How Safe Are TJA for Organ Transplant Patients?

A new study of 182 organ transplant patients who went on to have total joint arthroplasties has provided some heretofore unavailable data on the ability of organ transplant patients to have a total joint arthroplasty. The new multicenter work, “Total joint arthroplasty following solid organ transplants: complications and mid‐term outcomes,” (International Orthopaedics, October 12, 2022) documents outcomes and complications in this patient population.

“Prior work on this topic has been fairly broad,” said co-author Christine J. Wu, M.D., a second-year orthopedic resident at Duke University. “This has ranged from single-institution studies (including at ours, several years ago) to large national database studies regarding outcomes.”

“Studies have varied from single organ transplant retrospective studies to grouping transplant patients together. Interestingly, studies have been overall contradictory as far as if organ transplant patients have worse outcomes or not, and if there is one organ type that has worse outcomes than others.”

The researchers performed a retrospective review from August 2000 to March 2020 of patients who had primary total hip arthroplasties (THA) or total knee arthroplasties (TKA) and who had undergone previous heart, kidney, liver, or lung transplantation. The study group consisted of 119 total hip arthroplasties and 63 total knee arthroplasties. The most common solid organ transplant was renal (39%), then lung (27%), liver (24%), and heart (10%).

“Our implant survivorship was good at 96% at 1 year, 92% at 4 years overall,” said Dr. Wu to OTW. “However, 1-year mortality was ~3% and 4-year mortality was 24%, with lung transplant patients faring the worse and kidney transplant patients faring the best in terms of survivorship. While this is a complex and heterogeneous patient cohort, this is a relatively high mortality rate. These are important considerations for patients and surgeons in the preoperative consultation process.”

Eight patients required revision (4 kidney, 2 lung, 1 heart, 1 liver). Indications for THA revisions were early dislocations, periprosthetic joint infection (2), aseptic loosening (2), and periprosthetic fracture (1). Indications for TKA revisions included periprosthetic joint infection (3) and painful TKA (1). The incidence of periprosthetic joint infection was 2.7% (5 patients total; 3 TKA, 4.8%; 2 THA, 1.7%). Interestingly, lung transplant patients had higher mortality as compared to heart transplant patients (Relative Risk 4.39), kidney (7.98), and liver (7.98) patients.

Past and Current Data at Odds

“We were surprised that the overall rate of periprosthetic joint infection and revisions in our solid organ transplant population was not drastically higher [thab] what has been reported in our institutions’ tertiary referral total joint patient population. We were surprised that our lung patients had such a higher risk of mortality post-TJA than other organ transplant types, especially since other literature has reported renal transplant patients doing worse. Additionally, our institution has some of the best, world-renowned transplant surgeons and transplant medicine faculty, so this was surprising to us.”

“We hope that our study helps guide surgeons who are considering offering TJA to patients with a history of organ transplant, as the outcomes overall regarding arthroplasty were good as implant survivorship and joint-related complications. More frequently postoperative ED visits and hospital admissions were related to organ transplant or other health issues, so possibly postoperative transplant care and/or touchpoints with the orthopedics team (i.e., triage staff, etc.) could be more frequent.”

“Timing between solid organ transplant and TJA is interesting and may warrant further research—should we be encouraging patients with end stage arthritis to pursue TJA as soon as reasonably recovered from an organ transplant?”