Estrogen Replacement Therapy Decreases Associated Risk of Postoperative Venous Thromboemboli and Medical Complications After Total Joint Arthroplasty

Stephanie Zhao; Mackenzie Kelly; Spencer Smith; Nathanael D Heckmann; Kathryn Schabel; Elizabeth Lieberman; Jung Yoo; Ryland Kagan

doi:10.1016/j.arth.2025.05.027

Estrogen Replacement Therapy Decreases Associated Risk of Postoperative Venous Thromboemboli and Medical Complications After Total Joint Arthroplasty

J Arthroplasty. 2025 Nov;40(11):2995-2999.e1. doi: 10.1016/j.arth.2025.05.027. Epub 2025 May 14.

Authors

Stephanie Zhao¹, Mackenzie Kelly¹, Spencer Smith¹, Nathanael D Heckmann², Kathryn Schabel¹, Elizabeth Lieberman³, Jung Yoo¹, Ryland Kagan¹

Affiliations

¹ Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, Oregon.
² Department of Orthopaedic Surgery, University of Southern California, Los Angeles, California.
³ Orthopedic + Fracture Specialists, Portland, Oregon.

PMID: 40379114
DOI: 10.1016/j.arth.2025.05.027

Abstract

Background: Estrogen replacement therapy (ERT) and total joint arthroplasty (TJA) are prevalent in the geriatric population, with limited evidence for how ERT influences postoperative outcomes. ERT is often held before arthroplasty due to the perceived risk for venous thromboembolism (VTE). Our primary aim was to investigate the relationship between ERT and VTE risk and secondarily to investigate major medical complications following TJA.

Methods: A retrospective review was performed with a large national database querying International Classification of Diseases, tenth revision procedure codes, identifying 893,759 primary total hip arthroplasty (THA) and 1,660,909 total knee arthroplasty (TKA) procedures from 2015 to 2020. Of THAs, a cohort of 3,425 (3.5%) were prescribed ERT within 90 days before surgery and propensity matched to 6,850 control patients for age, tobacco use, obesity, and diabetes diagnosis. Of TKAs, a cohort of 7,409 (3.5%) was prescribed ERT and similarly propensity matched to 14,818 control patients. Propensity-matched data were qualified with adjusted odds ratios (OR) and 95% confidence intervals (CI) for deep vein thrombosis (DVT), pulmonary embolism (PE), and total medical complications.

Results: After propensity matching, ERT use in THA demonstrated decreased risk of DVT (OR 0.52, CI 0.29 to 0.91, P = 0.028) but no difference in PE (OR 0.67, CI 0.34 to 1.32, P = 0.31). The ERT cohort had lower medical complications (OR 0.47, CI 0.31 to 0.73, P < 0.001). Among TKAs, ERT use was associated with decreased risk of DVT (OR 0.60, CI 0.44 to 0.82, P = 0.001), PE (OR 0.56, CI 0.37 to 0.83, P = 0.005), and medical complications (OR 0.53, CI 0.42 to 0.67, P < 0.001).

Conclusions: The use of ERT with TJA is associated with decreased risk of VTE and major medical postoperative complications. These findings should be considered when counseling patients regarding the management of ERT when undergoing TJA.

Keywords: complications; estrogen replacement therapy; total hip arthroplasty; total knee arthroplasty; venous thromboembolism.

MeSH terms

Aged
Aged, 80 and over
Arthroplasty, Replacement, Hip* / adverse effects
Arthroplasty, Replacement, Knee* / adverse effects
Estrogen Replacement Therapy*
Female
Humans
Male
Middle Aged
Postoperative Complications* / epidemiology
Postoperative Complications* / etiology
Postoperative Complications* / prevention & control
Pulmonary Embolism / epidemiology
Pulmonary Embolism / etiology
Pulmonary Embolism / prevention & control
Retrospective Studies
Risk Factors
Venous Thromboembolism* / epidemiology
Venous Thromboembolism* / etiology
Venous Thromboembolism* / prevention & control
Venous Thrombosis / epidemiology
Venous Thrombosis / etiology
Venous Thrombosis / prevention & control