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

Postoperative Considerations

If an inpatient stay is required after surgery, it is important that transgender patients are treated with respect and correct/desired pronouns are used. A patient should be asked which pronoun they prefer to use as part of the preoperative assessment. Simple tasks, such as room assignments and how the patient is addressed by supporting floor staff, can be of the key to a satisfying surgical experience. Large portions of transgender patients find themselves uncomfortable seeking health care and discussing health matters that may relate directly to their sex.[16] Studies have noted that carefully noting the patient's preferred name and confirming how they wish to be addressed can improve patient comfort.[12] Patients should be roomed according to their gender identity if shared rooms are necessary. If the gender and sex of the patient cannot be separated in the medical chart, perform careful planning before room assignments to avoid any confusion.[12] Discussing a private room for added patient safety is appropriate; however, placing a patient in a private room may contribute to feelings of isolation.[12] To avoid any complications because of miscommunications or a lack of trust in the healthcare providers, consider these small details in the planning of their hospital stay.

Deep vein thrombosis (DVT) risk in transgender women (MTF) receiving exogenous hormones is poorly studied and understood. When looking at the cisgender female exogenous hormone supplementation (either through estrogen therapy or hormone replacement therapy in postmenopausal women), all types of exogenous estrogen has shown increased DVT risk, in some cases as high as a fourfold increase in DVT rates.[17,18] In addition, men who receive exogenous estrogen as part of treatment of prostate cancer also show a substantial increase in DVT incidence.[17] The few retrospective studies looking at MTF DVT risk while using exogenous hormone therapy show that DVT rates are highest in those taking oral estrogen supplementation and lowest in those receiving transdermal estrogen supplementation.[17,18] Recommendations to lower this risk include avoiding the use of progestin supplementation in addition to estrogen, avoiding ethinyl estradiol (highest VTE risk) and converting to transdermal estrogen supplementation if possible.[18] The orthopaedic surgeon should discuss all these options to lower the risk of DVT/VTE preoperatively, in addition to treating the patient as a high-risk VTE patient postoperatively with more aggressive anticoagulation beyond the standard aspirin currently recommended.

Long-term survival of implants placed in transgender patients has no substantiated follow-up. Surveillance of implants in the postoperative period may require more diligence in those at the earlier stages of transitioning because those who begin exogenous estrogen administration after an arthroplasty has been performed will experience a rapid rate of bone loss, which may affect implant stability.[6,7,15] Therefore, it is our recommendation that additional follow-up during initiation of hormone therapy be undertaken to catch potential complications early. Long-term infection risk with subsequent gender-conforming surgeries (particularly where surgery might involve bowel perforation risk) is unknown, and recommendations cannot be made at this time.