madman
Super Moderator
Abstract
» Testosterone replacement treatment (TRT) and anabolic androgenic steroid (AAS) use is common and possibly increasing.
» Diagnosing and treating hypogonadism in men is controversial.
» Hypogonadism and the use of AASs seem to have a detrimental effect on the musculoskeletal system. The current literature on TRT and the musculoskeletal system shows an increased risk of tendon injury.
» There may be a role for testosterone supplementation in the postoperative period.
Orthopaedic patients using testosterone are not easily identified. Indication criteria for prescribing TRT vary widely among prescribers. Anabolic androgenic steroid (AAS) use is illicit, which means patients may not want to admit to its use. Consequently, there is a very heterogeneous population of patients taking testosterone. In certain clinical scenarios, which will be discussed in greater detail in this review article, questioning patients regarding TRT or AAS intake may be an important component of eliciting a complete history and physical examination.
Anabolic Androgenic Steroids
There is a high prevalence of anabolic steroid use in the general population11. Almost all orthopaedic surgeons encounter patients on AAS in their careers. Being aware of the risks of supraphysiological doses of testosterone and self-medication will help the surgeon counsel patients about potential injuries and complications.
Indications for TRT
A risk-benefit discussion should take place between the prescribing physician and patients seeking TRT. The consensus in the literature seems to be that indications for TRT should be tailored to individual patients 17,18. In summary, TRT can improve the lives of many patients, but determining who is best treated and with which medication is best determined by the patient and his physician.
Testosterone Replacement Treatment
Patients with primary hypogonadism are expected to obtain significant benefits from the return of normal hormone levels. For example, Klinefelter’s syndrome, orchidectomy or radiation treatment may be treated with TRT. Secondary hypogonadism stemming from systemic disorders such as AIDS and diabetes have shown some improvement in symptoms with treatment. Patients suffering from mixed hypogonadism have also been treated successfully with TRT. Patients with LOH can be treated by TRT with improvement of symptoms. The prescribing criteria can vary depending on which guidelines are being used 3.
*Benefits
*Complications of TRT
Musculoskeletal Risks of TRT
Because all the above mentioned studies are database studies, it is difficult to infer the reason these tears are seen. These studies were performed by using patient-matching techniques. Therefore, the groups were similar except for the use of TRT. Theories to explain the differences in rates of tearing include an anabolic effect such as seen in users of anabolic steroids on the muscles and tendons involved. This results in a stiffer tendon that would be more prone to tearing off the bone. There is also decreased remodeling in tendons that are exposed to testosterone. This may cause a relative weakening in the face of an increasingly stronger muscle. As we have seen earlier, testosterone increases lean muscle mass. An imbalance between the force generated by an increased muscle mass and this force on a potentially stiffer or weaker tendon may contribute to the results found in these studies. The mismatch may decrease or increase with time, but this is also unknown. Acquiring more knowledge of testosterone’s influence on the tendon and muscles will allow better counseling for patients in the future. The years of testosterone deficiency before tendon tears must also be considered in light of the important role of this hormone on tendon health.
Future
Obviously, more studies are required to elucidate the mechanism causing testosterone supplementation to increase the rate of tears. Finding the reason that TRT and hypogonadism are both causing an increase in rupture rates is important and would allow the patients’ healthcare team devise strategies to mitigate this risk.
In a recent article, Thomson et al.44 reported on testosterone levels before and after anterior cruciate ligament reconstruction. This study reports that in the postoperative period, male patients had lower testosterone levels. These levels correlated with the patient’s Patient Reported Outcome Scores. They suggest that testosterone supplementation may help return the patient to pre operative activity levels quicker than waiting for the hormone to return to baseline. A more normal testosterone level would help improve the rate of return to function during the rehabilitation period. A similar study performed on rats by Tashjianet al.45 demonstrated that supplementation of sex hormones after rotator cuff repair may allow a faster return to preoperative activity and histologically superior tendon healing. These studies suggest that patient outcomes, activity levels, and tendon healing may be improved by supplying missing testosterone in the postoperative period. This may have implications in a lot of other surgical fields. These studies may also change the pharmacology used as postoperative regimens after major and mino rorthopaedic surgeries.
A lot of work remains to be done in this domain. It is important to recognize that most surgeons will encounter patients taking these medications, as TRT or AAS, throughout their careers. Given the attention that testosterone is receiving in the lay press, it is important that we, orthopaedic surgeons, have at least basic knowledge of TRT.
Although the role of the orthopaedic surgeon is not to initiate TRT or AAS, being aware of the complications these treatments can cause is important. Patients taking hormones seem to be at a higher risk of tendon injury. When treating these patients, having a high index of suspicion for tendon injuries is important. Counseling patients who are contemplating or using these hormonal treatments is an important part of the surgeon’s responsibilities. Raising awareness of these complications among .our colleagues helps everyone’s patients.
» Testosterone replacement treatment (TRT) and anabolic androgenic steroid (AAS) use is common and possibly increasing.
» Diagnosing and treating hypogonadism in men is controversial.
» Hypogonadism and the use of AASs seem to have a detrimental effect on the musculoskeletal system. The current literature on TRT and the musculoskeletal system shows an increased risk of tendon injury.
» There may be a role for testosterone supplementation in the postoperative period.
Orthopaedic patients using testosterone are not easily identified. Indication criteria for prescribing TRT vary widely among prescribers. Anabolic androgenic steroid (AAS) use is illicit, which means patients may not want to admit to its use. Consequently, there is a very heterogeneous population of patients taking testosterone. In certain clinical scenarios, which will be discussed in greater detail in this review article, questioning patients regarding TRT or AAS intake may be an important component of eliciting a complete history and physical examination.
Anabolic Androgenic Steroids
There is a high prevalence of anabolic steroid use in the general population11. Almost all orthopaedic surgeons encounter patients on AAS in their careers. Being aware of the risks of supraphysiological doses of testosterone and self-medication will help the surgeon counsel patients about potential injuries and complications.
Indications for TRT
A risk-benefit discussion should take place between the prescribing physician and patients seeking TRT. The consensus in the literature seems to be that indications for TRT should be tailored to individual patients 17,18. In summary, TRT can improve the lives of many patients, but determining who is best treated and with which medication is best determined by the patient and his physician.
Testosterone Replacement Treatment
Patients with primary hypogonadism are expected to obtain significant benefits from the return of normal hormone levels. For example, Klinefelter’s syndrome, orchidectomy or radiation treatment may be treated with TRT. Secondary hypogonadism stemming from systemic disorders such as AIDS and diabetes have shown some improvement in symptoms with treatment. Patients suffering from mixed hypogonadism have also been treated successfully with TRT. Patients with LOH can be treated by TRT with improvement of symptoms. The prescribing criteria can vary depending on which guidelines are being used 3.
*Benefits
*Complications of TRT
Musculoskeletal Risks of TRT
Because all the above mentioned studies are database studies, it is difficult to infer the reason these tears are seen. These studies were performed by using patient-matching techniques. Therefore, the groups were similar except for the use of TRT. Theories to explain the differences in rates of tearing include an anabolic effect such as seen in users of anabolic steroids on the muscles and tendons involved. This results in a stiffer tendon that would be more prone to tearing off the bone. There is also decreased remodeling in tendons that are exposed to testosterone. This may cause a relative weakening in the face of an increasingly stronger muscle. As we have seen earlier, testosterone increases lean muscle mass. An imbalance between the force generated by an increased muscle mass and this force on a potentially stiffer or weaker tendon may contribute to the results found in these studies. The mismatch may decrease or increase with time, but this is also unknown. Acquiring more knowledge of testosterone’s influence on the tendon and muscles will allow better counseling for patients in the future. The years of testosterone deficiency before tendon tears must also be considered in light of the important role of this hormone on tendon health.
Future
Obviously, more studies are required to elucidate the mechanism causing testosterone supplementation to increase the rate of tears. Finding the reason that TRT and hypogonadism are both causing an increase in rupture rates is important and would allow the patients’ healthcare team devise strategies to mitigate this risk.
In a recent article, Thomson et al.44 reported on testosterone levels before and after anterior cruciate ligament reconstruction. This study reports that in the postoperative period, male patients had lower testosterone levels. These levels correlated with the patient’s Patient Reported Outcome Scores. They suggest that testosterone supplementation may help return the patient to pre operative activity levels quicker than waiting for the hormone to return to baseline. A more normal testosterone level would help improve the rate of return to function during the rehabilitation period. A similar study performed on rats by Tashjianet al.45 demonstrated that supplementation of sex hormones after rotator cuff repair may allow a faster return to preoperative activity and histologically superior tendon healing. These studies suggest that patient outcomes, activity levels, and tendon healing may be improved by supplying missing testosterone in the postoperative period. This may have implications in a lot of other surgical fields. These studies may also change the pharmacology used as postoperative regimens after major and mino rorthopaedic surgeries.
A lot of work remains to be done in this domain. It is important to recognize that most surgeons will encounter patients taking these medications, as TRT or AAS, throughout their careers. Given the attention that testosterone is receiving in the lay press, it is important that we, orthopaedic surgeons, have at least basic knowledge of TRT.
Although the role of the orthopaedic surgeon is not to initiate TRT or AAS, being aware of the complications these treatments can cause is important. Patients taking hormones seem to be at a higher risk of tendon injury. When treating these patients, having a high index of suspicion for tendon injuries is important. Counseling patients who are contemplating or using these hormonal treatments is an important part of the surgeon’s responsibilities. Raising awareness of these complications among .our colleagues helps everyone’s patients.
