Aims. We aim to evaluate the usefulness of postoperative blood tests by investigating the incidence of abnormal results following total joint replacement (TJR), as well as identifying preoperative risk factors for abnormal blood test results postoperatively, especially pertaining to anaemia and acute kidney injury (AKI). Methods. This is a retrospective cohort study of patients who had elective TJR between January and December 2019 at a tertiary centre. Data gathered included age at time of surgery, sex, BMI, American Society of Anesthesiologists (ASA) grade, preoperative and postoperative laboratory test results, haemoglobin (Hgb), white blood count (WBC), haematocrit (Hct), platelets (Plts), sodium (Na. +. ), potassium (K. +. ), creatinine (Cr), estimated glomerular filtration rate (eGFR), and Ferritin (ug/l). Abnormal blood tests, AKI, electrolyte imbalance, anaemia, transfusion, reoperation, and readmission within one year were reported. Results. The study included 2,721 patients with a mean age of 69 years, of whom 1,266 (46.6%) were male. Abnormal postoperative bloods were identified in 444 (16.3%) patients. We identified age (≥ 65 years), female sex, and ASA grade ≥ III as risk factors for developing abnormal postoperative blood tests. Preoperative haemoglobin (≤ 127 g/dl) and packed cell volume (≤ 0.395 l/l) were noted to be significant risk factors for postoperative anaemia, and potassium (≤ 3.7 mmol/l) was noted to be a significant risk factor for AKI. Conclusion. The costs outweigh the benefits of ordering routine postoperative blood tests in TJR patients. Clinicians should risk-stratify their patients and have a lower threshold for ordering blood tests in patients with abnormal preoperative haemoglobin (≤ 127 g/l), blood loss > 300 ml, chronic kidney disease, ASA grade ≥ III, and clinical concern. Cite this article: Bone Jt Open 2023;4(11):899–905

Aims

The rate of day-case total knee arthroplasty (TKA) in the UK is currently approximately 0.5%. Reducing length of stay allows orthopaedic providers to improve efficiency, increase operative throughput, and tackle the rising demand for joint arthroplasty surgery and the COVID-19-related backlog. Here, we report safe delivery of day-case TKA in an NHS trust via inpatient wards with no additional resources.

Primary total joint arthroplasty (TJA) is an increasingly common and safe way of treating joint disease. Robust preoperative assessment improved intraoperative techniques and holistic rehabilitation contribute to an uneventful postoperative period. Despite there being evidence against the utility of postoperative blood tests, it is still often part of routine practice. We aim to evaluate the usefulness of these tests by investigating their incidence following TJA as well as identifying preoperative risk factors for abnormal blood test results postoperatively especially pertaining to anaemia and acute kidney injury (AKI). This is a retrospective cohort study of patients who had elective TJA between January and December 2019 at a tertiary centre. An independent student's t-test and Fisher's exact test was used to compare variables between the normal and abnormal postoperative results groups. An analysis of variance (ANOVA) was performed to identify risk factors for an abnormal blood test result. Analyses of receiver operating characteristic (ROC) curves and the area under the curve (AUC) were used to determine cut off values that could be suggestive of abnormal test results postoperatively. The study included 2721 patients with a mean age of 69 of which 46.6% were males. Abnormal postoperative bloods were identified in 444 (16.3%) patients. We identified age (≥65 years), female gender, ASA ≥ 3 as risk factors for developing abnormal postoperative blood tests. Preoperative haemoglobin (≤ 127 g/dL), haematocrit (≤ 0.395L/L) and potassium (≤ 3.7 mmol/L) were noted as cut-offs that could be predictive of postoperative anaemia or AKI respectively. The costs outweigh the benefits of ordering routine postoperative blood tests in TJA patients. Clinicians should risk stratify their patients and have a lower threshold for ordering blood tests in patients with one or more of the risk factors we have identified. These risk factors are age (≥65 years), females, ASA ≥ 3, preoperative haemoglobin (≤ 127 g/L), haematocrit (≤ 0.395L/L), and potassium (≤ 3.7 mmol/L)

Aims. It is common practice for patients to have postoperative blood tests after total joint replacement (TJR). However, there have been significant improvements in perioperative care with arthroplasty surgery, and a drive to reduce the length of stay (LOS) and move towards day-case TJR. We should reconsider whether this intervention is necessary for all patients. Methods. This retrospective study included all patients who underwent a primary unilateral TJR at a single tertiary arthroplasty centre during a one-year period. Electronic medical records of 1,402 patients were reviewed for patient demographics, LOS, and American Society of Anesthesiologists (ASA) grade. Blood tests were examined to investigate the incidence of postoperative anaemia, electrolyte abnormalities, and incidence of acute kidney injury (AKI). Results. For total knee arthroplasties, preoperative (R = −0.22) and postoperative haemoglobin (R = 0.2) levels were both negatively correlated with LOS (p < 0.001). For all patients who had undergone a TJR, 19 patients (0.014%) required a blood transfusion postoperatively due to symptomatic anaemia. Risk factors identified were age, preoperative anaemia, and long-term aspirin use. Significant abnormal sodium levels were found in123 patients (8.7%). However, only 36 patients (2.6%) required intervening treatment. Risk factors identified were age, preoperative abnormal sodium level, and long-term use of non-steroidal anti-inflammatory drugs, angiotensin receptor blockers, and corticosteroids. Similarly, abnormal potassium levels were evident in 53 patients (3.8%), and only 18 patients (1.3%) required intervening treatment. Risk factors identified were preoperative abnormal potassium level, and long-term use of angiotensin-converting enzyme inhibitors and diuretics. The incidence of AKI was 4.4% (61 patients). Risk factors identified were age, increased ASA grade, preoperative abnormal sodium, and creatinine level. Conclusion. Routine blood tests after primary TJR is unnecessary for most patients. Blood tests should only be performed on those with identifiable risk factors such as preoperative anaemia and electrolyte abnormalities, haematological conditions, long-term aspirin use, and electrolyte-altering medications. Cite this article: Bone Jt Open 2023;4(5):357–362

Routine post-operative bloods following all elective arthroplasty may be unnecessary. This retrospective cohort study aims to define the proportion of post-operative tests altering clinical management. Clinical coding identified all elective hip or knee joint replacement under Hawkes Bay District Health Board contract between September 2019-December 2020 (N=373). Uni-compartmental and bilateral replacements, procedures performed for cancer, and those with insufficient data were excluded. Demographics, perioperative technique, and medical complication data was collected. Pre- and post-operative blood tests were assessed. Outcome measures included clinical intervention for abnormal post-operative sodium (Na), creatinine (Cr), haemoglobin (Hb), or potassium (K) levels. A cost-benefit analysis assessed unnecessary testing. 350 patients were Included. Median age was 71 (range 34-92), with 46.9% male. Only 26 abnormal post-operative results required intervention (7.1%). 11 interventions were for low Na, 4 for low K, and 4 for elevated Cr. Only 7 patients were transfused blood products. Older age (p=0.009) and higher ASA (p=0.02) were associated with intervention of any kind. Abnormal preoperative results significantly predicted intervention for Na (p<0.05) and Cr (p<0.05). All patients requiring treatment for K used diuretic medication. Preoperative Hb level was not associated with need for transfusion. Overall, there were 1027 unnecessary investigations resulting in $18,307 excess expenditure. Our study identified that the majority of elective arthroplasty patients do not require routine postoperative blood testing. We recommend investigations for patients with preoperative electrolyte abnormality, those taking diuretics, and patients with significant blood loss noted intra-operatively. In future, a larger, randomised controlled trial would be useful to confirm these factors

Abstract. Introduction. It is common practice for all patients to have postoperative bloods tests after total knee arthroplasty (TKA). However there have been significant improvement in perioperative care with arthroplasty surgery. As healthcare systems and providers strive towards a more efficient service we must re-consider whether such an intervention is necessary for all patients. Methodology. This retrospective study included all patients who underwent a primary unilateral TKA at a single tertiary arthroplasty centre during a 1 year period. Electronic medical records of 776 patients were reviewed for patient demographics, length of stay and American Society of Anaesthesiologists grade. Blood tests were examined to investigate the incidence of post operative anaemia requiring transfusion, electrolyte abnormalities that required treatment and the incidence of acute kidney injury. Results. Average length of stay in hospital was 4.3 days. Pre-operative (R=-0.22) & post-operative haemoglobin (R=0.2) levels were both negatively correlated with length of stay (p<0.01). There was 1 patient that required a blood transfusion post operatively due to symptomatic anaemia. This patient underwent a complex primary TKA. Significant abnormal post-operative electrolyte levels were found in 100 (12.9%) of patients. 87 of these patients either had abnormal electrolyte levels pre-operatively or were taking a medication that causes the electrolyte abnormality. Medical treatment for abnormal electrolyte levels was required in 32 (4.1%) of all patients. The incidence of acute kidney injury was 4.4%. Conclusion. Routine blood tests after primary total knee arthroplasty is unnecessary for most patients. Blood tests should only be performed in those with identifiable risk factors

Abstract. Objectives. Routine blood test following total shoulder arthroplasty (TSA) cost the NHS more than £72000 in 2018 without definite evidence of their impact on patients’ management or outcomes. This study aimed to ascertain if routine laboratory tests are a necessity post TSA or can be implemented on a per-patient. Methods. A retrospective review of the electronic records completed for 251 patients underwent TSA over 6 years. 193 patients were eligible for analysis. Primary outcomes were interventions to the abnormal postoperative blood tests. Secondary outcomes were the length of stay (LOS), and readmission within 30 days and 90 days. Results. 193 patients underwent 216 TSAs; 72 % were females and 18% males. The mean age was 78 ± 7.2 years. Completed procedures included 134 reverse, 64 anatomical and 18 revision TSAs. 136 patients (63%) had an abnormal postoperative blood test, however, only 8 (3.7%) required intervention. The average postoperative haemoglobin (Hb) drop was 19 g/L with 94 patients (43.5%) having Hb <109g/L. 4 patients (1.8%) dropped Hb < 80g/L; only 2 patients (0.9%) were symptomatic and received RBC transfusion . 6 patients (2.8%) developed acute kidney injury and treated by IV fluids. The mean LOS was 3.2 ± 2.9 days .5 patients (2.3%) were readmitted within 30 days and 6 patients (2.8%) within 90 days. Univariate analysis showed association only between abnormal Creatinine and LOS (p<0.05) and of these patients, all had abnormal preoperative Creatinine baseline. No statistical correlation detected between age (p=0.287), postoperative Hb (p=0.230) and LOS nor readmission at 30 or 90 days. Conclusions. Routine postoperative blood tests are not required as they have not shown to produce a meaningful clinical impact in this cohort of patients nor on the re-admission rate, causing unnecessary costs. We recommend assessing each patient and request for investigations in a coherent and justified manner. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Aims. 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. Methods. We performed a prospective study of consecutive unilateral primary total knee arthroplasties (TKAs) and total hip arthroplasties (THAs) performed at a single institution. Prospectively collected data included preoperative and postoperative Hb levels, need for blood transfusion, length of hospital stay, and Outpatient Arthroplasty Risk Assessment (OARA) score. Results. A total of 504 patients met inclusion criteria. Mean age at time of arthroplasty was 65.3 years (SD 10.2). Of the patients, 216 (42.9%) were THAs and 288 (57.1%) were TKAs. Six patients required a blood transfusion postoperatively (1.19%). Transfusion after surgery was associated with lower postoperative day 1 Hb (median of 8.5 (interquartile range (IQR) 7.9 to 8.6) vs 11.3 (IQR 10.4 to 12.2); p < 0.001), longer length of stay (1 day (IQR 1 to 1) vs 2 days (IQR 2 to 3); p < 0.001), higher OARA score (median of 60.0 (IQR 40 to 75) vs 5.0 (IQR 0-35); p = 0.001), and total hip arthroplasty (p < 0.001). All patients who received a transfusion had an OARA score > 34; however, this did not reach statistical significance as a screening threshold. Conclusion. Risk of blood transfusion after primary TJR was uncommon in our series, with an incidence of 1.19%. Transfusion was associated with OARA scores > 60. The OARA score, not American Society of Anesthesiologists grade, reliably identified patients at risk for postoperative blood transfusion. Selective Hb monitoring may result in substantial cost savings in the era of cost containment. Cite this article: Bone Joint J 2021;103-B(1):65–70

Introduction. Postoperative total shoulder arthroplasty (TSA) blood tests cost the National Health Service in the UK more than £72000 annually without definite evidence of their impact on outcomes. This study aimed to ascertain if these blood tests can be implemented on a per-patient basis. Methods. A retrospective review of one centre TSA patients over 6 years. Primary outcomes were interventions to abnormal postoperative blood tests. Secondary outcomes were the length of stay (LOS), and readmission within 30 and 90 days. Results. 193 patients underwent 216 TSAs; 72 % were females and 18% males. The mean age was 78 ± 7.2 years. Completed procedures included 134 reverse, 64 anatomical and 18 revision TSAs. 136 patients (63%) had an abnormal postoperative blood test, however, only 8 (3.7%) required intervention. The average postoperative Hb drop was 19 g/L with 94 patients (43.5%) having Hb <109g/L. 4 patients (1.8%) dropped Hb < 80g/L; only 2 (0.9%) were symptomatic and received RBC transfusion. 6 patients (2.8%) developed acute kidney injury and treated by IV fluids. The mean LOS was 3.2 ± 2.9 days .5 patients (2.3%) were readmitted within 30 days and 6 patients (2.8%) within 90 days. Univariate analysis showed association only between abnormal Creatinine and LOS (p<0.05) and of these patients, all had abnormal preoperative Creatinine baseline. No statistical correlation detected between age (p=0.287), postoperative Hb (p=0.230) and LOS nor readmission at 30 or 90 days. Conclusions. Routine postoperative blood tests are not required as no detected meaningful clinical impact and should be requested on an individual justified basis

Aims

Calcium sulphate has traditionally been used as a filler of dead space arising during surgery. Various complications have been described following the use of Stimulan bio-absorbable calcium sulphate beads. This study is a prospective observational study to assess the safety profile of these beads when used in revision arthroplasty, comparing the complication rates with those reported in the literature.

Aims: Evaluation of postoperative infections in T.H.R. and T.K.R., after randomized prophylactic use of Fusidic acid, Vancomycin and Cefuroxime and assessment of their side effects. Methods: From December 2000 to September 2002, 182 patients (43 males and 139 females), were operated on T.H.R. and T.K.R. in Orthopaedic Department of University of Patras. Mean age was 65.8 years (range 33–90yrs.). The patients were categorized into three groups (A, B and C). In group A was administrated Fusidic acid 500mg and Cefuroxime 1.5gr preoperatively and 2 doses of Fusidic acid 500mg postoperatively. Group B received Vancomycin 1gr and Cefuroxime 1.5gr preoperatively and 2 doses of Vancomycin 1gr postoperatively. Group C received Cefuroxime 1.5gr preoperatively and 2 doses of Cefuroxime 750mg postoperatively. Blood tests were systematically performed preoperatively, and the þrst and þfth postoperative day. Mean follow up was 10,5 months (range 2–21 months). Results: One patient of group B developed deep wound infection. Superþcial infections developed 2 pt. (3.2%) of group A, 2 pt. (3.9%) of group B and 2 pt. (2.8%) of group C. Temperature over 38.3û C attributed to another infection site was observed in 6 pt. (9.8%) of group A, 3 pt. (5.8%) of group B and 5 pt. (7.1%) of group C, while temperature over 38.3û C with unknown origin was noted in 7,3,8 patients respectively. No side effect was recorded. Conclusions: The proper use of antibiotic prophylaxis according to pharmakoki-netic and pharmakodynamic properties combined with sterile surgical techniques prevents early deep wound infections in T.H.R. and T.K.R. The use of speciþc anti-staphylococcal agents is of no beneþt in antimicrobial prophylaxis for the above operations

Aims: Evaluation of postoperative infections in T.H.R. and T.K.R., after randomized prophylactic use of Fusidic acid, Vancomycin and Cefuroxime and assessment of their side effects. Methods: From December 2000 to April 2002, 128 patients were operated on T.H.R. and T.K.R. in Orthopaedic Department of University of Patras (64 for T.H.R. and 47 for T.K.R.). Mean age was 66.5 years (range 45–90yrs.). The patients were categorized into three groups. In the first group was administrated Fusidic acid 500mg and Cefuroxime 1.5gr preoperatively and 2 doses of Fusidic acid 500mg postoperatively. The second group received Vancomycin 1gr and Cefuroxime 1.5gr preoperatively and 2 doses of Vancomycin 1gr postoperatively. The third group received Cefuroxime 1.5gr preoperatively and 2 doses of Cefuroxime 750mg postoperatively. Blood tests were systematically performed preoperatively, and the first and fifth postoperative day. Mean follow up was 8 months. Results: No deep wound infection was observed. Superficial infections developed 2 pt. (1.58%) of the first group, 2 pt. (1.58%) of the second group and 3 pt. (2.3%) of the third group. Temperature over 38.3° C attributed to another infection site was observed in 4 pt. of the first group, 2 pt. of the second group and 7 pt. of the third group, while temperature over 38.3° C with unknown origin was noted in 7,2,6 patients respectively. No side effect was recorded. Conclusions: The proper use of antibiotic prophylaxis according to pharmakokinetic and pharmakodvnamic properties combined with sterile surgical techniques, prevents early deep wound infections in T.H.R. and T.K.R. The use of specific antistaphylococcal agents is of no benefit in antimicrobial prophylaxis for the above operations