There were 22 patients with cerebral palsy aged six to 17 years who underwent an acetabuloplasty as part of an open reduction of the hip. In 11 patients a paediatric cell saver was used to collect autologous blood which was re-infused per-operatively. This group was compared to a cohort of 11 patients undergoing similar operations in whom only banked homologous blood was transfused. On average, 432 ml of autologous blood was re-infused compared to 909 ml of homologous blood (p <
0.01), representing 19.6% and 47% of the total blood volume, respectively (p <
0.002). Two units of homologous blood were transfused in the cell saver group compared with 20 units in the control group (p <
0.001). When using a paediatric cell saver, homologous blood transfusion was avoided in 82% of patients and there were no complications.
Intra-operative, peri-articular injection of
local anaesthesia is an increasingly popular way of controlling
pain following total knee replacement. 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.
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 ( 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:
Total knee arthroplasty (TKA) is a common, effective operation but postoperative infection has devastating consequences. Several papers have associated perioperative
Objective: It has been observed in previous studies of autologous blood transfusion in total knee arthroplasty, that this technique is associated with a lower infection rate, though studies have not been sufficiently large to demonstrate a significant difference. We hypothesised that autologous salvage blood contained high levels of pro-inflammatory mediators which may prime or augment the patients’ inflammatory response, and, in particular, the function of the polymorphonuclear leukocyte (PMN). Methods: Patients were randomised after consent to those receiving
We prospectively randomised 104 consecutive patients undergoing primary cemented total knee arthroplasty to receive either a standard suction drain© (Redivac) or
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
Introduction: There is increasing awareness and concern among the medical profession, general public and media about the various complications of homologous blood transfusion. Primary arthroplasty of either the hip or knee has an estimated total bleeding of 1.51 (Lotke et al 1991), commonly resulting in transfusion. In knee arthroplasty, performed with the use of a tourniquet, almost all the bleeding occurs postoperatively. Several studies have shown that salvage of blood after the operation and reinfusion can reduce the need for homologous transfusion (Majkowski RS et al, Newman JH et al). We studied prospectively 100 consecutive patients for knee replacement to compare post-operative transfusion requirements in blood salvage and reinfusion group and a no drain technique. Methods: After written consent 100 consecutive patients for knee replacement surgery were randomly allocated by computer generated numbers to either the no drain group (n=50) or the reinfusion group (n=50). The patients were anaesthetised as deemed appropriate by their anaesthetist. All the patients were operated on using a tourniquet. At the end of surgery the wound was closed with or without a deep drain. The drain was attached to the Constavac CBC II closed suction system. Preoperative haemoglobin and haematocrit values were recorded. Homologous blood was transfused to the patients as per the standard protocol depending on the haematocrit and or haemoglobin at 4 &
8 hours post-operatively, as well as days 1,2 &
3. In the reinfusion group blood collected in the reservoir was transferred to the blood bag and reinfused at 5 hours or 500 mls depending which was earlier. At 8 hours the reservoir blood was collected and reinfused, no more blood was reinfused as per the manufacturer recommendations. Cardiovascular stability was assessed by hourly blood pressure and heart rate during the first 24 hours and twice daily thereafter. Blood loss was assesses by measuring the drain loss, assessing the wound ooze serial haematocrits and total transfusion requirements. Results: 50 patients were completed in each group. The mean preoperative haemoglobin in the drain group was 12.8 g/dl and in the no drain group it was 12.9 g/dl. No difference in predisposing factors for bleeding was recorded in the two groups. The mean volume of blood collected in the drain group was 1008mls and the mean volume of
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,
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
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
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
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.
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
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
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
Background: Perioperative red cell salvage may be of use in cases where significant blood loss is likely. The purpose of this investigation was to see if its use in revision hip surgery led to a reduction in homologous blood transfusion requirement. Methods: 48 patients were identified who had undergone revision hip surgery with the use of a Cell Saver device for perioperative
Background: Perioperative red cell salvage may be of use in cases where significant blood loss is likely. The purpose of this investigation was to see if its use in revision hip surgery led to a reduction in homologous blood transfusion requirement. Methods: 48 patients were identified who had undergone revision hip surgery with the use of a Cell Saver device for perioperative
Introduction and Aims: Evaluate the efficacy of epsilon aminocaproic acid (Amicar) in decreasing peri-operative blood loss in patients with idiopathic scoliosis. Method: Thirty-six patients participated in this prospective, randomised, double blind, IRB-approved study. The patients who received Amicar were unknown until the completion of the study. All patients were 11–18 years of age, had idiopathic scoliosis, and underwent a posterior spinal fusion and segmental spinal instrumentation using standard hypotensive anesthesia. Factors analysed included age, gender, curve severity, number of vertebrae fused, operating time, hemoglobin and hematocrit pre-operatively and post-operatively, number of autologous units donated, pre-operative and post-operative fibrinogen levels, height, weight, estimated blood volume, estimated intra-operative blood loss, post-operative suction drainage, total peri-operative blood loss, and the
Anterior scoliosis surgery is associated with potentially significant intra-operative blood loss, requiring homologous transfusion either intra- or post-operatively. Blood loss in this type of surgery correlates with surgical &
anaesthetic techniques. In our centre the development of specific anaesthetic techniques as well as the routine use of Cell Salvage has dramatically reduced the rates of homologous blood transfusion. Currently specific indications for the use of the Cell Saver in Anterior Scoliosis have not been proven. Previous studies have commented on the beneficial aspects of recovered
Introduction: Infection after hip or knee replacement occurs with low frequency but shares high morbidity. Aim of this study was an evaluation of incidence and risk factors related to post operative infection after joint lower limb joint replacement in an orthopaedics unit. Material and methods: This is a monocentric, retrospective, case control study over the years 2000 to 2002. All first intention Total Hip and Knee Replacement and revision cases for mechanical reasons that became infected were identified. Demographic, surgical and medical variables, potentially associated to prosthetic infection were compared for these patients to a control group of non ifected patients over the same time, matched for sex, age and surgery type. Results: Ten patients, all male, contracted post operative joint infection, out of 630 Total Hip or Knee Arthroplasties. This represented 1.2% after hip replacement and 3.1% after knee replacement. Bacteriological datas showed a majority of Staphylococal infection (5 aureus, 1 epidermidis), 2 among these being resistant to meticillin, but also evidence of ENT commensals (2 Streptococci milleri, 1 Actinomyces) and one epidermal commensal (Propionobacterium acnes). Univariate analysis: datas associated with increased risk of infection were diabetes melitus (OR 9.3; CI 95% 1.4–63), operating time exceeding 120 minutes (OR15.5 ; CI 95% 1,73–139,66), superficial wound infection (odds ratio 29; CI95% 2,77–303,32), coinfection outside the operation site (urinary tract , dental infection) (OR: 9,3 ; CI 95% 1,33–63,2). In our study an MNIS score higher than 1,
Background: Anterior scoliosis surgery is associated with potentially significant intra-operative blood loss, requiring homologous transfusion either intra- or postoperatively. Blood loss in this type of surgery correlates with surgical &
anaesthetic techniques. In our centre the development of specific anaesthetic techniques as well as the routine use of Cell Salvage has dramatically reduced the rates of homologous blood transfusion. Currently, specific indications for the use of the Cell Saver in Anterior Scoliosis Surgery have not been proven. Previous studies have commented on the beneficial aspects of
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
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
This study investigated whether the use of tranexamic acid (TXA)
decreased blood loss and transfusion related cost following surface
replacement arthroplasty (SRA). A retrospective review of patients treated with TXA during a
SRA, who did not receive autologous blood (TXA group) was performed.
Two comparison groups were established; the first group comprised
of patients who donated their own blood pre-operatively (auto group)
and the second of patients who did not donate blood pre-operatively
(control). Outcomes included transfusions, post-operative haemoglobin
(Hgb), complications, and length of post-operative stay. Aims
Methods
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
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
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.
We undertook a prospective, randomised study in order to evaluate the efficacy of clamping the drains after intra-articular injection of saline with 1:500 000 adrenaline compared with post-operative blood salvage in reducing blood loss in 212 total knee arthroplasties. The mean post-operative drained blood volume after drain clamping was 352.1 ml compared to 662.3 ml after blood salvage (p <
0.0001). Allogenic blood transfusion was needed in one patient in the drain group and for three in the blood salvage group. Drain clamping with intra-articular injection of saline with adrenaline is more effective than post-operative autologous blood transfusion in reducing blood loss during total knee arthroplasty.
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:
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.
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.
We randomised 120 patients who were undergoing either primary total hip or knee arthroplasty to receive either ferrous sulphate or a placebo for three weeks after surgery. The level of haemoglobin and absolute reticulocyte count were measured at one and five days, and three and six weeks after operation. Ninety-nine patients (ferrous sulphate 50, placebo 49) completed the study. The two groups differed only in the treatment administered. Recovery of level of haemoglobin was similar at five days and three weeks and returned to 85% of the pre-operative level, irrespective of the treatment group. A small, albeit greater recovery in the level of haemoglobin was identified at six weeks in the ferrous sulphate group in both men (ferrous sulphate 5%, placebo 1.5%) and women (ferrous sulphate 6%, placebo 3%). The clinical significance of this is questionable and may be outweighed by the high incidence of reported side effects of oral iron and the cost of the medication. Administration of iron supplements after elective total hip or total knee arthroplasty does not appear to be worthwhile.
Using a computer-based quality assurance program, we analysed peri-operative data on 160 patients undergoing one-stage bilateral hip or knee arthroplasties under regional anaesthesia with routine anaesthetic monitoring and only using peripheral intravenous access for peri-operative safety. We monitored defined intra-operative adverse events such as hypotension, myocardial ischaemia, arrhythmias, hypovolaemia, hypertension and early post-operative complications. We also determined post-operative hip and knee function, and patient satisfaction with different aspects of the anaesthetic management. Those patients undergoing one-stage bilateral arthroplasties were matched according to a cross-stratification which used three variables (American Society of Anesthesiologists’ physical status scoring system, age and joint replaced) to patients undergoing unilateral hip or knee arthroplasties. Serious intra-operative adverse events were, with the exception of intra-operative hypotension, very infrequent in patients undergoing bilateral (nine adverse events) as well as unilateral arthroplasties (five adverse events). Early post-operative complications were also infrequent in both groups. However, the risks of receiving a heterologous blood transfusion (odds ratio 2.5; 95% confidence interval (CI) 1.3 to 5.0, estimated by exact conditional logistic regression) or vasoactive drugs (odds ratio 3.9; 95% CI 2.0 to 7.8) were significantly greater for patients undergoing bilateral operations. Patient satisfaction with anaesthesia was high; all patients who underwent the one-stage bilateral operation would choose the same anaesthetic technique again.