Orthopedic Surgery

Feb. 16, 2024

At Mayo Clinic in Florida, orthopedic surgeons and a transplant specialist have collaborated to improve total hip arthroplasty (THA) and total knee arthroplasty (TKA) for patients who have had a solid organ transplant (SOT). These patients have some of the most medically complex cases; thus, this team's focus is to optimize their joint replacement perioperative course and protect the transplanted organ.

Cameron K. Ledford, M.D., orthopedic surgeon at Mayo Clinic in Florida, and colleagues authored a 2022 review article about their team's THA and TKA strategies for these patients plus relevant risks and benefits.

"In the past few decades, patients undergoing solid organ transplant are living longer and being more active," says Dr. Ledford. "As these patients age, they may develop symptomatic hip and knee degenerative joint disease.

"Given the increasing success and longevity of solid organ transplants, we're seeing more of these patients present for THA and TKA. It takes meticulous multidisciplinary optimization and close surveillance by our teams to ensure the best possible outcomes."

Managing this population's risks

The challenge with patients who have undergone SOT is that they are immunocompromised.

"Transplant patients require anti-rejection medication, which suppresses the immune system," says Dr. Ledford. "Subsequently, these patients inherently have increased risk of poor wound healing, infection or medical complications."

Although TKA and THA top the list of successful orthopedic surgeries, according to a 2018 Journal of Orthopaedics publication, the risks remain high for patients who have undergone SOT surgery. Due to the risks, not all hospitals have chosen to perform joint replacements for this population.

Mayo Clinic performs a considerable number of SOTs. When a patient who has had a SOT at Mayo Clinic needs a THA or TKA, they often turn to Mayo again. This allows the orthopedic surgeon to speak directly to the medical transplant physicians who actively manage post-transplant care for collaboration.

"Make no mistake — these patients have a history of organ failure, so their medical fitness is not the same as others who have not had a transplant," says Dr. Ledford. "Thus, fully assessing medical and physical capacity to withstand THA or TKA surgery and recovery is critical for both patients and surgeons."

Dr. Ledford and colleagues also are keenly aware that not all SOTs are alike: A kidney and a liver transplant, for example, are not the same. He and his team are knowledgeable about the variability and risk mitigation for each type of SOT.

Timing of TKA or THA

No consensus guideline exists regarding ideal time to perform joint replacement for individuals with SOT.

"In general, we want the transplanted organ functioning, free from rejection and the remaining systems stable before we indicate them for joint replacement," he says. "The most ideal timing appears to be approximately one year from transplant."

Ultimately, the orthopedic surgeon, transplant medical physician and patient decide on appropriate THA or TKA timing based on the individual's medical status and need.

Expectations for this population

Patients who have undergone a SOT and then seek a THA or TKA need to be well informed to set their expectations before a joint replacement, including:

• Anti-rejection medication taper. Patients must optimize anti-rejection medications prior to joint surgery, under careful supervision of the medical transplant physician.
• Rapid dismissal. Because of improved joint arthroplasty preparations in general, hospital length of stay has dramatically shortened. All patients who have previously had a SOT will have a multidisciplinary evaluation available post-surgically. Some patients leave the hospital the day of surgery; others stay overnight.
• Longer healing. Due to immunosuppressed status, patients must be informed of potential wound healing delays. This may require use of additional measures such as prophylactic antibiotics and wound care.
• Adherence to appointment regimen. Because of higher risk and necessary monitoring, patients must be dedicated to attending all medical appointments.

Despite the risks, these patients can expect positive results, as joint-specific outcome scores and satisfaction of those who have had a SOT are similar to those of patients who have not had a transplant.

THA or TKA referral for patients with SOT

Whether a THA or TKA is performed locally or referred to a medical center with specialized expertise can be variable. This decision should be made on the ability of the local surgeon and healthcare system to address the patient's medical needs post-transplant and the surgical complexities for this unique population.

In addition to patients who have had a SOT at Mayo Clinic, the medical center welcomes referrals from any institution and desires collaboration with the patient's transplant medical team. A potential advantage of referral to Mayo Clinic for joint replacement is an integrated multidisciplinary team to optimize the surgery and manage any arising medical issues, says Dr. Ledford.

Accepting patients for THA or TKA who have previously had a SOT is not new for Mayo Clinic, yet today the pathway is clearer for managing their health before, during and after surgery.

"We undertake a holistic approach to give our patients who've had transplants the best chance of success," he says. "Now the understanding of how to manage these patients is more refined. We truly believe the benefits of pain relief, function and improved quality of life from THA or TKA outweigh the higher risks for the unique population."

For more information

Ledford CK, et al. Total hip and knee arthroplasty in solid organ transplant patients: Perioperative optimization and outcomes. Journal of the American Academy of Orthopaedic Surgeons. 2022;30:1157.

Varacallo M, et al. Joint perception and patient perceived satisfaction after total hip and knee arthroplasty in the American population. Journal of Orthopaedics. 2018;15:495.

Refer a patient to Mayo Clinic.