Hemostatic techniques to reduce blood transfusion after primary TKA: a meta-analysis and systematic review

J-shaped association of operation duration and blood transfusion risk in patients undergoing primary total knee arthroplasty

PURPOSE

Blood transfusion is a common perioperative complication of primary total knee arthroplasty (TKA) that can lead to adverse outcomes, prolonged hospital stays, and increased medical costs. The purpose of our study was to explore the risk factors for blood transfusion and to establish whether operation duration is independently related to blood transfusion risk in patients undergoing primary TKA after adjusting for other covariates.

METHODS

This was a secondary analysis of data from a retrospective cohort study involving patients who underwent primary TKA in Singapore. The patients' baseline data, comorbidity, and surgical characteristics were collected. The independent variable was operation duration and the dependent variable was blood transfusion events. Patients were divided into three groups according to operation durations (90 and 120 min). Univariate logistic regression was used to explore the risk factors associated with blood transfusion after primary TKA. Multivariate analysis was used to assess the independent effect of operation duration on blood transfusion risk after adjusting for other covariates. Additionally, we performed subgroup analyses to identify specific groups, test the robustness of the relationships, and explore whether there were interactions between the different variables. Furthermore, restricted cubic splines (RCS) were used to identify the relationship between the two variables.

RESULTS

A total of 2,562 patients were included in the study, of whom 136 (5.61%) had a transfusion event. Operation durations were 95.55 ± 36.93 and 83.86 ± 26.29 min for blood transfused and non-transfused patients, respectively. Univariate logistic regression analysis showed that age, BMI, ASA status, Hb level, OSA, CHF, creatinine level > 2 mg/dL, and anaesthesia type were risk factors for blood transfusion. After adjusting for all covariates, multivariate logistic regression models showed that operation duration was positively associated with blood transfusion risk (odds ratio [OR] = 1.87, 95% CI = 1.174-2.933, P = 0.007). Compared to patients with an operation duration of less than 90 min, those with an operation duration of more than 120 min had a 2.141-fold increased risk of blood transfusion (OR = 2.141, 95% CI = 1.035-4.265, P = 0.035). Stratified analysis results showed that the association persisted in patients aged > 50 years, Chinese, BMI > 30 kg/m 2, Hb level > 11 g/dL, ASA status levels 2 and 3, general anaesthesia, and unilateral primary TKA. A non-linear (P-non-linear = 0.30) and J-shaped relationship was identified. The risk of transfusion increased as the operation duration decreased or exceeded the inflection point (73.2 min).

CONCLUSION

Our study demonstrated a non-linear and J-shaped relationship between operation duration and blood transfusion events in patients undergoing primary TKA. Blood transfusion risk was the lowest when the operation duration was 73.2 min. A shorter operation duration implies irregular surgical procedures and incomplete intraoperative haemostasis, leading to increased perioperative blood loss and blood transfusion. These results will be useful for clinical decision-making.

The natural course of hemoglobin levels after allogenic blood transfusion in total knee arthroplasty

We retrospectively investigated the natural course of hemoglobin levels after allogenic blood transfusion in total knee arthroplasty. All patients were treated according to the same clinical pathway, and blood tests were performed on the same day. All blood tests were done on pre-op, immediate post-op, midnight of op day, 1st, 2nd, 3rd, 5th, 7th, and 11th day after surgery. Of the total 593 cases, a total of 197 cases (33.2%) were performed within 3 days of surgery. Hemoglobin level was significantly lowest on the 3rd day after surgery and tended to increase afterwards in the non-transfusion group. In the case of blood transfusion on the day of surgery, the hemoglobin level showed an increase on the next day and then showed a minimum value on the fifth day of surgery and then increased. The same pattern was identified when blood transfusion was done on the 1st and 2nd day of surgery. However, when blood transfusion was done on the 3rd day, the hemoglobin level showed a steady increase afterwards. The hemoglobin level of total knee arthroplasty patients with no blood transfusion was the lowest on the 3rd day after surgery and increased afterwards. If blood transfusion was done within 2 days after surgery, the hemoglobin level was the lowest on the 5th day after surgery and increased afterwards. If blood transfusion was done on the 3rd day after surgery, the hemoglobin level increased afterwards.

Comparison of three methods for sealing of the intramedullary femoral canal during total knee arthroplasty; a randomized controlled trial

PURPOSE

The purpose of this randomized controlled study was to examine the effect of sealing the intramedullary canal with a bone or cement plug or leaving it empty on postoperative bleeding and pain MATERIALS AND METHODS: A total of 120 patients with knee osteoarthritis who underwent unilateral TKA participated in the trial and were assigned to one of three groups. The femoral canal was sealed with an autogenous bone plug (Group I) or cement plug (Group II), or it was left open (Group III). Estimated blood loss, Hemoglobin decline, bleeding into the drain, and postoperative pain w compared between groups.

RESULTS

Six patients were excluded due to various reasons, and the remaining 114 patients were included in the final analysis. There were no significant variations in baseline clinical characteristics between the three groups (p > 0.05). Hemoglobin reduction between preoperative and 72 h after the surgery (p: 0.034) and estimated blood loss (p: 0.003) were significantly different between groups. The cement plug group showed the least bleeding. Although there was a significant difference between the cement and empty canal groups (p: 0.03 and p: 0.002, respectively), the difference between the cement and bone groups was similar regarding both hemoglobin reduction and estimated blood loss. The blood volume in the suction drain (p: 0.598) and transfusion rate (p: 0.087) were similar between the groups. VAS at the 12 h after the surgery was similarly high in each group (p: 0.676). It declined at 36 h after surgery, but no significant difference was determined between groups (p: 0.815).

CONCLUSIONS

This study showed that estimated blood loss and hemoglobin reduction were significantly lower in the cement plug group than in the empty canal group. But bone plug group did not show any difference with both empty canal and cement plug groups. Sealing the IM canal or leaving it open did not change the bleeding into the drain, transfusion rate, and postoperative pain between groups. Based on these findings, sealing the IM canal with a cement plug might be recommended to diminish bleeding during TKA despite similar transfusion rates.

LEVEL OF EVIDENCE

Level I, randomized controlled trial.

One-stage bilateral unicompartmental knee arthroplasty is a suitable option vs. the two-stage approach: a meta-analysis

To compare one-stage vs. two-stage bilateral unicondylar knee arthroplasty (UKA) in terms of complications, mortality, reinterventions, transfusion rate, days to discharge, and outcomes for the treatment of bilateral mono-compartmental knee osteoarthritis.

A systematic review was performed in the PubMed, Web of Science, and Cochrane databases up to February 2021. Randomized controlled trials, case-control studies, and case series describing the use of bilateral UKA were retrieved. A meta-analysis was performed on complications, mortality, reinterventions, transfusion rate, and days to discharge comparing one-stage vs. two-stage replacement, and outcomes were also reported. Assessment of risk of bias and quality of evidence was performed with the Newcastle-Ottawa Scale.

Fifteen articles were included on 1451 patients who underwent bilateral UKA (44.9% men, 55.1% women, mean age 66 years). The systematic review documented, for bilateral one-stage UKA: 2.6% major and 5.4% minor complication rates, 0.5% mortality, 1.9% reintervention, 4.1% transfusion rates, and 4.5 mean days to discharge. No studies reported functional differences. The meta-analysis did not find differences for major complications, minor complications, mortality, reintervention, transfusion rates, or days to discharge versus two-stage bilateral procedures. The operative time was 112.3 vs. 125.4 minutes for one-stage and two-stage surgeries, respectively. The overall quality of the retrieved studies was high.

Bilateral single-stage UKA is a safe procedure, with a few complications, and overall positive clinical results. No differences were found in terms of complications, mortality, reinterventions, transfusion rate, and days to discharge in comparison with the two-stage approach.

Cite this article: EFORT Open Rev 2021;6:1063-1072. DOI: 10.1302/2058-5241.6.210047

Blood loss after revision knee arthroplasty is 1.38- to 2.17-fold higher than after primary knee arthroplasty: A retrospective analysis of 898 cases

BACKGROUND

There are a number of factors that influence blood loss during and after primary total knee arthroplasty (TKA) and revision TKA (rTKA). The purpose of this study was to provide a factorial assessment that would aid surgeons in managing expected blood loss in rTKA, when compared to TKA. The first question asked was the blood loss and transfusions between TKA and rTKA and the second question was risk factors for blood loss after rTKA.

HYPOTHESIS

Blood loss in any rTKA is higher than in TKA by a factor of 2.

PATIENTS AND METHODS

A retrospective single-centre consecutive series of rTKA between 2006 and 2018 was performed. Based on the rTKA types identified in joint registries, 4 rTKA cohorts were created: aseptic minor rTKA, aseptic major rTKA, 1st stage, and 2nd stage septic rTKA. A consecutive TKA cohort from the same study period was used to create a propensity score matched cohort with the aseptic major rTKA cohort.

RESULT

A total of 622 rTKA were identified. Aseptic major rTKA had double the median blood loss than TKA. The lowest blood loss was observed in the TKA group followed by aseptic minor rTKA, and the highest in 2nd stage septic rTKA. The median total blood loss was higher in all rTKA by a factor ranging between 1.38 and 2.17. Higher age, female gender, lower preoperative hemoglobin, chronic heart disease and history of myocardial infarction were risk factors for increased blood loss. The type of rTKA performed was not predictive of blood loss in the linear regression analysis.

DISCUSSION

Blood loss after rTKA is 1.38 to 2.17-fold higher than after TKA. The blood loss observed in 2nd stage septic rTKA and aseptic major rTKA was the highest. Older female patients, with a low preoperative hemoglobin, were identified to be at the highest risk of blood loss after rTKA. Strategies for further blood loss reductions need to be utilised to the fullest extent for these procedures.

LEVEL OF EVIDENCE

III; retrospective prognostic study.

How I treat anemia in the perisurgical setting

Anemia is a common finding in the perioperative setting with significant untoward consequences including worsening of outcomes and diminished quality of life as well as increased risk of allogeneic blood transfusions. Here, we present 3 cases that illustrate how anemia can be perioperatively managed in patients undergoing cardiac, orthopedic, and oncology surgeries. Timely detection of anemia prior to high-blood loss surgeries can allow clinicians to manage it and optimize hemoglobin level, making patients better prepared for the surgery. Treatment of anemia should be guided by the etiology and may include erythropoietic agents, folic acid, B12, and iron preparations. Other blood management strategies geared toward reducing surgical blood loss such as autologous transfusion techniques and agents to optimize hemostasis are used during surgery and in the immediate postoperative period. Patients should be closely monitored following surgery for signs of ongoing bleeding in need of control. Finally, screening for and management of anemia should continue in the postoperative and postdischarge period, as persistence and recurrence of anemia can further undermine patient's outcomes.

Higher doses of topical tranexamic acid safely improves immediate functional outcomes and reduces transfusion requirement in total knee arthroplasty

BACKGROUND

Topical administration of tranexamic acid (TXA) in patients undergoing total knee arthroplasty (TKA) is increasingly popular as it avoids the risks related with systemic absorption of the medication. Previous studies have established the efficacy of TXA in TKA, however here are limited direct comparison studies available and the dosing regimens vary. Hence, there is no consensus on an optimal dose. Our objective is to compare blood loss, transfusion requirement and immediate post-operative function between high (2 g) and low (1 g) dose tranexamic acid in patients undergoing TKA.

METHODS

This is a retrospective cohort study of 104 patients undergoing total knee arthroplasty in a single institution under a single surgeon. In total, 61 and 43 patients receiving 1 g and 2 g of topical TXA respectively. Blood loss as estimated from the difference in haemoglobin (Hb) and haematocrit (HCT) levels post-surgery and number of blood transfusions required were compared between groups. Immediate post-operative function and complications were also measured.

RESULTS

Patient characteristics were mostly similar between groups. The transfusion requirements were higher in 1 g group compared to the 2 g group (0.11 vs 0.00, p = 0.034). The mean post op day 1 (POD1) range of motion higher in the 1 g group vs 2 g group (72.1 vs 63.7, p = 0.035). The 2 g group had a lower POD1 pain score compared to the 1 g group (4.02 vs 5.43, p < 0.01). There was no statistically significant difference in complications that were related to the administration of TXA between the two groups.

CONCLUSION

Higher dose of topical TXA is safe, helps improve immediate post-operative functional outcomes and reduces transfusion requirements.

The Effect of Antifibrinolytic Use on Intraoperative Cell Salvage: Results from a National Registry of Surgical Procedures

Intraoperative cell salvage (ICS) is a critical component of any blood management program involving surgery with a high potential for blood loss. The introduction of antifibrinolytics (AF) may reduce blood loss. The purpose of this study was to evaluate the use of AF on ICS in non-cardiac surgical procedures. Following institutional review board approval, 69,935 consecutive case records between January 2016 and September 2019 from a national registry of adult surgical patients were reviewed. Procedure types were stratified into one of nine surgical categories: general (GN, n = 1,525), neurosurgical (NS, n = 479), obstetric (OB, n = 1,563), cervical spine (CS, n = 2,701), lumbar spine (LS, n = 38,383), hip arthroplasty (HA, n = 13,327), knee arthroplasty (KA, n = 596), vascular (VA, n = 9,845), or orthopedic other (OO, n = 1,516). The primary endpoint was the use of AF with the secondary endpoints ICS shed blood volume and volume available for return. The overall use of AF across all surgical procedures increased from 21.4% in 2016 to 25.4% in 2019. The greatest increases were seen in NS (4.4% to 16.2%), LS (13.7% to 23.1%), and HA (55.8% to 61.9%). For several procedure types, there was an initial increase then either a leveling off or a decline in AF use: OB initially increased from 6.2% to 10.8% in 2018, whereas GN (9.4% to 7.2%) and VA surgery declined slightly (9.9% to 5.7%). When comparing patients who did not receive AF with those who did, there were similar volumes of ICS available for return in all groups, except for LS, GN, and VA, where lower volumes were seen in the No-AF groups. The use of AF has increased each year over the 4-year period in most of the surgical categories, but several have declined. There may be a beneficial effect of AF with lower ICS volumes available for return in a few groups.

Comparative changes of pre-operative autologous transfusions and peri-operative cell salvage in the United States

BACKGROUND

With improved safety of allogeneic blood supply, the use of preoperative autologous donations (PADs) and perioperative autologous cell salvage (PACS) has evolved. This study evaluated temporal trends in PAD and PACS use in the United States.

METHODS

The National Inpatient Sample database, a stratified probability sample of 20% of hospitalizations in the United States, was used to compare temporal trends in hospitalizations reporting use of PADs and PACS from 1995 to 2015. Factors associated with their use were examined between 2012 and 2015 with use of multivariable Poisson regression. Sampling weights were applied to generate nationally representative estimates.

RESULTS

There was a steady decrease in hospitalizations reporting PAD transfusions from 27.90 per 100 000 in 1995 to 1.48 per 100 000 hospitalizations in 2015 (P-trend <.001). In contrast, PACS increased from a rate of 1.16 per 100 000 in 1995 to peak of 20.51 per 100 000 hospitalizations in 2008 and then steadily declined (P-trend<.001). Higher odds of PACS and PADs were observed in older patients, elective procedures (vs urgent), and urban teaching/nonteaching hospitals (vs rural hospitals) (P < .001). PACS was more common in hospitalizations in patients with higher levels of severity of illness as compared to those with minor severity (adjusted prevalence ratio [adjPR], 2.39; 95% confidence interval [CI], 2.08-2.73; P<.001), while PADs were performed less often in patients with higher underlying severity of illness (All Patient Refined Diagnosis Related Groups, 4 vs 1, adjPR, 0.61; 95% CI, [0.39-0.95]; P = .028).

CONCLUSIONS

There was a significant decrease in PAD red blood cell transfusions, while PACS has increased and subsequently decreased; PACS plays an important role in surgical blood conservation. The subsequent decline in PACS likely reflects further optimization of transfusion practice through patient blood management programs and improvement of surgical interventions.

Risk factors for periprosthetic joint infection after total knee arthroplasty

INTRODUCTION

Periprosthetic joint infection (PJI) is the most serious and feared complication in total knee arthroplasty (TKA) and can have catastrophic consequences. The number of total knee arthroplasties is increasing, so infections could also be greater in the future. The aim of this study is to identify the most relevant risk factors associated with infection after a total knee arthroplasty.

METHODS

This is a case-control study of patients who underwent total knee arthroplasty at the University Hospital of Salamanca. We included 66 TKA PJI patients and 66 control TKA patients. Demographic and clinical variables were collected. A descriptive and inferential analysis was performed by logistic regression and attributable risk fraction assessed.

RESULTS

Prolonged operative time (> 90') and tourniquet time (> 60') were the most relevant risk factors described (OR 40.77, AFE 0.97, p > 0.001 and OR 37.14, AFE 0.97, p < 0.001, respectively). The use of non-antibiotic-laded cement (OR 3.62), obesity (BMI > 30, OR 8.86), diabetes (OR 2.33), high ASA grade (III-IV, OR 15.30), and blood transfusion requirement (OR 4.60) were also statistically significant risk factors for TKA PJI.

CONCLUSIONS

Our study provides evidence concerning that operative time, tourniquet time, cement type, diabetes, obesity, ASA grade, and blood transfusion requirement as independently associated risk factors for TKA PJI. Modifiable risk factors were specifically relevant, so we should be able to reduce the infection rate.