Total Hip Arthroplasty for Osteonecrosis of the Femoral Head Following Allogeneic Haematopoietic Stem Cell Transplantation, with Graft-Versus-Host Disease as a Candidate Effect Modifier: A Systematic Review and Meta-Analysis.

Background/

Objectives

Osteonecrosis of the femoral head is a common late complication of allogeneic haematopoietic stem cell transplantation, driven largely by graft-versus-host disease (GVHD) and its immunosuppressive treatment. We evaluated implant survivorship, all-cause revision and periprosthetic joint infection or septic loosening after total hip arthroplasty, and whether GVHD modifies these outcomes.

Methods

Six databases were searched from inception to July 2026. The review was registered with PROSPERO (CRD420261446131) and reported per PRISMA 2020. Proportions were pooled with a random-intercept logistic model, with sensitivity analyses for the registered Freeman-Tukey approach, follow-up duration, within-patient clustering and competing mortality. Risk of bias used ROBINS-I and MINORS, certainty GRADE; GVHD was the prespecified effect modifier.

Results

Six studies were included; four cohorts (228 hips) were pooled. Pooled all-cause revision was 4.39% (95% CI 2.38-7.96) and pooled infection or septic loosening 1.05% (95% CI 0.28-3.87). In the two cohorts followed beyond five years (182 hips), these rose to 5.49% (95% CI 2.98-9.91) and 1.62% (95% CI 0.51-5.01), the two shorter cohorts recording no event in 46 hips. All three infection events arose in one cohort, in patients with chronic GVHD on steroids at revision. With no GVHD-stratified denominators reported, however, this remains descriptive, not an estimable relative risk. Certainty was very low throughout.

Conclusions

Total hip arthroplasty after allogeneic transplantation is durable over the first post-operative decade. All infection-related failures arose in patients with chronic GVHD on continuing immunosuppression-a mechanistically plausible pattern, but one resting on three events in one cohort and still unquantified. GVHD-stratified reporting is the next step.