Total hip replacement in a heart transplant recipient with multiple comorbidities: a case report

Background. According to available literature, recipients of solid organ transplants have a progressively increased risk of developing aseptic necrosis and osteoarthritis due to long-term corticosteroid and immunosuppressive therapy. Approximately 5% of transplant recipients develop femoral head avascular necrosis (FHAN). In such cases, the gold standard of treatment is total hip replacement (THR). However, this approach carries a high risk of postoperative infectious complications.

Clinical case. A patient was admitted in Moscow at the City Center for Bone and Joint Endoprosthetics, Botkin Hospital for a planned THR. Six years earlier, she had undergone a heart transplant. Her clinical profi le was further complicated by multiple comorbidities, placing her in a highrisk category for perioperative complications according to the ASA classifi cation.

Conclusion. Despite the high intraoperative and postoperative risks, THR was the only viable option to improve the patient’s quality of life, given the progression of FHAN.

1. Taylor DO, Stehlik J, Edwards LB, Aurora P, Christie JD, Dobbels F, et al. Registry of the International Society for Heart and Lung Transplantation: Twenty-sixth Official Adult Heart Transplant Report-2009. J Heart Lung Transplant. 2009;28(10):1007-22. https://doi.org/10.1016/j.healun.2009.08.014.

2. Egan B, O'Byrne JM, O'Farrell D, O'Donnell A, Wood AE, Neligan MC, et al. Orthopaedic complications following cardiac transplantation. Ir Med J. 1996;89(1):26-7. PMID: 8984077.

3. Bradbury G, Benjamin J, Thompson J, Klees E, Copeland J. Avascular necrosis of bone after cardiac transplantation. Prevalence and relationship to administration and dosage of steroids. J Bone Joint Surg Am. 1994;76(9):1385-8. https://doi.org/10.2106/00004623-199409000-00014.

4. León JL, Resines C, Zafra A. Total hip arthroplasty in heart transplant patients. Acta Orthop Belg. 2007;73(6):720-8. PMID: 18260484.

5. Lieberman JR, Roth KM, Elsissy P, Dorey FJ, Kobashigawa JA. Symptomatic osteonecrosis of the hip and knee after cardiac transplantation. J Arthroplasty. 2008;23:90–96. https://doi.org/10.1016/j.arth.2007.01.006

6. Leonard GR, Davis CM 3rd. Outcomes of total hip and knee arthroplasty after cardiac transplantation. J Arthroplasty. 2012;27(6):889-94. https://doi.org/10.1016/j.arth.2011.

7. Kulak CA, Borba VZ, Kulak Júnior J, Campos DJ, Shane E. Post-transplantation osteoporosis. Arq Bras Endocrinol Metabol. 2010;54(2):143-9. https://doi.org/10.1590/s0004-27302010000200009.

8. Ledford CK, Watters TS, Wellman SS, Attarian DE, Bolognesi MP. Risk versus reward: total joint arthroplasty outcomes after various solid organ transplantations. J Arthroplasty. 2014;29:1548–1552. https://doi.org/10.1016/j.arth.2014.03.027

9. Khubutia MSh, Klyukvin IYu, Slastinin VV, Bogatsky GV, Bogolubsky YuA, Syutkin VE. Hip replacement in female patient after liver transplantation (Case report). Trudnyy patsiyent. 2015; 13 (4): 21–23. (In Russ.).

10. Harris WH. Traumatic arthritis of the hip after dislocation and acetabular fractures: treatment by mold arthroplasty. An end-result study using a new method of result evaluation. J Bone Joint Surg Am. 1969;51(4):737-55. PMID: 5783851.

11. Lieberman JR, Scaduto AA, Wellmeyer E. Symptomatic osteonecrosis of the hip after orthotopic liver transplantation. J Arthroplasty. 2000;15:767–771. https://doi.org/10.1054/arth.2000.6635

12. Marston SB, Gillingham K, Bailey RF, Cheng EY. Osteonecrosis of the femoral head after solid organ transplantation: a prospective study. J Bone Joint Surg Am. 2002;84(12):2145-51. https//doi.org/10.2106/00004623-200212000-00004.

13. Wu C. J., Brekke A.C., Hinton Z.W., Kim B.I., Ryan S.P., Bolognesi M.P., et al. Total joint arthroplasty following solid organ transplants: complication and mid–term outcomes. International Orthopaedics. 2022;46:2735–2745. https//doi.org/10.1007/s00264–022–05597–6

14. Chalmers BP, Ledford CK, Statz JM, Perry KI, Mabry TM, Hanssen AD, et al. Survivorship after primary total hip arthroplasty in solid–organ transplant patients. J Arthroplasty. 2016;31:2525–2529. https://doi.org/10.1016/j.arth.2016.04.012

15. Duplantier NL, Rivere AE, Cohen AJ, Chimento GF. Hip and knee arthroplasty outcomes after abdominal organ transplantation. J Surg Orthop Adv. 2018;27:119–124. PMID: 30084819.

16. Klatt BA, Steele GD, Fedorka CJ, Sánchez AI, Chen AF, et al. Solid organ transplant patients experience high rates of infection and other complications after total knee arthroplasty. J Arthroplasty. 2013;28:960–963. https://doi.org/10.1016/j.arth.2013.02.005

17. Cavanaugh PK, Chen AF, Rasouli MR, Post ZD, Orozco FR, et al. Total joint arthroplasty in transplant recipients: in–hospital adverse outcomes. J Arthroplasty. 2015;30:840–845. https://doi.org/10.1016/j.arth.2014.11.037

18. Klement MR, Penrose CT, Bala A, Green CL, Mather RC 3rd, Wellman SS, et al. Complications of total hip arthroplasty following solid organ transplantation. J Orthop Sci. 2017;22:295–299. https://doi.org/10.1016/j.jos.2016.12.004

19. Upfill–Brown A, Hart CM, Hsiue PP, Burgess K, Chen CJ, Khoshbin A, et al. Revision total hip arthroplasty in solid organ transplant patients: a propensity score–matched cohort study for aseptic and infected revisions. Arthroplast Today. 2022;14:6–13. https://doi.org/10.1016/j.artd.2021.10.007

20. Upfill-Brown A, Wu SY, Hart C, Hsiue PP, Chen CJ, Ponzio D, et al. Revision total knee arthroplasty outcomes in solid organ transplant Patients, a matched cohort study of aseptic and infected revisions. Knee. 2022;34:231-237. https://doi.org/10.1016/j.knee.2021.12.007.

21. Sperling J.W., Cofield R.H. Case reports: shoulder arthroplasty in transplant recipients: a report of five cases. Clin Orthop Relat Res. 2006;442:273–5. https://doi.org/10.1097/01.blo.0000191271.57657.07.

22. Brown N, Ralles S, Kroin E, Adams W, Wu K. Complications of total joint arthroplasty in solid organ transplant patients versus a large control group. J Clin Orthop Trauma. 2020;11:91–95. https://doi.org/10.1016/j.jcot.2019.07.018

23. Navale SM, Szubski CR, Klika AK, Schiltz NK, Desai PP, Barsoum WK. The Impact of Solid Organ Transplant History on Inpatient Complications, Mortality, Length of Stay, and Cost for Primary Total Hip Arthroplasty Admissions in the United States. J Arthroplasty. 2017;32(4):1107-1116.e1. https://doi.org/10.1016/j.arth.2016.10.017.