Multiple total hip arthroplasties in refractory immune thrombocytopenic purpura: A case report and literature review

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Abstract

Rationale:

Refractory immune thrombocytopenic purpura (RITP) manifests as low platelet count, with a high risk of hemorrhage, treatment difficulty, and high mortality. Total hip arthroplasty (THA) in RITP is rarely reported. This study aimed to evaluate multiple THAs or revision total hip arthroplasties (RTHAs) in RITP.

Patient concerns:

The male patient with RITP was 54-year-old patient and hospitalized on September 21, 2009, with the main complaint of bilateral hip pain after traveling for 2 weeks. The patient had a history of ITP for 16-years, with no response to hormone therapy (after adequate hormone therapy, platelet count persistently remained below 30 × 109/L). Two year prior to visit, the patient underwent splenectomy, and postoperative platelet persistently fluctuated around 10 to 20 × 109/L. The patient did not undergo regular reexaminations, and declined immunosuppressants.

Diagnoses:

Femoral neck fracture; Refractory immune thrombocytopenic purpura (RITP).

Interventions:

A RITP patient with femoral neck fracture received 2 THAs and 1 RTHA. First THA indication was significant left dislocation of Garden III type. RTHA was performed following prosthetic loosening after left total hip arthroplasty. The second THA was prompted by non-healing of the old fracture, significant pain, and a low Harris score. Platelet count remained <20 × 109/L, and conventional drugs, splenectomy, and platelet transfusion had no effects. A large gamma-globulin dose was administered preoperatively. When platelet increased to 75 × 109/L, 2 THAs and 1 RTHA were successfully completed.

Outcomes:

Postsurgery, conventional management was applied; no severe complications occurred. The wound was well healed, with platelet count reduced to <15 × 109/L at hospital discharge. The patient recovered, with a Harris score >80 at 1 year postsurgery.

Lessons:

Extremely low platelet count is a contraindication of surgery. In this patient, preoperative platelet count was <100 × 109/L. Extended disease course and multiple operations lowered platelet count, and increased risk in surgery. However, high postoperative gamma-globulin dose impacted therapy, and all surgeries were successful, with no severe complications. The wound healed well, and the quality of life was significantly improved, demonstrating the feasibility and safety of this surgery. Multiple THA or RTHA surgeries are feasible and safe for RITP patients.

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