Total Hip Arthroplasty in Solid Organ Transplant Patients - Case Series

Background: Patients undergoing Solid Organ Transplantation (SOT) have an increased fracture risk and are prone to Avascular osteonecrosis (AVN). With the development of postoperative protocols, surgical techniques and healthcare systems, the number of patients with SOT and degenerative joint disease is steadily increasing. The aim of the present study was to determine the surgical outcomes in a series of kidney and liver graft recipients who underwent Total Hip Arthroplasty (THA) for various indications.

Methods: This review examines our experience with THA in patients with end-stage kidney and liver disease following SOT at a single center. From 2017 to 2023, 11 THAs were performed. Surgery was performed after ineffective conservative treatment. All patients underwent extended preoperative preparation and were cleared for surgery by their transplant specialist. The surgical approach was the lateral Hardinge approach. An uncemented press-fit technique was preferred in 9 cases, while 2 were cemented. Patients were examined at 2 weeks, 1 month, 2 months and 6 months after surgery. All patients were evaluated using the Harris Hip Score (HHS) and Visual Analogue Scale (VAS).

Results: We performed 11 THAs in a group of 5 kidney and 5 liver transplant recipients. The time between organ transplantation and joint replacement averaged approximately 4 years. Surgical indications were osteoarthritis, AVN and femoral neck fracture. Cemented prosthetic components were used in 2 cases, while uncemented components were used in the remaining 9 cases. Two patients experienced complications and required revision surgeries. The average improvement in the HHS score postoperatively was 42 points, and the VAS score improved by 37 points.

Conclusion: THA in transplant recipients significantly improves joint function and quality of life, particularly in cases of avascular necrosis and osteoarthritis. While complications may occur, careful patient selection and thorough preoperative preparation result in substantial postoperative improvements.

Solid Organ Transplantation (SOT) has emerged as one of the most successful surgical interventions worldwide. Over the past decade, there has been an increase in the number of SOTs performed in Bulgaria, however, the overall transplantation rate in the country remains among the lowest in Europe. SOT is a life-saving procedure, while total hip and knee arthroplasties significantly enhance patients`quality of life. With advances in medical technology and practice, the population of patients who have undergone SOT and require joint replacement is steadily increasing. According to the Bulgarian transplantation registry, from 2017 to 2024, a total of 200 SOTs were performed, primarily involving kidney and liver transplants [1].

Transplant patients undergo intensive immunosuppressive regimens postoperatively, which have various effects on the human body. Musculoskeletal complications following SOT are a significant concern and must be managed in a timely manner. Studies indicate a 5% incidence of avascular necrosis (AVN), predominantly affecting the femoral head, as well as an increased risk of osteoporotic fractures [2,3]. The exact incidence of AVN may vary depending on the type of organ transplant, with corticosteroid use being a key contributing factor. With advancements in perioperative protocols and immunosuppressive regimens, the survival rates of transplant patients have improved, leading to an increasing number of arthroplasties. In the early years of SOT, the primary indication for total hip arthroplasty (THA) was AVN due to long-term systemic corticosteroid exposure [4]. However, with the introduction of newer immunosuppressive medications, the group of patients requiring joint replacement has expanded, now including those with arthrosis in addition to AVN. It is important to note that corticosteroid use still plays a significant role in postoperative immunosuppressive regimens to prevent transplant rejection, though there has been a trend toward reducing their use due to their adverse effects, such as causing AVN.

Tacrolimus has been shown to decrease the risk of AVN in SOT patients, as demonstrated by a research conducted by Sakai T, et al. [5]. In a study of 68 patients, 32 received tacrolimus, and after three years of follow-up, none of these patients developed osteonecrosis.

The transplant population undergoing joint replacement surgery is theoretically at higher risk for complications due to factors such as anemia, poor bone stock, and disturbed vitamin D metabolism, often linked to renal osteodystrophy and the effects of immunosuppressive drugs [6].

Despite the advent of new immunosuppressive therapies and the decreasing reliance on corticosteroids, the risk of wound infections and prosthetic joint infections remains a significant concern. The purpose of this study is to review the outcomes of patients with SOT who underwent THA at a single medical center.

This study retrospectively reviewed patients who underwent THA at a single center between 2017 and 2023, all of whom had previously received kidney or liver transplants due to end-stage organ failure. Eleven THAs were performed in 10 patients. One patient had a femoral neck fracture, while the remaining patients had end-stage arthrosis and AVN of the femoral head non-surgical treatment yielding no significant improvement.

The patients underwent extended preoperative anesthesiology and cardiology consultations due to the potential complications related to immunosuppressive therapy and other comorbidities. Additionally, all patients were cleared for surgery by their primary transplant specialist who coordinated with the surgical team to ensure appropriate management of their immunosuppressive therapy.

During hospitalization, all patients were placed in individual rooms. Extremity preparation before surgery included the use of electric clippers for the surgical field, skin decolonization and standard scrubbing of the surgical field. Antibiotic prophylaxis was administered to all primary cases with Cefuroxime during the surgery and for 24-48 hours postoperatively, while revision cases were treated with Vancomycin for 7 days.

All patients underwent surgery using the direct lateral "Hardinge" approach, based on our general experience with THA surgeries and its associated lower rates of hip dislocation and skin complications. In all primary cases, THA was performed using the Müller Stem; two of these were cemented prostheses, while the others were uncemented press-fit implants. For revision cases, a modular revision stem was used. In all cases, we used highly cross-Linked Polyethylene (XLPE) produced by various manufacturers. For femoral heads, we preferred ceramic heads in seven cases, while in the remaining cases, we used metal heads (CoCr).

The average hospital stay was 7 days with some variation depending on individual patient recovery. Clinical follow-up was performed with clinical exams at 2 weeks, 1 month, 2 months, and 6 months. All patients were evaluated at these follow-up visits using the Harris Hip Score (HHS) and the Visual Analogue Scale (VAS) by the surgeon who performed the surgery.

We performed 10 THAs in a cohort of 5 kidney transplant recipients and 5 liver transplant recipients. The average age of the patients at the time of surgery was 44 years. The time between organ transplantation and joint replacement varied, with an average of approximately 4 years. The indications for surgery included osteoarthritis, avascular necrosis, and femoral neck fracture. Cemented components were used in 2 cases, while uncemented components were used in the remaining 8.

In 3 of the cases, patients required a 24-hour stay in the Intensive Care Unit (ICU) postoperatively before being transferred to the orthopedic and trauma department. Postoperative complications, such as electrolyte abnormalities requiring medical intervention and urinary tract infections, were observed in 6 out of 9 patients. Blood transfusions for anemia were performed in 7 of the cases. Two patients required 2-stage revisions due to prosthetic joint infection, with the first stage involving an antibiotic spacer for 7 weeks. The average postoperative improvement in the Harris Hip Score (HHS) and in the Visual Analogue Scale (VAS) were 42 and 37 points, respectively.

In recent years, the number of patients undergoing organ transplantation has increased significantly. According to the Global Observatory on Donation and Transplantation (GODT), 157,494 organs were transplanted worldwide in 2022, representing a 9.1% increase from 2021 [7]. In Bulgaria, while the pace has been slower, the number of SOT procedures has been gradually rising over the past decade. With improvements in survival following SOT, the population of transplant recipients affected by degenerative joint disease is growing. As a result, THA has become an important option for improving quality of life in these patients. Another major indication for THA in this group is femoral head osteonecrosis, which results from the immunosuppressive therapy required to prevent organ rejection.

The increased risk of complications in transplant patients is well-documented across numerous studies [6,8-11]. However, it is equally important to note the positive outcomes, particularly in terms of pain relief and function improvement that can be achieved through THA in this population. A comparison of transplant and non-transplant patients undergoing THA reveals no significant differences in outcomes [12-20]. A study by Upfill-Brown A, et al. [21] finds no significant difference in 90-day mortality and revision rates THA between SOT patients and matched controls in series of 414,756 patients underwent revision THA (rTHA) - 412,919 non-transplant patients and 1837 transplant patients.

Infections remain a major concern for transplant patients undergoing THA. Various studies report differing rates of Prosthetic Joint Infection (PJI) reoperation. Ledford, et al. [14] found a relatively low reoperation rate of 1.8% (1 in 55 THA cases), while Nicolas Brown reported a higher rate of 5.6% in 71 arthroplasties [4]. In our experience, 2 out of 9 patients required reoperation for PJI. The risk of infection is higher following revision surgery, so it is essential to discuss the long-term outcomes of revision arthroplasty with transplant patients. Another study by Ledford, et al. [15] examined complications, clinical outcomes, and survivorship in SOT patients after THA and Total Knee Arthroplasty (TKA). They found that 46% of revision THAs failed at midterm follow-up. Prophylactic measures, including MRSA screening, administration of perioperative antibiotics, and private hospital rooms, are crucial in managing this population. However, due to the small sample size and short observation period, our findings lack statistical significance.

Based on data published by Alpkaya AT, et al. [19], polyethylene-on-metal is the most commonly used combination for THA. XLPE (cross-linked polyethylene) significantly reduces revision rates due to implant wear. However, the release of metal ions from the femoral head and the associated negative consequences have led us to prefer ceramic heads and a ceramic-on-polyethylene bearing design. Data from a study [20] concluded that the liner wear rate over a 5-year follow-up was 0.0438 mm per year in 143 patients. Additionally, there were no reported revisions due to loosening or corrosion.

Historically, cemented prosthesis fixation was considered the only viable option for SOT patients, particularly those with renal transplants, due to the poor bone quality associated with renal disease. Osteopenia, resulting from secondary hyperparathyroidism in renal transplant patients, exacerbates this issue. For reliable press-fit techniques, however, good bone quality is essential. Despite this, many transplant patients are younger, and cemented techniques have been linked to higher rates of polyethylene wear, osteolysis, and revision surgeries. A study by Chang on 52 patients (74 hips) found a 96.6% chance of THA survival over 16.4 years [18]. These findings, along with others in the literature, have led us to prefer the uncemented technique. In our practice, we performed 9 uncemented THAs and 3 cemented THAs. Among the 2 patients who required 2-stage revision surgery, both needed reoperation due to PJI. No cases of loosening due to poor bone stock were observed.

The selection of the surgical approach is based on our experience, with a focus on achieving the lowest rates of postoperative joint dislocation and intraoperative sciatic nerve injury. While the Direct Anterior Approach (DAA) may be a potential option for the future, given its improved early outcomes-such as lower postoperative pain, shorter hospital stays, and faster rehabilitation-there is currently no data to suggest any long-term differences or benefits between DAA and the lateral approach in terms of survivorship and outcomes.

A successful approach involves educating patients about the benefits and risks of the procedure, as well as assembling a multidisciplinary team that includes the patient's transplant specialist, orthopedic surgeon, and anesthesiologist. Proper preoperative preparation is also crucial. A study by Cavanaugh, et al. [12] which analyzed National Inpatient Sample (NIS) data from 1993 to 2011, found that revision procedures were more common than primary procedures in transplant patients. The study compared in-hospital complications in 4,493 transplant patients to non-transplant patients. The most common in-hospital complication was Acute Renal Failure (ARF). The etiology of ARF depends on factors such as hemoglobin levels, medication nephrotoxicity, baseline renal function before the intervention, and coagulation capacity. Ledford and colleagues reported that perioperative complication rates were high, at 29% [13]. In contrast, in our practice, we did not observe any cases of ARF in the early postoperative period.

The literature on discharge to rehabilitation facilities for these patients shows mixed results, influenced primarily by the patients' age [16,17]. Younger patients typically do not require specialized rehabilitation facilities, while older patients are more likely to need discharge to a rehabilitation unit for closer monitoring. Returning to normal daily activities after surgery is a key goal in modern orthopedics. Joint replacement implants are being developed with the aid of Motion Capture (MOCAP) systems in gait laboratories. This approach is essential for designing implants that closely mimic physiological movement.

There are several limitations to our study. It is a retrospective analysis involving a small patient cohort, and the sample size is insufficient for statistical significance. Additionally, the follow-up period is relatively short compared to global data on this topic. Another limitation is the lack of an official joint replacement registry in Bulgaria, which restricts our study to patients who underwent THA at our medical center [22].

Despite these limitations, our results suggest that THA in SOT patients is a relatively safe procedure that leads to significant improvement in quality of life. There is no significant difference in outcomes between transplant patients and the general population. Although the risk of complications is higher in transplant patients, patient satisfaction remains high. In recent years, studies have increasingly shown no significant difference in the risk of postoperative complications between transplant recipients and the general population. Joint replacement is a common procedure in Bulgaria, with many centers performing THA. However, the lack of sufficient transplantation resources remains a societal issue. The growing number of transplant recipients requiring joint replacement underscores the need for improvements in the healthcare system.

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