Late complications after total hip replacement in renal allograft recipients

Outcomes of total hip arthroplasty in haemodialysis and renal transplant patients: systematic review

BACKGROUND

Chronic renal failure is increasing in prevalence and reported to have deleterious effects on the outcome of total hip arthroplasty (THA).

AIM

To investigate the clinical and functional outcomes of THA in patients receiving haemodialysis or who have previously undergone renal transplantation.

METHODS

Systematic review of the literature using bibliographic databases up to July 2018 to determine the functional outcome, complications and revision rates of THA in patients receiving haemodialysis for end-stage renal failure and those with a previous renal transplant.

RESULTS

25 studies were identified with a total of 797 THAs. 166 patients (20.8%) were receiving haemodialysis and 631 patients (79.2%) had undergone transplantation. All studies reported a marked improvement in hip function following THA. There were 27 failures (15.7% revision rate) in the haemodialysis group and 101 failures (16.0% revision rate) in the transplant group. The revision rate for cemented implants was higher in haemodialysis versus transplant patients (23% vs. 15%), with the converse being true for uncemented implants (3.8% vs. 6.9%). The deep infection rate was higher in the haemodialysis group (10.8% vs. 2.1%).

CONCLUSIONS

Patients receiving haemodialysis or with a history of renal transplantation can expect good functional outcome following THA. However, the revision rate and deep infection rate are higher than would be expected in patients receiving THA for primary OA. Aseptic loosening is the most common reason for revision. Uncemented implants appear to be associated with lower failure rates both in haemodialysis patients and those who have had a transplant.

Review article: Total hip replacement in haemodialysis or renal transplant patients

25 studies involving 755 hips in 534 patients were reviewed to determine the complication rates of total hip replacement in haemodialysis or renal transplant patients. In comparison of both groups, renal transplant patients were generally younger and more likely to receive an uncemented implant, whereas haemodialysis patients had approximately twice the infection rate and higher rates of mortality, revision, aseptic loosening, and hip dislocation. Both groups had increased complication rates, compared with patients without renal failure.

Prosthetic joint infection due to Salmonella species: a case series

Background

Prosthetic joint infection (PJI) due to Salmonella is rare. Numerous outbreaks of Salmonella have been reported throughout the United States in the last decade. We reviewed and analyzed cases of Salmonella PJI seen at our institution.

Methods

The medical records of all patients diagnosed with a Salmonella PJI between 1969–2013 were reviewed. Patients were followed till death, treatment failure or loss to follow-up.

Results

Six patients of Salmonella PJI were identified during the 44 year study period. Five were male; median age was 63.5 years (range 52–76). Five patients were immunodeficient. Five had a total hip arthroplasty infection, while one had a total knee arthroplasty infection. Median prosthesis age at the time of diagnosis of first episode of Salmonella PJI was 5 years (range 4 months-9 years). Four presented with fever and constitutional signs within two weeks of symptom onset. Two patients each had gastrointestinal symptoms and Salmonella bacteremia. Salmonella enterica serovar Enteritidis was the most common organism isolated (4 patients). None were Salmonella enterica serovar Typhi. Initial management included aspiration and antimicrobial therapy only (3), debridement and component retention (1) and two-staged exchange (2). All four patients treated without resection failed treatment a median of 2.5 months (range 2–11) after diagnosis and required resection arthroplasty. All six patients who underwent prosthesis removal (and exchange or arthrodesis) had successful outcome with a median duration of follow-up of 11 years (range 4–21). Three of these received oral antimicrobial therapy for a median duration eight weeks (range 4–8) and three received parenteral antimicrobial therapy for a median duration of six weeks (range 4–6).

Conclusions

The increase in Salmonella outbreaks does not seem to lead to increased Salmonella PJI. PJIs due to Salmonella remain rare, and the presentation is often acute with fever. It frequently occurs in immunocompromised patients. In our patient population, removal of prosthesis with or without reimplantation, along with 4–6 weeks of effective parenteral antimicrobial therapy was most often associated with successful eradication of infection.

Salmonella enterica enteritidis arthritis following trauma in a child with thalassemia major

Osteoarticular infections caused by Non-typhi Salmonella are exceptionally encountered. We report a case of a bacteriologically documented knee joint infection due to Salmonella enterica serotype enteritidis, following trauma in a child with thalassemia major. Emergency arthrotomy combined with antimicrobial therapy was helpful in eradication of infection. Physicians should be aware of this rare manifestation of Non-typhi Salmonella infections in thalassemic patients.

Long-term survivorship analysis of cemented total hip replacement (THR) after avascular necrosis of the femoral head in renal transplant recipients

BACKGROUND

We studied the long-term survival and the rate of revision of 93 consecutive total hip replacements (THRs) performed for avascular necrosis of the femoral head after renal transplantation from 1971 to 1988. Seventy-four were primary procedures while 19 hips had undergone previous surgery procedures on the same hip in the form of other conservative options.

METHODS

The patients of mean age of 38 years were analysed by the Kaplan-Meier method with revision for any reason as the end-point. The follow-up period averaged 216 months (range 1-332).

RESULTS

Thirteen hips were revised while 26 patients (36 hips) died during the follow-up period. The cumulative survival of the implant was 98.8% at 10 years and 63.8% at 20 years.

CONCLUSIONS

Cemented THR performed after renal transplantation is satisfactory and, at least for the first 10 post-operative years, the results are equivalent to those obtained in the general population with primary osteoarthritis.

Hospitalizations for total hip arthroplasty after renal transplantation in the United States

The national incidence of and factors associated with total hip arthroplasty in renal transplant recipients has not been reported. We conducted an historical cohort study of 42096 renal transplant recipients in the United States between 1 July 1994 and 30 June 1998. Primary outcomes were associations with hospitalizations for a primary discharge code of total hip arthroplasty (ICD9 procedure code 81.51x) within 3 years after renal transplant using Cox regression. Renal transplant recipients had a cumulative incidence of total hip arthroplasty of 5.1 episodes/1000 person-years, which is 5-8 times higher than reported in the general population. Avascular necrosis of the hip was the most frequent primary diagnosis associated with total hip arthroplasty in this population (72% of cases). Repeat surgeries were performed in 27% of patients with avascular necrosis, vs. 15% with other diagnoses. Total hip arthroplasty was more frequent in transplant recipients who were older, African American, or who experienced allograft rejection. Mortality after total hip arthroplasty was 0.21% at 30 days and 15% at 3 years, similar to the mortality of all transplant recipients. The most common indication for total hip arthroplasty after renal transplant is avascular necrosis of the hip, in contrast to the general population. Although repeat surgeries are common, total hip arthroplasty is well tolerated and is not associated with increased mortality in this population.