Introduction. The correction of paediatric scoliosis is a surgical procedure in which substantial bleeding occurs, and which historically has been associated with high levels of blood transfusion. Transfusions are associated with risks of infection, allergic reactions, volume overload and immunosuppression. The purpose of our study was to evaluate the efficacy of a care pathway implemented at St Thomas' hospital over ten years with a focus on minimising the need for blood transfusions. A Spinal Surgery Care Pathway was developed including: nurse-led clinics facilitating pre-operative haemoglobin optimisation; intra operative cell-salvage, the use of tranexamic acid, and a transfusion criteria awareness programme. Methods. We reviewed the records of all patients 18 years of age or younger undergoing spinal corrective surgery between 2000 and 2010. Collating data from the surgical records and haematology laboratory, we identified the proportion of patients requiring transfusion and the respective volume of blood or blood products transfused. Results. 534 spinal procedures were undertaken on patients over the decade of interest. Over this time, the proportion of patients requiring transfusion reduced from 83.3% in 2000, to 6.4% in 2010 (p < 0.001); a consistent year on year reduction was witnessed between 2005 and 2010. In those requiring transfusion, the volume of packed red cells transfused fell from a mean of 7.7 units in 2000, to 1.5 units in 2010 (p < 0.001). These results were despite an increase in posterior fusions, associated with higher bleeding, from 50.0% to 79.4% over the same time period. Conclusion. Over ten years, we have demonstrated that the implementation of a multifaceted, multidisciplinary pathway together with challenging cultural attitudes to blood transfusion, can dramatically and sustainably reduce the need for blood transfusion and the risks associated therewith. These data lends weight to the adoption of such a care pathway in paediatric scoliosis surgery

Aim. The aim of this study was to determine the effects of using the Bellovac autologous blood salvage system on blood transfusion requirements, adverse event rate, post-operative length of stay (POLOS) and mobilisation in patients who have undergone a total knee replacement. Methods. This is a retrospective cohort study of 471 patients who underwent a total knee replacement (TKR) at our institution between January 2008 and August 2009. All patients received an autologous blood salvage drain in theatre. Their medical records were reviewed and a database created to assess the efficacy of the blood salvage system. Results. Overall 70% of the patients were re-transfused (77% of males, 65% of females). In the remainder there was too little blood in the drain by the time the re-transfusion window had ended. Re-transfused patients were comparable to those not re-transfused in terms of age, BMI, comorbidity, pre-op mobility, anaesthetic type and pre-operative haemoglobin concentration. Re-transfused patients had lower allogeneic transfusion requirements (6.5 vs 12.9%, p=0.022). This was not a result of the gender discrepancy. Number needed to treat with a re-infusion drain was 8.9 (95%CI 5.8–19.3) to prevent one unit of allogeneic blood being transfused. Re-transfused patients also had a lower post-operative adverse event rate (18 vs 24% p=0.18) but this was not statistically significant. POLOS and post-operative mobilisation were not affected, even after the elimination of patients with adverse events. Cost analysis showed that autologous re-infusion drains (£50 each) were not cost-effective in preventing allogeneic blood transfusion (vein-to-vein cost £135). One adverse event attributable to the re-infusion system occurred: a drain tip had to be removed operatively after becoming bent. Conclusion. Autologous re-infusion systems are effective but not cost-effective in reducing blood transfusion requirement after TKR. Autologous re-infusion may be associated with a reduced adverse event rate post-operatively

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

This study aimed to identify factors associated with increased rates of blood transfusion in patients with adolescent idiopathic scoliosis (AIS) treated with posterior spinal fusion (PSF). A retrospective case-control study was performed for AIS patients treated at a large children's hospital between August 2018 and December 2020. All patients with a diagnosis of AIS were evaluated. Data on patient demographics, AIS, and transfusion parameters were collected. Univariate regression and multivariate logistic modeling were utilized to assess risk factors associated with requiring transfusion. Odds ratios (OR) and 95% confidence interval (CI) were calculated. Surgeries were done by three surgeons and thirty anesthesiologists. To quantify the influence of anesthesia practice preferences a categorical variable was defined as “higher-transfusion practice preference”, for the provider with the highest rate of transfusion. A total of 157 AIS patients were included, of whom 56 were transfused RBC units (cases), and 101 did not receive any RBC transfusion (controls). On univariate analysis, the following variables were significantly correlated with receiving RBC transfusion: “higher-transfusion practice preference,” “administration of crystalloids,” “receiving fresh frozen plasma (FFP),” “receiving platelets,” “pre-operative hemoglobin,” “cell saver volume,” and “surgical time.” On multiple regression modeling, “pre-operative hemoglobin less than 120 g/L” (OR 14.05, 95% CI: 1.951 to 135.7) and “higher-transfusion practice preference” (OR 11.84, 95% CI: 2.505 to 63.65) were found to be meaningfully and significantly predictive of RBC transfusion. In this cohort, we identified pre-operative hemoglobin of 120 g/L as a critical threshold for requiring transfusion. In addition, we identified significant contribution from anesthesia transfusion practice preferences. Our multivariate model indicated that these two factors are the major significant contributors to allogenic blood transfusion. Although further studies are required to better understand factors contributing to transfusion in AIS patients, we suggest standardized, peri-operative evidence-based strategies to potentially help reduce variations due to individual provider preferences

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

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

Extended patient waiting lists for assessment and treatment are widely reported for planned elective joint replacement surgery. The development of regionally based Elective Orthopaedic Centres, separate from units that provide acute, urgent or trauma care has been suggested as one solution to provide protected capacity and patient pathways. These centres will adopt protocolised care to allow high volume activity and increased day-case care. We report the plan to establish a new elective orthopaedic centre serving a population of 2.4 million people. A census conducted in 2022 identified that 15000 patients were awaiting joint replacement surgery with predictions for further increases in waiting times. The principle of care will be to offer routine primary arthroplasty surgery for low risk (ASA 1 and 2) patients at a new regional centre. Pre-operative assessment and preparation will be undertaken digitally, virtually and/or in person at local centres close to the where patients live. This requires new and integrated pathways and ways of working. Predicting which patients will require perioperative transfusion of blood products is an important safety and quality consideration for new pathways. We reviewed all cases of hip and knee arthroplasty surgery conducted at our centre over a 12-month period and identified pre-operative patient related predictive factors to allow us to predict the need for the perioperative transfusion of blood products. We examined patient sex, age, pre-operative haemaglobin and platelet count, use of anti-coagulants, weight and body mass index to allow us to construct the Imperial blood transfusion tool. We have used the results of our study and the transfusion tool to propose the patient pathway for the new regional elective orthopaedic centre which we present

Shoulder replacement surgery is a well-established orthopaedic procedure designed to significantly enhance patients’ quality of life. However, the prevailing preoperative admission practices within our tertiary shoulder surgery unit involve a two-stage group and save testing process, necessitating an admission on the evening before surgery. This protocol may unnecessarily prolong hospital stays without yielding substantial clinical benefits. The principal aim of our study is to assess the necessity of conducting two preoperative group and save blood tests and to evaluate the requirement for blood transfusions in shoulder arthroplasty surgeries. A secondary objective is to reduce hospital stay durations and the associated admission costs for patients undergoing shoulder arthroplasty. We conducted a retrospective observational study covering the period from 1st January 2023 to 31st August 2023, collecting data from shoulder arthroplasty procedures across three hospitals within the Aneurin Bevan University Health Board. Our analysis included 21 total shoulder replacement cases and 13 reverse shoulder replacement cases. Notably, none of the patients required postoperative blood transfusions. The mean haemoglobin drop observed was 14 g/L for total shoulder replacements and 15 g/L for reverse shoulder replacements. The mean elective admission duration was 2.4 nights for total shoulder replacements and 2 nights for reverse shoulder replacements. Our data indicated that hospital stays were extended by one night primarily due to the preoperative group and save blood tests. In light of these findings, we propose a more streamlined admission process for elective shoulder replacement surgery, eliminating the need for the evening-before-surgery group and save testing. Hospital admissions in these units incur a cost of approximately £500 per night, while the group and save blood tests cost around £30 each. This revised admission procedure is expected to optimise the use of healthcare resources and improve patient satisfaction without compromising clinical care

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

To determine whether pre-operative cessation of anticoagulant or antiplatelet medication is necessary for patients undergoing total shoulder arthroplasty (TSA) or reverse total shoulder arthroplasty (RTSA). A prospectively maintained database was used to identify 213 consecutive patients treated with TSA or RTSA performed by a single surgeon across 3 centres. This cohort included 24 patients on an anticoagulant agent (warfarin, apixaban, rivaroxaban, dabigatran), 52 patients on an antiplatelet agent (aspirin, clopidogrel), and a control group of 137 patients not on anticoagulant or antiplatelet medication. Patients on anticoagulant or antiplatelet medications continued these agents peri-operatively. Outcomes included haemoglobin drop, intra-operative blood loss, operative time, transfusion requirements and post-operative complications. The mean age of the cohort was 74.3 years (range 47 – 93) and 75 (35.2%) of the patients were male. TSA was performed in 63 cases and RTSA in 150 cases. The mean haemoglobin drop in the control group was 17.3 g/L, compared to 19.3 g/L in the anticoagulant group (p = 0.20) and 15.6 g/L in the anti-platelet group (p = 0.14). The mean intra-operative blood loss in the control group was 107.8 mL, compared to 143.0 mL in the anticoagulant group (p = 0.03) and 134.3 mL in the anti-platelet group (0.02). The mean operative time in the control group was 49.3 minutes, compared to 47.1 minutes in the anticoagulant group (p = 0.56) and 50.3 minutes in the anti-platelet group (p = 0.78). Post-operatively no patients developed a wound infection or haematoma requiring intervention. Three patients not on anticoagulant or antiplatelet medication developed pulmonary embolism. Continuing anticoagulant or antiplatelet medication was associated with higher intra-operative blood loss, but produced no statistically significant differences in haemoglobin drop, operative time, transfusion requirements or post-operative complications. We now do not routinely stop any anticoagulant or antiplatelet medication for patients undergoing total shoulder arthroplasty

Introduction. Distal femur fractures have traditionally been stabilized with either lateral locking plate or retrograde intramedullary nail. Dual-plates and nail-plate combination fixation have the theoretical biomechanical advantage, faster union and allows patients to weight bear immediately. The aim of this study is to compare single vs combination fixation, and evaluate outcomes and complications. Method. We retrospectively reviewed all patients over 60, admitted to Christchurch Hospital, between 1st Jan 2016 and 31st Dec 2022, with an AO 33A/33B/33C distal femur fracture. Patient demographics, fracture characteristics, operation details, and follow up data were recorded. Primary outcomes are union rate, ambulatory status at discharge, and surgical complications. Secondary outcomes include quality of reduction, operation time and rate of blood transfusions. Results. 114 patients were included. (92 single fixation, 22 combination fixation). Baseline demographic data and fracture characteristics did not differ between the cohorts. There was no difference in the rate of union or time to union between the two cohorts. Combination fixation patients were allowed to weight-bear as tolerated significantly more than single fixation patients (50% vs 18.9%, p=0.003). There was no difference in length of hospital stay, transfusion, complication and mortality rates. Medial translation of the distal articular block was significantly lower in the combination fixation cohort (1.2% vs 3.4%, p=0.021). Operation time was significantly longer in the combination fixation cohort (183mins vs 134mins, p<0.001). Discussion. The results show no difference in achieving union or time to union, despite better quality of fracture reduction with dual fixation. This differs to previously published literature. The clear benefit of combination fixation is immediate weight-bearing. As expected, operation times were longer with combination fixation, however this did not translate to more complications. Conclusion. Combination fixation allows earlier weight bearing, at the cost of longer operation times

Aim. As the number of performed total hip arthroplasties (THA) and total knee arthroplasties (TKA) has increased over the years, revision surgeries are expected to increase as well. Revision surgeries are associated with a longer operating room time, prolonged length of stay (LOS), and more frequent complications. Postoperative hematomas are a major reason for wound healing disturbances and periprosthetic joint infections (PJI). We aimed to systematically assess the use and safety of a microporous polysaccharide hemosphere (MPH) in revision THA and TKA. We focused on the risk reduction of further revision surgeries in case of wound healing disorders and hematoma, transfusion of packed red blood cells (PRBC), loss of hemoglobin (hb) and mean LOS following the use of MPH. Method. Our prospective study includes 89 patients who underwent revision surgery after THA and TKA with application of MPH and were compared to 102 patients who did not receive MPH and underwent revision surgery after THA and TKA. Five grams of MPH. 1. were applied periarticular before fascia closure and to the subcutaneous soft tissue. The follow-up was conducted in daily clinical visits during the inpatient stay and three months postoperatively in our outpatient clinic. Repeated revision surgery was performed in case of prolonged secretion (>10 days) or clinical suspicion of infection. After matching the cohorts the outcomes were statistically analyzed using paired methods. Results. A significantly lower odds ratio for repeat revisions was found for the MPH cohort (OR=0.312; 95%-CI 0.090, 0.893; p=0.027). Differences between pre- and postoperative hb levels, LOS and transfusions of PRBC did not reach significance. No intra- or postoperative complications to MPH occurred. Moreover, no infection relapse occurred after applying MPH. Conclusions. Routine use of MPH in revision arthroplasty management after TKA and THA appears to be safe and an effective way to support hemostasis, with no observed adverse events related to MPH use. There were noticeably less hematomas and revision surgeries in the MPH group. 1. Arista BD, Franklin Lakes, NJ, USA

Prior to the introduction of steroid management in Duchenne Muscular Dystrophy (DMD), the prevalence of scoliosis approached 100%, concomitant with progressive decreases in pulmonary function. As such, early scoliosis correction (at 20-25°) was advocated, prior to substantial pulmonary function decline. With improved pulmonary function and delayed curve progression with steroid treatment, the role of early surgery has been questioned. The purpose of this study was to compare the post-operative outcomes of early versus late scoliosis correction in DMD. We hypothesize that performing later surgery with larger curves would not lead to worse post-operative complications. Retrospective cohort study. Patients with DMD who underwent posterior scoliosis correction, had pre-operative pulmonary function testing, and at least 1-year post-operative follow-up, were included; divided into 2 Groups by pre-operative curve angle – 1: ≤45°, 2: >45°. Primary outcome was post-operative complications by Clavien-Dindo (CD) grading. Secondary outcomes included: age at surgery, forced vital capacity (FVC), steroid utilization, fractional shortening (FS) by echocardiogram, surgery duration, blood transfusion requirements, ICU length of stay (LOS), days intubated post-operatively, hospital LOS, infection, curve correction. Two-tailed t-test and chi-square testing were used for analysis of patient factors and CD complication grade, respectively. 31 patients met the inclusion criteria, with a mean total follow-up of 8.3±3.2 years. Steroid treatment (prednisone, deflazacort) was utilized for 21 (67.7%) patients, for a mean duration of 8.2±4.0 years. Groups were comparable for steroid use, FVC, echo FS, and age at surgery (p>0.05). Primary curve angle was 31.7±10.4° and 58.3±11.1° for Groups 1 and 2, respectively (p 0.05). Surgery duration, ICU LOS, days intubated, hospital LOS, were also not different between Groups. For the entire cohort, however, the overall complication rate was higher for patients with steroid treatment [61.9% vs 10%, respectively (p=0.008)], the majority being CDII. Neither FVC nor echo FS were different between Groups at final follow-up (p=0.6; p=0.4, respectively). Post-operative complication rates were not different for early and late scoliosis correction in DMD. In general, however, patients undergoing steroid treatment were at higher risk of blood transfusion and deep infection. Delaying scoliosis correction in DMD while PF is favourable is reasonable, but patients with prior steroid treatment should be counseled regarding the higher risk of complications

Background. Tourniquets and tranexamic acid (TXA) are commonly used in total knee arthroplasty (TKA), but there is not consensus on how these interventions affect blood transfusion rates and total blood loss. Few studies examine the combined use of both interventions. We compared outcome measures and transfusion rates following TKA, with and without the use of tourniquet and TXA. Methods. Retrospective cohort study of 477 consecutive patients undergoing primary TKA at a single center between 2008 and 2013. There were 243 in the tourniquet-assisted (TA) and 234 in the tourniquet-unassisted (TU) group. Subanalysis was performed on those patients receiving TXA. Results. Mean operative duration was 66.4 minutes (30–135) in the TA group and 87.5 minutes (43–162) in the TU group (p<0.0001). Mean post-operative drop in hemoglobin was significantly greater in TU group (3.1g/dl vs. 2.8g/dl, p=0.002). The transfusion rate was 9.5% in TA compared to 11.5% in TU patients (p=0.46) with comparable mean units transfused (2.6 vs. 2.2, p=0.30). There was no significant difference in rate of wound infection (2% vs. 1.7%, p = 0.82) and total complication rate (4.1% vs. 2.5%, p=0.19) between groups. Mean length of stay was 5.8 days in TA and 7 days in the TU group (p=0.07). Those patients given TXA had a lower hemoglobin drop (2.6g/dl vs. 3.3g/dl, p=0.04) with similar transfusion (10.9% vs. 13.3%, p=0.61) and complication (3.3% vs. 5.2%, p=0.95) rates. Discussion. Tourniquet-unassisted TKA had a greater operative duration and post-operative drop in hemoglobin than tourniquet-assisted TKA. However, transfusion rates were similar between groups. TXA use reduced the operative decrease in hemoglobin with no effect on complication or transfusion rates. Key words. TKA, tourniquet, tranexamic acid, transfusion rates, outcomes. For any figures or tables, please contact authors directly

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

Aims. Joint arthroplasties may be associated with a blood loss, which necessitates transfusion. Especially, hip arthroplasties are highly associate with transfusion to compensate perioperative bleeding. Orthopaedic surgeons and patients have increasing concerns regarding complications of blood transfusions. Although various methods to reduce transfusions have been attempted in TJA, a high percentage of patients require a transfusion during and after the procedures. The purposes of this study were to evaluate the trends of the transfusion(transfusion rates, transfusion amounts, economic burden) in hip arthroplasties, using nationwide data from the National Health Insurance Service (NHIS). Patients and methods. We used data from nationwide claims database of Health Insurance Review Assessment Service (HIRA). The data managed by the NHIS were used to identify the 161,934 hip arthroplasties by 3 categories including bipolar hemiarthroplasty(BH), total hip arthroplasty(THA), and revision arthroplasty(RA) from 2007 to 2015. These 3 categories were classified using the operation code recorded in the requisition data of NHIS. The transfusion rates, transfusion amounts, proportion of transfusion, cost of each type of operation was investigated and stratified by age, gender, hospital type, and area in hip arthroplasties. The proportion of transfusion about whole blood, red blood cell, fresh frozen plasma, platelet, was also evaluated in hip arthroplasties. Results. The patients of hip arthroplasties who receive transfusion was observed 11,224/13,584 in 2007, 12,823/15,325 in 2008, 13,447/16.144 in 2009, 14,915/17,702 in 2010, 15,623/18,648 in 2011, 16,374/19,878 in 2012, 16,961/20,423 in 2013, 16,367/20,060 in 2014 and 16,116/20,170 in 2015. Total transfusion rate was 81.1% in 9 years data.(82.6% in 2007, 83.7% in 2008, 83.3% in 2009, 84.3% in 2010, 83.8% in 2011, 82.4% in 2012, 83% in 2013, 81.6% in 2014, 79.9% in 2015. The overall proportion of transfusion was 7% fresh frozen plasma, 12% platelet, and 77% RBC. The total amount of transfusion was 47,351 in 2007, 56.387 in 2008, 58,320 in 2009, 66,604 in 2010, 68,472 in 2011, 74,735 in 2012, 73,370 in 2013, 67,736 in 2014, and 62,749 in 2015. The average dose of transfusion is 4.1 times in bipolar hemiarthroplasty(343,815/ 83,729), 8.7 times in revision arthroplasty(35,044/4,024), 4.3 times in total hip arthroplasty from 2007 to 2015. Conclusion. In this nationally representative study of patterns of transfusion use in hip arthroplasty, we observed relatively high rates in the use of blood transfusion among patients undergoing hip arthroplasties regardless of many factors including patient, hospital, characteristics, compared with researches in other countries. The total amount of transfusion shows decreasing trends recently, however, it does not seem a big difference in transfusion rate

The aim of this study was to determine the incidence, annual trend, perioperative outcomes, and identify risk factors of early-onset (≤ 90 days) deep surgical site infection (SSI) following primary total knee arthroplasty (TKA) for osteoarthritis. Risk factors for early-onset deep SSI were assessed. We performed a retrospective population-based cohort study using prospectively collected patient-level data from several provincial administrative data repositories between January 2013, and March 2020. The diagnosis of early-onset deep SSI was based on published Centre for Disease Control/National Healthcare Safety Network (CDC/NHSN) definitions. The Mann-Kendall Trend Test was used to detect monotonic trends in early-onset deep SSI rates over time. The effects of various patient and surgical risk factors for early-onset deep SSI were analyzed using multiple logistic regression. Secondary outcomes were 90-day mortality and 90-day readmission. A total of 20,580 patients underwent primary TKA for osteoarthritis. Forty patients had a confirmed deep SSI within 90-days of surgery representing a cumulative incidence of 0.19%. The annual infection rate did not change over the 7-year study period (p = 0.879). Risk factors associated with early-onset deep SSI included blood transfusions (OR, 3.93 [95% CI 1.34-9.20]; p=0.004), drug or alcohol abuse (OR, 4.91 [95% CI 1.85-10.93]; p<0.001), and surgeon volume less than 30 TKA per year (OR, 4.45 [1.07-12.43]; p=0.013). Early-onset deep SSI was not associated with 90-days mortality (OR, 11.68 [0.09-90-58]; p=0.217), but was associated with an increased chance of 90-day readmission (OR, 50.78 [26.47-102.02]; p<0.001). This study establishes a reliable baseline infection rate for early-onset deep SSI after TKA for osteoarthritis through the use of a robust methodological process. Several risk factors for early-onset deep SSI are potentially modifiable or can be optimized prior to surgery and be effective in reducing the incidence of early-onset SSI. This could guide the formulation of provincial screening programs and identify patients at high risk for SSI

Abstract. Introduction. There is paucity of evidence in predicting outcomes following cervical decompression in patients in octogenerians with cervical myelopathy. Our aim is to analyse the predictive value of Charlson comorbidity index (CCI) on clinical outcomes in this group. Methods. All patients age >80 years who underwent cervical decompression+/−stabilisation between January 2006-December 2021 at University Hospitals of Derby & Burton were included. Logistic regression analysis was performed using JASP. Results. Total 72 patients (n=32 male, n=28 female). Mean age 83.44 ± 3.21 years. 67 patients underwent posterior decompression+ stabilisation & 5 patients had posterior decompression alone. Mean CCI was 5; graded moderate in 32 (44%, CCI=<4) and severe in 40 (55.5%, CCI>4). Mean age and preoperative Nurick grade was similar between moderate and severe groups. Postoperative Nurick grade improved equally in both groups by 0.67 and 0.68 respectively (p=0.403). Mean LOS 16±16.12 days. 5 complications in the moderate group (21.8%) and 8 complications in severe group (21.6%); wound infection (n=7), other infection (n=2), electrolyte derangement (n=2), AKI (n=1), blood transfusion (n=1) and early death (n=3) (p=0.752). 1 early postoperative death <30 days occurred in the moderate group (4.3%) whereas 2 occurred in the severe group (5.3%) (p=0.984). No patients with moderate CCI required nursing home discharge whereas 7.9% of severe patients required this. Conclusion. Both groups benefitted from neurological improvement postoperatively, low 1 year mortality. No difference in hospital stay, complication rate and early mortality between both groups. More patients with severe CCI require nursing care after discharge than those with moderate CCI

Background. While tranexamic acid (TXA) has been well shown to reduce blood loss after joint replacement surgery, little is known regarding its effectiveness in obese patients. The aim of this study was to evaluate the effect of TXA changes in hematocrit and hemoglobin levels as well as incidence of packed red blood cell (pRBC) transfusions in obese patients undergoing total joint arthroplasty (TJA). Material and Methods. Between January 2014 and May 2015, 420 consecutive primary joint replacements were performed by two surgeons at our institution. 157 patients (THA=29; TKA=128) were obese with a body mass index (BMI) greater than or equal to 30 kg/m. 2. Medical records were reviewed and identified that TXA was utilized in 85 (54.1%) arthroplasties [study group] and was compared to a consecutive series of 72 (45.9%) TJAs [control group]. TXA was given intravenously(IV) in two doses: (1) one gram prior to incision and (2) one gram at the time of femoral preparation in THA or prior to cementation in TKA. Changes in hemoglobin and hematocrit levels, number of pRBC transfusions, and occurrence of thrombolytic events were recorded. Results. The changes in hematocrit (7.2% vs. 8.1%) and hemoglobin levels (3.0 g/dl vs. 3.3 g/dl) were less for group that received TXA than the control group, albeit not significantly (p=0.100 and p=0.278, respectively). Within the control group 26 (36.1%) patients required a pRBC transfusion with a mean of 2.0 units per patient (range:1–5); whereas, only 8 (9.4%) patients with TXA required a mean of 1.6 units per patient (range:1–2 units). The use of TXA significantly reduced the incidence of pRBC transfusions, especially in TKA (p<0.001). Sub-analyses revealed that transfusion rates were even more significantly reduced by TXA in obesity type II and III. Two pulmonary emboli were reported in the group that did not receive TXA, whereas no thrombolytic events were reported in the group that did receive TXA. Conclusion. Utilization of TXA significantly reduced the rate of pRBC transfusions in obese patients

Limited strong data exists in current literature comparing the 90-day morbidity and mortality following general or spinal anesthetic in patients who underwent total hip or knee arthroplasty, especially between matched cohorts. Because of this, there continues to be an ongoing debate regarding the risks and benefits of using general versus spinal anesthetic for patients undergoing elective total hip arthroplasty (THA) or total knee arthroplasty (TKA) for end-stage osteoarthritis. The Alberta Bone and Joint Health Institute (ABJHI) database was searched to identify all patients who underwent either primary THA or TKA between April 2005 and December 2015. Those identified were matched 1:1 based on age, sex, type of joint replacement (THA or TKA), American Society of Anesthesiologists (ASA) score, and anesthetic type. Patients were stratified into two groups based on whether they received a general anesthesia (GA) or a spinal anesthesia (SA) at the time of their index surgery. Perioperative complications (medical events, mechanical events, deep infection, need for blood transfusion), length of stay (LOS), 30-day readmission, and 90-day mortality were compared between cohorts. Included in this study are 5,580 patients who underwent THA and 7,712 patient who underwent TKA. All were successfully matched based on similar categorical criteria (THA, 2,790 matched-pairs, TKA, 3,856 matched-pairs). Following stratifications of cohorts, no statistical differences were appreciated between patient baseline demographics. Patients who underwent GA showed a trend towards higher 90-day mortality, however no statistical differences were found between anesthetic type on rates of 90-day mortality following either THA or TKA (THA, p = 0.290, TKA, p = 0.291). Considering this, patients who underwent THA with SA experienced fewer 90-day complications (medical events, p = 0.022, mechanical events, p = 0.017), needed fewer blood transfusions (p < 0 .001), and required shorter LOS (p = 0.038). Moreover, patient who underwent TKA with SA had fewer blood transfusion (p < 0 .001), 30-day readmission rates (p = 0.011), and fewer deep infections (p = 0.030) that required additional surgery compared to those in the GA cohort. Regardless of surgery performed, patients in the SA cohorts were more commonly discharged home without requiring additional support (i.e. home care). General anesthesia during THA and TKA appears to be associated with increased 90-day morbidity and more frequent need for allogenic blood transfusion. No statistical difference in 90-day mortality is reported between cohorts for either THA or TKA, yet a trend is appreciated favoring SA. Surgeons who commonly perform these surgeries should consider the added benefits of spinal anesthesia for those patients who are candidates