Aims

Despite declining frequency of blood transfusion and electrolyte supplementation following total joint arthroplasty, postoperative blood analyses are still routinely ordered for these patients. This study aimed to determine the rate of blood transfusion and electrolyte restoration in arthroplasty patients treated with a perioperative blood conservation protocol and to identify risk factors that would predict the need for transfusion and electrolyte supplementation.

Aims

The pre-operative level of haemoglobin is the strongest predictor of the peri-operative requirement for blood transfusion after total knee arthroplasty (TKA). There are, however, no studies reporting a value that could be considered to be appropriate pre-operatively.

This study aimed to identify threshold pre-operative levels of haemoglobin that would predict the requirement for blood transfusion in patients who undergo TKA.

Aims

This study investigated whether the use of tranexamic acid (TXA) decreased blood loss and transfusion related cost following surface replacement arthroplasty (SRA).

The October 2015 Hip & Pelvis Roundup³⁶⁰ looks at: Smoking and complications in arthroplasty; Smoking cessation beneficial in arthroplasty; Intermediate care and arthroplasty; Do we still need cell salvage?; Femoroacetabular impingement in the Japanese population; Trunnionosis or taperosis and geometry; Decontamination for staphylococcus aureus works!; Policeman or opportunity? Quality improvement with registries; Death rates higher in readmission to other hospitals

We examined the risk of thrombotic and major bleeding events in patients undergoing total hip and knee replacement (THR and TKR) treated with thromboprophylaxis, using nationwide population-based databases. We identified 83 756 primary procedures performed between 1997 and 2011. The outcomes were symptomatic venous thromboembolism (VTE), myocardial infarction (MI), stroke, death and major bleeding requiring hospitalisation within 90 days of surgery.

A total of 1114 (1.3%) and 483 (0.6%) patients experienced VTE and bleeding, respectively. The annual risk of VTE varied between 0.9% and 1.6%, and of bleeding between 0.4% and 0.8%. The risk of VTE and bleeding was unchanged over a 15-year period. A total of 0.7% of patients died within 90 days, with a decrease from 1% in 1997 to 0.6% in 2011 (p < 0.001). A high level of comorbidity and general anaesthesia were strong risk factors for both VTE and bleeding, with no difference between THR and TKR patients. The risk of both MI and stroke was 0.5%, which remained unchanged during the study period.

In this cohort study of patients undergoing THR and TKR patients in routine clinical practice, approximately 3% experienced VTE, MI, stroke or bleeding. These risks did not decline during the 15-year study period, but the risk of dying fell substantially.

Cite this article: Bone Joint J 2014;96-B:479–85.

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

Autologous retransfusion and no-drainage are both blood-saving measures in total hip replacement (THR). A new combined intra- and post-operative autotransfusion filter system has been developed especially for primary THR, and we conducted a randomised controlled blinded study comparing this with no-drainage.

A total of 204 THR patients were randomised to autologous blood transfusion (ABT) (n = 102) or no-drainage (n = 102). In the ABT group, a mean of 488 ml (sd 252) of blood was retransfused. The mean lowest post-operative haemoglobin level during the hospital stay was higher in the autotransfusion group (10.6 g/dl (7.8 to 13.9) vs 10.2 g/dl (7.5 to 13.3); p = 0.01). The mean haemoglobin levels for the ABT and no-drainage groups were not significantly different on the first day (11.3 g/dl (7.8 to 13.9) vs 11.0 g/dl (8.1 to 13.4); p = 0.07), the second day (11.1 g/dl (8.2 to 13.8) vs 10.8 g/dl (7.5 to 13.3); p = 0.09) or the third day (10.8 g/dl (8.0 to 13.0) vs 10.6 g/dl (7.5 to 14.1); p = 0.15). The mean total peri-operative net blood loss was 1464 ml (sd 505) in the ABT group and 1654 ml (sd 553) in the no-drainage group (p = 0.01). Homologous blood transfusions were needed in four patients (3.9%) in the ABT group and nine (8.8%) in the no-drainage group (p = 0.15). No statistically significant difference in adverse events was found between the groups.

The use of a new intra- and post-operative autologous blood transfusion filter system results in less total blood loss and a smaller maximum decrease in haemoglobin levels than no-drainage following primary THR.

Cite this article: Bone Joint J 2013;95-B:616–22.

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

Intra-operative, peri-articular injection of local anaesthesia is an increasingly popular way of controlling pain following total knee replacement. At the same time, the problems associated with allogenic blood transfusion have led to interest in alternative methods for managing blood loss after total knee replacement, including the use of auto-transfusion of fluid from the patient’s surgical drain. It is safe to combine peri-articular infiltration with auto-transfusion from the drain. We performed a randomised clinical trial to compare the concentration of local anaesthetic in the blood and in the fluid collected in the knee drain in patients having either a peri-articular injection or a femoral nerve block. Clinically relevant concentrations of local anaesthetic were found in the fluid from the drains of patients having peri-articular injections (4.92 μg/ml (sd 3.151)). However, none of the patients having femoral nerve blockade had detectable levels. None of the patients in either group had clinically relevant concentrations of local anaesthetic in their blood after re-transfusion.

The evidence from this study suggests that it is safe to use peri-articular injection in combination with auto-transfusion of blood from peri-articular drains during knee replacement surgery.

Purpose of the study: The risk of homologous blood transfusion for primary total knee arthroplasty (TKA) varies between centres from 4 to 72%. Measurement of mean blood loss for patients undergoing primary total hip or knee arthroplasty led us to adopt a global blood-sparing protocol. Material and methods: This was a prospective observational study involving 90 TKA (TC-SB) implanted by one surgeon in 56 women and 33 men, mean age 74 years, ASA 3 for 29%, mean BMI=31. Programmed autologous transfusion and blood recovery were not applied. Alpha epoeitine (EPO was administered in the preoperative period in accordance with the predicted serum haemoglobin at discharge. Tranexamic acid (TA) was injected intravenously during the operation. Results: The mean operative time was 63 minutes, mean tourniquet time 51 minutes. During the perioperatively period, the mean 7-day blood loss was 566±254 ml red cells and 1560±643 total blood. Mean serum haemoglobin at discharge was 1.0 g/dl. Fourteen percent of patients had a postoperative serum haemoglobin less than 10 g/dl (lowest level 8.4 g/dl). One patient had a transfusion; this was a man in his nineties who was operated on without a tourniquet and without TA because of a poor arterial system. Nearly 86% of patients received TA with a significant (p< 0.05) decrease in bleeding compared with those who did not receive TA (365 ml total blood). EPO was delivered for 22% of patients (2.8 injections on average) to reached 14.2 g/dl the day before the operation. Discussion: This overall strategy for blood sparing enabled us to reduce the risk of transfusion and limit costs. In this series, the prescription of EPO was not targeted to reach a set level preoperatively but was based on the predicted serum haemoglobin level at discharge. Thus seven patients with a preoperative haematocrit below 39 did not receive EPO. None of these patients were transfused. Their discharge haemoglobin was between 10.7 and 12.4g/dl. Use of TA should be included in the calculation of the predicted discharge haemoglobin level in order to better determine candidates for EPO injections

Primary hip and knee replacements can be associated with significant blood loss. Tranexamic acid is a fibrinolytic inhibitor that has been shown to significantly reduce blood loss and transfusion requirement in hip and knee replacement, however the cost-benefit has not been widely investigated. Our study involved 100 patients, comprising a prospective cohort of 50 consecutive primary hip and knee replacements (treatment group) and a control group of the preceding 50 patients undergoing the same surgery. All knee replacements were computer navigated. The prospective cohort all had tranexamic acid 1g intravenously at the time of surgery, repeated at 8 and 16 hours. All patients had 28 days thromboprophylaxis with subcutaneous low-molecular-weight-heparin. The control group comprised 24 hip replacements and 26 knees versus 17 hips and 33 knees in the treatment group. Autologous transfusion drains were used in the control group knee replacements and the mean volume reinfused was 458ml. These drains were only used in the first 15 knee replacements in the treatment group as only one patient drained enough for reinfusion (100ml; p< 0.001). The mean fall in haemoglobin in the control group post surgery was 3.4g/dl versus 2.3g/dl in the treatment group (p< 0.001). Seven patients were transfused in the control group (14 units of red cells) versus two in the treatment group (5 units). The potential cost saving per patient averaged across all joints in the treatment group is £102.51. This is a function of savings in transfusion, cessation of drains for re-infusion in knee replacement and the cost of tranexamic acid. The only thromboembolic event was 1 deep vein thrombosis in the treatment group. Our data shows the cost savings associated with the use of tranexamic acid in primary hip and knee surgery are considerable and supports its use to significantly reduce blood loss and transfusion requirement

Venous thromboembolism (VTE) is a frequent, life-threatening postoperative complication of orthopaedic surgery. Preoperative autologous blood donation has been advocated to reduce the risk of transfusion reactions and to limit potential infectious risk associated with donor blood. Experimental data suggest that autologous leukocytes might lead to immunomodulation similar to the effect attributed to allogenic leukocytes, but autologous whole blood (WB) is often still being used in Japan. We investigated the incidence rate of VTE and plasma D-dimer levels of the autologous WB transfusion and compared the findings with autologous red cell concentrates (RCC) and fresh frozen plasma (FFP) with regard to the cases of lower extremity arthroplasty. The subjects of this study were 138 patients with lower extremity arthroplasty who were scheduled to receive surgery. The operations included 72 total hip arthroplasties (THA) and 66 total knee arthroplasties (TKA). Postoperatively, plasma D-dimer levels were measured latex agglutination turbidimetric immunoassay. Ultrasonography and contrast-enhanced helical computed tomography was used for diagnosing VTE. There was no statistically significant difference in the post-surgery incidence rate of VTE between the autologous WB group (THA:20.0%, TKA: 27.9%) and autologous RCC/FFP group (THA: 11.9%, TKA: 30.4%). On the first post-surgery day, the plasma D-dimer levels were significantly higher in autologous WB group (THA: 8.1±9.5 μg/ml, TKA: 12.1±15.9 μg/ml) compared to the autologous RCC/FFP group (THA: 4.2±2.9 μg/ml, TKA:8.0±6.6 μg/ml). However, the plasma D-dimer levels were almost the same in both groups on the 14th day from the surgery. The results of this study suggest that donation and transfusion of autologous WB do not negatively influence the post operative VTE compared with autologous RCC/FFP. However, we must cautiously assess the plasma D-dimer levels of the autologous WB group on the first post-surgery day because of the high propensity of showing false positive rate compared to the RCC/FFP group

We prospectively randomised 78 patients into two groups, ‘drains’ or ‘no drains’ to assess the effectiveness of suction drains in reducing haematoma and effusion in the joint and its effect on wound healing after total knee replacement. Ultrasound was used to measure the formation of haematoma and effusion on the fourth post-operative day. This was a semi-quantitative assessment of volume estimation. There was no difference in the mean effusion between the groups (5.91 mm in the drain group versus 6.08 mm in the no-drain, p = 0.82). The mean amount of haematoma in the no-drain group was greater (11.07 mm versus 8.41 mm, p = 0.03). However, this was not clinically significant judged by the lack of difference in the mean reduction in the post-operative haemoglobin between the groups (drain group 3.4 g/dl; no-drain group 3.0 g/dl, p = 0.38). There were no cases of wound infection or problems with wound healing at six weeks in any patient.

Our findings indicate that drains do not reduce joint effusion but do reduce haematoma formation. They have no effect on wound healing.

Purpose: To study the judicious use of re-infusion drains in knee replacement on a target population with strict inclusion criteria and its impact on the transfusion rate and cost savings. Method: We devised an inclusion criterion after a preliminary study on 200 knee replacements and identified the target population likely to need transfusion after the index procedure. All bilateral total knee replacements, revision total knee replacements and primary total knee replacements were the pre-operative haemoglobin was less then 5 gm/l above the patient’s transfusion trigger were included. These criteria were further validated by retrospective application. 56 patients fulfilled the criteria and 50 patients were included in the study between September 2006 – May 2007. Male/female ratio was 18: 32. Mean age was 66.2 years. Procedure included 33 total knees, 13 bilateral and 4 revision knee replacements. Results: The overall transfusion rates dropped to 3% (bilateral, revisions 12%) during the period of this study. Mean volume re-infused was 600 ml (0–2600). Average drop in haemoglobin was 2.9 g/dl. No adverse incidents were reported. Prior to our study the expenditure on allogenic blood transfusion was £13,230. The estimated cost of using the re-infusion system was £6230. A saving of £ 7500 was achieved as a result of using the drain in the “at risk” patient. Conclusion: Post-operative autologous transfusion is a safe and efficient way to reduce patient’s exposure to donor blood. Use of re-infusion drains directed at a target population reduces need for allogenic blood and is cost effective

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

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: Patients undergoing total knee arthroplasty may experience significant blood loss and are at risk of receiving blood transfusions. A bipolar sealing device designed to reduce intraoperative and postoperative blood loss, was compared to conventional electrocautery to determine its efficacy in maintaining hemoglobin levels and reducing transfusions in minimally invasive unilateral total knee arthroplasty. METHODS: A retrospective, matched control review of one hundred patients undergoing primary total knee arthroplasty by a single surgeon. Conventional electrocautery was used for hemostasis in 50 patients and bipolar sealing technology used in another 50 patients. RESULTS: Patients in the bipolar sealing group had a significantly lower mean decline in hemoglobin compared to the control group (3.3 ± 1.1 g/dL vs. 3.9 ± 1.2 g/dL; p = 0.0085). The prevalence of autologous transfusion was significantly lower for the bipolar sealing group (16%) compared to the controls (44%) (p < 0.001). The prevalence of allogeneic transfusion was also significantly lower for the bipolar sealing group (8%) compared to control group (22%) (p < 0.001). The prevalence of transfusion as a whole was significantly reduced by 64 percent (p < 0.001). While not statistically significant the break through allogeneic transfusion rate was reduced by 75 percent (4 controls compared to 1 treatment). DISCUSSION/CONCLUSION: The use of bipolar sealing technology in patients undergoing minimally invasive primary unilateral total knee arthroplasty is associated with a significant reduction in blood loss and transfusion rates compared to the use of conventional electrocautery. No funds were received in support of this study

We undertook a prospective randomised controlled trial to investigate the efficacy of autologous retransfusion drains in reducing the need for allogenic blood requirement after unilateral total knee replacement. We also monitored the incidence of post-operative complications. There were 86 patients in the control group, receiving standard care with a vacuum drain, and 92 who received an autologous drain and were retransfused postoperatively. Following serial haemoglobin measurements at 24, 48 and 72 hours, we found no difference in the need for allogenic blood between the two groups (control group 15.1%, retransfusion group 13% (p = 0.439)). The incidence of post-operative complications, such as wound infection, deep-vein thrombosis and chest infection, was also comparable between the groups. There were no adverse reactions associated with the retransfusion of autologous blood.

Based on this study, the cost-effectiveness and continued use of autologous drains in total knee replacement should be questioned.

Purpose: To develop a regression equation using preoperative variables to predict the likelihood of transfusion intra- or post- operatively for patients undergoing elective spinal fusion surgery. Methods: This study was a retrospective chart review of patients (n=774; 51% female; mean age=56 years; mean BMI=29) who underwent elective spinal fusion surgery between February 2001 and May 2005 at the QEII Health Sciences Centre in Halifax, Nova Scotia. The variables recorded were incidence of allogeneic and autologous transfusions (intra- and post-operatively), body mass index, age, gender, number of spinal levels fused, preoperative hemoglobin and hematocrit, ASA grade and pedicle screw and bone graft use. Results: Spinal fusion of 4 or more levels (n=24) resulted in a transfusion rate of 83%, therefore, the regression equation was calculated using only spinal fusions of 1 to 3 levels (n=750; transfusion rate=14%). The number of spinal levels fused and preoperative hemoglobin levels were found to be significantly related to the likelihood of receiving a transfusion. A predictive logistic regression equation was derived (Prediction = 3.615 + 1.018 x Levels fused–0.052 x Preop Hgb) where a probability cutoff of 0.160 gave a sensitivity of 63.5% and a specificity of 81.2%. Conclusions: The high sensitivity and specificity of the regression equation suggest that the results are clinically useful for determining whether alternatives to allogeneic transfusions should be investigated preoperatively for each patient undergoing elective spinal fusion surgery. The results could also have economic implications because implementing the use of a cell salvage device would be less costly than allogeneic units if the patient required a transfusion

Clinical, haematological or economic benefits of post-operative blood salvage with autologous blood re-transfusion have yet to be clearly demonstrated for primary total hip replacement. We performed a prospective randomised study to analyse differences in postoperative haemoglobin levels and homologous blood requirements in two groups of patients undergoing primary total hip replacement.

A series of 158 patients was studied. In one group two vacuum drains were used and in the other the ABTrans autologous retransfusion system. A total of 58 patients (76%) in the re-transfusion group received autologous blood. There was no significant difference in the mean post-operative haemoglobin levels in the two groups. There were, however, significantly fewer patients with post-operative haemoglobin values less than 9.0 g/dl and significantly fewer patients who required transfusion of homologous blood in the re-transfusion group. There was also a small overall cost saving in this group.