Abstract
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.
Keywords
1. Introduction
Both the incidence of solid organ transplant and survival of these patients are increasing with improved perioperative protocols and immunosuppressant regimens.
1
However, the immunosuppressant medication regimens and medical complexity of these patients increases their need for arthroplasty, often due to avascular necrosis (AVN) or osteoporotic fractures. Studies have demonstrated an overall 5% rate of AVN in transplant patients.2
, 3
, - Lopez-Ben R.
- Mikuls T.R.
- Moore D.S.
- et al.
Incidence of hip osteonecrosis among renal transplantation recipients: a prospective study.
Clin Radiol. 2004; https://doi.org/10.1016/j.crad.2003.11.001
4
Additionally, many of these patients now live long enough to develop osteoarthritis treated with subsequent joint replacement.- Hedri H.
- Cherif M.
- Zouaghi K.
- et al.
Avascular osteonecrosis after renal transplantation.
Transplant Proc. 2007; https://doi.org/10.1016/j.transproceed.2007.02.031
5
For these reasons, it has been estimated that transplant patients have a fivefold increased incidence of joint replacement when compared to the general population.- Bia M.
Evaluation and management of bone disease and fractures post transplant.
Transplant Rev. 2008; https://doi.org/10.1016/j.trre.2007.09.001
6
,7
- Veenstra D.L.
- Best J.H.
- Hornberger J.
- Sullivan S.D.
- Hricik D.E.
Incidence and long-term cost of steroid-related side effects after renal transplantation.
Am J Kidney Dis. 1999; https://doi.org/10.1016/S0272-6386(99)70414-2
While joint replacement is now relatively common in the transplant population, the risk of complications is also theoretically higher in this population for a number of reasons. The immunosuppressant medications create concern for infection and wound complications. Many of these patients are thrombocytopenic and/or anemic, and patients with a cardiac or lung transplant are especially sensitive to decreases in hemoglobin. Additionally, poor bone density is common as a result of a combination of factors including renal osteodystrophy, vitamin D metabolic dysfunction, poor nutrition, and medication related osteopenia.
8
These conditions can lead to periprosthetic fracture, poor bone ingrowth, and decreased construct durability.- Trautwein C.
- Possienke M.
- Schlitt H.J.
- et al.
Bone density and metabolism in patients with viral hepatitis and cholestatic liver diseases before and after liver transplantation.
Am J Gastroenterol. 2000; https://doi.org/10.1111/j.1572-0241.2000.02269.x
9
, - Chang J.-S.
- Han D.J.
- Park S.-K.
- Sung J.-H.
- Ha Y.-C.
Cementless total hip arthroplasty in patients with osteonecrosis after kidney transplantation.
J Arthroplast. 2013; https://doi.org/10.1016/j.arth.2013.01.020
10
, - Nikkel L.E.
- Hollenbeak C.S.
- Fox E.J.
- Uemura T.
- Ghahramani N.
Risk of fractures after renal transplantation in the United States.
Transplantation. 2009; https://doi.org/10.1097/TP.0b013e3181a6bbda
11
Finally, these patients are typically more medically complex and often have medical issues beyond just the transplanted organ.- Lim B.-H.
- Lim S.-J.
- Moon Y.-W.
- Park Y.-S.
Cementless total hip arthroplasty in renal transplant patients.
Hip Int. 2012; https://doi.org/10.5301/HIP.2012.9471
Despite the theoretical increased risk of complications, the published results are heterogeneous in terms of complication rates and outcomes.
12
, - Deo S.
- Gibbons C.L.
- Emerton M.
- Simpson A.H.
Total hip replacement in renal transplant patients.
J Bone Joint Surg Br Vol. 1995; https://doi.org/10.1302/0301-620X.89B12.19400
13
, - Ledford C.K.
- Watters T.S.
- Wellman S.S.
- Attarian D.E.
- Bolognesi M.P.
Risk versus reward: total joint arthroplasty outcomes after various solid organ transplantations.
J Arthroplast. 2014; https://doi.org/10.1016/j.arth.2014.03.027
14
, - Ledford C.K.
- Chalmers B.P.
- Statz J.M.
- et al.
Primary total knee arthroplasty after solid organ transplant: survivorship and complications.
J Arthroplast. 2017; https://doi.org/10.1016/j.arth.2016.07.018
15
, - Ledford C.K.
- Statz J.M.
- Chalmers B.P.
- Perry K.I.
- Hanssen A.D.
- Abdel M.P.
Revision total hip and knee arthroplasties after solid.
Organ Transplant. J Arthroplasty. 2017; https://doi.org/10.1016/j.arth.2016.11.047
16
, - Ledford C.K.
- Chalmers B.P.
- Statz J.M.
- et al.
Primary total knee arthroplasty after solid organ transplant: survivorship and complications.
J Arthroplast. 2017; https://doi.org/10.1016/j.arth.2016.07.018
17
, - Boquet J.
- Goffin E.
- Poilvache P.
Outcome of total knee arthroplasties after renal transplantation.
Arch Orthop Trauma Surg. 2008; https://doi.org/10.1007/s00402-008-0733-4
18
Many of these studies are older and do not reflect advances in the fields of solid organ transplant including improved patient and donor selection, perioperative care, and better optimized immunosuppressant regimens with a decreased reliance on steroids. The purpose of this study was to evaluate the recent outcomes of TJA in solid organ transplant patients as compared to non-organ transplant controls at one academic medical center.- Shrader M.W.
- Schall D.
- Parvizi J.
- McCarthy J.T.
- Lewallen D.G.
Total hip arthroplasty in patients with renal failure: a comparison between transplant and dialysis patients.
J Arthroplast. 2006; https://doi.org/10.1016/j.arth.2005.07.008
2. Materials and methods
Following institutional IRB approval, a retrospective review was performed to identify all patients who had a primary hip or knee replacement following solid organ transplantation. All procedures were performed by one of four fellowship-trained arthroplasty surgeons between September 2006 and December 2016 at one academic institution. These were compared to a consecutive series of patients who underwent primary joint replacement during this same time period.
A total of 55 patients undergoing 71 arthroplasty procedures following their transplantation and 3161 non-transplanted control patients undergoing 3695 arthroplasty procedures were identified (Table 1). The transplant cohort included 34 males and 21 females who underwent 30 Total Knee Arthroplasties (TKAs) and 41 Total Hip Arthroplasties (THAs) (Table 1). Among these 55 patients, there were a total of 74 transplanted organs including 28 kidneys, 20 hearts, 18 lungs, and 8 livers. Of the 71 procedures, 43 were for osteoarthritis, 18 for osteonecrosis, 5 for fracture, 4 for inflammatory arthritis, and 1 was for post-traumatic arthritis. Regarding the control group, there were a total of 1218 males and 1943 females undergoing 2029 TKAs and 1666 THAs (Table 1). Indications for surgery included 3115 cases for osteoarthritis, 198 for osteonecrosis, 146 for fracture, 131 post-traumatic, 72 inflammatory, and 33 listed as other.
Table 1Summary frequencies.
| Control | Case | Total | |||||
|---|---|---|---|---|---|---|---|
| n | Col% | n | Col% | N | Col% | ||
| Diabetes | No | 3093 | 83.7% | 34 | 47.9% | 3127 | 83.0% |
| Yes | 602 | 16.3% | 37 | 52.1% | 639 | 17.0% | |
| Sex | Female | 2292 | 62.0% | 26 | 36.6% | 2318 | 61.6% |
| Male | 1403 | 38.0% | 45 | 63.4% | 1448 | 38.4% | |
| Race | Black | 493 | 13.3% | 8 | 11.3% | 501 | 13.3% |
| White | 2931 | 79.3% | 60 | 84.5% | 2991 | 79.4% | |
| Other | 271 | 7.3% | 3 | 4.2% | 274 | 7.3% | |
| Ethnicity | Non-Hispanic | 3371 | 91.6% | 69 | 97.2% | 3440 | 91.7% |
| Hispanic | 309 | 8.4% | 2 | 2.8% | 311 | 8.3% | |
| Admission Type | Routine | 3533 | 95.6% | 65 | 91.5% | 3598 | 95.5% |
| Urgent | 162 | 4.4% | 6 | 8.5% | 168 | 4.5% | |
| Procedure Type | Hip | 1666 | 45.1% | 41 | 57.7% | 1707 | 45.3% |
| Knee | 2029 | 54.9% | 30 | 42.3% | 2059 | 54.7% | |
| Readmission 30 Days | No | 3525 | 95.4% | 66 | 93.0% | 3591 | 95.4% |
| Yes | 170 | 4.6% | 5 | 7.0% | 175 | 4.7% | |
| Readmission 90 Days | No | 3440 | 93.1% | 61 | 85.9% | 3501 | 93.0% |
| Yes | 255 | 6.9% | 10 | 14.1% | 265 | 7.0% | |
| Infection 30 Days | No | 3666 | 99.2% | 70 | 98.6% | 3736 | 99.2% |
| Yes | 29 | 0.8% | 1 | 1.4% | 30 | 0.8% | |
| Infection 90 Days | No | 3647 | 98.7% | 70 | 98.6% | 3717 | 98.7% |
| Yes | 48 | 1.3% | 1 | 1.4% | 49 | 1.3% | |
| Infection 1 Year | No | 3626 | 98.1% | 69 | 97.2% | 3695 | 98.1% |
| Yes | 69 | 1.9% | 2 | 2.8% | 71 | 1.9% | |
| Infection 5 Years | No | 3604 | 97.5% | 67 | 94.4% | 3671 | 97.5% |
| Yes | 91 | 2.5% | 4 | 5.6% | 95 | 2.5% | |
| Overall Infection | No | 3601 | 97.5% | 67 | 94.4% | 3668 | 97.4% |
| Yes | 94 | 2.5% | 4 | 5.6% | 98 | 2.6% | |
| Mortality | No | 3533 | 95.6% | 52 | 73.2% | 3585 | 95.2% |
| Yes | 162 | 4.4% | 19 | 26.8% | 181 | 4.8% | |
| Discharged Home | No | 1378 | 37.3% | 29 | 40.8% | 1407 | 37.4% |
| Yes | 2317 | 62.7% | 42 | 59.2% | 2359 | 62.6% | |
Note: N = Number of valid procedures. Col% = Column percent.
The mean BMI in the transplanted group (29.18, SE = 1.18) was lower when compared to the control cohort (32.07, SE = 0.15; p = .02) (Table 2). Similarly, patients undergoing transplantation were younger (M = 61.15, SE = 1.63) than those in the control cohort (M = 65.30, SE = 0.21; p = .01) (Table 2). Thirty (55%) patients in the transplant group were diabetic as compared to 496 (16%) in the control group (p < .001).
Table 2Summary statistics for age and BMI.
| Control | Case | Total | |||||||
|---|---|---|---|---|---|---|---|---|---|
| n | M | SD | n | M | SD | N | M | SD | |
| BMI | 3566 | 32.07 | 8.48 | 68 | 29.18 | 5.56 | 3634 | 32.12 | 8.44 |
| Age | 3695 | 65.30 | 12.15 | 71 | 61.15 | 9.37 | 3766 | 65.07 | 12.12 |
Note: N = Number of valid procedures. M = Mean. SD = Standard Deviation. BMI = Body Mass Index.
2.1 Statistical analysis
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 (Table 3). In these models, a binomial distribution with logit link was specified for each outcome. Further, because patients could contribute multiple procedures to the analysis, random intercepts were allowed for each patient to account for their within-subject correlation.
Table 3Unadjusted and adjusted effect sizes for cases versus controls.
| Valid N | Odds Ratio (95% CI) | p | Valid N | Adjusted Odds Ratio (95% CI) | p | |
|---|---|---|---|---|---|---|
| Infection | ||||||
| Overall | 3766 | 2.16 (0.68–6.84) | .19 | 3634 | 2.36 (0.72–7.73) | .16 |
| 90-day | 3766 | 1.10 (0.15–8.25) | .93 | |||
| 1-year | 3766 | 1.56 (0.36–6.81) | .55 | |||
| 5-year | 3766 | 2.23 (0.71–7.00) | .17 | |||
| Readmission | ||||||
| 30-day | 3766 | 1.59 (0.62–4.08) | .33 | 3766 | 1.08 (0.41–2.85) | .87 |
| 90-day | 3766 | 2.25 (1.12–4.53) | .02 | 3766 | 1.55 (0.75–3.20) | .23 |
| Mortality | 3766 | 7.55 (3.77–15.12) | <.001 | 3619 | 7.42 (3.37–16.32) | <.001 |
| Discharged Home | 3766 | 0.90 (0.52–1.54) | .69 | 3619 | 0.54 (0.30–0.97) | .04 |
Valid N = The number of procedures used to compute the estimates.
a Adjusted for age, body mass index, and diabetes status.
b Adjusted for age, procedure type, admission type, race, and diabetes status.
c Adjusted for procedure type, admission type, race, diabetes status, and sex.
d Adjusted for age, body mass index, infection status, diabetes status, sex, ethnicity, admission type, and procedure type.
e Adjusted for age, body mass index, diabetes status, sex, ethnicity, admission type, and procedure type.
For readmission, separate models were estimated for 30-day and 90-day readmission and were adjusted for patients' age, sex, diabetes status, race, admission type (urgent versus routine), and procedure type (hip versus knee). These covariates were selected because of their importance on univariable analysis and improvement in model fit statistics. A similar approach was used to compare the odds of infection between cases and controls while controlling for patients’ age, body mass index (BMI), and diabetes status.
Regarding mortality, we compared the odds (rather than risk) of mortality between transplanted and non-transplanted patients because time-to-event data was unavailable for this analysis. This model adjusted estimates for patients’ age, BMI, infection status, diabetes status, sex, ethnicity, admission type, and procedure type. The same approach was used to compare the odds of being discharged home between transplanted and non-transplanted patients. As before, these covariates were selected because of their importance on univariable analysis and improvement in model fit statistics. All analyses were completed using SAS version 9.4 (Cary, NC).
3. Results
Ten of 71 (14%) arthroplasty procedures among transplanted patients required readmission. This included five within 30-days of the procedure and another five within 90-days of the procedure (Table 1). Two hundred fifty-five (6.9%) of the 3695 arthroplasty procedures in the control cohort were re-admitted. This included 170 complications within 30-days and another 85 within 90-days of the procedure (Table 1). Reasons for re-admission in the transplant group included one for wound drainage, one DVT, one dislocation, and the remainder were medical complications. In the control group there were 69 wound issues (drainage, hematoma, superficial infection, dehiscence), 10 periprosthetic fractures, 5 deep infections, 4 dislocations, 4 isolated DVTs and another 4 with DVT/PE, and the remainder were medical complications. Four (5.6%) of the 71 arthroplasty procedures among transplanted patients resulted in an infection as compared to 94 (2.5%) of the 3695 procedures among non-transplanted patients (Table 1). Fourteen (25%) of the 55 patients in the transplant group died compared to 141 (4.5%) of the 3161 control participants. Death occurred at an average of 3.83 years following surgery (range 19 days to 8.94 years). These patients were followed for a mean 7.18 years (range 2–12). Twenty-nine (41%) of the 71 arthroplasty procedures among transplanted patients and 1378 (37%) of 3695 procedures of non-transplanted patients required discharge to an acute rehab or skilled nursing facility (Table 1).
In this sample of data, there was no statistical difference in the odds of 30-day (OR = 1.08, 95% CI: 0.41–2.85; p = .87) or 90-day (OR = 1.55, 95% CI: 0.75–3.20; p = .23) readmission between transplanted and non-transplanted patients undergoing arthroplasty – even after controlling for patients' age, sex, diabetes, race, urgency of their index admission, and procedure type (Table 3). Further, controlling for patients’ age, BMI, and diabetes status, there remained no statistical difference in the odds of infection between transplanted and non-transplanted patients (OR = 2.36, 95% CI: 0.72–7.73; p = .16) (Table 3). Univariable sensitivity analyses confirmed the infection rate was comparable between transplanted and non-transplanted patients 90-days post arthroplasty (OR = 1.10, 95% CI: 0.15–8.25; p = .93) as well as 1 year after the procedure (OR = 1.56, 95% CI: 0.36–6.81; p = .55) and 5 years post-procedure (OR = 2.23, 95% CI: 0.71–7.00; p = .17) (Table 1).
Transplanted patients undergoing arthroplasty were far more likely to die when compared to their non-transplanted peers. That is, controlling for patients’ age, BMI, infection status, diabetes status, sex, ethnicity, urgency of their index admission, and procedure type, transplanted patients were 7.42 (95% CI: 3.37–16.32) times more likely to die (p < .001) (Table 3). Conversely, they were only 0.54 (95% CI: 0.30 to 0.97) times as likely to be discharged home when compared to non-transplanted patients (p = .04) (Table 3).
4. Discussion
This study of patients who underwent primary hip or knee arthroplasty following solid organ transplantation at one academic center overall demonstrated no difference in readmission or infection rates as compared to a non-transplant control cohort. The transplant patients were younger, had a lower BMI, but a higher incidence of diabetes. When controlling for these factors, there continued to be no statistically significant difference in infection rate between the cohorts (OR = 2.26, p = .16) (Table 3). However, the transplant patients were less likely to be discharged home versus rehab (OR = 0.54, p = .04) and had a higher risk of post-operative death (OR = 7.42, p < .001) Table 3.
The published data is mixed on whether the presence of a solid organ transplant dramatically increases the risk of complications following primary total hip or knee arthroplasty.
13
, - Ledford C.K.
- Watters T.S.
- Wellman S.S.
- Attarian D.E.
- Bolognesi M.P.
Risk versus reward: total joint arthroplasty outcomes after various solid organ transplantations.
J Arthroplast. 2014; https://doi.org/10.1016/j.arth.2014.03.027
14
, - Ledford C.K.
- Chalmers B.P.
- Statz J.M.
- et al.
Primary total knee arthroplasty after solid organ transplant: survivorship and complications.
J Arthroplast. 2017; https://doi.org/10.1016/j.arth.2016.07.018
15
, - Ledford C.K.
- Statz J.M.
- Chalmers B.P.
- Perry K.I.
- Hanssen A.D.
- Abdel M.P.
Revision total hip and knee arthroplasties after solid.
Organ Transplant. J Arthroplasty. 2017; https://doi.org/10.1016/j.arth.2016.11.047
16
, - Ledford C.K.
- Chalmers B.P.
- Statz J.M.
- et al.
Primary total knee arthroplasty after solid organ transplant: survivorship and complications.
J Arthroplast. 2017; https://doi.org/10.1016/j.arth.2016.07.018
17
The reason for the variability in outcomes is unknown. Many of these procedures are performed at high volume tertiary centers, which potentially may lead to a higher level of care and lower complications. Conversely, these centers also may attract more complicated patients, which could result in a higher complication rate. Angermeier, et at found a 6.8% infection rate in transplant patients versus a 1.8% rate overall.- Boquet J.
- Goffin E.
- Poilvache P.
Outcome of total knee arthroplasties after renal transplantation.
Arch Orthop Trauma Surg. 2008; https://doi.org/10.1007/s00402-008-0733-4
19
Diabetic patients were at particularly high risk, which is consistent with the non-transplant arthroplasty literature. While rates of infection have been reported as high as 50%,- Angermeier E.W.
- Demos H.A.
- Del Schutte H.
- Barfield W.R.
- Leddy L.R.
Complications of hip and knee joint replacement in solid-organ transplant patients.
J Surg Orthop Adv. 2013; https://doi.org/10.3113/JSOA.2013.0204
20
a systematic review by Nowicki et al. demonstrated the incidence of infection to be closer to 4.5%21
and a large study by Goffin et al. had a similar 4.3% rate.- Nowicki P.
- Chaudhary H.
Total hip replacement in renal transplant patients.
J Bone Joint Surg Br Vol. 2007; https://doi.org/10.1302/0301-620X.89B12.19400
22
This is consistent with the 4.6% of patients in this study with a post-operative infection. However, Chang et al. had no infections at 10 year follow-up in 74 THAs performed for AVN after kidney transplant.- Goffin E.
- Baertz G.
- Rombouts J.-J.
Long-term survivorship analysis of cemented total hip replacement (THR) after avascular necrosis of the femoral head in renal transplant recipients.
Nephrol Dial Transplant Off Publ Eur Dial Transpl Assoc - Eur Ren Assoc. 2006; https://doi.org/10.1093/ndt/gfi233
9
- Chang J.-S.
- Han D.J.
- Park S.-K.
- Sung J.-H.
- Ha Y.-C.
Cementless total hip arthroplasty in patients with osteonecrosis after kidney transplantation.
J Arthroplast. 2013; https://doi.org/10.1016/j.arth.2013.01.020
Data on discharge to a rehab facility is also mixed.
6
,13
,- Ledford C.K.
- Watters T.S.
- Wellman S.S.
- Attarian D.E.
- Bolognesi M.P.
Risk versus reward: total joint arthroplasty outcomes after various solid organ transplantations.
J Arthroplast. 2014; https://doi.org/10.1016/j.arth.2014.03.027
19
,- Angermeier E.W.
- Demos H.A.
- Del Schutte H.
- Barfield W.R.
- Leddy L.R.
Complications of hip and knee joint replacement in solid-organ transplant patients.
J Surg Orthop Adv. 2013; https://doi.org/10.3113/JSOA.2013.0204
23
Some studies have found higher rates of discharge to rehab facilities in the transplant population, presumably due to higher medical complexity and desire for closer monitoring. In contrast, others have shown decreased rates likely due to relatively younger patient age and longer inpatient admissions. Despite the younger age of transplant patients in this study (61 years versus 65 years, p = .01) (Table 2), there was a lower likelihood of discharge home as compared to the control cohort (p = .04) (Table 3).- Levitsky J.
- Te H.S.
- Cohen S.M.
The safety and outcome of joint replacement surgery in liver transplant recipients.
Liver Transplant. 2003; https://doi.org/10.1053/jlts.2003.50067
The higher rate of mortality in the transplant cohort is expected given the nature of the transplant population in general. These patients are typically more medically complex, and the presence of a transplanted organ increases the risk for a variety of medical complications including infection, malignancy, medication side effects, and many others.
24
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- Cervera C.
- Gavaldá J.
- et al.
Bloodstream infections among transplant recipients: results of a nationwide surveillance in Spain.
Am J Transplant. 2007; https://doi.org/10.1111/j.1600-6143.2007.01964.x
25
, - Engels E.A.
- Pfeiffer R.M.
- Fraumeni J.F.
- et al.
Spectrum of cancer risk among US solid organ transplant recipients.
J Am Med Assoc. 2011; https://doi.org/10.1001/jama.2011.1592
26
, - Hall E.C.
- Pfeiffer R.M.
- Segev D.L.
- Engels E.A.
Cumulative incidence of cancer after solid organ transplantation.
Cancer. 2013; https://doi.org/10.1002/cncr.28043
27
, - Acuna S.A.
- Fernandes K.A.
- Daly C.
- et al.
Cancer mortality among recipients of solid-organ transplantation in Ontario, Canada.
JAMA Oncol. 2016; https://doi.org/10.1001/jamaoncol.2015.5137
28
, - Fishman J.A.
Infection in solid-organ transplant recipients.
N Engl J Med. 2007; https://doi.org/10.1056/NEJMra064928
29
While organ transplant has a clear survival benefit, these patients do have a higher risk of mortality than the general population.- Green M.
Introduction: infections in solid organ transplantation.
Am J Transplant. 2013; https://doi.org/10.1111/ajt.12093
30
Despite the higher mortality rate, we feel that joint replacement is safe in the transplant population. The deaths occurred at an average of 3.83 years post op, and the cause of mortality was related to the transplanted organ rather than the joint replacement in most cases.- Rana A.
- Gruessner A.
- Agopian V.G.
- et al.
Survival benefit of solid-organ transplant in the United States.
JAMA Surg. 2015; https://doi.org/10.1001/jamasurg.2014.2038
This study was limited by the fact that it was a retrospective review. The patient cohorts and complications were identified based on a query of ICD 9/10 and CPT codes in the electronic medical record system. Therefore, it is possible that complications were under or over-reported. However, the search criteria were standardized to be consistent between the groups. Additionally, there were a limited number of patients in the transplant cohort. This precluded the analysis of risk factors specific to a transplanted organ or immunosuppressant regimen. Finally, these outcomes are not necessarily generalizable as all cases were performed by fellowship trained arthroplasty surgeons at a high-volume transplant center.
Overall, this study demonstrated that there was no statistically significant difference in infection or readmission rates between the transplant and control cohorts after total joint arthroplasty when controlling for covariate factors. Therefore, the presence of a solid organ transplant is not a contraindication to total joint arthroplasty. However, it is critical to note that transplant patients often have multiple co-morbidities that also increase their risk of complication and these must be taken into account along with age and BMI when determining whether a patient is a candidate for the procedure. Further, the transplant patients were more likely to require discharge to a post-acute care facility. Additionally, they had a higher rate of death, but this is likely independent of the joint replacement status and more related to the lower overall health status of the organ transplant population.
Author contribution
Nicholas Brown, MD (Contribution: study design, analysis, data interpretation, manuscript preparation).
Steven Ralles, MD (Contribution: study design, analysis, data interpretation, manuscript preparation).
Ellen Kroin, MD (Contribution: study design, data acquisition, critical manuscript revision).
William Adams, PhD (Contribution: data acquisition, analysis, critical manuscript revision).
Karen Wu, MD (Contribution: study design, data acquisition, manuscript preparation).
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors
Disclosures
The authors received no funding for this study and report no conflicts of interest. One senior author is a board or committee member with the American Orthopedic Association and has a patent pending regarding methods for determining object orientation in a two-dimensional image.
Appendix A. Supplementary data
The following is the Supplementary data to this article:
- Multimedia component 1
References
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Article info
Publication history
Published online: August 01, 2019
Accepted:
July 27,
2019
Received in revised form:
July 6,
2019
Received:
March 4,
2019
Identification
Copyright
© 2019 Delhi Orthopedic Association. All rights reserved.
