Aims

In the last decade, perioperative advancements have expanded the use of outpatient primary total knee arthroplasty (TKA). Despite this, there remains limited data on expedited discharge after revision TKA. This study compared 30-day readmissions and reoperations in patients undergoing revision TKA with a hospital stay greater or less than 24 hours. The authors hypothesized that expedited discharge in select patients would not be associated with increased 30-day readmissions and reoperations.

Aims

The volume of ambulatory total hip arthroplasty (THA) procedures is increasing due to the emphasis on value-based care. The purpose of the study is to identify the causes for failed same-day discharge (SDD) and perioperative factors leading to failed SDD.

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.

Aims

Antifibrinolytic agents, including tranexamic acid (TXA) and epsilon-aminocaproic acid (EACA), have been shown to be safe and effective for decreasing perioperative blood loss and transfusion following total hip arthroplasty (THA) and total knee arthroplasty (TKA). However, there are few prospective studies that directly compare these agents. The purpose of this study was to compare the benefits of intraoperative intravenous TXA with EACA.

Total hip and knee arthroplasty is known to have a significant blood loss averaging 3–4 g/dL. Historically, transfusion rates have been as high as 70%. Despite years of work to optimise blood management, some published data suggests that transfusion rates (especially with allogeneic blood) are rising. There is wide variability between surgeons as well, suggesting that varying protocols can influence transfusion rates. Multiple studies now associate blood transfusions with negative outcomes including increased surgical site infection, costs, and length of stay.

Preoperative measures can be employed. Identify patients that are at increased risk of blood transfusion. Smaller stature female patients, have pre-operative anemia (Hgb less than 13.0 gm/dl), or are undergoing revision or bilateral surgery are at high risk. We identify these patients and check a hemoglobin preoperatively, using a non-invasive finger monitor for screening. For anemic patients, iron administration (oral or IV) can be given, along with Procrit/Epogen in select cases. Insurance coverage for that medication has been challenging.

Intraoperative measures that have been linked to reduced postoperative transfusions include regional anesthesia and intraoperative hypotension (mean arterial pressure <60mm/hg). Lowering the surgical time by practicing efficient, organised, and quality surgery, along with leaving a dry field at the completion of surgery can reduce blood loss.

Tranexemic acid (TXA) is an antifibrinolytic agent that has been shown to be effective, reducing average blood loss by 300 cc per case. There are multiple different administration protocols: IV using either a weight-based dosing 10–20 mg/kg or standardised dosing for all patients. Our current regimen is 1 gm IV preoperatively, 1 gm IV in PACU. Topical TXA can be used, usually 2–3 gm mixed in 50–100 cc of saline, sprayed in wound and allow to soak for 3–5 minutes. Oral administration is attractive for ease of use and reduced cost, standard oral dosing is 1950 mg PO 2 hours prior to surgery.

The American Association of Hip and Knee Surgeons, in collaboration with the American Association of Orthopedic Surgeons, American Society of Regional Anesthesiologists, and the Hip & Knee Society have developed a Clinical Practice Guideline with 8 recommendations for TXA as follows: All individual formulations are effective at reducing blood loss – strong; No method of administration is clearly superior at reducing blood loss and the risk of transfusion; The dose of IV or topical TXA does not significantly affect the drug's ability to reduce blood loss and risk of transfusion; Multiple doses of IV or oral TXA compared to a single dose does not significantly alter the risk of blood transfusion; Pre-incision IV TXA administration potentially reduces blood loss and risk of transfusion compared to post-incision administration; Administration of all TXA formulations in patients without history of VTE does not increase the risk of VTE; Administration of all TXA formulations in patients with a history of VTE, MI, CVA, TIA, or vascular stent does not appear to increase the risk of VTE; Administration of all TXA formulations does not appear to increase the risk of arterial thrombotic events; Postoperative measures to reduce transfusion rates include changing transfusion triggers. Instead of treating a “number”, use lower thresholds and employ safe algorithms established.

In conclusion, a comprehensive blood management program can reduce transfusion rates to less than 3% for THA and 1% for TKA and facilitate outpatient total joint arthroplasty.

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. Patients and Methods. Patients undergoing primary total joint arthroplasty of the hip or knee between July 2016 and February 2017 at a single institution were included in the study. Standard preoperative and postoperative laboratory data were collected and reviewed retrospectively. A uniform blood conservation programme was implemented for all patients. Need for blood transfusion or potassium supplementation was determined through a coordinated decision by the care team. Rates of transfusion and supplementation were observed, and patient risk factors were noted. Results. The overall rate of blood transfusion was 1.06% in the study population of 1132 total joint arthroplasties performed in 1023 patients. Of the 12 patients requiring transfusion, 11 were female, ten occurred in patients undergoing total hip arthroplasty, and all 12 patients had a preoperative haemoglobin level less than 130 g/l. Operative duration and surgical blood loss were significantly greater in those patients requiring blood transfusion. Nearly all patients requiring transfusion had a history of, or risk factors for, cardiovascular disease. Potassium supplementation was required in 15.5% of the study cohort; 72% of these patients receiving potassium presented with a potassium level less than 4 mmol/l during preoperative testing, while the remaining 28% had a past medical history of either significant anaemia, cardiopulmonary, cardiovascular, or renal diseases that had required substantial medical management. Conclusion. A consistent blood-conserving perioperative strategy effectively minimized need for blood transfusion in total joint arthroplasty patients below previously reported rates in the literature. We suggest that postoperative full blood counts and basic metabolic panels should not routinely be ordered in these patients unless their preoperative haemoglobin and potassium is below 130 g/dl or 4 mmol/l respectively, and they have medical comorbidities

Periacetabular osteotomy (PAO) is a demanding procedure that puts patients at risk for potentially significant blood loss, and blood transfusions. Avoidance of transfusions in otherwise healthy young patients is important. This project was designed to study the effectiveness of our blood conservation efforts. 178 consecutive PAOs performed in one hospital by one surgeon (RFS) from 2008 to 2016 were reviewed retrospectively. PAO's were performed in other hospitals, too, but a majority were from the study group hospital. Data were collected from digitalized patient office charts and hospital electronic medical records. Collected data were analyzed for categorical associations between blood loss, demographic data, and transfusion risks. Over the past 27 months, the transfusion rate in 63 consecutive patients has been reduced to Zero. Discontinuation of drains, use of TXA, spinal anesthesia, reducing trigger for transfusion to Hgb of <7, cell saver use in all cases, and careful intraop coagulation, among others, have been incrementally incorporated. The overall transfusion rate was 10.7% for all patients. In the early years of this study, prior to adoption of all of these blood conservation measures, the transfusion rate was 12.5%. Over the past four years the transfusion rate was 1.5%. Over the last two years it has been zero. There is little data specifically regarding transfusion rates in PAOs but this study establishes that an aggressive approach to blood saving techniques and limitation of bleeding can reduce the risk of transfusion to virtually zero in this population of mostly young patients

Introduction. Total joint arthroplasty is associated with substantial blood loss as well as changes in basic metabolic labs. Routinely patients receive multiple post-operative blood draws for measuring hematocrit, hemoglobin (H&H), and basic metabolic panels (BMP). Based on a multimodal approach to blood conservation and pre-operative optimization, we questioned the need to check daily labs on our inpatient primary total hip and knee patients. The purpose of this study was to identify risk factors for transfusion and metabolic abnormalities requiring treatment in an attempt to reduce the number of post-operative blood draws and labs. Methods. We retrospectively reviewed all 1134 patients who underwent primary total hip (THA) or total knee arthroplasty (TKA) from July 2016 to March 2017 in our inpatient hospital setting. There were 733 TKA and 401 THA. Pre- and post-operative lab values were reviewed and correlated with transfusion and medical treatments. Results. Twelve patients received a post-operative transfusion (1.1%). In TKA patients 2 of 733 (0.2%) were transfused while in THA patients 10 of 401 (2.4%) were transfused. Of the 12 patients receiving transfusions 11 were females, and in all 12 the pre-operative hemoglobin was less than 13. For the overall series of 1134 patients, 176 (15.5%) required potassium chloride supplementation based on BMP. Only patients with pre-existing renal disease or diuretic treatment received potassium chloride supplementation. Conclusions. Based on our findings, only patients with pre-operative hemoglobin less than 13 require post-operative H&H. Additionally, only patients with low pre-operative potassium, history of renal disease, or active treatment with a diuretic require post-operative BMP

Tranexamic acid (TXA) is an effective medication to limit blood loss and transfusion requirements in association with contemporary total joint arthroplasty. TXA is in a class of medications termed anti-fibrinolytics due to their action to limit the breakdown of clot that has already been formed. It is useful to note that TXA does not promote the formation of clot, it simply limits the breakdown of already established clot. A recent systematic review and meta-analysis of randomised clinical trials of TXA use in total hip replacement demonstrated: 1) a substantial reduction in the proportion of patients who required transfusion and 2) no increase in DVT or PE. Similarly a recent Cochrane Database systematic review assessed Anti-fibrinolytic Use for Minimizing Perioperative Blood Transfusion and found tranexamic acid to be effective in reducing blood loss during and after surgery and to be free of serious adverse effects. In orthopaedic surgery varying doses have been used over time. A pragmatic dosing approach for Total Knee and Total Hip patients has been used at the Mayo Clinic over the past 16 years: 1 gram IV over 10 minutes prior to incision (delivered at same time as pre-op antibiotics) followed by 1 gram IV over 10 minutes at the time wound closure is initiated. Infusion rates greater than 100 mg/minute have been associated with hypotension and thus the recommendation for 1 gram over 10 minutes. A recent review of 1500 TKA patients at Mayo Clinic revealed a very low prevalence of clinically symptomatic DVT and PE when tranexamic acid was used with 3 different thromboembolic prophylaxis regimens (aspirin and foot pumps; coumadin; low molecular weight heparin). The safety of TXA for patients with coronary stents has not been fully clarified.

Aims

The aim of this study was to examine the efficacy and safety of multiple boluses of intravenous (IV) tranexamic acid (TXA) on the hidden blood loss (HBL) and inflammatory response following primary total hip arthroplasty (THA).

Blood conservation is an essential aspect of total hip arthroplasty (THA). As recently as 10 years ago, it was standard practice across North America for patients to undergo pre-operative autologous blood donation (PAD) prior to an elective TJA. Though the cost of PAD is about the same as allogenic blood transfusion, it has fallen out of favor due to mixed results. Instead, most surgeons have implemented a practice of obtaining pre-operative hemoglobin levels. If anemia is diagnosed, the patient should be worked up for the underlying cause. In cases of pre-operative anemia where a specific deficiency cannot be elucidated, consideration can be given to the use of erythropoietin (EPO). The routine use of tranexamic acid (TXA) has become the standard of care at most institutions since it is safe, inexpensive, easy to administer, and very effective at minimizing peri-operative blood transfusion. Intravenous TXA can be administered effectively in a variety of different ways and a number of different protocols are described. The popularised Mayo Clinic protocol is to administer TXA once prior to incision (1g IV in 50mL of normal saline) and once during wound closure. Acute normovolemic hemodilution is a technique utilised just before or after the induction of anesthesia in which whole blood is removed while keeping the patient normovolemic with acellular fluids (i.e. crystalloids or colloids). This technique is rarely used. Hypotensive anesthesia is a technique utilised to keep mean arterial pressures (MAP) at a level around 50mm Hg. It appears to be most effective with the use of epidural anesthesia. Certain patients may not be good candidates for hypotensive anesthesia (high cardiac risk factors), but it can be an effective corollary to other intra-operative measures. Historically, many surgeons practiced reflexive transfusion protocols rather than treating patients on an individual basis. Current practice has adopted a more pragmatic approach to transfusion. Specifically, patients are assessed for signs of anemia and are often allowed to drift well below 8g/dL as long as they remain asymptomatic and have a suitable cardiac risk

Acute peri-operative blood loss warranting transfusion is a frequent consequence of major joint replacement (TJR) surgery. Significant peri-operative anemia can contribute to hypotension, dyspnea, coronary ischemia and other peri-operative medical events that can result in increased risk of peri-operative complications, readmissions and impair the patient's ability to mobilise after surgery resulting in a longer length of stay (LOS) and increase skilled nursing facility (SNF) utilization. The risks associated with allogeneic blood transfusions (ABT) administered to treat symptomatic peri-operative anemia are numerous and extend beyond the concerns of transmission of communicable disease (HIV, hepatitis, other). Patients receiving ABTs have been shown to have a longer hospital LOS, higher risk of infection, and higher mortality after TJR than those who do not require transfusion after surgery. As a result, many different pre-operative, peri-operative and post-operative strategies have been utilised to minimise peri-operative blood loss and transfusion need for patients undergoing TJR. Several studies have shown that the strongest predictor of the need for ABT in the TJR patient is the pre-operative hematocrit (Hct). As a result, all patients with unexplained pre-operative anemia should be evaluated for an underlying cause prior to elective TJR surgery. In recent years, focus has shifted towards peri-operative reduction of blood loss with the use of pharmacologic agents like tranexamic acid (TXA). These agents work by inhibiting fibrinolysis and activating plasminogen. Numerous studies have shown that TXA given IV, applied topically into the surgical wound or given orally have been shown to reduce peri-operative bleeding and ABT after both THA and TKR. Regardless of route of administration, all appear to be more efficacious and considerably more cost-effective in reducing the need for ABT than other methods discussed previously. Despite concerns about the potential increased thromboembolic risk in patients undergoing TJR, there does not appear to be any conclusive evidence suggesting an increased risk of venous thromboembolic disease (VTED) in TJR patients who receive peri-operative TXA. Although it may be unnecessary, many TJR surgeons still, however, avoid use of TXA in patients with a past history of VTED, stroke, coronary artery disease (including coronary stents), renal insufficiency, hypercoagulable state and seizure disorder. The use of topical TXA may be safer in some of these high risk patients since systemic absorption is minimal when administered via this route. Although the optimal method of administration (IV, topical, oral or combined) has not yet been determined based on safety, cost and reduction of need for ABT, incorporation of tranexamic acid into a blood conservation program is clearly the standard of care for all TJR programs that should nearly eliminate the need for ABT for patients undergoing TJR

Purpose. This meta-analysis was designed to evaluate the effects of computer navigation on blood conservation after total knee arthroplasty (TKA) by comparing postoperative blood loss and need for allogenic blood transfusion in patients undergoing computer navigation and conventional primary TKAs. Methods. Studies were included in this meta-analysis if they compared change in haemoglobin concentration before and after surgery, postoperative blood loss via drainage or calculated total blood loss, and/or allogenic blood transfusion rate following TKA using computer navigation and conventional methods. For all comparisons, odds ratios and 95 % confidence intervals (CI) were calculated for binary outcomes, while mean difference and 95 % CI were calculated for continuous outcomes. Results. Twelve studies were included in this meta-analysis. The change in haemoglobin concentration was 0.39 g/dl lower with computer navigation than with conventional TKA (P = 0.006). Blood loss via drainage was 83.1 ml (P = 0.03) lower and calculated blood loss was 185.4 ml (P = 0.002) lower with computer navigation than with conventional TKA. However, the need for blood transfusion was similar for the two approaches (n.s.). Conclusions. The primary TKA with computer navigation was effective in reducing haemoglobin loss and blood loss, but had no effect on transfusion requirement, compared with conventional primary TKA. These findings suggest the importance of analysing several blood loss parameters, because each may not always accurately reflect true postsurgical bleeding

Perioperative blood conservation remains an important topic today in order to reduce complications, improve function, and facilitate recovery after a total knee replacement (TKR). Studies have shown that the degree of postoperative anemia is related to an increase in complications. A greater blood loss and need for transfusion is associated with a higher risk of infection, a slower recovery process, increased morbidity to patients, as well as an increased cost to the health care system. Typical blood loss estimates range from 800cc to over 1700cc, when accounting not only for intraoperative but postoperative blood loss. Several strategies have been developed to help mitigate the risk of perioperative blood loss and need for subsequent transfusion. Firstly, preoperative measures such as vitamin and mineral supplementation can ensure the starting hemoglobin and red cell count are maximised. Additionally, erythropoietin can be helpful in refractory cases of preoperative anemia. Preoperative autologous blood donation was used extensively in the past, but has fallen out of favor due to its inefficiency and cost. Intraoperatively, measures such as the use of a tourniquet, meticulous technique, and expeditious surgery can help reduce blood loss. The most effective method, however, has been the use of tranexamic acid (TXA). TXA, an antifibrinolytic compound, has been extremely effective at reducing perioperative blood loss without increasing the risk of thromboembolic events. TXA can be used topically or intravenously. Other methods that can reduce intraoperative blood loss include the use of fibrin sealants, applied to the soft tissues and bony surfaces around the knee. Postoperatively, the avoidance of wound drains is associated with a higher blood count and reduced transfusion risk. Alternatively, drainage reinfusion systems can be used to raise the postoperative blood count, particularly in cases of bilateral TKR

Tranexamic acid (TXA) is an effective medication to limit blood loss and transfusion requirements in association with contemporary total joint arthroplasty. TXA is in a class of medications termed anti-fibrinolytics due to their action to limit the breakdown of a clot that has already been formed. It is useful to note that TXA does not promote the formation of a clot, it simply limits the breakdown of already established clots. A recent systematic review and meta-analysis of randomised clinical trials of TXA use in total hip replacement demonstrated: 1) a substantial reduction in the proportion of patients who required transfusion and 2) no increase in DVT or PE. Similarly a recent Cochrane Database systematic review assessed Anti-fibrinolytic Use for Minimizing Perioperative Blood Transfusion and found tranexamic acid to be effective in reducing blood loss during and after surgery and to be free of serious adverse effects. In orthopaedic surgery, varying doses have been used over time. A pragmatic dosing approach for Total Knee and Total Hip patients has been used at the Mayo Clinic over the past 16 years: 1 gram IV over 10 minutes prior to incision (delivered at same time as pre-operative antibiotics) followed by 1 gram IV over 10 minutes at the time wound closure is initiated. Infusion rates greater than 100 mg/minute have been associated with hypotension and thus the recommendation for 1 gram over 10 minutes. A recent review of 1500 TKA patients at Mayo Clinic revealed a very low prevalence of clinically symptomatic DVT and PE when tranexamic acid was used with 3 different thromboembolic prophylaxis regimens (aspirin and foot pumps; coumadin; low molecular weight heparin). The safety of TXA for patients with coronary stents has not been fully clarified.

Total joint arthroplasty is commonly associated with post-operative anemia. Blood conservation programs have been developed to optimise patients prior to surgery. Epoetin Alfa (Eprex) or intravenous (IV) iron transfusions are two modalities that can be used pre-operatively to optimise hemoglobin and ferritin levels. There are, however, potential complications and increased costs associated with their use. Oral iron is a less costly option for those undergoing surgery but requires more time to take effect. There are no studies to date that examine the effects of an early screening program utilising oral iron supplementation prior to total joint arthroplasty. The purpose of this study is to evaluate the effect of implementing early pre-operative oral iron supplementation on patients prior total joint arthroplasty. A retrospective review of patients undergoing total joint arthroplasty was performed using our institution clinical informatics database. We identified all patients seen in pre-admission clinic (PAC) between Jan 1, 2009 and March 31, 2010 representing our control group. We then identified all patients seen in PAC between October 1, 2012 and December 31, 2013. Patients in this cohort received screening blood work when booked for surgery, and oral iron supplementation was given to patients with hemoglobin of less than 135g/L or ferritin less than 100ug/L, thus representing our treatment group. Patients undergoing revision, uni-compartment knee arthroplasty and bilateral arthroplasties were excluded from the study. Pearson Chi-Square tests were used to calculate significance between groups with main outcomes including pre-admission hemoglobin, and pre-operative requirements for Eprex or IV iron. In our control group, we identified 354 patients (25.6%) with hemoglobin less than 130 g/L at time of pre-admission clinic. In our treatment group, this number dropped significantly to only 16.4% of patients (p<0.005). Implementation of an early screening program using oral iron supplementation resulted in a decrease in the number of patients with hemoglobin lower than 130 g/L at the time of pre-admission clinic. There was also a significant decrease in the use of Eprex and IV iron pre-operatively in the patients in the early screening program. These results encourage the use of early oral iron supplementation for patients with hemoglobin less than 135 g/L or ferritin less than 100ug/L in order to optimise patients prior to total joint arthroplasty