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

Intraoperative Considerations

It is important to note that FTM patients may still have functioning female reproductive organs. Therefore, before surgery, FTM patients must undergo pregnancy testing if within the recommended age group from the American Society of Anesthesiologists.[12] Discussion of this testing should be approached with compassion and a clear explanation as to why it is still needed, even if the patient identifies as male.

Anesthesia considerations in transgender patients must consider not only structural changes that may be present in the patient but also metabolic differences in those taking exogenous hormones. Transgender women may have completed a laryngoplasty and/or chondroplasty to alter the voice pitch, which have the potential complications of vocal cord damage and reduction of tracheal lumen or stenosis, all of which may affect intraoperative airway management and require caution during intubation.[12] In regard to anesthetic agent use in those using exogenous estrogen, the general consensus is that there is no known drug-to-drug interaction between estrogen and any commonly used anesthetic agent.[12] However, a response to that study noted that estrogen is known to decrease pseudocholinesterase activity.[13] They also cautioned using reversals agents such as sugammadex, which has known to poorly interact with estrogen-containing birth control and decrease it's effectiveness (patients should use alternative contraceptive for 7 days after receiving the medication).[13] It is not known how this drug may interact with exogenous hormones received by transgender women and what unintended consequences it may have.

Although positioning of any patient undergoing arthroplasty is important to ensure a safe and efficient surgery, special care must be taken with patients who have undergone phalloplasty. An understanding of the type of neophallus created and its blood supply can prevent untoward kinking or pressure on the vasculature and avoid unintended or unrecognized tissue ischemia. This is especially important in those who have undergone free flap phalloplasty, where the arterial recipient vessels include the inferior epigastric and femoral vessels with or without vein grafting.[9] Neurorrhaphy is also performed to the dorsal clitoral and/or ilioinguinal nerves.[9] The presence of these neurovascular structures must be taken into account when positioning and performing an anterior approach total hip arthroplasty, as previous surgical procedures may have altered the anatomic landmarks. During lateral decubitus positioning, placement of the stabilizing posts must be monitored carefully. The use of Stuhlberg clamps with pressure directly applied to the anterior superior iliac spines, rather than the use of a pegboard post where pressure may be placed at the mid symphysis, would lower the risk of unintentional vessel compression (Figure 1). No concerns were identified in regard to positioning for a total knee arthroplasty or in the use of a tourniquet for such procedures, as these lie well distal to any potential anastamosis sites.

Figure 1.

Image showing the anatomic placement of a phalloplasty anastamosis in reference to major pelvic anatomic landmarks, in addition to its relation to a direct anterior total hip incision placement.

As previously mentioned, patients who have undergone phalloplasty frequently encounter urethral complications because of the addition of urethral length and have reported urethral stricture rates as high as 51%.[14] Owing to anatomic variations, the knowledge required to pass a foley in these patients is complex, with a high potential for injury (either because of the presence of a stricture or by a lack of recognizing that a prostate is still present). Urology should be consulted in advance of any elective surgical procedure in the event that a foley catheter will have to be placed. This knowledge needs to be passed along to nursing staff in the operating room and on the inpatient floor to prevent unintended injury to the patient.

A paucity of the literature exists in regard to the effect of BMD on implant placement and longevity; however, the drastic reduction in BMD found particularly in transgender women (MTF) after the initiation of exogenous hormones may affect implants.[6,7,15] A study by Delgado-Ruiz et al[15] looked at how exogenous hormone administration affected dental implants based on surrounding bone density. He found that patients with low BMD were more likely to have implant loosening, early implant failure, lower osseointegration, and lower likelihood of being able to load the implant immediately. It is not unreasonable to extend these findings to press-fit implant design, and surgeons should use caution during implant selection, having cemented options available as backup in both hip and knee arthroplasties.