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Peer-reviewedCC BY-NC-ND 4.0Journal of Orthopaedic Translation

LDL-C target attainment and risk of revision following knee and hip replacements: real-world evidence from a target trial emulation study

  • Wei Li1
  • Yadan Xiao2,1
  • Dongxing Xie1,3,4
  • Martin Englund5
  • Nancy E. Lane6
  • Yuqing Zhang7,8
  • Yilun Wang1,3,4
  • Kai Zhao9,10
  • Jie Wei1,2,3,4,11
  • Guanghua Lei1,3,4,11,12
  • Chao Zeng1,2,3,4,12
12 affiliations
  1. 1Department of Orthopaedics, Xiangya Hospital, Central South University, Changsha, China
  2. 2Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha, China
  3. 3Hunan Key Laboratory of Joint Degeneration and Injury, Xiangya Hospital, Central South University, Changsha, China
  4. 4Key Laboratory of Aging-related Bone and Joint Diseases Prevention and Treatment of Ministry of Education, Xiangya Hospital, Central South University, Changsha, China
  5. 5Department of Clinical Sciences Lund, Orthopaedics, Clinical Epidemiology Unit, Lund University, Lund, Sweden
  6. 6Center for Musculoskeletal Health and Department of Medicine, University of California School of Medicine, Sacramento, CA, USA
  7. 7Division of Rheumatology, Allergy, and Immunology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, USA
  8. 8The Mongan Institute, Massachusetts General Hospital, Harvard Medical School, Boston, USA
  9. 9Department of Hematology and Critical Care Medicine, Third Xiangya Hospital, Central South University, Changsha, China
  10. 10Key Laboratory of Sepsis Translational Medicine of Hunan, Central South University, Changsha, China
  11. 11FuRong Laboratory, Changsha, Hunan, China
  12. 12National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, China
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Abstract

Objective: Hyperlipidaemia is common in knee and hip replacement patients, with nearly half untreated. Elevated low-density lipoprotein cholesterol (LDL-C) has been associated with postoperative pain and prosthetic joint infections; however, the impact of LDL-C lowering on revision surgery remains unclear. We aimed to examine the association between pragmatic LDL-C management strategies, operationalized according to LDL-C target attainment during the 1-year grace period, and the risk of revision among patients with hyperlipidaemia undergoing knee and hip replacement.

Methods: Using The Health Improvement Network database, we identified knee and hip replacement patients with hyperlipidaemia aged 40 years or older initiating LDL-C-lowering medications. We emulated a hypothetical target trial to compare the 5-year revision risk between pragmatic LDL-C management strategies, with adherence to the goal-based strategy operationalized as having an LDL-C level <3 mmol/L during the 1-year grace period.

Results: Among 28,756 qualified participants, the 5-year revision risk was lower in those achieving the target LDL-C level (2.35%) compared to those not achieving it (2.76%), with a risk difference of −0.41% (95%CI: −0.72% to −0.09%), and a hazard ratio (HR) of 0.74 (95%CI: 0.61 to 0.90). For knee replacement revision, the 5-year risk difference was −0.47% (95%CI: −0.91% to −0.09%), with an HR of 0.69 (95%CI: 0.51 to 0.92). For hip replacement revision, the 5-year risk difference was −0.28% (95%CI: −0.80% to 0.20%), with an HR of 0.80 (95%CI: 0.63 to 1.01).

Conclusion: Adherence to a goal-based LDL-C management strategy, operationalized as having an LDL-C level <3 mmol/L during the 1-year grace period, was associated with a lower risk of revision surgery among patients with hyperlipidaemia undergoing joint replacement, especially after knee replacement.

The translational potential of this article: This study highlights postoperative lipid management as a potentially modifiable component of joint replacement care. If confirmed in future prospective studies, strategies to achieve guideline-recommended LDL-C targets may be considered as part of routine postoperative management to potentially improve long-term outcomes following joint replacement.

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Cite

BibTeXRIS
BibTeX
@article{li2026ldlc,
  title = {{LDL-C target attainment and risk of revision following knee and hip replacements: real-world evidence from a target trial emulation study}},
  author = {Wei Li and Yadan Xiao and Dongxing Xie and Martin Englund and Nancy E. Lane and Yuqing Zhang and Yilun Wang and Kai Zhao and Jie Wei and Guanghua Lei and Chao Zeng},
  journal = {Journal of Orthopaedic Translation},
  year = {2026},
  month = oct,
  doi = {10.1016/j.jot.2026.101223},
  url = {https://doi.org/10.1016/j.jot.2026.101223},
  note = {CC BY-NC-ND 4.0},
}
RIS
TY  - JOUR
TI  - LDL-C target attainment and risk of revision following knee and hip replacements: real-world evidence from a target trial emulation study
AU  - Wei Li
AU  - Yadan Xiao
AU  - Dongxing Xie
AU  - Martin Englund
AU  - Nancy E. Lane
AU  - Yuqing Zhang
AU  - Yilun Wang
AU  - Kai Zhao
AU  - Jie Wei
AU  - Guanghua Lei
AU  - Chao Zeng
PY  - 2026
DA  - 2026/10/17
JO  - Journal of Orthopaedic Translation
DO  - 10.1016/j.jot.2026.101223
UR  - https://doi.org/10.1016/j.jot.2026.101223
AB  - Objective: Hyperlipidaemia is common in knee and hip replacement patients, with nearly half untreated. Elevated low-density lipoprotein cholesterol (LDL-C) has been associated with postoperative pain and prosthetic joint infections; however, the impact of LDL-C lowering on revision surgery remains unclear. We aimed to examine the association between pragmatic LDL-C management strategies, operationalized according to LDL-C target attainment during the 1-year grace period, and the risk of revision among patients with hyperlipidaemia undergoing knee and hip replacement.  Methods: Using The Health Improvement Network database, we identified knee and hip replacement patients with hyperlipidaemia aged 40 years or older initiating LDL-C-lowering medications. We emulated a hypothetical target trial to compare the 5-year revision risk between pragmatic LDL-C management strategies, with adherence to the goal-based strategy operationalized as having an LDL-C level <3 mmol/L during the 1-year grace period.  Results: Among 28,756 qualified participants, the 5-year revision risk was lower in those achieving the target LDL-C level (2.35%) compared to those not achieving it (2.76%), with a risk difference of −0.41% (95%CI: −0.72% to −0.09%), and a hazard ratio (HR) of 0.74 (95%CI: 0.61 to 0.90). For knee replacement revision, the 5-year risk difference was −0.47% (95%CI: −0.91% to −0.09%), with an HR of 0.69 (95%CI: 0.51 to 0.92). For hip replacement revision, the 5-year risk difference was −0.28% (95%CI: −0.80% to 0.20%), with an HR of 0.80 (95%CI: 0.63 to 1.01).  Conclusion: Adherence to a goal-based LDL-C management strategy, operationalized as having an LDL-C level <3 mmol/L during the 1-year grace period, was associated with a lower risk of revision surgery among patients with hyperlipidaemia undergoing joint replacement, especially after knee replacement.  The translational potential of this article: This study highlights postoperative lipid management as a potentially modifiable component of joint replacement care. If confirmed in future prospective studies, strategies to achieve guideline-recommended LDL-C targets may be considered as part of routine postoperative management to potentially improve long-term outcomes following joint replacement.
SN  - 2214-031X
SN  - 2214-0328
ER  -