Complications after Hand Transplantation: Osteonecrosis of the Hips

Osteonecrosis of the hip is a well-known complication of solid organ transplantation. The prevalence of osteonecrosis in kidney transplants is approximately 3% to 41%. Of the 18 patients transplanted today (24 hands), one of the American patients developed this complication 28 months after the hand transplant, representing a prevalence of 5.5%. Early results of osteonecrosis after hand transplant seem to mimic that after renal transplantation. The authors reported the first case in the world experience of osteonecrosis of hips occurring after hand transplantation. The patient was evaluated through clinical exam and images evaluation. Plain x-ray and MRI (T1∕T2-weighted coronal and T2-weighted sagittal images) of both hips joints were available for evaluation. Plain x-ray (AP view) of hip revealed a lytic process in the right femoral head with surrounding sclerosis. MRI of the right hip revealed: 1) marrow abnormality of the femoral head extending into the intertrochanteric region of the femoral neck; 2) small joint effusion; and 3) subchondral collapse (crescent sign) without flattening of the femoral head. MRI of the left hip revealed: lucent and sclerotic changes in the femoral head with a normal contour. MRI imaging results indicated: 1) FICAT stage II-III osteonecrosis involving the right femoral head and neck; 2) FICAT stage I-II osteonecrosis limited to the left femoral head. The authors' algorithm for osteonecrosis in stage I and II prior to femoral head collapse is timely steroid withdrawal, protective weight bearing, and core decompression with or without vascularized bone grafting. This approach could increase the probability of salvaging the hip without the need for a THA. Stage III, the total hip arthroplasty, (THA) is considered as an indication in transplant patients and stage IV is indicated. The core procedure in the general population could provide excellent pain relief and good functional restoration for stage III, but poses unique problems in transplanted patients on chronic steroid immunosuppression. Protocols in transplanted patients also should involve the aggressive decision of stopping steroids, which may potentially increase the risk of losing the hand. The use of steroid-sparing immunosuppressive regimens must then be strongly considered. In one particular case, the patient chose to have the THA against the core procedure with withdrawal of steroid. Total hip arthroplasty (THA) was performed over the right hip as a treatment option for stage III disease and conservative management over the left hip. Osteonecrosis of the hip is the one complication that can undermine the life-enhancing benefits of hand transplantation. The authors recommended that the program should; 1) screen patients early for asymptomatic disease using bilateral hip MRI within 1 year of transplant and at yearly follow up; 2) minimize use of bolus steroids for treatment of rejection; 3) consider use of the treatment algorithm for stage I and II disease; and ideally 4) contemplate use of steroid-free protocols to reduce risk of not only this but other complications of steroids.