The safety and outcome of joint replacement surgery in liver transplant recipients

Safety and outcomes of hip and knee replacement surgery in liver transplant recipients

BACKGROUND

Liver transplant (LT) is becoming increasingly common with improved life expectancy. Joint replacement is usually a safe procedure; however, its safety in LT recipients remains understudied.

AIM

To evaluate the mortality, outcome, and 90-d readmission rate in LT patients undergoing hip and knee replacement surgery.

METHODS

Patients with history of LT who underwent hip and knee replacement surgery between 2016 and 2019 were identified using the National Readmission Database.

RESULTS

A total of 5046119 hip and knee replacement surgeries were identified. 3219 patients had prior LT. Mean age of patients with no history of LT was 67.51 [95% confidence interval (CI): 67.44-67.58], while it was 64.05 (95%CI: 63.55-64.54) in patients with LT. Patients with history of LT were more likely to have prolonged length of hospital stay (17.1% vs 8.4%, P < 0.001). The mortality rate for patients with no history of LT was 0.22%, while it was 0.24% for patients with LT (P = 0.792). Patients with history of LT were more likely to have re-admissions within 90 d of initial hospitalization: 11.4% as compared to 6.2% in patients without history of LT (P < 0.001). The mortality rate between both groups during readmission was not statistically different (1.9% vs 2%, P = 0.871) respectively.

CONCLUSION

Hip and knee replacements in patients with history of LT are not associated with increased mortality; increased re-admissions were more frequent in this cohort of patients. Chronic kidney disease and congestive heart failure appear to predict higher risk of readmission.

Primary total hip arthroplasty complications and costs in liver transplant recipients: a matched analysis using a national database

BACKGROUND

The number of liver transplant recipients (LTR) is worldwide increasing and, as the survival is improving as well, there is an increasing number of patients needing total hip arthroplasty (THA). There might be increased risks for this specific group of patients and due to their comorbidities costs might be higher too. Using a big national database outcome and cost of THA should be compared between liver transplant recipients and the general population.

METHODS

The study was performed using a collection of Medicare, Medicaid, and private insurance claims. Length of stay (LOS), 30-day readmissions, complications rates up to 5 years, and 90-day total cost of care between liver transplant recipients and matched non-transplant patients should be compared. All primary THAs from 2010 to 2019 were identified. 513 patients with a liver transplant before their THA were matched to 10,759 patients without a history of solid organ transplant at a 1:20 ratio based on age, sex, Charlson Comorbidity Index, obesity, and diabetes status.

RESULTS

LTR had a longer average LOS (4.2 vs. 3.4 days, p < 0.001). There was no difference in the thirty-day readmissions (5.7% vs. 4.1%, p = 0.117) and 90-day dislocation rates (2.9% vs. 2.4%, p = 0.600). Total costs in the first ninety days after THA were not different between the LTR and controls (p = 0.756).

CONCLUSIONS

These findings suggest that complications and costs are no major point of concern in patients with liver transplant that are operated with THA.

Total Hip and Knee Arthroplasty in Solid Organ Transplant Patients: Perioperative Optimization and Outcomes

The success of renal, liver, cardiac, pulmonary, and other solid organ transplantation (SOT) has resulted in increasing volume of transplant procedures and recipient survivorship. Subsequently, many SOT patients develop end-stage degenerative joint disease and are presenting for total hip or total knee arthroplasty more frequently. Surgeons must be aware of the medical complexities and prepare for the perioperative risks associated with these immunocompromised patients. Preoperative evaluation should be conducted in coordination with transplant specialists to ensure optimization, including appropriate surgical timing and advanced, organ-specific medical assessments. Although often unable to be modified, the transplant patient's antirejection medication regimens should be reviewed with understanding of inherent risks of poor wound healing or acute infection. Despite higher rates of complications, revision surgeries, and mortality compared with the general population, SOT recipients continue to demonstrate markedly improved pain relief, function, and quality of life. An ongoing multidisciplinary approach is required throughout the perioperative process and beyond to deliver successful outcomes after total joint arthroplasty in the SOT population.

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.

Hip Arthroplasty Outcomes for Femoral Neck Fractures in Transplant Patients

BACKGROUND

The purpose of this study was to compare the short-term complications between transplant and nontransplant patients who undergo hip arthroplasty for femoral neck fractures (FNFs). Additionally, we sought to further compare the outcomes of total hip arthroplasty (THA) versus hemiarthroplasty (HA) within the transplant group.

METHODS

This was a retrospective review utilizing the Nationwide Readmissions Database. Transplant patients were identified and stratified based on transplant type: kidney, liver, or other (heart, lung, bone marrow, and pancreas). Outcomes of interest included index hospitalization mortality, perioperative complications, length of stay, costs, hospital readmission, and surgical complications within 90 days of discharge.

RESULTS

From 2010 to 2018, a total of 881,061 patients underwent THA or HA for FNFs, of which 2163 (0.2%) were transplant patients. When compared with nontransplant patients, all transplant patients had an increased risk of requiring blood transfusion (odds ratio [OR] = 1.51, P = .001), acute kidney injury (OR = 2.02, P < .001), and discharge to facility (OR = 1.67, P = .001) while having increased index hospitalization length of stay and costs. Liver and other transplant patients had an increased risk of readmission within 90 days (OR = 1.82, P < .001 and OR = 1.60, P = .014 respectively). Subgroup analysis for transplant patients comparing HA with THA demonstrated no differences in perioperative complication rates and decreased hospitalization length of stay and cost associated with THA.

CONCLUSION

In this retrospective cohort study, transplant patients had an increased risk of requiring blood transfusions and acute kidney injury after hip arthroplasty for FNFs. There were no differences in short-term complications between transplant patients treated with HA versus THA.

LEVEL OF EVIDENCE

3 (Retrospective cohort study).

A Complication Profile of Total Hip and Knee Arthroplasty in Liver Transplantation Patients: A Meta-Analysis

BACKGROUND

There is an increasing demand for total joint arthroplasty in liver transplantation patients. However, significant heterogeneity in existing studies creates difficulty to draw conclusions on the risk profile of arthroplasty in this population.

METHODS

A systematic review of the literature dated from 1980 to 2020 describing the complication rates of liver transplantation patients receiving either total hip or knee arthroplasty was conducted. Multiple outcomes were extracted and a meta-analysis was performed. Four cohorts were created for analysis purposes: liver transplant patients undergoing THA and TKA (1), THA only (2), TKA only (3), and controls (4).

RESULTS

A total of 13 studies were included in this meta-analysis, accounting for 3024 liver transplantation patients. The rate of infection (odds ratio [OR] = 2.14, OR = 1.61, OR = 2.52), myocardial infarction (OR = 1.65, OR = 1.75, OR = 1.57), respiratory failure (OR = 2.19, OR = 2.50, OR = 1.96), acute kidney injury (OR = 5.71, OR = 5.40, OR = 4.35), sepsis (OR = 3.72, OR = 3.30, OR = 4.02), and blood transfusions (OR = 2.09, OR = 3.65, OR = 1.74) were all significantly higher in the 3 cohorts compared to the controls. Revision/reoperation rates were significantly higher in cohorts 1 and 3 (OR = 1.52 and OR = 1.62, respectively). Patient-reported outcomes saw improvements in Harris Hip Score, objective Knee Society Score, and functional Knee Society Score postoperatively (average improvement = 32.4, 37.2, and 15.3, respectively).

CONCLUSION

Liver transplantation patients functionally benefit from total hip and knee arthroplasty, but at the cost of increased risk of infection, revision/reoperation, and medically related complications compared to controls. Mortality may also be a short-term risk.

Safety of shoulder arthroplasty in lung transplant recipients

PURPOSE

Although shoulder arthroplasty is relatively safe in general population, it remains unclear in transplant recipient. Aim of this study was to determine outcomes and morbidity after shoulder arthroplasty in lung transplant recipients.

METHODS

A retrospective analysis was performed at our university hospital center from 2001 to 2015. Main inclusion criterion was all lung transplant recipient who underwent shoulder arthroplasty. Clinical outcomes including Constant score, visual analogue scale (VAS), American Shoulder and Elbow Surgeons score (ASES) were determined in pre-operative period and a minimum follow-up of 36 months. Special attention was taken about complications.

RESULTS

Among 700 lung transplant recipients, we identified 12 patients who underwent 14 shoulder arthroplasties. Arthroplasties were performed after proximal humeral avascular necrosis (n = 10), degenerative osteoarthritis (n = 1) and non-union of proximal humeral fracture (n = 1). 8 anatomical total shoulder arthroplasties and 6 reversed shoulder arthroplasties were performed. Mean follow-up was 61.4 months (± 22.1). Mean age was 47.1 (± 9.3) years. All patients had immunosuppression therapy at the time of surgery. Mean Constant score was improved at last follow-up [43(± 9.7) vs 94(± 4), p < 0.001]. VAS decreased from 6.4 (± 1.2) to 0.4 (± 0.8), p < 0.001. Mean ASES was improved from 33 (± 6) to 91 (± 5) at last follow-up (p < 0.001). Range of motion were improved between early post-operative evaluation and last follow-up: forward flexion: 85° (± 8°) vs 119°(± 13°); abduction: 83° (± 14°) vs 106°(± 23°); external rotation (RE1): 26° (± 7°) vs 36°(± 10°). At last follow-up, one revision was required for humeral prothesis loosening at 2 years post-surgery. One patient died due to acute pulmonary decompensation on chronic rejection 66 months after shoulder arthroplasty.

CONCLUSION

Shoulder arthroplasty is a safe procedure in this vulnerable population of lung transplant recipients. Such results encourage us to continue arthroplasty surgery when required.

LEVEL OF EVIDENCE

IV.

Short-Term Outcomes of Total Hip Arthroplasty after Liver Transplantation

Background

Idiopathic osteonecrosis of the femoral head (ONFH) frequently occurs after liver transplantation (LT) because of lifelong administration of corticosteroids or immunosuppressants and often requires total hip arthroplasty (THA). This study examines patient characteristics and short-term outcomes of THA after LT.

Methods

We observed 9 hips in 7 patients who underwent THA from August 2015 to December 2017 for ONFH after LT (group L). Cementless implants were inserted in all hips. Medical records were retrospectively reviewed to reveal reasons for LT, type of donor, and period from LT to THA. Preoperative laboratory data, operative time, intraoperative blood loss, complication rates, and Harris Hip Score were compared with a control group of 27 cementless THAs in 27 patients with ONFH.

Results

Causative diseases were liver cirrhosis (n = 4), type B fulminant hepatitis (n = 1), congenital biliary atresia (n = 1), and iatrogenic biliary tract injury (n = 1). Four livers were from living donors and 3 from cadavers. Mean time from LT to THA was 10.4 (1-20) years. Preoperative blood test showed a significant decrease in platelet count (178 vs 268 [∗10³/μl]) and rise in total bilirubin (1.1 vs 0.7 [mg/dL]) in group L. There was no significant difference in operative time (86 vs 100 [minutes]), but intraoperative blood loss (303 vs 163 [mL]) increased significantly in group L. There were no significant differences in complication incidence or Harris Hip Score between the 2 groups.

Conclusion

THA after LT requires caution because risks for bleeding increase. However, short-term outcomes appear to be equivalent to normal THA.

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.

Total hip arthroplasty in patients with chronic liver disease: A systematic review

INTRODUCTION

Chronic liver disease (CLD) is a significant and increasingly prevalent co-morbidity in patients undergoing total hip arthroplasty (THA). These patients may develop metabolic bone disease (MBD) and systemic dysfunction, which pose challenges to THA surgery. This systematic review of literature aims to examine clinical outcomes and complications in patients with CLD undergoing THA and provide evidence-based approaches as to the optimization of their perioperative care.

METHODS

A Pubmed search was performed, identifying eight studies on 28 514 THAs for inclusion. Two additional studies reported on 44 patients undergoing THA post liver transplant. These were reviewed separately.

RESULTS

Increased early perioperative complications are reported recurrently. Review of long-term complications demonstrates an increased postoperative infection rate of 0.5% (p < 0.001) and perioperative mortality of 4.1% (p < 0.001). The need for revision surgery is more frequent at 4% (p < 0.001). Aetiology of need for revision surgery included; periprosthestic infection (70%), aseptic loosening (13%), instability (13%), periprosthetic fracture (2%) and liner wear (2%). THA in patients with liver transplants seems to offer functional improvement; however, no studies have formally assessed functional outcomes in the patient with active CLD.

DISCUSSION

A multidisciplinary perioperative approach is suggested in order to minimize increased complication risks. Specific measures include optimizing haemoglobin and taking measures to reduce infection. This review also highlights gaps in available literature and guides future research to appraise functional outcomes, further detail long-term failure reasons and study any differences in outcomes and complications based on the range of operative approaches and available implant choices.

No Difference in Morbidity and Mortality After Total Joint Arthroplasty in Liver Transplant Recipients: A Propensity Score-Matched Analysis of a Nationwide, Population-Based Study Using Universal Healthcare Data

BACKGROUND

Controversy remains regarding the outcomes after total joint arthroplasty (TJA) among patients with or without liver transplantation (LT). This study aimed at investigating the prevalence of TJA in patients after LT and comparing the morbidity and mortality with the non-LT group.

METHODS

We conducted a nationwide, population-based study, with data extracted from a universal health insurance database, based on the International Classification of Disease, Ninth Revision, Clinical Modification. Patients who underwent TJAs between January 2001 and December 2014 were included. Patients who had bilateral TJAs or a TJA before LT were excluded. A total of 43 patients with LT and 350,337 patients without LT were included. The analysis was implemented using data from all patients and those matched by 1-to-10 propensity score matching. Multivariable logistic regression was used to control confounding variables.

RESULTS

The prevalence of patients undergoing TJA after LT was 1.3% (43/3276). After propensity score matching, patients with LT were not associated with 30-day complications (adjusted odds ratio [aOR], 0.98; 95% confidence interval [CI], 0.93-1.03; P = .35), 30-day readmission rates (aOR, 0.93; 95% CI, 0.92-1.08; P = .87), 90-day complication rates (aOR, 0.95; 95% CI, 0.88-1.02; P = .16), 1-year infection rates (aOR, 1.04; 95% CI, 0.96-1.12; P = .35), reoperation rates (aOR, 1.06; 95% CI, 0.92-1.23; P = .41), or mortality (aOR, 0.91; 95% CI, 0.80-1.04; P = .18).

CONCLUSION

The morbidity and mortality seem to be comparable whether TJA is performed in patients with or without LT. Methods for risk assessment would be feasible in liver transplant recipients.

Total Hip Arthroplasty in Patients With Avascular Necrosis After Hematopoietic Stem Cell Transplantation

The immunosuppressive regimens required for hematopoietic stem cell transplantation predispose recipients to complications, including avascular necrosis. Cancer-related comorbidities, immunosuppression, and poor bone quality theoretically increase the risk for perioperative medical complications, infection, and implant-related complications in total joint arthroplasty. This study reviewed 20 primary total hip arthroplasties for avascular necrosis in 14 patients. Outcomes were assessed at routine clinical visits and Harris hip scores were calculated. Follow-up radiographs were evaluated for component malposition, loosening, polyethylene wear, and osteolysis. Average follow-up was 44.5 months for all patients. Postoperative clinical follow-up revealed good to excellent outcomes, with significant improvement in functional outcome scores. There were no periprosthetic infections or revisions for aseptic loosening. There was 1 dislocation on postoperative day 40, which was treated successfully with a closed reduction. Two patients with a prior history of venous thromboembolism developed a pulmonary embolus on postoperative day 13 and 77, respectively. Four patients died several months to years after arthroplasty of complications unrelated to the surgical procedure. Total hip arthroplasty can both be safely performed and greatly improve quality of life in recipients of hematopoietic stem cell transplantation who develop avascular necrosis. However, prolonged venous thromboembolism prophylaxis should be carefully considered in this high-risk patient population. [Orthopedics. 2018; 41(2):e257-e261.].

Perioperative Management of Cardiac Transplant Recipients Undergoing Noncardiac Surgery: Unique Challenges Created by Advancements in Care

Advancements in postcardiac transplant care have resulted in significant reductions in morbidity and increased life expectancy for cardiac transplant recipients. Consequently, many cardiac transplant recipients are living long enough to require subsequent noncardiac surgery. The perioperative care of heart transplant recipients presents a unique challenge as many of the common preoperative risk assessments do not apply to a transplanted heart, immunosuppressive medications have side effects and potential for drug-drug interactions, and the denervated heart results in an altered autonomic physiology and response to medications. Further adding to the challenge is that many of these noncardiac surgeries need to be performed urgently at nontransplant centers that may not be familiar with the care of these patients. This review aims to summarize the current data regarding preoperative assessment, perioperative immunosuppression management, intraoperative and anesthetic considerations, and outcomes of cardiac transplant recipients undergoing noncardiac surgery.

Revision Total Hip and Knee Arthroplasties After Solid Organ Transplant

BACKGROUND

As solid organ transplant (SOT) patients' survival improves, the number undergoing total hip (THA) and total knee arthroplasty (TKA) is increasing. Accordingly, the number of revision procedures in this higher-risk group is also increasing. The goals of this study were to identify the most common failure mechanisms, associated complications, clinical outcomes, and patient survivorship of SOT patients after revision THA or TKA.

METHODS

A retrospective review identified 39 revision procedures (30 revision THAs and 9 revision TKAs) completed in 37 SOT patients between 2000 and 2013. The mean age at revision surgery was 62 years with a mean follow-up of 6 years.

RESULTS

The most common failure mode for revision THA was aseptic loosening (10/30, 33%), followed by periprosthetic joint infection (PJI; 7/30, 23%). The most common failure mode for revision TKA was PJI (5/9, 56%). There were 6 re-revision THAs for PJI (3/30; 10%) and instability (3/30; 10%). There were 2 reoperations after revision TKA, both for acute PJI (2/9; 22%). Final Harris Hip Scores significantly (P = .03) improved as did Knee Society Scores (P = .01). Estimated survivorship free from mortality at 5 and 10 years was 71% and 60% after revision THA and 65% and 21% after revision TKA, respectively.

CONCLUSION

Revision THA and TKA after solid organ transplantation carry considerable risk for re-revision, particularly for PJI. Although SOT recipients demonstrate improved clinical function after revision procedures, patient survivorship at mid- to long-term follow-up is low.

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.

Primary Total Knee Arthroplasty After Solid Organ Transplant: Survivorship and Complications

BACKGROUND

Clinical outcomes remain largely unknown beyond perioperative and short-term follow-up of solid organ transplant (SOT) patients undergoing total knee arthroplasty (TKA).

METHODS

Patient mortality, implant survivorship, and complications of 96 TKAs (76 patients) after SOT were retrospectively reviewed through an internal joint registry. Mean age at index arthroplasty was 66 years, and mean follow-up was 4 years.

RESULTS

Overall mortality rates at 1 year, 2 years, and 5 years from TKA were 2.6%, 7.9%, and 13.2%, respectively, and combined SOT patient survivorship was 92% at 2 years and 82% at 5 years. Implant survivorship free of any component revision or implant removal was 98% at 2 years and 93% at 5 years. There was a high rate of perioperative complications (12.5%), including periprosthetic fractures (5.2%) and deep periprosthetic infection (3.2%).

CONCLUSION

TKA does not appear to have any effect on SOT patient survivorship following the procedure. However, SOT patients may have a higher risk of perioperative complications and a lower implant survivorship than the general population of TKA patients at midterm follow-up.

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.

Early Postoperative Outcomes of Primary Total Knee Arthroplasty After Solid Organ Transplantation in the United States, 1998-2011

This review of the Nationwide Inpatient Sample (1998-2011) examined trends in solid organ transplant patients who received a total knee arthroplasty (TKA) to determine whether length of stay (LOS), cost, and perioperative complications differed from non-transplant peers. Primary TKA patients (n=5,870,421) were categorized as: (1) those with a history of solid organ transplant (n=6104) and (2) those without (n=5,864,317). Propensity matching was used to estimate adjusted effects of solid organ transplant history on perioperative outcomes. The percentage of TKA patients with a transplant history grew during the study period from 0.069% to 0.103%. Adjusted outcomes showed patients with a transplant had a 0.44 day longer LOS, $962 higher cost of admission, and were 1.43 times more likely to suffer any complication (P=0.0002).

Total joint arthroplasty in transplant recipients: in-hospital adverse outcomes

This study aims to determine in-hospital complications and mortality in transplant recipients following total joint arthroplasty. The Nationwide Inpatient Sample database was queried for patients with history of transplant and joint arthroplasty (primary or revision) from 1993 to 2011. Kidney transplant increased risk of surgical site infection (SSI) and wound infections (OR=2.03), systemic infection (OR=2.85), deep venous thrombosis (OR=2.07), acute renal failure (ARF) (OR=3.48), respiratory (OR=1.34), and cardiac (OR=1.21) complications. Liver transplant was associated with SSI/wound infections (OR=2.32), respiratory complications (OR=1.68), cardiac complications (OR=1.34), and ARF (OR=4.48). Other transplants grouped together were associated with wound complications (OR=2.13), respiratory complications (OR=2.06), and ARF (OR=4.42). Our study suggests these patients may be at increased risk of in-hospital complications, particularly ARF in renal and liver transplant patients.

Risk versus reward: total joint arthroplasty outcomes after various solid organ transplantations

Clinical outcomes were retrospectively reviewed for 76 primary total hip (THA) and total knee arthroplasties (TKA) performed after kidney, liver, cardiac, and lung transplantation with follow-up of 30.2 and 41.2 months, respectively. For the THA and TKA cohorts, there were a high rate of medical complications (29% and 33%), increased hospital length of stay (4.2 and 3.7 days), and more reoperations (7.2% and 9.1%). Only 1 (1.8%) periprosthetic infection was documented for THAs but 3 (14.2%) TKAs required two-stage revisions for infection. All transplant cohorts demonstrated significant increases (P < 0.05) in HHS and KSS scores with majority of patients reporting overall good or excellent outcomes (82%-100%). These results suggest that various organ transplant patients may accept higher surgical risks for rewarding outcomes.

Outcomes of primary total joint arthroplasty after lung transplantation

Lung transplantation is increasingly common with improving survival rates. Post-transplant patients can be expected to seek total hip (THA) and knee arthroplasty (TKA) to improve their quality of life. Outcomes of 20 primary total joint arthroplasties (15 THA, 5 TKA) in 14 patients with lung transplantation were reviewed. Clinical follow-up time averaged 27.5 and 42.8 months for THA and TKA respectively. Arthroplasty indications included osteonecrosis, osteoarthritis, and fracture. All patients subjectively reported good or excellent outcomes with a final average Harris Hip Score of 88.7, Knee Society objective and functional score of 92.0. There were 4 minor and 1 major acute perioperative complications. 1 late TKA infection was successfully treated with two-stage revision. The mortality rate was 28.5% (4/14 patients) at an average 20.6 months following but unrelated to arthroplasty. Overall, total joint arthroplasty can be safely performed and provide good functional outcomes in lung transplant recipients.

Solid organ transplant patients experience high rates of infection and other complications after total knee arthroplasty

Survival after solid organ transplants in the United States is increasing, and there is a need to understand the complications in knee arthroplasty patients who underwent organ transplantation. A retrospective study was conducted from 1993-2008 on 19 patients (23 knee arthroplasties) with previous successful solid organ transplants. Eleven knee arthroplasties were performed after renal transplantation, and 12 after nonrenal solid organ transplant (seven liver, four heart, one lung). Complications occurred in 9/23 patients (39.1%) and infections occurred in 4/23 patients (17.3%). Of the infected knees, two had MRSA, one had MSSA, and one Escherichia coli. Noninfectious complications (5/24, 21.7%) include aseptic loosening, quadriceps rupture, femoral fracture, hemarthrosis, and arthrofibrosis. All patients with complications were on immunosuppressant medications at the time of arthroplasty. There was a significantly higher rate of infection in the renal group compared to the non-renal group (P = 0.022). There was also a higher overall complication rate in the renal group however this did not reach significance.

Outcomes of total hip and knee arthroplasty after cardiac transplantation

The outcomes of 18 primary or revision total hip (THA) and knee arthroplasties (TKA) in 9 patients with cardiac transplants were reviewed. Primary total joint arthroplasties were performed for osteonecrosis (5 hips) or osteoarthritis (5 hips, 4 knees). There were no infections in any of these patients. Final Harris Hip Scores were 71.8 for patients with osteonecrosis and 88.6 for osteoarthritis. Eight of 10 hips were pain-free at final follow-up. Two of the 10 primary THAs required late revision at 7 and 10 years after the index arthroplasty. One patient (2 hips and 1 knee) had chronic bilateral lower extremity pain. Total knee arthroplasty range of motion averaged from 7.5° to 118°. Average final Knee Society function score was 79, and objective score was 88. One of 4 patients with primary TKA required a manipulation under anesthesia. No reoperations were required in this group. Overall, patients with heart transplantations on immunosuppression had generally good pain relief after THA and TKA. There were no infections in this small cohort; however, there were many complications.

Joint Arthroplasties other than the Hip in Solid Organ Transplant Recipients

Transplantation Surgery has undergone a great development during the last thirty years and the survival of solid organ recipients has increased dramatically. Osteo-articular diseases such as osteoporosis, fractures, avascular bone necrosis and osteoarthritis are relatively common in these patients and joint arthroplasty may be required. The outcome of hip arthroplasty in patients with osteonecrosis of the femoral head after renal transplantation has been studied and documented by many researchers. However, the results of joint arthroplasties other than the hip in solid organs recipients were only infrequently reported in the literature. A systematic review of the English literature was conducted in order to investigate the outcome of joint arthroplasties other than the hip in kidney, liver or heart transplant recipients. Nine pertinent articles including 51 knee arthroplasties, 8 shoulder arthroplasties and 1 ankle arthroplasty were found. These articles reported well to excellent results with a complication rate and spectrum comparable with those reported in nontransplant patients.

Outcome of total knee arthroplasties after renal transplantation

The fate of total knee arthroplasty in renal graft recipients is unknown. We retrospectively reviewed the outcome of 16 total knee arthroplasties (TKAs) performed after renal transplantation in 12 renal graft recipients from February 1997 to December 2003. The patients (mean age 63) were submitted to a clinical evaluation using the Knee Society Score (KSS) and a radiological evaluation using the Knee Society Total Knee Arthroplasty Roentgenographic Evaluation. The follow-up period averaged 65 (range 25-107) months. No knee had to be revised and one patient died during the follow-up period. The mean knee score was 97.1 (range 93-100) and the mean function score was 87.7 (range 60-100). The alignments of the prosthetic components were correct for all but one patient who, however, kept a good knee score (95). No case of aseptic loosening or osteolysis was detected at last X-rays examination. We conclude that TKA is a safe and symptomatically effective treatment of knee osteonecrosis or severe osteoarthritis in renal graft recipients and should thus be proposed in this population when symptomatology becomes significant. Long-term follow-up studies are necessary to confirm this initial report.

Outcomes of total and unicompartmental knee arthroplasty for secondary and spontaneous osteonecrosis of the knee

BACKGROUND

The reported outcomes of patients who underwent total or unicompartmental knee arthroplasty for secondary and spontaneous osteonecrosis of the knee are often from studies that lack the number of subjects necessary to generate meaningful conclusions. We systematically reviewed the available literature in order to define the outcomes of patients after total knee arthroplasty for secondary osteonecrosis and after total or unicompartmental knee arthroplasty for spontaneous osteonecrosis of the knee.

METHODS

A literature review yielded twenty cohorts with demographic patient information and outcome scores (global knee scores, radiographic outcomes, and revision rates) for patients who had knee arthroplasty as treatment for either secondary or spontaneous osteonecrosis of the knee. The mean preoperative and postoperative global knee scores, the mean revision rate, and the categorization of the mean "poor" and mean "good" outcomes for the knees with each underlying disease were tabulated and reported. The demographic data and the reported mean global knee scores were weighted by the number of knees in each study.

RESULTS

Total knee arthroplasty was performed in 150 knees with secondary osteonecrosis and 148 knees with spontaneous osteonecrosis, and unicompartmental knee arthroplasty was performed in sixty-four knees with spontaneous osteonecrosis. Total knee arthroplasty for spontaneous osteonecrosis of the knee was associated with the best outcomes (higher "good" and postoperative global knee scores and lower revision [3%] and "poor" outcome [6%] rates compared with the other two groups). The outcomes after total knee arthroplasty in knees with secondary osteonecrosis as well as in knees with spontaneous osteonecrosis were better in the cohorts operated on during or after 1985 than in those operated on before 1985. Similarly, the outcomes after unicompartmental knee arthroplasty in knees with spontaneous osteonecrosis of the knee were also better in the cohorts operated on during or after 1985 than in those operated on before 1985.

CONCLUSIONS

Total knee arthroplasty performed as treatment for either secondary osteonecrosis or spontaneous osteonecrosis and unicompartmental knee arthroplasty performed as treatment for spontaneous osteonecrosis were associated with improved outcomes in cohorts with more recent operative dates. The evidence suggests that the use of contemporary cemented implants in total knee arthroplasty and the selective use of stems and augments in patients who have development of secondary osteonecrosis after total knee arthroplasty are producing outcomes that are comparable to those seen after total knee arthroplasty for osteoarthritis. Although the outcomes of patients who have total knee arthroplasty for the treatment of spontaneous osteonecrosis of the knee have historically been favorable, such outcomes have also shown particular improvement in the studies from more recent operative periods. Although poor outcomes were seen after unicompartmental knee arthroplasty in earlier studies of patients with spontaneous osteonecrosis of the knee, it is possible that those results were secondary to inappropriate patient selection, as the authors of the most recent and, to our knowledge, the only study to follow established operative indications regarding the use of unicompartmental knee arthroplasty reported excellent results.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions to Authors on jbjs.org for a complete description of levels of evidence.

Perioperative management of medications used in the treatment of rheumatoid arthritis

Patients with rheumatoid arthritis (RA), an inflammatory arthritis that can destroy joint structures, are often on multiple medications to control disease activity. These medications may have significant toxicities and side effects. Over the course of their lifetime, patients with this disease often require orthopedic procedures, including total joint arthroplasty, and the medications they are taking present management issues specific to the perioperative period. As many of these medications are immunosuppressive, the concern for postoperative infection and delayed wound healing are particularly worrisome. We conducted a review of the available literature pertaining to the perioperative use of the most commonly prescribed medications for RA. Although the existing data directly addressing perioperative complications in orthopedic surgery is sparse, information on relevant complications resulting from the general use of these drugs may be used as a basis for conservative recommendations.

Avascular Bone Necrosis of the Hip Joint after Solid Organ Transplantation in Childhood: A Clinical and MRI Analysis

BACKGROUND

Aseptic osteonecrosis is a well-known complication after solid organ transplantation in adults. The occurrence of osteonecrosis in growing age has been studied after kidney transplantation, but no systematic evaluation of the joints has been reported after heart or liver transplantation in childhood.

METHODS

A total of 196 children--93% of patients surviving kidney, liver and heart transplantation in Finland--participated in a cross-sectional survey. All children underwent a detailed clinical examination and filled out a questionnaire on musculoskeletal symptoms. Radiographs were taken in case of joint pain or abnormal clinical findings. In addition, magnetic resonance imaging (MRI) from the hips was taken on a random basis from 34 adult patients transplanted as a child. The mean follow-up time of all patients after transplantation was 9.2 years (range, 2.4 to 20.5 years).

RESULTS

Twenty-eight (14%) patients reported prolonged joint or limb pain without previous trauma. Specific etiology for the limb pain was not found in 10 (5.1%) patients. Osteonecrosis seen in radiographs or MRI was noted in seven (3.6%) patients, of which three had received kidney, three liver, and one heart graft. Femoral head was affected in five patients, as well as talus bilaterally in one patient and lateral femoral condyle in one patient. All patients were older than 12 years at the time of diagnosis of the osteonecrosis. MRI of the hips of 34 randomly selected patients showed only one asymptomatic necrosis of the femoral head.

CONCLUSIONS

Symptomatic osteonecrosis of the hip is uncommon after solid organ transplantation in childhood using the current immunosuppressive medications.

Osseous complications of pediatric transplantation

Adult stature and peak bone mass are achieved through childhood growth and development. Multiple factors impair this process in children undergoing solid organ transplantation, including chronic illness, pretransplant osteodystrophy, use of medications with negative impact on bone, and post-transplant renal dysfunction. While growth delay and short stature remain common, the most severe forms of transplant-related bone disease, fracture and avascular necrosis, appear to have become less common in the pediatric age group. Osteopenia is very prevalent in adult transplant recipients and probably also in pediatrics, but its occurrence and sequelae are difficult to study in these groups due to methodological shortfalls of planar densitometry related to short stature and altered patterns of growth and development. Although the effect on lifetime peak bone mass is not clear, data from adult populations suggest an elevated long-term risk of bone disease in children receiving transplants. Optimal management of pretransplantation osteodystrophy, attention to post-transplant renal insufficiency among both renal and non-renal transplant patients, reduction of steroid dose in select patients, and supplementation with calcium plus vitamin D during expected periods of maximal bone loss may improve bone health. Careful research is required to determine the role of bisphosphonate therapy in pediatric transplantation.