Timing of Renal Transplant Prior to Total Knee Arthroplasty Impacts 90-Day Postoperative Outcomes.

BACKGROUND: Renal transplant (RT) patients are at increased risk for complications after total knee arthroplasty (TKA); however, it is unknown if the time from RT to TKA influences such risks. This study evaluated RT patients undergoing primary TKA at various time intervals after transplant. We hypothesized that increased time between RT and TKA would decrease the risk of complications after TKA. METHODS: There were 499 RT patients in a national database undergoing subsequent primary TKA from 2010 to 2020. Patients were stratified by intervals of less than 1 year, between 1 and 2 years, and more than 2 years from RT to TKA. Medical complications up to 90 days, readmissions, and 2-year revisions were compared via univariable and multivariable analyses. RESULTS: Patients who underwent TKA less than 1 year after RT were associated with higher 90-day medical complications when compared to those who underwent TKA 1 to 2 years after RT (odds ratio [OR] 0.4, confidence interval [CI] 0.2 to 0.8, P = .01) and more than 2 years (OR 0.3, CI 0.2 to 0.7, P < .01) after RT. Acute kidney injury and blood transfusion were the most common complications. The TKAs performed 2 years after RT were less likely to have 90-day readmissions when compared to TKAs performed less than 1 year after RT (OR 0.4, CI: 0.2 to 0.9, P < .01). However, time from RT to TKA did not increase the risk of revision at 2 years (P > .30). CONCLUSIONS: Patients undergoing TKA within 1 year of RT have an increased risk of 90-day postoperative medical complications and readmissions, but the time interval from RT does not appear to affect revision risk. These findings suggest waiting 1 year after RT before proceeding with TKA may be advantageous.

Surgical Approach and Body Mass Index Impact Risk of Wound Complications Following Total Hip Arthroplasty.

BACKGROUND: Previous studies have suggested that wound complications may differ by surgical approach after total hip arthroplasty (THA), with particular attention toward the direct anterior approach (DAA). However, there is a paucity of data documenting wound complication rates by surgical approach and the impact of concomitant patient factors, namely body mass index (BMI). This investigation sought to determine the rates of wound complications by surgical approach and identify BMI thresholds that portend differential risk. METHODS: This multicenter study retrospectively evaluated all primary THA patients from 2010 to 2023. Patients were classified by skin incision as having a laterally based approach (posterior or lateral approach) or DAA (longitudinal incision). We identified 17,111 patients who had 11,585 laterally based (68%) and 5,526 (32%) DAA THAs. The mean age was 65 years (range, 18 to 100), 8,945 patients (52%) were women, and the mean BMI was 30 (range, 14 to 79). Logistic regression and cut-point analyses were performed to identify an optimal BMI cutoff, overall and by approach, with respect to the risk of wound complications at 90 days. RESULTS: The 90-day risk of wound complications was higher in the DAA group versus the laterally based group, with an absolute risk of 3.6% versus 2.6% and a multivariable adjusted odds ratio of 1.5 (P < .001). Cut-point analyses demonstrated that the risk of wound complications increased steadily for both approaches, but most markedly above a BMI of 33. CONCLUSIONS: Wound complications were higher after longitudinal incision DAA THA compared to laterally based approaches, with a 1% higher absolute risk and an adjusted odds ratio of 1.5. Furthermore, BMI was an independent risk factor for wound complications regardless of surgical approach, with an optimal cut-point BMI of 33 for both approaches. These data can be used by surgeons to help consider the risks and benefits of approach selection. LEVEL OF EVIDENCE: Level III.

Femoral Head Length Impact on Outcomes Following Total Hip Arthroplasty in 36 Millimeter Cobalt Chrome-on-Highly Crosslinked Polyethylene Articulations.

BACKGROUND: Despite concerns for corrosion, dislocation, and periprosthetic femur fractures, minimal literature has investigated the effect of adjusting femoral head length on outcomes after primary total hip arthroplasty (THA). Therefore, we aimed to investigate the effect of femoral head length on the risk of any revision and reoperation following cobalt chromium (CoCr)-on-highly crosslinked polyethylene (HXLPE) THAs. METHODS: Between 2004 and 2018, we identified 1,187 primary THAs with CoCr-on-HXLPE articulations using our institutional total joint registry. The mean age at THA was 71 years (range, 19-97), 40% were women, and mean body mass index was 30 (range, 10-68). All THAs using 36 mm diameter femoral heads were included. Neutral (0 mm), positive, or negative femoral head lengths were used in 42, 31, and 27% of the THAs, respectively. Kaplan-Meier survivorship was assessed. The mean follow-up was 7 years (range, 2-16). RESULTS: The 10-year survivorships free of any revision or reoperation were 94 and 92%, respectively. A total of 47 revisions were performed, including periprosthetic femur fracture (17), periprosthetic joint infection (8), dislocation (7), aseptic loosening of either component (6), corrosion (4), and other (5). Nonrevision reoperations included wound revision (11), open reduction and internal fixation of periprosthetic femur fracture (4), and abductor repair (2). Multivariable analyses found no significant associations between femoral head length and revision or reoperation. CONCLUSION: Altering femoral head lengths in 36 mm CoCr-on-HXLPE THAs did not affect outcomes. Surgeons should select femoral head lengths that optimize hip stability and center of rotation. LEVEL OF EVIDENCE: III.

The Fate of the Patient With Superficial Dehiscence Following Direct Anterior Total Hip Arthroplasty.

BACKGROUND: Direct anterior approach (DAA) total hip arthroplasty (THA) has been associated with higher rates of superficial incisional dehiscence. However, limited data are available regarding the outcomes following initial treatment of this complication. This study aimed to evaluate patient risk factors, reoperations, and revisions in those who developed superficial wound dehiscence following DAA THA. METHODS: We identified 3,687 patients who underwent a primary DAA THA between 2010 and 2019 from our enterprise total joint registry. Of these, 98 (2.7%) patients developed a superficial wound dehiscence requiring intervention [irrigation and debridement (n = 42) or wound care with or without antibiotics (n = 56)]. Dehiscence was noted at a median of 27 (range, 2-105) days. These patients were compared to patients who did not have a superficial wound complication (n = 3,589). Landmark survivorship analysis was performed to account for immortal time bias with a 45-day landmark time. RESULTS: Patients who had superficial wound dehiscence compared to those who did not, were more often women (64 versus 53%, P = .02) and had increased mean body mass index (33 versus 29, P < .001). There was no difference in 4-year survivorship free from any revision between cohorts (97 versus 98%, respectively, P = .14). There were 2 (2.0%) revisions in the superficial dehiscence group: 1 for periprosthetic joint infection and 1 for aseptic femoral loosening. CONCLUSION: Superficial wound dehiscence following DAA THA was associated with higher body mass index and was more common in women. Fortunately, with proper index management, the risk of revision THA and periprosthetic joint infection was not increased for these patients.

Short Course of Oral Antibiotic Treatment After Two-Stage Exchange Arthroplasty Appears to Decrease Early Reinfection.

BACKGROUND: Recent evidence has suggested a benefit to extended postoperative prophylactic oral antibiotics after two-stage exchange arthroplasty for treatment of periprosthetic joint infections. We sought to determine reinfection rates with and without a short course of oral antibiotics after two-stage exchange procedures. METHODS: A retrospective review identified patients undergoing two-stage exchange arthroplasty for periprosthetic joint infection of the hip or knee. Patients were excluded if they failed a prior two-stage exchange, had positive cultures at reimplantation, prolonged intravenous antibiotics postoperatively, and/or life-long suppression. This resulted in 444 reimplantations (210 hips and 234 knees). Patients were divided into three cohorts based on the duration of oral antibiotics after reimplantation: no antibiotics (102), ≤2 weeks (266), or >2 weeks (76). The primary endpoint was reinfection within 1 year of reimplantation. RESULTS: Within 1 year of reimplantation, there were 34 reinfections. In the no-antibiotic, ≤ 2-week, and >2-week cohorts the reinfection rates were 14.1, 7.0, and 6.4%, respectively. Multivariate Cox regression showed a reduced reinfection rate in the ≤2-week cohort relative to no antibiotics (hazard ratio [HR]: 0.38, P = .01). While the smaller cohort with >2 weeks of antibiotics did not significantly reduce the reinfection rate (HR: 0.41, P = .12), when combined with the ≤2-week cohort, use of oral antibiotics had an overall reduction of the reinfection rate (HR: 0.39, P = .01). CONCLUSIONS: These data support the hypothesis that a short course of oral antibiotics after reimplantation decreases the 1-year reinfection rate. Future randomized studies should seek to examine the efficacy of different durations of oral antibiotics to reduce reinfection. LEVEL OF EVIDENCE: Prognostic Level IV.

Does Metabolic Syndrome Impact the Risk of Reoperation, Revision, or Complication After Primary Total Knee Arthroplasty?

BACKGROUND: Metabolic syndrome (MetS) is an increasingly frequent condition characterized by insulin resistance, abdominal obesity, hypertension, and dyslipidemia. This study evaluated implant survivorship, complications, and clinical outcomes of primary TKAs performed in patients who have MetS. METHODS: Utilizing our institutional total joint registry, 2,063 primary TKAs were performed in patients with a diagnosis of MetS according to the World Health Organization criteria. MetS patients were matched 1:1 based on age, sex, and surgical year to those who did not have the condition. The World Health Organization's body mass index (BMI) classification was utilized to evaluate the effect of obesity within MetS patients. Kaplan-Meier methods were utilized to determine implant survivorship. Clinical outcomes were assessed with Knee Society scores. The mean follow-up was 5 years. RESULTS: MetS and non-MetS patients did not have significant differences in 5-year implant survivorship free from any reoperation (P = .7), any revision (P = .2), and reoperation for periprosthetic joint infection (PJI; P = .2). When stratifying, patients with MetS and BMI >40 had significantly decreased 5-year survivorship free from any revision (95 versus 98%, respectively; hazard ratio = 2.1, P = .005) and reoperation for PJI (97 versus 99%, respectively; hazard ratio = 2.2, P = .02). Both MetS and non-MetS groups experienced significant improvements in Knee Society Scores (77 versus 78, respectively; P < .001) that were not significantly different (P = .3). CONCLUSION: MetS did not significantly increase the risk of any reoperation after TKA; however, MetS patients with BMI >40 had a two-fold risk of any revision and reoperation for PJI. These results suggest that obesity is an important condition within MetS criteria and remains an independent risk factor. LEVEL OF EVIDENCE: Level 3, Case-control study.

Risk Factors in Patients Who Had Prior Renal or Liver Transplant Undergoing Primary Total Knee Arthroplasty.

BACKGROUND: More solid organ transplant (SOT) patients are undergoing total knee arthroplasty (TKA). This study identifies risk factors for complications, implant survivorship, and mortality in TKA patients who had prior SOT. METHODS: We identified 176 TKAs in patients who had prior SOT. Of these, 77 had a prior renal (RT), 77 had a prior liver (LT) transplant, and 22 had multiple prior transplants (MT). Median survival was estimated using Kaplan-Meier. Univariate analyses were assessed with mixed-effects logistic regressions for complications and Cox-regressions for mortality. Median follow-up was 63 months (range, 24 to 109). RESULTS: At least one acute medical complication occurred in 25, 13, and 27% of cases with prior RT, LT, and MT, respectively (P = .12). None of the variables were significantly associated with acute medical complications. At least one surgical complication occurred in 14, 13 and 14% of cases with prior RT, LT, and MT, respectively (P = 1). Vitamin D supplementation (Odds Ratio [OR] = 0.38, P < .03) was associated with lower risk of surgical complications. Reoperation and revision rates were 5 and 3%, respectively. Older age at time of transplantation and greater level of serum creatinine at time of TKA were associated with lower risk (OR = 0.96, P = .01), and higher risk of reoperation (OR = 4.9, P = .01), respectively. Coronary artery disease was associated with higher mortality (Hazard Ratio = 2.35, P = .01). CONCLUSIONS: Vitamin D was associated with lower surgical complications, whereas a younger age at time of transplantation increased the risk of reoperation. Additionally, SOT patients with coronary artery disease demonstrated higher mortality after TKA.

What are the Outcomes After Primary Total Hip and Knee Arthroplasty in Patients With Prior Cerebrovascular Accidents?

BACKGROUND: For patients who have a history of cerebrovascular accident (CVA) with neurological sequelae undergoing primary total hip arthroplasty (THA) and total knee arthroplasty (TKA), we sought to determine mortality rate, implant survivorship, complications, and clinical outcomes. METHODS: Our total joint registry identified CVA sequelae patients undergoing primary THA (n = 42 with 25 on affected hip) and TKA (n = 56 with 34 on affected knee). Patients were 1:2 matched based upon age, sex, body mass index, and surgical year to a non-CVA cohort. Mortality and implant survivorship were evaluated via Kaplan-Meier methods. Clinical outcomes were assessed via Harris Hip scores or Knee Society scores . Mean follow-up was 5 years (range, 2-12). RESULTS: For CVA sequelae and non-CVA patients, respectively, the 5-year patient survivorship was 69 versus 89% after THA (HR = 2.5; P = .006) and 56 versus 90% after TKA (HR = 2.4, P = .003). No significant difference was noted between groups in implant survivorship free from any reoperation after THA (P > .2) and TKA (P > .6). Postoperative CVA occurred at an equal rate in CVA sequelae and non-CVA patients after TKA (1.8%); none after THA in either group. The magnitude of change in Harris Hip scores (P = .7) and Knee Society scores (P = .7) were similar for CVA sequelae and non-CVA patients. CONCLUSION: Complications, including the risk of postoperative CVA, implant survivorship, and outcome score improvement are similar for CVA sequelae and non-CVA patients. A 2.5-fold increased risk of death at a mean of 5 years after primary THA or TKA exist for CVA sequelae patients.

The Impact of Metabolic Syndrome on Reoperations and Complications After Primary Total Hip Arthroplasty.

BACKGROUND: Metabolic syndrome (MetS) represents a constellation of interrelated conditions including insulin resistance, abdominal obesity, hypertension, and dyslipidemia. The goals of this study are to determine the impact of MetS on implant survivorship, complications, and clinical outcomes after primary total hip arthroplasty (THA). METHODS: Utilizing our institutional total joint registry, 1,268 patients undergoing primary THA were identified with MetS based on the World Health Organization definition and matched 1:1 to those without MetS based on age, gender, and surgical year. MetS patients were further stratified according to the World Health Organization body mass index (BMI) classification to contextualize obesity. Kaplan-Meier analyses were utilized to compare survivorship free of any reoperation, revision, and complications. Clinical outcomes were assessed with Harris hip scores. Mean follow-up after THA was 5 years. RESULTS: MetS patients had significantly worse 5-year survivorship free from any reoperation compared to those without MetS (93.5% vs 96.1%, respectively; hazard ratio [HR] 1.4, P = .04). When stratifying MetS and BMI classification, the BMI >40 kg/m2 had significantly decreased 5-year implant survivorship free from any reoperation (85.9% vs 96.1%, HR 3.4, P < .001), any revision (91.7% vs 97.3%, HR 2.7, P < .001), and reoperation for periprosthetic joint infection (95% vs 99%, HR 5.1, P < .001). Both groups experienced significant and similar improvement in final Harris hip scores (P < .001). CONCLUSION: Patients with MetS had a 1.4-fold increased risk of reoperation after primary THA compared to a matched cohort without the condition. MetS patients with a BMI >40 kg/m2 had the highest risk of reoperation, and had a significantly higher revision and periprosthetic joint infection rates, suggesting that morbid obesity remains a critical, independent risk factor beyond MetS. LEVEL OF EVIDENCE: Level 3, Case-control study.

Intertrochanteric fracture fixation in solid organ transplant patients: outcomes and survivorship.

BACKGROUND: Solid organ transplantation (SOT) recipients have complex medical and surgical risk factors; however, the outcomes of these patients undergoing surgical fixation of hip fractures are unknown. This study sought to evaluate SOT patients' outcomes and survivorship after intertrochanteric (IT) fracture fixation. METHODS: A retrospective review identified 12 SOT patients who underwent cephalomedullary (CMN) nail fixation for IT fractures and were matched (1:2) to a cohort of 24 non-SOT IT fracture patients. Perioperative results and complications, mortality/patient survivorship, and clinical outcomes were compared between the cohorts. RESULTS: The time from presentation to surgical fixation was within 48 h of presentation for the non-SOT patients, while only 75% of SOT patients underwent surgery within 48 h of presentation (p = 0.034). The 90-day readmission rate for SOT patients was 25% versus 13% in the non-SOT group (p = 0.38). Similarly, the SOT cohort experienced a higher rate of major medical complication (25% vs. 13%, p = 0.38). There were two (16%) reoperations in the SOT group and three (13%) in the non-SOT matched group (p = 0.99). Respectively, the 90-day and 1-year estimated patient survivorship was similar between the two cohorts: SOT patients with 92% (95% CI 54-99%) and 73% (95% CI 24-93%) versus 86% (95% CI 62-95%) and 72% (95% CI 47-86%, HR 0.92, 95% CI 0.18-4.62, p = 0.92) in non-SOT patients. CONCLUSION: SOT patients who underwent CMN fixation for IT fractures required more time from hospital presentation to surgical management than non-SOT patients. Although not statistically significant, SOT patients demonstrated more acute complications and readmissions, but similar mortality compared to those without transplant.

Incorporating telemedicine into an ambulatory orthopedic practice.

ABSTRACT: The COVID-19 pandemic resulted in many challenges for the healthcare system. This article describes how an ambulatory orthopedic practice transitioned to telemedicine in order to continue to provide effective, efficient, and safe care for patients. Although this discipline relies heavily on physical assessment and examination, telemedicine can be successfully implemented in this area.

Primary reverse shoulder arthroplasty in patients with metabolic syndrome is associated with increased rates of deep infection.

BACKGROUND: Metabolic syndrome (MetS) is an abnormal physiological condition that has been increasingly identified as a risk factor for complications after orthopedic surgery. Given the lack of information on the effect of MetS in shoulder arthroplasty (SA), this investigation analyzed the rates of postoperative complications and implant survivorship free from reoperation and revision in patients with and without MetS. METHODS: Between 2007 and 2017, data from 4635 adults who underwent a primary SA were collected and classified based on the presence or absence of MetS. MetS was defined as the existence of type 2 diabetes mellitus and a minimum of 2 of the following diagnoses: hyperlipidemia, hypertension, and body mass index ≥ 30 kg/m2 within 1 year of surgery. Of the 4635 arthroplasties, 714 were performed in patients with MetS (anatomic total shoulder arthroplasty [aTSA] in 289 and reverse shoulder arthroplasty [RSA] in 425) and 3921 were performed in patients without MetS (aTSA in 1736 and RSA in 2185). Demographic characteristics, complications, reoperations, and revision surgery were compared. RESULTS: At a mean of follow-up of 4.5 ± 2.3 years, 67 MetS patients (9.4%) and 343 non-MetS patients (8.7%) had sustained at least 1 postoperative complication (P = .851). Rotator cuff failure was the most common complication overall, with 84 cases (1.8%) (15 MetS cases [2.1%] and 69 non-MetS cases [1.8%], P = .851), and in both MetS and non-MetS patients, followed by infection, with 68 cases (1.2%) (10 MetS cases [1.4%] and 58 non-MetS cases [1.2%], P = .913). For aTSAs, the most common complication was rotator cuff failure (84 shoulders, 1.8%); for RSAs, the most common complication was periprosthetic fracture (52 shoulders, 1.1%). In RSAs, the rates of deep infection (1.9% vs. 0.7%, P = .04), instability (3.1% vs. 1.5%, P = .04), and deep venous thrombosis or pulmonary embolism (0.5% vs. 0.3%, P = .03) were found to be significantly higher in patients with MetS than in those without MetS. Reoperations were observed in 36 MetS patients (5%) and 170 non-MetS patients (4.3%) (P = .4). Revisions were performed in 30 MetS patients (4.2%) and 127 non-MetS patients (3.2%) (P = .19). The Kaplan-Meier 5-year rate of survivorship free from reoperation, revision, and prosthetic joint infection was equal between groups. CONCLUSIONS: A preoperative diagnosis of MetS in patients undergoing primary SA did not significantly increase the risk of postoperative complications, infection, reoperation, or revision following primary SA. However, in the RSA subgroup, complications were significantly more common in patients with MetS. Individual risk factors may be more appropriate than the umbrella diagnosis of MetS prior to aTSA.

Robotic-Assisted versus Manual Total Knee Arthroplasty in a Crossover Cohort: What Did Patients Prefer?

BACKGROUND: Robotic-assisted total knee arthroplasty represents an increasingly utilized surgical technology; however, there remains clinical question whether the technique produces improved clinical and patient-reported outcomes. The purpose of this study was to evaluate early clinical outcomes and patient preference of robotic-assisted total knee arthroplasty (rTKA) versus manual TKA (mTKA) in a direct crossover cohort of patients who underwent consecutive TKAs by each technique. MATERIALS AND METHODS: A retrospective chart review and telephone interview was performed on 36 patients who underwent both rTKA and mTKA by a single surgeon between 2012-2018. Perioperative outcomes-complications/reoperations and patient-preferred technique-were collected with mean clinical follow up of 4.8 and 2.0 years for mTKA and rTKA, respectively. RESULTS: mTKA were performed significantly (p<0.01) more quickly than rTKA, including shorter tourniquet time (56 versus 73 minutes) and total operating room time (93 versus 116 minutes). rTKA patients length of stay (LOS) was significantly (p<0.01) decreased (1.8 days) compared to mTKA (2.3 days). For rTKA and mTKA, respectively, there was no difference in final range of motion (119 versus 122 degrees), Visual Analog Scale (1.6 versus 0.9), or Knee Osteoarthritis Outcome Score, Jr (85 versus 87). Twenty (56%) reported rTKA as the preferred technique over mTKA. CONCLUSION: In same patient direct comparison, rTKA required longer operative time but improved LOS compared to mTKA. There was no difference in final outcomes with only slightly more patients preferring rTKA.

Cementation of a Dual Mobility Construct in Recurrently Dislocating and High Risk Patients Undergoing Revision Total Arthroplasty.

BACKGROUND: Recurrent instability remains a challenge after revision total hip arthroplasty (THA). We report the outcomes of cementing a cementless dual mobility (DM) component into a stable acetabular shell for the treatment and/or prevention of instability in revision THA. METHODS: Eighteen patients (18 THAs) undergoing revision THA with a specific monoblock DM construct cemented into a new acetabular component or an existing well-fixed component from 2011 to 2014 were retrospectively reviewed. Tumor prostheses and total femoral replacements were excluded. In 9 patients (50%), components were implanted specifically for recurrent dislocations. Mean age was 64 years; mean follow-up was 3 years. Patients underwent an average of 4 prior hip operations (range 2-6). RESULTS: No cemented DM cups dissociated at the cement-cup interface. Three patients (17%) experienced a postoperative dislocation. One required a revision to constrained liner and 2 underwent open reduction with retention of the DM construct. Harris Hip Scores improved from 53 to 82 postoperatively (P < .001). CONCLUSION: Cementation of a monoblock cup DM construct, an off-label use as the construct is not specifically made for cementation, into a well-fixed acetabular component provides an alternative to enhance prosthetic stability in (1) recurrently dislocating THAs with well fixed, well-positioned acetabular components and (2) complex acetabular reconstructions in which constraint should be avoided. While not a perfect solution in this series, DM constructs provide a number of advantages including no added constraint at the interface and a large effective femoral head to diminish prosthetic impingement.

What Risks are Associated with Primary THA in Recipients of Hematopoietic Stem Cell Transplantation?

INTRODUCTION: As patients who receive hematopoietic stem cell transplantation are at increased risk of avascular necrosis (AVN) and subsequent degenerative arthritis, THA may be considered in some of these patients, particularly as overall patient survival improves for patients undergoing stem-cell transplants. Patients receiving hematopoietic stem cell transplantation theoretically are at increased risk of experiencing complications, infection, and poorer implant survivorship owing to the high prevalence of comorbid conditions, immunosuppressive therapy regimens including corticosteroids, and often low circulating hematopoietic cell lines; however, there is a paucity of studies elucidating these risks. QUESTIONS/PURPOSES: We asked: (1) What is the overall mortality of patients with hematopoietic stem cell transplantation who have undergone THA? (2) What is the complication rate for these patients? (3) What are the revision and reoperation rates and implant survivorship for these patients? PATIENTS AND METHODS: Between 1999 and 2013, we performed 42 THAs in 36 patients who underwent stem-cell transplants. Other than those who died, all were available for followup at a minimum of 2 years; of the patients whose procedures were done more than 10 years ago and who are not known to have died, two (5%) had not been seen in the last 5 years and so are considered lost to followup. All patients underwent thorough evaluation by the transplant team before arthroplasty; general contraindications included active medical comorbidities or evidence of unstable end-organ damage, active rejection, and critically low circulating hematopoietic cell lines. Underlying primary diseases leading to hematopoietic stem cell transplantation included lymphoma (14/42; 33%), plasma cell disorders (10/42; 24%), leukemia (9/42; 21%), and amyloidosis (3/42; 7%). Complications, reoperations, revisions, and implant and patient survivorship, were recorded from chart review and data from the institutional total joint registry. Mean followup was 5 years (range, 2-15 years). RESULTS: Patient survivorship free of mortality was 91% (95% CI, 81%-100%) and 82% (95% CI, 68%-96%) at 2 and 5 years, respectively. Complications occurred in four of 42 THAs (10%); these complications included an intraoperative fracture and a venous thromboembolism. Revisions occurred in two of 42 (5%) THAs; there were no reoperations. Implant survivorship free of component revision for any reason or implant removal accounting for death as a competing risk was 93% (95% CI, 83%-100%) at 5 years. CONCLUSION: With appropriate medical evaluation and comanagement by transplant specialists, carefully selected patients with hematopoietic stem cell transplants may undergo elective primary THA, although complications do occur in this relatively fragile patient population. Although implant survivorship was modest at 93% at 5 years, there was not a high risk of revision for infection. Improved outcomes for these patients may be expected as their medical management advances and additional comparative studies may clarify other important patient factors. LEVEL OF EVIDENCE: Level IV, therapeutic study.

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.

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.

Outcomes of shoulder arthroplasty in haematopoietic stem cell transplant patients.

BACKGROUND: With the growing population of patients undergoing haematopoietic stem cell transplants (HSCTs), the demand for shoulder arthroplasty (SA) in this population can be expected to increase. No studies in the literature have examined the outcomes of SA in HSCT patients. PATIENTS AND METHODS: A retrospective review of 11 SAs in 10 patients with previous HSCT was performed. We characterized the clinical outcomes, survivorship, and peri-operative complication rates in patients who underwent SA after receiving a HSCT. We also performed a subanalysis based on implant and transplant type. RESULTS: Seven of ten patients died with average two and five year post-operative patient survival rates of 70% +/- 14% and 47% +/- 17%, respectively. At average follow up of 4.2 years of the seven patients with two year followup, pain and range of motion improved with SA (p = 0.0625-0.2500). At final follow-up, five of seven shoulders were rated as satisfactory or excellent with modified Neer ratings. Two and five year survival rates free of re-operation were 100% +/- 0% and 67% +/- 27%, respectively. There were no other complications. No differences in outcomes were seen based on implant or transplant type besides RSA being associated with greater mortality risk (p = 0.0424, hazard ratio = 10.6). CONCLUSIONS: Patients with previous HSCT who undergo SA can expect to have good pain relief, range of motion improvement, subjective satisfaction, and low peri-operative complication rate with appropriate choice of implant. However, surgeons must inform patients about realistic post-operative outcomes given the high post-operative mortality rate. LEVEL OF EVIDENCE: Level IV, Prognosis.

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.