Total Hip replacement in sickle cell disease

• Substitution of Valine for Glutamic acid – 6th position – beta chain Hb

• Improved diagnostic and management many people survive to middle age

• Osteonecrosis of femoral Head – common skeletal problem of SCD

B/l 30% - Hyperplasia of bone marrow - Sickling of red cells - Increased blood viscosity - Arterial occlusion & venous obstruction

Management• Early stage

Head preserving T/t to delay THR

- Rest - Non weight bearing mobilization- Core decompression- Vascular Graft- Osteotomy- Cement injection

Advanced Disease

Total hip replacement

Despite challenges – functional outcome better than Arthrodesis & Resection Arthroplasty

Preoperative

• Improve level of Hb ( > 9g acceptable – chronic anemia )

• Reduce level of HbS < 30% ( Hb electrophoresis )

• Exchange transfusion

• Arrange 3- 4 units blood ( Higher intraop blood loss)

High incidence of infection

• Pre op broad spectrum antibiotic.

• Post op continue antibiotic for 3 – 5 days

• Staph is commonest • Salmonella is characteristic

Universal precaution

• Repeated blood transfusion – pt may aquire

- Hep B- Hep C- HIV

Anaesthesia

• Spinal anesthesia is preffered.

- Close monitoring of - Operative room temperature - Cardiopulmonary function - Blood gases - Oxygenation - Hydration - Blood Loss

To Avoid Sickle cell crisis

Increased Intraop Bleeding

• Arrange Adequate blood

• Cell saver ( These pt develop rare antibodies due to repeated transfusion so cross match blood not available)

Acetabular perforation

• The bones may be soft or sclerotic

• Adhesions are present

Intra op femoral Fracture

• Normal incidence < 1%• Much higher in sickler

• Torsional force during dislocation• Preparing narrow medullary canal• Difficult reduction

• Intra –op C arm• Long Drill bit (4.5mm)• Nailing Guide wire• Flexible reamers

• CDH stem • Ceramic head

• Higher incidence of Heterotopic ossification

• Preparation of Sclerosed bone of sickle cell – Bone Debris

- Minimize tissue damage - Frequent irrigation of exposed area - Use of indomethacin – post op prophylaxis

Post op

• Adequate Hydration

• DVT prophylaxis

• Identify Sickle cell crisis and manage

• High Failure rate

• Short Term Follow up – upto 50% failure

Aseptic loosening(These patients are Young & Active)Infection

• Despite all precaution • Many THR after sickle cell disease will fail

• Revision of THR in Sickle cell disease extremely challenging problem

• THANK YOU