Cementless total hip arthroplasty in patients with osteonecrosis after kidney transplantation

End-stage renal disease patients have comparable results to renal transplant patients after shoulder arthroplasty

Background

End-stage renal disease (ESRD) and renal transplant (RT) patients are known to have more perioperative and postoperative complications after arthroplasty surgeries when compared to patients without. We hypothesize that RT patients undergoing shoulder arthroplasty (SA) have fewer systemic and surgical complications when compared to ESRD patients undergoing SA.

Methods

This was a retrospective review from the PearlDiver Patient Record Database. International Classification of Diseases and Current Procedural Terminology codes were used to identify patients who had undergone primary total and reverse shoulder arthroplasty, respectively, and subsequent surgical revisions. Unadjusted univariate analysis of patient demographics, Charlson Cormorbidty Index, and surgical complications at 90 days, 1 year, and 2 years after was performed using chi-squared testing. Multivariate logistic regression analyses were subsequently performed for systemic complications and prosthesis outcomes at all time points.

Results

Of 1191 patients with ESRD or previous RT and who underwent either total shoulder arthroplasty or reverse total shoulder arthroplasty, 1042 (87.5%) had ESRD and 149 (12.5%) had a previous RT. ESRD SA patients were more likely to have hypertension, liver disease, coronary artery disease, and hypothyroidism. Interestingly no statistical significance was found in multivariate analysis for systemic complications at 90 days, nor for surgical complications at the 90-day, 1-year, or 2-year mark between ESRD and RT cohorts.

Conclusion

SAs have comparable outcomes in ESRD and RT patients. The differing conclusions among studies might be partially accounted for by the demographic differences and comorbidities between these 2 patient populations. Providers should continue to provide appropriate counseling concerning risks, benefits, and timing of SA for these patients.

Total joint arthroplasty following solid organ transplants: complications and mid-term outcomes

PURPOSE

Survival after solid organ transplant (SOT) is improving, and demand for total joint arthroplasty (TJA) among SOT recipients is rising. Outcomes including revision, periprosthetic joint infection, and survivorship based on SOT type are variable. We sought to compare peri-operative complications, implant survivorship, and mortality for patients undergoing TJA following SOT.

METHODS

A retrospective review of the institutional database for primary TJA among SOT recipients from 2000 to 2020 was performed. Revisions, conversion TJA, and patients with multiple organ transplants were excluded. Patients were stratified by transplant organ. Transfusions, 90-day readmissions and emergency department (ED) visits, revisions, and mortality were compared using descriptive statistics and Cox proportional hazard ratios.

RESULTS

A total of 119 total hip arthroplasties (THA) and 63 total knee arthroplasties (TKA) in SOT recipients were studied. Most common SOT was renal (39%), then lung (27%), liver (24%), and heart (10%). TKA postoperative transfusion rates varied by organ (p = 0.037; [heart 0%, liver 9.5%, renal 24.0%, lung 50.0%]). Implant survivorship was 95.6% at one year (95% CI 90.3-98.1) and 92.1% at four years (83.9-96.3). Mortality was 2.9% at one year (95% CI 1.1-7.4) and 23.2% at four years (95% CI 16.1-32.3). After adjusting for procedure, duration from transplant to TJA, age, and Elixhauser Index, lung recipients had higher mortality versus heart (RR 4.39 [95% CI 1.64-15.38]; p = 0.002), kidney (7.98 [3.04-24.61]; p < 0.001), and liver (7.98 [3.04-24.61; p < 0.001) patients.

CONCLUSION

TJA after SOT yields acceptable peri-operative outcomes and implant survivorship, but mortality risk is substantial, especially among lung transplant recipients.

Comparison of total hip arthroplasty outcomes between hemodialysis and renal transplant patients

INTRODUCTION

Total hip arthroplasty (THA) in end-stage renal disease (ESRD) patients is associated with increased complications. Controversy exists whether elective THA should be performed while these patients are on haemodialysis (HD) or following renal transplant (RT). This study seeks to compare THA outcomes in HD versus RT patients.

METHODS

A national database was retrospectively reviewed using ICD codes to identify all HD and RT patients who underwent primary THA from 2010 to 2018. Demographics, comorbidities, and hospital factors were compared between cohorts using Wald and chi-square tests. The primary outcome was in-hospital mortality, while secondary outcomes included length of stay (LOS), non-home discharge, cost, readmission, and medical/surgical complications. Multivariate regression was used to determine independent associations. Significance was determined with a 2-tailed p-value of 0.05.

RESULTS

11,133 patients underwent THA, 61.6% HD and 39.4% RT patients. RT patients were younger, had fewer comorbidities, and more likely to have private insurance. After adjusting for these differences, RT patients had a lower rate of mortality (OR 0.31, p = 0.01), complications (OR 0.54, p < 0.01), cardiopulmonary complications (OR 0.54, p = 0.04), sepsis (OR 0.43, p < 0.01), and blood transfusion (OR 0.39, p < 0.001) during the index hospitalisation. RT was associated with decreased LOS (-2.0 days, p < 0.001), non-home discharge (OR 0.35, p < 0.001), and hospital cost (-$6,000, p < 0.001). RT had a lower rate of readmission (OR 0.60, p < 0.001) and revision surgery (OR 0.24, p = 0.01) within 90 days.

CONCLUSIONS

These findings suggest HD patients are a high-risk population in THA compared to RT patients and warrant stringent perioperative monitoring.

Corticosteroid-associated osteonecrosis of the femoral head after orthotopic liver transplantation and the outcomes of subsequent total hip arthroplasty

BACKGROUND

Corticosteroids are essential for immunosuppression after orthotopic liver transplantation (OLT), but also have many side effects. Osteonecrosis of the femoral head (ONFH) is one of the most serious complications requiring prostheses. However, few studies have investigated ONFH after OLT. The purpose of this study is to survey the incidence of corticosteroid-induced ONFH after OLT and the outcomes of total hip arthroplasty (THA).

METHODS

Between January 2001 and December 2010, a series of 926 patients underwent OLT at our Hospital. A retrospective analysis was performed on a total of 738 patients who survived at least 2 years after OLT. The incidence of symptomatic ONFH, the interval from OLT to the initial diagnosis of ONFH, and the cumulative dose of corticosteroids were analyzed. The side effects related to OLT, such as other osteonecrosis lesions, osteoporotic fractures, and infection, were monitored. For patients who underwent THA, radiological findings and Japanese Orthopaedic Association (JOA) scores were evaluated.

RESULTS

ONFH occurred in 10 patients (13 hips) (6 men [7 hips], 4 women [6 hips]), with an incidence of 1.36%. The average age at OLT was 51.4 years (range, 31-61 years). The average interval from OLT to ONFH was 86.7 months (range, 22-155 months). The average cumulative dose of corticosteroids was 7274 mg (range, 1342-29,514 mg). Twenty patients suffered from side effects related to OLT. Seven patients (8 hips) underwent THA. No adverse events including infection arose during the perioperative process. One hip dislocated, and one femoral stem displayed a radiolucent line. The average JOA score improved from 45.4 (range, 25-76) preoperatively to 86.9 (range, 73-99) at final follow-up. No patients required revision surgery.

CONCLUSIONS

The incidence of symptomatic ONFH after OLT was 1.36%. Once the graft function becomes stable, THA can be a safe and effective treatment option for patients with ONFH after OLT.

Dialysis patients have comparable results to patients who have received kidney transplant after total joint arthroplasty: a systematic review and meta-analysis

Patients with end-stage renal disease (ESRD) have inferior outcomes after hip and knee total joint arthroplasty (TJA), with higher risk for surgical site complications (SSC) and periprosthetic joint infection (PJI).

We conducted a systematic review and meta-analysis regarding outcomes after hip and knee TJA in ESRD patients who have received dialysis or a kidney transplant (KT) using PubMed, MEDLINE, Cochrane Reviews, and Embase in order to: (1) determine the mortality and infection rate of TJA in patients receiving dialysis or KT and (2) to identify risk factors associated with the outcome.

We included 22 studies and 9384 patients (dialysis, n = 8921, KT, n = 463). The overall mortality rate was 14.9% and was slightly higher in KT patients (dialysis vs. KT, 13.8% vs. 15.8%). The overall SSC rate was 3.4%, while dialysis and KT patients each had an incidence of 3.3% and 3.6%, respectively. For PJI, the overall rate was 3.9%, while the incidence for dialysis patients was 4.0% and for KT patients was 3.7%.

Using multi-regression analysis, age, sex, the type of arthroplasty (knee or hip) performed, and the form of renal replacement therapy (dialysis or KT) were not significant risk factors.

In patients on dialysis or who had received a KT, TJA is associated with a slight increase in mortality, SSC and PJI rates.

Cite this article: EFORT Open Rev 2021;6:618-628. DOI: 10.1302/2058-5241.6.200116

Japanese Orthopaedic Association 2019 Guidelines for osteonecrosis of the femoral head

PURPOSE

The Clinical Practice Guidelines for Osteonecrosis of the Femoral Head (ONFH) 2019 Edition, written by the working group for ONFH guidelines of the Japanese Investigation Committee (JIC) for ONFH under the auspices of the Japanese Ministry of Health, Labour, and Welfare and endorsed by the Japanese Orthopaedic Association, were published in Japanese in October 2019. The objective of this guideline is to provide a support tool for decision-making between doctors and patients.

METHODS

Procedures for developing this guideline were based on the Medical Information Network Distribution Service Handbook for Clinical Practice Guideline Development 2014, which proposed an appropriate method for preparing clinical guidelines in Japan.

RESULTS

This clinical practice guideline consists of 7 chapters: epidemiology; pathology; diagnosis; conservative therapy; surgical treatment: bone transplantation/cell therapy; surgical treatment: osteotomy; and surgical treatment: hip replacement. Twelve background questions and 13 clinical questions were determined to define the basic features of the disease and to be addressed when deciding treatment in daily practice, respectively.

CONCLUSIONS

The clinical practice guidelines for the ONFH 2019 edition will be useful for physicians, investigators, and medical staff in clinical practice, as well as for patients, during the decision-making process when defining how to treat ONFH.

Shoulder arthroplasty in patients with immunosuppression following solid organ transplantation

BACKGROUND

The purpose was to determine the risk and outcomes of primary shoulder arthroplasties in patients with immunosuppression who had undergone solid organ transplantation.

METHODS

Using a single institution's total joint registry, we reviewed 30 primary shoulder arthroplasties in 25 post-transplantation patients, including 12 total shoulder arthroplasties, 10 hemiarthroplasties, and 8 reverse shoulder arthroplasties, between 1985 and 2012. Therapy and patient variables were recorded, including immunosuppressive therapy protocols, the date of preceding solid organ transplantation, and specific medications taken in the perioperative period. We matched a cohort of control patients for age, sex, type of implant, and year of surgery at a ratio of 4:1. Two groups were compared regarding mortality risk, complications, and clinical outcomes (pain score, range of motion, and American Shoulder and Elbow Surgeons score).

RESULTS

No periprosthetic infections occurred in the post-transplantation group at a mean follow-up of 39 months. However, the post-transplantation group showed an increased risk of periprosthetic fractures compared with the control group (hazard ratio, 8.18; 95% confidence interval, 1.22-70.98; P = .03). Despite the increase in fractures, the overall number of complications did not differ between the groups. Furthermore, postoperative shoulder function and outcome scores were not significantly different between patients who had a prior transplant and those who did not.

CONCLUSION

Primary shoulder arthroplasty in patients with immunosuppression who underwent solid organ transplantation is a successful procedure to treat glenohumeral arthritis. In contrast, there may be an increased risk of periprosthetic fractures in patients with a history of a solid organ transplant.

Complications of total joint arthroplasty in solid organ transplant patients versus a large control group

BACKGROUND

Solid organ transplant patients are theoretically at increased risk for complications after total joint replacement due to immunosuppressive medication regimens and multiple medical co-morbidities. There are a number of studies that report on outcomes of total joint arthroplasty (TJA) following solid organ transplant, however, the results are heterogeneous. This study evaluated the outcomes of TJA in solid organ transplant patients as compared to non-organ transplant controls at one academic medical center.

METHODS

This study was a single institution retrospective review of a consecutive series of patients who underwent joint replacement following solid organ transplant as compared to a control cohort over a 10-year period. Univariable and multivariable generalized linear mixed effects models were used to compare the odds of readmission, infection, mortality, and being discharged home between transplanted (cases) and non-transplanted (control) patients.

RESULTS

Transplant and non-transplant cohorts had similar BMI, although transplant patients were younger (61 versus 65 years) and had a higher incidence of Diabetes (55% vs. 16%). On multivariable analysis, there was no difference in the odds of re-admission or rate of infection, but there was an increased risk of death and admission to a rehab facility in the transplant cohort.

CONCLUSION

Overall, this study demonstrates that solid organ transplant alone does not increase the risk of peri-operative complications in patients who underwent hip and knee replacement. However, it should be expected that these patients have a higher mortality rate and that many of them will need to be discharged to a post-acute care facility.

Long-Term Survivorship of Total Hip Arthroplasty with Highly Cross-Linked Polyethylene for Osteonecrosis

BACKGROUND

Osteonecrosis of the hip is the underlying etiology for 3% to 12% of total hip arthroplasties (THAs). Compared with patients who undergo THA because of osteoarthritis, those who do so because of osteonecrosis typically are younger, have a greater number of underlying diagnoses, and have inferior clinical outcomes and implant survivorship. The purpose of this study was to compare the long-term implant survivorship (median follow-up, 10 years), functional outcomes, and radiographic results of contemporary THAs with a highly cross-linked polyethylene (HXLPE) liner between patients with osteonecrosis and those with osteoarthritis.

METHODS

All patients who underwent primary THA with an HXLPE liner from 1999 to 2007 were identified from our institutional total joint registry. Patients with a primary diagnosis of osteonecrosis were matched 1:1, on the basis of age, sex, and body mass index (BMI), to patients with a diagnosis of osteoarthritis. This resulted in 461 hips in 413 patients with osteonecrosis matched to 461 hips in 427 patients with osteoarthritis (mean age, 59 years; 47% female; and mean BMI, 29 kg/m). Long-term implant survivorship, patient-reported outcomes, and radiographic findings were compared. In addition, a subgroup analysis of the osteonecrosis group was performed to see whether certain underlying etiologies portended poor outcomes. The median follow-up was 10 years.

RESULTS

The 15-year cumulative rates of revision were 6.6% and 4.5% in the osteonecrosis and osteoarthritis groups, respectively (hazard ratio [HR] = 1.8, p = 0.09). The 15-year cumulative rates of any reoperation were 10.5% and 6.4% in the osteonecrosis and osteoarthritis groups, respectively (HR = 2.2, p = 0.008). There were no radiographic signs of component loosening or osteolysis in the entire cohort. Despite a lower median preoperative Harris hip score (HHS) for patients with osteonecrosis, both groups had marked improvements in their scores, which were similar at all time points after surgery. The cumulative rate of reoperations at 15 years was 0% for hips with radiation-induced osteonecrosis, 6.3% for those with alcohol-induced osteonecrosis, 9.0% for those with posttraumatic osteonecrosis, 12.1% for those with steroid-induced osteonecrosis, and 25% for those with idiopathic osteonecrosis.

CONCLUSIONS

Contemporary THA with an HXLPE liner offers excellent long-term implant survivorship and functional outcomes for patients with osteonecrosis; however, the risk of a reoperation is higher when compared with patients with osteoarthritis.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Perioperative management of renal transplant patients undergoing total joint arthroplasty

The success of renal transplantation depends on lifelong immunosuppression. This can lead to a high incidence of avascular necrosis of major joints in the body for which arthroplasty is the treatment of choice. The risk of surgical complications is high in these patients, and there is no current set of cohesive perioperative management guidelines. In this review, we discuss the perioperative management of renal transplant patients undergoing elective total joint arthroplasty.

Short stem survival after osteonecrosis of the femoral head

INTRODUCTION

Short stems were developed as a bone-conserving alternative especially for the young hip arthroplasty patient. Patients suffering from osteonecrosis of the femoral head are frequently younger than primary arthritis patients. The outcome of short stems in these patients remains unclear. The aim of our study was to compare mid-term survival of short stems after osteonecrosis of the femoral head (ONFH) and primary arthritis.

MATERIALS AND METHODS

Data on short stem implantations over a 10-year period were collected. Demographic data and X-ray measurements before and after surgery were recorded. Indication for operation was determined from medical records and X-rays. Patients were asked by post about any revision. Reason for revision was identified by analysis of operation protocols. Short stem revision rates were analyzed using Kaplan-Meier charts, comparing 212 ONFH patients (231 operations) and 1284 primary arthritis patients (1455 operations).

RESULTS

Follow-up time averaged 5.3 and 6 years and was complete for 92% (ONFH) and 94% (primary arthritis) of the patients. ONFH patients were significantly younger (53 years vs. 59 years, p < 0.001) and more frequently male (55 vs. 42%, p < 0.001). The total revision rate did not differ between the two groups (8 years: 4.2 vs. 5.6%, p = ns). A trend towards more stem revisions was detected for ONFH patients (3 vs. 1.8%, p = ns). The aseptic stem loosening rate was significantly elevated for osteonecrosis patients (8 years: 2.6 vs. 0.7%, p = 0.013).

CONCLUSIONS

Our study showed elevated short stem loosening rates after ONFH. Similar results are published for classic cementless stems. The question of which stem is best for the young osteonecrosis patient cannot be answered yet. Consecutive studies directly comparing loosening rates of short and classic cementless stems in young osteonecrosis patients are required.

The Impact of Solid Organ Transplant History on Inpatient Complications, Mortality, Length of Stay, and Cost for Primary Total Hip Arthroplasty Admissions in the United States

BACKGROUND

As the prevalence of and life expectancy after solid organ transplantation increases, some of these patients will require total hip arthroplasty (THA). Immunosuppressive therapy, metabolic disorders, and post-transplant medications may place transplant patients at higher risk of adverse events following surgery. The objective of this study was to compare inpatient complications, mortality, length of stay (LOS), and costs for THA patients with and without solid organ transplant history.

METHODS

A retrospective cross-sectional analysis was conducted using 1998-2011 Nationwide Inpatient Sample. Primary THA patients were queried (n = 3,175,456). After exclusions, remaining patients were assigned to transplant (n = 7558) or non-transplant groups (n = 2,772,943). After propensity score matching, adjusted for patient and hospital characteristics, logistic regression and paired t-tests examined the effect of transplant history on outcomes.

RESULTS

Between 1998 and 2011, THA volume among transplant patients grew approximately 48%. The overall prevalence of one or more complications following THA was greater in the transplant group than in the non-transplant group (32.0% vs 22.1%; P < .001). In-hospital mortality was minimal, with comparable rates (0.1%) in both groups (P = .93). Unadjusted trends show that transplant patients have greater annual and overall mean LOS (4.47 days) and mean admission costs ($18,402) than non-transplant patients (3.73 days; $16,899; P < .001). After propensity score matching, transplant history was associated with increased complication risk (odds ratio, 1.56) after THA, longer hospital LOS (+0.64 days; P < .001), and increased admission costs (+$887; P = .005).

CONCLUSION

Transplant patients exhibited increased odds of inpatient complications, longer LOS, and greater admission costs after THA compared with non-transplant patients.

Total hip arthroplasty survival in femoral head avascular necrosis versus primary hip osteoarthritis: Case-control study with a mean 10-year follow-up after anatomical cementless metal-on-metal 28-mm replacement

BACKGROUND

Total hip arthroplasty is the most widely used procedure to treat avascular necrosis (AVN) of the femoral head. Few studies have compared the outcomes of THA in femoral head AVN and primary hip osteoarthritis. Therefore we performed a case-control study to compare THA for femoral head AVN vs. primary hip osteoarthritis in terms of: (1) prosthesis survival, (2) complication rates, (3) functional outcomes and radiographic outcomes, (4) and to determine whether specific risk factors for THA failure exist in femoral head AVN.

HYPOTHESIS

THA survival is similar in femoral head AVN and primary hip osteoarthritis.

MATERIAL AND METHODS

We compared two prospective cohorts of patients who underwent THA before 65 years of age, one composed of cases with femoral head AVN and the other of controls with primary hip osteoarthritis. In both cohorts, a cementless metal-on-metal prosthesis with a 28-mm cup and an anatomical stem was used. Exclusion criteria were THA with other types of prosthesis, posttraumatic AVN, and secondary osteoarthritis. With α set at 5%, to obtain 80% power, 246 patients were required in all. Prosthesis survival was assessed based on time to major revision (defined as replacement of at least one implant fixed to bone) and time to aseptic loosening. The other evaluation criteria were complications, Postel-Merle d'Aubigné (PMA) score, and the Engh and Agora Radiographic Assessment (ARA) scores for implant osseointegration.

RESULTS

The study included 282 patients, 149 with AVN and 133 with osteoarthritis. Mean age was 47.8±10.2 years (range, 18.5-65) and mean follow-up was 11.4±2.8 years (range, 4.5-18.3 years). The 10-year survival rates were similar in the two groups: for major revision, AVN group, 92.5% (95% confidence interval [95% CI], 90.2-94.8) and osteoarthritis group, 95.3% (95% CI, 92.9-97.7); for aseptic loosening, AVN group, 98.6% (95% CI, 97.6-98.6) and osteoarthritis, 99.2% (95% CI, 98.4-100). The AVN group had higher numbers of revision for any reason (19 vs. 6, P=0.018) and for dislocation (8 vs. 1, P=0.031). Mean PMA scores at last follow-up were comparable in the AVN group (17.65±1.27 [range, 10-18]) and osteoarthritis group (17.59±1.32 [range, 14-18]) (P=0.139). Osseointegration was also similar in the two groups: global Engh score, 26.51±1.81 (range, 14-27) for AVN and 26.84±0.91 (range, 19.5-27) for osteoarthritis (P=0.065); femoral ARA score, 5.83±0.46 (range, 3-6) for AVN and 5.90±0.42 (range, 3-6) for osteoarthritis (P=0.064); and cup ARA score, 5.74±0.67 (range, 3-6) for AVN and 5.78±0.66 (range, 3-6) for osteoarthritis (P=0.344).

DISCUSSION

Survival in this study was good and consistent with recent data on AVN, with no difference between AVN and osteoarthritis. Revisions for any cause or for dislocation were more common after THA for AVN. Functional outcomes were similar in the AVN and osteoarthritis groups. An anatomical cementless prosthesis combined with metal-on-metal 28-mm bearing provides durable good outcomes.

LEVEL OF EVIDENCE

III, non-randomized comparison of two prospective cohorts.

Survivorship After Primary Total Hip Arthroplasty in Solid-Organ Transplant Patients

BACKGROUND

Although a growing number of primary total hip arthroplasties (THAs) are being performed on solid-organ transplant (SOT) recipients, long-term patient and implant survivorships have not been well studied in contemporary transplant and arthroplasty practices.

METHODS

A total of 136 THAs (105 patients) with prior SOT were retrospectively reviewed from 2000 to 2013 at mean clinical follow-up of 5 years. The mean age was 59 years, with 39% being females. The most common SOT was renal (56%), followed by liver (24%).

RESULTS

Patient mortality was 3.8% and 13.3% at 2 and 5 years, respectively. There were 9 revisions (6.6%), including 5 (4%) for deep periprosthetic infection. Implant survivorship free of any revision was 95% and 94% at 2 and 5 years, respectively. Transplant type or surgical indication did not significantly impact patient or implant survivorship.

CONCLUSION

Compared with the general population, SOT patients undergoing THA have slightly higher mortality rates at 5 years. Implant survivorship free of revision was slightly lower than the general population, primarily due to an increased risk of periprosthetic joint infection.

Is total hip arthroplasty safely performed in lung transplant patients? Current experience from a retrospective study of the Zurich lung transplant cohort

Background

In recent years, the number of lung transplants has increased rapidly, with higher quality of life and improved survival rates in transplant recipients, including patients with advanced age. This, in turn, means that more transplant recipients will seek musculoskeletal care to treat degenerative joint disease and also trauma incidents. Safety concerns regarding elective and posttraumatic hip arthroplasty in transplant patients include an increased risk of infection, wound healing problems, periprosthetic fractures and loosening of the implants.

Methods

Clinical outcomes and safety aspects were retrospectively reviewed for five primary total hip arthroplasties (THA) in lung transplant recipients with minimal follow-up of two years at average of 2.6 (2–11) years. Patients were recruited from the Zurich Lung Transplant Center comprising of a cohort of 253 patients between January 1st, 2004 and December 31st, 2013.

Results

All five patients subjectively reported excellent outcomes after THA with a final average Harris Hip Score of 97 (86–100). One 71-year-old patient died 26 months after THA unrelated to arthroplasty. One superficial wound healing disturbance was documented. No periprosthetic fractures, no dislocations, no periprosthetic infections, no further revision surgery, no implant loosening was observed.

Conclusions

In conclusion, THA can be safely and successfully performed even in lung transplant patients under long-term immunosuppressive therapy and polymedication, provided a multidisciplinary approach can be granted.

Complications and Mortality in Chronic Renal Failure Patients Undergoing Total Joint Arthroplasty: A Comparison Between Dialysis and Renal Transplant Patients

BACKGROUND

In total joint arthroplasty (TJA) literature, there is a paucity of large cohort studies comparing chronic kidney disease (CKD) and end-stage renal disease (ESRD) vs non-CKD/ESRD patients. Thus, the purposes of this study were (1) to identify inhospital complications and mortality in CKD/ESRD and non-CKD/ESRD patients and (2) compare inhospital complications and mortality between dialysis and renal transplantation patients undergoing TJA.

METHODS

We queried the Nationwide Inpatient Sample database for patients with and without diagnosis of CKD/ESRD and those with a renal transplant or on dialysis undergoing primary or revision total knee or hip arthroplasty from 2007 to 2011. Patient comorbidities were identified using the Elixhauser comorbidity index. International Classification of Diseases, Ninth Revision, codes were used to identify postoperative surgical site infections (SSIs), wound complications, deep vein thrombosis, and transfusions.

RESULTS

Chronic kidney disease/ESRD was associated with greater risk of SSIs (odds ratio [OR], 1.4; P<.001), wound complications (OR, 1.1; P=.01), transfusions (OR, 1.6; P<.001), deep vein thrombosis (OR, 1.4; P=.03), and mortality (OR, 2.1; P<.001) than non-CKD/ESRD patients. Dialysis patients had higher rates of SSI, wound complications, transfusions, and mortality compared to renal transplant patients.

CONCLUSION

Chronic kidney disease/ESRD patients had a greater risk of SSIs and wound complications compared to those without renal disease, and the risk of these complications was even greater in CKD/ESRD patients receiving dialysis. These findings emphasize the importance of counseling CKD patients about higher potential complications after TJA, and dialysis patients may be encouraged to undergo renal transplantation before TJA.

Nontraumatic Osteonecrosis of the Femoral Head: Where Do We Stand Today? A Ten-Year Update

➤ Although multiple theories have been proposed, no one pathophysiologic mechanism has been identified as the etiology for the development of osteonecrosis of the femoral head. However, the basic mechanism involves impaired circulation to a specific area that ultimately becomes necrotic.➤ A variety of nonoperative treatment regimens have been evaluated for the treatment of precollapse disease, with varying success. Prospective, multicenter, randomized trials are needed to evaluate the efficacy of these regimens in altering the natural history of the disease.➤ Joint-preserving procedures are indicated in the treatment of precollapse disease, with several studies showing successful outcomes at mid-term and long-term follow-up.➤ Studies of total joint arthroplasty, once femoral head collapse is present, have described excellent outcomes at greater than ten years of follow-up, which is a major advance and has led to a paradigm shift in treating these patients.➤ The results of hemiresurfacing and total resurfacing arthroplasty have been suboptimal, and these procedures have restricted indications in patients with osteonecrosis of the femoral head.

Current concepts on osteonecrosis of the femoral head

It is estimated that 20000 to 30000 new patients are diagnosed with osteonecrosis annually accounting for approximately 10% of the 250000 total hip arthroplasties done annually in the United States. The lack of level 1 evidence in the literature makes it difficult to identify optimal treatment protocols to manage patients with pre-collapse avascular necrosis of the femoral head, and early intervention prior to collapse is critical to successful outcomes in joint preserving procedures. There have been a variety of traumatic and atraumatic factors that have been identified as risk factors for osteonecrosis, but the etiology and pathogenesis still remains unclear. Current osteonecrosis diagnosis is dependent upon plain anteroposterior and frog-leg lateral radiographs of the hip, followed by magnetic resonance imaging (MRI). Generally, the first radiographic changes seen by radiograph will be cystic and sclerotic changes in the femoral head. Although the diagnosis may be made by radiograph, plain radiographs are generally insufficient for early diagnosis, therefore MRI is considered the most accurate benchmark. Treatment options include pharmacologic agents such as bisphosphonates and statins, biophysical treatments, as well as joint-preserving and joint-replacing surgeries. the surgical treatment of osteonecrosis of the femoral head can be divided into two major branches: femoral head sparing procedures (FHSP) and femoral head replacement procedures (FHRP). In general, FHSP are indicated at pre-collapse stages with minimal symptoms whereas FHRP are preferred at post-collapse symptomatic stages. It is difficult to know whether any treatment modality changes the natural history of core decompression since the true natural history of core decompression has not been delineated.

Outcomes of total hip arthroplasty in patients with osteonecrosis of the femoral head-a current review

The purpose of this review was to analyze (1) patient-reported outcomes and implant survivorship of osteonecrosis (ON) patients following total hip arthroplasty (THA), (2) if prior hip-preserving procedures influence these outcomes, (3) if resurfacing procedures alter outcomes; and (4) how these outcomes may have been impacted by the choice of different bearing surfaces. Today, with implant innovations such as cementless constructs, ceramic bearing surfaces, and highly cross-linked polyethylene, ON patients derive great benefit and have high survivorship following THA. Most studies have shown that previous hip-preserving procedures do not have a deleterious effect on outcomes. Literature on the use of ceramic and highly cross-linked polyethylene bearing surfaces have shown that these implant designs are useful in younger and more active patients. Future research should evaluate the long-term outcomes and survivorship of these new THA constructs.

Management of femoral head osteonecrosis: Current concepts

Osteonecrosis of femoral head (ONFH) is a disabling condition of young individuals with ill-defined etiology and pathogenesis. Remains untreated, about 70-80% of the patients progress to secondary hip arthritis. Both operative and nonoperative treatments have been described with variable success rate. Early diagnosis and treatment is the key for success in preserving the hip joint. Once femoral head collapses (>2 mm) or if there is secondary degeneration, hip conservation procedures become ineffective and arthroplasty remains the only better option. We reviewed 157 studies that evaluate different treatment modalities of ONFH and then a final consensus on treatment was made.

How have alternative bearings and modularity affected revision rates in total hip arthroplasty?

BACKGROUND

Total hip arthroplasty (THA) continues to be one of the most successful surgical procedures in the medical field. However, over the last two decades, the use of modularity and alternative bearings in THA has become routine. Given the known problems associated with hard-on-hard bearing couples, including taper failures with more modular stem designs, local and systemic effects from metal-on-metal bearings, and fractures with ceramic-on-ceramic bearings, it is not known whether in aggregate the survivorship of these implants is better or worse than the metal-on-polyethylene bearings that they sought to replace.

QUESTIONS/PURPOSES

Have alternative bearings (metal-on-metal and ceramic-on-ceramic) and implant modularity decreased revision rates of primary THAs?

METHODS

In this systematic review of MEDLINE and EMBASE, we used several Boolean search strings for each topic and surveyed national registry data from English-speaking countries. Clinical research (Level IV or higher) with ≥ 5 years of followup was included; retrieval studies and case reports were excluded. We included registry data at ≥ 7 years followup. A total of 32 studies (and five registry reports) on metal-on-metal, 19 studies (and five registry reports) on ceramic-on-ceramic, and 20 studies (and one registry report) on modular stem designs met inclusion criteria and were evaluated in detail. Insufficient data were available on metal-on-ceramic and ceramic-on-metal implants, and monoblock acetabular designs were evaluated in another recent systematic review so these were not evaluated here.

RESULTS

There was no evidence in the literature that alternative bearings (either metal-on-metal or ceramic-on-ceramic) in THA have decreased revision rates. Registry data, however, showed that large head metal-on-metal implants have lower 7- to 10-year survivorship than do standard bearings. In THA, modular exchangeable femoral neck implants had a lower 10-year survival rate in both literature reviews and in registry data compared with combined registry primary THA implant survivorship.

CONCLUSIONS

Despite improvements in implant technology, there is no evidence that alternative bearings or modularity have resulted in decreased THA revision rates after 5 years. In fact, both large head metal-on-metal THA and added modularity may well lower survivorship and should only be used in select cases in which the mission cannot be achieved without it. Based on this experience, followup and/or postmarket surveillance studies should have a duration of at least 5 years before introducing new alternative bearings or modularity on a widespread scale.

Osteonecrosis of the femoral head

Symptomatic hip osteonecrosis is a disabling condition with a poorly understood aetiology and pathogenesis. Numerous treatment options for hip osteonecrosis are described, which include non-operative management and joint preserving procedures, as well as total hip replacement (THR). Non-operative or joint preserving treatment may improve outcomes when an early diagnosis is made before the lesion has become too large or there is radiographic evidence of femoral head collapse. The presence of a crescent sign, femoral head flattening, and acetabular involvement indicate a more advanced-stage disease in which joint preserving options are less effective than THR. Since many patients present after disease progression, primary THR is often the only reliable treatment option available. Prior to the 1990s, outcomes of THR for osteonecrosis were poor. However, according to recent reports and systemic reviews, it is encouraging that with the introduction of newer ceramic and/or highly cross-linked polyethylene bearings as well as highly-porous fixation interfaces, THR appears to be a reliable option in the management of end-stage arthritis following hip osteonecrosis in this historically difficult to treat patient population.

Cite this article: Bone Joint J 2013;95-B, Supple A:46–50.