Total Joint Arthroplasties in Transgender Patients

Unique Considerations for an Emerging Patient Population

Katharine D. Harper, MD; Eric Maiorino, MD


J Am Acad Orthop Surg. 2022;30(13):607-612. 

In This Article

Preoperative Considerations

Transgender patients encounter unique complications not only because of the use of cross-gender hormones but also because of previous medical and surgical interventions. These include endocrine abnormalities, increased clotting risk, cardiovascular risk, urethral complications, and bone density variations. The use of cross-gender hormone therapy is common in the transgender community and thus requires consideration in the perioperative period in how it will affect surgical risks and outcomes. Exogenous testosterone is used in FTM patients to induce virilization and suppress feminizing characteristics. Exogenous estrogen is used in MTF patients to help feminization while antiandronergic agents are used as adjuncts to help suppress masculinizing features.[4] Testosterone can be administered intramuscularly, subcutaneously, or transdermally; the use of oral testosterone formulas is not available in the United States.[4] Estrogen can be administered through all four routes listed above. In addition, antiandrogen adjuncts can include progesterone, medroxyprogesterone acetate, leuprolide, spironolactone or finasteride.[4] Large fluctuations are seen in laboratory work (blood counts [decreased], hematocrit [decreased], and lipid panels [increased]), bone mineral density (BMD) (decreased), and sexual characteristics within the first year of initiation.[4] This requires monitoring every 2 to 3 months, before stabilizing, and requiring less frequent monitoring (every 6 to 12 months).[4,5] A surgeon should consider postponing elective surgeries until a stabilized medication dose and normalized laboratory values have been achieved.[5] Values should be expected return to normal reference levels that are routinely used for laboratory values,[5] and if this does not occur, referral to a specialist should be performed before surgery.

In addition to regular medical clearances, the surgeon should consider endocrine and cardiac clearance for transgender patients. Osteoporosis is a notable risk factor, even in those younger than 60 years, if sex hormone levels remain too low through exogenous supplementation. In addition, antiandrogen medications have shown to produce drastically lower BMD in MTF patients than cis-gendered patients.[4–7] Recommendations suggest transgender patients should be screened at an earlier age for osteoporosis.[4] Establishing a stable hormone therapy level and BMD before surgery through endocrine clearance will ensure optimal survivability of the total joint and assist in decision making and surgical planning when choosing an implant (cemented versus noncemented). Cardiovascular risk is increased in patients taking exogenous estradiol, showing higher rates of cardiovascular events, myocardial infarction, venous thromboembolism (VTE), and stroke than those not taking them.[4,8] Exogenous testosterone has not been shown to increase cardiac risk in FTM patients.[4] Patients may be unaware of this added risk and may not have been previously assessed for this due to their age and/or medical history; therefore, baseline cardiac evaluation should be performed before surgery.

Although many transgender patients are able to realize their gender identity without surgical intervention, an ever-increasing portion of the gender-dysphoric population is seeking gender-confirming surgery.[9] For the patient being affirmed, common procedures can include genital surgery ("bottom surgery"), chest contouring ("top surgery"), and facial reconstruction. Although the timing of many of these procedures is important to note in relation to their planned arthroplasty to ensure proper healing and aesthetic result for the patient, the stage and timing of their "bottom surgery" is of particular importance. According to the World Professional Association for Transgender Health, in order for a patient to be a candidate for genital surgery, they must meet the following criteria: persistent, well documented gender dysphoria, capacity to make a fully informed decision and to consent for treatment, age of majority, well-controlled medical/mental health if present, 12 continuous months of hormone therapy, and 12 months of living in a gender role congruent with their gender identity.[10] For the MTF patient, the most common genital operation is vaginoplasty with some variation of the penile inversion procedure.[11] Importantly, the prostate is left intact to avoid complications such as incontinence and urethral strictures. For the FTM patient, the most common procedures are metoidioplasty, pedicled locoregional flap phalloplasty (ie, anterolateral thigh flap), and free flap phalloplasty (ie, radial forearm, lateral arm, and latissimus dorsi). For most of these patients, the ability to void while standing up is an important goal necessitating a urethroplasty in each procedure; however, the timing and reconstructive technique used for creation of the neourethra can vary and in some instances be performed in a delayed fashion.[9] A suprapubic catheter is often used in these patients in the postreconstructive period while the neourethra is allowed to heal for a period of 4 to 5 weeks.[9] The location and manner in which each patient voids should be noted before any surgical procedure to avoid potential postoperative complications or confusion among medical staff not familiar with the care of transgender patients.