Perioperative antihypertensive medication use is associated with no antifibrotic benefit but higher complications and revision rates following shoulder arthroplasty

Q: What are the key findings of this study?

Perioperative exposure to RAAS inhibitors was not associated with antifibrotic benefits but was associated with higher rates of 1-year revision (OR 1.40 for ARBs) and medical complications following shoulder arthroplasty.

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Primary total shoulder arthroplasty (n=117080). Intervention: Renin-angiotensin-aldosterone system (RAAS) inhibitors vs. No RAAS inhibitor exposure. Primary outcome: 1-year revision arthroplasty (ARB vs. Control) (OR 1.40, 95% CI 1.24-1.59, p=<0.001).

Q: What does this research mean for the field?

Perioperative exposure to RAAS inhibitors confers no antifibrotic benefit and is associated with higher rates of medical complications and one-year revision after shoulder arthroplasty. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Q: What question did this study set out to answer?

To evaluate the association between perioperative renin-angiotensin-aldosterone system inhibitor exposure, specifically ACE inhibitors and ARBs, and postoperative outcomes following total shoulder arthroplasty.

Tarishi Parmar; Miguel Fiandeiro; Mohammad Daher; Akin Adio; Jad Lawand; Adam Khan; Joseph Abboud

doi:10.1007/s00590-026-04883-y

August 1, 2026European Journal of Orthopaedic Surgery & TraumatologyOpen Access

Perioperative antihypertensive medication use is associated with no antifibrotic benefit but higher complications and revision rates following shoulder arthroplasty

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Key result

Perioperative RAAS inhibitors are linked to ~40% higher 1-year revision risk after shoulder arthroplasty.

OR 1.40
95% CI 1.24-1.59
P<0.001
n=117,080

Why the study?

RAAS inhibitors have proposed antifibrotic and bone-protective effects, but their impact on outcomes following total shoulder arthroplasty remains unclear.

Does perioperative RAAS inhibitor use reduce antifibrotic procedures or improve outcomes in patients undergoing total shoulder arthroplasty?

Key Points

To evaluate the association between perioperative renin-angiotensin-aldosterone system inhibitor exposure, specifically ACE inhibitors and ARBs, and postoperative outcomes following total shoulder arthroplasty.
A retrospective cohort study analyzed patients undergoing primary shoulder arthroplasty between 2005 and 2025 using the TriNetX network.
Patients were stratified by perioperative ACE inhibitor or ARB exposure and matched 1:1 using propensity scores, yielding 27,938 matched pairs for the ARB cohort and 30,602 matched pairs for the ACE inhibitor cohort.
Assessed endpoints included 90-day medical complications along with 1-year mechanical complications, antifibrotic procedures, and surgical revision rates.
Neither ARB nor ACE inhibitor use reduced 1-year antifibrotic procedures, including capsular release (ARB 0.1% vs. 0.1%, OR 0.94, 95% CI 0.47–1.863, P=0.862) or manipulation under anesthesia (ARB 0.0% vs. 0.1%, OR 0.53, 95% CI 0.24–1.13, P=0.095).
Both cohorts experienced higher 90-day rates of myocardial infarction (ARB 2.56% vs. 1.56%, OR 1.66, P<0.001; ACEi 2.6% vs. 1.4%, OR 1.86, P<0.001) and renal failure (ARB 6.55% vs. 5.405%, OR 1.23, P<0.001; ACEi 6.5% vs. 4.7%, OR 1.4, P<0.001), with ACE inhibitors additionally linked to higher rates of pulmonary embolism, deep-vein thrombosis, transfusion, and sepsis.
At one year, both drug classes showed increased rates of revision (ARB 2.7% vs. 2.0%, OR 1.40, P<0.001; ACEi 2.6% vs. 2.1%, OR 1.26, P<0.001), periprosthetic joint infection (ARB 2.9% vs. 2.2%, OR 1.306, P<0.001; ACEi 3.1% vs. 2.4%, OR 1.32, P<0.001), and loosening (ARB 1.6% vs. 1.2%, OR 1.35, P<0.001; ACEi 1.5% vs. 1.2%, OR 1.24, P<0.003).

Study Design

Type

Cohort (n=117,080)

Multicenter

Yes

Structured PICO

Does perioperative RAAS inhibitor use reduce antifibrotic procedures or improve outcomes in patients undergoing total shoulder arthroplasty?

P

Population

117,080 adult patients undergoing primary total shoulder arthroplasty, stratified by perioperative ACE inhibitor or ARB exposure, followed for at least two years.

E

Exposure

Perioperative use of angiotensin receptor blockers (ARBs) or angiotensin-converting enzyme inhibitors (ACEis) from 1 year prior to surgery through 3 months postoperatively.

C

Comparator

Patients without ARB or ACEi exposure during the same perioperative window, propensity score matched 1:1.

O

Outcome

90-day medical complications (emergency department visits, hospital readmissions, myocardial infarction, pulmonary embolism, deep vein thrombosis, blood transfusion, acute renal failure, and sepsis) and 1-year mechanical complications and revision (capsular release, manipulation under anesthesia, revision arthroplasty, periprosthetic joint infection, implant loosening, and postoperative dislocation).hard clinical

Main Result

Odds Ratio: 1.4 (95% CI 1.24–1.59)

Absolute Event Rate: 2.7% vs 2%

p-value: p=<0.001

Limitations

Retrospective data derived from a federated electronic health record network subject to administrative coding constraints and potential misclassification.
Medication exposure based on documented prescriptions without verification of perioperative continuation, dosage, duration, or adherence.
Lacks granularity regarding surgical technique, implant selection, surgeon volume, and perioperative management.
Functional outcomes, pain scores, patient satisfaction, and quality-of-life measures were unavailable.
Residual confounding and selection bias are likely due to higher underlying comorbidity burden in patients prescribed ACE inhibitors or ARBs.
Retrospective data derived from a federated electronic health record network subject to administrative coding constraints
Misclassification of outcomes possible
Medication exposure based on documented prescriptions but could not be verified for perioperative continuation, dosage, duration, or adherence
Residual confounding related to underlying comorbidity burden

Implication

Perioperative RAAS inhibitor use in total shoulder arthroplasty is associated with higher rates of medical complications and revision, without providing antifibrotic benefits.

Abstract

Purpose Renin-angiotensin-aldosterone system (RAAS) inhibitors, including angiotensin-converting enzyme inhibitors (ACEis) and angiotensin receptor blockers (ARBs), are commonly prescribed antihypertensive medications with proposed antifibrotic and bone-protective effects. Their impact on outcomes following total shoulder arthroplasty (TSA) remains unclear. This study evaluates the association between perioperative RAAS inhibitor exposure and postoperative outcomes after TSA. Methods A retrospective cohort study using the TriNetX network identified patients undergoing primary shoulder arthroplasty (2005–2025), stratified by ACEi or ARB use. One-to-one propensity score matching was performed. Outcomes included 90-day medical complications and 1-year mechanical complications and revision. Results Post-matching, 27,938 patients per cohort (ARB vs. control) and 30,602 per cohort (ACEi vs. control) were included. Neither ARB nor ACEi use reduced rates of manipulation under anesthesia or capsular release at one year. Both cohorts had higher 90-day rates of emergency department visits, readmission, myocardial infarction, and acute renal failure. ACEi use was additionally associated with pulmonary embolism, deep-vein thrombosis, transfusion, and sepsis. At one year, both cohorts showed higher rates of periprosthetic joint infection, aseptic loosening, and revision. Dislocation risk was increased with ACEi use only. Conclusion Perioperative RAAS inhibitor use was not associated lower rates of antifibrotic procedures following TSA. Instead, RAAS inhibitor use was associated with higher rates of several perioperative medical complications and longer-term surgical events, including infection and revision. ACE inhibitor exposure demonstrated a broader complication profile compared with ARB exposure. However, because patients receiving RAAS inhibitors often have greater comorbidity burden, these findings should be interpreted as associative rather than causal. Level of evidence III Retrospective Cohort Study.

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Cite This Study

Parmar et al. (2026) conducted a cohort in Primary total shoulder arthroplasty (n=117,080). Renin-angiotensin-aldosterone system (RAAS) inhibitors vs. No RAAS inhibitor exposure was evaluated on 1-year revision arthroplasty (ARB vs. Control) (OR 1.40, 95% CI 1.24-1.59, p=<0.001). Perioperative exposure to RAAS inhibitors was not associated with antifibrotic benefits but was associated with higher rates of 1-year revision (OR 1.40 for ARBs) and medical complications following shoulder arthroplasty.

synapsesocial.com/papers/6a70405975942ff7265e550e https://doi.org/10.1007/s00590-026-04883-y

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Perioperative antihypertensive medication use is associated with no antifibrotic benefit but higher complications and revision rates following shoulder arthroplasty

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

Perioperative antihypertensive medication use is associated with no antifibrotic benefit but higher complications and revision rates following shoulder arthroplasty

Key Points

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

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