Total Joint Arthroplasties in Transgender Patients

Abstract and Introduction

Abstract

Currently, no studies exist on transgender patients undergoing orthopaedic procedures within the orthopaedic literature at large. This echoes a trend within medicine in general, where despite their unique characteristics, transgender patients are largely ignored in medical research. As gender reassignment surgery becomes more commonplace and these patients' age into joint arthroplasties, orthopaedic surgeons will rapidly be faced with treating this patient group. Unique considerations include medical comorbidities commonly associated with the patient population, deep vein thrombosis risk while on cross-gender hormone therapy, surgical positioning considerations, and social support implications after surgery. In addition, risk reductions for possible future gender reassignment surgeries include consideration for extended perioperative antibiotics and diligent surveillance for implant ingrowth issues. An emphasis is placed on being comfortable with transgender patients to ensure equal access to health care while ensuring understanding and accuracy in describing the risks of surgery that are unique to this patient population.

Introduction

The size of the transgender community is difficult to calculate because of lack of survey data that specifically ask about gender identity. That being said, the transgender population in the United States is estimated to be anywhere from 0.39% to 0.60% of the adult population, working out to approximately 1.5 million adults,^[1,2] with male-to-female (MTF) being more prevalent than female-to-male (FTM).^[2] These numbers are believed to be on the conservative side and are likely to increase in the coming years (as they have increased since first being evaluated through national surveys in the early 2000's).^[2] Transgender patients also skew on the younger side of the spectrum (age <50 years) when compared with their cis-gendered counterparts.^[2] As acceptance and prevalence continue to progress, they will find themselves requiring orthopaedic interventions, which need to be considered in the context of their unique circumstances.

Transgender patients are more likely to have HIV and suffer from depression or anxiety, are 1.5× more likely to smoke, and have a 26× higher rate of previously attempted suicide.^[3] These are in addition to the medical and surgical complications that can arise from cross-gender hormone therapy and previous gender reassignment surgery.^[3] Currently, no data or review articles exist on transgender patients undergoing orthopaedic procedures within the orthopaedic literature at large. This echoes a trend within medicine in general, where despite their unique characteristics, transgender men and women are largely ignored in medical research.^[1,2] In addition, transgender treatment is not taught in conventional medical curricula, and too few physicians have the requisite knowledge and comfort level to appropriately care for their unique characteristics.^[3] This poses an ongoing barrier to appropriate health care and the potential for unexplained or unnecessary risks when the practitioner is unaware of these differences. This study will attempt to address these disparities by providing an overview of common medical comorbidities found in the transgender population, detailing common intraoperative issues that may be encountered (in both positioning and surgical approach), and reviewing literature to provide appropriate postoperative care to mitigate risks. Describing these concerns in the scope of performing a truly elective surgery with well-documented risks and an ability to mitigate those risks through optimization will allow orthopaedic surgeons to gauge the risk of complication that exists within this population.