An 84-year-old lady presented for an elective total hip replacement for progressive osteoarthritic changes requiring surgical intervention. She was noted to have a severe nut allergy with a known previous reaction approximately 10 years ago of anaphylactic symptoms including airway angioedema and haemodynamic instability.

The patient presented with clinical findings consistent of severe osteoarthritis, originating 1.5 years ago with gradual worsening pain and mobilisation over the preceding 2-3 months. She required the assistance of a stick to mobilise and exercise tolerance was limited to 100-200 yards. Upon examination, she presented with an antalgic gait, point tenderness in the groin and limited hip range of motion. Flexion was limited to 70-80⁰ with only 10-15⁰ of internal and external rotation. Her symptoms were isolated to the hip with satisfactory examination findings of the lumbar spine and knee to exclude these as concurrent factors in her presentation.

Severe osteoarthritis was present on the radiographs with anterior acetabular and femoral head osteophytes (Figure 1).

Local guidelines and consensus encourage the use of cemented implants for both acetabular and femoral components for patients above the age of 70 years. Therefore, the patient was listed for a left total hip replacement which was initially planned to be cemented. However, due the severe nut allergy; an uncemented approach was preferred, with concerns regarding the Palacos bone cement containing peanut derivatives.

Standard practice within our unit utilises spinal anaesthesia for hip arthroplasty procedures and therefore the patient was conscious with minimal sedation during surgery.

Preoperative tranexamic acid and antibiotics were administered as per local protocols. A modified Hardinge approach was used with the capsule incised longitudinally and with hip dislocation. The acetabulum was exposed with excision of anterior osteophytes. A 52mm Pinnacle hydroxyapatite-coated cup was implanted with a secure press fit and secured with two screws with a 52/32mm liner satisfactorily placed. During femur rasping, a stable anteromedial calcar split was noted during the final 12mm rasp. Fixation with tensioned steel cable and conversion to cemented implant was considered to ensure stable fixation of the femoral stem. Cementation was therefore a key component of the final implantation strategy. Prior to and during cementation, close discussion with and monitoring by the anaesthetic team was actioned. A consultant anaesthetist was present and regular monitoring of the patient’s observations was performed, including carbon dioxide trace, haemodynamic status and, clinical status. As the patient was conscious, she was evaluated at 2–5-minute intervals, for symptoms like angioedema, vomiting, bronchospasm, and signs of shock during and after the cementation.

Intraoperatively, the patient remained stable with saturations consistently above 97%, heart rate between 55-88 bpm and systolic blood pressure between 100-140. A size 1, 44mm offset, 150mm Exeter long stem was securely implanted. Two mixes of cement were used for stem cementation and pressurisation was performed. A +4/32 mm stainless steel head was implanted. The final position is shown in Figure 2. During cementation and pressurisation, there was no observed change in her haemodynamic status or clinical status.

Whilst in recovery her observations remained stable, and she remained alert with no adverse effects. No antihistamines or other common medications used to treat allergic reaction were required. She progressed well postoperatively with appropriate interaction with the nursing team, with no reports of pain/discomfort, nausea, vomiting, or loss of appetite. Her intra-operative and post-operative observations can be seen in Table 1. She engaged well with physiotherapy and mobilised successfully on the first post-operative day. She was discharged once deemed fit by the physiotherapy and medical teams on the second postoperative day.

She subsequently received follow-up in clinic at the six weeks and was successfully rehabilitated. She mobilised unaided with no complications. Pain was managed with occasional paracetamol and no further opioid analgesia was required upon discharge. She was discharged to a routine follow-up as per the arthroplasty protocols of our unit.

Hence, it is safe to conclude that there were no reports of any adverse allergic reaction during the intraoperative or postoperative period during this patient’s care.

Table 1: Intra and Post Operative Observations.