Aims. The aim of this study was to determine the impact of the severity of anaemia on postoperative complications following total hip arthroplasty (THA) and total knee arthroplasty (TKA). Methods. A retrospective cohort study was conducted using the American College of Surgeons National Quality Improvement Program (ACS-NSQIP) database. All patients who underwent primary TKA or THA between January 2012 and December 2017 were identified and stratified based upon hematocrit level. In this analysis, we defined anaemia as packed cell volume (Hct) < 36% for women and < 39% for men, and further stratified anaemia as mild anaemia (Hct 33% to 36% for women, Hct 33% to 39% for men), and moderate to severe (Hct < 33% for both men and women). Univariate and multivariate analyses were used to evaluate the incidence of multiple adverse events within 30 days of arthroplasty. Results. Following adjustment, patients in the THA cohort with moderate to severe anaemia had an increased odds of 6.194 (95% confidence interval (CI) 5.679 to 6.756; p < 0.001) for developing any postoperative complication. Following adjustment, patients in the TKA cohort with moderate to severe anaemia had an increased odds of 5.186 (95% CI 4.811 to 5.590; p < 0.001) for developing any postoperative complication. Among both cohorts, as severity increased, there was an increased risk of postoperative complications. Conclusion. Preoperative anaemia is a risk factor for complications following primary arthroplasty. There is a significant relationship between the severity of anaemia and the odds of postoperative complications. Patients who had moderate to severe anaemia were at increased risk of developing postoperative complications relative to patients with mild anaemia. When considering elective primary THA or TKA in a moderately or severely anaemic patient, surgeons should strongly consider correcting anaemia prior to surgery if possible. Cite this article: Bone Joint J 2020;102-B(4):485–494

Little literature exists about how trauma-induced anemia affects bone healing. Moreover, the definition of anemia has now changed. Until recently, anemia was defined as peripheral Hemoglobin (Hgb) of less than 10 grams/deciliter (gm/dL). Contemporary literature defines anemia as Hgb < 8gm/dL. This re-definition prompted three questions: (1) Does the presence of hemorrhagic anemia (Hgb< 10gm/dL) alter bone healing rates?; (2) If not, does the newer definition (Hgb< 8gm/dL) influence bone healing?; (3) If so, does the newer definition result in more profound changes in bone healing than those previously seen?. We reviewed the charts of patients treated for long bone, diaphyseal fractures over a ten-year period at a Level 1 Trauma Centre to determine rates of fracture healing when anemia by either definition was present. Patients who were skeletally immature, died during hospitalisation, or had incomplete medical records were excluded. All charts were reviewed for: development of anemia, need for blood transfusion, quantity of blood administered and subsequent association with bone healing. Inclusion criteria were met by 627 patients (700 individual fractures). When anemia was defined as Hgb< 10gm/dL, there was an 81.5% healing rate among anemic patients vs 88.8% in non-anemic patients (p=0.013); with a definition of Hgb< 8gm/dL, healing rates were 81.3% and 86.2%, respectively (p=0.041). Tibial healing was especially noted to be influenced (p = 0.002 and 0.0001, respectively). Femoral healing was likewise, but less dramatically, affected (p = 0.0082 and 0.0843). ANOVA showed no significance for open vs closed status, or NSAID use. Our study found a statistically significant difference in long bone healing between patients who developed anemia and those who did not. This is the first evidence based clinical review demonstrating that hemorrhagic anemia has a significant impact on the healing rates of long bone fractures, especially those of the tibia

AIM:. Preoperative anemia in patients undergoing elective total knee arthroplasty has been associated with increased allogeneic blood transfusion therapy and increased rates of in hospital morbidity, which often leads to a longer length of hospital stay. We measured the prevalence of anaemia among patients attending pre-admission clinic before elective major joint arthroplasty. METHODS:. Retrospectively, a randomized sample of all patients undergoing total hip arthroplasty between Dec 2009 and June 2010 were included. The computerized laboratory results were analysed for anaemia as defined by the local reference range (<11.5g/dL for females, <13g/dL for males). Patients were reviewed 6 weeks post operatively and range of flexion and extension was documented. RESULTS:. 96 patients were included with an average age of 67.2 years (SD 9.1). 54% were female; haematology data was complete for all patients. 13 (13.5%, 7 women) of these patients were anaemic on pre-admission haematological testing. There were two intra operative blood transfusions, both were in patients found to be anaemic pre-operatively. Overall, 23% of admissions were transfused an average of 2.2 (SD 0.39) units, an average of 2.2 (SD 1.2) days after surgery. Significantly, 71.4% of those patients identified as anaemic preoperatively were transfused post operatively, whereas only 23.1% of the pre-operatively non-anaemic patients were transfused (p = 0.0026 Fisher's exact test). The average length of stay for patients who were found to be anaemic at pre-operative assessment was 6.8 days (SD 3.5, range 4–13 days) compared to 4.9 days (SD 1.5, range 3–10 days) for the patient group that were not found to be anaemic (p = 0.004). Range of Motion at 6 weeks post operatively also varied significantly. Extension was significantly different (p = 0.003), as was flexion, (p = 0.014) by two-tailed student t-test. DISCUSSION:. A significant number of post-operative transfusions were performed in patients found to be anaemic pre-operatively. We have identified that pre-operative anaemia is associated with two negative outcomes post operatively: Increased length of hospital stay and decreased final range of movement. There is a clear indication for a standardized approach for the detection and treatment of anaemia in preparation for elective total knee arthroplasty

Aim. In Two-Stage Revision, utilizing temporary antibiotic spacers is widely accepted. These spacers are available prefabricated or can be individually moulded intraoperatively. In this study, we analysed the efficacy of prefabricated and individual spacers in infection eradication of periprosthetic joint infection in knee and hip arthroplasties. Method. All spacers implanted at a tertiary academic center during two-stage exchanges between June 2010 and December 2019 were retrospectively analysed. Among 249 patients, 167 cases (minimum follow-up ≥ 12 months) were included. Commercial spacers contained vancomycin and gentamycin, while individual spacers contained vancomycin alone. Subgroup analysis by manufacturers was conducted using non-parametric methods including Mann-Whitney U and Kruskal-Wallis tests. Survival analysis utilized Kaplan-Meier curves, and categorical data were analyzed using the Chi² test. Statistical significance was defined as p < 0.05. Results. Of the 167 patients included, a prefabricated spacer was implanted in 105 cases (62.9%) and an individual spacer was implanted in 62 cases (37.1%). In 106 cases, infection healing according to the Delphi consensus was achieved with a mean follow-up of 37.8 months [12;99]. Infection persistence was seen in 31.4% of the preformed spacers and in 45.2% of the individual spacers, with no statistically significant difference (p = 0.09). (Results are shown in the illustration). In the multivariate analysis, preoperative anemia (p = 0.02 OR 2.25 CI-95% 1.2-4.4 p = 0.01) and diagnosed paraneoplastic disease (p = 0.01 OR 3.0 CI-95% 1.4-6.7 p = 0.01) were found to be risk factors for failure. Conclusions. Two-stage Revisions are successfully suitable options for the treatment of PJI. In this study, infection eradication was independent of the type of spacer. Anemia and paraneoplastic diseases were found to be risk factors of failure

Aim. Tedizolid is an oxazolidinone antibiotic that: (i) is recommended at the dose of 200 once daily in patients with skin and soft tissue infection; (ii) seems to have a better long-term hematological and neurological safety profile in comparison with linezolid; (iii) remains active on multidrug-resistant (MDR) Gram-positive pathogens. Consequently, it might represent an option as suppressive antimicrobial treatment (SAT) in patients with complex implant-associated bone and joint infection (BJI) due to MDR Gram-positive pathogens. Method. We performed a cohort study (2017–2020) to evaluate the long-term safety of tedizolid (200mg qd) as SAT in patients with implant-associated BJI. In all cases, the use of tedizolid was validated as the last oral treatment option during multidisciplinar meetings in a reference center for the management of BJI. Serious adverse events, any reason for discontinuation, and standard biological data, were prospectively collected. Results. Seventeen patients (13 males; median age 73 years) received tedizolid as SAT for late complex prosthetic-joint infections (n=16) or osteosynthesis (n=1). Pathogens were MDR coagulase negative staphylococci (16 patients), Corynebacterium striatrum (2 patients), Enterococcus faecium (1 patient) and/or S. aureus (1 patient). Tedizolid was always started after a primary treatment (median duration of intravenous 47 days; followed by linezolid in 12 patients including 9 who experienced linezolid-induced serious adverse event) that followed a surgery, mainly debridement and implant retention (13 patients). Median duration of tedizolid was 6 months (min, 1 month; max, 31 months). The only reason for discontinuation was a failure of the conservative strategy that occurred in four patients (17%) during the follow-up. No patients developed a serious adverse event, or a discontinuation of tedizolid due to an adverse event. Anemia was observed in two patients, who had already other known cause of anemia (chronic leukemia and oesophageal varices); stable thrombopenia was observed in a cirrhotic patient (80 G/L, stable during the treatment course of 12 months); and a transient mild neutropenia (1.4 G/L) was observed in another patient (Figure). No neurological adverse event was observed. Conclusions. Tedizolid seems to be a safe option as SAT in patients with complex implantassociated BJI due MDR Gram-positive pathogens. For any tables or figures, please contact the authors directly

Numerous prediction tools are available for estimating postoperative risk following spine surgery. External validation studies have shown mixed results. We present the development, validation, and comparative evaluation of novel tool (NZSpine) for modelling risk of complications within 30 days of spine surgery. Data was gathered retrospectively from medical records of patients who underwent spine surgery at Waikato Hospital between January 2019 and December 2020 (n = 488). Variables were selected a priori based on previous evidence and clinical judgement. Postoperative adverse events were classified objectively using the Comprehensive Complication Index. Models were constructed for the occurrence of any complication and significant complications (based on CCI >26). Performance and clinical utility of the novel model was compared against SpineSage (. https://depts.washington.edu/spinersk/. ), an extant online tool which we have shown in unpublished work to be valid in our local population. Overall complication rate was 34%. In the multivariate model, higher age, increased surgical invasiveness and the presence of preoperative anemia were most strongly predictive of any postoperative complication (OR = 1.03, 1.09, 2.1 respectively, p <0.001), whereas the occurrence of a major postoperative complication (CCI >26) was most strongly associated with the presence of respiratory disease (OR = 2.82, p <0.001). Internal validation using the bootstrapped models showed the model was robust, with an AUC of 0.73. Using sensitivity analysis, 80% of the model's predictions were correct. By comparison SpineSage had an AUC of 0.71, and in decision curve analysis the novel model showed greater expected benefit at all thresholds of risk. NZSpine is a novel risk assessment tool for patients undergoing acute and elective spine surgery and may help inform clinicians and patients of their prognosis. Use of an objective tool may help to provide uniformity between DHBs when completing the “clinician assessment of risk” section of the national prioritization tool

Abstract. Background. Elderly patients with degenerative lumbar disease are increasingly undergoing posterior lumbar decompression without instrumented stabilisation. There is a paucity of studies examining clinical outcomes, morbidity & mortality associated with this procedure in this population. Methods. A retrospective analysis of aged 80–100 years who underwent posterior lumbar decompression without instrumented stabilisation at University Hospitals of Derby &Burton between 2016–2020. Results. Total 167 eligible patients, 163 octogenarians & 4 nonagenarians. Mean age was 82.78 ± 3.07 years. Mean length of hospital stay 4.79 ± 10.92 days. 76% were pain free at 3months following decompression. The average Charleston co-morbidity index (CCI) was 4.87. No association found with CCI in predicting mortality (ODD ratio 0.916, CI95%). 17patients suffered complications; dural tear (0.017%), post-op paralysis (0.017%), SSI(0.01%), and 0.001% of hospital acquired pneumonia, delirium, TIA, urinary retention, ileus, anaemia. High BMI (35+) was associated with increased incidence of complication (CI 95%, p<0.002). There was significant social drift following discharge as 147 patients went home and 4 patients to rehabilitation facility (p<0.001FE test). The mean operative time was 91.408±41.17 mins and mean anaesthetic time was 36.8±16.06 mins. Prolonged operative time was not associated with increased mortality.2year revision decompression rate was 0.011%. Conclusion. Posterior lumbar decompression without instrumented stablisation in elderly is safe & associated with low mortality with 99.5%survival at 1 year. It significantly improves PROMs & has extremely low revision rate. Incidence of post-op complication is <0.05% and 54% of patients get discharged within 72hours of surgery. Careful selection & optimising patients with high BMI would reduced perioperative morbidity and mortality

Aim. Long term use of antibiotics following surgical debridement are the cornerstone of PJI treatment. Due to increasing resistance of bacteria for many first line antibiotics new options are needed. One such option is linezolid known for its low percentage of resistance against many Gram positive bacteria causing PJI. Success rates up to 86% have been reported. At the same time many adverse events (AE) have been described including anemia, thrombocytopenia, gastrointestinal effects and sometimes neuropathy, e.g. irreversible vision loss [1, 2]. Therefore, linezolid use is advised to be limited to a maximum of 28 days. Literature about the effects of prolonged use is currently lacking and therefore this study will aim to determine the safety of long-term (>28 days) linezolid use in patients with orthopedic infections. Methods. We performed a retrospective descriptive study on patient records of orthopedic patients who were treated with linezolid between January 2014 and January 2019 for >28 days. Data were collected from medical charts including co-morbidities, pre-existing liver/kidney dysfunctions, diagnosis, treatment, type of prosthesis, pathogens, adverse events associated with linezolid use and follow up laboratory data. Results. 91 patients treated with linezolid were identified. 46 patients (25 male), mean age 64 (SD 11.49) received long-term linezolid with an average treatment duration of 45.3 (range 29 – 91) days. AE were observed in 32 with gastrointestinal AE's (16 patients) being the most frequent following anemia (7 patients) thrombocytopenia (6 patients), leucopenia (2 patients). One patient reported optic neuritis but no association with linezolid could be confirmed. Linezolid treatment was ended in 7 patients (15.2%) due to AE (predominantly anemia) compared to 14 patients (31.1%) who received short-term treatment (predominantly gastrointestinal AE). Decreased post-surgery hemoglobin levels tended to increase during the first two weeks of linezolid use after which hemoglobin levels showed an average decrease of 0.39 mmol/L between week 2 and week 7 of treatment. Leucocyte and thrombocyte levels showed an average decrease between baseline measures and week 7 of treatment of 2.21∗10. 9. /L and 89.0∗10. 9. /L respectively. AE were resolved after a mean 12 days (range 2–30 days). Conclusions. Long-term linezolid use was not associated with an increase in serious irreversible AE and can therefore be considered generally safe, provided that patients are well monitored considering high drop out in the first weeks mainly due to gastrointestinal AE and anemia during prolonged treatment. These observations help to fill the gap in knowledge about prolonged linezolid use

Abstract. Background. Blood transfusion requirement after primary total hip replacements (THR) and total knee replacements (TKR) was found to be related to increased post-operative complications rate and length of hospital stay. Pre-operative haemoglobin level remains the single most important factor determining the requirement for post-operative blood transfusion. Methods. We carried out a local retrospective audit of 977 THRs and TKRs in 2019. Pre-operative and pre-transfusion haemoglobin levels for transfused group of patients were recorded. Results. A total of 977 patients had THRs and TKRs of which 34 (3.5%) had blood transfusions. From the 437 THRs, 24(5.5%) had bloods transfusions of which 19 were female. From the 540 TKRs 10(1.8%) were transfused, 9 were female. The average length of stay (LOS) for those transfused was 6.8 days and the average LOS for our trust is 3.2 days. Conclusion. The incidence of blood transfusion after primary THR or TKR was 3.5% in 2019. The majority of patients who received post-operative blood transfusion were found to have pre-operative haemoglobin level below 12 g/dl representing 61.7% of all the transfused patients. Transfused patients had more than double the average expected length of stay. The incidence of blood transfusion and associated risks can be improved by early detection and proper management of pre-op anaemia. Pre-assessment clinic has got a pivotal role but needs reminding of pre-op haemoglobin management strategies. Pre-operative optimisation of patients using either oral, intravenous iron supplements or erythropoietin according to the blood management protocol by the Royal College of Surgeons

Introduction. Deep venous thrombosis (DVT) is a potentially serious complication after total hip (THA) and knee (TKA) arthroplasty, traditionally justifying aggressive prophylaxis with low molecular weight heparin (LMWH) or direct oral anticoagulants (DOA) at the cost of an increased risk of bleeding. However, fast-track procedures might reduce the DVT risk and decrease the cost-benefit ratio of the current recommendations. The objective of this study was to compare thrombotic and bleeding risk in an unselected population of elective THA and TKA with a fast-track procedure. MATERIAL - METHODS. A series of 1,949 patients were analyzed prospectively. There were 1,136 women and 813 men, with a mean age of 70 years. In particular, 16% were previously treated by antiplatelet agents and 8% by anticoagulants. All patients followed a fast-track procedure including early walking within 24 hours of surgery, and 80% of patients returned home after surgery, with a mean length of stay of 3 days (THA) or 4 days (TKA). The occurrence of a thromboembolic event or hemorrhagic complication has been identified. Results. Out of the 1,110 THAs, 5 thromboembolic events were identified (0.4%): 2 non-fatal pulmonary embolism and 3 DVTs. There was no impact of these complications on the final result. 19 hemorrhagic complications were identified (1.7%): 10 significant haematomas (3 of which were complicated by infection), 9 anemias (with 4 transfusions). Out of the 839 TKAs, 9 thromboembolic events were identified (1.0%): 4 non-fatal pulmonary embolism and 5 DVTs. There was no impact of these complications on the final result. 14 hemorrhagic complications were identified (1.7%): 8 haematomas including 4 reoperations, 6 anemias (with 5 transfusions). Discussion. Thromboembolic complications after elective THA and TKA have virtually disappeared, with a rate of 0.7%. On the other hand, bleeding complications are now more frequent, with a rate of 1.7%. This suggests that the cost-benefit ratio of preventive treatments with LMWH or DOA should be reassessed. Prescribing LMWH or DOA after elective THA and TKA with fast-track procedures exposes the patient to a much higher risk of bleeding than thrombotic risk. The use of aspirin may represent an acceptable compromise in these patients

INTRODUCTION. In recent years, there has been a shift toward outpatient and short-stay protocols for patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA). We developed a peri-operative THA and TKA short stay protocol following the Enhance Recovery After Surgery principles (ERAS), aiming at both optimizing patients’ outcomes and reducing the hospital length of stay. The objective of this study was to evaluate the implementation of our ERAS short-stay protocol. We hypothesized that our ERAS THA and TKA short-stay protocol would result in a lower complication rate, shorter hospital length of stay and reduced direct health care costs compared to our standard procedure. METHODS. We compared the complications rated according to Clavien-Dindo scale, hospital length of stay and costs of the episode of care between a prospective cohort of 120 ERAS short-stay THA or TKA and a matched historical control group of 150 THA or TKA. RESULTS. Significantly lower rate of Grade 1 and 2 complications in the ERAS short-stay group compared with the standard group (mean 0.8 vs 3.0, p<0.001). Postoperative complications that were experienced by significantly more patients in the control group included pain (67% vs 13%, p<0.001), nausea (42% vs 12%, p<0.001), vomiting (25% vs 0.9%, p<0.001), dizziness (15% vs 4%, p=0.006), headache (4% vs 0%, p=0.04), constipation (8% vs 0%, p=0.002), hypotension (26% vs 11%, p=0.003), anemia (8% vs 0%, p=0.002), oedema of the operated leg (9% vs 1%, p=0.005), persistent lameness (4% vs 0%, p=0.04), urinary retention (13% vs 4%, p=0.006) and anemia requiring blood or iron transfusion (8% vs 0%, p=0.002). No difference was found between the 2 groups for Grade 3, 4, or 5 complications. The mean hospital length of stay for the ERAS short-stay group decreased by 2.8 days for the THAs (0.1 vs 2.9 days, p bellow 0.001) and 3.9 days for the TKAs (1.0 vs 4.9 days, p<0.001). The mean estimated direct health care costs reduction with the ERAS short-stay protocol was 1489% per THA and 4206% per TKA. DISCUSSION AND CONCLUSION. Shorter hospitalization time after THA and TKA is associated with lower risk of nosocomial infections and adverse events related to reduced mobilization such as venous thromboembolism, pulmonary atelectasis, and constipation. In addition, it increases bed availability in a restricted environment and is very favorable economically for the care provider. Multiple strategies have been described to reduce hospital length of stay. One attractive option is to follow the ERAS principles to improve patient experience to a level where they will feel confident to leave for home earlier. Implementation of a ERAS short-stay protocol for patients undergoing THA or TKA at our institution resulted not only in reduced hospital length of stay, but also in improved patient care and reduced direct health care costs

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

Background. One-stage bilateral total hip arthroplasty (THA) is twice as invasive as unilateral THA. Therefore, increases in bleeding, postoperative anemia, and complications are a concern. The purpose of this study was to investigate hemoglobin values and the use of autologous and allogenic blood transfusion after one-stage bilateral THA. Methods. Twenty-nine patients (7 men and 22 women; 58 hips) were treated with one-stage bilateral THA. The mean age of subjects at the time of surgery was 60.6 years. The average body mass index for patients was 21.7 kg/m. 2. The diagnoses were secondary osteoarthritis due to developmental dysplasia of the hip (n=25) and avascular necrosis (n=4). All patients had donated 800 ml of autologous blood in 2 stages preoperatively (1 to 4 weeks apart). All patients took iron supplements starting from 5 weeks preoperatively. For all patients, the procedure was performed under general anesthesia in the lateral decubitus position via a posterolateral approach. Intra-operative blood salvage was not used. Suction drains were inserted subfascially. As a general rule, pre-donated autologous blood was transfused back to the patients intra- or post-operatively. Allogenic blood transfusion was performed when clinical symptoms of anemia occurred (hypotension, low urinary output, tachycardia, etc.) rather than using a preset blood threshold (hemoglobin level <8 g/dl). To determine changes in blood pressure following surgery until the next morning, systolic and diastolic blood pressure were measured at 3-hr intervals. Results. The mean duration of surgery was 67.4 min for the procedure on the side that was operated on first, 32.7 min to change to the other side, and 68.4 min for the procedure on the other side. The mean blood loss was 576.1 ml. Hemoglobin values at baseline, at the time of autologous blood donation, and on the first day after surgery were 13.2, 12.7, and 8.7 g/dl respectively. Hemoglobin values were significantly different between the 2 weeks before surgery and the first day after surgery. Systolic and diastolic blood pressure were the lowest 3–6 hrs postoperatively (mean, 86/55). Blood reinfusion using autologous blood was performed for all patients. The allogenic blood transfusion rate was 25.0% (range, 2–8 units). In terms of complications, one patient developed an arrhythmia on postoperative day 5. This was the patient for whom autologous blood donation could not be performed due to pre-existing anemia. This patient also had right-sided sciatic nerve palsy. Discussion. With respect to one-stage bilateral THA, Gie showed that allogenic blood transfusion rate with or without autologous blood donation was 42% and 87% respectively. The allogenic blood transfusion rate was 25.0% in our study. Establishing a procedure to perform surgery in a shorter time period may further reduce the rate of allogenic blood transfusion. Although not used herein, intraoperative blood salvage may also be considered. Conclusions. In one-stage bilateral THA, autologous blood donation is effective in managing perioperative anemia and reducing the rate of allogenic blood transfusion. Perioperative blood management based on individual patients' situations are important for the safe performance of one-stage bilateral THA

Objectives. Although most joint surgeons have reached a consensus that preoperative risk assessment and appropriate medical intervention for elderly patients of primary total hip arthrplasty (PTHA) could significantly reduce postoperative complications and mortality, there is still lack of a detailed and comprehensive approach for risk stratifying and a systematic method for risk allaying. We aimed to explore the risk factors related to the aggravation of preoperative complications and the appearance of complications post-operation of primary total hip arthrplasty (PTHA) in elderly patients for hip fracture. Patients and methods. We retrospectively reviewed the demographic and clinical data of 156 patients who underwent PTHA for hip fracture from January 2014 to December 2016, of which there were 61 male (39.1%) and 95 female (60.9%) patients; 111 patients aged 60–79 years (71.2%) and 45 patients ≥ 80 years old (28.8%); 125 patients of femoral neck fracture (80.1%) and 31 patients of inter-trochanteric fracture (19.9%); 109 patients of spinal anesthesia (69.9%) and 48 patients of general anesthesia (30.1%); 85 patients undergoing surgery within 3 days (54.5%) and 71 patients operated ≥ 4 days (45.5%) since admission. We evaluated the correlations among gender, age, type of fracture, methods of anesthesia, time of operation since admission, the aggravation of preoperative complications and the appearance of postoperative complications post PTHA using the IBM SPSS Statistics (version 21) and the Exce1 2016. Results. The appearance of postoperative complications were statistically correlated with age, time of operation since admission, and type of anesthesia. The appearance of postoperative complication were significantly more in patients operated ≥ 4 days since admission (P < 0.05), and patients with general anesthesia (P < 0.05). Age ≥ 80 years old was not only statistically correlated with the aggravation of three kind of preoperative complications, hypertension, heart disease and respiratory tract infection (P < 0.05), also statistically correlated with the postoperative exacerbation of respiratory tract infection (P < 0.01), the appearance of anemia (P < 0.01), hypoalbuminemia (P < 0.01), water and electrolyte balance disorder (P < 0.05), and gastrointestinal reaction (P < 0.05). Age ≥ 80 years old was neither significantly correlated with postoperative aggravation of diabetes mellitus, urinary tract infection and abnormal liver and kidney function (P > 0.05), nor with postoperative urinary retention (P > 0.05). Conclusion. The occurrence of postoperative complications of elderly patients post PTHA for hip fracture was correlated with age ≥ 80 years old, delayed surgery longer than 4 days since admission, and general anesthesia. Much more attention should be paid to the patients with preoperative diseases of hypertension, heart diseases, and respiratory tract infection, especially age ≥ 80 years patients with respiratory tract infection. Specific postoperative attention should be paid to correct anemia, supplement albumin, regulate the imbalance of water and electrolyte, and treat the digestive tract response for PTHA patients aged ≥ 80 years

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

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

Introduction. Hip arthroplasty is one of the most common procedures performed every year however complications do occur. Prior studies have examined the impact of insurance status on complications after TJA in small or focused cohorts. The purpose of our study was to utilize a large all-payer inpatient healthcare database to evaluate the effect of patient insurance status on complications following hip arthroplasty. Methods. Data was obtained from the Nationwide Inpatient Sample between 2004 and 2011. Analysis included patients undergoing hip arthroplasty procedures determined by ICD-9 procedure codes. Patient demographics and comorbidities were analyzed and stratified by insurance type. The primary outcome was medical complications, surgical complications and mortality during the same hospitalization. A secondary analysis was performed using a matched cohort comparing patients with Medicare vs private insurance using the coarsened exact matching algorithm. Pearson's chi-squared test and multivariate regression were performed. Results. Overall, 1,011,184 (64.8% Medicare, 29.3% private insurance, 3.7% Medicaid or uninsured, 2.0% Other) patients fulfilled criteria for inclusion into the study. Most were primary total hip arthroplasties (64.2%) and primary hip hemiarthroplasty (29.8%), with 6% revision hip arthroplasties. Multivariate regression analysis showed that patients with private insurance had fewer complications (OR 0.8, p=<0.001) and those with Medicaid or no insurance had more medical complications (OR 1.06, p=0.005) compared to Medicare patients. Similar trends were found for surgical complications and mortality. The matched cohort showed Medicare and private insurance patients had similar complication rates. The most common complication was postoperative anemia, occurring in 22.6% of Medicare patients and 21.1% of patients with private insurance (RR=1.06, p<0.001). Discussion and. Conclusion. This data reveals that patients with Medicare, Medicaid or no insurance have higher risk of medical complications, surgical complications and mortality following hip arthroplasty. Using a matched cohort to directly compare Medicare and private insurance patients, the risk of postoperative complications are similar and generally low with the notable exception of the most common complication, postoperative anemia, which occurs more frequently in patients with Medicare

Common reasons for higher-than-average cost for a total hip arthroplasty are prolonged patient hospitalisation, which can be caused by among other factors, bleeding complications. The incidence of perioperative anemia has direct costs (blood transfusions), but also numerous indirect costs such as longer hospital stays, poor performance in physical therapy, and the potential for blood-borne infection. The incidence of pre-operative anemia in patients undergoing total hip arthroplasty has been reported to be as high as 44%, while total peri-operative blood loss for total hip arthroplasty may average between 750 and 1,000 mL. Anemia negatively impacts length of stay, patient function during rehabilitation, and patient mortality. Transfusions carry well known risks, including infection and fatal anaphylaxis, which are important factors considering that the transfusion rate has been reported to be as high as 45% and that transfused patients receive, on average, two units of blood. Methods that have been described in the literature include pre-treatment with erythropoietin, pre-operative hemodilution with intra-operative blood salvage, surgical techniques such as gentle soft tissue handling and meticulous hemostasis, bipolar sealers, intravascular occlusion, hemostatic agents, and early removal of drains. Pharmacologic approaches include treatment with erythropoietin, iron and folate. Randomised trials have demonstrated reduction in the risk for transfusion in patients treated with erythropoietin. Several studies have established a once-weekly dosing schedule of 40,000 international units (300–600 IU/kg) to be effective, and synergism has been observed in patients treated in combination with iron (ferrous sulfate, 325 mg three times a day). Patients with hemoglobin values between 10 and 14 g/dL are most likely to benefit. Intra-operatively, antifibrinolytics such as tranexamic acid (10 mg/kg) given as a single dose pre-operatively has been shown to decrease blood loss and the transfusion rate. Hypotensive anesthesia also effectively decreases blood loss without impairing renal function, but is technically demanding. Post-operatively, re-infusion drains may reduce the need for transfusions in total hip and total knee arthroplasty, but cannot be used in cases of infection or malignancy. By minimising peri-operative bleeding and bleeding complications through pre-operative optimisation, intra-operative surgical techniques that minimise blood loss, and post-operative care, patient disposition can be streamlined and delays for patient discharge can be avoided

Background. Fungal infection at an arthroplasty site is rare and poses a therapeutic challenge. To the best of our knowledge, no reports have been published thus far on the success rate of prosthesis reimplantation after fungal prosthetic joint infections. Questions/purposes. We asked: (1) What is the success rate in terms of infection eradication using a two-stage exchange arthroplasty in patients with hip or knee fungal periprosthetic joint infections, particularly focusing on Candida infections? (2) What patient-, infection-, and treatment-related variables are associated with the success or failure of treatment?. Methods. From January 2000 to December 2010, 16 patients with hip or knee candidal periprosthetic joint infections were treated with two-stage exchange arthroplasty at our institute. Treatment success was defined as a well-functioning joint without relapse of candidal infection after prosthesis reimplantation, while treatment failure was defined as uncontrolled or a relapse of candidal infection or mortality. Variables, including age, sex, comorbidities, microbiology, antimicrobial agents used, and operative methods, were analyzed. Minimum followup was 28 months (mean, 41 months; range, 28–90 months). Results. At latest followup, the treatment failed to eradicate the infection in eight of the 16 patients, and there were four deaths related to fungemia. Four patients required permanent resection arthroplasty owing to uncontrolled or recurrent candidal infections. All eight patients (50% successful rate) who had their infections eradicated and successful prosthesis reimplantation had prolonged treatment with oral fluconazole before (mean, 8 months) and after (mean, 2.2 months) prosthesis reimplantation. The antifungal therapy correlated with successful treatment. Renal insufficiency, hypoalbuminemia, anemia, and chronic obstructive pulmonary disease were significantly more prevalent in the treatment-failure group than in the treatment-success group. Conclusions. Half of the patients treated with two-stage exchange arthroplasty for fungal periprosthetic joint infections had recurrence or lack of control of the infection. A prolonged antifungal therapy appeared to be essential for successful treatment of candidal periprosthetic joint infections. The presence of renal insufficiency, hypoalbuminemia, anemia, or chronic obstructive pulmonary disease might be associated with a poor outcome