Huang XC, Duan ZK, Zhang YJ, Huang HJ, Ma M, Tian C, Liu JM, Geng B. Associations of estrogen vs testosterone replacement therapy with complications after total joint arthroplasty: A systematic review. World J Orthop 2026; 17(10): 124852 [DOI: 10.5312/wjo.124852]
Corresponding Author of This Article
Bin Geng, MD, Department of Orthopedics, The Second Hospital of Lanzhou University, No. 82 Cuixingmen, Chengguan District, Lanzhou 730030, Gansu Province, China. cxxxf@foxmail.com
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Huang XC, Duan ZK, Zhang YJ, Huang HJ, Ma M, Tian C, Liu JM, Geng B. Associations of estrogen vs testosterone replacement therapy with complications after total joint arthroplasty: A systematic review. World J Orthop 2026; 17(10): 124852 [DOI: 10.5312/wjo.124852]
Xing-Chun Huang, Zhen-Kun Duan, Yu-Ji Zhang, Hua-Jie Huang, Ming Ma, Cong Tian, Jin-Min Liu, Bin Geng, Department of Orthopedics, The Second Hospital of Lanzhou University, Lanzhou 730030, Gansu Province, China
Co-first authors: Xing-Chun Huang and Zhen-Kun Duan.
Author contributions: Huang XC and Geng B conceived and designed the study; Huang XC, Duan ZK, Huang HJ, Zhang YJ, and Liu JM performed the data curation; Duan ZK, Huang HJ, and Zhang YJ conducted the formal analyses; Huang XC and Duan ZK wrote the original draft of the manuscript; Huang XC and Geng B conducted the subsequent review and editing of the manuscript; Ma M contributed to the investigation, methodology, and provision of resources; Tian C was responsible for validation and software; Geng B secured the funding and supervised the project; All authors have read and approved the final version of the manuscript for publication. Huang XC and Duan ZK made crucial and indispensable contributions towards the completion of the project and thus are qualified as the co-first authors of the paper.
AI contribution statement: Portions of this manuscript were edited using AI tools solely for language refinement. The authors carefully reviewed and verified all AI-assisted outputs and take full responsibility for the scientific content of the manuscript.
Supported by Natural Science Foundation of Gansu Province for Distinguished Young Scholars, No. 22JR5RA943; Science and Technology Project of Gansu Province, No. 23JRRA1500; Talent Innovation and Entrepreneurship Project in Chengguan District, Lanzhou City, No. 2025-rc-8; and Cuiying Scientific and Technological Innovation Program of Lanzhou University Second Hospital, No. CY2025-ZD-01.
Conflict-of-interest statement: The authors have no conflicts of interest to declare.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.
Corresponding author: Bin Geng, MD, Department of Orthopedics, The Second Hospital of Lanzhou University, No. 82 Cuixingmen, Chengguan District, Lanzhou 730030, Gansu Province, China. cxxxf@foxmail.com
Received: June 26, 2026 Revised: August 8, 2026 Accepted: August 31, 2026 Published online: October 18, 2026 Processing time: 113 Days and 1.6 Hours
Abstract
BACKGROUND
The populations undergoing total joint arthroplasty (TJA) and those receiving hormone replacement therapy (HRT) overlap considerably, as both predominantly comprise older adults. HRT includes estrogen RT (ERT) and testosterone RT (TRT). Whether these hormonal interventions influence postoperative medical complications (e.g., thromboembolism, acute kidney injury, cardiac events) or implant-related outcomes (e.g., infection, loosening, revision) remains uncertain. Existing studies provide conflicting results, and a direct comparison between ERT and TRT is lacking.
AIM
To systematically compare the associations of ERT and TRT with complications following TJA.
METHODS
PubMed, EMBASE, Web of Science, and Cochrane Library were searched through April 2026. Two reviewers independently screened studies, extracted data, and assessed bias. We examined medical complications, including venous thromboembolism (VTE), acute kidney injury (AKI), cardiac events, pneumonia, sepsis, blood transfusion, together with implant-related outcomes, including revision surgery, periprosthetic joint infection (PJI), periprosthetic fracture, and mechanical loosening. A narrative synthesis was performed due to design and clinical heterogeneity. The review followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines and was registered (PROSPERO: CRD420261366259).
RESULTS
A total of 15 studies met the inclusion criteria; 11 reported medical complications and 13 reported implant-related outcomes. ERT yielded mixed, procedure-specific results: Certain total knee arthroplasty (TKA) cohorts had reduced risks of deep vein thrombosis and blood transfusion, while others demonstrated elevated risks of TKA cardiac complications, total hip arthroplasty (THA) mechanical loosening, and total shoulder arthroplasty revision. By contrast, TRT showed a more consistent association with increased risks of PJI, AKI, and revision surgery, although several cohorts found no significant association with VTE after THA, periprosthetic fracture, or blood transfusion.
CONCLUSION
Evidence suggests inconsistent perioperative associations for ERT in TJA, whereas TRT may be linked to higher odds of PJI and AKI. However, heterogeneity and observational design limitations preclude causal inference, thus requiring prospective studies.
Core Tip: This study compared the associations of estrogen replacement therapy (ERT) and testosterone RT (TRT) with both medical and implant-related complications after total joint arthroplasty. The results indicated that existing clinical evidence on perioperative ERT remains contradictory, while TRT may be associated with elevated odds of periprosthetic joint infection and acute kidney injury. Nevertheless, these findings are inconsistent. Given substantial heterogeneity and the observational design of the included studies, no definitive conclusions can be drawn; prospective research is urgently needed to optimize perioperative hormone management.
Citation: Huang XC, Duan ZK, Zhang YJ, Huang HJ, Ma M, Tian C, Liu JM, Geng B. Associations of estrogen vs testosterone replacement therapy with complications after total joint arthroplasty: A systematic review. World J Orthop 2026; 17(10): 124852
Total joint arthroplasty (TJA) serves as a definitive surgical intervention for end-stage osteoarthritis and other destructive advanced joint disorders. The global volume of TJA procedures continues to expand alongside population aging[1-3]. Despite continuous improvements in surgical techniques and perioperative management strategies, postoperative complications-including venous thromboembolism (VTE), pulmonary embolism (PE), deep vein thrombosis (DVT), acute kidney injury (AKI), periprosthetic joint infection (PJI), aseptic loosening, and subsequent revision surgery-remain core issues affecting patient outcomes and increasing healthcare system burden[4-8].
Hormone replacement therapy (HRT) is a routine endocrine intervention used to supplement or replace deficient physiological hormones[9-11]. In recent years, the clinical use of HRT has become increasingly widespread, including testosterone RT (TRT) and estrogen RT (ERT)[12,13]. Notably, patient groups receiving TJA largely overlap with populations prescribed HRT, which renders perioperative hormonal management a vital clinical concern. A previous review[14] noted that although TRT use in orthopedics is increasing, the associated risks of VTE and cardiovascular events cannot be ignored. Other studies[15,16] suggest that testosterone supplementation may help improve clinical outcomes, optimize body composition, and increase bone mineral density. Furthermore, multiple large retrospective analyses built on real-world clinical databases have explored postoperative adverse events in HRT recipients, yet these published works yielded conflicting conclusions[17,18].
To the best of our knowledge, no previously published systematic review simultaneously synthesizes association of ERT and TRT with two categories of TJA postoperative outcomes: Medical adverse events (VTE, AKI, pneumonia, cardiovascular complications) and implant-related complications (PJI, aseptic loosening, periprosthetic fracture, revision arthroplasty). Therefore, this study systematically searched and synthesized existing evidence to clarify the differential associations of ERT and TRT with postoperative complications after TJA, in order to provide a new integrated perspective for clinical management of patients with TJA.
MATERIALS AND METHODS
Data sources and search strategy
This systematic review followed the PRISMA guidelines[19] and was registered with the International Prospective Register of Systematic Reviews, PROSPERO (CRD420261366259). Given the substantial clinical heterogeneity among included studies with respect to hormone formulation, time windows, and surgical sites, meta-analysis was not performed. Relevant studies published from database inception to April 2026 were searched. The electronic databases searched included PubMed, EMBASE, Web of Science, and the Cochrane Library. The detailed literature search strategy is reported in Supplementary Table 1. Two investigators independently completed all literature retrieval procedures, and any discrepancies arising during screening were settled via discussion with a third senior researcher.
Inclusion and exclusion criteria
Two authors independently screened titles/abstracts and performed full-text assessment of potentially eligible studies.
Inclusion criteria: (1) Participants were patients undergoing primary arthroplasty; (2) Interventions involved HRT before or after arthroplasty; (3) Comparisons included patients without HRT; (4) Outcomes included postoperative medical complications (DVT, PE, AKI, pneumonia, sepsis, transfusion) and implant-related complications (revision surgery, PJI, periprosthetic fracture, mechanical loosening); and (5) Study designs were cohort studies, cross-sectional studies, or case-control studies (prospective or retrospective).
Exclusion criteria: (1) Case reports, editorial commentaries, expert consensus opinions, and non-peer-reviewed conference abstracts; (2) Absence of full text or postoperative complication data; and (3) Non-English language publication.
Data extraction and quality assessment
We imported all retrieved bibliographic records into EndNote reference management software (version 21.5; Clarivate Analytics, Philadelphia, PA, United States). After duplicate removal, two authors independently screened the records and extracted prespecified data elements. Recorded information included: First author, publication year, baseline demographic information of study population (age, sex, body mass index), study period, number of patients with and without hormone use, primary outcomes, hormone type, and follow-up duration. Data were further checked through discussion to ensure accuracy. Two authors independently assessed the risk of bias of included studies using the Newcastle-Ottawa Scale[20], with a third author resolving any disagreements to reach final consensus.
RESULTS
Study selection
A total of 534 potentially relevant articles were retrieved from four electronic databases. After removing 181 duplicates, 329 irrelevant articles were excluded based on titles and abstracts, leaving 24 articles for full-text assessment. Subsequently, nine articles were further excluded for the following reasons: (1) Incorrect control group (n = 1); (2) Unobtainable research data (n = 2); (3) Inappropriate research type (n = 4); and (4) Incorrect selected research subject (n = 2). Finally, 15 articles met the inclusion criteria[17,18,21-33]. There was no disagreement between authors regarding the inclusion of these studies. The selection flow diagram is shown in Figure 1.
Figure 1 Flowchart of the study selection process.
Risk of bias assessment
Among all included studies, only 2 were considered to have low risk of bias, 10 were assessed as moderate risk of bias, and 3 were assessed as high risk of bias. The overall riskofbias scores are shown in Figure 2, and the detailed assessment results are presented in Supplementary Table 2.
Figure 2 Newcastle-Ottawa Scale scores of included studies.
NOS: Newcastle-Ottawa Scale.
Characteristics of included studies
Of the included studies, 14 were retrospective cohort studies and 1 was a case-control study. Sample sizes ranged from 318 to 291517 patients. All studies reported at least one postoperative complication. Thirteen studies were published between 2020 and 2026, while two studies were published before 2020. The overall characteristics of the included studies are detailed in Table 1.
Table 1 Characteristics of included studies, mean ± SD.
TRT (6 studies): Two included cohort studies consistently showed increased PE risk with TRT[28,29]. White et al[27] reported an increased risk of VTE at 1 year after total shoulder arthroplasty (TSA) (relative risk [RR] = 1.55), but no difference at 90 days postoperatively. All three studies on total hip arthroplasty (THA) found no significant association[17,31,32].
ERT (5 studies): Zhao et al[33] reported that ERT reduced the risk of DVT after THA by 48% (odds ratio [OR] = 0.52), with decreasing trends for both DVT and PE in total knee arthroplasty (TKA). Collins et al[32] found a reduction in DVT within 90 days after TKA (0.24% vs 0.32%), but an increase in PE after THA (0.78% vs 0.57%). Mousavi et al[30] reported a roughly 90% elevated risk at 90 days after TSA. The other two studies detected no significant association[17,23].
Other complications (pneumonia and sepsis, AKI, cardiac events, and transfusion)
TRT (5 studies): AKI risk was elevated in multiple studies: White et al[27] reported increased risk at 90 days (OR = 1.37) and 1 year (OR = 1.54) after TSA; Omurzakov et al[28] found 50% and 60% increased risk at 90 days and 1 year after TKA, respectively; Collins et al[32] also observed similar significant increases in THA and TKA (OR = 1.22 and 1.24). Only McCormick et al[17] found no significant difference after THA. Regarding infection, Omurzakov et al[28] found increased risk of pneumonia at 1 year after TKA (OR = 1.60), and 80% and 70% increased risk of sepsis at 90 days and 1 year, respectively. Evidence on cardiovascular events was conflicting: Omurzakov et al[28] reported increased risk of cardiac events at 1 year after TKA (OR = 1.30) but no significant difference at 90 days. The other three studies found no significant association[27,31,32]. Regarding transfusion, Collins et al[32] found a lower transfusion rate in the TRT group after TKA (OR 0.74), but no difference in THA; White et al[27] and McCormick et al[17] found no significant difference in TSA and THA.
ERT (3 studies): Collins et al[32] reported a slightly higher risk of cardiac events (OR 1.21) and a lower transfusion rate (OR 0.85) in the ERT group after TKA. No differences were found in THA. Furthermore, in terms of AKI, Collins et al[32] did not show any differences in THA or TKA. The other two studies found no significant association between ERT and AKI, pneumonia, or transfusion[17,30].
90 days: OR = 1.250, 95%CI: 0.650-2.404, P = 0.503; 2 years: 4.2% vs 2.5%, P = 0.004; 4 years: 5.5% vs 3.4%, P = 0.003; 10 years: 7.0% vs 4.6%, P = 0.002
90 days: OR = 1.706, 95%CI: 0.941-3.093, P = 0.075; 2 years: 3.9% vs 2.9%, P = 0.116; 4 years: 5.1% vs 3.8%, P = 0.060; 10 years: 6.6% vs 4.6%, P = 0.007
90 days: OR 1.193, 95%CI: 0.938-1.517, P = 0.149; 2 years: 10.3% vs 8.2%, P = 0.028; 4 years: 10.7% vs 9.1%, P = 0.092; 10 years: 11.2% vs 9.6%, P = 0.124
90 days: OR = 1.000, 95%CI: 0.417-2.397, P = 1.000; 2 years: 1.2% vs 0.6%, P = 0.033; 4 years: 1.8% vs 0.9%, P = 0.020; 10 years: 2.2% vs 1.5%, P = 0.104
1 year: 1.30% vs 0.84%, P = 0.01; 2 years: 1.65% vs 1.02%, P < 0.001; 3 years: 1.71% vs 1.08%, P < 0.001; 4 years: 1.71% vs 1.10%, P < 0.001; 5 years: 1.75% vs 1.12%, P < 0.001
TRT (7 studies): Most studies indicated increased revision risk with TRT. Omurzakov et al[28] reported 60% (OR = 1.60) and 50% (OR = 1.50) increased risk at 1 and 5 years after TKA, respectively; Coden et al[18] observed elevated cumulative reoperation rates between 1 and 5 years postoperatively. Collins et al[32] found 46% and 27% increased risk after THA and TKA, respectively. White et al[27] reported 60% and 48% increased risk at 1 and 5 years after TSA. Corban et al[26] reported higher cumulative incidences of infection-related and all-cause reoperation between 1 and 3 years. Furthermore, Jing et al[31] also reported an increase in risks. Only one study found no significant association after TSA[25].
ERT (4 studies): Prieto-Alhambra et al[22] found a reduction in revision risk among postoperative HRT users; no protection was seen with preoperative use. Mousavi et al[30] observed significantly elevated risk at 2, 4, and 10 years after TSA. McCormick et al[17] reported a 23% increased risk of 1-year revision after THA (OR = 1.23). Collins et al[32] reported a 31% increased revision risk after TKA with ERT, but no significant association after THA.
PJI
TRT (5 studies): Most studies demonstrated an elevated PJI risk. White et al[27] reported significant increases after TSA at 1 year (OR = 2.05) and 5 years (OR = 1.81). Omurzakov et al[28] observed similarly elevated risks after TKA at 1 year (OR = 2.7) and 5 years (OR = 2.3). Collins et al[32] noted a 67% increased risk after THA. Su et al[24] found that the risk was confined to recent preoperative exposure: OR 1.44 (95% confidence interval [CI]: 1.03-2.01) for exposure within 6 months, but no significant association for exposure 6–12 months preoperatively (OR = 1.18, 95%CI: 0.83-1.68). Furthermore, Parmar et al[25] reported no significant difference after reverse TSA (1.4% vs 1.6%; P = 0.597).
ERT (2 studies): McCormick et al[17] found no significant association. Mousavi et al[30] reported no significant differences at 90 days, 2 years, or 4 years; however, at 10 years the cumulative PJI incidence was significantly higher in the ERT group (6.6% vs 4.6%; P = 0.007).
Periprosthetic fracture
TRT (4 studies): Omurzakov et al[28] reported significantly increased risk at 1 and 5 years after TKA. Collins et al[32] saw an increasing trend in TKA but no association in THA. Parmar et al[25] and White et al[27] found no significant association.
ERT (3 studies): Mousavi et al[30] reported a 26% increased risk of fracture at 2 years after TSA (RR = 1.26), with no difference in long-term follow-up. The other two studies found no association in TKA or THA[17,32].
Mechanical loosening
TRT (4 studies): Omurzakov et al[28] reported an increased risk of loosening at 1 year (OR = 1.90) and 5 years (OR = 2.1) after TKA. Collins et al[32] saw an increasing trend in TKA (OR = 1.34) but no association in THA. White et al[27] found no significant difference at 90 days or 1 year after TSA; however, at 5 years the risk was significantly higher. Another study did not find an association in TSA[25].
ERT (3 studies): Mousavi et al[30] reported elevated risk of loosening at 2 and 4 years after TSA, but no correlation was observed at 10 years. Collins et al[32] found a 45% increased risk of loosening within 90 days after THA (OR = 1.45). The other two studies found no association[17,32].
DISCUSSION
The present narrative synthesis integrates all published clinical evidence describing the differential associations of ERT and TRT with postoperative adverse events after TJA. The central finding highlights divergent evidence profiles by hormone type: ERT demonstrates heterogeneous and procedure-dependent associations, whereas TRT appears to be associated with several postoperative risks across most analyses, despite some between-study inconsistency. These divergent associations likely stem from complex interactions between hormone type, surgical site, administration timing, therapeutic dosage, and individual patient characteristics.
Previous studies have shown that TRT can increase bone mineral density and that ERT can reduce the risk of hip fracture[34,35]; both can improve insulin sensitivity, lipid profile, and quality of life. In terms of specific benefits, TRT, as the first-line treatment for male hypogonadism, can relieve fatigue and muscle weakness, and may improve metabolic dysfunction-associated fatty liver disease[36,37]; ERT can effectively relieve menopausal hot flashes and night sweats, and improve urogenital atrophy[38]. Regarding cardiovascular safety, ERT initiated within the window period may have a protective effect[39], but is associated with an increased risk of atrial fibrillation[40]; the evidence for TRT in cardiovascular safety remains controversial[41]. ERT initiated within the window period does not increase the risk of heart failure[42], but oral estrogen significantly increases the risk of VTE[43]. Tumor risk is the area with the most significant differences between the two. For ERT, combined with progestin increases the risk of breast cancer, while estrogen alone may instead reduce its incidence[44,45]; in women with an intact uterus, estrogen alone increases the risk of endometrial cancer, so combined progestin is required[46]; long-term estrogen alone may be associated with an increased risk of ovarian cancer[47]. For TRT, current evidence does not support that it increases the risk of new-onset prostate cancer[48], but it is contraindicated in patients with untreated prostate cancer[49]; male breast cancer is rare, and TRT is also contraindicated in those with a history of breast cancer[49]. In addition, TRT may worsen symptoms of benign prostatic hyperplasia[50] and suppress spermatogenesis[51]; ERT may increase the risk of gallbladder disease[52], and combined therapy may increase the risk of dementia[53].
In summary, TRT and ERT have clear dual effects of benefit and risk in terms of bone mineral density, metabolism, cardiovascular safety, and tumor risk. The following will focus on the specific context of TJA to explore the associations of HRT with surgical outcomes.
TRT
TRT can induce erythrocytosis, enhance platelet function, modulate specific inflammatory immune cells, and exert complex effects on coagulation and the vascular endothelium[54-56]. When superimposed on surgical trauma and postoperative immobilization, these physiological perturbations may increase the risk of venous thrombosis. This review finds that TRT is associated with an increased risk of VTE after TKA, consistent with previous research[57-59]. However, no similar association was observed in THA[17,32], suggesting that the thrombotic risk of TRT may be related to the surgical site, degree of trauma, intraoperative hemostasis, and postoperative immobilization patterns.
TRT may cause erythrocytosis and increased blood viscosity, which imposes a burden on renal microcirculation and thereby increases the risk of AKI[60]. This association is observed across several surgical settings[27,28,32]. Regarding infection, TRT recipients had an increased risk of pneumonia and sepsis[28], which may be related to the immunomodulatory effects of testosterone and its impact on respiratory flora[61,62]. It should be noted that the relationship between TRT and sepsis is more complex, with the effect of testosterone on sepsis being context-dependent; some studies suggest that high testosterone levels may be associated with better sepsis outcomes[63]. The association between TRT and revision risk was relatively consistent in TKA and TSA, with PJI being the most prominent risk[24,27,28,32]. Notably, this risk may be time-dependent: Only those exposed within 6 months preoperatively showed significantly increased risk[24], suggesting that the immunosuppressive effect may attenuate after discontinuation, warranting further study. In addition, intramuscular formulations may increase PJI risk due to fluctuating serum concentrations or injection site infection[64,65]. At the microbiological level, testosterone users have a higher colonization density of Propionibacterium acnes in the skin[66], and changes in gut microbiota composition and decreased integrity of the intestinal barrier promote translocation of bacteria and endotoxins, thereby increasing the incidence of PJI[67,68].
In THA, the role of TRT in aseptic loosening and fracture was limited, possibly related to TRT improving hip bone mineral density and reducing fracture rates[69], whereas in TKA, the risk of aseptic loosening and periprosthetic fracture was increased. No significant association was observed in TSA, possibly due to differences in indication populations or because the 90-day follow-up period was insufficient to capture long-term events.
ERT
The association pattern for ERT is more complex. This relationship with VTE is influenced by the route of administration. Oral ERT can disrupt coagulation balance through the hepatic first-pass effect and thereby increase VTE risk[70]. In contrast, transdermal estrogen bypasses hepatic first-pass metabolism, has less effect on hepatic synthesis of coagulation factors, does not substantially activate the coagulation system, and does not appear to increase VTE risk[71,72]. This review shows that ERT may not increase the risk of VTE after TKA[33]; however, the risk of PE after THA is increased[32]. These findings indicate that higher-quality evidence is needed to define the true VTE risk of ERT and determine whether the association differs across surgical procedures[73]. Regarding medical complications, ERT was not significantly associated with AKI or pneumonia[17,30,32]. Some studies showed a slightly increased risk of cardiovascular events after TKA, but a lower transfusion rate, suggesting that ERT may have multiple effects through improving systemic status[32].
Among implant-related complications, the effect of ERT showed significant time dependence: Postoperative use significantly reduced revision risk with a dose-time effect[22], whereas long-term preoperative users had increased risk of late revision and mechanical complications[17,30]. This contradiction suggests that the timing of medication may be critical. Unlike TRT, ERT had no obvious connection with mechanical loosening and periprosthetic fracture in some studies[17,30,32]. Previous studies have shown that estrogen has beneficial effects on bone health, and ERT may increase bone mineral density and improve bone strength[74,75]; however, this study suggests that the improvement in bone mineral density by ERT may have limited translation into benefits for prosthesis stability. For PJI, some studies have shown no significant effect in the short to medium term. This indicates that the inflammatory and immune regulatory roles of estrogen and androgen may be different[17,32].
Clinical implications
Based on the findings of this study, the following clinical recommendations are proposed regarding complications after arthroplasty. For ERT recipients, the decision to continue therapy should weigh potential benefits (possible reduction in DVT and transfusion requirements in TKA) against procedure-specific risks (increased cardiac events in TKA, mechanical loosening in THA, and revision in TSA). For TRT recipients, clinicians should exercise caution regarding PJI, AKI, and PE risks. However, given the observational nature of included studies and significant heterogeneity in hormone formulations and patient characteristics, these findings should not be interpreted as directives for routine discontinuation or continuation. Instead, multidisciplinary consultation involving endocrinology and orthopedic surgery is advisable to individualize benefit-risk assessments and determine optimal hormone management strategies.
Limitations
This study has the following main limitations. (1) Given that all included studies are observational in nature, no definitive conclusions regarding causality can be drawn. Although most studies used propensity score matching or multivariable adjustment, unmeasured confounding factors (e.g., adherence to HRT) may still affect the results; (2) Data source overlap exists in some studies (e.g., TriNetX, PearlDiver); despite comparison, the possibility of duplicate counting remains; (3) Most studies did not differentiate hormone formulation, dosage, duration, or age stratification, resulting in significant heterogeneity and limiting pooled comparative analysis; (4) Outcome definitions (PJI, aseptic loosening, etc.) were not uniform, affecting comparability; and (5) The overall quality of evidence is low to moderate, which may limit the strength of our conclusions.
CONCLUSION
This systematic review shows that the associations of ERT and TRT with TJA complications are divergent. ERT has complex links with postoperative outcomes and the results are not yet consistent. TRT may be associated with an increased risk of PJI and AKI, but the results among different studies are inconsistent. Current evidence cannot yet clarify the exact relationships between them. Therefore, the use of HRT in the perioperative period should be carefully weighed. Given that the existing evidence is still limited, there is an urgent need for prospective studies to determine the optimal management strategy.
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[RCA] [PubMed] [DOI] [Full Text] [Full Text (PDF)][Cited by in Crossref: 125][Cited by in RCA: 100][Article Influence: 16.7][Reference Citation Analysis (2)]
Footnotes
Peer review: Externally peer reviewed.
Peer-review model: Single blind
Specialty type: Orthopedics
Country of origin: China
Peer-review report’s classification
Scientific quality: Grade C
Novelty: Grade C
Creativity or innovation: Grade C
Scientific significance: Grade C
P-Reviewer: Nagamine T, MD, PhD, Professor, Japan S-Editor: Liu H L-Editor: Filipodia P-Editor: Yang YQ
