Case Study: Transfusion-Free Hip Revision
A 75-year-old man presented to the USC Center for Arthritis and Joint Implant Surgery in referral for revision hip surgery. The patient had a total cement done 25 years ago for developmental dysplasia and the replacement had become loose. He had severe deformities because of the dysplasia. In addition, he had significant bone loss in his pelvis because of the long-term wear and tear of the prosthesis. He had been to several other surgeons, all of whom told him that his deformities were too bad to consider bloodless surgery for fear of loss of life. However, the patient had pain daily. He was at the point of requiring crutches for all of his walking.
The patient was evaluated at the Center. Severe deformities were evident, requiring major revision surgery with bone grafting, plating and revision of the hip replacement. The typical blood loss for such a surgery is in the range of four to eight units. In addition, the patient weighed only 135 pounds. His actual blood line was fairly low. Therefore, his risk of morbidity and mortality as a result of postoperative anemia was significant. If uncontrolled bleeding were to occur, it could result in the loss of limb or life. Still, the patient felt that his life was so restricted that he would nonetheless consider revision hip surgery.
At the time of his initial workup, the patient had a hemoglobin count of 13.6 and a hematocrit of 41 percent, which was within the normal range. But the anticipated blood loss was so great that supplementation of the blood count was performed using erythropoeitin injections. By the time of surgery, his blood counts had increased to a hemoglobin of 14.7 and a hematocrit of 46.8.
The patient underwent reconstructive surgery for his left hip on April 30, 1998, with Edward McPherson, M.D., as attending physician. His reconstruction consisted of extensive bone grafting of his pelvis with a reconstruction plate and cage with screws. He also underwent replacement of his worn-out hip replacement with a long-stem prosthesis. His left leg, which had been three inches shorter than the right, was restored to equal length.
The intraoperative course consisted of acute normovolemic hemodilution with 2.5 units of the patient’s own blood removed into an accessory circuit that was maintained in a continuous circuit with his own blood system. The remaining blood was diluted with albumin and crystalloid. In addition, a cell saver was employed to collect and clean the blood as it was lost and return it to the patient. To minimize blood loss, bone bleeders were covered with bone wax and the surgical area was packed with dilute epinephrine-soaked sponges.
The patient remained hemodynamically stable throughout the surgery. Postoperatively, his hemoglobin did drop very low: At its nadir, the hemoglobin was 7.5, with a hematocrit of 22.6 percent. By the time he was discharged on May 27th, however, his hemoglobin and hematocrits had recovered to a level of 10.4 and 31.7 percent.
The patient is now pain-free and enjoys walking more than a mile a day for exercise.