Osteonecrosis after Allogeneic Bone Marrow Transplantation

Abstract

Osteonecrosis after bone marrow transplantation is usually severe. Most patients develop acute and chronic graft-versus-host disease requiring a high dose of steroids for a long period of time. Generally ineffective nonoperative treatment in the past has resulted in treatment primarily with total hip arthroplasty (THA). We asked whether THA (1) reliably improved functional status, (2) led to more complications, and (3) THA after bone marrow transplantation was as durable as THA for idiopathic ON. We retrospectively reviewed 77 patients (123 hips) with osteonecrosis. The mean age at surgery was 33 years (range, 15.7-56 years). We performed all arthroplasties with an alumina ceramic bearing coupled with an alumina head 32 mm in diameter. The minimum followup was 2 years (mean, 9.2 years; range, 2-26 years). We documented seven revisions: three for late septic loosening, four for late aseptic loosening. Considering loosening of any component as the end point, the survivorship was 74.8% (range, 58.7%-90.9%) at 10 years. In this difficult situation, we believe the results acceptable. Septic loosening affecting this specific population has to be considered a serious event.

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

“…This is consistent with the numbers reported in similar studies of patients with prior solid organ transplants undergoing elective joint arthroplasty [3,[5][6][7][8]. In addition, this complication rate is consistent with those of two other studies reporting rates of 4.5% to 7.4% in patients with THAs for AVN after hematopoietic stem cell transplantation [1,12]. The higher rate of perioperative complications in patients with hematopoietic stem cell transplants undergoing elective hip arthroplasty is concerning and should be discussed with patients before surgery.…”

“…Among the risks of degenerative joint disease that increases with age, the increased risk of AVN from immunosuppressive medications and/or graft versus host disease, and the growing number of patients undergoing stem-cell transplantation, it seems likely that the number of such patients undergoing elective THA will increase. However, with a high incidence of medical comorbidities, immunosuppressive regimens, and often diminished numbers of circulating hematopoietic cell lines, these patients undergoing THA are at a potentially greater risk for perioperative complications [2,11,12]. We sought to determine the mortality, complications, and implant survivorship in this difficult-to-treat cohort undergoing THA at our institution.…”

“…Given these demographics, more patients with hematopoietic stem cell transplants are likely to have degenerative joint disease develop. Graft versus host disease, a known complication of hematopoietic stem cell transplantation, is a known risk factor for avascular necrosis (AVN) of the hip [1,12]. Compounding the substantial risk for AVN are immunosuppressive therapies, including corticosteroids, used to treat graft versus host disease or other hematopoietic malignancies [1].…”

“…With multiple medical comorbidities, immunosuppressive therapy regimens, and frequently diminished levels of erythrocytes, leukocytes, and platelets, patients receiving hematopoietic stem cell transplantation can be at increased risk of perioperative medical and surgical complications, including deep periprosthetic joint infection [11,12]. Historical studies have shown a high risk of complications and infections in such patients undergoing surgical reconstruction of proximal femoral pathologic fractures [2,4,9,12].…”

“…Historical studies have shown a high risk of complications and infections in such patients undergoing surgical reconstruction of proximal femoral pathologic fractures [2,4,9,12]. Although some studies have analyzed the perioperative outcomes, patient mortality, and implant survivorship in recipients of solid organ transplants undergoing THAs and/or TKAs [3,[5][6][7][8], there is a paucity of studies regarding elective THA outcomes in recipients of hematopoietic stem cell transplants [1,12].…”