The rate of homologous blood transfusion (HBT) following primary total hip replacement (THR) can be as high as 30–40% and is not without risk. Postoperative blood salvage (POS) with autologous blood transfusion may minimize the necessity for HBT but the clinical, haematological and economic benefits have yet to be clearly demonstrated for primary THR. The aim of this randomized prospective study was, therefore, to determine if the use of post-operative salvage affects post-operative haemoglobin and haematocrit values and reduces the rate of homologous blood transfusion. Secondary outcome measures included length of hospital stay and patient satisfaction. A cost analysis was also conducted on the basis of the results obtained. The patients were randomized during the operation (at the point of reduction of the primary THR) to receive either two Medinorm vacuum drains or the autologous retransfusion system. A power calculation estimated that 72 patients would be required in each group to detect a significant difference of 0.7 gdL-1 in post operative haemoglobin level (at 80% power with an value of 0.05). This assumed a standard deviation of 1.5 gdL-1 obtained from a previous retrospective study. There were 82 patients in the Medinorm vacuum drain group and 76 patients in the autologous retransfusion group. In the group with the autologous system, 76% of the patients were retransfused with a mean of 252mls. There was no significant difference between the groups when comparing haemoglobin and haematocrit values. However, significantly fewer patients in the group with the autologous system had a postoperative haemoglobin value less than 9.0 gdL-1 (8% vs. 20%, p = 0.035). Furthermore, significantly fewer patients with the autologous retransfusion system required a transfusion of homologous blood (8% vs. 21%, p = 0.022). There was a small overall cost saving in this group. This study has shown that use of an autologous retransfusion system for primary THR reduces the necessity for HBT and is cost effective. POS also results in significantly fewer patients dropping their post-operative haemoglobin level below 9.0 gdL-1. As a result our unit routinely uses the autologous retransfusion system for primary THR

Introduction: The rate of homologous blood transfusion following primary total hip replacement (THR) can be as high as 30–40% and is not without risk. Postoperative blood salvage (POS) with autologous blood transfusion may minimize the necessity for HBT but the clinical, haematological and economic benefits have yet to be clearly demonstrated for primary THR. The aim of this prospective randomized study was to determine if the use of POS affects postoperative haemoglobin and haematocrit values and reduces the rate of homologous blood transfusion. Secondary outcomes measures included length of hospital stay and patient satisfaction. A cost analysis was conducted on the basis of the results. Methods: Calculations following a preliminary study revealed that 72 patients would be required in each group to detect a significant difference of 0.7 gdL. −1. in the post operative haemoglobin level (with power of 80% and an α value of 0.05). The patients were block randomized on reduction of the primary THR, prior to closure, to receive either two vacuum drains or the autologous retransfusion system. Results: There were 82 patients in the vacuum drain group and 76 patients in the autologous retransfusion group. Haemoglobin and haematocrit values were not significantly different between the groups but significantly fewer patients with the autologous system had a postoperative haemoglobin value < 9.0 gdL. −1. (8% vs. 20%, p = 0.035). Significantly fewer patients with the autologous system required HBT (8% vs. 21%, p = 0.022). There was an overall cost saving in this group. Discussion: This study confirms that POS results in significantly fewer patients with a post-operative Hb below 9.0 gdL. −1. and confirms that POS significantly reduces the necessity for homologous blood transfusion following primary THR. As a result, our unit uses the autologous retransfusion system for primary THR

Homologous blood transfusion (HBT) following primary total hip replacement (THR) is not without risk. Postoperative blood salvage (POS) with autologous blood transfusion may minimize the necessity for HBT but the clinical, haematological and economic benefits have yet to be clearly demonstrated for primary THR. The aim of this randomized prospective study was to determine if the use of POS affects postoperative haemoglobin levels, haematocrit and HBT requirement. Secondary outcomes included length of stay and patient satisfaction. A cost analysis was conducted on the basis of the results. The patients were randomized at the point of reduction of the primary THR to receive either two vacuum drains (82 patients) or an autologous retransfusion system (76 patients). Haemoglobin and haematocrit values were not significantly different between groups but significantly fewer patients with the autologous system had a postoperative haemoglobin value < 9.0 gdL. −1. (8% vs. 20%, p = 0.035). Significantly fewer patients with the autologous system required HBT (8% vs. 21%, p = 0.022). There was an overall cost saving in this group. This study has shown that use of an autologous retransfusion system for primary THR reduces the necessity for HBT and is cost effective

The purpose of this paper is to present the results of the comparative study about the use of autologous transfusion system for drainage of surgical trauma after total knee arthroplasty, aiming to decrease the p.o. homologous blood transfusion need. During the period between Nov 2001 and Apr 2003 we studied 110 patients (80 women and 15 men, mean age 70,5 years) who underwent TKR. We used autologous transfusion system in 55 patients (group A) and for the rest 55 (group B) a plain negative pressure drainage system. From the group B patients, 35 (63,63%) were transfused with 2–4 blood units, while only 17 (30,9%) patients from group A had the need for homologous blood transfusion (2–5 units). But, we should mark that in 8 patients autologous transfusion system failed and 7 of them were transfused (2 units each). This means that from group A patients to whom autologous transfusion system was used successfully (47) only for 10 (21,27%) there was need for homologous blood transfusion. The autologous transfusion system gave 200–1650cc (mean 619cc) of blood. None of group A patients and 2 of group B had allergic reaction. In conclusion, the autologous transfusion system contributes to decreasing the homologous blood transfusion after TKR and in addition it decreases the transfusion’s complications

Background: Autologous blood from reinfusion drains are commonly used after major joint arthroplasties with a view to decrease the heterologous blood transfusion requirement. The aim of this study is to find the effect of reinfusion drains on the difference in haemoglobin (Hb) level before and after total knee arthroplasties. Material and Methods: Between January 2001 and October 2003, 158 patients had total knee arthroplasty on one side. The type of thromboprophylaxis used was the same in all the patients. 74 patients had autologous blood transfusion through reinfusion drains (Group I) while 84 patients had no autologous blood transfusion and ordinary suction drains were used to drain the wound in the immediate postoperative period (Group II). The mean age was 72.1 +/− 8.5 in group I and 69.3 +/− 9.1 in group II. In each patient the preoperative Hb level, the amount of autologous blood transfusion, the postoperative Hb level and the amount of heterologous bleed transfusion requirement were noted. Results: The mean preoperative Hb level was 13.6 +/− 1.4 g/dL (10.4–18.1) in group I and 13.7 +/− 1.3 g/dL (7.9–16.5) in group II. The mean postoperative Hb level was 10.7 +/− 1.5 g/dL (10.4–18.1) in group I and 10.7 + 1.6 g/dL (5.4 +/− 13.6) in group II. The difference in Hb level between the two groups was analysed using t-test and found to be not significant (p = 0.76), with the mean difference between the groups being 0.05 and the 95% CI to the mean difference includes zero (range −0.3 to +0.4). The difference in Hb level before and after surgery was plotted against the amount of autologous blood transfused and it was observed that there was no significant improvement with increased amount of autologous blood transfusion. The cost of reinfusion drain is 36.43 (~ 53.37 Euros) more than the suction drain. Conclusion: Autologous blood from reinfusion drains did not significantly improve the postoperative Hb level. Further usage of reinfusion drain is not cost-beneficial

Purpose: The purpose of this study was to use the thromboelastogram to determine whether autologous blood transfusion following primary total knee replacement surgery results in an alteration to systemic coagulation. Methods: 44 patients were randomised to receive either Hartmann’s solution alone postoperatively (control group), or Hartmann’s solution and autologous blood at six hours (ABT group). Thromboelastogram measurements of systemic blood clotting were performed pre-operatively, and post operatively at 6h just prior to the commencement of the ABT, 6h 30mins, and 8h. Results: At 8h post operation (2h post ABT), the ABT group when compared with the control group showed an earlier onset of coagulation (3.83 minutes versus 4.49 minutes, p=0.003) and the formation of a stronger clot as assessed by the TEG maximum amplitude (maximum clot strength 83.9mm versus 75.9mm, p< 0.001). Conclusion: The transfusion of drained autologous blood following total knee replacement may lead to an exaggerated hypercoagulable postoperative state. Further investigation of this potentially serious consequence of autologous blood transfusion is required

Introduction: Elective joint replacement patients routinely require transfusion following surgery. Haemoglobin must remain within red blood cells in order to be functional. The process of surgery and collection in the reinfusion drain may disrupt cell membranes resulting in non functional haemoglobin. The filtration and collection process does not eliminate free haemoglobin. This results in intracellular and free haemoglobin being transfused into patients giving false functional haemoglobin levels. Aim: To determine the proportion of intracellular haemoglobin in autologous blood transfusion drain following joint replacement. Research Methodology: Research ethical approval was obtained prior to conducting this study. 20 consecutive patients undergoing elective total hip replacement (THR) and 20 consecutive patients undergoing elective knee replacement (TKR) from April 08–July 08 were consented to participate in this study. A standard full blood count sample of 3 mls was taken from the rein-fused blood. Each sample had the total haemoglobin (THb) concentration determined (i.e. free and intra-cellular) from the blood in the specimen tube. The sample was then centrifuged, and the THb of the supernatant was determined. This determined the concentation of ‘free’ haemoglobin. From these two respective values, the proportion of haemolysed haemoglobin was determined from each sample. Results: There were a total of 35 participants of which 20 were TKR and 15 were THR. The average THb concentration for the THR and TKR were 7.7g/dl and 10.3g/dl respectively. The proportion of haemolysed Hb was 1.46% and 0% respectively. The THb and proportion of haemolysed Hb for all 35 patients were 8.76g/dl and 0.63%. Conclusion: Autologous blood transfusion is not only safe and economical but remains an effective procedure with a negligible proportion of haemolysis

Introduction: Total knee replacement commonly results in postoperative requirement of blood transfusion. Allogeneic blood transfusion carries transfusion related risks, continuing effort to reduce allogeneic blood transfusion is important. The purpose of this study was to asses the economic justification of the use of an autologous blood transfusion after total knee replacement and to determine whether it reduces allogeneic blood transfusion and length of postoperative hospital stay. Patients and Methods: Retrospectively, 149 patients undergoing primary unilateral total knee replacement using vacuum drain were selected. Demographics, pre and postoperative haemoglobin were recorded. Need for allogeneic blood and postoperative hospital stay were also recorded. Results: 8% (n12) received allogeneic blood. The average amounts received were 2 units. Mean length of stay in those received allogeneic blood were (n12) 8.1 days. Mean length of hospital stay in those not transfused (n137) were 5.5 days (p< 0.05). The cost of allogeneic blood per patient £29.31. Total cost of retansfusion system per patients £60.8. Excess bed occupancy in those transfused £55.21. The cost saving for employing a retransfuion system (55.21+29.31)−60.8 = £24.44 per patient. Conclusion: Employing autologous retransfusion system is effective method of reducing allogeneic blood requirement. Retransfusion system will reduce in hospital stay to the level seen patients not transfused. There would be a significant economic benefit in utilising such system in district general hospitals

Introduction. Early rehabilitation and discharge following minimally-invasive total hip arthroplasty has potential risks including the possibility that patients may become progressively anemic at home. The current study assess the use of pre-emptive autologous blood transfusion on the length of stay, readmission, and allogenous transfusion. Methods. Patients treated by primary total hip arthroplasty using the superior capsulotomy technique were studied. Patients were divided into two groups. Group 1 were patients who did donate autologous blood and received an intra-operative pre-emptive transfusion. There were 283 patients in Group 1. Group 2 were patients who were medically capable of donating autologous blood but did not for non-medical reasons. There were 71 patients in Group 2. Patients who did not donate autologous blood for medical reasons (preoperative Hgb less than 11.5, age over 80) were excluded. All patients received general anesthesia. Length of stay, allogenous transfusion and readmission were compared. Results. The mean length of stay after surgery for the Group 1 patients who received autologous blood donation during primary THA was 1.56 days (SD 78 days, range 0–4). The mean length of stay for the Group 2 patients who did not donate or receive autologous blood during primary THA was 1.87 days (SD 84 days, range 1–4). Patients who received autologous blood donation had a significantly shorter post-surgical length of stay than patients who did not (p = .002, Mann-Whitney test). Patients who did not donate and preemptively receive autologous blood received significantly more allogenous blood (Mann-Whitney, p=.0004). Moreover 15% of those who auto-donated were given allogenic transfusions, while 37% of those who did not auto-donate were given allogeneic transfusions. One patient who did receive autologous transfusion and was discharged on day 2 sustained an NSAID induced GI-bleed 3 weeks postop and was admitted for transfusion and treatment. There were no other readmissions in either group. Conclusions. Patients who receive pre-emptive autologous blood transfusion intra-operatively when treated specifically by total hip arthroplasty using the superior capsulotomy technique under general anesthesia have shorter hospital stays and lower allogenous transfusion rates than a matched cohort of patients that did not donate and receive autogenous blood

Introduction: A prospective analysis of the total blood losses (TBL) and the rate of blood transfusions was conducted for the unilateral primary TKA performed at our clinic from January 2008 to March 2009. A transfusion-sparing strategy was used, based on the use of the tourniquet, the intraoperative injection of tranexamic acid and the preoperative administration of erythropoietin for patients with hemoglobin baseline level less than 13 gr/dl. The formula of Gross and the values of Gilcher were utilized to calculate TBL and to estimate the blood volume of the patient. No autologous blood transfusion systems were employed. The postoperative program consisted of pain control and anticoagulants. Results were compared with a historical cohort of patients operated on with the aid of cell salvage. Materials and Methods: One hundred – five patients (mean age, 73 years) were admitted to the study group and compared to an historic group including 44 patients (mean age, 70 years). No significant differences were found between the study arms regarding BMI (31 kg/m2), ASA score and operating time (65 minutes). Results: Mean TBL was 1560 ml versus 1821 ml in the historic group throughout the entire 8-day period. In the study group, TBL was significantly reduced in the patients who received tranexamic acid. In both groups, one patient received homologous blood transfusion. In the historic group, 41 of the 44 patients received autologous blood transfusion from reinfusion drains (mean volume 314 ml). Finally, the mean Hb at postoperative day 8 (POD 8) was 10,95 g/dl in the study group versus 10,35 gr/dl in the historic group (p< 0.01). Costs were superior in the study group in relation to the use of erythropoietin. No complications were related to the use of the blood –sparing pharmacologic agents. Discussion: This study confirms that recent improvements in surgical and anesthetic procedure allow for performing routine unilateral TKA with a marginal rate of blood transfusion when the procedure is achieved by an experienced team using a blood-conserving strategy. The strengths of this study include the calculation of blood loss and the homogeneity between the study arms. However the reduction of TBL related to the use of tranexamic acid was not evaluated within the setting of a randomized clinical trial. Furthermore, the results were obtained in patients having a high BMI. Conclusion: The blood transfusion sparing plan improved quality of care by reducing the risks of transfusion and maintaining a satisfactory Hb level at POD 8

The entirety of the patient experience after contemporary total knee and total hip replacements in 2017 is markedly different from that encountered by patients just a decade ago. Ten years ago most patients were treated in a traditional sick-patient model of care and because they were assumed to require substantial hospital intervention, many cumbersome and costly interventions (e.g. indwelling urinary catheters, patient-controlled-analgesic pumps, autologous blood transfusion, continuous passive motion machines) were a routine part of the early post-operative experience. Today the paradigm has shifted to a well-patient model with a working assumption that once a patient has been medically optimised for surgery then the intervention itself, hip or knee replacement, will not typically create a sick-patient. Instead it is expected that most patients can be treated safely and more effectively with less intensive hospital intervention. While as orthopaedic surgeons we are enamored with the latest surgical techniques or interesting technologies most busy surgeons recognise that advances in peri-operative pain management, blood management, and early-mobilization therapy protocols account for the greatest share of improvements in patient experience over the past decade. One can think pragmatically to get ahead and stay ahead of 3 predictable physiologic disturbances that adversely impact rapid recovery after knee and hip replacement: fluid/blood loss; pain; and nausea. The modern orthopaedic surgeon and his/her care team needs a simple strategy to pro-actively, not reflexively, manage each of those 3 predictable impediments to early recovery. Those surgical teams that routinely get ahead and stay ahead in each of those areas will routinely witness faster recovery, lower costs and greater patient satisfaction and that is clearly a win for patient and surgeon alike. Effective pain management improves patient satisfaction, decreases hospital stay, and facilitates discharge to home. Today's emphasis is on a multi-modal strategy that minimises the use of opioids. Most protocols use pre-operative medications including an NSAID, acetaminophen, an oral opioid and some include gabapentin. Regional anesthesia is typically preferred over general. Both peripheral nerve blocks and periarticular local anesthetic cocktail injections have proved as effective adjuncts in decreasing early post-operative pain. Post-operative oral medications delivered on a schedule, not just as needed, often include acetaminophen, an NSAID and some include gabapentin. Oral and parenteral opioids are reserved for breakthrough pain

The entirety of the patient experience after contemporary total knee and total hip replacements in 2016 is markedly different from that encountered by patients just a decade ago. Ten years ago most patients were treated in a traditional sick-patient model of care and because they were assumed to require substantial hospital intervention, many cumbersome and costly interventions (e.g. indwelling urinary catheters, patient-controlled-analgesic pumps, autologous blood transfusion, continuous passive motion machines) were a routine part of the early post-operative experience. Today the paradigm has shifted to a well-patient model with a working assumption that once a patient has been medically optimised for surgery then the intervention itself, hip or knee replacement, will not typically create a sick-patient. Instead it is expected that most patients can be treated safely and more effectively with less intensive hospital intervention. While as orthopaedic surgeons we are enamored with the latest surgical techniques or interesting technologies most busy surgeons recognise that advances in peri-operative pain management, blood management, and early-mobilisation therapy protocols account for the greatest share of improvements in patient experience over the past decade. One can think pragmatically to get ahead and stay ahead of 3 predictable physiologic disturbances that adversely impact rapid recovery after knee and hip replacement: fluid/blood loss; pain; and nausea. The modern orthopaedic surgeon and his/her care team needs a simple strategy to pro-actively, not reflexively, manage each of those 3 predictable impediments to early recovery. Those surgical teams that routinely get ahead and stay ahead in each of those areas will routinely witness faster recovery, lower costs and greater patient satisfaction and that is clearly a win for patient and surgeon alike. Effective pain management improves patient satisfaction, decreases hospital stay, and facilitates discharge to home. Today's emphasis is on a multi-modal strategy that minimises the use of opioids. Most protocols use pre-operative medications including an NSAID, acetaminophen, an oral opioid and some include gabapentin. Regional anesthesia is typically preferred over general. Both peripheral nerve blocks and periarticular local anesthetic cocktail injections have proved as effective adjuncts in decreasing early post-operative pain. Post-operative oral medications delivered on a schedule, not just as needed, often include acetaminophen, an NSAID and some included gabapentin. Oral and parenteral opioids are reserved for breakthrough pain

The entirety of the patient experience after contemporary total knee and total hip replacements in 2016 is markedly different from that encountered by patients just a decade ago. Ten years ago most patients were treated in a traditional sick-patient model of care and because they were assumed to require substantial hospital intervention, many cumbersome and costly interventions (e.g. indwelling urinary catheters, patient-controlled-analgesic pumps, autologous blood transfusion, continuous passive motion machines) were a routine part of the early post-operative experience. Today the paradigm has shifted to a well-patient model with a working assumption that once a patient has been medically optimised for surgery then the intervention itself, hip or knee replacement, will not typically create a sick-patient. Instead it is expected that most patients can be treated safely and more effectively with less intensive hospital intervention. While as orthopaedic surgeons we are enamored with the latest surgical techniques or interesting technologies most busy surgeons recognise that advances in peri-operative pain management, blood management, and early-mobilization therapy protocols account for the greatest share of improvements in patient experience over the past decade. One can think pragmatically to get ahead and stay ahead of 3 predictable physiologic disturbances that adversely impact rapid recovery after knee and hip replacement: fluid/blood loss; pain; and nausea. The modern orthopaedic surgeon and his/her care team needs a simple strategy to proactively, not reflexively, manage each of those 3 predictable impediments to early recovery. Those surgical teams that routinely get ahead and stay ahead in each of those areas will routinely witness faster recovery, lower costs and greater patient satisfaction and that is clearly a win for patient and surgeon alike. Effective pain management improves patient satisfaction, decreases hospital stay, and facilitates discharge to home. Today's emphasis is on a multi-modal strategy that minimises the use of opioids. Most protocols use pre-operative medications including an NSAID, acetaminophen, an oral opioid and some include gabapentin. Regional anaesthesia is typically preferred over general. Both peripheral nerve blocks and periarticular local anesthetic cocktail injections have proved as effective adjuncts in decreasing early post-operative pain. Post-operative oral medications delivered on a schedule, not just as needed, often include acetaminophen, an NSAID and some included gabapentin. Oral and parenteral opioids are reserved for breakthrough pain

Surgeons have widely disparate views on how to improve outcomes for patients following total knee arthroplasty. Over the past decade we have witnessed a remarkable transformation of the entire process of care surrounding total knee arthroplasty. The entirety of the patient experience after contemporary total knee replacement in 2015 is markedly different from that encountered by patients just a decade ago. Ten years ago most patients were treated in a traditional sick-patient model of care and because they were assumed to require substantial hospital intervention, many cumbersome and costly interventions (e.g. indwelling urinary catheters, patient-controlled-analgesic pumps, autologous blood transfusion, continuous passive motion machines) were a routine part of the early postoperative experience. Today the paradigm has shifted to a well-patient model with a working assumption that once a patient has been medically optimised for surgery then the intervention itself, knee replacement, will not typically create a sick-patient. Instead it is expected that most patients can be treated safely and more effectively with less intensive hospital intervention. While as orthopaedic surgeons we are enamored with the latest surgical techniques or interesting technologies most busy surgeons recognise that advances in perioperative pain management, blood management, and early-mobilization therapy protocols account for the greatest share of improvements in patient experience over the past decade. With that paradigm shift in the hospital/surgical part of the total knee experience comes renewed interest and emphasis on function after TKA. Most surgeons are well aware of a “satisfaction gap” between the results of total hip replacement and total knee replacement. While studies report varying percentages (based on the definition of satisfaction and particular patient populations) what is clear is that 10–20% of patients are not fully satisfied after knee replacement. Researchers have highlighted some of this discordance with the introduction of the Forgotten Joint Score. These researchers and others can consistently point to higher satisfaction or fewer residual symptoms in patients who have undergone hip arthroplasty versus knee arthroplasty. What is also interesting to note, however, is that even amongst otherwise healthy control patients there are more baseline symptoms referable to the knee than to the hip. This may indicate that with knee arthroplasty we are chasing a more elusive target than is the case in hip arthroplasty. Most surgeons today would agree that alignment plays an important role in TKA function and survival, but certainly factors other than alignment are also important in determining the survival of modern total knee replacements. The evidence suggests that ideal alignment after knee replacement is probably very specific for any given patient and influenced by individual differences. There is a complex interplay between limb alignment, component rotation, sizing, ligament balance, and gait dynamics. Moving forward, more attention needs to be devoted to function in knee replacement in order to improve patient satisfaction. While the mechanical axis has been useful, future improvements are dependent on hitting better targets. The historic focus on radiographic outliers to explain total knee failures has been incomplete at best and has possibly dulled and constrained our collective intellectual curiosity

Introduction. The purpose of this study was to determine the efficacy of a multi-modal blood conservation protocol that involved pre–operative autologous blood donations (2 units) in conjunction with erythropoietin supplementation as well as intra-operative conservation modalities. Methods. A retrospective chart review of 90 patients with simultaneous bilateral total knee arthroplasty done between 2006–2009 by one of the 3 senior authors was performed. Patients donated two units of blood 4 weeks prior to surgery and also received erythropoietin injections (40,000 units: 3 weeks, 2 weeks and 1 week prior to surgery). Intra- operative blood management included use of pneumatic tourniquet, re-infusion drains, local epinephrine injections and fibrin spray. Post-operatively, autologous transfusions were provided based on symptoms. Pre-donation blood levels, peri-operative hemoglobin and hematocrit levels along with transfusion records were assessed. Results. The mean pre-donation hemoglobin was 13.1 g/dL. After 2 units of autologous blood donation and procrit injections, the mean preoperative hemoglobin was 13.0 g/dL. The mean hemoglobin dropped to 9.8 g/dL on postoperative day 3. The mean drop in hemoglobin from preadmission testing was 3.3 g/dl. Overall, 30% patients required autologous blood transfusion and no patients required allogenic transfusion. Conclusion. This multi-modal protocol was effective in not only avoiding allogeneic transfusions following bilateral TKA but also resulted in high blood levels at the time of discharge. This protocol was effective in eliminating allogenic transfusions and maintaining blood levels

Introduction. The purpose of this study was to determine the efficacy of a Multi-modal Blood Conservation protocol that involves pre–operative autologous blood donations (2 units) in conjunction with Erythropoietin supplementation as well as intra-operative conservation modalities. Methods. A retrospective review of 104 patients with simultaneous bilateral total knee arthroplasty done between 2006-2009 was performed. Patients donated two units of blood, 4 weeks prior to surgery and also received Erythropoetin injections (40 k units 3weeks,2 weeks and 1 week prior to surgery). Intra- operative Blood Management included symptom-based transfusions, blood salvage devices, local epinephrine injections and fibrin spray. Pre-donation blood levels, peri-operative hemoglobin and hematocrit levels along with transfusion records were assessed. Results. The mean pre-donation hemoglobin was 13.1 g/dL. After 2 units of autologous blood donation and procrit injection, the mean hemoglobin was 13.0 g/dL. The mean hemoglobin dropped to a nadir of 9.8 g/dL on postoperative day 3. The mean drop in hemoglobin from preadmission testing was 3.3g/dl. Overall, 28 % patients required autologous blood transfusion and no patients required allogeneic transfusion if the protocol was followed. 6 patients (5.8%) did require allogeneic transfusions but all 6 were protocol violations and did not follow the proposed treatment regiment. Conclusion. This multi-modal protocol was effective in not only avoiding allogeneic transfusions following Bilateral TKA but also resulted in high blood levels at the time of discharge. This protocol was effective in eliminating allogeneic transfusions and maintaining blood levels

To determine the current practice of scoliosis surgery in the UK. A 10 point questionnaire was constructed to identify the philosophy of surgeons on various aspects of scoliosis surgery such as choice of implant, bone graft, autologous blood transfusion (ABT), cord monitoring and computer assisted surgery. Results are compared with the current best evidence. Consultants and Fellows attending the 2009 British Scoliosis Society meeting. 50 questionnaires were completed: 45 Consultants and 5 Fellows. All pedicle screw construct favored by 25/50, hybrid 24/50 (one undecided). Posterior construct of less than 10 levels, 20/50 would not cross-link, 11/50 used one and 19/20 used two or more. More than ten levels 17/50 considered cross-links unnecessary, 4/50 used one and 29/50 used two or more. 88% preferred titanium alloy implants, while a mixture of stainless steel and cobalt chrome was used by others. For bone graft, substitutes (24), iliac crest (14), allograft (12) and demineralised bone matrix (9) in addition to local bone. 10/50 would use recombinant bone morphogenetic protein (3 for revision cases only). 39/50 routinely used intra-operative cell salvage or ABT drains and 4/50 never used autologous blood. All used cord monitoring, Sensory (19/50), Motor (2/50) and combined (29/50). None used computer-aided surgery. 26 operated alone 12 operated in pairs and 12 varied depending on type of case. This survey has brought to light interesting variations in scoliosis surgery in UK. It may reflect the conflicting evidence in the literature

Allogenic blood is becoming a scarce commodity, with many advocating autologous retransfusion systems to reduce the transfusion burden post primary arthroplasty. Many units have not embraced this, as the costs involved are perceived to be prohibitively expensive. The inpatient stays of 149 consecutive patients undergoing primary total knee arthroplasty, performed in a single unit by multiple surgeons, were reviewed. Length of post-operative stays and blood transfusion requirements were noted, and cost implications of allogenic and autologous transfusion determined. The total post-operative transfusion requirement was 28 units of allogenic blood in 12 patients (8%). The total transfusion cost per patient was £28.80. With the cheapest autologous re-infusion system costing £60.08 per patient, a marginal cost of £31.28 would need to be offset, to make such a system viable solely from an economic point of view. The average post operative stay was increased from 5.6 to7.7 days in those requiring blood transfusion. This extra bed occupancy was estimated to cost a minimum of £42.68 per patient. Autologous drainage systems not only lessen the risks associated with allogenic blood, but have been shown previously to shorten hospital stay and significantly reduce allogenic transfusion requirement. By doing so, they would easily offset the increased expenditure needed to institute such a system

Introduction: There is an increasing trend for autologous blood transfusion in hip and knee replacement and we therefore felt the need to properties of the fluid reinfused. Objectives of the study: The study objective was to determine the volume and Haemoglobin content of the reinfused blood. Materials and methods: We prospectively studied 108 patients with primary Hip and knee arthroplasty. The drained blood was reinfused within 6 hours as recommended by the manufacturer. The volume of the drained and reinfused fluid was measured in millilitres.. The Haemoglobin (Hb.) of the patient was measured preoperatively and postoperatively in recovery. The Hb. of the drained blood and reinfused blood were also measured. Results : The mean volume of the drained blood in the hip replacement group was 180.6 ml. while that of the reinfused blood was 132.7 ml. The mean volume of the drained blood in the knee group was 372.78 ml. while that of the reinfused blood was 362.76 ml. The mean Haemoglobin of the reinfused blood in the hip group was 6.9 gm/dl significantly lower (p< 0.05) than the drained blood Hb. of 10.9. Similarly the Haemoglobin of the blood reinfused in knee replacements was significantly lower at 6.8 gm/dl. (p< 0.001). This was less than half of the average Hb. content of homologous blood transfusion. Conclusion: The Haemoglobin content of the reinfused blood in Hip and knee replacement was quite low to be considered as a replacement for homologous blood transfusion and further studies may be required to confirm the efficacy of reinfusion drainage compared to homologous blood transfusion

Introduction: There is an increasing trend for autologous blood transfusion in hip and knee replacement and we therefore felt the need to properties of the fluid reinfused. Objectives of the study: The study objective was to determine the volume and Haemoglobin content of the reinfused blood. Methods: We prospectively studied 108 patients with primary Hip and knee arthroplasty. The drained blood was reinfused within 6 hours as recommended by the manufacturer. The volume of the drained and reinfused fluid was measured in millilitres.. The Haemoglobin (Hb.) of the patient was measured preoperatively and postoperatively in recovery. The Hb. of the drained blood and reinfused blood were also measured. Results: The mean volume of the drained blood in the hip replacement group was 180.6 ml. while that of the reinfused blood was 132.7 ml. The mean volume of the drained blood in the knee group was 372.78 ml. while that of the reinfused blood was 362.76 ml. The mean Haemoglobin of the reinfused blood in the hip group was 6.9 gm/dl significantly lower (p< 0.05) than the drained blood Hb. of 10.9. Similarly the Haemoglobin of the blood reinfused in knee replacements was significantly lower at 6.8 gm/dl. (p< 0.001). This was less than half of the average Hb. content of homologous blood transfusion. Discussion: The Haemoglobin content of the reinfused blood in Hip and knee replacement was quite low to be considered as a replacement for homologous blood transfusion and further studies may be required to confirm the efficacy of reinfusion drainage compared to homologous blood transfusion