Post-operative medical and surgical complications after primary total joint arthroplasty in solid organ transplant recipients: a case series

Management of Bilateral Synchronous Knee Prosthetic Joint Infection in a Patient with Infected Heart Transplant: A Case Report

CASE

A 74-year-old man presented with septic shock with infection of his heart transplant and bilateral prosthetic knee joints simultaneously. He underwent bilateral knee resection arthroplasties with placement of articulating spacers. At 3-year follow-up, the patient was alive and ambulating independently.

CONCLUSION

This case represents the first report of bilateral hematogenous prosthetic knee infections associated with concomitant enterococcal endocarditis of a heart transplant treated successfully and definitively with radical debridement and placement of articulating spacer with regular implants.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Preoperative Management of Medications for Rheumatologic and HIV Diseases: Society for Perioperative Assessment and Quality Improvement (SPAQI) Consensus Statement

Perioperative medical management is challenging because of the rising complexity of patients presenting for surgical procedures. A key part of preoperative optimization is appropriate management of long-term medications, yet guidelines and consensus statements for perioperative medication management are lacking. Available resources use recommendations derived from individual studies and do not include a multidisciplinary focus on formal consensus. The Society for Perioperative Assessment and Quality Improvement identified a lack of authoritative clinical guidance as an opportunity to use its multidisciplinary membership to improve evidence-based perioperative care. The Society for Perioperative Assessment and Quality Improvement seeks to provide guidance on perioperative medication management that synthesizes available literature with expert consensus. The aim of this consensus statement is to provide practical guidance on the preoperative management of immunosuppressive, biologic, antiretroviral, and anti-inflammatory medications. A panel of experts including hospitalists, anesthesiologists, internal medicine physicians, infectious disease specialists, and rheumatologists was appointed to identify the common medications in each of these categories. The authors then used a modified Delphi process to critically review the literature and to generate consensus recommendations.

Outcomes following Total Hip Arthroplasty for Femoral Head Osteonecrosis in Patients with History of Solid Organ Transplant

BACKGROUND

Osteonecrosis of the femoral head (ONFH) is a potentially debilitating condition, often requiring total hip arthroplasty (THA). Patients with solid organ transplant (SOT) are at increased risk of postoperative complications after THA for osteoarthritis. The objective of the present study is to evaluate SOT as a potential risk factor for complication after THA for ONFH.

METHODS

This is a retrospective study that identified patients with SOT who underwent THA for ONFH from 2005 to 2014 in a national insurance database and compared them to 5:1 matched controls without transplant. Subgroup analyses of patients with renal transplant (RT) and those with non-RT were also analyzed. A logistic regression analysis was used to compare rates of mortality, hospital readmission, emergency room (ER) visits, infection, revision, and dislocation while controlling for confounders. Differences in hospital charges, reimbursement, and length of stay (LOS) were also compared.

RESULTS

996 patients with SOT who underwent THA were identified and compared to 4,980 controls. SOT patients experienced no increased risk of early postoperative complications compared to controls. Solid organ transplant was associated with higher resource utilization and LOS. Renal transplant patients were found to have significantly higher risk of hospital readmission at 30 days (odds ratio [OR] 1.77; p = 0.001) and 90 days (OR 1.62; p < 0.001) and hospital LOS (p < 0.001), but had lower risk of infection (OR 0.65; p = 0.030). Non-RT patients had higher rate of ER visits at 30 days (OR 2.26; p = 0.004) but lower rates of all-cause revision (OR 0.22; p = 0.043).

CONCLUSIONS

Patients with history of SOT undergoing THA for ONFH utilize more hospital resources with longer LOS and greater risk of readmission but are not necessarily at an increased risk of early postoperative complications.

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).

Complications and safety of the transplanted organ after upper extremity surgery in patients receiving immunosuppressant therapy after solid organ transplantation

PURPOSE

The purpose of this study was to evaluate the complications and safety of transplanted organs after upper extremity surgery in patients taking immunosuppressants after solid organ transplantation (SOT).

METHODS

Seventy-two transplant recipients underwent 99 upper extremity surgeries while on immunosuppressants after SOT at our institution between January 2009 and December 2018. We retrospectively reviewed the clinical data of these patients, including their demographic information and data related to the SOT and upper extremity surgery.

RESULTS

Trigger/tendon release (n = 31, 31.3%) was the most frequently performed upper extremity surgery, followed by incision and drainage for an infection (n = 16, 16.2%). Post-operative complications occurred after ten upper extremity operative procedures (10.1%), among which uncontrolled infection after surgery for an infection (n = 4) was the most common. According to the Clavien-Dindo classification, the complications of three surgical procedures were grade I, three were grade II, and four were grade III, and all were treatable. The occurrence rate of the complications was not significantly different between emergent and elective surgery. All transplanted organ-specific indicators did not worsen significantly after emergent or elective upper extremity surgery.

CONCLUSIONS

Since the function of the transplanted organ was well-preserved after emergent or elective upper extremity surgery, common upper extremity procedures do not seem to be a worrisome practice for SOT patients. However, when treating hand and upper extremity infections in SOT patients, surgeons should explain the possible need for multiple operations  and the high complication rate.

Perioperative Management of Antirheumatic Medications in Patients with RA and SLE Undergoing Elective Foot and Ankle Surgery: A Critical Analysis Review

»

Recent literature has shown that continued use rather than discontinuation of various antirheumatic agents throughout the perioperative period may present an opportunity to mitigate the risks of elective surgery.

»

For patients with rheumatoid arthritis and systemic lupus erythematosus, perioperative management of medication weighs the risk of infection against the risk of disease flare when immunosuppressive medications are withheld.

»

Broadly speaking, current evidence, although limited in quality, supports perioperative continuation of disease-modifying antirheumatic drugs, whereas biologic drugs should be withheld perioperatively, based on the dosing interval of the specific drug.

»

For any withheld biologic drug, it is generally safe to restart these medications approximately 2 weeks after surgery, once the wound shows evidence of healing, all sutures and staples have been removed, and there is no clinical evidence of infection. The focus of this recommendation applies to the optimization of wound-healing, not bone-healing.

»

In most cases, the usual daily dose of glucocorticoids is administered in the perioperative period rather than administering "stress-dose steroids" on the day of surgery.

Outcomes of total hip arthroplasty in haemodialysis and renal transplant patients: systematic review

BACKGROUND

Chronic renal failure is increasing in prevalence and reported to have deleterious effects on the outcome of total hip arthroplasty (THA).

AIM

To investigate the clinical and functional outcomes of THA in patients receiving haemodialysis or who have previously undergone renal transplantation.

METHODS

Systematic review of the literature using bibliographic databases up to July 2018 to determine the functional outcome, complications and revision rates of THA in patients receiving haemodialysis for end-stage renal failure and those with a previous renal transplant.

RESULTS

25 studies were identified with a total of 797 THAs. 166 patients (20.8%) were receiving haemodialysis and 631 patients (79.2%) had undergone transplantation. All studies reported a marked improvement in hip function following THA. There were 27 failures (15.7% revision rate) in the haemodialysis group and 101 failures (16.0% revision rate) in the transplant group. The revision rate for cemented implants was higher in haemodialysis versus transplant patients (23% vs. 15%), with the converse being true for uncemented implants (3.8% vs. 6.9%). The deep infection rate was higher in the haemodialysis group (10.8% vs. 2.1%).

CONCLUSIONS

Patients receiving haemodialysis or with a history of renal transplantation can expect good functional outcome following THA. However, the revision rate and deep infection rate are higher than would be expected in patients receiving THA for primary OA. Aseptic loosening is the most common reason for revision. Uncemented implants appear to be associated with lower failure rates both in haemodialysis patients and those who have had a transplant.

Comparison of total joint arthroplasty outcomes between renal transplant patients and dialysis patients-a meta-analysis and systematic review

OBJECTIVES

End-stage renal disease (ESRD) patients are at an increased risk of needing total joint arthroplasty (TJA); however, both dialysis and renal transplantation might be potential predictors of adverse TJA outcomes. For dialysis patients, the high risk of blood-borne infection and impaired muscular skeletal function are threats to implants' survival, while for renal transplant patients, immunosuppression therapy is also a concern. There is still no high-level evidence in the published literature that has determined the best timing of TJA for ESRD patients.

METHODS

A literature search in MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials (up to November 2019) was performed to collect studies comparing TJA outcomes between renal transplant and dialysis patients. Two reviewers independently conducted literature screening and quality assessments with the Newcastle-Ottawa Scale (NOS). After the data were extracted, statistical analyses were performed.

RESULTS

Compared with the dialysis group, a lower risk of mortality (RR = 0.56, Cl = [0.42, 0.73], P < 0.01, I² = 49%) and revision (RR = 0.42, CI = [0.30, 0.59], P < 0.01, I² = 43%) was detected in the renal transplant group. Different results of periprosthetic joint infection were shown in subgroups with different sample sizes. There was no significant difference in periprosthetic joint infection in the small-sample-size subgroup, while in the large-sample-size subgroup, renal transplant patients had significantly less risk (RR = 0.19, CI = [0.13, 0.23], P < 0.01, I² = 0%). For dislocation, venous thromboembolic disease, and overall complications, there was no significant difference between the two groups.

CONCLUSION

Total joint arthroplasty has better safety and outcomes in renal transplant patients than in dialysis patients. Therefore, delaying total joint arthroplasty in dialysis patients until renal transplantation has been performed would be a desirable option. The controversy among different studies might be partially accounted for that quite a few studies have a relatively small sample size to detect the difference between renal transplant patients and dialysis patients.

Complications After Upper Extremity Surgery in Solid Organ Transplant Patients

PURPOSE

To determine the rate of and risk factors for complications in solid organ transplant (SOT) patients who have had surgery of the upper extremity.

METHODS

All SOT recipients who had an upper extremity procedure performed by 1 of 6 surgeons at our institution were identified from 2006 to 2018. Demographic data, transplant date and type, upper extremity surgery procedure and date, antirejection medications, American Society of Anesthesiologists Physical Status Classification System (ASA) score, and complications were recorded. Complications were defined as any surgical complication within 1 year and any medical complication within the first 30 days after surgery. Complications were categorized according to the Clavien-Dindo classification system.

RESULTS

Fifty-one upper extremity procedures in 32 SOT patients were included. Of the 51 procedures, 21 were complicated, for an overall complication rate of 41%. Surgical complications occurred equally before and after 30 days with infection being the most common. Only 1 of the procedures resulting in surgical site infection had an implant (temporary K-wire fixation). The majority of complications were grade II, and there were no grade IV or V complications. Age, ASA score, type or number of SOT, and immunosuppressive regimens were similar between complicated and noncomplicated procedures. Procedures involving male patients were more likely to be complicated than those involving female patients.

CONCLUSIONS

Complications after upper extremity operations are common in SOT patients, and surgical complications often occur after 30 days. Surgeons should counsel this population that they carry a higher complication risk than the general population and may require longer-term monitoring after surgery.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Cosmetic treatment in patients with autoimmune connective tissue diseases: Best practices for patients with lupus erythematosus

The cutaneous manifestations of lupus, especially chronic cutaneous lupus erythematosus, are a source of significant morbidity and can negatively impact patient quality of life. While the active inflammatory component of the disease may be adequately treated, patients are frequently left with residual skin damage and disfiguring aesthetic deficits. Dermatologists lack guidelines regarding the use and safety of various reconstructive and cosmetic interventions in this patient population. Laser treatments are largely avoided in the lupus population because of the possible photodamaging effects of ultraviolet and visible light. Similarly, given the autoimmune nature of this disease, some physicians avoid injectable treatment and grafts because of the concern for disease reactivation via antigenic stimulation. In the second article in this continuing medical education series we compile available data on this topic with the goal of providing evidence-based guidance on the cosmetic treatment of patients with lupus erythematosus with a focus on chronic cutaneous lupus erythematosus.

The impact of solid organ transplant history on inpatient complications, mortality, length of stay, and cost for primary total shoulder arthroplasty admissions in the United States

BACKGROUND

There is a growing population of patients with history of solid organ transplant (SOT) surgery among total joint patients. Patients with history of SOT have been found to have longer lengths of stay and higher inpatient hospital costs and complications rates after hip and knee arthroplasty. The purpose of this study was to determine whether this is true for shoulder arthroplasty in SOT patients.

METHODS

The Nationwide Inpatient Sample was queried to describe relative demographic, hospital, and clinical characteristics, perioperative complications, length of stay, and total costs for patients with a history of SOT (International Classification of Diseases-9th Edition-Clinical Modificiation V42.0, V42.1, V42.7, V42.83) undergoing shoulder arthroplasty (81.80, 81.88) from 2004 to 2014.

RESULTS

A weighted total of 843 patients (unweighted frequency = 171) and 382,773 patients (unweighted frequency = 77,534) with and without history of SOT, respectively, underwent shoulder arthroplasty. SOT patients were more often younger and more likely to be male, have Medicare, and undergo surgery in a large teaching institution in the Midwest or Northeast (P < .001). SOT patients had higher or similar comorbid disease prevalence for 27 of 29 Elixhauser comorbidities. The risk of any complication was significantly higher among SOT patients (15.5% vs. 9.3%, P = .007). SOT patients experienced inpatient admissions an average 0.27 days longer (P < .001) and $1103 more costly (P = .06) than non-SOT patients.

CONCLUSIONS

Patients with history of SOT undergoing shoulder arthroplasty appear to remain a unique population due to their specific vulnerability to minor complications and inherently increased inpatient resource utilization.

Perioperative Management of Patients with Inflammatory Rheumatic Diseases Undergoing Major Orthopaedic Surgery: A Practical Overview

Patients with inflammatory rheumatic diseases often need orthopaedic surgery due to joint involvement. Total hip replacement and total knee replacement are frequent surgical procedures in these patients. Due to the complexity of the inflammatory rheumatic diseases, the perioperative management of these patients must envisage a multidisciplinary approach. The frequent association with extraarticular comorbidities must be considered when evaluating perioperative risk of the patient and should guide the clinician in the decision-making process. However, guidelines of different medical societies may vary and are sometimes contradictory. Orthopaedics should collaborate with rheumatologists, anaesthesiologists and, when needed, cardiologists and haematologists with the common aim of minimising perioperative risk in patients with inflammatory rheumatic diseases. The aim of this review is to provide the reader with simple practical recommendations regarding perioperative management of drugs such as disease-modifying anti-rheumatic drugs, corticosteroids, non-steroidal anti-inflammatory drugs and tools for a risk stratification for cardiovascular and thromboembolic risk based on current evidence for patients with inflammatory rheumatic diseases.

2017 American College of Rheumatology/American Association of Hip and Knee Surgeons Guideline for the Perioperative Management of Antirheumatic Medication in Patients With Rheumatic Diseases Undergoing Elective Total Hip or Total Knee Arthroplasty

OBJECTIVE

This collaboration between the American College of Rheumatology and the American Association of Hip and Knee Surgeons developed an evidence-based guideline for the perioperative management of antirheumatic drug therapy for adults with rheumatoid arthritis (RA), spondyloarthritis (SpA) including ankylosing spondylitis and psoriatic arthritis, juvenile idiopathic arthritis (JIA), or systemic lupus erythematosus (SLE) undergoing elective total hip (THA) or total knee arthroplasty (TKA).

METHODS

A panel of rheumatologists, orthopedic surgeons specializing in hip and knee arthroplasty, and methodologists was convened to construct the key clinical questions to be answered in the guideline. A multi-step systematic literature review was then conducted, from which evidence was synthesized for continuing versus withholding antirheumatic drug therapy and for optimal glucocorticoid management in the perioperative period. A Patient Panel was convened to determine patient values and preferences, and the Grading of Recommendations Assessment, Development and Evaluation methodology was used to rate the quality of evidence and the strength of recommendations, using a group consensus process through a convened Voting Panel of rheumatologists and orthopedic surgeons. The strength of the recommendation reflects the degree of certainty that benefits outweigh harms of the intervention, or vice versa, considering the quality of available evidence and the variability in patient values and preferences.

RESULTS

The guideline addresses the perioperative use of antirheumatic drug therapy including traditional disease-modifying antirheumatic drugs, biologic agents, tofacitinib, and glucocorticoids in adults with RA, SpA, JIA, or SLE who are undergoing elective THA or TKA. It provides recommendations regarding when to continue, when to withhold, and when to restart these medications, and the optimal perioperative dosing of glucocorticoids. The guideline includes 7 recommendations, all of which are conditional and based on low- or moderate-quality evidence.

CONCLUSION

This guideline should help decision-making by clinicians and patients regarding perioperative antirheumatic medication management at the time of elective THA or TKA. These conditional recommendations reflect the paucity of high-quality direct randomized controlled trial data.

2017 American College of Rheumatology/American Association of Hip and Knee Surgeons Guideline for the Perioperative Management of Antirheumatic Medication in Patients With Rheumatic Diseases Undergoing Elective Total Hip or Total Knee Arthroplasty

OBJECTIVE

This collaboration between the American College of Rheumatology and the American Association of Hip and Knee Surgeons developed an evidence-based guideline for the perioperative management of antirheumatic drug therapy for adults with rheumatoid arthritis (RA), spondyloarthritis (SpA) including ankylosing spondylitis and psoriatic arthritis, juvenile idiopathic arthritis (JIA), or systemic lupus erythematosus (SLE) undergoing elective total hip (THA) or total knee arthroplasty (TKA).

METHODS

A panel of rheumatologists, orthopedic surgeons specializing in hip and knee arthroplasty, and methodologists was convened to construct the key clinical questions to be answered in the guideline. A multi-step systematic literature review was then conducted, from which evidence was synthesized for continuing versus withholding antirheumatic drug therapy and for optimal glucocorticoid management in the perioperative period. A Patient Panel was convened to determine patient values and preferences, and the Grading of Recommendations Assessment, Development and Evaluation methodology was used to rate the quality of evidence and the strength of recommendations, using a group consensus process through a convened Voting Panel of rheumatologists and orthopedic surgeons. The strength of the recommendation reflects the degree of certainty that benefits outweigh harms of the intervention, or vice versa, considering the quality of available evidence and the variability in patient values and preferences.

RESULTS

The guideline addresses the perioperative use of antirheumatic drug therapy including traditional disease-modifying antirheumatic drugs, biologic agents, tofacitinib, and glucocorticoids in adults with RA, SpA, JIA, or SLE who are undergoing elective THA or TKA. It provides recommendations regarding when to continue, when to withhold, and when to restart these medications, and the optimal perioperative dosing of glucocorticoids. The guideline includes 7 recommendations, all of which are conditional and based on low- or moderate-quality evidence.

CONCLUSION

This guideline should help decision-making by clinicians and patients regarding perioperative antirheumatic medication management at the time of elective THA or TKA. These conditional recommendations reflect the paucity of high-quality direct randomized controlled trial data.