Journal of Orthopaedic Translation · Oct 17, 2026

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

By Li W, Xiao Y, Xie D et al.

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.

doi.org/10.1016/j.jot.2026.101223Open accessPubMed 42935702Populations