utilization of testosterone replacement therapy (TRT) is an accepted treatment of various medical conditions. However, TRT is not without concern for adverse event risk, including cardiovascular events, and development of prostatic pathology.1 Unlike estrogen replacement therapy, studies have not identified increased risk of venous thromboembolic events (VTEs) in patients undergoing TRT. The relationship between TRT and the development of orthopaedic conditions and subsequent treatments has become a topic of interest, yet there remains a lack of consensus regarding management of TRT in the orthopaedic patient. The absence of definitive guidance for optimal utilization of TRT in the perioperative period is a gap in understanding that warrants investigation and development of evidence-based recommendations. Investigation of TRT and its effects on the broad scope of orthopaedic conditions and surgical interventions can help inform the surgeon and provide patients with improved clinical outcomes while mitigating adverse effects associated with TRT.
Testosterone Replacement Therapy
-Venous Thromboembolic Event Risk
-Cardiovascular Event Risk in Testosterone Replacement Therapy
-Prostatic Hyperplasia and Prostate Cancer Risk
Effect of Testosterone Replacement Therapy on Orthopaedic-Related Conditions and Surgical Interventions
Musculotendinous Pathology
Testosterone may have implications on musculotendinous injuries related to the intricate effect of testosterone on musculotendinous growth, laxity, and healing after repetitive microtrauma of activity.12
Osteoarthritis and Total Joint Arthroplasty
The current available data regarding the effect of endogenous testosterone on the development of osteoarthritis and need for total joint arthroplasty are unclear.
Osteoporosis
4 Current research suggests that exogenous TRT increases BMD, but no direct investigation of the relationship between TRT and potential risk reduction of osteoporosis or subsequent fracture exists.
Bone-Implant Integration
These current studies suggest that testosterone incorporation into implant surfaces may encourage increased osteogenesis;however, they do not attempt to assess the relationship of endogenous testosterone level and bone-implant integration. Future investigations may examine the influence of direct testosterone implant integration andsystemic TRT on bone-implant integration and healing.
Recovery and Rehabilitation
There are currently no data on the role TRT mayplay on early recovery in these settings. Evidence suggests higher endogenous levels of testosterone and exogenous supraphysiologic TRT can improve recovery rates after TKA. However, no study draws direct assessment of physiologic TRT on postoperative orthopaedic surgery rehabilitation outcomes
Infection Risk
Although current reports are limited, the literature supports an increased risk of C. acnes PJI in TSA for individuals with higher serum testosterone and that this risk may be exacerbated by TRT use. Outside of studies on TSA,there is minimal literature regarding TRT and infection risk in all other orthopaedic subspecialties and associated procedures. This paucity of data is concerning because infection with C. acnes have also been reported after THA, TKA, and arthroscopic procedures.37 At this time, appropriate assessment of the relationship between testosterone and perioperative infection risk cannot be made. Furthermore, C. acnes has also been reported as the offending pathogen in native joint septicarthritis.38-40 The relationship of serum testosterone and skin burden of C. acnes at anatomical locations other than the shoulder has not been investigated. Given the mortality rate and poor outcomes related to PJI and deep implant infection, future investigation of the effect that endogenous testosterone and TRT have on postoperative infection risk is warranted
Conclusion
In this review, we summarize the current literature surrounding risks and potential clinical benefits of TRT in the orthopaedic patient. The current data on TRT and risk of VTE, cardiac events, prostatic pathology suggest minimal risk, yet to date few studies assess these events in relation to orthopaedic surgery. There are presently data suggesting TRT may be correlated with increased risk of musculotendinous injury and subsequent repair failure. Moreover, there is a potential correlation of TRT and C. acnes PJI. There is also a potential benefit of TRT in improved rehabilitation ,recovery, and bone-implant integration. TRT in the field of orthopaedics requires additional investigation to outline its safety, efficacy, and potential for an effect on clinical outcomes.
Testosterone replacement therapy (TRT) is an indicated treatment of several medical conditions including late-onset hypogonadism,congenital syndromes, and gender affirmation hormonal therapy.Increasing population age, medical benefits, and public awareness of TRT have resulted in increased prevalence of its utilization. However,TRT is not without concern for adverse risks including venous thromboembolic complications, cardiovascular events, and prostate issues. In the field of orthopaedic surgery, research is beginning to delineate the complex relationship between TRT and the development of orthopaedic conditions and potential effects on surgical interventions and outcomes. In this review, we discuss current literature surrounding TRT and subsequent development of osteoarthritis, incidence of total joint arthroplasty, musculotendinous pathology, postoperative infection risk, improvements in postoperativere habilitation metrics, enhancement of osseous healing, and increased bone-implant integration. The authors suggest future areas of investigation that may provide guidance on how surgeons can mitigate adverse risks while optimizing benefits of TRT in the orthopaedic patient.
Hormone replacement therapy
(HRT) is a domain of endocrinology with a goal of hormonal normalization and optimization of the individual’s overall health. HRT encompasses numerous organ systems including hypothalamic, pituitary, and thyroid-related dysfunction, but may be most recognized for its role in sex steroid hormone regulation. HRT is commonly used for estrogen replacement therapy in perimenopausal women, and HRT with testosterone is becoming increasingly common formen during age-related androgen decline, as well as individuals undergoing gender-affirming hormone therapy. Utilization of testosterone replacement therapy (TRT) is an accepted treatment of various medical conditions. However, TRT is not without concern for adverse event risk, including cardiovascular events, and development of prostatic pathology.1 Unlike estrogen replacement therapy, studies have not identified increased risk of venous thromboembolic events (VTEs) in patients undergoing TRT. The relationship between TRT and the development of orthopaedic conditions and subsequent treatments has become a topic of interest, yet there remains a lack of consensus regarding management of TRT in the orthopaedic patient. The absence of definitive guidance for optimal utilization of TRT in the perioperative period is a gap in understanding that warrants investigation and development of evidence-based recommendations. Investigation of TRT and its effects on the broad scope of orthopaedic conditions and surgical interventions can help inform the surgeon and provide patients with improved clinical outcomes while mitigating adverse effects associated with TRT.
Testosterone Replacement Therapy
-Venous Thromboembolic Event Risk
-Cardiovascular Event Risk in Testosterone Replacement Therapy
-Prostatic Hyperplasia and Prostate Cancer Risk
Effect of Testosterone Replacement Therapy on Orthopaedic-Related Conditions and Surgical Interventions
Musculotendinous Pathology
Testosterone may have implications on musculotendinous injuries related to the intricate effect of testosterone on musculotendinous growth, laxity, and healing after repetitive microtrauma of activity.12
Osteoarthritis and Total Joint Arthroplasty
The current available data regarding the effect of endogenous testosterone on the development of osteoarthritis and need for total joint arthroplasty are unclear.
Osteoporosis
4 Current research suggests that exogenous TRT increases BMD, but no direct investigation of the relationship between TRT and potential risk reduction of osteoporosis or subsequent fracture exists.
Bone-Implant Integration
These current studies suggest that testosterone incorporation into implant surfaces may encourage increased osteogenesis;however, they do not attempt to assess the relationship of endogenous testosterone level and bone-implant integration. Future investigations may examine the influence of direct testosterone implant integration andsystemic TRT on bone-implant integration and healing.
Recovery and Rehabilitation
There are currently no data on the role TRT mayplay on early recovery in these settings. Evidence suggests higher endogenous levels of testosterone and exogenous supraphysiologic TRT can improve recovery rates after TKA. However, no study draws direct assessment of physiologic TRT on postoperative orthopaedic surgery rehabilitation outcomes
Infection Risk
Although current reports are limited, the literature supports an increased risk of C. acnes PJI in TSA for individuals with higher serum testosterone and that this risk may be exacerbated by TRT use. Outside of studies on TSA,there is minimal literature regarding TRT and infection risk in all other orthopaedic subspecialties and associated procedures. This paucity of data is concerning because infection with C. acnes have also been reported after THA, TKA, and arthroscopic procedures.37 At this time, appropriate assessment of the relationship between testosterone and perioperative infection risk cannot be made. Furthermore, C. acnes has also been reported as the offending pathogen in native joint septicarthritis.38-40 The relationship of serum testosterone and skin burden of C. acnes at anatomical locations other than the shoulder has not been investigated. Given the mortality rate and poor outcomes related to PJI and deep implant infection, future investigation of the effect that endogenous testosterone and TRT have on postoperative infection risk is warranted
Conclusion
In this review, we summarize the current literature surrounding risks and potential clinical benefits of TRT in the orthopaedic patient. The current data on TRT and risk of VTE, cardiac events, prostatic pathology suggest minimal risk, yet to date few studies assess these events in relation to orthopaedic surgery. There are presently data suggesting TRT may be correlated with increased risk of musculotendinous injury and subsequent repair failure. Moreover, there is a potential correlation of TRT and C. acnes PJI. There is also a potential benefit of TRT in improved rehabilitation ,recovery, and bone-implant integration. TRT in the field of orthopaedics requires additional investigation to outline its safety, efficacy, and potential for an effect on clinical outcomes.
