Total hip replacement with severe bilateral hip osteoarthritis

PIG Meeting: 18th February 2021

  • Elderly man seen in perioperative clinic for THR.
  • Requiring arthroplasty to both hips.

Background

  • Longstanding severe OA. Now wheelchair bound and sleeping in a chair
  • Significant bilateral peripheral oedema both legs, likely due to inability to mobilise/raise legs
  • Difficult social circumstances
  • Orthopaedic team consulted in perioperative clinic and discussed possibility of bilateral THR

Issues

  • Surgeon decided not suitable for bilateral hip arthroplasty. Likely due to frailty.
  • Discussion around optimal timing for the second joint replacement taking into VTE risk
  • No evidence but consensus was sensible to leave 6 weeks between surgeries
  • Update on case provided by procedural anaesthetist.
    • Unable to attempt neuraxial block due to difficulty in positioning
    • Significant post-operative delirium
    • Would have likely been a poor candidate for bilateral joint replacements
    • Predicted difficultly with rehab and post-operative mobilization due to severity of OA in other hip

Elderly Jehovah’s Witness for Total Hip Replacement

PIG Meeting: 11th February 2021

85yo male for THR

Background

  • Mantle cell lymphoma – in remission
  • HTN
  • Mild anaemia Hb 122

Discussion

  • Can his anaemia be optimised?
    • Discussed with haematologist – didn’t feel EPO was indicated
    • Fe replete
  • Should we use cell salvage?
    • Blood transfusion after primary THR is not uncommon (although usually occurs postoperatively)
    • Lymphoma is not a contraindication. See the HNE cell salvage guideline.
    • Info from one of the cell salvage coordinators:
      • “Closed circuits” for JW patients just means than the return bag is connected from the start by an infusion line to the patient.
      • Newer systems have a smaller collection bowl but still need to be filled. The circuit is flushed with saline to collect any red cells stuck in the filter and saline-soaked bloodied packs can also contribute to collection. There is still a minimum volume but this is small with an end-product of 135ml of 70% Hct red cells.
    • Disadvantages include the environmental costs of the circuit + staffing and resource allocation (outweighed by the benefits in a patient who declines allogeneic transfusion)
  • Which surgical cases warrant cell salvage in a JW patient?
    • Difficult to be specific, each case needs to be considered individually.
    • In general, cases which would normally warrant a G&S (and thus have a likely higher risk for transfusion), should likely have cell salvage, although this is not a hard rule and may need to be discussed with the surgeon.