Epidemiology and Perioperative Complications in Patients With Sickle Cell Disease After Orthopaedic Surgery: 26 Years' Experience at a Major Academic Center

Perioperative Complications of Pediatric Orthopaedic Surgery in Sickle Cell Disease

BACKGROUND

Vasoocclusion in sickle cell disease can be precipitated by cold temperatures, hypoxia, infection, dehydration, and stress, all of which can occur in the setting of surgery. The purpose of this study was to identify predictors of perioperative complications among pediatric patients with sickle cell disease undergoing orthopaedic surgery.

METHODS

An institutional review board approved single-center retrospective review was conducted of pediatric patients 21 years of age and younger with SCD who underwent any orthopaedic surgery at a single center between 2009 and 2019. Patient data and procedure-specific information were recorded. Preoperative admission for hydration and/or blood transfusion and preoperative laboratory studies were reviewed. The primary study outcome was postoperative complications within 30 days of surgery requiring an ED visit or hospital admission.

RESULTS

Ninety-two patients who underwent 118 orthopaedic surgeries were identified. The average age at surgery was 12.0 years (SD 4.8 y). Surgical cases were classified as elective (n=82, 70%), infection (n=26, 22%), and trauma (n=9, 8%). The lower extremity was the most frequent surgical site (n=86, 73%). Sixty surgeries (51%) received a preoperative blood transfusion. There were 19 surgeries with postoperative complications (16%) that required an ED visit or hospital readmission within 30 days of surgery. There were significantly more complications following surgery on the hip as compared with other sites (24% vs. 9%, P =0.04). Four or more ED visits in the past year were associated with an OR of 5.7 for a postoperative complication ( P =0.01, 95% CI 1.6-20.5). Patients who had a preoperative blood transfusion had significantly greater rates of complications than those that did not (27% vs. 5%, P <0.01).

CONCLUSIONS

Children with SCD are at increased risk for complications after orthopaedic surgery, and the current study found an overall postoperative complication rate of 16%. Patients undergoing hip surgery had a disproportionate number of complications, with a 5.8-fold increased risk of a postoperative complication. Patients with 4 or more ED visits in the past year had a 5.7-fold increased risk of a complication.

LEVEL OF EVIDENCE

IV Retrospective case series.

Orthopaedic Diagnoses in the Black Pediatric Population

The Black pediatric population is one that has been historically underserved and continues to have unmet needs. Factors including lack of diversity in orthopaedic studies and in historical standards, such as bone age, may inadvertently lead to inferior care. There are certain conditions in this population for which the practicing orthopaedic surgeon should have a higher degree of suspicion, including slipped capital femoral epiphysis, Blount disease, and postaxial polydactyly. Systemic diseases with higher rates in this population have orthopaedic manifestations, including sickle cell disease, vitamin D deficiency, and obesity. Racial discrepancies in access to prenatal care can have orthopaedic consequences for babies, especially cerebral palsy and myelodysplasia. Racial discrepancy exists in evaluation for nonaccidental trauma. Increased awareness of these issues better prepares practitioners to provide equitable care.

Treatment and outcomes of hepatocellular carcinoma in patients with Sickle cell disease: a population-based study in the U.S

BACKGROUND

Sickle cell disease (SCD) is a rare hemoglobinopathy which can result in chronic liver disease and cirrhosis. Patients with SCD have an increased risk of hematologic malignancy, but the prevalence of hepatocellular carcinoma (HCC) in this population is unknown. Herein, the association of SCD with HCC was examined using registry data.

METHODS

The SEER-Medicare database was queried to identify patients diagnosed with HCC between 2000 and 2015, and further stratified by SCD status. Propensity matching was performed to examine cancer-related survival and treatment outcomes.

RESULTS

Overall 56,934 patients with HCC were identified, including 81 patients with SCD. Patients with SCD more frequently had cirrhosis [48.1% (39/81) vs 23.5% (13,377/56,853), p < 0.01] yet presented with smaller tumors [<5 cm: 51.9% (42/81) vs 38.5% (21,898/56,853), p = 0.01]. After propensity matching, SCD was not associated with attenuated survival (aHR 0.73 95%CI 0.52-1.01). When stratified by treatment, patients with SCD had equivalent outcomes to chemotherapy (p = 0.65), TACE/TARE (p = 0.35), resection (p = 0.15) and transplantation (p = 0.67) when compared to non-SCD patients.

CONCLUSION

This study confirms that a subset of patients with SCD will develop HCC. Importantly, therapeutic options for HCC should not be limited by pre-existing SCD, and similar survival should be expected when compared to non-SCD patients.

Impact of sickle cell disease on postoperative outcomes following total hip arthroplasty

INTRODUCTION

Osteonecrosis (ON) of the femoral head is a common complication of sickle cell disease (SCD), frequently necessitating total hip arthroplasty (THA). Although THA is a common procedure with few complications when indicated for osteoarthritis (OA), patients with SCD have increased rates of complications. The purpose of this study is to determine the impact of SCD on outcomes and complications following THA.

METHODS

Subjects were retrospectively identified using a national insurance claims database (PearlDiver Technologies) using CPT and ICD-9/10. Patients were included if they underwent THA with at least 2-year follow-up and were diagnosed with SCD and ON, ON without SCD, or OA without SCD. The SCD cohort was matched based on age, gender, Charlson Comorbidity Index, and obesity to the other 2 cohorts. 2-year revision rate and 90-day complication rates were analyzed using chi-square tests.

RESULTS

Each cohort had 881 patients. The SCD cohort had significantly higher 90-day medical complications when compared to the ON without SCD and OA cohorts (p < 0.001). The SCD cohort had a higher rate of 2-year revision for PJI (5.0%) compared to the ON without SCD (2.8%) and OA (2.5%) groups (p = 0.019 and 0.005 respectively) and a higher rate of aseptic loosening (1.94%) compared to the ON without SCD cohort (0.68%; p = 0.021).

CONCLUSIONS

Patients with SCD who undergo THA have an increased risk for short-term postoperative medical complications and 2-year aseptic loosening and PJI compared to ON patients without SCD and patients with OA. Given the magnitude of these risks, patient counseling and optimised perioperative care are essential.

Aseptic osteonecrosis of the femoral head in patients with sickle cell anemia

Sickle cell disease (SCD) is a genetic trouble of the hemoglobin synthesis inherited as an autosomal recessive trait, whose prevalence can vary from 5 to 25% in the different parts of the world. It is characterized by the presence of abnormal hemoglobin HbS instead of hemoglobin A. Patients suffering from major forms of SCD present the risk of developing epiphyseal necrosis. Aseptic osteonecrosis of the femoral head (AOFH) caused by ischemia, or bone infarction can affect between 20 and 50% of SCD patients. The femoral head is the most frequent epiphyseal location with a range of 74.6%. AOFH can affect patients at any age, but is mainly detected in men under 50 years. Indeed, a large majority of cases, in a range of 60%, have been diagnosed at an early radiological stage in young adults whose average age varies, in the literature, between 27 and 36 years. A surgical procedure becomes sometimes necessary due to the severity of pain and the functional consequences, frequently following the mechanical collapse of the osteonecrosis area. It is estimated that approximately 25-30% of SCD patients will undergo a total hip arthroplasty before 50y. Although the mortality rate, between 0.2-2.6%, tends to be similar to the general population rate undergoing a prosthetic surgery, the perioperative complications vary from 11.5 to 67%. Here, we clarify the epidemiological data and present an exhaustive update on the different preventive and therapeutic strategies, as well as the perioperative management in patients with an AOFH caused by SCD and risking multiple complications.

Total Hip Arthroplasty in Patients With Sickle Cell Disease: A Comprehensive Systematic Review

BACKGROUND

Total hip arthroplasty (THA) is a common treatment for end-stage osteonecrosis of the hip in patients with sickle cell disease (SCD). This patient population presents unique challenges in the perioperative period. This systematic review aims to investigate the existing literature on the outcomes, complications, and survivorship of primary THA in SCD patients.

METHODS

A systematic search using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was performed of PubMed, MEDLINE, EMBASE, and Cochrane databases for clinical studies on THA in SCD patients. Studies on primary THA in SCD patients with a mean follow-up greater than 90 days were included.

RESULTS

Sixteen studies containing 5193 SCD patients met criteria for inclusion. The Coleman Quality of Evidence score ranged from poor to moderate. SCD patients had a significant increase in Harris Hip Scores and Merle d'Aubigne Scores after undergoing THA. Compared to non-SCD patients, SCD patients had increased hospital length-of-stay, 30-day and 90-day readmission rates, and rates of medical complications, including pain crises, acute chest syndrome, cardiac complications, sepsis, and mortality. SCD patients also had increased rates of surgical complications, including wound complications, infection, periprosthetic fracture, and aseptic loosening. Overall, THA revision rates were higher in SCD patients relative to those with primary osteoarthritis.

CONCLUSION

THA remains an effective treatment modality for osteonecrosis of the hip in SCD patients. However, these patients are at increased risk of medical and surgical complications. Surgeons should be aware of the unique challenges in this patient population when counseling and managing these patients in the perioperative period.