Postoperative Thrombocytopenia after Revision Arthroplasty: Features, Diagnostic and Therapeutic Considerations

Abstract

We present the case of a 66 year-old male patient who developed severe postoperative thrombocytopenia after revision total hip arthroplasty. The patient underwent surgery in a dedicated orthopedics hospital and was initially managed in the intensive care unit. Upon the development of thrombocytopenia, he was referred to a dedicated hematology clinic for investigation and advanced management. A thorough diagnostic algorithm was employed in order to rule out the main causes of thrombocytopenia. By exclusion, we diagnosed the patient as suffering from a rare and severe form of postoperative thrombocytopenia through an immune mechanism. Although postoperative thrombocytopenia is relatively frequent but transitory and no treatment is required, this condition was refractory to corticosteroids and substitution therapy; however, it quickly responded to treatment with thrombopoietin receptor agonists. The patient recovered and was successfully discharged with normal platelet values. While rare occurrences, alternative causes of thrombocytopenia such as infection, drug-induced, or immune should be considered in patients developing postoperative thrombocytopenia.

Keywords: disseminated intravascular coagulation; drug-induced; immune mechanism; immune thrombocytopenia; orthopedics; pathophysiology; platelets; postoperative thrombocytopenia.

Figure 1

Antero-posterior X-ray of the pelvic ring and a side view of the left hip. Radiological signs of loosening of the femoral component (arrows).

Figure 2

Surgical wound site (drainage tube and staples).

Figure 3

Postoperative radiographical aspect of the revision components.

Figure 4

Computed Tomography scan showing normal size of spleen (a), recent periprosthetic hematoma with densities of approximately 60–80 HU (b, arrow), and no active bleeding, i.e., no pathological enhancement with contrast injection (c).

Figure 5

Postoperative wound aspect after the second revision.

Figure 6

Capillary blood smear—a rare, isolated giant platelet. Courtesy of the Hematology Laboratory of Coltea Hematology Clinic, Bucharest, Romania.

Figure 7

Bone marrow aspirate—megakaryocytic lineage hyperplasia. Courtesy of Hematology Laboratory of Coltea Hematology Clinic, Bucharest, Romania.

Figure 8

Evolution of platelet values in the first 30 days postoperatively under associated interventions. RBC = red blood cells; PLT = platelets; dex = desamethasone; FBG = Fibrinogen; PCH = Prothrombin Complex Human; TXA = Tranexamic Acid; Methyl-PNL = Methylprednisolone; i.v. IgG= Intravenous Human Normal Immunoglobulin G; TPO-RAs = Thrombopoietin Receptor Agonists.