Fast-Track Hip and Knee Arthroplasty in Patients with Solid Organ Transplantation: What Do I Need to Pay Special Attention To?

With evolving surgical techniques and improving pharmacological immunosuppressive therapies, the number of patients who received a solid organ transplant (SOT) is increasing. In descending order, kidney, liver, heart, pancreas, and intestines are commonly transplanted solid organs, with renal transplants comprising more than 60% of all SOT in 2020 [1]. There are 5-year survival rates of more than 90% after renal or liver transplantation, and around 220,000 recipients of a kidney transplant lived in the United States in 2020 [1]. Hence, it is not surprising that meanwhile patients with SOT account for up to 0.17% of all patients treated with total joint arthroplasty (TJA) [2, 3]. Osteonecrosis of the femoral head or condyles especially following high-dose corticosteroid therapy after transplantation is a specific indication in these patients, as well as pathological fractures due to changes in the bone metabolism [4]. But with the aforementioned optimized therapies and survival rates, end-stage degenerative joint disease today is the most common reason for TJA also in the SOT patient cohort [5]. Despite satisfying results with mostly good to excellent functional and patient-related outcome measures, there is still a higher risk of complications in patients with SOT after TJA [2, 4, 6, 7]. In order to improve this situation as part of a modern Fast-Track Arthroplasty program, we want to summarize and emphasize the special precautions that have to be taken when treating SOT patients with TJA. Firstly, patients with SOT who present for TJA are often younger and more often male compared to other patients with TJA [2]. Nevertheless, the higher incidence of comorbidities like hypertension, complicated diabetes mellitus, deficiency anemia, fluid and electrolyte disorders, and coagulopathy in the SOT patients leads to typical perioperative complications like acute renal failure and the need for transfusion [2, 5]. Hence, it is recommended to have an all-time readily available consultation with each respective medical transplant service [4]. Especially a thorough interdisciplinary (orthopedics/transplant team) preoperative risk stratification has to be employed that usually differs between high-risk SOT patients, for example, lung, heart, and others, with lower risk, for example, kidney and liver [8]. If needed, there should be further preoperative investigations like serum levels of immunosuppressive drugs, echocardiography, cardiac catheterization, and pulmonary function testing [8]. According to the center-specific and patient individual preference, the perioperative treatment should be led by the orthopedic or transplant specialists [5, 8]. In general, antihypertensive and immunosuppressive medications should not be discontinued in the perioperative period [5, 8]. The only exception is sirolimus since the administration of the drug is associated with a higher risk for perioperative infections [9]. There should be an adapted blood patient management especially for patients after heart and lung transplantation as this cohort has been investigated with transfusion rates of 75% to 67%, respectively [5]. A hematocrit of 25% and less with symptoms like tachycardia, orthostasis, and light-headedness is recommended as a transfusion trigger [5]. The perioperative administration of tranexamic acid in order to reduce the risk of excessive bleeding as an off-label use can be recommended with some good evidence in patients with liver transplant [10]. With other SOT, the absolute contraindications for tranexamic acid and a possibly decreased renal function have to be respected [11]. The risk for perioperative infections in SOT patients is significantly higher than that in other patients [5, 8]. Some authors even argue that it is the most common indication for revision TJA surgery in these patients [12]. Although the immunocompromised SOT patients should theoretically be more susceptible to atypical infections caused by anaerobes, mycobacteria, and fungals, Gram-positive bacteria are the most common reason for periprosthetic joint infections in SOT and non-SOT patients [8]. Therefore, the standard perioperative antibiotic prophylaxis regimen with three doses of a second-generation cephalosporine is also recommended in patients with SOT [8]. Special attention should be paid to SOT patients with a known cytomegalovirus infection since they have higher susceptibility to bacterial infection where a prolonged antibiotic prophylaxis should be discussed on an individual basis [8]. Furthermore, the use of additional PJI prevention strategies like staphylococcus decolonization, intraoperative betadine wash, preoperative weight optimization, and strict perioperative blood-glucose-level control is highly recommended [7]. Finally in the case of a suspected PJI, there should be always microbiological testing also for atypical pathogens [8]. Another essential part of a modern Fast-Track Arthroplasty program is the immediate postoperative mobilization of the patient. In the SOT patients, this can be complicated by preexisting comorbidities like sarcopenia, osteoporosis, and polyneuropathy that are either caused by the underlying disease or as side effects of the immunosuppressive medication [4]. That is why we recommend a preoperative rehabilitation program with weight resistance training and early evaluation regarding orthotics and walking aids to reduce these risk factors and negative influence of polyneuropathy. Furthermore, especially renal transplant patients planned for an THA should be evaluated for their bone density/osteoporosis since aseptic loosening of the femoral component and periprosthetic fractures seems to be a complication mainly seen in this group of patients [3, 8]. The decreased cardiopulmonary and hepatorenal function in SOT patients needs a profoundly planned and cautious anesthesia. Regional procedures like spinal anesthesia or peripheral nerve blocks can reduce the systemic administration of anesthetic and pain medication [8]. Multimodal pain regimens are recommended but special attention has to be paid to avoid contraindicated drugs (e.g., NSAIDs in renal transplant) and to individually adapt dosages [8]. This also applies to the antithrombotic prophylaxis medication where low-molecular-weight heparin can be used accordingly to the locally valid guidelines despite a mildly elevated risk of thromboembolic events [7, 8]. Since some authors report a significantly longer postoperative length of stay in SOT patients with lower likelihood of being discharged home, hospital social services should be involved early and instructed accordingly [5, 6].