Pre-operative proton pump inhibitor use and risk of adverse outcomes after total elbow arthroplasty: a propensity-matched analysis

Proton pump inhibitors (PPIs) are widely prescribed and commonly used in orthopedic patients, yet increasing evidence links chronic PPI exposure to infectious, skeletal, and thromboembolic complications. While associations have been reported following hip, knee, and spine surgery, the impact of PPI use on outcomes after total elbow arthroplasty (TEA) remains poorly characterized. We performed a retrospective propensity-matched cohort study using the TriNetX Global Collaborative Network. Adult patients undergoing primary TEA were stratified by pre-operative PPI exposure within 6 months of surgery. One-to-one propensity score matching was conducted on demographic variables and relevant comorbidities. Outcomes included revision TEA, periprosthetic joint infection (PJI), mechanical loosening, periprosthetic fracture, venous thromboembolism (VTE), and mortality assessed at 90 days and 1 year and within 5-year and 10-year analysis windows using time-to-event methods with censoring at last recorded clinical activity. Risk ratios (RRs) and hazard ratios (HRs) were calculated using Kaplan-Meier survival analyses and Cox proportional hazards models. After matching, cohorts were well balanced (n = 1,629-1,646 per cohort). Early (90-day) outcomes did not differ significantly between groups. By 1 year, PPI users demonstrated higher rates of revision surgery (RR: 1.74; HR: 1.87) and PJI (RR: 1.72; HR: 1.81). Within the 5-year and 10-year analysis windows, PPI exposure was associated with increased hazards of revision TEA (HR: 2.60 and 2.39), PJI (HR: 1.68 and 1.78), mechanical loosening (HR: 2.19 and 2.25), periprosthetic fracture (HR: 1.84 and 2.14), and VTE (HR: 2.08 and 1.93). Pre-operative PPI exposure was associated with higher risks of implant-related complications and VTE following TEA, with divergence emerging after the early post-operative period and persisting at long-term follow-up. These findings suggest that PPI use may represent a marker of elevated risk in patients undergoing TEA and may be relevant to pre-operative optimization and post-operative surveillance among chronic PPI users. Prospective studies are needed to clarify causality and distinguish the effects of pre-operative vs. post-operative PPI exposure.