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

Total Joint Arthroplasty Is a Viable Treatment Option for Patients With Osteonecrosis and Osteoarthritis After Bone Marrow Transplantation

Background

Long-term survival in patients who receive bone marrow transplantation (BMT) is increasing. However, osteonecrosis and secondary osteoarthritis (OA) of the hip and knee are common complications in this population due to post-transplant steroid treatment to prevent graft vs host disease. The purpose of this study was to evaluate the outcomes of total joint arthroplasty (TJA) in patients with prior BMT and compare them to those of patients undergoing TJA for primary OA.

Methods

Patients with a history of BMT undergoing primary TJA from 2013 to 2021 were retrospectively reviewed. Patients were matched 1:1 by surgical site, sex, age, body mass index, American Society of Anesthesiologists score, and Elixhauser Comorbidity Index to patients undergoing TJA for primary OA. Demographics, intraoperative blood loss, perioperative transfusion requirements, hospital length of stay, 90-day emergency department visits and readmissions, all-cause revisions, and 2-year mortality were compared between cohorts.

Results

There were 17 patients undergoing total knee arthroplasty (TKA) after BMT (TKA-BMT) and 43 patients undergoing total hip arthroplasty (THA) after BMT (THA-BMT). More TKA-BMT and THA-BMT patients were immunosuppressed preoperatively compared to 17 matched TKA-OA and 43 THA-OA patients (P = .018 and P < .001). There were no other significant perioperative differences between BMT and OA groups. Two-year patient and implant survivorship for TKA-BMT and THA-BMT patients were high and not statistically different from TKA-OA and THA-OA cohorts.

Conclusions

TJA after BMT provides satisfactory perioperative and short-term outcomes and is a viable treatment option for patients with osteonecrosis and secondary OA after BMT treatment.

Global mapping of institutional and hospital-based (Level II-IV) arthroplasty registries: a scoping review

PURPOSE

Four joint arthroplasty registries (JARs) levels exist based on the recorded data type. Level I JARs are national registries that record primary data. Hospital or institutional JARs (Level II-IV) document further data (patient-reported outcomes, demographic, radiographic). A worldwide list of Level II-IV JARs must be created to effectively assess and categorize these data.

METHODS

Our study is a systematic scoping review that followed the PRISMA guidelines and included 648 studies. Based on their publications, the study aimed to map the existing Level II-IV JARs worldwide. The secondary aim was to record their lifetime, publications' number and frequency and recognise differences with national JARs.

RESULTS

One hundred five Level II-IV JARs were identified. Forty-eight hospital-based, 45 institutional, and 12 regional JARs. Fifty JARs were found in America, 39 in Europe, nine in Asia, six in Oceania and one in Africa. They have published 485 cohorts, 91 case-series, 49 case-control, nine cross-sectional studies, eight registry protocols and six randomized trials. Most cohort studies were retrospective. Twenty-three per cent of papers studied patient-reported outcomes, 21.45% surgical complications, 13.73% postoperative clinical and 5.25% radiographic outcomes, and 11.88% were survival analyses. Forty-four JARs have published only one paper. Level I JARs primarily publish implant revision risk annual reports, while Level IV JARs collect comprehensive data to conduct retrospective cohort studies.

CONCLUSIONS

This is the first study mapping all Level II-IV JARs worldwide. Most JARs are found in Europe and America, reporting on retrospective cohorts, but only a few report on studies systematically.

Acetabular Insufficiency Fractures in the Setting of Graft vs Host Disease: A Report of Two Cases

We report a case series of 2 patients with unilateral acetabular insufficiency fractures who received allogeneic peripheral blood stem cell transplantation for hematologic malignancies complicated by chronic graft vs host disease. These were managed with uncemented cup and cage total hip arthroplasty and stabilization of posterior column with plating. Osteonecrosis of the acetabulum is an uncommon musculoskeletal complication of chronic graft vs host disease. The orthopedic impact of this disease should not be overlooked. Surgical intervention with this construct can provide necessary stability to improve patient function.

Team approach: Management of osteonecrosis in children with acute lymphoblastic leukemia

With current treatments for acute lymphoblastic leukemia (ALL), the overall prognosis for survival is favorable. Increasing emphasis is placed on recognizing and managing the long-term consequences of ALL and its treatment, particularly involving osteonecrosis. Early osteonecrosis diagnosis and management may improve outcomes and is best accomplished through coordinated teams that may include hematologic oncologists, radiologists, orthopedic surgeons, physical therapists, and the patient and their family. Magnetic resonance imaging is the "gold standard" for diagnosis of early-stage and/or multifocal osteonecrosis. Treatments for osteonecrosis in ALL patients are risk stratified and may include observation, corticosteroid or chemotherapy adjustment, and pharmaceutical or surgical approaches.

Bone Health Management After Hematopoietic Cell Transplantation: An Expert Panel Opinion from the American Society for Transplantation and Cellular Therapy

Bone health disturbances commonly occur after hematopoietic cell transplantation (HCT) with loss of bone mineral density (BMD) and avascular necrosis (AVN) foremost among them. BMD loss is related to pretransplantation chemotherapy and radiation exposure and immunosuppressive therapy for graft-versus-host-disease (GVHD) and results from deficiencies in growth or gonadal hormones, disturbances in calcium and vitamin D homeostasis, as well as osteoblast and osteoclast dysfunction. Although the pathophysiology of AVN remains unclear, high-dose glucocorticoid exposure is the most frequent association. Various societal treatment guidelines for osteoporosis exist, but the focus is mainly on menopausal-associated osteoporosis. HCT survivors comprise a distinct population with unique comorbidities, making general approaches to bone health management inappropriate in some cases. To address a core set of 16 frequently asked questions (FAQs) relevant to bone health in HCT, the American Society of Transplant and Cellular Therapy Committee on Practice Guidelines convened a panel of experts in HCT, adult and pediatric endocrinology, orthopedics, and oral medicine. Owing to a lack of relevant prospective controlled clinical trials that specifically address bone health in HCT, the answers to the FAQs rely on evidence derived from retrospective HCT studies, results extrapolated from prospective studies in non-HCT settings, relevant societal guidelines, and expert panel opinion. Given the heterogenous comorbidities and needs of individual HCT recipients, answers to FAQs in this article should be considered general recommendations, with good medical practice and judgment ultimately dictating care of individual patients. Readers are referred to the Supplementary Material for answers to additional FAQs that did not make the core set.

Elevated Infection and Complication Rates in Patients Undergoing a Primary THA With a History of a PJI in a Prior Hip or Knee Arthroplasty: A Matched Cohort Study

BACKGROUND

There are little data on the outcomes of primary total hip arthroplasties (THAs) in patients with a prior surgically treated hip or knee periprosthetic joint injection (PJI). The goal of this study was to compare the risk of infection in this population with matched controls.

METHODS

We retrospectively reviewed 48 patients whom underwent 50 primary THAs from 2000 to 2014 with a history of a PJI in a total knee arthroplasty or contralateral THA. Thirteen patients (27%) were on chronic antibiotic suppression at the time of primary THA. Mean age was 67 years, and mean body mass index was 35 kg/m². Mean follow-up was 6 years. We 1:3 matched (age, sex, body mass index, cemented vs cementless femoral fixation, and surgical year) these cases to 150 primary THAs. Competing risk analysis, with death as the competing risk, was performed.

RESULTS

The cumulative incidence of PJI with death as a competing risk was 1.5-fold higher in the study cohort (2.0%) compared with matched controls (1.4%) (hazards ratio, 1.5; P = .75). The cumulative incidence of any infection with death as a competing risk was 2-fold higher in the study cohort (4.0%) compared with matched controls (2.1%) (hazards ratio, 2.0; P = .45). However, these were both statistically similar given the relatively small cohort. The overall complication rate, including infections and reoperations, was 17% in the study cohort.

CONCLUSION

Patients undergoing a clean primary THA with a history of a total knee arthroplasty or contralateral THA PJI in another joint have a 2% and 4% risk of PJI and any infection, respectively. Moreover, nearly 1 in 5 patients experience at least 1 complication.

Outcomes of Primary Total Knee Arthroplasty in Patients With Hematopoietic Stem Cell Transplantation

Patients who have undergone hematopoietic stem cell transplantation to treat underlying bone marrow pathology represent a unique and potentially high-risk patient population for total knee arthroplasty (TKA). This study retrospectively reviewed 15 TKA procedures performed on 11 patients with a history of hematopoietic stem cell transplantation. The authors analyzed patient survivorship; clinical outcomes, including complications; and implant survivorship. Mean follow-up was 5 years (range, 2-10 years). Patient survivorship free from mortality was 91% (95% confidence interval, 76%-100%) and 55% (95% confidence interval, 25%-85%) at 2 and 5 years, respectively. Patients who underwent hematopoietic stem cell transplantation for multiple myeloma had a significantly higher 5-year mortality rate (100%) compared with patients who had an underlying diagnosis of non-Hodgkin's lymphoma (0%) (P=.008). Mean Knee Society Score improved to 83 postoperatively (P<.001). Two patients (13%) had postoperative wound healing complications that did not lead to periprosthetic joint infection; however, an additional patient (7%) underwent revision surgery at 5 years for periprosthetic joint infection. Estimated implant survivorship without revision was 80% (95% confidence interval, 60%-100%) at 5 years. Elective primary TKA does not appear to affect survivorship in patients with a history of hematopoietic stem cell transplantation. These patients have modest clinical outcomes, higher complication rates as a result of delayed wound healing, and poorer implant survivorship compared with historical control subjects. [Orthopedics. 2017; 40(5):e774-e778.].