Total Hip Arthroplasty Complications in Sickle Cell Disease: Systematic Review and Meta-Analysis

Background: Microvascular occlusions caused by sickle-shaped erythrocytes in patients with sickle cell disease (SCD) can lead to increased intraoperative and postoperative complications during total hip arthroplasty (THA). This systematic review and meta-analysis aimed to estimate the overall rate of complications following THA in patients with SCD and to identify the predictors of these complications including the surgical approach. Methods: The search was conducted across the grey literature, Google Scholar, and seven databases: Scopus, MEDLINE Central/PubMed, ProQuest, SciELO, SAGE, and Web of Science. All observational studies reporting the proportional THA complications in SCD were included. The Newcastle-Ottawa Scale quality assessment tool was used to assess the quality of the studies. The random effect model was applied to estimate the pooled outcomes. A sub-group analysis for the different approaches was performed. A sensitivity analysis and meta-regression were used to explain heterogeneity and to identify the THA complication predictors. Results: Of 3230 citations, only 23 studies were eligible for the meta-analysis. The pooled proportion of total primary THA complications in patients with SCD was 42% (95% CI: 30-56%, I² = 95%). The sub-group analysis highlighted the anterolateral approach as the approach accompanied with the least complications. The meta-regression revealed that the anterolateral approach decreases the complications significantly, -28.67 (95%CI, -56.45--0.88, p = 0.044), while the number of hips increased the complications by 0.43 (95%CI, 0.30-0.57, p < 0.001). Male gender, age, lateral approach, and HbSS non-significantly affect the THA complications in SCD 52.05, 0.18, 6.06, and 55.78, respectively. The pooled proportions for an SCD crisis 9% (95%CI, 5-14%, I² = 61%), dislocation 4% (95%CI: 2-7%, I² = 66%), aseptic loosening 12% (95%CI, 7-20%, I² = 91%), revision 6% (3-11, I² = 92%), heterotopic ossification 12% (95%CI, 3-35%, I² = 95%), and prosthetic joint infection (PJI) 6% (95%CI, 3-11%, I2 = 92%). The most fitted model of meta-regression illustrated that HbSS significantly increases PJI, 0.05 (95%CI: 0.02-0.08, p = 0.009), and male gender and age non-significantly increase PJI, 2.28 (95%CI: -4.99-13.56, p = 0.311) and 0.001 (95%CI: -0.27-0.27, p = 0.990), respectively. Meanwhile, the anterolateral, lateral, and posterior approaches non-significantly decrease PJI, -3.55, -0.92, and -1.27, respectively. The pooled proportion for a sickle cell disease crisis after revision was 16% (95%CI: 6-36%, I² = 0) and for aseptic loosening after revision, it was 24% (95%CI: 12-43%, I² = 0). Conclusions: This study revealed the high rate of complications in patients with SCD and highlighted that the anterolateral approach was associated with the lowest rate of complications. Furthermore, this study illustrated that homozygous (HbSS) individuals are more susceptible to prosthetic joint infection.