In recent years, reduction in the length of stay in patients undergoing UKA has gained considerable interest. This has led to development of ‘fast-track' and even day-case protocols aimed at decreasing length of stay (LOS), enhancing post-operative recovery and decreasing post-operative morbidity. One potential barrier to faster discharge and patient recovery is the need for post-operative haemoglobin checks and allogenic blood transfusion; which has been shown to increase LOS. Allogenic blood transfusion itself is not without risk, including immunological reactions, transfusion associated lung injury, infection and transmission of disease, thus reducing blood loss and the need for transfusion is imperative. Currently there is a knowledge gap regarding post-operative transfusion need and blood loss following UKA. We aimed to investigate blood loss and transfusion rates following UKA. Our primary aim was to evaluate the extent of post-operative transfusion need following UKA and identify which patients are at higher risk of needing transfusion. Following institutional approval, a retrospective analysis of all patients undergoing unicompartmental knee arthroplasty (UKA) at our level one academic university hospital was conducted. Operative records of all patients undergoing primary UKA were reviewed between March 2016 and March 2019. Patients' pre-operative haemoglobin and haematocrit, BMI, co-morbidities, application of tourniquet, tourniquet time, administration of Tranexamic Acid, need for post-operative blood transfusion, hospital length of stay, complications and re-admission were all recorded. Blood loss was estimated using the post-operative haematocrit. A total number of 155 patients were included. There were 70 females (45%) and 85 males (55%). The mean age was 66±10 years. Median pre-op blood volume was 4700mls (IQR; 4200–5100). Median blood loss was 600 mls (IQR; 400–830). Mean pre-op Haemoglobin was 135±14g/L and mean post-op Haemoglobin was 122±13g/L. No patient had a post-op Haemoglobin under 80g/L (Range 93–154). No patients in our study needed transfusion. A further comparison group of high-blood loss and low-blood loss patients was included in analysis. High-blood loss patients were defined as those losing greater than 20% of their pre-operative blood volume whilst low-blood loss patients were defined as those losing ≤20% of their blood volume. Results of these groups are presented in Table 3. No significance was found between the two groups in patient's demographics and in terms of intra-operative factors including TXA usage (p=0.68) and tourniquet time (p=0.99). There was no difference in terms of post-operative complications (p=1.0), length of stay (p=0.36) or readmission rates (p=0.59). The results of our study indicated that post-operative haemoglobin and haematocrit check proved unnecessary in all of our patients and could have been omitted from post-operative routines. We conclude that routine post UKA check of haemoglobin and haematocrit can be avoided and be saved for special circumstances depending on patient's physiology

Background. Non-invasive hemoglobin measurement was introduced to potentially eliminate blood draws postoperatively. We compared the accuracy and effectiveness of a non-invasive hemoglobin measurement system with a traditional blood draw in patients undergoing total joint arthroplasty. Methods. After IRB approval, 100 consecutive patients undergoing primary total hip or knee arthroplasty had their hemoglobin level tested by both traditional blood draw and a non-invasive hemoglobin monitoring system. Results were analyzed for the entire group, further stratifying patients based on gender, race, surgery (THA versus TKA), and post-operative hemoglobin level. Finally, we compared financial implications and patient satisfaction with the device. Paired t-test with 0.05 conferring significance was used. Stratified analyses of the absolute difference between the two measures were assessed using Mann- Whitney test. To assess the level of agreement between the two measures, the concordance correlation coefficient (CCC) was calculated. Results. Mean blood-draw hemoglobin value on POD1 was 11.063 ± 1.39 g/dL and 11.192 ± 1.333 g/dL with the non-invasive device. For all patients, the mean absolute difference between the two methods was 0.13 g/dL (p = 0.30). The CCC between the two methods was 0.58, conferring a moderate to strongly positive linear relationship (Figure 1). Non-invasive measurement was preferred by 100% of patients with a mean VAS score of 0/10. Additionally, the cost savings with the non-invasive system was $16.50 per patient. Discussion. Overall, there was no significant difference between the hemoglobin level obtained by traditional laboratory methods versus the Masimo Radical-7 system on post-operative day #1 in patients who underwent total joint arthroplasty. In the minority of patients (19%) who had a hemoglobin level of less than 10 g/dL, the difference between the two methods was statistically significant. Additionally, 100% of patients preferred the Masimo device to a traditional blood draw and the Masimo device was substantially cheaper. While further investigation of non-invasive hemoglobin monitoring systems is necessary, particularly in patients with a post-operative hemoglobin of less than 10 g/dL, our study shows that the Masimo Radical-7 device provides an accurate, preferable, and less expensive alternative to a traditional blood draw after total joint replacement. Conclusion. Overall, the non-invasive hemoglobin monitoring system offered a similar hemoglobin reading to the standard lab-draw reading, while improving satisfaction and lowering cost. The system relies on adequate perfusion for measurement, and our study demonstrated that lower hemoglobin values may reduce finger-tip perfusion and affect the hemoglobin reading

Shoulder replacement surgery is a well-established orthopaedic procedure designed to significantly enhance patients’ quality of life. However, the prevailing preoperative admission practices within our tertiary shoulder surgery unit involve a two-stage group and save testing process, necessitating an admission on the evening before surgery. This protocol may unnecessarily prolong hospital stays without yielding substantial clinical benefits. The principal aim of our study is to assess the necessity of conducting two preoperative group and save blood tests and to evaluate the requirement for blood transfusions in shoulder arthroplasty surgeries. A secondary objective is to reduce hospital stay durations and the associated admission costs for patients undergoing shoulder arthroplasty. We conducted a retrospective observational study covering the period from 1st January 2023 to 31st August 2023, collecting data from shoulder arthroplasty procedures across three hospitals within the Aneurin Bevan University Health Board. Our analysis included 21 total shoulder replacement cases and 13 reverse shoulder replacement cases. Notably, none of the patients required postoperative blood transfusions. The mean haemoglobin drop observed was 14 g/L for total shoulder replacements and 15 g/L for reverse shoulder replacements. The mean elective admission duration was 2.4 nights for total shoulder replacements and 2 nights for reverse shoulder replacements. Our data indicated that hospital stays were extended by one night primarily due to the preoperative group and save blood tests. In light of these findings, we propose a more streamlined admission process for elective shoulder replacement surgery, eliminating the need for the evening-before-surgery group and save testing. Hospital admissions in these units incur a cost of approximately £500 per night, while the group and save blood tests cost around £30 each. This revised admission procedure is expected to optimise the use of healthcare resources and improve patient satisfaction without compromising clinical care

Introduction: Several patients with fracture neck of femur were noted to have alarmingly low postoperative haemoglobin unexplained by the intra-operative and postoperative blood loss. We conducted this study to determine the magnitude of preoperative fall in haemoglobin in patients with hip fractures. Methods: Full blood count was repeated after a minimum of 12 hours of fluid resuscitation in 50 consecutive patients admitted with fracture neck of femur. Patients requiring blood transfusion prior to collection of second specimen were excluded. Patients were grouped according to the type of fracture (intracapsular, inter-trochanteric and sub-tro-chanteric). Results: The average drop in haemoglobin of 0.8 (range,0–2.1), 0.8 (range,0–2.8) and 2.5 (range,0.6–4.9) gm/dl in intracapsular, inter-trochanteric and sub-trochanteric fractures respectively were statistically significant in all three groups (student-t-test, p-value < 0.05) but appears to be clinically significant in only sub-trochanteric group. By close analysis of data it is noted that although average drop in first two groups is low but at least 15 % of patients in both groups dropped their haemoglobin by 2 gm/dl or more. This can be compounded by the drop in haemoglobin following surgery, the average of which was 2.5 gm/dl (range,0–6.4). Discussion and Conclusion: During this study at least 5 patients were saved from going to theatre with dangerously low haemoglobin with no cross-matched blood. There is clinically significant drop in haemoglobin prior to surgery in patients admitted with fracture neck of femur. On admission haemoglobin can be falsely reassuring. We recommend all patients with sub-trochanteric fracture and all patients with intra-capsular and inter-trochanteric fractures with haemoglobin of 12 gm/dl or less to have a repeat haemoglobin check prior to their surgery. This practice may reduce the morbidity and mortality associated with very low haemoglobin in this group of patients with high pre-existent co-morbidities

Introduction. There is a paucity of studies analyzing the rates of revision total knee arthroplasty in diabetic patients stratified by glycated hemoglobin levels. The purpose of this study was to: 1) determine the incidence of revision TKA; 2) correlate the percent of glycated hemoglobin with incidence of revision; and 3) determine the cause of revision in diabetic patients stratified by glycated hemoglobin level. Methods. We utilized a national private payer dataset within the PearlDiver database from 2007 to 2015 quarter 1 to determine who had diabetes and underwent TKA. There were 424,107 patients who were included in the analysis. We determined the incidence of revision TKA in the overall cohort, in addition to stratifying the incidence by glycated hemoglobin levels. To determine the effect of glycated hemoglobin levels on revision TKA rate, we performed a correlation analysis between the level of glycated hemoglobin and the incidence of revision TKA. We performed descriptive statistics of the underlying cause of revision TKA in both the overall and stratified cohorts. Results. There was a 3.2% incidence of revision in the overall cohort. When stratified by glycated hemoglobin levels, the cohort in the 6.6 to 7.0% category had the lowest incidence of revision (2.9%). The cohorts in the 8.6 to 9%, 5.1 to 5.5%, and 4.6 to 5%, glycated hemoglobin categories had the highest revision rates of 3.7, 3.7 and 4.7%, respectively. There was a significantly positive correlation between rate of revision and ascending glycated hemoglobin levels, and significantly negative correlation between descending glycated hemoglobin levels and revision incidence. The most common cause of revision was infection in the overall and stratified groups. Conclusion. Sub-optimal glycated hemoglobin levels in diabetic patients correlated with increase revision rates in those who underwent TKA. This may imply that management of blood glucose levels should be optimized before undergoing total knee arthroplasty to minimize revision surgery risk

Introduction. Allogeneic blood transfusion (ABT) remains a widely used therapeutic intervention in patients undergoing total knee arthroplasty (TKA). There is mounting evidence that tranexamic acid (TXA), a powerful antifibinolytic, can significantly reduce perioperative blood loss with a concomitant lower ABT rate. In May 2012, TXA intravenous infusion was introduced as standard therapy in all patients undergoing major hip and knee arthroplasty. The TXA protocol included infusing 1 gm prior to incision and 1 gm after lowering the tourniquet. Nadir hemoglobin (Hb) level has been shown to be the single most important predictor of ABT in patients undergoing TKA. It is often used as the main trigger for ABT and in research trials examining restrictive transfusion trials. There is a paucity of information regarding the impact of TXA on Hb levels in patients undergoing primary TKA. The purpose of this retrospective study was to examine the impact of TXA on hemoglobin levels in primary TKA patients. Methods. Patients undergoing primary single, or bilateral, TKA from a single orthopedic surgeon from the years 2009–2010 before TXA infusion (n=78) were compared to patients undergoing the same operation after TXA was introduced as a therapeutic intervention (n=97). TKA is a very standardized operation that has stayed consistent over the convening years in terms of surgical technique and intra-operative management. The following Hb values were selected for analysis between the two groups: pre-surgical Hb value, immediate post-operative Hb, nadir Hb, and discharge Hb. Paired t-test was used for analysis with p-value set at 0.05. Additional data analysis included: length of stay (LOS) and rate of ABT. Results. Demographically, the control group was younger compared to the experimental group (60 vs. 64 years). Table 1 shows the difference in the selected Hb values between the two groups. There was no difference in Hb values going into surgery between the two groups. For all other Hb values, there was a significant difference between the control group and the TXA group throughout the postoperative period. In addition, Hb drift was significantly lower in the TXA group compared to the control group by 0.7 g/dl. ABT rate was 4% for the TXA group and 50% for the control group. The control group had a higher LOS compared to the TXA, 4.9 vs. 4.3 days. Conclusion. TXA infusion in the intraoperative period is an effective therapeutic intervention for reducing the downward drift of Hb levels throughout the postoperative period in patients undergoing TKA, and in turn, significantly impacts ABT rate and resource utilization

Introduction. Neck of femur (NOF) fractures are one of the predominant reasons for hospital admissions in patients >65 year. These fractures are associated with a poor outcome; end to independent living in 60% of patients and a 6 month mortality of 30%. Previous studies have shown show elements of under/mal-nutrition on admission. In addition, their nutritional status shows some deterioration thereafter. The aim of this present study is to examine if the nutritional status of patients with NOF fracture admitted at our institution is associated with a larger post-operative haemoglobin drop. This is compared to an independent living age matched control group from the same geographical area. Methods. A retrospective audit of pathology results for three hundred fracture patients (n = 300) and one hundred age matched home living group pre-assessed of total hip replacement (n = 100). Total serum protein, albumin, total lymphocyte count levels were determined at the time of admission to assess nutritional status. Pre/post-operative haemoglobin, resultant haemoglobin drop, and 6 month mortality was assessed in NOF fracture patients. The nutritional parameters were correlated with the haemoglobin levels and mortality. Results. Fracture patients were found to be malnourished on hospital admission. 10% showed a total serum protein level of <60g/L, 21% showed an albumin level of <35 g/L and 66% had on a total lymphocyte count of <1,200 cells/ml. When compared to an age matched home living group, fracture patients had a significantly (p = <0.0001) lower protein (67.4 vs 74.5), albumin (38.8 vs 43.9) and total lymphocyte counts (1173.3 vs 1840.8). Pre/post-operative haemoglobin showed a positive correlation with albumin and protein levels (p = <0.01). Haemoglobin drop post-operatively showed a negative correlation with albumin and protein levels (p = <0.01). 6 month mortality was correlated with albumin, protein, and total lymphocyte count levels. Discussion. This study confirms that patients admitted with NOF fractures are malnourished on admission. In addition, we report that not only pre-operative haemoglobin is correlated to the malnourishment but also the post-operative haemoglobin drop is correlated to albumin/protein levels on admission. This leads us to hypothesise that these malnourished patients have a higher bleeding tendency. Thus, we propose that malnourishment can be identified by the orthopaedic team using relatively inexpensive laboratory tests such as albumin, protein and total lymphocyte count. Thereafter, appropriate measures should be instituted to prepare for intra/post-operative bleeding and higher need for blood transfusion

Introduction: During the postoperative follow up of patients who underwent primary total hip replacement, it was observed that the haemoglobin concentration had dropped more than expected when compared to the intra and postoperative (drain) loss. This study was carried out to ascertain whether this drop in haemoglobin reflects a real blood loss or is due to hemodilution secondary to intravenous fluids, or both. Also to establish the average amount of blood loss responsible for the drop of one gm of haemoglobin concentration, in order to confirm or alter the old belief that every 500ml of blood loss is responsible for 1 gm drop in Hb concentration. Method: A prospective study was carried out to include 20 patients undergoing primary total hip replacement due to osteoarthritis in the period, March to November 2006. 2 drains were used, one was deep and the other was superficial. 7 samples of haemoglobin were taken in every case. The first sample preoperatively, the second postoperatively in the recovery room, the third and forth samples taken 6 hours postoperatively from the patient and the deep drain. The fifth and sixth samples from the patient and the deep drain 24 hours postoperatively. And the last sample from the patient 5 days postoperatively. Also the IV Fluids given were recorded in the first 24 hours. Results:. The Hb concentration in the deep drain was gradually decreasing over the first 24 hours after the operation when compared to the patient’s Hb which means that the total volume of the drain loss doesn’t mean an equal volume of blood loss. The second drain which was inserted superficial to the iliotibial tract showed blood loss with an average of 11.2% of the total blood loss and this amount is usually missed in calculating the blood loss when using one deep drain only. The average blood loss responsible for the drop of one gram Hb was variable. It was 258 ml when comparing intraoperative blood loss with the immediate postoperative patient’s Hb. This increased to 341 ml when comparing the drain blood with the patient’s Hb 24 hours after the operation due to the above mentioned changes in RBCs concentration in the drain over the first 24 hours postoperatively. IVF has no effect in giving false readings of the Hb

Introduction: Failure to meet rehabilitation targets after total knee replacement is the main reason for delayed discharge in our orthopaedic unit. Low haemoglobin levels are associated with increased length of stay possibly due to poor participation in physiotherapy and delayed attainment of the functional goals necessary for safe discharge. This report describes the rehabilitation of patients with post operative haemoglobin levels between 7.1–8g/dL and provides a comparison with individuals rehabilitating with much higher levels. Materials and Methods: Case notes of 64 primary total knee replacements over the period January – October 2007 (10 months) were reviewed in a comprehensive retrospective analysis. All aspects of care were standardised. Joint replacements were performed using recognised surgical techniques and implants. Patients were given access to a minimum of two physiotherapy sessions each day, 6 days a week. Typical gait re-education began with the delta rolator frame progressing to walking sticks, stair assessment and finally discharge. Care pathways, operative and medial notes were reviewed for postoperative haemoglobin levels, complications and achievement of functional physiotherapy targets. Results: 8 of 64 patients were found to have a postoperative haemoglobin level bellow 8g/dL (sample average 10.2g/dL). 3 of these patients underwent transfusion for levels bellow 7g/dL and were excluded from further analysis. 5 patients began rehabilitation with haemoglobin levels between 7.1–8g/dL. All 5 mobilised with the delta frame on post op day one, progressed to sticks between days two to four and managed a stairs assessment on postoperative days two to five with an average inpatient stay of six days. Conclusion: These gains were almost identical to the overall sample average suggesting that in isolation, haemoglobin levels between 7.1–8g/dL do not significantly impede postoperative rehabilitation. It would seem there is no justification for ‘top up’ transfusions to expedite rehabilitation after joint replacement surgery in this patient group

Aim: To compare the acute haemoglobin level drop following hip fracture fixation with IMHS and CHS at James Cook University Hospital and assess whether the surgeon’s seniority has any effect on the amount of blood loss in these two procedures. Methods: Trauma data base was searched for all IMHS procedures performed from January 2002 till March 2007 both included and CHS procedures performed from January 2007 till March 2008 both included. There were 159 CHS procedures and 146 IMHS procedures. 137 CHS and 123 IMHS procedures fulfilled the blood testing and transfusion criteria. Haemoglobin levels were used as an indication for blood loss attributable to surgery. The difference between the last level of haemoglobin checked preoperatively and the first post operative level performed between 12–48 hours postoperatively is calculated. Cases where blood transfusion was carried out preoperatively without further preoperative haemoglobin check were excluded, so were cases receiving intra or post operative blood transfusion prior to the defined postoperative haemoglobin check was carried out. Results: SPSS 13.0 statistical package was used to analyse the results. Levene’s test proved equality of variances of blood loss within the two groups of patients undergoing one of the two procedures, P=0.5. Hence, Independent Samples T test was applicable and showed that patients undergoing an IMHS procedure dropped their haemoglobin levels by 2.96 g/dl. While, those undergoing a CHS procedure dropped their haemoglobin levels by 2.32 g/dl. The 0.64 g/dl difference in haemoglobin drop was statistically significant at 5% significance level with 95% CI (0.27 to 1.01), P=0.001. The surgeons’ grades were classified into three groups as: Consultants, Registrars and Senior House Officers. Levene’s test again proved the variances of haemoglobin drop within each group to be homogeneous. Hence a One-Way ANOVA test was carried out showing that the differences in haemoglobin drop were not statistically significant when comparing the three groups of surgeons to each other. This was true for both IMHS and CHS procedures. Conclusion: Patients undergoing a CHS procedure drop their haemoglobin levels by 0.64 g/dl less than those undergoing an IMHS procedure. The surgeon’s seniority does not make difference to the amount of haemoglobin level drop following either of the two procedures. We recommend the use of CHS for stable fractures and reserve the IMHS for the unstable ones due to the increased blood loss with IMHS procedures

Context: Diabetes is associated with a several fold increase in the risk of lower extremity amputation. Although a number of epidemiologic studies have reported positive associations between glycaemia and lower extremity amputation, the magnitude of the risk has not been adequately quantified. Objective: To synthesize the available prospective epidemiologic data on the association between glycaemia as measured by glycosylated haemoglobin and lower extremity amputation in individuals with diabetes. Data Sources: We searched electronic databases (MED-LINE and EMBASE) and the reference lists of relevant articles. Study Selection: We considered prospective epidemiologic studies of cohort or nested case-control design that measured glycosylated haemoglobin level and assessed lower extremity amputation as an outcome. Of 2,398 citations identified, we included 14 studies comprising 94,640 subjects and 1,227 cases. Data Extraction: Data were abstracted using standardized forms or obtained from investigators when published information was insufficient. Data included characteristics of case and control populations, measurement of glycaemia, assay methods, outcome, and covariates. Results: The overall risk ratio for lower extremity amputation was 1.26 (95% CI, 1.16–1.36) for each percentage point increase in glycosylated hemoglobin level. There was significant heterogeneity across studies (I2: 76%, 67–86%; p< 0.001) not accounted for by recorded study characteristics. Among studies that reported the type of diabetic population, the combined estimate was 1.44 (1.25–1.65) for individuals with type 2 diabetes and 1.18 (95% CI, 1.02–1.38) for type 1 diabetes, but the difference was not statistically significant (p=0.09). We found no significant publication bias. Conclusions: There a substantial increase in risk of lower extremity amputation associated with every 1% higher HbA1c in individuals with diabetes, highlighting a potential benefit of blood glucose control. In the absence of evidence from clinical trials, this paper supports glucose-lowering as a component of overall care in the patient at high risk of amputation

Objective: To examine the impact of aspirin and non-steroidal anti-inflammatory drugs (NSAIDs) on preoperative haemoglobin levels and perioperative transfusion rates in patients undergoing total knee arthroplasty (TKA). Methods: We examined the pre-operative haemoglobin (Hb) and haematocrit (Hct) of a consecutive series of 81 patients, looking at the relationship between the pre-operative use of Aspirin/NSAIDs on preoperative Hb, postoperative Hb deficit and the perioperative transfusion rate. A single surgeon performed all procedures using an LCS TKR (Depuy, Leeds UK). A standardised transfusion protocol was used. Results: The patients were grouped according to their pre-operative use of aspirin or a NSAID, singly or in combination. The patient groups are as shown in the table below. All groups were comparable for age, BMI and ASA grade. Results show a significantly higher transfusion rate (p=0.048) in the group of patients who received a combination of aspirin and a NSAID compared to the other groups. The patients on aspirin or a NSAID alone also had an increased transfusion rate but the increase was not statistically significant (p=0.12 and p=0.07 respectively). Conclusion: The use of both aspirin and an NSAID in combination leads to a lower preoperative Hb and an increased post-operative transfusion requirement following total knee arthroplasty

It is well recognised that patients with diabetes mellitus have a predisposition towards stenosing flexor tenosynovitis (FTS). However, recent research has suggested an association between the development of FTS and haemoglobin A1c (HbA1c) level which is used as a marker of glycaemic control. National guidelines on management of diabetes suggest treatment should aim to maintain HbA1c at <6.5%. The aim of our study is to quantify glycaemic control in patients undergoing surgical A1 pulley release. We retrospectively reviewed the blood results of 78 patients who underwent FTS surgery. 27 of these had an HbA1c checked within 6 months of their surgery and we therefore presumed these patients were diabetic. For diabetic patients the average HbA1c was 7.9% (range 5.3–11.4) and only 7 of the 27 patients had an HbA1c within the recommended range. In this cohort 33% of patients were presumed diabetic and 74% of these had a documented HbA1c above the national target suggesting a significant number presenting for surgery have poor glycaemic control. Therefore it may be of benefit to screen for this in patients undergoing FTS surgery

Introduction. Tranexamic acid (TXA) reduces total knee replacement (TKR) & total hip replacement (THR) blood loss. We launched a ‘fast track’ protocol to reduce inpatient stay including a single 15mg/kg dose of TXA. We conducted a retrospective cohort analysis on haemoglobin balance and transfusion requirement before and after the protocol, which aimed to reduce blood loss during lower limb arthroplasty. Methods. Patients undergoing primary cemented THR or TKR were drawn from the periods: control 1/10/06 to 31/3/07; fast track 1/4/08 -31/7/08. We identified pre- and post-operative Day 1 haemoglobin concentration (Hb g/dl), and transfusion number & timing. Transfusion trigger was Hb<8 unless symptomatic. In patients transfused before the Day 1 assay, we corrected Hb drop for number of units given, (1 unit ≍ 1g/dl). Outcome measures are Day 1 Hb drop corrected for transfusion (t-test) and number transfused (Chi-squared). Results. We excluded 3 patients pre-operatively. All patients had pre-operative Hb & all apart from 9 (excluded) fast track patients had Day 1 Hb assay. Conclusions. Correcting Hb drop for transfusion gives a single measure of blood loss independent of clinical management. The protocol demonstrated reduced blood loss of about 50% in TKR and 30% in THR, and reduced transfusion rates. Other studies show comparable reductions using maintenance dosing. A single dose of 15mg/Kg TXA before incision is as effective. The fast track protocol reduced in-patient stay from 5.5 to 2.3 days. Reduction in peri-operative blood loss may make an important contribution to recovery

120 patients undergoing primary TKR/THR were randomised to receive ferrous sulphate (FS) or placebo (P) for three weeks following their arthroplasty. Haemoglobin levels and absolute reticulocyte counts were measured at days 1 and 5, and weeks 3 and 6. Ninety-nine patients FS (50), P (49) completed the study. The two groups differed only in treatment administered. Haemoglobin recovery was similar at day 5 and by week 3, haemoglobin levels recovered to 85% of their pre-operative levels, irrespective of treatment group. A small but greater recovery in haemoglobin level was identified at 6 weeks in the FS group for females (6% Vs 3%) and males (5% Vs 1.5%). The clinical significance of this is questionable and may be outweighed by the high incidence of reported side effects of oral iron, and the economic costs of the medication. Administration of iron supplements following elective TKR or THR does not appear to be a worthwhile practice

Study Purpose: To investigate whether the use of reinfusion drains and post-operative autogenous blood transfusion reduces the rate of allogeneic blood transfusion after primary total knee replacement in our unit. Methods: A prospective audit was carried out over a 14-week period. Patients received either a reinfusion drain, a suction drain or no drain according to surgeon preference. Post-operative allogeneic blood transfusion criteria were based on clinical indication rather than an absolute haemoglobin level. Results:127 consecutive patients underwent total knee replacement during the study period. Patients were matched between the three groups for age, medical co-morbidity, DVT prophylaxis, and implant used. Conclusion: The use of reinfusion drains did not significantly reduce the requirement for post-operative allogeneic blood transfusion. This directly contrasts much of the published literature

Introduction: Blood management in the perioperative period of the total joint arthroplasty procedure has evolved over the last 3 decades. We performed two separate studies:. 1) observational study to analyse surgeon’s and anaesthetist’s attitude to transfusion. 2) prospective study to analyse the influence of perioperative haemoglobin concentration (Hb) on post-operative fatigue, hand grip strength, duration of in-patient physiotherapy and post-operative morbidity score (POMS) and also the prognostic factors to predict functional recovery. Method: 500 orthopaedic surgeons and 336 anaesthetists were surveyed to assess current UK attitudes towards transfusion practice following arthroplasty. 200 patients (88 THR, 99 TKR, 13 hip resurfacing) were evaluated. Blood Hb, hand grip strength and vigour scores using fatigue questionnaire were estimated both preoperatively and at 3 days following surgery. POMS and the required duration of in-patient physiotherapy were also noted. The protocol for blood transfusion was for those with Hb less than 8 g/dL and/or post-operative symptoms attributable to anaemia. Results: In an uncomplicated patient following total hip arthroplasty, 53.2% of surgeons and 63.1% of anaesthetists would transfuse at or below Hb of 8g/dL. Mean transfusion threshold in surgeons was 8.3g/dL compared to 7.9g/dL for anaesthetists (p< 0.01). 97% of surgeons transfused two or more units compared to 78% anaesthetists (p< 0.01). This threshold Hb increased if patient was symptomatic (surgeons 9.3g/dL, anaesthetists 8.8g/dL, p< 0.05), or if known to have pre-existing ischaemic heart disease (surgeons 9.0g/dL, anaesthetists 9.2g/dL, p< 0.05). A greater fall in postoperative Hb correlated significantly with a greater reduction in post-operative vigour score (p=0.02). Also a greater fall in vigour score was found to correlate significantly with the duration of in-patient physiotherapy (p< 0.001). A reduction in Hb of > 4g/dL from the pre-operative Hb predicted a significantly higher reduction in vigour score (p=0.03). A weak correlation was seen between a fall in Hb and POMS (p=0.09). A higher pre-operative Hb did not reduce the required duration of in-patient physiotherapy (p=0.72). There was no correlation between post-operative Hb and POMS (p=0.21) or duration of in-patient physiotherapy (p=0.20). A higher pre-operative grip strength predicted an early date of discharge by the physiotherapists (p=0.02). Conclusion: Haemoglobin level below 9g/dL is the most common ‘trigger’ for blood transfusion. Surgeons tend to be more aggressive in their attitude to transfusion. A fall in Hb of more than 4 g/dL has a detrimental effect on post-operative rehabilitation. Pre-operative grip strength measurements are valuable in predicting the rehabilitation potential of patients undergoing lower limb arthroplasty

Introduction: We present the results of a prospective study of the blood transfusion requirements in patients undergoing a Bernese periacetabular osteotomy (PAO) with the use of an intra-operative cell-saver and without pre-donated blood. These data were compared with an earlier audit of patients who underwent this procedure without use of a cell saver. Material and Methods: A cohort of 50 patients (56 hips) underwent a PAO for hip dysplasia between December 2006 and November 2008 performed by the senior author. The average age was 29 years (17–51) and there were 38 females and 12 males. The average weight was 69.96 kg (46–110) and the mean duration of operation was 136 minutes (100–240). A cell saver (Fresenius-Hemocare, Germany) was used intra-operatively for this cohort. Pre-operative Hb, post-operative Hb taken the day after surgery and any units transfused were documented. A post-operative transfusion policy was adopted where a haemoglobin (Hb) concentration of < 7.5 g/dl was an indication for transfusion or where a patient was sufficiently symptomatic. Results: The mean pre-operative Hb was 13.60 g/dl (10.8–15.9) and the mean post-operative Hb was 9.91 g/dl (6.4–11.8). Overall 4 patients received post-operative allogenic blood transfusion; 3 patients receiving one unit and one patient receiving 2 units. No patients received intra-operative allogenic blood. Conclusion: Compared to our previous audit, the use of the cell saver resulted in an improvement in the mean post-operative Hb, (9.2 g/dl compared to 8.0 g/dl). The transfusion rate was also reduced (7.27% compared to 10.8%)

Background and Objective. Patients undergoing hip fracture surgery have a high peri-operative mortality rate. We performed a retrospective study to ascertain if there is any relation between postoperative haemoglobin (Hb) decrease and cardiac related events following the surgery. Methodology. We carried out a retrospective study in this University Hospital's trauma unit. All patients operated for fracture neck of femur (hemiarthroplasty and DHS – Dynamic Hip Screw) between July 2006 and August 2008 were included in the study. Electronic records from the trauma unit, pathology portal, operating theatre and blood bank were obtained to identify the pre-operative and post-operative Hb levels, amount of blood transfused and Troponin T (TnT) level. Results. A total of 632 patients were operated for fracture neck of femur surgery during the study period of which 616 had complete perioperative blood results (DHS: 341; 80 male and 261 females and Hemiarthroplasty: 275; 68 male and 207 females). 60 patients had TnT levels performed within 10 days of the operation, thus suggesting possible cardiac related symptoms. Of these, 25 patients had a raised TnT (= 0.03). 24 (96%) of these patients had a post-operative Hb decrease compared with 550/591 (93%) patients without TnT (mean 2.3, range 0.1-5.6 g/dl compared with a mean of 2.4 and a range of 0-7 g/dl). Scatter diagram illustrated a positive correlation between post-operative Hb drop and TnT rise. Linear regression analysis concluded that a post-operative Hb drop is significantly correlated to TnT rise at the 10% level (p = 0.064). Conclusions. Post-operative Hb decline correlates with a raised TnT. As a standard protocol, post-operative bloods including Hb are performed the day after surgery. Given the correlation demonstrated, we recommend Hb levels to be analysed on day of surgery, to effectively manage low Hb levels before cardiac symptoms can develop

Aims: We decided to investigate the efþcacy of postoperative Epoetin Alfa in decreasing allogenic transfusion exposure in patient who had an mediummajor orthopaedic intervention who could conduct in major loss of blood. Material-Method: Between July 2000-Mars 2002 in our department a trial was conducted comparing the safety and efþcacy of a weekly epoetin alfa dosing regimen (40000⋄4) with a daily regimen (10000⋄15) in patients with hemoglobin levels 9g/dl< Hb< 11g/dl in the 2nd postoperative day after a major orthopaedic procedure. The average age was 28–85y. Results: In the þrst group (24p) there was a increase of the Ht 6units and in the 2nd group 4units. In the þrst group we had a death in the 13een postoperative day from diffuse intravascular coagulation. In both groups the rehabilitation and discharge of the patients were quicker and there was no postoperative transfusion. In 9 cases of the þrst group and only in 2 of the second we observed a enormous augmentation of the platelets (600000–1000000) but without any signs of thrombosis. This point needs more investigation. Conclusion: These data showed the weekly Epoetin Alfa regimen to be at least as efþcacious and more convenient as the daily regimen in the treatmen of the postoperative anaemic patients. More investigation is needed for possible complications