Aim: Allogenic blood transfusion rate and related factors, in a cohort of 78 consecutive primary total knee replacements without patellar substitution (TKR) between January 2007 and December 2008 in the Hospital Axarquía (Málaga; Spain). Patients and Methods: All patients were diagnosed of primary knee osteoarthritis. Along 2007 (group I) they were admitted in the previous day to a TKR and discharged following surgeon criteria. In 2008 (group II), patients were admitted on the day surgery, underwent a cemented TKR and were discharged following an objective clinical pathway. Variables: age, sex, comorbidities, previous surgery, length of stay (LOS), Ahlbäck classification, prosthesis fixation, surgery time, pre- and postoperative Hb, blood transfusion, readmission at the first 30-days and complications in the first postoperative year. Statistical analysis were carried out by the software SPSS 11.0. Results: Group I: Mean age 69 yrs (52–80), gender 1:2,4. 89,7% Ahlbäck 3 and 4. 44% hybrid implants. Mean surgery time 100 minutes. LOS 13,3 days (7–28). Mean preop Hb 12,9 g/dl (10–16,5) and Hb at discharge 10,27 g/dl (8,4–13,1). Transfusion rate 14,63%. There were a 25% of complications in the first year. Group II: Mean age 69,7 yrs (54–84), gender 1:1,3. 94,2% Ahlbäck 3 and 4. 8 % of hybrid implants. Mean surgery time 112 minutes. LOS 3,78 days (2–8). Mean preop Hb 13,24 g/dl (11–15,8) and Hb level at discharge 10,15 g/dl (8–13,5). Transfusion rate was 10,8%. There were a 8,1% of complications in the first year. None of complications was related with a tisular oxigenation deficit, nor there were readmissions within the first postoperative month. Transfusion rates difference were not statistically significative. Statistically associated variables were preoperative Hb level < 12,5 g/dl (p=0,001), and postoperative Hb level at 24 hr. < 9,5 g/dl (p=0,017). Discussion: Allogenic transfusion rates reported in our country without specific blood saving measures ranged from 30% to 46%. Several strategies have been developed to reduce blood transfusions and its complications. The golden rule is the appropriateness of the transfusion, attending clinical and analytical parameters based on guidelines. Our study suggest the best strategy is an appropriate transfusion indication, thus obtaining a transfusion rate low enough to made expensive pre-operative autologous blood predonation and peri-operative blood salvage programs unnecessary. Postoperative hemoglobin level predictive blood transfusion enables a safe and saving time hospital discharge. Conclusions: The main factors predicting the need for postoperative blood transfusion after TKA are preoperative hemoglobin levels and postoperative hemoglobin levels at 24 hr. Short time results are improved when surgeons use transfusion guidelines with less transfusional morbidity and cost-saving without compromising patients’ safe and outcomes

Introduction:. Primary total knee arthroplasty (TKA) is associated with perioperative bleeding, and some patients will require allogenic blood transfusion during their inpatient admission. While blood safety has improved in the last several decades, blood transfusion still carries significant complications and costs. Transfusion indications and alternative methods of blood conservation are being explored. However, there is limited nationally representative data on allogenic blood product utilization among TKA patients, and its associated outcomes and financial burden. The purpose of this study was to use a national administrative database to investigate the trends in utilization and outcomes (i.e. in-hospital mortality, length of stay, admission costs, acute complications) of allogenic blood transfusion in primary TKA patients. Methods:. The Nationwide Inpatient Sample (NIS), the largest all-payer inpatient care database representing a 20% stratified sample of United States hospitals, was utilized. Primary TKA (ICD-9-CM 81.54) cases from 2000 to 2009 were retrospectively queried (n = 4,544,999; weighted national frequency). A total of 67,841 admissions were excluded (Figure 1). The remaining 4,477,158 cases were separated into two study cohorts: (1) patients transfused with allogenic blood products (red blood cells, platelets, serum) (n = 540,270) and (2) patients not transfused (n = 3,936,888). Multivariable regression and generalized estimating equations were used to examine the effect of transfusion on outcomes, adjusting for patient/hospital characteristics and comorbidity. Results:. During the study period, the overall allogenic blood transfusion rate in primary TKA patients was 12.1%. The rate increased ∼5% from 2000 to 2009, and stayed constant around 13% from 2006 to 2009. Transfusion rates were higher in older patients (80–89 yrs, 21.4%; ≥ 90 yrs, 30.7%), blacks (19.6%), females (14.0%), Medicare patients (14.6%), and Medicaid patients (14.4%). Transfused TKA patients had a greater percent of comorbidities than their non-transfused peers. The largest differences in comorbidity prevalence among transfused and non-transfused patients were: deficiency anemia (27.5% vs. 10.1%), renal failure (4.0% vs. 1.4%), chronic blood loss (3.7% vs. 1.4%), and coagulopathy (3.1% vs. 1.0%) (p < 0.001). Unadjusted trends show that from 2000 to 2009, in-hospital mortality rate decreased (Figure 2A), mean length of stay decreased (Figure 2B), and mean admission cost increased (Figure 2C) for both transfused and non-transfused patients following TKA. Adjusting for patient and hospital characteristics, transfused patients had a 22% (95% CI, 4%–43%) greater likelihood of in-hospital mortality (p = 0.013), 0.68 ± 0.02 days longer length of stay (p < 0.001), and $2,237 ± 76 increased admission costs (p < 0.001). Additionally, patients who received a transfusion had a greater adjusted risk of a postoperative infection (odds ratio, 2.35), pulmonary insufficiency (odds ratio, 1.60), and other complications (p < 0.001) (Figure 3). Conclusions:. The allogenic blood transfusion rate increased between 2000 and 2009 in the United States. Transfusion has a considerable burden on patients and healthcare institutions, increasing in-hospital mortality, length of stay, admission costs, and acute complications. Preoperative optimization strategies, transfusion criteria, and hemostatic agents for at-risk patients need to be further researched as possible ways to reduce transfusion occurrence and its effects

Purpose. Transfusion rates after primary total hip has been reported up to 39.2%. The purpose of our study was to evaluate the efficacy of TXA in minimizing risk of allogeneic blood transfusion after primary total hip and hip resurfacing arthroplasty. Method. Retrospective data on a cohort of 88 patients undergoing total hip arthroplasty and 44 who undergoing hip resurfacing arthroplasty who received a single pre-operative bolus of 1g TXA was compared with a control group matched for starting haemoglobin (Hg), body mass index (BMI), age, gender, blood loss, surgical time, and surgeon. All procedures were completed at a single institution with standardized post-operative care. Endpoints included allogeneic blood transfusion rate, post operative day one Hg, and overall Hg decrease. Results. Transfusion rate among the total hip TXA group was 5.7% and among control patients 22.7% (p=0.001). Transfusion rates among resurfacing patients showed no statistical difference between the treatment group and matched controls. Mean overall haemoglobin decrease was found to be significantly lower in the TXA treatment groups for both total hip and hip resurfacing arthroplasty (p<0.0001 and p=0.01 respectively). Patients who received TXA and allogeneic blood transfusion were found to have a significantly lower pre-operative Hg versus transfusion negative TXA treated patients (113.7 g/dL and 141.5 g/dL respectively). Conclusion. We have shown TXA use in primary total hip arthroplasty significantly decreases allogeneic blood transfusion rate. TXA use in hip resurfacing arthroplasty failed to show significant difference in transfusion rate yet calculated blood loss was less. Patients presenting with low pre-operative Hb remain high risk for allogeneic blood transfusion despite TXA treatment

Blood donation in England is voluntary and a limited resource. Blood transfusion is essential and beneficial in some postoperative hip replacements, however is not without inherent risks. Royal College of Physician audit in 2007 has shown wide variation in transfusion with an average rate of 25% (22% – 97%). Patient blood management is an established approach to optimising need for post- operative transfusion. The Surgical Blood Conservation Service (SBCS) was set up in 2009 to enable a reduction in the demand for blood transfusion during and postoperatively in many orthopaedic procedures. We aimed to achieve preoperative haemoglobin of 12g/dl (males) and 11g/dl (females). Low levels were treated with iron therapy. Surgery was deferred till satisfactory Hb levels were reached. During surgery cell salvage was routinely used. Transfusion was recommended at postoperative Hb < 8g/dl. The transfusion rate was estimated at 47% in 2002. Following the introduction of SCBS, the transfusion rate reduced considerably to 7.9% in 2009 with a further reduction to 7.29% in 2011 and 3.16% in 2012. In 2013, 10 out of 442 hip replacements received transfusion (2.21%). Our results demonstrate successful Patient blood management, minimising the need for post- operative transfusion

Patients and Methods: We conducted a retrospective study of neck of femur fractures over a period of two years. Variables analysed were the perioperative haemoglobin levels, type of fracture and surgery, age, gender and blood transfusion in the perioperative period. Results: Out of a total of 310 patients 49 required a postoperative blood transfusion. The mean preoperative Hb of patients who required blood transfusion was 11; S.D. 1.49 while those who did not require a transfusion it was 12.5; S.D.1.42. Transfusion was required in 23% of patients having extra-capsular neck of femur fractures fixed with a DHS and in 9.5% of patients having intracapsular neck of femur fractures undergoing a hemiarthroplasty. The univariate analysis showed a significant relationship between post-operative transfusion and the pre-operative Hb level (p=0.0001) and the type of fracture (p=0.001). However no relationship was found between transfusion and age (p=0.423) and the gender of the patient (p=0.611). Discussion: The results of our study indicate that the most important factor in the prediction for blood transfusion in fracture neck of femur is the preoperative level of Hb as well as the type of fracture. Predicting a priori, the target population at a higher risk of requiring blood transfusion would enable us to establish appropriate prophylactic measures

Background. Conflicting results about the impact of blood transfusions on outcomes after total knee arthroplasty (TKA) have been reported. We hypothesized that transfusions would be associated with greater readmission and complication rates after primary TKA. Methods. We conducted a retrospective cohort study of the 100% 2008 Medicare Provider Analysis and Review database, and identified primary THA patients by ICD9 codes and excluded fractures/ER admissions to select for elective cases. Patients who received a perioperative blood transfusion (6,951 patients) were compared to a control group who did not receive transfusion (332,762 patients). Descriptive statistics of age, sex, race, diagnosis for surgery, Elixhauser comorbidities, mortality (inpatient, 30, 60, and 90 days and 2 years), readmissions (30, 60, and 90 days), complications (medical and surgical at 30 and 90 days), and revision at 2 years were assessed for both groups. Continuous variables were compared with Student's T-test and categorical variables with chi-square test. Multivariate logistic regression models were constructed to assess the association of transfusion with readmissions, complications, and revisions. Statistical significance was set at p < 0.01. Results. Patients who received a transfusion were older (mean 74.4 vs. 72.6, p<0.0001), more likely to be male (75% vs. 66%, p<0.0001), and had a higher Elixhauser comorbidity count (2.0 vs. 1.85, p<0.0001). Transfused patients had significantly greater readmission rates at 30-days (8.2% vs 5.7%, p<0.0001), 60-days (11.7% vs 8.2%, p<0.0001), and 90-days (14.4% vs 10.4%, p<0.0001). Their overall complication rates at 30 days (2.1% vs 1.4%, p<0.0001) and 90 days (3.2% vs 2.1%, p<0.0001) were greater mainly due to greater surgical complications at 30 days (1.4% vs 0.9%, p<0.0001) and 90 days (2.1% vs 1.3%, p<0.0001). Patients who received a transfusion had significantly higher mortality rates at 2-years (2.2% vs. 1.4%, p<0.0001). Two years after discharge, transfused patients had no difference in revision rates (2.4% vs 2.4%, p=0.8805). Multivariate regression found that transfusion was the third most important factor for surgical complications at 30-days (OR: 1.6, 95% CI: 1.3 to 2.0) and an independent risk factor for readmissions at 60-days (OR: 1.4, 95% CI: 1.3 to 1.5). At 2-years, transfusion was independently associated with mortality (OR: 1.4, 95% CI: 1.2 to 1.7), but not revision (OR: 1.1, 95% CI: 0.9 to 1.3). Conclusion. Primary TKA patients who were transfused had an independently higher risk for surgical complications and readmissions at 30 and 90 days, and mortality within 2 years. Transfusion, however, did not impact revision rates. A restrictive transfusion threshold should be considered for patients undergoing TKA

Loss of blood is inevitable during knee replacement surgery, sometimes requiring transfusion. Allogenic blood leads to a risk of disease transmission and immunological reaction. There are various practices used. There is still a risk of bacterial transmission with stored blood and haemolytic transfusion reactions can still occur. Data was collected between 1998 and 2006. There was data on transfusion in 1532 patients undergoing primary knee replacements. There were 1375 unilateral TKRs and 157 bilateral TKRs. After reducing the bilateral cases to one record per patient, it was agreed to restrict the main analysis to 1532 patients. Data was collected prospectively at a pre-admission clinic 3 weeks prior to surgery. Haemoglobin was checked and body demographics including BMI were obtained. Each patient also had a knee score assessed. All patients received a LMWH pre-op until discharge. A tourniquet was used in each case and all patients had a medial para-patellar approach. No drains were used and operation details such as a lateral release were recorded. As per unit protocol, patients with a post-op haemoglobin less than 8.5g/dl were transfused as were symptomatic patients with haemoglobin between 8.5g/dl and 10g/dl. Each of the possible predictive factors was tested for significant association with transfusion using chi-squared or t-tests as appropriate. Multiple logistic regression was used to test for the independent predictive of factors after adjusting for one another. Results show that transfusion was more likely if the patient was older, female, short, light or thin. Among peri-operative factors, the chance of a transfusion was increased for bilateral patients, those with low knee scores and those with high ASA scores. Also patients undergoing a lateral release, those with low pre-op haemoglobin and those with a large post-op drop were more likely to be transfused. All the significant variables were entered into a forward stepwise multiple logistic regression. Transfusion was significantly more likely in those undergoing a bilateral procedure, with a low BMI, low pre-op haemoglobin and those with a large post-op drop (> 3g/dl). Allogenic transfusion is associated with immune-related reactions, from pyrexia to urticaria to haemolytic transfusion reactions, which can be life threatening. There is also the risk of viral pathogen transmission. Women were shown to be almost twice as likely to need transfusion. This has been shown in previous studies and is thought to be due to women having a lower weight and pre-op haemoglobin, both of which were shown to be significant independent factors in increasing the risk of transfusion. A pre-operative haemoglobin of less than 13g/dl, a BMI less than 25, and undergoing a bilateral procedure were shown to have an increased risk of transfusion. For patients falling into these categories, measures can be planned to try and reduce this risk

To date, there are no clear guidelines from the National Institute of Clinical Excellence or the British Orthopaedic Association regarding the use of Autologous Blood Transfusion (ABT) drains after elective primary Total Knee Replacement (TKR). There is little evidence to comparing specifically the use of ABT drains versus no drain. The majority of local practice is based on current evidence and personal surgical experience. We aim to assess whether the use of ABT drains effects the haemoglobin level at day 1 post-operation and thus alter the requirement for allogenic blood transfusion. In addition we aim to establish whether ABT drains reduce post-operative infection risk and length of hospital stay. Forty-two patients undergoing elective primary TKR in West London between September 2011 and December 2011 were evaluated pre- and post-operatively. Patient records were scrutinised. The patient population was divided into those who received no drain post-operatively and those with an ABT drain where fluid was suctioned out of the knee in a closed system, filtered in a separate compartment and re-transfused into the patient. Twenty-six patients had ABT drains and 4 (15.4%) required an allogenic blood transfusion post-operatively. Sixteen patients received no drain and 5 (31.3%) required allogenic blood. There was no statistical difference between these two groups (p=0.22). There was no statistical difference (p=0.75) in the average day 1 haemoglobin drop between the ABT drain and no drain groups with haemoglobin drops of 2.80 and 2.91 respectively. There was no statistical difference in the length of hospital stay between the 2 groups (p=0.35). There was no statistical difference (p=0.26) in infection rates between the 2 groups (2 in ABT drains Vs. 0 in no drains). Of the 2 patients who experienced complications one had cellulitis and the other had an infected haematoma, which was subsequently washed out. The results identify little benefit in using ABT drains to reduce the requirement for allogenic blood transfusion in the post-operative period following TKR. However, due to small patient numbers transfusion rates of 31.3% in the ABT drain group Vs. 15.4% in the no drain group cannot be ignored. Therefore further studies including larger patient numbers with power calculations are required before a true observation can be identified

Anterior scoliosis surgery is associated with potentially significant intra-operative blood loss, requiring homologous transfusion either intra- or post-operatively. Blood loss in this type of surgery correlates with surgical & anaesthetic techniques. In our centre the development of specific anaesthetic techniques as well as the routine use of Cell Salvage has dramatically reduced the rates of homologous blood transfusion. Currently specific indications for the use of the Cell Saver in Anterior Scoliosis have not been proven. Previous studies have commented on the beneficial aspects of recovered autologous transfusion for Orthopaedic patients in general, whilst others have shown a negligible advantage specifically in anterior thoracolumbar fusion surgery. In order to assess the cost-effectiveness of the techniques used in Anterior Scoliosis Surgery we carried out a retrospective study of 180 consecutive patients, all of whom underwent instrumented anterior scoliosis correction between July 2000 and September 2004. A cell saver was used in all the cases, and hospital data (including haematological indices and number of levels fused) was collected. The median age of the study cohort was 11.2 years (range 7 – 64), and the male:female ratio was 1:8.4. The average preoperative haemoglobin in all patients was 12.7g/dl and the average postoperative haemoglobin was 9.8g/dl. In total the rate of homologous transfusion requirement was 1 unit per 9.1 patients. Results show that homologous transfusion was required in less than 11% of all patients. This is better than previously published rates of transfusion in similar procedures. The range of volume of intra-operatively salvaged cells was 200 to 770mls. There was no correlation between the number of levels fused (extent of scoliosis corrective surgery) and units transfused. Our experience shows that the use of Salvaged Autologous Blood Transfusion in anterior scoliosis surgery has an important role in reducing the incidence of postoperative anaemia and homologous transfusion requirements

Background: Anterior scoliosis surgery is associated with potentially significant intra-operative blood loss, requiring homologous transfusion either intra- or postoperatively. Blood loss in this type of surgery correlates with surgical & anaesthetic techniques. In our centre the development of specific anaesthetic techniques as well as the routine use of Cell Salvage has dramatically reduced the rates of homologous blood transfusion. Currently, specific indications for the use of the Cell Saver in Anterior Scoliosis Surgery have not been proven. Previous studies have commented on the beneficial aspects of autologous transfusion for Orthopaedic patients in general; However, others have shown a negligible advantage specifically in anterior thoracolumbar fusion surgery. The aim of our study was to assess and quantify the use of homologous blood, as well as the effects on haematological indices. Methods: We carried out a retrospective study of 144 consecutive patients, all of whom underwent instrumented anterior scoliosis correction between April 2001 and October 2004. A cell saver was used in all the cases, and hospital data (including haematological indices and number of levels fused) was collected. Results: The median age of the study cohort was 15.0 years (range 8 – 46), and there were 31 males and 113 females. The mean preoperative haemoglobin in patients was 13.5g/dl and the mean postoperative haemoglobin was 10.6g/dl. Haematocrit values followed a similar pattern, the mean pre-op value being 0.41, mean post-op value was 0.29. The range of volume of intra-operatively salvaged cells was 200 to 1100mls. 25 of 144 patients required transfusion. In these patients, the average number of units given was 2.3, although the total homologous transfusion rate was 0.4 units per patient. Results show that homologous transfusion was not required in 82.6% of patients. This is better than previously published rates of transfusion in this procedure. There was no correlation between the number of levels instrumented and the number of units transfused (Pearson Correlation Coefficient 0.19), and no correlation between the number of levels instrumented and postoperative haematocrit values (Pearson Correlation Coefficient 0.16). None of the patients required intra-operative homologous transfusion. Conclusion: Our experience shows that along with meticulous surgical haemostasis, and hypotensive anaesthesia the use of Salvaged Autologous Blood Transfusion in anterior scoliosis surgery has an important role in reducing the incidence of postoperative anaemia and homologous transfusion requirements

Introduction: The aims of this study were to determine whether patients were transfused appropriately, after a Unilateral Cemented Primary Total Knee Replacement (TKR), and whether it would be cost effective to use autologous transfusion drains compared with standard group & save and cross match protocols. Method: Retrospective study of the pre- and postoperative day 1 haemoglobin values of all patients who underwent unilateral primary cemented TKR between November 2004 – November 2005 at the Kent & Sussex Hospital, Tunbridge Wells. Haemoglobin data and length of stay was obtained from computerised records & transfusion data from the blood transfusion department. Results: 150 patients were assessed: 97 (65%) female and 53 (35%) male. 20 (14.6%) patients required blood transfusion. The mean preoperative haemoglobin for non-transfused and transfused patient’s was 13.7 and 12.5g/dl respectively (P = 0.0029). The mean postoperative haemoglobin for non-transfused and transfused patient’s was 11.1 and 9.27g/dl respectively (P< 0.001). The mean blood loss for non-transfused and transfused patient’s was 2.64 and 3.26g/dl respectively (P< 0.001). There was no significant correlation between length of stay and either preoperative haemoglobin or blood loss after surgery; Spearman’s correlation coefficient was 0.0222 and 0.0036 respectively. The cost of a standard group & save and cross match, plus the 56 required units of blood in this study was £15,443.60. The theoretical cost of using a CellTrans Autologous Transfusion System on these 150 patients would be £14,355.00, a saving of only £1,088.60. However, by only using the autologous drains on patients with a preoperative haemoglobin ≤ 12.5g/dl, this saving could be increased to £4,131.20 per annum. Conclusion: Using autologous transfusion drains on patients with a preoperative haemoglobin ≤ 12.5g/dl would save over £4,000 per annum at Maidstone & Tunbridge Wells Hospital Trust. There is no correlation between length of stay in hospital and either preoperative haemoglobin or blood loss after surgery. Patients transfused had significantly lower pre- and postoperative haemoglobins

Aims

Orthopaedic surgeries are complex, frequently performed procedures associated with significant haemorrhage and perioperative blood transfusion. Given refinements in surgical techniques and changes to transfusion practices, we aim to describe contemporary transfusion practices in orthopaedic surgery in order to inform perioperative planning and blood banking requirements.

In consecutive patients undergoing unilateral TKA in a single institution, we undertook an audit of blood transfusion practices before and after introduction of a blood transfusion protocol.

Before and after the introduction of the protocol, 393 patients (group I) and 295 patients (group II) respectively were audited. The protocol stated that only patients with preoperative haemoglobin of less than 11 were cross-matched before surgery. The criterion for postoperative transfusion was a postoperative haemoglobin of less than 8.5 or a symptomatic patient with a haemoglobin greater than 8.5. The introduction of the protocol reduced the transfusion rates from 31% in group I to 11.9% in group II (CI 13.1% to 24.9%). The length of stay was reduced from 11.4 to 9.3 days (CI 1.4 to 2.9).

There were no adverse outcomes related to the introduction of the protocol.

Purpose : The evaluation of the results of the comparison, between homologous blood transfusion and reinfusion of wound drainage blood, to patients with primary total knee replacement.

Materials and methods: A study on 44 consequent patients,who underwent to primary total knee replacement. Study group comprised 29 patients, employing a post operative autologous collection system and the control group 15 patients, using a standard drainage system.

The patiens of the control group transfused with homologous blood when it was needed.

The amount of drainage blood autotransfused in the study group was 633,15cm3 per patient, approximately. The preoperative haematocrit of this group was 39,24% average.

In the study group, 10/29 patients required two extra units of homologous blood per patient,where the preoperative haematocrit was 36,01% average. The control group, required 2,66 units of homologous blood per patient, wherees the preoperative haematocrit was 39,23% average.

Results : The haematocrit in the 3rd post operative days, to the group of autotransfusion, was 32,70% average, while to the group of homologous blood transfusion was 31,91%.

The temperature was approximately at the same levels to both groups of patients, post operatively, with a mean rate of 38,350C and it’s duration was two days post operatively, average.

There were no complications to both groups after the operation.

Conclusions: The system of reinfusion of unwashed shed whole blood is effective and safe as far as it concerns the decrease of the dangers from the homologous blood transfusion.

Moreover, the cost is cheaper comparing to the homologous transfusion, whereas it is the solution of choice, to the people who refuse the blood transfusion, due to religion reasons.

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

The purpose of this study was to first determine if neuromuscular scoliosis results in greater peri-operative transfusion requirements compared to idiopathic scoliosis, and secondly to compare the effects of tranexamic acid (TXA) dosing on reducing transfusion requirements in scoliosis surgery. Previous studies have suggested that patients with neuromuscular scoliosis tend to have more blood loss during scoliosis corrective surgery as compared to patients with idiopathic scoliosis. Tranexamic acid has not been studied extensively in these populations and consensus regarding appropriate dosing has not yet been elucidated. A retrospective chart review of all patients who underwent posterior instrumentation and fusion for scoliosis for the years 1999 to 2006 was performed. Peri-operative transfusion requirements for idiopathic and neuromuscular scoliosis patients were compared and grouped according to TXA use. Transfusion requirements for those patients receiving either a low (10mg/kg loading, 1mg/kg/h infusion) or high (20mg/kg loading, 10mg/kg/h infusion) dose TXA were also compared. Idiopathic patients had significantly decreased transfusion requirements overall (no TXA: idiopathic 1028.3 ± 558.7ml vs. neuromuscular 1400.7 ± 911.3ml, p = 0.02; with TXA: idiopathic 1082.9 ± 1005.5ml vs. neuromuscular 2043.8 ± 1397.5ml, p = 0.03). In the idiopathic group, high dose TXA resulted in a significant reduction in peri-operative transfusion requirements compared to low dose TXA (687.9 ± 778.1ml vs. 1355.0 ± 965.8ml, p = 0.04). Neuromuscular scoliosis patients have significantly higher transfusion requirements as compared to idiopathic patients. For patients with idiopathic scoliosis, the use of the high dose TXA is suggested over low dose TXA given the relative reduction in transfusion requirements for the high dose group

Extended patient waiting lists for assessment and treatment are widely reported for planned elective joint replacement surgery. The development of regionally based Elective Orthopaedic Centres, separate from units that provide acute, urgent or trauma care has been suggested as one solution to provide protected capacity and patient pathways. These centres will adopt protocolised care to allow high volume activity and increased day-case care. We report the plan to establish a new elective orthopaedic centre serving a population of 2.4 million people. A census conducted in 2022 identified that 15000 patients were awaiting joint replacement surgery with predictions for further increases in waiting times

The principle of care will be to offer routine primary arthroplasty surgery for low risk (ASA 1 and 2) patients at a new regional centre. Pre-operative assessment and preparation will be undertaken digitally, virtually and/or in person at local centres close to the where patients live. This requires new and integrated pathways and ways of working. Predicting which patients will require perioperative transfusion of blood products is an important safety and quality consideration for new pathways. We reviewed all cases of hip and knee arthroplasty surgery conducted at our centre over a 12-month period and identified pre-operative patient related predictive factors to allow us to predict the need for the perioperative transfusion of blood products.

We examined patient sex, age, pre-operative haemaglobin and platelet count, use of anti-coagulants, weight and body mass index to allow us to construct the Imperial blood transfusion tool.

We have used the results of our study and the transfusion tool to propose the patient pathway for the new regional elective orthopaedic centre which we present.

We prospectively randomised 104 consecutive patients undergoing primary cemented total knee arthroplasty to receive either a standard suction drain© (Redivac) or autologous transfusion drain® (Bellovac). There were fifty two patients in each group. Randomisation was performed using a software program (Minim) which set to stratify patients based on their age, sex and body mass index (BMI). All procedures were performed under pneumatic tourniquet.

Drains were released in recovery room 20 minutes after surgery and were removed 24 hours following surgery. Blood collected in the standard suction drain was discarded but blood collected in the autologous transfusion drains was transfused unwashed to the patient within six hours of collection.

13 patients (25%) in the study group had two or more units of homologous blood transfused in addition to the blood collected postoperatively and re-transfused (Average= 438mls). 12 patients (23%) in the control group had two or more units of homologous blood transfused. No sepsis, transfusion reactions, or coagulopathies were associated with the autologous blood re-transfused in the study group.

The use of autologous transfusion system (Bellovac) proved to be safe but failed to reduce the need for postoperative homologous blood transfusion following uncomplicated total knee arthroplasty.

This study aimed to identify factors associated with increased rates of blood transfusion in patients with adolescent idiopathic scoliosis (AIS) treated with posterior spinal fusion (PSF).

A retrospective case-control study was performed for AIS patients treated at a large children's hospital between August 2018 and December 2020. All patients with a diagnosis of AIS were evaluated. Data on patient demographics, AIS, and transfusion parameters were collected. Univariate regression and multivariate logistic modeling were utilized to assess risk factors associated with requiring transfusion. Odds ratios (OR) and 95% confidence interval (CI) were calculated. Surgeries were done by three surgeons and thirty anesthesiologists. To quantify the influence of anesthesia practice preferences a categorical variable was defined as “higher-transfusion practice preference”, for the provider with the highest rate of transfusion.

A total of 157 AIS patients were included, of whom 56 were transfused RBC units (cases), and 101 did not receive any RBC transfusion (controls). On univariate analysis, the following variables were significantly correlated with receiving RBC transfusion: “higher-transfusion practice preference,” “administration of crystalloids,” “receiving fresh frozen plasma (FFP),” “receiving platelets,” “pre-operative hemoglobin,” “cell saver volume,” and “surgical time.” On multiple regression modeling, “pre-operative hemoglobin less than 120 g/L” (OR 14.05, 95% CI: 1.951 to 135.7) and “higher-transfusion practice preference” (OR 11.84, 95% CI: 2.505 to 63.65) were found to be meaningfully and significantly predictive of RBC transfusion.

In this cohort, we identified pre-operative hemoglobin of 120 g/L as a critical threshold for requiring transfusion. In addition, we identified significant contribution from anesthesia transfusion practice preferences. Our multivariate model indicated that these two factors are the major significant contributors to allogenic blood transfusion. Although further studies are required to better understand factors contributing to transfusion in AIS patients, we suggest standardized, peri-operative evidence-based strategies to potentially help reduce variations due to individual provider preferences.

Patients who are Jehovah's witnesses do not accept blood transfusions. Thus, total hip arthroplasty can be challenging in this group of patients due to the potential for blood loss. Multiple strategies have been developed in order to prevent blood loss.

A 76-year-old female, Jehovah's witness medicated with a platelet antiaggregant, presented to the emergency department after a fall from standing height. Clinically, she had pain mobilizing the right lower limb and radiological examination revealed an acetabular fracture with femoral head protrusion and ipsilateral isquiopubic fracture. Skeletal traction was applied to the femur during three weeks and no weight bearing was maintained during the following weeks. Posteriorly, there was an evolution to hip osteoarthritis with necrosis of the femoral head.

The patient was submitted to surgery six months after the initial trauma, for a total hip arthroplasty. The surgery was performed with hypotensive anaesthesia, careful surgical technique and meticulous haemostasis and there was no need for blood transfusion. Posteriorly, there was a positive clinical evolution with progressive improvement on function and deambulation.

Total hip arthroplasty may be safely carried out with good clinical outcomes in Jehovah's witnesses, without the need for blood transfusion, if proper perioperative precautions are taken, as has already been shown in previous studies.