1. Sickle Cell Disease &
Total Hip Arthroplasty

2. The three principle
orthopaedic
manifestations
• pyogenic infections
• marrow hyperplasia
• osteonecrosis
J Am Acad Orthop Surg 2005;13:208-217

3. Organisms
• Staphylococcus aureus
• Streptococcus pneumoniae
• Salmonella typhi,
• Klebsiella pneumoniae
N Engl J Med 1999;340: 1021-1030
Clin Orthop 1993;294:140-148

4. Marrow Hyperplasia
• Increased erythropoiesis
• widening of the medullary canal and
thinning of the trabeculae and cortices,
J Bone Joint Surg Br 1989;71: 465-470

5. Osteonecrosis
• hypoxia-induced erythrocyte sickling, along
with extravascular compression of the
intraosseous blood supply caused by
medullary hyperplasia
• bone or marrow infarction, focal and
patchy areas

6. Patient Evaluation and
Natural History
• Groin pain
• limited ROM
• Often bilateral

7. Nonsurgical
Management
• pain management
• assistive devices
• typically progresses
J Bone Joint Surg Am 2003;85:500-504

8. Surgical Management
• disabling hip pain
• severely damaged hip joint
• Medically fit

9. Surgical Management
• THA
• Core decompression
• Femoral osteotomy
• Arthrodesis
• Hemiarthroplasty
• Resection arthroplasty

10. • No Level 1 or 2 evidence
• Steinberg stages I and II
J Am Acad Orthop Surg 2005;13:208-217

11. • it does not address the primary underlying
pathophysiology of vaso-occlusion
• femoral head involvement usually is diffuse
and too large to decompress
• chronic nature of the disease makes future
infarcts inevitable despite decompression
Am J Orthop 1995;24:18-24

12. Preoperative
Considerations
• preventing sickle cell crises
• paying careful attention to cardiac status
and fluid balance
• assessing infection
• using preoperative transfusion or
plasmapheresis
• considering anesthetic modalities and pain
management technique

13. Preoperative
Considerations
• hemoglobin S level < 30%
Am J Hematol. 1999 Nov;62(3):129-38

14. Intraoperative
Considerations
• wide medullary canal an thin cortices
• sclerosis, and canal obliteration

15. Accetabular
Preparation &
Component Insertion
• Acetabular bone quality may be poor
• patches of densely sclerotic bone
(eccentric reaming
• acetabular protrusio ( medial reaming, Bone
Graft, acetabular support and In-situ
Osteotomy)
J Am Acad Orthop Surg 2005;13:208-217

16. Femoral Canal
Preparation
• Areas of sclerosis may be so diffuse that
the canal becomes completely obliterated
• hyperplastic medullary canals, thin cortices
• introducing a drill bit under image
intensifier until it is possible to insert a
guidewire for flexible reamers
Int Orthop 2002;26:157-161

17. Medical Complications
• excessive bleeding (18%)
• pulmonary complications
• sickle cell crises
• cardiac complications (4%)
• mental status changes
Am J Hematol 1999;62:129-138

18. Surgical Complications
• Infection (25%)
• There are no reported cases of
Salmonella osteomyelitis complicating a
THA; therefore, prophylactic
administration of antibiotics that provide
coverage for this gram-negative
microorganism is not recommended
Am J Orthop 1996;25: 353-356
Clin Orthop 1993;294:140-148

19. Surgical Complications
• Hip Dislocation (26%)
J Arthroplasty 1997;12:420-425