Bone graft for large bone cysts of the femoral neck in patients on hemodialysis

Mid-Term Outcomes of Primary Hip Replacement in Patients with End-Stage Chronic Renal Disease

Purpose — to evaluate mid-term outcomes of primary hip replacement in patients with end-stage chronic renal disease and to develop an algorithm for selection of surgical tactics and perioperative treatment.

Materials and Methods. The authors evaluated outcomes of primary hip replacement in 45 patients receiving renal substitution therapy and 47 patients without chronic renal disease. Patients with end-stage chronic renal disease (CRD) were divided into two groups: group I included 30 (66.6%) patients receiving chronic hemodialysis (CH) and group II included 15 (33.4%) patients after renal transplantation (RT). Group III of 47 (51.1%) patients without any signs of CRD who underwent hip arthroplasty within relevant period of time was established to evaluate the effectiveness of primary hip replacement. Blood serum Ca2+ and P5+ levels as well as levels of parathyroid hormone (PTH) and 1.25-dihydroxyvitamin D were measured to determine the rate of calcium- phosphoric metabolism disturbance. Multi-spiral CT scans of hip joint were performed to identify bone mineral density and the mean Hounsfield (Hu) value was calculated for which the data was obtained from five various points on the proximal femur and acetabulum. Beta-2 microglobulin (B2M) blood test was performed to confirm amyloid bone disease.

Results. The authors did not observe statistically significant differences for arthroplasty outcomes in patients of group II and III. Patients receiving long-term hemodialysis demonstrated significantly lower parameters of Harris score and Barthel’s index of social adaptation after hip replacement as compared to groups II and III: patients of group I demonstrated outcomes improvement at 19.55%, in group II — at 13.03%, in group III — at 10.15% as compared to preoperative status. Decrease of 1.25-dihydroxyvitamin D below 20,0 mcg results in resorption of cancellous bone in proximal femur and acetabulum along with myopathy of gluteus muscles. Sharp increase of parathyroid hormone level (over 600 pcg/ml) was accompanied by inhibition of osteoblasts proliferation and differentiation resulting in substantial impairment of mineralization.

Conclusion. According to the algorithm suggested by the authors the key parameters that need to be evaluated in preoperative period are parathyroid hormone (PTH) and 1.25-dihydroxyvitamin D. Five-fold increase of PTH (>600 pcg/ml) demands parathyroidectomy as the first stage of treatment to decrease risk of early aseptic loosening of hip prosthesis and development of periprosthetic fracture.

Treatment strategy for amyloid hip arthropathy in long-term hemodialysis patients

BACKGROUND

The number of hemodialysis patients has been progressively increasing in our country. On the other hand, chronic hip arthropathy associated with long-term hemodialysis is a devastating problems affecting patients' quality of life. In our previous study, we proposed a classification system for radiological abnormalities seen in hemodialysis-related hip lesions. The purpose of the study was to propose the surgical strategy for hip disorders caused by long-term hemodialysis.

METHODS

Patients with a history of hemodialysis for more than 10 years, 191 hip lesions in 165 consecutive patients who visited our institute due to hip symptoms. Various abnormalities were identified in 116 out of 191 hips. A retrospective assessment of the patient record and radiographs was performed for the included subjects examining the natural course of the disease process as well as the results of surgical treatment.

RESULTS

Seventy-six hip lesions (69.0%) were conservatively managed at the time of the initial visit. Surgeries were performed for 75 hips (64.7%) during the study period. Among those, surgical treatment was indicated for 40 hips at the time of the initial visit. On the other hand, surgeries were performed for 35 hips during the subsequent follow-up period due to progression of the disease process.

CONCLUSIONS

Based on the analysis of our surgical experiences by the retrospective chart review, we have established a flowchart of the treatment strategy for chronic hip arthropathy in long-term hemodialysis patients.

STUDY DESIGN

This study is retrospective clinical study.

Radiologic case study. Dialysis-related amyloidosis

A 59-year-old woman presented with worsening bilateral hip pain for 6 months. She had been receiving hemodialysis for 12 years.

Special issues involving periprosthetic infection in immunodeficiency patients

Chronic systemic illnesses such as diabetes mellitus, chronic kidney disease (CKD), liver cirrhosis, neoplasia, etc. have been clearly associated with high rates of SWI. However, the exact mechanisms underlying these observations are still under investigation.

Chronic kidney disease (CKD) is a growing problem in our society. Many of these patients will require an arthroplasty and it appears that the prosthetic infection risk for these types of patients is much higher than in the normal population. The risk of complications due to infection seems to be lower in patients with kidney transplants than in patients undergoing haemodialysis. Both prophylaxis and treatment of infection in patients with CKD should be carried out with a strict monitoring of potentially nephrotoxic antibiotics.

The literature on the prognosis and risk of infection in patients with haematopoietic stem cell transplant is scarce and occasionally contradictory. The optimal time for the surgery should be determined by taking into account the immunological state of the patient and should be avoided, as much as possible, during the first year after the HSCT.

Child’s classification system is the most widely used method of stratifying the surgical risk for patients with cirrhosis; the infection appeared to be associated in a statistically significant way with advanced age and a Child B pre-operative classification.

The prevention of prosthetic joint infections in HIV-infected patients should not be significantly different from the prevention for any other patient. Those patients that receive adequate antiretroviral treatment and periodic laboratory control show infection rates and periprosthetic complications that are similar to those for patients not affected by HIV. Therefore, the patient’s level of immunodeficiency is the most important prognostic factor for prosthetic infection.

The particular immunological condition of these patients can lead to infections due to particular microorganisms that immunocompetent patients do not have to deal with. Of all possibilities, because of their frequency and difficulty to treat, infections caused by methicillin-resistant S. aureus and fungus are highlighted.

Radiological classification of hip arthropathy associated with long-term haemodialysis

Various types of hip lesion associated with long-term haemodialysis have been observed. We present a new radiological classification system of haemodialysis-related hip arthropathy. In total, 103 hip lesions were analyzed in 84 patients undergoing haemodialysis for more than ten years. The hip lesions were classified into 3 types; Type I--cystic type with further subdivisions based on cyst location, Type II--arthritic type, and Type III--deformity of the femoral head. Surgery was performed on 60 hips. We believe our classification system assists decision making on behalf of these patients.

Results of total hip arthroplasty for dialysis arthropathy in long-term hemodialysis patients

BACKGROUND

The number of hemodialysis patients has progressively increased in Japan. Among the orthopedic complications in this population, chronic hip arthropathy associated with long-term hemodialysis is one of the most devastating problems. Total hip arthroplasty (THA) is often indicated. However, varying results have been reported for THA in these patients. This study was undertaken to assess the risk-benefit ratio of THA performed in patients with dialysis hip arthropathy.

METHODS

We evaluated 17 patients (19 hips) with dialysis hip arthropathy who underwent THA. The duration of hemodialysis before surgery ranged from 10 to 27 years. Histological examination of the tissue samples revealed accumulation of amyloid deposits in all cases. Three patients died within 2 years after operation; the remaining 14 patients (16 hips) were followed for a minimum of 3 years.

RESULTS

The cumulative survival rate of the prostheses in these 16 hips up to the latest follow-up was 94%. Regarding surgery-related complications, deep infection occurred in one hip, and revision THA was required in one patient with recurrent dislocation and aseptic loosening.

CONCLUSIONS

THA for dialysis hip arthropathy in long-term hemodialysis patients is associated with substantial local and general risks. Despite the substantial risk, THA for this patient population seems to afford reasonably satisfactory results.