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

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.

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.

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.

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.

Introduction. Total knee arthroplasty [TKA] is a common procedure to relieve painful disability from advanced knee arthritis. However, related blood loss, ranging from 800 to 1200 ml, increase risk and disruption of recovery in anemic patients following TKA. Various methods for blood conservation had been proposed and examined. In the literature, the intra-articular administration of a solution mixing bupivacaine and epinephrine was commonly used after knee surgeries. Therefore, we conducted a retrospective, case controlled review of our primary TKAs to determine the hemostatic efficacy of this regimen following TKAs. Material and Methods. Over a period of 12 months, 135 eligible patients were divided two groups simply according to the intra-articular injection or not: a control group (N=63) and a treatment group (N=72). In the treatment group, a 40 ml vial of 0.5% bupivacaine with epinephrine 1: 200000 was given prior to the deflation of pneumatic tourniquet. No drainage was used in all TKAs. Without recordable drainage, a Gross formula, considering gender and body composition, was used for estimate blood loss following TKAs. In addition, serial changes in hemoglobin as well as the requirement of allogenic transfusion were also compared between groups. Results. The mean calculated blood loss in the treatment group was 650.4 +/− 257.1 ml, compared to 648.8+/− 222.1 ml in the control group (p=0.9). Similar decrease in hemoglobin as well as rates of allogenic transfusion needs were observed between groups.[2.5+/− 0.9 g/dl vs. 2.4+/− 0.8 g/dl; 13.9% vs. 12.7%, respectively]. Discussion and Conclusion. Although local analgesics mixing vasoconstrictive agents seem a logic solution to save blood loss and relieve pain simultaneously, the hypothesis that intra-articular injection of bupivacaine and epinephrine would save blood and even transfusion needs following TKAs is not supported by various bleeding parameters in this study. In addition to temporary benefit in pain relief, this regimen only has little effect on blood conservation. Therefore, new regimen as well as hemostatic means are still required and explored to reduce blood loss following TKAs

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

The purpose of this article is to provide the reader with a seven-step checklist that could help in minimising the risk of PJI. The check list includes strategies that can be implemented pre-operatively such as medical optimisation, and reduction of the bioburden by effective skin preparation or actions taking during surgery such as administration of timely and appropriate antibiotics or blood conservation, and finally implementation of post-operative protocols such as efforts to minimise wound drainage and haematoma formation. Cite this article: Bone Joint J 2016;98-B(1 Suppl A):18–22

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

Blood donation in England is voluntary and a limited resource. Blood transfusion is essential and beneficial in some postoperative hip replacements, however is not without inherent risks. Royal College of Physician audit in 2007 has shown wide variation in transfusion with an average rate of 25% (22% – 97%). Patient blood management is an established approach to optimising need for post- operative transfusion. The Surgical Blood Conservation Service (SBCS) was set up in 2009 to enable a reduction in the demand for blood transfusion during and postoperatively in many orthopaedic procedures. We aimed to achieve preoperative haemoglobin of 12g/dl (males) and 11g/dl (females). Low levels were treated with iron therapy. Surgery was deferred till satisfactory Hb levels were reached. During surgery cell salvage was routinely used. Transfusion was recommended at postoperative Hb < 8g/dl. The transfusion rate was estimated at 47% in 2002. Following the introduction of SCBS, the transfusion rate reduced considerably to 7.9% in 2009 with a further reduction to 7.29% in 2011 and 3.16% in 2012. In 2013, 10 out of 442 hip replacements received transfusion (2.21%). Our results demonstrate successful Patient blood management, minimising the need for post- operative transfusion

Total knee arthroplasty is an operation that can be performed with or without the use of tourniquet. Two systematic reviews and meta-analyses of the available literature have demonstrated that the use of tourniquet leads to a reduction in blood loss and also shortens the operative time. The opponents for use of tourniquet cite development of complications such as skin bruising, neurovascular injury, and metabolic disturbances as a deterrent for the use of tourniquet. Although the latter may be true for some patients such as those with previous vascular grafts, there is little evidence that routine use of tourniquet during TKA results in any of the above complications. The use of tourniquet on the other hand provides a bloodless field that allows the surgeon to perform the procedure with expediency and optimised visualisation. Blood conservation has gained extreme importance in recent years because of increased understanding of problems associated with blood transfusion such as increased surgical site infection (due to immunomodulation effect), increased length of hospital stay, increased cost and so on. Based on our understanding of the available evidence, we believe that routine use of tourniquet during TKA is justified and a good surgical practice

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

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 healthcare 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

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, autologous transfusions were provided based on symptoms. Pre-donation blood levels, peri-operative hemoglobin and hematocrit levels along with transfusion records were assessed. Results. The mean pre-donation hemoglobin was 13.1 g/dL. After 2 units of autologous blood donation and procrit injections, the mean preoperative hemoglobin was 13.0 g/dL. The mean hemoglobin dropped to 9.8 g/dL on postoperative day 3. The mean drop in hemoglobin from preadmission testing was 3.3 g/dl. Overall, 30% patients required autologous blood transfusion and no patients required allogenic transfusion. Conclusion. This multi-modal protocol was effective in not only avoiding allogeneic transfusions following bilateral TKA but also resulted in high blood levels at the time of discharge. This protocol was effective in eliminating allogenic transfusions and maintaining blood levels

Introduction. The purpose of this study was to determine the efficacy of a Multi-modal Blood Conservation protocol that involves pre–operative autologous blood donations (2 units) in conjunction with Erythropoietin supplementation as well as intra-operative conservation modalities. Methods. A retrospective review of 104 patients with simultaneous bilateral total knee arthroplasty done between 2006-2009 was performed. Patients donated two units of blood, 4 weeks prior to surgery and also received Erythropoetin injections (40 k units 3weeks,2 weeks and 1 week prior to surgery). Intra- operative Blood Management included symptom-based transfusions, blood salvage devices, local epinephrine injections and fibrin spray. Pre-donation blood levels, peri-operative hemoglobin and hematocrit levels along with transfusion records were assessed. Results. The mean pre-donation hemoglobin was 13.1 g/dL. After 2 units of autologous blood donation and procrit injection, the mean hemoglobin was 13.0 g/dL. The mean hemoglobin dropped to a nadir of 9.8 g/dL on postoperative day 3. The mean drop in hemoglobin from preadmission testing was 3.3g/dl. Overall, 28 % patients required autologous blood transfusion and no patients required allogeneic transfusion if the protocol was followed. 6 patients (5.8%) did require allogeneic transfusions but all 6 were protocol violations and did not follow the proposed treatment regiment. Conclusion. This multi-modal protocol was effective in not only avoiding allogeneic transfusions following Bilateral TKA but also resulted in high blood levels at the time of discharge. This protocol was effective in eliminating allogeneic transfusions and maintaining blood levels

Introduction:. Efforts continue to reduce blood loss in total knee arthroplasty (TKA). Computer assisted surgery (CAS) has been shown to reduce outliers in component position and improve functional outcomes in TKA, yet few studies have reported specifically on blood loss. The primary study objective was to determine whether a modern abbreviated CAS protocol would reduce blood loss in TKA compared to conventional instrumentation. A secondary objective was to assess the effect of CAS on cost and surgical efficiency. Methods:. A retrospective cohort study of 100 consecutive patients was performed comparing an abbreviated and modern CAS protocol versus conventional IM instrumentation. All TKAs utilized an identical surgical technique without any hemostatic agent. Blood loss was determined using drain output, change in hemoglobin, and calculated blood loss. Tourniquet times were recorded as an indicator of procedural efficiency. A cost analysis compared the CAS protocol to the cost associated with tranexamic acid (TXA) to reduce blood loss and long-leg alignment radiographs to optimize component position. Results:. Height, weight, BMI, and preoperative hemoglobin were similar between groups. The CAS group demonstrated a decrease in average hourly drain output (CAS 33.8 ml; conventional 40.5 ml; p = 0.024), decreased change in hemoglobin (CAS 2.2; conventional 3.1; p < 0.001), and estimated total blood loss (CAS 925 ml; conventional 1327 ml; p < 0.001) compared to conventional instrumentation. No patients in either group required a blood transfusion. In non-teaching cases, there was a mean increase of 5 minutes surgical time in the CAS group. Cost-analysis demonstrated CAS was less expensive than using TXA and long-leg alignment radiographs, with a savings of $564 for 200 TKAs annually and $284 for 100 TKAs annually. Conclusion:. AbbreviatedCAS is effective in reducing blood loss in TKA comparable to TXA, likely due to avoidance of the femoral IM canal, with minimal effect on surgical efficiency. Along with proven advantages of accurate component placement and improved functional outcome after TKA, the additional blood conservation supports CAS providing value in healthcare and obviates the need for advanced preoperative imaging and TXA, and can be used in patients regardless of cardiac or thromboembolic risk

Total knee arthroplasty has been associated with substantial blood loss in the perioperative period necessitating a substantial risk for blood transfusions. There are various methodologies utilized to decrease postoperative anemia and minimize the need for allogeneic blood transfusions. These include autologous pre-donation, the use of erythropoietin and the use of perioperative cell salvage. Although all of these are successful in decreasing postoperative anemia, there is still a significant risk of allogeneic blood transfusions in the postoperative period. This is a retrospective review of a consecutive series of total knee replacements investigating blood loss and the need for postoperative blood transfusions utilizing MIS surgical techniques and Symphony (tm) platelet gel as the sole means of blood conservation. PATIENT DEMOGRPAHICS. Between January 1, 2005 to December 31, 2005, 83 total knee arthroplasties were performed in a variety of community hospitals by a single orthopedic surgeon. The mean age was 64 years (SD 11.6, range 28-90) and the mean BMI was 34.1 (SD 7.6, range 21.3 to 53.4). 71% of the patients were females and 29% males. All patients, regardless of deformity, age or size, had a quad sparing MIS total knee arthroplasty performed utilizing cemented posterior stabilized components and all patellae were resurfaced. No patients pre-donated any blood products or had erythropoietin and no drains were utilized postoperatively. All patients had application of Symphony (tm) platelet gel prior to the interoperative release of the tourniquet. All patients received Coumadin on the day of surgery and were managed for four weeks postoperatively to keep their INR approximately 2.0. RESULTS. The mean preoperative hemoglobin was 14 (SD 1.2, range 10.7 to 16.6). The average postoperative hemoglobin was 10.0 (SD 1.1, range 8.0 to 14.2). The average drop in hemoglobin was 4.0 with a SD of 1.1. A total of two patients were transfused in this series of 83 patients for a total transfusion rate of 2.4%. The average length of stay was 3.4 days with the SD of 3.7. No patients suffered a CVA, myocardial infarction or pulmonary embolus in the two-month postoperative period. CONCLUSIONS. The results show that even utilizing MIS surgical techniques and Symphony (tm) platelet gel, there is still substantial blood loss in patients undergoing unilateral total knee arthroplasty utilizing cemented components with a mean drop of hemoglobin of four grams or 20% of their mean preoperative hemoglobin. However, in spite of significant loss of hemoglobin, most patients tolerated the postoperative anemia very well and there were no complications in this series related to anemia and this did not prolong their length of stay, which was an average of 3.4 days. Only a very low percentage of patient's in this series required a postoperative transfusion (2.4%). This report supports the continued use of MIS surgical techniques along with Symphony (tm) platelet gel to minimize the need for postoperative transfusions in total knee arthroplasties

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. Transfusion rates were higher in older patients (80–89 yrs, 21.4%; ≥ 90 yrs, 30.7%), blacks (19.6%), females (14.0%), Medicare patients (14.6%), and Medicaid patients (14.4%). Transfused TKA patients had a greater percent of comorbidities than their non-transfused peers. The largest differences in comorbidity prevalence among transfused and non-transfused patients were: deficiency anemia (27.5% vs. 10.1%), renal failure (4.0% vs. 1.4%), chronic blood loss (3.7% vs. 1.4%), and coagulopathy (3.1% vs. 1.0%) (p < 0.001). Unadjusted trends show that from 2000 to 2009, in-hospital mortality rate decreased (Figure 2A), mean length of stay decreased (Figure 2B), and mean admission cost increased (Figure 2C) for both transfused and non-transfused patients following TKA. Adjusting for patient and hospital characteristics, transfused patients had a 22% (95% CI, 4%–43%) greater likelihood of in-hospital mortality (p = 0.013), 0.68 ± 0.02 days longer length of stay (p < 0.001), and $2,237 ± 76 increased admission costs (p < 0.001). Additionally, patients who received a transfusion had a greater adjusted risk of a postoperative infection (odds ratio, 2.35), pulmonary insufficiency (odds ratio, 1.60), and other complications (p < 0.001) (Figure 3). Conclusions:. The allogenic blood transfusion rate increased between 2000 and 2009 in the United States. Transfusion has a considerable burden on patients and healthcare institutions, increasing in-hospital mortality, length of stay, admission costs, and acute complications. Preoperative optimization strategies, transfusion criteria, and hemostatic agents for at-risk patients need to be further researched as possible ways to reduce transfusion occurrence and its effects