The aim of this study was to examine perioperative blood transfusion practice, and associations with clinical outcomes, in a national cohort of hip fracture patients. A retrospective cohort study was undertaken using linked data from the Scottish Hip Fracture Audit and the Scottish National Blood Transfusion Service between May 2016 and December 2020. All patients aged ≥ 50 years admitted to a Scottish hospital with a hip fracture were included. Assessment of the factors independently associated with red blood cell transfusion (RBCT) during admission was performed, alongside determination of the association between RBCT and hip fracture outcomes.Aims
Methods
Total hip arthroplasty (THA) using the direct anterior approach (DAA) is undertaken with the patient in the supine position, creating an opportunity to replace both hips under one anaesthetic. Few studies have reported simultaneous bilateral DAA-THA. The aim of this study was to characterize a cohort of patients selected for this technique by a single, high-volume arthroplasty surgeon and to investigate their early postoperative clinical outcomes. Using an institutional database, we reviewed 643 patients who underwent bilateral DAA-THA by a single surgeon between 1 January 2010 and 31 December 2018. The demographic characteristics of the 256 patients (39.8%) who underwent simultaneous bilateral DAA-THA were compared with the 387 patients (60.2%) who underwent staged THA during the same period of time. We then reviewed the length of stay, rate of discharge home, 90-day complications, and readmissions for the simultaneous bilateral group.Aims
Methods
It has been suggested that the direct anterior approach (DAA) should be used for total hip arthroplasty (THA) instead of the posterior approach (PA) for better early functional outcomes. We conducted a value-based analysis of the functional outcome and associated perioperative costs, to determine which surgical approach gives the better short-term outcomes and lower costs. This meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol and the Cochrane Handbook. Several online databases were searched. Non-stratified and stratified meta-analyses were conducted to test the confounding biases in the studies which were included. The mean cost and probability were used to determine the added costs of perioperative services.Aims
Methods
The purpose of this study was to examine the efficacy and safety of carbazochrome sodium sulfonate (CSS) combined with tranexamic acid (TXA) on blood loss and inflammatory responses after primary total hip arthroplasty (THA), and to investigate the influence of different administration methods of CSS on perioperative blood loss during THA. This study is a randomized controlled trial involving 200 patients undergoing primary unilateral THA. A total of 200 patients treated with intravenous TXA were randomly assigned to group A (combined intravenous and topical CSS), group B (topical CSS), group C (intravenous CSS), or group D (placebo).Aims
Methods
Many surgeons choose to perform total knee arthroplasty (TKA) surgery with the aid of a tourniquet. A tourniquet is a device that fits around the leg and restricts blood flow to the limb. There is a need to understand whether tourniquets are safe, and if they benefit, or harm, patients. The aim of this study was to determine the benefits and harms of tourniquet use in TKA surgery. We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled trials, and trial registries up to 26 March 2020. We included randomized controlled trials (RCTs), comparing TKA with a tourniquet versus without a tourniquet. Outcomes included: pain, function, serious adverse events (SAEs), blood loss, implant stability, duration of surgery, and length of hospital stay.Aims
Methods
The aim of this study was to investigate the hypothesis that a single dose of tranexamic acid (TXA) would reduce blood loss and transfusion rates in elderly patients undergoing surgery for a subcapital or intertrochanteric (IT) fracture of the hip. In this single-centre, randomized controlled trial, elderly patients undergoing surgery for a hip fracture, either hemiarthroplasty for a subcapital fracture or intramedullary nailing for an IT fracture, were screened for inclusion. Patients were randomly allocated to a study group using a sealed envelope. The TXA group consisted of 77 patients, (35 with a subcapital fracture and 42 with an IT fracture), and the control group consisted of 88 patients (29 with a subcapital fracture and 59 with an IT fracture). One dose of 15 mg/kg of intravenous (IV) TXA diluted in 100 ml normal saline (NS,) or one dose of IV placebo 100 ml NS were administered before the incision was made. The haemoglobin (Hb) concentration was measured before surgery and daily until the fourth postoperative day. The primary outcomes were the total blood loss and the rate of transfusion from the time of surgery to the fourth postoperative day.Aims
Methods
Tranexamic acid (TXA) has been shown to reduce blood loss and transfusion requirements in patients undergoing orthopaedic surgery. There remains a lack of prospective evidence for the use of TXA in patients undergoing periacetabular osteotomy (PAO). The purpose of this study was to determine if intravenous (IV) TXA is effective in reducing calculated blood loss and transfusions after PAO. This was a single-centre prospective double-blind placebo-controlled randomized trial of 81 patients aged 12 to 45 years undergoing elective PAO by a single surgeon. The intervention group (n = 40) received two doses of IV TXA of a maximum 1 g in each dose; the control group (n = 41) received two doses of 50 ml 0.9% saline IV. The primary outcome was perioperative calculated blood loss. Secondary outcomes included allogenic transfusions and six-week postoperative complications.Aims
Methods
The aim of this study was to examine whether tourniquet use can improve perioperative blood loss, early function recovery, and pain after primary total knee arthroplasty (TKA) in the setting of multiple-dose intravenous tranexamic acid. This was a prospective, randomized clinical trial including 180 patients undergoing TKA with multiple doses of intravenous tranexamic acid. One group was treated with a tourniquet during the entire procedure, the second group received a tourniquet during cementing, and the third group did not receive a tourniquet. All patients received the same protocol of intravenous tranexamic acid (20 mg/kg) before skin incision, and three and six hours later (10 mg/kg). The primary outcome measure was perioperative blood loss. Secondary outcome measures were creatine kinase (CK), CRP, interleukin-6 (IL-6), visual analogue scale (VAS) pain score, limb swelling ratio, quadriceps strength, straight leg raising, range of motion (ROM), American Knee Society Score (KSS), and adverse events.Aims
Methods
Tranexamic acid (TXA) has been shown to significantly reduce transfusion rates in primary total hip arthroplasties (THAs), but high-quality evidence is limited in the revision setting. The purpose of the current study was to compare the rate of blood transfusions and symptomatic venous thromboembolic events (VTEs) in a large cohort of revision THAs treated with or without intravenous (IV) TXA. We performed a retrospective review of 3264 revision THAs (2645 patients) between 2005 and 2014, of which 1142 procedures received IV TXA (1 g at incision and 1 g at closure). The mean age in the revision group with TXA was 65 years (28 to 95), with 579 female patients (51%). The mean age in the revision group treated without TXA was 67 years (21 to 98), with 1160 female patients (55%). Outcomes analyzed included rates of transfusion and symptomatic VTEs between procedures undertaken with and without TXA. These comparisons were performed for the overall cohort, as well as within cases subcategorized for aseptic or septic aetiologies. A propensity score was developed to minimize bias between groups and utilized age at revision THA, sex, body mass index, American Society of Anesthesiologists (ASA) score, preoperative anticoagulation, and year of surgery.Aims
Patients and Methods
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 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.Aims
Patients and Methods
Introduction. Perioperative hospital adverse events are an issue that every surgeon endeavors to avoid and minimize as much as possible. Even “minor events” such as fever or tachycardia may lead to significant costs due to workup tests, inter-consultations, and/or increased hospital stay. The objective of this study was compare perioperative outcomes (hospital length of stay [LOS], discharge disposition), rates of in-hospital adverse events and transfusion, and postoperative readmission and reoperation rates for simultaneous and staged bilateral direct anterior total hip arthroplasty (DA-THA) patients. Methods. A retrospective chart review was conducted on a consecutive series of 411 primary bilateral DA-THAs performed between 2010 and 2016 at a single institution by two fellowship trained surgeons. These were categorized as: (1) simultaneous (same anesthesia, n=122) and (2) staged (different hospitalizations, n=289). The mean time between staged surgeries was 468 days (± 414 days). Baseline patient demographics as well as hospital LOS, discharge disposition (home vs. other), hospital adverse events (i.e., nausea, vomiting, tachycardia, fever, confusion, pulmonary embolism, etc.), blood transfusions, and unplanned hospital readmissions and reoperations within 90 days were collected. Groups were compared using independent –tests, Fisher's exact test, and Pearson Chi-Square. Results. Overall, the baseline patient characteristics of the simultaneous DA-THA group had significantly younger patients, a higher proportion of males, and twice the proportion of patients with ASA 1 status compared with the staged DA-THA group. The simultaneous group showed statistically significant longer LOS (2.6 vs. 1.8 days, p<0.001) and an increased proportion of patients discharged to an extended care facility (23% vs. 5.9%, p<0.001). The overall rate of hospital adverse events in the series was 136/411 (33.1%), with a higher rate in the simultaneous DA-THA patients (54.1% vs. 24.2%, p<0.001).
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.
Background. There are multiple documented advantages of undertaking total knee arthroplasty (TKA) without tourniquet, however, increased rates of blood loss and transfusion are often cited as contraindications to this approach. The aim of this study was to examine the effect of intra-operative TA administration on blood loss and transfusion rates in TKA without pneumatic tourniquet, using Rivaroxaban as thrombo-embolic prophylaxis. Method. 120 patients split into two continuous data sets, (A+B), underwent TKA without application of above knee tourniquet, receiving a post operative dose of oral Rivaroxaban within 8 hours. Group B patients received an intra-operative dose of 1 gram of Tranexamic Acid intravenously before the first cut, whilst those in group A did not. Haemoglobin and haematocrit levels were recorded peri-operatively. A revised Gross formula was used to calculate blood loss. Four patients were excluded from the study for incomplete data. Results. 58 patients (M34F24) in Group A, average age 6, had a mean haemoglobin drop of 33gram/litre, haematocrit drop of 0.097litre/litre (9.7%), with an average calculated blood loss of 1393ml. 58 (M34, F24) patients in group B, average age 67, had a haemoglobin drop of 25.2gram/litre, haemotocrit drop of 0.076litre/litre (7.6%) with an average calculated blood loss of1079ml. Thus Group A patients were seen to sustain significantly more blood loss without TA administration, with a 29.1% larger calculated blood loss, a 25.5% larger drop in haemoglobin and a 27.6% larger fall in haematocrit.
Background. Intraoperative blood loss is a known potential complication of total knee arthroplasty (TKA). Tranexamic acid (TXA) has been shown to reduce intraoperative blood loss and postoperative transfusion in patients undergoing TKA. While there are numerous studies demonstrating the efficacy of intravenous and topical TXA in patients undergoing TKA, there are comparatively few demonstrating the effectiveness and appropriate dosing recommendations of oral formulations. Methods. A retrospective cohort study of 2230 TKA procedures at a single institution identified 3 treatment cohorts: patients undergoing TKA without the use of TXA (no-OTA, n=968), patients undergoing TKA with administration of a single-dose of oral TXA (single-dose OTA, n=164), and patients undergoing TKR with administration of preoperative and postoperative oral TXA (two-dose OTA, n=1098). The primary outcome was transfusion rate. Secondary outcomes included maximum postoperative decline in hemoglobin, number of blood units transfused, length of hospital stay, total drain output, cell salvage volume, and operating room time. Results.
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. Analysis of receiver operator characteristic (ROC) curves of
2284 consecutive patients undergoing unilateral TKA was used to
determine gender specific thresholds predicting peri-operative transfusion
with the highest combined sensitivity and specificity (area under
ROC curve 0.79 for males; 0.78 for females).Aims
Patients and Methods
The purpose of this prospective randomized study was to compare the visible, hidden, total blood loss and postoperative haemodynamic change of subcutaneous and intra-articular indwelling closed suction drainage method after total knee arthroplasty (TKA). Patients with primary osteoarthritis, who underwent unilateral TKA were enrolled; Group A with subcutaneous (n=78) and group B with intra-articular (n=79) indwelling closed suction drainage method. Total blood loss, visible blood loss, internal blood loss, postop (day 1), 5th, 10th day hemoglobin, hematocrit levels were compared. Allogenic blood transfusion rate and complications related to soft tissue hematoma formation were additionally compared. Subcutaneous indwelling closed suction drainage method reduced both the visible blood loss and total blood loss (hemovac drainage + internal blood loss) thus decreasing the rate of allogenic transfusion. Although the minor complications such as the incidence of bullae formation and the ecchymosis were higher in the subcutaneous indwelling group, the functional outcome at postoperative 2 year did not demonstrate difference from intra-articular drainage group.
Tranexamic acid (TXA), an inhibitor of fibrinolysis,
reduces blood loss after total knee arthroplasty. However, its effect
on minimally invasive total hip arthroplasty (THA) is not clear.
We performed a prospective, randomised double-blind study to evaluate
the effect of two intravenous injections of TXA on blood loss in
patients undergoing minimally invasive THA. In total, 60 patients (35 women and 25 men with a mean age of
58.1 years; 17 to 84) who underwent unilateral minimally invasive
uncemented THA were randomly divided into the study group (30 patients,
20 women and ten men with a mean age of 56.5 years; 17 to 79) that
received two intravenous injections 1 g of TXA pre- and post-operatively
(TXA group), and a placebo group (30 patients, 15 women and 15 men
with a mean age of 59.5 years; 23 to 84). We compared the peri-operative
blood loss of the two groups. Actual blood loss was calculated from
the maximum reduction in the level of haemoglobin. All patients
were followed clinically for the presence of venous thromboembolism. The TXA group had a lower mean intra-operative blood loss of
441 ml (150 to 800) This prospective, randomised controlled study showed that a regimen
of two intravenous injections of 1 g TXA is effective for blood
conservation after minimally invasive THA. Cite this article:
Anterior supine intermuscular total hip arthroplasty (ASI-THA) has emerged as a muscle sparing, less-invasive procedure. The anterior interval is both intermuscular and internervous, providing the advantages of little or no muscle dissection, and a true minimally invasive alternative. It is versatile, with reported use expanding beyond the primary realm to revision and resurfacing THA as well as treatment of acute fracture in elderly patients, who due to their diminished regenerative capacity may benefit more from the muscle-sparing nature of the anterior approach. The ASI approach involves the use of a standard radiolucent operative table with the table extender at the foot of the bed and the patient supine. Fluoroscopy is used in every case. A table-mounted femur elevator is utilised to facilitate femoral preparation. A retrospective review identified 824 patients undergoing 934 consecutive primary ASI-THA performed between January 2007 and December 2010. Age averaged 63.2 years (27‐92), BMI averaged 29.9 kg/m2 (16.9–59.2). Gender was 49% males and 51% females. Stem types were short in 82% and standard length in 18%. Follow-up averaged 23.1 months (1‐73). Operative time averaged 63.1 minutes (29‐143). Blood loss averaged 145.3 mL (25‐1000).
Anterior supine intermuscular total hip arthroplasty (ASI-THA) has emerged as a muscle sparing, less-invasive procedure. The anterior interval is both intermuscular and internervous, providing the advantages of little or no muscle dissection, and a true minimally invasive alternative. It is versatile, with reported use expanding beyond the primary realm to revision and resurfacing THA as well as treatment of acute fracture in elderly patients, who due to their diminished regenerative capacity may benefit more from the muscle-sparing nature of the anterior approach. The ASI approach involves the use of a standard radiolucent operative table with the table extender at the foot of the bed and the patient supine. Fluoroscopy is used in every case. A table-mounted femur elevator is utilised to facilitate femoral preparation. A retrospective review identified 824 patients undergoing 934 consecutive primary ASI-THA performed between January 2007 and December 2010. Age averaged 63.2 years (27–92), BMI averaged 29.9 kg/m2 (16.9–59.2). Gender was 49% males and 51% females. Stem types were short in 82% and standard length in 18%. Follow-up averaged 23.1 months (1–73). Operative time averaged 63.1 minutes (29–143). Blood loss averaged 145.3 minutes (25–1000).
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.
