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. 2025 Nov;40(11):2835-2842.
doi: 10.1016/j.arth.2025.05.042. Epub 2025 May 19.

Long-Term Risk of Heart Failure in Total Joint Arthroplasty: A Population-Based Cohort Study

Mingzhao Hu  1 , Lindsey E Turner  2 , Joshua P Slusser  1 , Maria Vassilaki  1 , Daniel J Berry  3 , David G Lewallen  3 , Walter K Kremers  1 , Hilal Maradit Kremers  4
Affiliations

Long-Term Risk of Heart Failure in Total Joint Arthroplasty: A Population-Based Cohort Study

Mingzhao Hu et al. J Arthroplasty. 2025 Nov.

Abstract

Background: Previous case reports raised concerns about the cardiovascular effects of metal particles and ions produced by mechanical wear and corrosion of total joint arthroplasty (TJA) implants. We compared the long-term risk of heart failure in a cohort of individuals who had TJA and in a general population comparison cohort.

Methods: This was a population-based, retrospective cohort study of 7,182 TJA subjects who first had total hip arthroplasty (THA) or total knee arthroplasty surgeries between 1990 and 2020 and 7,407 age-, sex-, and calendar year-matched non-TJA subjects. All subjects were followed up until death, incident heart failure, migration, or 2020. The medical records were reviewed to collect data on surgical history, cardiovascular risk factors, and heart failure outcomes. Poisson regression models were used to estimate the risk of heart failure in TJA subjects, accounting for the competing risk of death and adjusting for cardiovascular risk factors.

Results: At baseline, TJA subjects had a higher prevalence of several cardiovascular risk factors than the non-TJA subjects. The risk of heart failure in TJA subjects was similar to the general population during the first decade after surgery. However, the risk increased over time, and by the second decade after surgery, the risk of heart failure in both the THA (hazard ratio 1.34, 95% confidence interval [CI]: 1.13 to 1.58) and total knee arthroplasty (hazard ratio 1.33, 95% confidence interval: 1.16 to 1.53) subjects was higher than the non-TJA subjects. The long-term risk of heart failure was higher among THA subjects with cobalt-chromium-containing implants and those who underwent surgery for fractures and inflammatory arthritis.

Conclusions: We observed a higher risk of heart failure beyond the first decade after TJA surgery. However, the magnitude of the risk is small and should be interpreted with caution due to the possibility of informative presence and confounding bias.

Keywords: cohort study; heart failure; hip arthroplasty; implants; knee arthroplasty; total joint arthroplasty.

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