Total hip replacement in renal transplant patients

Abstract

Avascular necrosis of the femoral head creates considerable morbidity in successful renal transplant recipients who are generally young and expect active lifestyles. Total hip replacement is considered the treatment of choice in these patients, but surgeons may be wary because of a supposed increase in the risk of infection and other complications. A review of the literature reveals that cemented hip arthroplasty provides good to excellent functional outcomes for renal transplant patients. Most authors have found that the risk of infection is not increased despite chronic immunosuppression, but the rates of general complications are and should be anticipated and treated. There is a high rate of early failure in these patients because of their young age and diffuse osteopenia as a result of secondary hyperparathyroidism related to the underlying renal disease and chronic steroid use. Recent studies have found that despite decreased bone stock in these patients, porous-coated prostheses are not contraindicated.

What Are the Risk Factors for Infection in Hemiarthroplasties and Total Hip Arthroplasties?

“…We did find alcohol abuse was a clear risk factor for infection, but this does not agree with others' findings [37]; this disagreement could be explained by a sociological difference (prevalence of alcohol abuse in population, highly variable among regions and cultures), or by alcohol abuse (immunosuppressant) in the perioperative period (once the patient is outside the hospital). Finally, while some preoperative conditions are not major risk factors in our case-controlled study, contradictory published data include diabetes [17,20], obesity [20,24,33,35], rheumatoid arthritis [5,6,13,46], and immunosuppressants [28,40].…”

“…Moreover, several of those studies are not primarily focused on infection, although they contain information on infected patients [11,13,17,18,24,36,40,45,46]. Finally, the level of evidence in many of them is low; we have found seven case series (Level of Evidence IV) [3,6,13,16,17,21,40,46] and many nonsystematic reviews (Level of Evidence V) [1,18,23,25,28,34,38,45] and expert opinions (Level of Evidence V) [2,4,30]. We believe it important to learn and identify these risk factors in the individual patient for to check for and minimize risk factors or, when not possible to consider specific prophylactic measures.…”

“…Previous surgery, chronic liver disease, corticoid therapy, and intravenous drug abuse reportedly increase the risk [5,9,16,34,35,46], whereas nonrheumatoid inflammatory arthritis or thalassemia do not [5,45,46]. The data on whether diabetes, obesity, rheumatoid arthritis, or immunosuppressants increase the risk of infection are contradictory [6,13,17,20,24,28,33,35,37,40]. Surgical time [22,33,35,38,44] and inadequate antibiotic prophylaxis [1,41,44] are accepted major risk factors among intraoperative variables.…”

Total hip arthroplasty in steroid-induced osteonecrosis: early functional and radiological outcomes

“…[28][29][30] The infection rate for THA in corticosteroid-induced osteonecrosis ranges from 1.3% to 19% in various studies. 8,26,[31][32][33] In the present study, the infection rate was 6%; this only represents 2 hips, and from our small sample size it is difficult to draw any firm conclusions about the incidence of periprosthetic infection in patients with corticosteroid-induced osteonecrosis compared with the general THA population.…”

“…7 However, other authors have reported acceptable results and low failure rates with the use of cementless femoral stems using modern implant designs and post-transplant immunosuppression protocols, despite the previously mentioned risks. 8,9 Given the potential complications previously associated with THA following renal transplantation, it is possible that patients with osteonecrosis using corticosteroids for other indications may also be at risk.…”