Aims

This study aimed to assess the risk of acute kidney injury (AKI) associated with combined intravenous (IV) and topical antibiotic therapy in patients undergoing treatment for periprosthetic joint infections (PJIs) following total knee arthroplasty (TKA), utilizing the Kidney Disease: Improving Global Outcomes (KDIGO) criteria for classification.

BACKGROUND. Theatre-listed trauma patients routinely require two ‘group and save’ blood-bank samples, in case they need perioperative transfusion. The Welsh Blood Service (WBS) need patients to have one recorded sample from any time in the last 10 years. A second sample, to permit cross-matching and blood issuing, must be within 7 days of transfusion (or within 48 hours if the patient is pregnant, or has been transfused within the last 3 months). The approximate cost of processing a sample is £15.00. AIM. To investigate whether routine pretransfusion blood sampling for trauma admissions exceeds requirements. METHODS. Electronic records were used to collect pretransfusion sampling data for all adult non-elective trauma patients listed for theatre under a trauma and orthopaedics consultant between 1/1/2023-31/1/2023. Data were collected on unnecessary samples, rejected samples and total excess samples. RESULTS. 113 patients (mean age[±SD] 64.09[±19.96]) underwent 132 procedures. On average, unnecessary sampling occurred at a rate of 0.48 samples per operation, equating to a cost of £945.00/month. Samples were rejected by the laboratory at a rate of 0.25 samples per operation. Common reasons for rejection were ‘patient date of birth discrepancy’ (between sample and request form), ‘patient address discrepancy’ and ‘signature discrepancy’. Overall, total excessive sampling occurred at a rate of 0.60 samples per operation. CONCLUSION. Nearly half of trauma patients undergo unnecessary blood testing in anticipation of potential perioperative transfusion. This has implications for sustainability, financial cost and patient welfare. This signals poor understanding of WBS requirements and is an area that requires improvement

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

Aims. Blood transfusion and postoperative anaemia are complications of total knee arthroplasty (TKA) that are associated with substantial healthcare costs, morbidity, and mortality. There are few data from large datasets on the risk factors for these complications. Methods. We retrospectively reviewed the records of TKA patients from a single tertiary care institution from February 2016 to December 2020. There were a total of 14,901 patients in this cohort with a mean age of 67.9 years (SD 9.2), and 5,575 patients (37.4%) were male. Outcomes included perioperative blood transfusion and postoperative anaemia, defined a priori as haemoglobin level < 10 g/dl measured on the first day postoperatively. In order to establish a preoperative haemoglobin cutoff, we investigated a preoperative haemoglobin level that would limit transfusion likelihood to ≤ 1% (13 g/dl) and postoperative anaemia likelihood to 4.1%. Risk factors were assessed through multivariable Poisson regression modelling with robust error variance. Results. In multivariable analyses, each gram of tranexamic acid reduced transfusion likelihood by 39% (adjusted risk ratio (ARR) 0.61 (95% confidence interval (CI) 0.47 to 0.78)). Risk factors associated with an increased risk of transfusion included operating time (ARR 2.07 (95% CI 1.54 to 2.77)) and drain use (ARR 1.73 (95% CI 1.34 to 2.24)). Conclusion. In this study, we found that increased tranexamic acid dosing, decreased operating time, and decreased drain use may reduce transfusions following TKA. We also established a single preoperative haemoglobin cutoff of 13 g/dl that could help minimize transfusions and reduce postoperative complete blood counts. Cite this article: Bone Joint J 2023;105-B(10):1086–1093

Aims. 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. Methods. 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. Results. A total of 23,266 individual patient records from 18 hospitals were included. The overall rate of blood transfusion during admission was 28.7% (n = 6,685). There was inter-hospital variation in transfusion rate, ranging from 16.6% to 37.4%. Independent perioperative factors significantly associated with RBCT included older age (90 to 94 years, odds ratio (OR) 3.04 (95% confidence interval (CI) 2.28 to 4.04); p < 0.001), intramedullary fixation (OR 7.15 (95% CI 6.50 to 7.86); p < 0.001), and sliding hip screw constructs (OR 2.34 (95% CI 2.19 to 2.50); p < 0.001). Blood transfusion during admission was significantly associated with higher rates of 30-day mortality (OR 1.35 (95% CI 1.19 to 1.53); p < 0.001) and 60-day mortality (OR 1.54 (95% CI 1.43 to 1.67); p < 0.001), as well as delays to postoperative mobilization, higher likelihood of not returning to their home, and longer length of stay. Conclusion. Blood transfusion after hip fracture was common, although practice varied nationally. RBCT is associated with adverse outcomes, which is most likely a reflection of perioperative anaemia, rather than any causal effect. Use of RBCT does not appear to reverse this effect, highlighting the importance of perioperative blood loss reduction. Cite this article: Bone Joint J 2022;104-B(11):1266–1272

This trial aims to assess the effectiveness of quality improvement collaboratives as a technique to introduce large-scale change and improve outcomes for patients undergoing primary elective total hip or total knee arthroplasty. 41 NHS Trusts that did not have; a preoperative anaemia screening and optimisation pathways, or a methicillin sensitive Staphylococcus Aureus (MSSA) decolonisation pathway, in place were randomised to one of two parallel collaboratives in a two arm, cluster randomised controlled trial. Each collaborative focussed on implementing one of these two preoperative pathways. Collaboratives took place from May 2018 to November 2019. 27 Trusts completed the trial. Outcome data were collected for procedures between November 2018 and November 2019. Co-primary outcomes were perioperative blood transfusion (within 7 days of surgery) and deep surgical site infections (SSI) caused by MSSA (within 90 days) for the anaemia and MSSA arms respectively. Secondary outcomes include deep and superficial SSIs (any organism), length of stay, critical care admissions, and readmissions. Process measures include the proportion of patients receiving each preoperative initiative. 19,254 procedures from 27 Trusts are included. Process measures show both preoperative pathways were implemented to a high degree (75.3% compliance in MSSA arm; 61.2% anaemia arm), indicating that QICs can facilitate change in the NHS. However, there were no improvements in blood transfusions (2.9% v 2.3% adjusted-OR 1.20, 95% CI 0.52–2.75, p=0.67), MSSA deep SSIs (0.13% v 0.14% adjusted-OR 1.01, 95%CI 0.42–2.46, p=0.98), or any secondary outcome. Whilst no significant improvement in patient outcomes were seen, this trial shows quality improvement collaboratives can successfully support the implementation of new preoperative pathways in planned surgery in the NHS

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. Methods. We performed a retrospective cohort study of adult patients who underwent orthopaedic surgery at four Canadian hospitals between 2014 and 2016. We studied all patients admitted to hospital for nonarthroscopic joint surgeries, amputations, and fracture surgeries. For each surgery and surgical subgroup, we characterized the proportion of patients who received red blood cell (RBC) transfusion, the mean/median number of RBC units transfused, and exposure to platelets and plasma. Results. Of the 14,584 included patients, the most commonly performed surgeries were knee arthroplasty (24.8%), hip arthroplasty (24.6%), and hip fracture surgery (17.4%). A total of 10.3% of patients received RBC transfusion; the proportion of patients receiving RBC transfusions varied widely based on the surgical subgroup (0.0% to 33.1%). Primary knee arthroplasty and hip arthroplasty, the two most common surgeries, were associated with in-hospital transfusion frequencies of 2.8% and 4.5%, respectively. RBC transfusion occurred in 25.0% of hip fracture surgeries, accounting for the greatest total number of RBC units transfused in our cohort (38.0% of all transfused RBC units). Platelet and plasma transfusions were uncommon. Conclusion. Orthopaedic surgeries were associated with variable rates of transfusion. The rate of RBC transfusion is highly dependent on the surgery type. Identifying surgeries with the highest transfusion rates, and further evaluation of factors that contribute to transfusion in identified at-risk populations, can serve to inform perioperative planning and blood bank requirements, and facilitate pre-emptive transfusion mitigation strategies. Cite this article: Bone Jt Open 2021;2(10):850–857

Aims

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.

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Debate continues regarding the optimum management of periprosthetic distal femoral fractures (PDFFs). This study aims to determine which operative treatment is associated with the lowest perioperative morbidity and mortality when treating low (Su type II and III) PDFFs comparing lateral locking plate fixation (LLP-ORIF) or distal femoral arthroplasty (DFA).

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To assess the safety of tranexamic acid (TXA) in a large cohort of patients aged over 65 years who have sustained a hip fracture, with a focus on transfusion rates, mortality, and thromboembolic events.

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Recent improvements in surgical technique and perioperative blood management after total joint replacement (TJR) have decreased rates of transfusion. However, as many surgeons transition to outpatient TJR, obtaining routine postoperative blood tests becomes more challenging. Therefore, we sought to determine if a preoperative outpatient assessment tool that stratifies patients based on numerous medical comorbidities could predict who required postoperative haemoglobin (Hb) measurement.

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The impact of tobacco use on readmission and medical and surgical complications has been documented in hip and knee arthroplasty. However, there remains little information about the effect of smoking on the outcome after total shoulder arthroplasty (TSA). We hypothesized that active smokers are at an increased risk of poor medical and surgial outcomes after TSA.

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Hospital case volume is shown to be associated with postoperative outcomes in various types of surgery. However, conflicting results of volume-outcome relationship have been reported in hip fracture surgery. This retrospective cohort study aimed to evaluate the association between hospital case volume and postoperative outcomes in patients who had hip fracture surgery. We hypothesized that higher case volume would be associated with lower risk of in-hospital and one-year mortality after hip fracture surgery.

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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.

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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.

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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.

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

Surgery for DDH is one of the common paediatric orthopaedics procedures in a tertiary care paediatrics hospital. There are no uniformly agreed guidelines about the pre-operative work up related to blood transfusion in DDH surgery. This leads to lack of uniformity in practice, sometimes causes cancellations of operations on the day of surgery (due to no cross matched blood available) and on other occasions wastage of the cross matched blood. The aims of our study were to know the incidence of perioperative blood transfusion in a series of DDH operations and to determine what types of operations/kids have more chances of needing a blood transfusion peri-operatively. We included all children who had surgery for DDH between April 2009 and October 2012 in our institution. We found out which of these children had blood transfusion peri-operatively and reviewed their notes to determine any trends in transfusion requirements. 165 children had operations for DDH during the study period. This included operations ranging from hip open reduction to Ganz osteotomy. 6 out of 165 (4%) were transfused blood. Children needing blood transfusion tended to be older and had multiple hip operations previously. Only 3 (2 during Ganz and 1 during bilateral hip reconstruction) of these 6 children needed intra-operative blood transfusion. None of the under 4 years old children needed intra-operative blood transfusion. We conclude that children for unilateral primary hip operations for DDH do not need pre operative blood cross match. A group and save is enough in these cases