• View in gallery

    Flow chart illustrating the literature search.

  • View in gallery

    Risk-of-bias graph.

  • View in gallery

    Risk-of-bias summary (+, low risk of bias; −, high risk of bias; ?, unclear or unknown risk of bias).

  • View in gallery

    Forest plot of comparison of length of surgery (in minutes). CKD, chronic kidney dysfunction.

  • View in gallery

    Forest plot of comparison of length of stay (in days). CKD, chronic kidney dysfunction.

  • View in gallery

    Forest plot of comparison of postoperative infection rate. CKD, chronic kidney dysfunction; M-H, Mantel-Haenszel.

  • View in gallery

    Forest plot of comparison of deep vein thrombosis. CKD, chronic kidney dysfunction; M-H, Mantel-Haenszel.

  • View in gallery

    Forest plot of comparison of pulmonary embolism. CKD, chronic kidney dysfunction; M-H, Mantel-Haenszel.

  • View in gallery

    Forest plot of comparison of readmission. CKD, chronic kidney dysfunction; M-H, Mantel-Haenszel.

  • View in gallery

    Forest plot of comparison of revision. CKD, chronic kidney dysfunction; M-H, Mantel-Haenszel.

  • View in gallery

    Forest plot of comparison of mortality. CKD, chronic kidney dysfunction; M-H, Mantel-Haenszel.

  • 1. 

    Shukla R, Singh M & Jain RK et al.: Functional outcome of bipolar prosthesis versus total hip replacement in the treatment of femoral neck fracture in elderly patients. Malays Orthop J 11: 1, 2017.

    • Crossref
    • PubMed
    • Web of Science
    • Search Google Scholar
    • Export Citation
  • 2. 

    Miric A, Inacio MCS & Namba RS: Can total knee arthroplasty be safely performed in patients with chronic renal disease? Acta Orthop 85: 71, 2014.

    • Crossref
    • PubMed
    • Web of Science
    • Search Google Scholar
    • Export Citation
  • 3. 

    Sharma V, Awasthi B & Kumar K et al.: Outcome analysis of hemiarthroplasty vs. total hip replacement in displaced femoral neck fractures in the elderly. J Clin Diagn Res 10: RC11, 2016.

    • Web of Science
    • Search Google Scholar
    • Export Citation
  • 4. 

    Li Q, Dai B & Yao Y et al.: Chronic kidney dysfunction can increase the risk of deep vein thrombosis after total hip and knee arthroplasty. Biomed Res Int 2017: 8260487, 2017.

    • PubMed
    • Web of Science
    • Search Google Scholar
    • Export Citation
  • 5. 

    Tan TL, Kheir MM & Tan DD et al.: Chronic kidney disease linearly predicts outcomes after elective total joint arthroplasty. J Arthroplasty 31 (suppl): 175, 2016.

    • Crossref
    • PubMed
    • Web of Science
    • Search Google Scholar
    • Export Citation
  • 6. 

    Schmidt AH, Leighton R & Parvizi J et al.: Optimal arthroplasty for femoral neck fractures: is total hip arthroplasty the answer. J Orthop Trauma 23: 428, 2009.

    • Crossref
    • PubMed
    • Web of Science
    • Search Google Scholar
    • Export Citation
  • 7. 

    Zhang YL, Chen S & Ai ZS et al.: Osteonecrosis of the femoral head, nonunion and potential risk factors in Pauwels grade-3 femoral neck fractures: a retrospective cohort study. Medicine (Baltimore) 95: e3706, 2016.

    • Crossref
    • Web of Science
    • Search Google Scholar
    • Export Citation
  • 8. 

    Wang C, Xu GJ & Han Z et al.: Correlation between residual displacement and osteonecrosis of the femoral head following cannulated screw fixation of femoral neck fractures. Medicine (Baltimore) 94: e2139, 2015.

    • Crossref
    • Web of Science
    • Search Google Scholar
    • Export Citation
  • 9. 

    Zuo WM, Yang L & Wang JJet al:. Middle-and short-term follow-up of biological artificial femoral head replacement in elderly patients with proximal femoral fracture of chronic renal disease. Chin J Tissue Eng Res 15: 2315, 2018.

    • Search Google Scholar
    • Export Citation
  • 10. 

    Engh CA, McAuley JP & Sychterz CJ et al.: The accuracy and reproducibility of radiographic assessment of stress-shielding. A postmortem analysis. J Bone Joint Surg Am 82: 1414, 2000.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11. 

    Dorr LD, Absatz M & Gruen TA et al.: Anatomic porous replacement hip arthroplasty: first 100 consecutive cases. Semin Arthroplasty 1: 77, 1990.

  • 12. 

    Howell SJ, Sear YM & Yeates Det al. Risk factors for cardiovascular death after elective surgery under general anaesthesia. Br J Anaesth 80: 14, 1998.

  • 13. 

    Wattanakit K, Cushman M & Stehman-Breen C et al.: Chronic kidney disease increases risk for venous thromboembolism. J Am Soc Nephrol 19: 135, 2008.

    • Crossref
    • PubMed
    • Web of Science
    • Search Google Scholar
    • Export Citation
  • 14. 

    Gruen TA, McNeice GM & Amstutz HC: “Modes of failure” of cemented stem-type femoral components: a radiographic analysis of loosening. Clin Orthop Relat Res 141: 17, 1979.

    • Search Google Scholar
    • Export Citation
  • 15. 

    Nagoya S, Nagao M & Takada J et al.: Efficacy of cementless total hip arthroplasty in patients on long-term hemodialysis. J Arthroplasty 20: 66, 2005.

  • 16. 

    Li WC, Shih CH & Ueng SW et al.: Uncemented total hip arthroplasty in chronic hemodialysis patients. Acta Orthop 81: 178, 2010.

    • Crossref
    • PubMed
    • Web of Science
    • Search Google Scholar
    • Export Citation
  • 17. 

    Rogmark C, Fenstad AM & Leonardsson O et al.: Posterior approach and uncemented stems increases the risk of reoperation after hemiarthroplasties in elderly hip fracture patients. Acta Orthop 85: 18, 2014.

    • Crossref
    • PubMed
    • Web of Science
    • Search Google Scholar
    • Export Citation
  • 18. 

    Sunday JM, Guille JT & Torg JS: Complications of joint arthroplasty in patients with end-stage renal disease on hemodialysis. Clin Orthop Relat Res 397: 350, 2002.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 19. 

    Koebnick C, Langer-Gould AM & Gould MK et al.: Sociodemographic characteristics of members of a large, integrated health care system: comparison with US Census Bureau data. Perm J 16: 37, 2012.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20. 

    McCleery MA, Leach WJ & Norwood T: Rates of infection and revision in patients with renal disease undergoing total knee replacement in Scotland. J Bone Joint Surg Br 92: 1535, 2012.

    • Web of Science
    • Search Google Scholar
    • Export Citation
  • 21. 

    Wang TI, Hung SH & Su YP et al.: Noncemented total hip arthroplasty for osteonecrosis of the femoral head in elderly patients. Orthopedics 36: e271, 2013.

    • PubMed
    • Web of Science
    • Search Google Scholar
    • Export Citation
  • 22. 

    Bozic KJ, Lau E & Kurtz S et al.: Patient-related risk factors for postoperative mortality and periprosthetic joint infection in medicare patients undergoing TKA. Clin Orthop 470: 130, 2012.

    • Crossref
    • PubMed
    • Web of Science
    • Search Google Scholar
    • Export Citation
  • 23. 

    Bozic KJ, Lau E & Kurtz S et al.: Patient related risk factors for periprosthetic joint infection and postoperative mortality following total hip arthroplasty in Medicare patients. J Bone Joint Surg Am 94: 794, 2012.

    • Crossref
    • PubMed
    • Web of Science
    • Search Google Scholar
    • Export Citation
  • 24. 

    Lejus C, Desdoits A & Lambert C et al.: Preoperative moderate renal impairment is an independent risk factor of transfusion in elderly patients undergoing hip fracture surgery and receiving low-molecular-weight heparin for thromboprophylaxis. J Clin Anesth 24: 378, 2012.

    • Crossref
    • PubMed
    • Web of Science
    • Search Google Scholar
    • Export Citation
  • 25. 

    Sonaje JC, Meena PK & Bansiwal RC et al.: Comparison of functional outcome of bipolar hip arthroplasty and total hip replacement in displaced femoral neck fractures in elderly in a developing country: a 2-year prospective study. Eur J Orthop Surg Traumatol 28: 493, 2018.

    • Crossref
    • Search Google Scholar
    • Export Citation

Can Total Joint Arthroplasty Be Safely Performed in Patients with Chronic Kidney Disease?

Kai Sun MD, Meng Fan PhD, and Wenxue Jaing PhD
View More View Less

Background

Patients suffering from chronic kidney disease are at greater risk of perioperative and postoperative complications. There is no systematic review study demonstrating whether total joint arthroplasty can be safely performed in patients with chronic kidney disease.

Methods

A literature search was performed in the PubMed, Embase, Web of Science, China National Knowledge Infrastructure, Wanfang, and Cochrane Library databases for information from the earliest date of data collection to September of 2018. Studies comparing the perioperative and postoperative outcomes of no–chronic kidney dysfunction (CKD) patients with those of CKD patients were included. Statistical heterogeneity was quantitatively evaluated by means of the χ2 test, with significance set at P < .10 or I 2 > 50%.

Results

Three articles consisting of 38,209 patients were included (35,363 no-CKD patients and 2,846 CKD patients). The results showed that CKD was related to a greater increase in postoperative infection rate, deep vein thrombosis, readmission, and mortality (P < .1). No differences in length of surgery, length of stay, pulmonary embolism, or revision were observed (P > .10).

Conclusions

Compared with no-CKD patients, CKD patients demonstrated an increased risk of perioperative and postoperative complications.

Background

Patients suffering from chronic kidney disease are at greater risk of perioperative and postoperative complications. There is no systematic review study demonstrating whether total joint arthroplasty can be safely performed in patients with chronic kidney disease.

Methods

A literature search was performed in the PubMed, Embase, Web of Science, China National Knowledge Infrastructure, Wanfang, and Cochrane Library databases for information from the earliest date of data collection to September of 2018. Studies comparing the perioperative and postoperative outcomes of no–chronic kidney dysfunction (CKD) patients with those of CKD patients were included. Statistical heterogeneity was quantitatively evaluated by means of the χ2 test, with significance set at P < .10 or I2 > 50%.

Results

Three articles consisting of 38,209 patients were included (35,363 no-CKD patients and 2,846 CKD patients). The results showed that CKD was related to a greater increase in postoperative infection rate, deep vein thrombosis, readmission, and mortality (P < .1). No differences in length of surgery, length of stay, pulmonary embolism, or revision were observed (P > .10).

Conclusions

Compared with no-CKD patients, CKD patients demonstrated an increased risk of perioperative and postoperative complications.

Total joint arthroplasty (TJA) is an effective surgical procedure that can improve the quality of life and function of patients affected by end-stage arthritis of the hip or knee.1,2 Chronic renal insufficiency generally has a long history, and advanced uremia patients have a long history of hemodialysis or peritoneal dialysis, with varying degrees of anemia and malnutrition. It is generally believed that some patients with hyperkalemia and other medical diseases have an increased risk of surgery and postoperative complications.2-5 Disease in these patients is often accompanied by severe osteoporosis, and joint arthroplasty is prone to lack of control, postoperative loosening, head and neck screw cutting, and other complications leading to surgical failure.

Chronic kidney dysfunction (CKD) is a clinical situation with a rising prevalence, from 10% in 1994 to 13% in 2004 in the United States.6,7 It is especially common among elderly patients undergoing TJA. The degree of renal dysfunction in CKD is graded in five stages. Stages 3 to 5 represent individuals who have lost at least half of normal adult renal function. Impaired renal function of this degree is related to the dysfunction of multiple organ systems, and its effect on the health of an individual is well documented.4,9-11

There is no comparative study demonstrating advantages of nonchronic kidney disease and chronic kidney disease treatment of TJA. Furthermore, the influence of TJA treatment perioperatively or postoperatively for patients with CKD is unknown. Consequently, it is necessary to perform a comprehensive systematic review and meta-analysis that consists of all the studies to address the question of whether TJA is safe for patients with chronic kidney disease. Therefore, the purpose of this study was to evaluate the association between no-CKD, CKD, and perioperative and postoperative outcomes.

Methods

Literature and Search Strategy

Two different reviewers independently searched electronic databases (ie, PubMed, Embase, Web of Science, China National Knowledge Infrastructure, Wanfang, and Cochrane Library) for information from database inception to September of 2018. The following related terms were searched: primary unilateral total knee arthroplasty (TKA); total hip arthroplasty (THA) patients with chronic kidney disease; and meta-analysis. The search strategy was constructed by combining the above terms with “AND” or “OR.” No restrictions were imposed on the language of studies. We had also screened reference lists of retrieved articles so that relevant studies were not missed. This retrospective study was approved by the Institutional Review Board of Tianjin First Center Hospital.

Study Selection Criteria

Two different reviewers independently assessed the retrieved articles to determine whether they met the inclusion criteria. In case of disagreements, a third reviewer was involved in the discussion until a consensus was reached. The criteria for inclusion of articles selected for detailed review included first-procedure TKA and THA. In addition, all TJAs were performed using the direct transgluteal approach. Exclusion criteria included case-control studies, animal studies, cadaver studies, single case reports, comments, letters, editorials, protocols, guidelines, publications based on surgical registries, and review papers. For clinical studies, inclusion of fewer than 10 patients was the exclusion criterion. The following baseline characteristic were collected: age, sex, and body mass index. The degree of renal dysfunction in CKD is graded in five stages. Normal kidney function was defined as estimated glomerular filtration rate (eGFR) greater than or equal to 90 mL/min per 1.73 m2; mildly decreased kidney function was defined as eGFR between 60 and 89 mL/min per 1.73 m2; and stage 3 to 4 CKD was defined as eGFR between 15 and 59 mL/min per 1.73 m2.

The patients were divided into the no-CKD and CKD groups. We analyzed the study type (randomized controlled trial, retrospective review, cohort studies) and treatment methods described. The sample size in each study was extracted from the information available. Any complications of treatment, overall length of stay, length of surgery, deep vein thrombosis, pulmonary embolism, infection, readmission, revision, and mortality rates were considered.

Data Extraction and Quality Assessment

Two different reviewers independently performed data extraction and methodologic quality assessment. Data extracted from the included studies consisted of authors, publication date, study design, number of patients, and outcome data in both no-CKD and CKD groups. The outcome measures consisted of the length of stay, length of surgery, deep vein thrombosis, pulmonary embolism, infection, readmission, revision rate, and mortality rate. The methodologic quality of a study was evaluated in seven domains, including sequence generation, allocation concealment, participants' blinding, assessors' blinding, incomplete data, selective reporting, and other bias. Each included study could be considered as being unclear or at low risk or high risk of bias for each domain according to the Cochrane Handbook 5.1.0.

Statistical Analysis

Statistical analyses were performed using Review Manager Software 5.3. For dichotomous outcomes, odds ratio (OR) with 95% CI (CI) were calculated to estimate a pooled average difference between the no-CKD and CKD groups. Weighted mean differences (WMD) and 95% CIs were calculated for continuous outcomes. Statistical heterogeneity was evaluated quantitatively by means of the χ2 test, with significance set at P < .10 or I2 > 50%. The data were presented in the form of Forest plots. Publication bias was assessed by funnel plot.

Results

Literature Search

The retrieval strategy is displayed in Figure 1. A total of 65 potentially eligible citations were searched online. After removing duplicates, browsing title and abstract, and reviewing full text, three articles met the inclusion and exclusion criteria.2,4,9 In three articles, the outcomes for a total of 38,209 patients were described, of which 35,363 no-CKD patients were treated with TJA, and 1,717 CKD patients were treated with TJA. The detailed characteristics of the studies are listed in Table 1. All three articles were designed as retrospective case reviews of hospital admissions. None used randomization. All articles were written by orthopedic units. The remainder included collaboration of all the specialities mentioned above. No other apparent bias was found among the included studies. Figures 2 and 3 show a summary of the risk of bias.

Figure 1.
Figure 1.

Flow chart illustrating the literature search.

Citation: Journal of the American Podiatric Medical Association 111, 5; 10.7547/20-007

Table 1.

Characteristics of the Included Studies

Table 1.
Figure 2.
Figure 2.

Risk-of-bias graph.

Citation: Journal of the American Podiatric Medical Association 111, 5; 10.7547/20-007

Figure 3.
Figure 3.

Risk-of-bias summary (+, low risk of bias; −, high risk of bias; ?, unclear or unknown risk of bias).

Citation: Journal of the American Podiatric Medical Association 111, 5; 10.7547/20-007

Results of the Meta-Analysis

Two trials reported the details of length of surgery. The results showed no significant difference between the CKD and no-CKD groups with regard to length of surgery (WMD = −0.33; 95% CI, −0.56 to −0.51; P = .92), without significant heterogeneity (I2 = 48%; P = .17) (Fig. 4).

Figure 4.
Figure 4.

Forest plot of comparison of length of surgery (in minutes). CKD, chronic kidney dysfunction.

Citation: Journal of the American Podiatric Medical Association 111, 5; 10.7547/20-007

Two studies reported the hospital days, and the results showed no significant difference between CKD and no-CKD patients (WMD = −0.00; 95% CI, −0.02 to 0.02; P = 1.00), without significant heterogeneity (I2 = 44%; P = .18) (Fig. 5). Two studies reported the postoperative infection rate and showed that CKD was related to a greater increase in postoperative infection (OR, 0.71; 95% CI, 0.51–0.99; P = .04), without significant heterogeneity (I2 = 0%; P = .68) (Fig. 6). Three studies reported deep vein thrombosis and showed that CKD was related to a greater increase in deep vein thrombosis complications (OR, 0.64; 95% CI, 0.47–0.88; P = .006), without significant heterogeneity (I2 = 0%; P = .52) (Fig. 7).

Figure 5.
Figure 5.

Forest plot of comparison of length of stay (in days). CKD, chronic kidney dysfunction.

Citation: Journal of the American Podiatric Medical Association 111, 5; 10.7547/20-007

Figure 6.
Figure 6.

Forest plot of comparison of postoperative infection rate. CKD, chronic kidney dysfunction; M-H, Mantel-Haenszel.

Citation: Journal of the American Podiatric Medical Association 111, 5; 10.7547/20-007

Figure 7.
Figure 7.

Forest plot of comparison of deep vein thrombosis. CKD, chronic kidney dysfunction; M-H, Mantel-Haenszel.

Citation: Journal of the American Podiatric Medical Association 111, 5; 10.7547/20-007

Two studies reported pulmonary embolism and showed no significant difference between CKD and no-CKD groups (OR, 0.88; 95% CI, 0.53–1.47; P = .63), without significant heterogeneity (I2 = 0%; P = .55) (Fig. 8). Two studies reported readmission and showed that CKD was related to a greater increase in readmission (OR, 0.41; 95% CI, 0.34–0.48; P < .0001), without significant heterogeneity (I2 = 0%; P = .52) (Fig. 9). Two studies reported revision and showed no significant difference between CKD and no-CKD groups (OR, 1.09; 95% CI, 0.81–1.47; P = .56), without significant heterogeneity (I2 = 0%; P = .57) (Fig. 10). Two studies reported the mortality and showed that CKD was related to a greater increase in mortality (OR, 0.51; 95% CI, 0.42–0.62; P < .0001), without significant heterogeneity (I2 = 0%; P = .70) (Fig. 11).

Figure 8.
Figure 8.

Forest plot of comparison of pulmonary embolism. CKD, chronic kidney dysfunction; M-H, Mantel-Haenszel.

Citation: Journal of the American Podiatric Medical Association 111, 5; 10.7547/20-007

Figure 9.
Figure 9.

Forest plot of comparison of readmission. CKD, chronic kidney dysfunction; M-H, Mantel-Haenszel.

Citation: Journal of the American Podiatric Medical Association 111, 5; 10.7547/20-007

Figure 10.
Figure 10.

Forest plot of comparison of revision. CKD, chronic kidney dysfunction; M-H, Mantel-Haenszel.

Citation: Journal of the American Podiatric Medical Association 111, 5; 10.7547/20-007

Figure 11.
Figure 11.

Forest plot of comparison of mortality. CKD, chronic kidney dysfunction; M-H, Mantel-Haenszel.

Citation: Journal of the American Podiatric Medical Association 111, 5; 10.7547/20-007

Discussion

There is evidence to suggest that less advanced forms of the disease may have an appreciable effect on individuals undergoing TJA surgery.12 Patients with CKD are more likely to have associated medical problems; the disease is a risk factor for postoperative complications; and the impact of renal impairment on patients undergoing orthopedic procedures has been documented. Compared with individuals with normal kidney function, CKD patients are reported to have higher levels of D-dimer, C-reactive protein, and fibrinogen.12,13 Wattanakit et al13 reported that patients with stages 3 and 4 CKD had an almost twofold increased risk for venous thromboembolism compared with those with normal kidney function. Similarly, Tan et al5 found that stage 3 CKD substantially increased the risk of venous thromboembolism (OR, 1.95). However, Miric et al2 found that the risk of deep venous thrombosis in CKD patients following TKA was not significant.

Chronic renal insufficiency was divided into five phases according to CKD stage; in stages 3 to 5, the renal function damage reached over 50% of normal people. Chronic renal insufficiency is a risk factor for severe postoperative complications, such as renal failure and cardiovascular complications. Multiple organ dysfunction and metabolic imbalance lead to low immunity, increased risk of infection, and a significant increase in mortality.14,15

Kidney transplantation has become the preferred treatment for the majority of patients with end-stage renal disease. Successful kidney transplantation can eliminate the need for dialysis and is more effective in treating renal failure than peritoneal dialysis or hemodialysis.16 The clinical outcomes of THA in renal transplant recipients have been reported to be superior to outcomes in long-term dialysis recipients. However, the causes may be younger age, more exercise, and longer survival time in renal transplant recipients.17 In kidney transplantation patients undergoing joint replacement, a good job needs to be done in the perioperative and postoperative treatment of complications to reduce the mortality of patients.

The most important finding of the meta-analysis was that, compared with no-CKD patients, CKD patients had a greater increase in postoperative infection rate, deep vein thrombosis, readmission, and mortality. Chronic kidney dysfunction surgery is a dangerous procedure with significant complications, and it was highly recommended that patients decrease the incidence of perioperative and postoperative complications.

Sunday et al18 reported that 29% of patients with end-stage kidney disease died during hospitalization after arthroplasty, 14% of whom underwent primary replacement and 86% of whom underwent revision. Most studies reported that patients with renal impairment had higher mortality, infection, and revision rates during joint replacement surgery. Most published studies focused on THA were performed in patients with end-stage renal disease.18,19 McCleery et al20 reported an increase in rates of TKA-related infection and revision in patients with renal failure, patients on hemodialysis, and patients after renal transplantation. Because of the complications of end-stage renal disease, long-term hemodialysis patients have a higher mortality rate. Congestive heart failure and platelet dysfunction are common complications of renal failure. Similar to the results in the present study, several prior studies have also demonstrated an increased risk of complications in renal disease patients.21,22

There are a variety of reasons why our results differed from those of previous studies. First, we elected to include patients at stages 1 to 5 in an effort to describe surgical outcome in a broader patient sample. Second, we consider that the improved TKA outcomes in our patient sample may also have been attributable to advances in patient care since the earlier studies. The mechanism explaining the greater risk for deep vein thrombosis in CKD remains unclear. Hypercoagulability can be potentially induced by the increased inflammatory state associated with CKD. It was reported that the levels of various cytokines, such as interleukin-6, are elevated.23 In addition, patients with CKD have higher levels of D-dimer, C-reactive protein, fibrinogen, factor VII, and factor VIII.24,25

Conclusions

Whether patients who suffer from chronic kidney disease should undergo total joint arthroplasty is still under debate. This systematic study reports the serious effect of TJA and its perioperative and postoperative complications for patients with chronic kidney disease. The most important finding was the clear difference with regard to complications between no-CKD and CKD patients. The patients with CKD showed more complications such as postoperative infection, deep vein thrombosis, readmission, and mortality compared with the no-CKD patients. Also, it appears reasonable that the patient with CKD at least benefits from a thorough analysis of existing comorbidity and optimization of his or her medical condition, and further higher quality, multicenter, prospective studies with a good design and a large number of participants, and randomized controlled trials with long-term follow-up, are necessary to confirm this topic.

Acknowledgment

Tianjin First Center Hospital for providing the database.

Financial Disclosure: None reported.

References

  • 1. 

    Shukla R, Singh M & Jain RK et al.: Functional outcome of bipolar prosthesis versus total hip replacement in the treatment of femoral neck fracture in elderly patients. Malays Orthop J 11: 1, 2017.

    • Crossref
    • PubMed
    • Web of Science
    • Search Google Scholar
    • Export Citation
  • 2. 

    Miric A, Inacio MCS & Namba RS: Can total knee arthroplasty be safely performed in patients with chronic renal disease? Acta Orthop 85: 71, 2014.

    • Crossref
    • PubMed
    • Web of Science
    • Search Google Scholar
    • Export Citation
  • 3. 

    Sharma V, Awasthi B & Kumar K et al.: Outcome analysis of hemiarthroplasty vs. total hip replacement in displaced femoral neck fractures in the elderly. J Clin Diagn Res 10: RC11, 2016.

    • Web of Science
    • Search Google Scholar
    • Export Citation
  • 4. 

    Li Q, Dai B & Yao Y et al.: Chronic kidney dysfunction can increase the risk of deep vein thrombosis after total hip and knee arthroplasty. Biomed Res Int 2017: 8260487, 2017.

    • PubMed
    • Web of Science
    • Search Google Scholar
    • Export Citation
  • 5. 

    Tan TL, Kheir MM & Tan DD et al.: Chronic kidney disease linearly predicts outcomes after elective total joint arthroplasty. J Arthroplasty 31 (suppl): 175, 2016.

    • Crossref
    • PubMed
    • Web of Science
    • Search Google Scholar
    • Export Citation
  • 6. 

    Schmidt AH, Leighton R & Parvizi J et al.: Optimal arthroplasty for femoral neck fractures: is total hip arthroplasty the answer. J Orthop Trauma 23: 428, 2009.

    • Crossref
    • PubMed
    • Web of Science
    • Search Google Scholar
    • Export Citation
  • 7. 

    Zhang YL, Chen S & Ai ZS et al.: Osteonecrosis of the femoral head, nonunion and potential risk factors in Pauwels grade-3 femoral neck fractures: a retrospective cohort study. Medicine (Baltimore) 95: e3706, 2016.

    • Crossref
    • Web of Science
    • Search Google Scholar
    • Export Citation
  • 8. 

    Wang C, Xu GJ & Han Z et al.: Correlation between residual displacement and osteonecrosis of the femoral head following cannulated screw fixation of femoral neck fractures. Medicine (Baltimore) 94: e2139, 2015.

    • Crossref
    • Web of Science
    • Search Google Scholar
    • Export Citation
  • 9. 

    Zuo WM, Yang L & Wang JJet al:. Middle-and short-term follow-up of biological artificial femoral head replacement in elderly patients with proximal femoral fracture of chronic renal disease. Chin J Tissue Eng Res 15: 2315, 2018.

    • Search Google Scholar
    • Export Citation
  • 10. 

    Engh CA, McAuley JP & Sychterz CJ et al.: The accuracy and reproducibility of radiographic assessment of stress-shielding. A postmortem analysis. J Bone Joint Surg Am 82: 1414, 2000.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11. 

    Dorr LD, Absatz M & Gruen TA et al.: Anatomic porous replacement hip arthroplasty: first 100 consecutive cases. Semin Arthroplasty 1: 77, 1990.

  • 12. 

    Howell SJ, Sear YM & Yeates Det al. Risk factors for cardiovascular death after elective surgery under general anaesthesia. Br J Anaesth 80: 14, 1998.

  • 13. 

    Wattanakit K, Cushman M & Stehman-Breen C et al.: Chronic kidney disease increases risk for venous thromboembolism. J Am Soc Nephrol 19: 135, 2008.

    • Crossref
    • PubMed
    • Web of Science
    • Search Google Scholar
    • Export Citation
  • 14. 

    Gruen TA, McNeice GM & Amstutz HC: “Modes of failure” of cemented stem-type femoral components: a radiographic analysis of loosening. Clin Orthop Relat Res 141: 17, 1979.

    • Search Google Scholar
    • Export Citation
  • 15. 

    Nagoya S, Nagao M & Takada J et al.: Efficacy of cementless total hip arthroplasty in patients on long-term hemodialysis. J Arthroplasty 20: 66, 2005.

  • 16. 

    Li WC, Shih CH & Ueng SW et al.: Uncemented total hip arthroplasty in chronic hemodialysis patients. Acta Orthop 81: 178, 2010.

    • Crossref
    • PubMed
    • Web of Science
    • Search Google Scholar
    • Export Citation
  • 17. 

    Rogmark C, Fenstad AM & Leonardsson O et al.: Posterior approach and uncemented stems increases the risk of reoperation after hemiarthroplasties in elderly hip fracture patients. Acta Orthop 85: 18, 2014.

    • Crossref
    • PubMed
    • Web of Science
    • Search Google Scholar
    • Export Citation
  • 18. 

    Sunday JM, Guille JT & Torg JS: Complications of joint arthroplasty in patients with end-stage renal disease on hemodialysis. Clin Orthop Relat Res 397: 350, 2002.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 19. 

    Koebnick C, Langer-Gould AM & Gould MK et al.: Sociodemographic characteristics of members of a large, integrated health care system: comparison with US Census Bureau data. Perm J 16: 37, 2012.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20. 

    McCleery MA, Leach WJ & Norwood T: Rates of infection and revision in patients with renal disease undergoing total knee replacement in Scotland. J Bone Joint Surg Br 92: 1535, 2012.

    • Web of Science
    • Search Google Scholar
    • Export Citation
  • 21. 

    Wang TI, Hung SH & Su YP et al.: Noncemented total hip arthroplasty for osteonecrosis of the femoral head in elderly patients. Orthopedics 36: e271, 2013.

    • PubMed
    • Web of Science
    • Search Google Scholar
    • Export Citation
  • 22. 

    Bozic KJ, Lau E & Kurtz S et al.: Patient-related risk factors for postoperative mortality and periprosthetic joint infection in medicare patients undergoing TKA. Clin Orthop 470: 130, 2012.

    • Crossref
    • PubMed
    • Web of Science
    • Search Google Scholar
    • Export Citation
  • 23. 

    Bozic KJ, Lau E & Kurtz S et al.: Patient related risk factors for periprosthetic joint infection and postoperative mortality following total hip arthroplasty in Medicare patients. J Bone Joint Surg Am 94: 794, 2012.

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Tianjin First Center Hospital, Tianjin, People's Republic of China.

Corresponding author: Kai Sun, MD, Tianjin First Center Hospital, Fukang Rd #24, Nankai District, Tianjin 300192, People's Republic of China. (E-mail: sunkaiortholivea@sina.cn)

Conflict of Interest: None reported.