Blood management strategies for total knee arthroplasty

STICKS study - Short-sTretch Inelastic Compression bandage in Knee Swelling following total knee arthroplasty - a feasibility study

BACKGROUND

Postoperative knee swelling is common and impairs early postoperative function following total knee arthroplasty. It was hypothesised that the use of a short-stretch, inelastic compression bandage would reduce knee swelling and improve pain and early function. The aim of this study was to provide preliminary data and test feasibility with a view to informing a larger, future trial.

METHODS

Fifty consecutive patients selected for primary total knee arthroplasty underwent distance randomisation to receive a short-stretch, inelastic compression bandage or a standard wool and crepe bandage for the first 24 h postoperatively. Study feasibility including recruitment rates, retention rates and complications were analysed. The Oxford Knee Score, the EQ-5D-3L index score, knee swelling, knee range of motion, visual analogue pain score and length of stay were compared between groups. Analysis of covariance (ANCOVA) was performed adjusting for the preoperative measurement.

RESULTS

Sixty-eight percent of eligible patients were recruited into the trial. The retention rate was 88%. There were no complications regarding compression bandage use. There was a greater mean but non-significant improvement in Oxford Knee Score (p = 0.580; point estimate = 2.1; 95% CI -3.288 to 7.449) and EQ-5D-3L index score (p = 0.057; point estimate = 0.147; 95% CI -0.328 to 0.005) in the compression bandage group at 6 months. There was no significant difference between groups regarding knee swelling, knee range of motion, visual analogue pain score, complications and length of stay.

CONCLUSION

Preliminary data suggests that the use of an inelastic, short-stretch compression bandage following total knee arthroplasty is a safe technique that is acceptable to patients. A larger, multicentre trial is required to determine its effect postoperatively.

TRIAL REGISTRATION

The study was registered with Current Controlled Trials, identifier: ISRCTN86903140 . Registered on 30 May 2013.

Intravenous vs Topical Tranexamic Acid in Total Knee Arthroplasty Without Tourniquet Application: A Randomized Controlled Study

BACKGROUND

Use of tranexamic acid (TXA) is effective and safe in reducing the blood loss in total knee arthroplasty (TKR) performed using a tourniquet, but, data in TKR performed without tourniquet are limited, and there is no study comparing the topical (T) with intravenous (IV) TXA administration. Our aim was to compare the topical (T) with intravenous (IV) TXA administration in TKR performed without tourniquet.

MATERIAL AND METHODS

A total of 120 patients undergoing unilateral TKR for knee osteoarthritis were included in a prospective randomized study. Operations were performed under spinal anesthesia, no tourniquet was used, and the postoperative regime was the same for all patients. Patients were divided into 3 groups; in group C (control), 40 patients received no TXA, in group IV, 40 patients received 1 g of TXA intravenously, and in group L, 1 g of TXA was applied locally to 40 patients. The primary outcome measures included the calculated blood loss, the transfusion rate, and quantity of allogeneic blood units, whereas secondary outcome measures were complications.

RESULTS

There was no statistically significant difference in patient's demographics and perioperative results. Calculated blood loss, allogeneic blood transfusion rate, and quantity in group C were significantly higher compared with those of TXA groups (P < .001). There was no significant difference in complications rate between the 3 groups.

CONCLUSIONS

According to the results of this study, IV or T administration of 1-g TXA significantly reduced the blood loss and the need for allogeneic blood transfusion in patients undergoing TKR without a tourniquet (with no significant difference between the 2 routes of administration).

Comparison Between Closed Suction Drainage and No Drainage Following Total Knee Arthroplasty in a Tertiary Care Setting in Pakistan

BACKGROUND

Total knee arthroplasty is associated with hematoma formation and extensive blood loss up to 1.5 liters. The placement of a closed suction drain to control this complication is controversial. The purpose of this study is to determine the efficacy between total knee arthroplasty without a drain and with a closed suction drain.  Methods: A retrospective cohort study was conducted between January 2014 and December 2015 on 100 patients to assess the hemoglobin and hematocrit levels, the rate of allogeneic blood transfusion, and the length of hospital stay in patients with a closed suction drain versus no suction post-total knee arthroplasty.

RESULTS

Fifty-six units of packed red blood cells were transfused in 36 out of 50 patients (72%) in the closed suction group compared to 21 units of packed red blood cells in 18 out of 50 patients (36%) in the no suction group after 24 hours post-surgery. The hemoglobin levels at multiple intervals were lower in the closed suction group (p < 0.05). The closed suction group also had an extra one-day stay in the hospital (p = 0.0492, 95% CI = 0.70 - 0.94).

CONCLUSION

 Closed suction drain placement is associated with low hemoglobin levels, an increased rate of allogeneic blood transfusion, and a longer hospital stay.

Reducing Length of Stay in Total Joint Arthroplasty Care

As health care reforms continue to improve quality of care, significant emphasis will be placed on evaluation of orthopedic patient outcomes. Total joint arthroplasty (TJA) has a proven track record of enhancing patient quality of life and are easily replicable. The outcomes of these procedures serve as a measure of health care initiative success. Specifically, length of stay, will be targeted as a marker of quality of surgical care delivered to TJA patients. Within this review, we will discuss preoperative and postoperative methods by which orthopedic surgeons may enhance TJA outcomes and effectively reduce length of stay.

Topical versus systemic tranexamic acid after total knee and hip arthroplasty: A meta-analysis of randomized controlled trials

BACKGROUND

Tranexamic acid (TXA) is an antifibrinolytic drug widely used to reduce blood loss during joint replacements, including total knee arthroplasty (TKA) and total hip arthroplasty (THA). However, there is no final consensus regarding the composition of an optimal administration of TXA regime between topical and systemic (intravenous). The purpose of our study was to compare the efficacy of topical and intravenous (IV) regimen of TXA during TKA and THA.

METHODS

Five relevant electronic online databases, PubMed, EMBASE, the Cochrane Central Register of Controlled Trials, Web of Science and Chinese Biomedical Database were systematically searched in November 2015. Randomized controlled trials (RCTs) that compared topical with intravenous TXA in patients with TKA or THA were included. The search terms included "topical," "intravenous," "tranexamic acid," "knee arthroplasty" and "hip arthroplasty." Two reviewers independently extracted data and assessed the risk of bias and study quality. Data were analyzed with Review Manager 5.3 software. Grades of Recommendation Assessment, Development and Evaluation (GRADE) were used to assess the quality of evidence.

RESULTS

Sixteen RCTs with 1250 patients undergoing TKA and 4 RCTs involving 550 patients undergoing THA were included. There were no significant differences in total blood loss (mean difference [MD]TKA = -28.72 mL, 95% confidence interval [CI] -195.97 to 138.54 mL, P = 0.74; MDTHA = 14.03 mL, 95% CI -35.53 to 63.59 mL; P = 0.78), total drain out (MDTKA = -3.09 mL, 95% CI -39.05 to 32.88 mL; P = 0.87; MDTHA -31.00 mL, 95% CI -66.56 to 4.66 mL; P = 0.09), and transfusion rates (ORTKA = 0.90, 95% CI 0.58-1.40, P = 0.64; ORTHA = 1.19, 95% CI 0.67-2.09; P = 0.63) between topical and intravenous (IV) TXA.

CONCLUSIONS

The current evidence suggested that topical TXA was equally effective and safe compared with intravenous TXA in reducing blood loss and transfusion rate following TKA or THA. We recommended that either topically or systemically could be used in TKA and THA to decrease perioperative blood loss.

Comparison of Difference in Hematologic and Hemodynamic Outcomes between Primary Total Knee Arthroplasty and Revision of Infected Total Knee Arthroplasty

Purpose

This study is to identify preoperative cautions for revision of infected total knee arthroplasty (TKA) by understanding the differences in hematologic and hemodynamic changes between primary TKA and revision of infected TKA.

Materials and Methods

The study included 40 patients in each of the two groups: one group with patients who underwent TKA and the other group with patients who underwent revision of infected TKA. All patients matched for age and body mass index. The following data were compared between the groups: changes in blood pressure, variations in hemoglobin level, amount of postoperative blood loss and transfused blood, incidence of blood transfusion, white blood cell (WBC) count, albumin level, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), and liver enzyme level.

Results

The hemoglobin levels, transfusion rate, and the amount of blood loss were significantly higher in the revision group (p=0.012). In both groups, CRP reached the highest level on the 3rd postoperative day but it was normalized 2 weeks postoperatively; however, the revision TKA group showed a greater tendency to normalization (p=0.029). There were significant differences between the groups in ESR, WBC, blood pressure, and changes in liver enzyme levels.

Conclusions

Revision of infected TKA results in greater hemodynamic variations than primary TKA. Therefore, more efforts should be made to identify pre- and postoperative hemodynamic changes and hematologic status.

Cost Analysis of Tranexamic Acid in Anemic Total Joint Arthroplasty Patients

BACKGROUND

Preoperative anemia is present in 20% of total joint arthroplasty patients. Current preoperative treatment options, including iron supplementation (FE) and erythropoietin (EPO), are expensive. Tranexamic acid (TXA) has been adopted as an intraoperative adjunct to decrease blood loss. Our hypothesis is that TXA is a cost-effective treatment compared to FE and EPO in anemic patients.

METHODS

In this study, a cost analysis was performed, comparing the material costs of TXA and packed red blood cells (PRBCs) to the theoretical administration and material costs of FE and EPO per standard preoperative anemia protocol.

RESULTS

A total of 243 patients were included in the study. Of this group, 18.5% (45/243) had preoperative anemia. The rate of transfusion was 6.7% (3/45), and 5 units of PRBCs was transfused. The combined cost of TXA and PRBCs was $5317.08. Even assuming a best-case scenario with FE or EPO treatment without a postoperative PRBC requirement, the cost of treatment would range from 2 to 17 times more than treatment with TXA. An additional 50 units of PRBC (1.1 units per patient) would need to be transfused for the cost of TXA treatment to be equivalent to FE or EPO treatment.

CONCLUSION

Tranexamic acid is significantly less expensive than FE or EPO as a treatment option for total joint arthroplasty patients presenting with preoperative anemia. It is a cost-effective adjunct for limiting transfusion rates in this patient population. We recommend that new preoperative anemia levels that necessitate preoperative intervention be established.

Minimizing Blood Transfusion in Total Hip and Knee Arthroplasty Through a Multimodal Approach

BACKGROUND

We introduced a multimodal, multidisciplinary approach to perioperative blood management aimed at reducing blood transfusions in primary knee (TKA) and hip (THA) arthroplasty. The protocol included (1) preoperative hemoglobin optimization through a multidisciplinary approach, (2) minimization of perioperative blood loss, and (3) adherence to evidence-based transfusion guidelines.

METHODS

Evaluation of 1010 consecutive patients undergoing primary TKA (488) or THA (522) was performed.

RESULTS

A significant reduction in the overall transfusion rate (1.4% vs 17.9%, P<.0001) resulted after algorithm introduction, when compared with the 1814 previous patients. Zero (0%) TKA and 4 (0.8%) THA patients adherent to protocol, and 4/488 (0.8%) TKA and 10/522 (1.9%) THA patients overall received transfusions.

CONCLUSION

Adoption of a multimodal blood management algorithm can significantly reduce blood transfusions in primary joint arthroplasty.

Benefits of Limited Use of a Tourniquet Combined With Intravenous Tranexamic Acid During Total Knee Arthroplasty

BACKGROUND

Blood loss during total knee arthroplasty (TKA) may require blood transfusions that are associated with increased risk, morbidity, and cost. Multiple techniques exist to reduce blood loss in TKA, including the use of a tourniquet and tranexamic acid (TXA). While multiple studies suggest that TXA is effective in reducing blood loss, the use of a tourniquet is more controversial. We studied the combined effect of TXA with a limited-use tourniquet on blood loss and complications in the setting of primary TKA.

METHODS

A retrospective review of a prospectively gathered arthroplasty database from a single institution was performed. We compared our limited-use cohort data with the published results of randomized controlled trials evaluating the effectiveness of tourniquets used during the entire TKA procedure.

RESULTS

Fifty-one procedures from our institution's database met the inclusion criteria. TXA (administered in a single 15-mg/kg dose) with limited tourniquet use (a mean duration of 26.3 minutes) resulted in an average intraoperative estimated blood loss of 94.7 mL. The mean decrease in hemoglobin from the preprocedure baseline to postoperative day 1 was 2.6 ± 0.9 g/dL (P<0.001), and only 2 of the 51 procedures required a blood transfusion. When compared to recent randomized controlled trials, the 51 procedures demonstrated lower levels of blood loss, similar operative time, and no increase in morbidity or mortality.

CONCLUSION

Our study results suggest that using TXA in combination with a tourniquet during the cementation portion only of a TKA provides a reasonable operative time and low intraoperative blood loss without increasing perioperative morbidity or complications.

What Is the Benefit of Tranexamic Acid vs Reinfusion Drains in Total Joint Arthroplasty?

We sought to compare the efficacy and cost of reinfusion drains vs tranexamic acid (TA) in primary total joint athroplasty (TJA) patients. We randomized 186 primary TJAs (71 hips, 115 knees) to standard drains (61/186), autologous reinfusion drains (60/186), or single dose (20 mg/kg) of TA (65/186). There was a statistically significant (P < .0001) less drop in hemoglobin levels (2.98 mg/dL; range, 0.5-6.10) in the TA group compared with standard drains (P < .0001) and reinfusion drains (P < .0061). There was no significant difference in transfusion rates. At $581.89, the unit cost of the reinfusion system is substantially higher than the standard drain ($7.56) and TA ($35.91/g). The results of this randomized controlled trial demonstrate that TA is more efficacious and provides cost savings compared with reinfusion drains as a blood management tool for TJA.

Predicting Blood Loss in Total Knee and Hip Arthroplasty

Marked blood loss during lower extremity total joint arthroplasties may lead to higher rates of transfusion, which may negatively affect surgical outcomes and yield greater complication rates. It is therefore ideal to identify factors that may increase the likelihood of blood loss, so they can be modified. From this review, it can be concluded that preoperative anemia, older age, multiple comorbidities, increased operative time, and use of postoperative anticoagulation may lead to higher blood loss and transfusion rates, although the influence of other factors remains controversial.

Can tranexamic acid change preoperative anemia management during total joint arthroplasty?

AIM: To investigate the postoperative transfusion and complication rates of anemic and nonanemic total joint arthroplasty patients given tranexamic acid (TXA).

METHODS: A cross-sectional prospective study was conducted of primary hip and knee arthroplasty cases performed from 11/2012 to 6/2014. Exclusion criteria included revision arthroplasty, bilateral arthroplasty, acute arthroplasty after fracture, and contraindication to TXA. Patients were screened prior to surgery, with anemia was defined as hemoglobin of less than 12 g/dL for females and of less than 13 g/dL for males. Patients were divided into four different groups, based on the type of arthroplasty (total hip or total knee) and hemoglobin status (anemic or nonanemic). Intraoperatively, all patients received 2 g of intravenous TXA during surgery. Postoperatively, allogeneic blood transfusion (ABT) was directed by both clinical symptoms and relative hemoglobin change. Complications were recorded within the first two weeks after surgery and included thromboembolism, infection, and wound breakdown. The differences in transfusion and complication rates, as well as the relative hemoglobin change, were compared between anemic and nonanemic groups.

RESULTS: A total of 232 patients undergoing primary joint arthroplasty were included in the study. For the total hip arthroplasty cohort, 21% (18/84) of patients presented with preoperative anemia. Two patients in the anemic group and two patients in the nonanemic group needed ABTs; this was not significantly different (P = 0.20). One patient in the anemic group presented with a deep venous thromboembolism while no patients in the nonanemic group had an acute complication; this was not significantly different (P = 0.21). For nonanemic patients, the average change in hemoglobin was 2.73 ± 1.17 g/dL. For anemic patients, the average change in hemoglobin was 2.28 ± 0.96 g/dL. Between the two groups, the hemoglobin difference of 0.45 g/dL was not significant (P = 0.13). For the total knee arthroplasty cohort, 18% (26/148) of patients presented with preoperative anemia. No patients in either group required a blood transfusion or had an acute postoperative complication. For nonanemic patients, the average change in hemoglobin was 1.85 ± 0.79 g/dL. For anemic patients, the average change in hemoglobin was 1.09 ± 0.58 g/dL. Between the two groups, the hemoglobin difference of 0.76 g/dL was significant (P < 0.001).

CONCLUSION: TXA administration results in low transfusion and complication rates and may be a useful adjunct for TJA patients with preoperative anemia.

Is postoperative cell salvage necessary in total hip or knee replacement? A meta-analysis of randomized controlled trials

OBJECTIVE

The purpose of this study was to determine whether there are hematological or clinical differences with the use of postoperative cell salvage after total knee (TKR) and hip replacement (THR).

METHODS

A systematic literature review based on PubMed, EMBASE, the Cochrane Library Database in any language regarding postoperative cell salvage following TKR or THR was performed. High quality of randomized controlled trials were identified. The data was analyzed using Rev Man 5.2.

RESULTS

19 randomized controlled trials (12 in TKR, 4 in THR and 3 in both) about 3482 patients were identified and included in this meta-analysis. Postoperative cell salvage significantly reduced the allogeneic blood transfusion requirement after TKR (RR = 0.46, 95% CI = 0.30 to 0.72) and THR (RR = 0.46, 95%CI = 0.32 to 0.68). It also demonstrated a higher level of postoperative Hemoglobin (MD = 0.26 g/dL, 95%CI = 0.15 to 0.37) with the use of postoperative cell salvage. No significant differences were detected regarding length of hospital stay, the incidence of febrile reaction, wound infection and deep vein thrombosis.

CONCLUSION

The results strengthen the fact that postoperative cell salvage is effective and safe to reduce the rate of transfusion after TKR and THR. As the relatively poor methodological quality and heterogeneity, further research is needed to confirm its safety and cost-effectiveness.

Fibrinolytic Dysregulation in Total Joint Arthroplasty Patients

Background:

The alterations of the fibrinolytic components in osteoarthritic joint disease and their postsurgical modulation are not clearly understood. Preexisting hemostatic dysfunction may lead to both thrombotic and bleeding events in these patients.

Aim:

To profile fibrinolytic parameters in patients undergoing total joint arthroplasty prior to and on postoperative day 1.

Methods:

A total of 98 total joint arthroplasty patients were included in this study. Blood samples were drawn preoperatively and on postoperative day 1 status posttotal knee or total hip arthroplasty surgery. d-Dimer, plasminogen activator inhibitor 1 (PAI-1), and tissue plasminogen activator (tPA) were measured using commercially available enzyme-linked immunosorbent assay kits. Antiplasmin activity was measured by using a functional method.

Results:

Preoperative PAI-1, d-dimer, and tPA levels were significantly higher in arthroplasty patients compared to healthy controls. Preoperative antiplasmin level was lower than controls. Postoperative levels of PAI-1 and d-dimer were increased compared to preoperative values. Postoperative antiplasmin values were lower than preoperative levels. Changes in tPA was not significant. There was no correlation between preoperative PAI-1 and d-dimer levels. Pre- and postoperative percentage changes in each individual were calculated for PAI-1, d-dimer, tPA, and antiplasmin. There was a positive correlation between d-dimer and PAI-1. Negative correlations between antiplasmin and d-dimer and between antiplasmin and PAI-1 were noted.

Conclusion:

These results confirm the perturbation in the fibrinolytic system of patients undergoing total joint arthroplasty surgery. Surgical intervention may also enhance the observed changes. The alterations in the fibrinolytic system may lead to the observed hemostatic complications such as bleeding, hematoma formation, or potential need for blood transfusion.

Are Routine Blood Salvage/Preservation Measures Justified in All Patients Undergoing Primary TKA and THA?

A sequential series of 366 primary total knee arthroplasties and 320 total hip arthroplasties was reviewed to determine the incidence of allogeneic transfusion. Surgery was performed under regional anesthesia and all patients had a hemovac drain for 24°. Tourniquet hemostasis in TKA was maintained through wound closure. Coumadin, SCD and TED hose were utilized for DVT prophylaxis. No additional blood conservation measures were employed. The transfusion incidence in primary TKA was 2.2% (males .6%/females 3.5%). The transfusion incidence in THA was 1.9%, (males .8%/females 2.6%). The low incidence of allogeneic transfusion in a contemporary series of primary TKA and THA, especially in males, would question the need for routine blood preservation techniques in this group of patients.

Short-stretch inelastic compression bandage in knee swelling following total knee arthroplasty study (STICKS): study protocol for a randomised controlled feasibility study

Background

Enhanced recovery programmes in total knee arthroplasty are well established. Post-operative knee swelling is common and impairs early post-operative function. The use of a short-stretch, inelastic compression bandage is hypothesised to reduce knee swelling and improve pain and early function. A study was designed to test feasibility with a view to informing a larger, future trial and to provide preliminary data.

Methods/design

This is a randomised controlled feasibility study. Fifty consecutive patients selected for primary total knee arthroplasty will be enrolled in the trial. Patients with a BMI >35, latex allergy or neurological or peripheral vascular disease are excluded. Patients are randomised by distance randomisation to receive a compression bandage for 24 hours after surgery or a standard wool and crepe bandage. The bandages are applied by one of two consultant surgeons who have had training with their application. Knee swelling, range of motion and pain scores will be compared pre-operatively and at day 1, day 2 and at 6 weeks between groups. The Oxford knee score and EQ-5D health status will be compared pre-operatively and at 6 months between groups. Recruitment rates, retention rates, resource allocation, completeness of data collection, and tolerance and complications with the compression bandage are recorded. Descriptive statistics are used to calculate a standard deviation for post-operative knee swelling in the groups and to perform a power calculation incorporating anticipated patient retention rates to inform a future trial. Preliminary data will be analysed using the independent samples t-test for equal distributions and the Mann-Whitney U for unequal distributions with the significance denoted at P <0.05.

Discussion

Enhanced recovery programmes have revolutionized the management of total knee arthroplasty. There is a paucity of clinical data regarding the efficacy of compression bandages. Large, randomised controlled trials are uncommon in orthopaedic surgery. The results of this study will provide feasibility and preliminary data prior to the construction of a larger, multicentre study.

Trial registration

The study was registered with Current Controlled Trials (ISRCTN86903140) on 30 May 2013.