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knee replacement with careul and meticulous perioperative
management.
Case Report
A 61-year-old man with a history o IP presented with chronic
severe right knee pain. He had been suffering rom IP or
eleven
years and despite corticosteroids, dapsone and azathioprine
Perioperative Care o a Patient with ReractoryIdiopathic
Trombocytopenic Purpura Undergoingotal Knee Arthroplasty Rohit
Singhal, MS (Ortho), MRCSEd1, Veera Gudimetla, FRCA2, Andrew
Stewart, FRCP Edin, FRCPath3,Karen L Luscombe, FRCS (r &
Orth)1 and Charalambos P Charalambous, MSc, MD, FRCS (r &
Orth)41Department o rauma and Orthopaedics, Leighton Hospital,
Crewe; 2Department o Anaesthesiology, Leighton Hospital, Crewe;
3Department o Haematology,University Hospital o North
Staffordshire, Stoke-on-rent;4Department o rauma and Orthopaedics,
Blackpool Victoria Hospital, Blackpool, United Kingdom
Tis is an Open Access article distributed under the terms o the
Creative CommonsAttribution Non-Commercial License
(http://creativecommons.org/licenses/by-nc/3.0/)which permits
unrestricted non-commercial use, distribution, and reproduction in
anymedium, provided the original work is properly cited.
Copyright © 2012. HE KOREAN KNEE SOCIEY
www.jksrr.org
Case ReportKnee Surg Relat Res 2012;24(4):245-248
http://dx.doi.org/10.5792/ksrr.2012.24.4.245
pISSN 2234-0726 · eISSN 2234-2451
Knee Surgery & Related Research
Idiopathic thrombocytopenic purpura (IP) is an autoimmune
disorder leading to low platelet count and an increased risk o
bleeding. Major joint replacement surgery in a patient with IP
can be associated with severe postoperative bleeding. We present
our experience o perioperativemanagement in a patient with severe
reractory chronic idiopathic thrombocytopenic purpura who
successully underwent a cemented total kneereplacement.
Key words: Perioperative management, Immune
thrombocytopenic purpura, Total knee replacement.
Received August 20, 2012; Revised September 21, 2012;Accepted
October 24, 2012.Correspondence to: Rohit Singhal, MS (Ortho),
MRCSEd.Department o rauma and Orthopaedics, Leighton Hospital,
6,ennyson Drive, Ormskirk, United Kingdom.el: +44-7838008900, Fax:
+44-1250768999Email: [email protected]
Introduction
Reractory chronic immune thrombocytopenic purpura (IP)
is an auto-immune disorder with persistently low platelet
count
which is unresponsive to any recognised modality o
treatmentwithout unacceptable toxicity 1). Surgical procedures
carried out
in patients with IP involve risk o severe intra operative
and
postoperative bleeding and inection. Appropriate
preoperative
preparation o patients with severe IP undergoing major joint
replacement surgery is essential to avoid such
complications.
We present a case report o a 61-year-old male patient with
severe chronic reractory IP who underwent cemented total
245
Fig. 1. Preoperative lateral radiograph o right knee.
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246 Singhal et al. Perioperative Care of a Patient with
Refractory ITP Undergoing TKR
treatment as well as previous splenectomy his platelet count
remained in the range 20-30×109/L with occasional dips to
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Knee Surg Relat Res, Vol. 24, No. 4, Dec. 2012 247
discharged rom the hospital on the eighth postoperative day
afer achieving independent walking with stair climbing and
knee
flexion o 80 degrees.
he patient was reviewed in the haematology clinic three
days ollowing discharge rom the hospital. he platelet count
measured then was 327×109. His platelet count trend is shown
in Fig. 3. He was reviewed in the orthopaedic clinic ater
one
week, three week and six weeks. Te postoperative radiographs
o his knee were satisactory (Figs. 4, 5). No complications
were
observed. At three months ollow-up 130o o knee lexion
was
achieved. His postoperative Oxord Knee score was calculated
to be 40. he patient was able to carry out all the activities
o
daily living including driving and he was very satisfied with
the
outcome.
Discussion
his report describes a case o severe reractory chronic IP
undergoing cemented total knee replacement surgery or severe
osteoarthritis o the knee. Successul result was achieved
with
constant supervision, careul monitoring and
multi-disciplinaryteam approach.
IP is an immune disorder characterised by auto antibodies
ormation against platelets leading to accelerated platelet
destruction and retarded platelet production1). Te prevalence
o
IP in adults in the UK is approximately 5.8 to 6.6 per
100,000.
As compared to IP in children, IP in adults oten runs a
chronic course and in about 10% o adult patients are
reractory
to treatment3). Te risk o bleeding requiring treatment
increase
with increasing severity o thrombocytopenia and is highest
in
patients with platelet count o
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248 Singhal et al. Perioperative Care of a Patient with
Refractory ITP Undergoing TKR
o arthrofibrosis due to bleeding leading to knee stiffness.
Bone
cuts made during knee replacement surgery results in large
raw
suraces o bone with high potential o bleeding. In the
present
case, cement was used to cover the bleeding bony suraces as
cemented knee replacement has been shown to result in
lowerperioperative blood loss as compared to uncemented knee
replacement10).
he clinical needs and perioperative management o patients
undergoing an emergency operation are dierent rom that o
those undergoing elective surgery such as a joint
replacement
procedure, which can be deerred or indeinite period as the
procedure is not lie saving. Surgeons might postpone knee or
hip
replacement, which is mainly undertaken to improve the
quality
o lie, i the expected intra or post operative complications
are deemed to be lie threatening. With speciic guidelines,
scrupulous preparation, close communication and constant
monitoring these procedures can be conducted with a
successul
outcome.
IP is a complex disorder. Close monitoring is paramount to
prevent severe complications. Medical therapy and
appropriate
surgical technique can minimise complications in patients
with
severe reractory IP undergoing total knee replacement.
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