The 2026 arthroplasty literature on testosterone replacement therapy and surgical complications now covers all three major joint replacement procedures. A new propensity-matched analysis in The Journal of Arthroplasty extends earlier knee data to total hip replacement, and a separate 2026 analysis in the Journal of Shoulder and Elbow Surgery does the same for shoulder arthroplasty. Both signal the same direction: preoperative TRT is associated with meaningfully higher rates of medical and prosthetic complications.
For men on testosterone who have an elective joint replacement scheduled, this is the data point that should change the preoperative conversation.
Key Takeaways
The 2026 hip arthroplasty study found TRT users had 4.7x the sepsis rate at 90 days, 1.7x the cardiac event rate at 1 year, and 1.8x the revision surgery rate at 5 years
The 2026 shoulder arthroplasty study found TRT users had 2x the periprosthetic joint infection rate at 1 year and 1.7x at 5 years
Findings replicate the 2026 AAOS knee replacement signal across three different joints — the pattern is now consistent
A 2025 rotator cuff repair study showed timing matters: stopping TRT within 6 months of surgery was associated with worse outcomes than stopping 6-12 months out
Current best practice: discuss TRT with your surgeon 4-6 weeks before any scheduled joint replacement and consider a 3-6 month preoperative pause
This does not change overall TRT safety established by TRAVERSE — it changes the perioperative protocol
What the 2026 Hip Arthroplasty Study Actually Showed
The Journal of Arthroplasty paper used a large national real-world database to match TRT users 1:1 against non-users undergoing total hip replacement. The propensity-match controlled for age, BMI, comorbidities, smoking, and other variables that confound hormone-outcome studies.
Hip Arthroplasty Complication Rates by Follow-Up Window
Time Point
Complication
TRT Users
Non-Users
P Value
90 days
Deep vein thrombosis
2.8%
2.0%
0.023
90 days
Pneumonia
3.2%
1.7%
<0.001
90 days
Sepsis
4.2%
0.9%
<0.001
1 year
Deep vein thrombosis
4.3%
3.0%
0.002
1 year
Cardiac events
2.9%
1.7%
<0.001
1 year
Pneumonia
6.1%
3.4%
<0.001
1 year
Acute kidney injury
7.6%
5.6%
<0.001
1 year
Sepsis
3.8%
1.9%
<0.001
5 years
Periprosthetic joint infection
3.1%
1.6%
<0.001
5 years
Periprosthetic fracture
2.4%
1.4%
0.003
5 years
Loosening
1.7%
1.0%
0.007
5 years
Prosthetic dislocation
2.5%
1.2%
<0.001
5 years
Revision surgery
4.1%
2.3%
<0.001
The sepsis differential at 90 days — 4.2% versus 0.9% — is the largest absolute risk gap in the dataset. That is a 4.7-fold increase in a life-threatening complication during the immediate postoperative window. The 5-year prosthetic complication panel is the second concerning cluster: every single hardware-related outcome was elevated, and the revision-surgery rate was nearly double.
What the 2026 Shoulder Arthroplasty Study Showed
The Journal of Shoulder and Elbow Surgery analysis used the TriNetX database to identify total shoulder arthroplasty patients with documented preoperative TRT use within one year of surgery. After 1:1 propensity-score matching, 1,369 patients sat in each cohort with no baseline differences.
Shoulder Arthroplasty Outcomes
Time Point
Outcome
TRT Users
Non-Users
Relative Risk
90 days
Emergency department visits
13.7%
8.1%
1.69
1 year
Emergency department visits
26.6%
16.9%
1.58
1 year
Acute kidney injury
17.5%
12.1%
1.45
1 year
Periprosthetic joint infection
4.8%
2.4%
2.00
5 years
Periprosthetic joint infection
7.9%
4.5%
1.74
The doubling of one-year PJI risk after shoulder replacement is the headline number. PJI is one of the most consequential orthopedic complications — it often requires multi-stage revision surgery, prolonged antibiotic therapy, and in some cases permanent functional loss. A relative risk of 2.0 in a propensity-matched cohort of 1,369 pairs is a hard signal to ignore.
How This Fits the Broader 2025-2026 Surgical Picture
The hip and shoulder data extend a pattern that was already visible in the 2026 AAOS knee replacement analysis, which we covered in detail in TRT and surgery risk.
Joint
Study Size
1-Year PJI / Infection Signal
5-Year Revision Signal
Knee
13,250 matched pairs
Elevated
Elevated
Hip
Propensity-matched cohort (J. Arthroplasty 2026)
Elevated
4.1% vs 2.3%
Shoulder
1,369 matched pairs
4.8% vs 2.4% (RR 2.0)
7.9% vs 4.5%
Three independent databases, three different joints, three propensity-matched designs, three positive signals in the same direction. The replication is what makes this matter — single studies in observational data can be confounded; three convergent studies across distinct procedures are harder to explain away.
The closely related rotator cuff repair literature (2025 Journal of Sports Health, retrospective cohort) adds timing data: men whose last testosterone use was within 6 months of surgery had higher rates of revision rotator cuff repair, frozen shoulder, and prolonged opioid use compared to men who stopped TRT 6-12 months preoperatively. That is the only published study so far that quantifies a preoperative washout window — and the answer it suggests is "longer than 6 months is probably safer."
The mechanisms are not fully nailed down, but the candidate pathways are reasonable.
Elevated hematocrit and blood viscosity. Testosterone increases red blood cell production, often pushing hematocrit into the upper 40s or low 50s. Above roughly 52%, microvascular flow worsens and clot risk rises. This is the most established mechanism and likely explains a lot of the DVT, pulmonary embolism, and stroke signal. See our coverage of TRT polycythemia and hematocrit management.
Altered immune modulation. Testosterone affects neutrophil function and biofilm clearance. The persistent 5-year periprosthetic joint infection signal — where infections can seed years after the implant goes in — suggests sustained androgen exposure may impair the body's ability to control low-grade implant colonization.
Bone remodeling effects at the implant interface. Periprosthetic fracture and loosening rates were elevated at 5 years in the hip data. Both are mechanical failures of the bone-implant junction. Testosterone has complex effects on bone density and remodeling — net beneficial in most contexts, but possibly disruptive at the high-stress micro-motion zones around implants.
Cardiac arrhythmia signal. The 2.9% versus 1.7% cardiac event rate at 1 year after hip replacement aligns with the atrial fibrillation signal seen in TRAVERSE (3.5% vs 2.4%). Major orthopedic surgery is itself an arrhythmia trigger; layering TRT on top appears to compound the risk. See TRAVERSE trial coverage.
Selection bias is a real caveat. None of the 2026 arthroplasty studies are randomized. Men on TRT may differ from non-users in ways the propensity-match did not capture — they may be more sedentary at baseline, have higher visceral adiposity, or have undiagnosed cardiometabolic disease that drove them to seek hormone optimization in the first place. This is the strongest argument against over-interpreting the signal.
What This Means for Your Preoperative Plan
If you are on TRT and have an elective joint replacement scheduled, the data argue for three concrete adjustments to your preoperative protocol.
1. Disclose TRT at Surgical Consultation
This sounds obvious but a lot of men do not mention TRT during preoperative consults because they got it through a telehealth clinic and do not think of it as a "real" prescription. It is. Your surgical team needs to know.
If you got your prescription through an online clinic, log into your portal, screenshot your protocol (dose, frequency, duration of use), and bring it to the consult. If your prescriber will not provide records on request, that is a TRT clinic red flag and worth addressing independently of the surgery question.
2. Get Your Hematocrit in Range Before Surgery
Most surgical centers want hematocrit below 50% — some want below 47% — for elective procedures. If you are running in the 51-54% range on TRT, you have three levers:
Reduce TRT dose for 6-12 weeks preoperatively (work with your prescriber)
Donate blood (therapeutic phlebotomy) on a schedule your surgeon approves
Pause TRT entirely for a defined washout window — typically 3-6 months
The optimal lever depends on your symptoms, baseline hematocrit, and surgical timing. Discuss with your prescriber, not just your surgeon.
3. Build a Documented Pause-and-Resume Plan
A defensible preoperative protocol for TRT users facing joint replacement, synthesizing the current 2025-2026 literature:
Time Point
Action
6 months pre-op
Surgical consult; flag TRT status; align prescriber + surgeon
Final preop labs; confirm hematocrit, kidney function, coagulation
Surgery day
Document TRT pause duration in chart
4-8 weeks post-op
Surgical clearance check before TRT resumption
8+ weeks post-op
Resume TRT once wound healing complete, infection risk passed
The 3-6 month preoperative pause is the part most likely to be inconvenient. You will likely feel libido and energy decline during the washout, especially in the final weeks before surgery. That is the trade-off the current data argue for.
Observational, not randomized. Propensity matching reduces confounding but cannot eliminate it. The men who chose TRT may have baseline differences from those who did not that no database captures.
Real-world prescribing variability. The studies pooled all TRT modalities — injections, gels, pellets, oral. Whether the risk profile differs by route is unknown. Pellets in particular run hematocrit higher on average than weekly injections; that may matter.
No washout-window data for joint replacement. Only the rotator cuff repair study has quantified preoperative timing. The 3-6 month window suggested here is extrapolated, not directly tested for hip or shoulder arthroplasty.
Cannot apply to non-arthroplasty surgery. These are joint-replacement-specific findings. Whether the signal extends to laparoscopic, cardiac, or vascular surgery is plausible but unproven.
Does not address resumption protocols. When and how to safely resume TRT after joint replacement has no published randomized guidance. The 4-8 week post-op window cited above is consensus practice, not trial-derived.
How to Talk to Your Surgeon
Most orthopedic surgeons in 2026 have heard of the AAOS knee data. Fewer have absorbed the hip and shoulder replications yet. Bring the references with you.
When you sit down for your preoperative consult, three questions to ask:
What is your protocol for patients on testosterone replacement therapy?
What hematocrit threshold do you want before clearing me for surgery?
How long before surgery should I pause TRT, and when can I safely resume?
If your surgeon does not have a protocol or dismisses the question, that is not necessarily a deal-breaker — but it is worth raising your TRT prescriber into the conversation. Some larger TRT clinics have developed perioperative protocols and can coordinate directly with the surgical team. For how to identify clinics that take perioperative coordination seriously, see how to choose a TRT clinic and the best online TRT clinics.
Bottom Line
The 2026 hip and shoulder arthroplasty data replicate the AAOS knee signal — preoperative TRT is consistently associated with higher rates of infection, kidney injury, cardiac events, and 5-year prosthetic failure across three different joint replacement procedures. The studies are observational, not randomized, but the convergent pattern is hard to dismiss.
For most men on TRT, this changes the perioperative protocol, not the decision to be on testosterone in the first place. A documented 3-6 month preoperative pause, hematocrit normalization, and coordination between your TRT prescriber and surgical team appears to be the safer path given current evidence. Randomized data on washout windows and resumption protocols are still missing — until they arrive, treat this as a planning problem rather than a panic signal.
Coming off TRT temporarily is rough but recoverable. A revision joint replacement is not.
References
Preoperative Testosterone Replacement Therapy Is Associated With Increased Complication Risk After Total Hip Arthroplasty: A Propensity-Matched Analysis of Real-World Data. The Journal of Arthroplasty. 2026. PMID: 41519493.
Preoperative testosterone replacement therapy is associated with increased rates of periprosthetic joint infection, acute kidney injury, and emergency department utilization after total shoulder arthroplasty: a propensity-score matched analysis. Journal of Shoulder and Elbow Surgery. 2026. PMID: 40902712.
Preoperative Testosterone Replacement Therapy Is Associated With Increased Complication Risk After Total Knee Arthroplasty: A Propensity-Matched Analysis of 13,250 Patients. The Journal of Arthroplasty. 2026. PMID: 41177190.
Preoperative testosterone replacement therapy: a potential risk-factor for complications and reoperation after rotator cuff repair. Sports Health. 2025. PMID: 41459022.
Lincoff AM, Bhasin S, Flevaris P, et al. Cardiovascular Safety of Testosterone-Replacement Therapy (TRAVERSE). N Engl J Med. 2023;389:107-117.
AAOS 2026 Annual Meeting Press Release. New research links testosterone therapy with serious health risks after total knee replacement surgery.
What did the 2026 hip arthroplasty TRT study find?
A propensity-matched analysis published in The Journal of Arthroplasty in 2026 found that men on preoperative TRT had significantly higher rates of complications at every time point after total hip replacement. At 90 days: deep vein thrombosis (2.8% vs 2.0%), pneumonia (3.2% vs 1.7%), and sepsis (4.2% vs 0.9%). At one year: cardiac events (2.9% vs 1.7%) and acute kidney injury (7.6% vs 5.6%) joined the list. At five years: periprosthetic joint infection (3.1% vs 1.6%), prosthetic dislocation (2.5% vs 1.2%), and revision surgery (4.1% vs 2.3%) were all elevated.
What about shoulder replacement and TRT?
A 2026 propensity-score matched analysis of 1,369 matched pairs in the Journal of Shoulder and Elbow Surgery found preoperative TRT was associated with significantly higher rates of emergency department visits (13.7% vs 8.1% at 90 days), acute kidney injury (17.5% vs 12.1% at 1 year), and periprosthetic joint infection (4.8% vs 2.4% at 1 year, 7.9% vs 4.5% at 5 years) after total shoulder arthroplasty. The relative risk of PJI at 1 year was 2.0, meaning TRT patients had double the infection rate.
Should I stop TRT before joint replacement surgery?
There is no universal guideline yet, but the converging 2025-2026 data on knee, hip, and shoulder arthroplasty all point in the same direction: preoperative TRT raises complication risk. Most surgical teams now recommend discussing TRT status at least 4-6 weeks before any scheduled joint replacement. A documented pause of 3-6 months before surgery — combined with hematocrit normalization — appears to be the safer path based on current evidence, though randomized data are still missing.
How long before surgery should I stop TRT?
The rotator cuff repair literature offers the only timing-specific data so far: patients whose last testosterone use was within 6 months of surgery had higher revision and opioid-use rates than those who stopped 6-12 months before. Extrapolating cautiously, a 3-6 month preoperative pause is a defensible starting point for elective joint replacement. The decision should be coordinated between your surgeon, anesthesiologist, and TRT prescriber.
Does this mean TRT is unsafe?
No. The 2026 hip and shoulder data describe perioperative risk for a specific group — men undergoing major joint replacement. It does not change the overall cardiovascular safety profile established by the TRAVERSE trial, nor does it apply to non-surgical TRT use. The signal is that surgical planning needs to account for TRT status the same way it accounts for blood thinners, GLP-1 agonists, or any other modifier.
What labs and prep does my surgeon need before joint replacement on TRT?
At minimum: complete blood count with focus on hematocrit (most surgeons want it below 50% before elective surgery), comprehensive metabolic panel for kidney function, coagulation panel (PT/INR, PTT), and a documented TRT pause date. Some centers will also require a hematology consult if hematocrit has run above 52%, and an infection-disease consult if you have any indwelling devices.
Why are infection and dislocation rates higher years after surgery?
The 5-year prosthetic complication signal — periprosthetic joint infection, fracture, loosening, dislocation, revision — is the part of this data most worth thinking about. The mechanisms are not fully nailed down, but candidates include immune modulation effects on biofilm clearance, altered bone remodeling around implants from sustained androgen exposure, and elevated red cell mass affecting microcirculation at the bone-implant interface. None of this is proven causally, but the signal is consistent across knee, hip, and shoulder.
