total hip replacement in sickle cell disease
TRANSCRIPT
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Total Hip replacement in sickle cell disease
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• Substitution of Valine for Glutamic acid – 6th position – beta chain Hb
• Improved diagnostic and management many people survive to middle age
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• 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
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Management• Early stage
Head preserving T/t to delay THR
- Rest - Non weight bearing mobilization- Core decompression- Vascular Graft- Osteotomy- Cement injection
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Advanced Disease
Total hip replacement
Despite challenges – functional outcome better than Arthrodesis & Resection Arthroplasty
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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)
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High incidence of infection
• Pre op broad spectrum antibiotic.
• Post op continue antibiotic for 3 – 5 days
• Staph is commonest • Salmonella is characteristic
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Universal precaution
• Repeated blood transfusion – pt may aquire
- Hep B- Hep C- HIV
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Anaesthesia
• Spinal anesthesia is preffered.
- Close monitoring of - Operative room temperature - Cardiopulmonary function - Blood gases - Oxygenation - Hydration - Blood Loss
To Avoid Sickle cell crisis
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Increased Intraop Bleeding
• Arrange Adequate blood
• Cell saver ( These pt develop rare antibodies due to repeated transfusion so cross match blood not available)
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Acetabular perforation
• The bones may be soft or sclerotic
• Adhesions are present
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Intra op femoral Fracture
• Normal incidence < 1%• Much higher in sickler
• Torsional force during dislocation• Preparing narrow medullary canal• Difficult reduction
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• Intra –op C arm• Long Drill bit (4.5mm)• Nailing Guide wire• Flexible reamers
• CDH stem • Ceramic head
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• 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
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Post op
• Adequate Hydration
• DVT prophylaxis
• Identify Sickle cell crisis and manage
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• High Failure rate
• Short Term Follow up – upto 50% failure
Aseptic loosening(These patients are Young & Active)Infection
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• Despite all precaution • Many THR after sickle cell disease will fail
• Revision of THR in Sickle cell disease extremely challenging problem
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• THANK YOU