What Should Define Preoperative Anemia in Primary THA?

Factors associated with increased risk of postoperative blood transfusion in patients undergoing total hip arthroplasty at an Irish University Hospital

INTRODUCTION

Approximately 7000 total hip arthroplasty (THA) surgeries occur in Ireland each year. A number of preoperative factors have been identified that increase the risk of postoperative blood transfusion after THA, including anaemia. The ability to identify patients at risk may allow preoperative management strategies to reduce blood transfusions. Data from Irish orthopaedic patients is currently lacking.

AIM

To investigate if preoperative anaemia and other factors are associated with postoperative blood transfusions in patients who undergo THA.

METHODS

A retrospective cohort study of all patients who underwent THA in 2019 in SIVUH, Cork, using medical chart review.

RESULTS

In total, 350 charts met the inclusion criteria, with 291 charts reviewed. 8.9% of the patients who underwent THA had preoperative anaemia. Among these, 19.2% had a postoperative blood transfusion, compared to 1.5% of patients who were not anaemic preoperatively. The odds of receiving a blood transfusion was 15.5 times greater in the preoperative anaemia group compared to the non-anaemic group. Increasing age and higher ASA scores were associated with preoperative anaemia and postoperative blood transfusions. Length of stay was increased by 2.2 days (p < 0.00016) if blood transfusion was required.

CONCLUSION

Preoperative anaemia was common in an Irish orthopaedic population undergoing THA. Preoperative anaemia predisposes patients to the greatest increased risk of postoperative blood transfusions. The other factors associated with the need for postoperative transfusion were ASA grade 3 or more and age greater than 65 years. Patients who received postoperative blood transfusions had a significantly increased length of hospital stay.

Identification of Data-Driven Preoperative Hemoglobin Strata That Predict the Likelihood of Blood Transfusion and the Risk of Major Complications and Prosthetic Joint Infection After Total Hip Arthroplasty

INTRODUCTION

Preoperative anemia is an independent risk factor of complications after primary total hip arthroplasty (THA). Currently used hemoglobin thresholds are not developed for risk stratification of arthroplasty patients and do not provide surgery-specific information on postoperative complication risk. Thus, we aimed to calculate THA-specific preoperative hemoglobin strata that observe the likelihood of 90-day blood transfusion and determine whether these strata are associated with increased risk of 90-day complications and 2-year prosthetic joint infection (PJI).

METHODS

A retrospective cohort analysis identified 56,101 patients who underwent primary THA from 2013 to 2022. Using the lowest hemoglobin value for each patient one month before THA, stratum-specific likelihood ratio (SSLR) analysis calculated sex-based hemoglobin strata associated with the likelihood of 90-day postoperative blood transfusion. Propensity score matching was performed. Incidence rates and risk of 90-day major complications and 2-year PJI were observed for each identified preoperative hemoglobin stratum.

RESULTS

SSLR analysis identified five male (strata, likelihood ratio [<10.4 g/dL, 12.5; 10.5 to 11.4 g/dL, 8.0; 11.5 to 12.4 g/dL, 2.4; 12.5 to 13.4 g/dL, 1.3; 13.5 to 13.9 g/dL, 0.5]) and five female (<8.9 g/dL, 10.7; 9.0 to 10.9 g/dL, 4.0; 11.0 to 11.4 g/dL, 2.0; 12.0 to 12.9 g/dL, 1.0; 13.0 to 13.4 g/dL, 0.6) preoperative hemoglobin strata associated with varying likelihoods of 90-day blood transfusion after THA. After matching in both male and female cohorts, as the calculated preoperative hemoglobin strata decreased, the relative risk of overall 90-day major complications and 2-year PJI increased incrementally (all P < 0.05).

CONCLUSION

SSLR analysis established THA-specific sex-based preoperative hemoglobin strata that observe the likelihood of 90-day blood transfusion and predict the risk of 90-day medical complications and 2-year PJI. These strata are a first of their kind in THA research. While preoperatively optimizing patients, we recommend using these hemoglobin thresholds to help guide decisions on presurgery anemia optimization and to reduce the need for postoperative blood transfusion.

LEVEL OF EVIDENCE

Level III.

Optimised fast-track protocols in total knee arthroplasty determine shorter hospitalisation time and lower perioperative/postoperative complications

PURPOSE

This literature review aims to present evidence-based clinical recommendations for the eight most debated topics related to perioperative management in total knee arthroplasty: counselling, prehabilitation, transfusion risk, tranexamic acid, drainage, analgesia, urinary catheter and compression stockings.

METHODS

A multidisciplinary team conducted a systematic review on these topics. The study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines for the literature review and result presentation. The research encompassed articles from 1 January 2009 to 28 February 2023, retrieved through the MEDLINE database via PubMed, Embase database and Cochrane Library.

RESULTS

Forty-five articles were selected. Preoperative counselling has limited evidence for its impact on postoperative outcomes; yet, it can help alleviate surgery-related anxiety and manage postoperative symptoms. Prehabilitation can also prepare patients for surgery, reducing hospital stays and improving postsurgery functionality. Numerous studies suggest that preoperative Hb levels are independently linked to transfusion risk, with a recommended level of 13 g/dL. Combining intravenous and local tranexamic acid administration is strongly advised to reduce perioperative blood loss, while drainage after primary total knee arthroplasty offers no functional advantages. Employing a multimodal analgesia approach yields better results with reduced opioid usage. Indwelling urinary catheters provide no benefit and avoiding them can lower the risk of urinary tract infections. As for compression stockings, there is insufficient evidence in the literature to support their efficacy in preventing venous thromboembolism.

CONCLUSION

The best-track protocol has demonstrated its efficacy in reducing hospitalisation time and perioperative/postoperative complications. It is success relies on a collaborative, resource-adaptive approach led by a multidisciplinary team. Both patients and hospitals benefit from this approach, as it enhances care quality and lowers costs. Several studies have highlighted the significance of a patient-centred approach in achieving high-quality care. Creating a novel treatment protocol could be a prospective goal in the near future.

LEVEL OF EVIDENCE

Level III.

Do Patients with Borderline Anemia Need Treatment before Total Hip Arthroplasty? A Propensity Score-Matched Cohort Study

OBJECTIVE

Preoperative anemia has been identified as a modifiable risk factor for multiple adverse outcomes. In real clinical practice, considering treatment of anemia would increase costs and delay surgery. Patients undergoing total hip arthroplasty (THA) with mild anemia are usually neglected and still underdiagnosed or inadequately treated. This study investigated the effects of preoperative borderline anemia and anemia intervention before THA on perioperative outcomes.

METHODS

We screened 706 patients from those receiving THA at our hospital from January 2020 to January 2022, with 112 in the borderline anemia group and 594 in the non-anemia group. The cohort for this retrospective study was created by using propensity score matching (PSM) and subgroup analysis. The primary outcome was perioperative blood loss, while secondary outcomes were the rate of allogeneic blood transfusion and human serum albumin transfusion, perioperative laboratory indicators, postoperative length of stay, and complications. The independent sample t-test and the Mann-Whitney U-test were used to analyze continuous data, and the Pearson χ2 -test or the Fisher exact test was used to analyze categorical variables.

RESULTS

After PSM, there was no significant difference in perioperative blood loss between patients in the borderline anemia group and the non-anemia group. The primary outcomes of hidden (p = 0.004) and total (p = 0.005) blood loss were significantly lower in the intervention group than in the control group. No statistical differences were found in allogeneic blood transfusion, human serum albumin transfusion, postoperative length of stay, or complications (p > 0.05).

CONCLUSIONS

Anemia treatments for patients with borderline anemia before THA significantly reduced hidden blood loss and total blood loss in the perioperative period and decreased the drop of hemoglobin and hematocrit without increasing postoperative complications.

Identification of the haemoglobin level associated with a lower risk of complications after total hip and knee arthroplasty

BACKGROUND

Preoperative anaemia is associated with poor outcomes in surgical patients, but the preoperative haemoglobin cut-off that determines lower morbidity in total knee arthroplasty (TKA) and total hip arthroplasty (THA) is not well established.

METHODS

Planned secondary analysis of data collected during a multicentre cohort study of patients undergoing THA and TKA in 131 Spanish hospitals during a single 2-month recruitment period. Anaemia was defined as haemoglobin <12 g dl-1 for females and < 13 g dl-1 for males. The primary outcome was the number of patients with 30-day in-hospital postoperative complications according to European Perioperative Clinical Outcome definitions and specific surgical TKA and THA complications. Secondary outcomes included the number of patients with 30-day moderate-to-severe complications, red blood cell transfusion, mortality, and length of hospital stay. Binary logistic regression models were constructed to assess association between preoperative Hb concentrations and postoperative complications, and variables significantly associated with the outcome were included in the multivariate model. The study sample was divided into 11 groups based on preoperative Hb values in an effort to identify the threshold at which increased postoperative complications occurred.

RESULTS

A total of 6099 patients were included in the analysis (3818 THA and 2281 TKA), of whom 8.8% were anaemic. Patients with preoperative anaemia were more likely to suffer overall complications (111/539, 20.6% vs. 563/5560, 10.1%, p < .001) and moderate-to-severe complications (67/539, 12.4% vs. 284/5560, 5.1%, p < .001). Multivariable analysis showed preoperative haemoglobin ≥14 g dl-1 was associated with fewer postoperative complications.

CONCLUSION

Preoperative haemoglobin ≥14 g dl-1 is associated with a lower risk of postoperative complications in patients undergoing primary TKA and THA.

Predisposing factors for allogeneic blood transfusion in patients with ankylosing spondylitis undergoing primary unilateral total hip arthroplasty: a retrospective study

BACKGROUND

The transfusion rate is relatively high in patients with ankylosing spondylitis (AS) undergoing total hip arthroplasty (THA). However, relevant studies focusing on the predisposing factors for transfusion with a large sample size are lacking. This study aimed to investigate the incidence of and risk factors for allogeneic blood transfusion in patients with AS undergoing primary unilateral THA.

METHODS

This retrospective study included 331 patients with AS who underwent primary unilateral THA between 2011 and 2021. Relevant parameters were collected through a chart review. Multivariate logistic regression analysis was conducted to identify possible factors associated with perioperative allogeneic blood transfusion.

RESULTS

A total of 113 (34.1%) patients received perioperative allogeneic blood transfusions. Factors related to receiving an allogeneic blood transfusion included prolonged operative duration (odds ratio [OR] per 10 min = 1.139, P = 0.047), increased estimated intraoperative blood loss (OR per 100 mL = 1.348, P < 0.001), and increased postoperative drainage volume (OR per 100 mL = 1.235, P = 0.024). A higher body mass index (BMI) (OR = 0.914, P = 0.012), perioperative tranexamic acid (TXA) use (OR = 0.166, P < 0.001), and a higher preoperative hemoglobin level (OR per 1 g/dL = 0.744, P = 0.004) decreased the risk of transfusion.

CONCLUSIONS

In patients with AS undergoing THA, prolonged operative duration, increased estimated intraoperative blood loss, and increased postoperative drainage volume were found to be risk factors for transfusion, whereas a higher BMI, perioperative TXA use, and a higher preoperative hemoglobin level were protective factors. These results may aid in developing a better perioperative management strategy, ultimately reducing the need for transfusion.

Predict Postoperative Anemia of Patients: Nomogram Construction and Validation

Introduction

The loss of blood is a significant problem in Total Knee Arthroplasty (TKA). Anemia often occurs after such surgeries, leading to serious consequences, such as higher postoperative infection rates and longer hospital stays. Tools for predicting possible anemia can provide additional guidance in realizing better blood management of patients.

Methods

2,165 patients who underwent TKA from 2015 to 2019 in the same medical center were divided into training and validation cohorts. Both univariate and multivariate logistic regression analyses were performed to identify independent preoperative risk factors for anemia. Based on these predictors, a nomogram was established using the area under the curve (AUC), calibration curve (AUC), and the area under the curve (AUC). The model was then applied to the validation cohort, and decision curve analyses (DCA) were also plotted.

Results

Through analysis of both univariate and multivariate logistic regression, five independent predictors were found in the training cohort: female, relatively low BMI, low levels of preoperative hemoglobin, abnormally high levels of ESR, and simultaneously two sides of TKA in the same surgery. The AUCs of the nomogram were 74.6% (95% CI, 71.35%–77.89%) and 68.8% (95% CI, 63.37%–74.14%) of training and the validation cohorts separately. Furthermore, the calibration curves of both cohorts illustrated the consistency of the nomogram with the actual condition of anemia of patients after TKA. The DCA curve was higher for both treat-none and treat-all, further indicating the relatively high practicality of the model.

Conclusion

Female, lower BMI, lower levels of preoperative Hb, simultaneous bilateral TKA, and high levels of preoperative ESR were figured out as five independent risk factors for postoperative anemia (&lt;9.0 g/dL) in patients undergoing TKA. Based on the findings, a practical nomogram was constructed to predict risk of postoperative anemia. The evidence level should be level 4 according to guideline.

Transfusion Rates in Total Hip Arthroplasty Are lower in Patients with Direct Anterior Approach

BACKGROUND

Blood conservation and reduction in the need for allogeneic blood transfusion (ABT) has been a subject of importance in total hip arthroplasty. There are a number of well-recognized parameters that influence blood loss during total hip arthroplasty (THA). The role of surgical approach on blood loss and the rate of ABT during THA is not well studied. The hypothesis of this study was that blood loss and the need for ABT is lower with direct anterior (DA) approach.

METHODS

In a case-control retrospective cohort study, we analyzed 1,524 primary THAs performed at a single institution by seven fellowship-trained surgeons between January 2015 to March 2017. All patients received THA using either the modified direct lateral (DL) or direct anterior (DA) approach using a standard operating table. The overall ABT rate was 10.2% (155/1,524) in the cohort. Demographic, surgical, and postoperative data were extracted and analyzed. Logistic regression was used to identify independent risk factors for transfusion.

RESULTS

Higher preoperative hemoglobin (p<0.001), use of DA approach (p<0.016) and administration of tranexamic acid TXA, (p=0.024) were identified as independent factors which reduced the odds of ABT. Operative time (p<0.001) was associated with an increased odd of ABT, while age, BMI and type of anesthesia were not statistically significant.

CONCLUSION

Based on the findings of this study, direct anterior approach for THA appears to be protective against blood loss and reduced ABT rate, when controlling for confounding variables.

Efficacy and cost-effectiveness of universal pre-operative iron studies in total hip and knee arthroplasty

Background

The prevalence of anaemia in patients planned for total hip and knee arthroplasty is about 20%. Optimising pre-operative haemoglobin levels by iron supplementation has been shown to decrease transfusion rates, complications and associated morbidity. The need for universal screening with iron studies of all elective arthroplasty patients is not clearly defined at present.

Methods

Retrospective review of 2 sequential cohorts of patients undergoing primary hip or knee arthroplasty by a single surgeon at a single centre between January 2013 and December 2017. The first group of patients underwent pre-operative iron studies only if found to be anaemic, with a haemoglobin below 12g/dl. From January 2015, all patients irrespective of the presence of anaemia were screened with a complete iron profile before surgery. Patients with a confirmed iron deficiency were administered with intravenous iron prior to surgery. The 2 cohorts were compared with regard to blood transfusion rate post-operatively and cost efficiency for universal screening with iron studies.

Results

There was a net decrease in the allogenic blood transfusion rate from 4.76 to 2.92% when universal iron studies were introduced but the difference was not statistically significant. Obtaining universal pre-operative iron studies is cost neutral with the price of allogenic blood transfusion in a similar cohort. We also diagnosed 5 patients with occult malignancies.

Conclusions

Universal screening with pre-operative iron studies and iron infusion in elective arthroplasty patients may reduce allogenic blood requirements and is cost neutral. An additional benefit is the potential to diagnose asymptomatic malignancies. Further studies are required to show the true benefit of universal pre-operative iron screening.

Tranexamic Acid Reduces the Rate of Periprosthetic Joint Infection After Aseptic Revision Arthroplasty

BACKGROUND

Revision total joint arthroplasty (TJA) has a higher rate of periprosthetic joint infection (PJI) compared with primary TJA, possibly as the result of increased allogeneic blood transfusion. Tranexamic acid (TXA) is gaining popularity in revision TJA to minimize blood loss and the need for transfusion; however, its effect on PJI reduction has yet to be investigated. The hypothesis of this study was that the administration of TXA during revision arthroplasty is protective against subsequent PJI.

METHODS

A prospectively maintained institutional database was used to identify patients who underwent revision TJA for aseptic failure from 2009 to 2018 and had a minimum follow-up of 90 days. Patients who developed PJI following revision arthroplasty were identified. All patients with PJI met Musculoskeletal Infection Society (MSIS) criteria. A multivariate analysis was performed to identify variables independently associated with PJI after aseptic revision TJA.

RESULTS

Overall, 1,731 patients who underwent aseptic revision were identified; of these patients, 83 (4.8%) developed PJI. Patients who received TXA had significantly lower rates (p = 0.029) of PJI postoperatively at 3.30% compared with those who did not receive TXA at 5.73%. After controlling for relevant confounding variables, TXA remained a significant independent factor that protected against PJI (odds ratio [OR], 0.47 [95% confidence interval (CI), 0.23 to 0.90]; p = 0.030). Female sex was also identified as a significant independent factor that protected against PJI (OR, 0.52 [95% CI, 0.30 to 0.88]; p = 0.016). However, preoperative anemia was independently associated with an increased risk of subsequent PJI (OR, 2.37 [95% CI, 1.34 to 4.16]; p = 0.003).

CONCLUSIONS

Based on this study conducted at a single institution, the use of TXA during aseptic revision arthroplasty was independently associated with a reduced risk of subsequent acute PJI after adjusting for multiple patient characteristics and surgical factors.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Treating Preoperative Anemia to Improve Patient Outcomes After Orthopaedic Surgery

For patients undergoing orthopaedic surgery, preoperative risk modification and control of comorbidities can maximize safety and improve outcomes. Anemia is common among orthopaedic patients, and its prevalence increases with patient age. Although surgeons are well versed in intraoperative blood conservation, preoperative anemia treatment is often deferred to primary care physicians, who may not understand the importance of a thorough assessment and treatment. Orthopaedic surgeons should understand the causes and treatments of anemia to advocate that patients receive appropriate preoperative care. Mean corpuscular volume and reticulocyte count can help determine the cause of anemia and assess the bone marrow's ability to produce red blood cells. These values can be used to aid in diagnosis and treatment plans. Iron deficiency anemia, the most common type, is a microcytic anemia easily treated with iron supplementation. In cases of trauma, anemia can be related to acute blood loss and underlying conditions. Fracture patterns and preexisting comorbidities should be assessed. The role of intravenous iron supplementation in this setting has not been clearly shown. Patients needing urgent procedures that might involve substantial blood loss should receive transfusions if they have hemoglobin levels <8 g/dL or symptomatic anemia.

Surgical prescription of epoetin alfa in contemporary total hip arthroplasty: a prospective comparative study

Purpose

Pre-operative anaemia treatment has been associated with reduced morbidity in joint arthroplasty. This study examined the impact of a surgical prescription of epoetin (EPO) in contemporary total hip arthroplasty (THA).

Methods

We conducted a comparative study in a series of 1402 primary THAs performed in patients all having a pre-operative haemoglobin (Hb) level documented four to eight  weeks before THA surgery. In group A (647 hips), one subcutaneous injection of 40,000 IU EPO once a week for four weeks was prescribed at the discretion of anaesthetist during the pre-operative visit in patients with pre-operative Hb between 10 and 13 g/dl. In group S comprising the remaining 755 hips, an amended EPO therapy including two  injections of 20,000 to 40,000 IU was prescribed by the surgeon in patients with Hb less than 12 g/dl deemed at high risks to be transfused following THA. Primary study endpoint was the bleeding index (BI).

Results

EPO therapy was delivered in 43 patients (6.7%) in group A and in 26 patients (3.4%) in group S (p = 0.006). The mean total dose of EPO administrated was 115,349 IU in group A versus 75,200 IU in group S (p < 0.001). The mean BI were 2.7 ± 1.0 in group A and 2.8 ± 1.0 g/dl in group S (p = 0.375). No patient was blood-transfused up to post-operative day seven in group S versus five patients in group A (p = 0.021).

Conclusions

The amended protocol does not lead to increased peri-operative bleeding. Advances in intra-operative methods to reduce the bleeding allow changing indications of EPO in patients undergoing THA with a low level of Hb.

Preoperative Hemoglobin Predicts Postoperative Transfusion Despite Antifibrinolytics During Total Knee Arthroplasty

Current antifibrinolytics have decreased perioperative blood loss; however, some patients still require transfusions postoperatively. The authors sought to determine the risk factors associated with postoperative transfusions and to establish a "cutoff" preoperative hemoglobin threshold value specific to total knee arthroplasty (TKA) that would identify patients who would benefit from blood conservation programs. The institutional database was queried for primary TKA patients. Preoperative patient demographics and hemoglobin values were determined in addition to intraoperative and postoperative variables, including transfusion rate. Patients were stratified by whether they received a transfusion perioperatively, and risk factors were identified through univariable and multivariable analysis. Optimal cutoff values for hemoglobin were identified by concurrently maximizing the sensitivity and specificity for predicting the risk of a postoperative transfusion event. Men and women were analyzed independently. A total of 532 primary TKAs were included for analysis, and 33 patients (6.2%) required a transfusion. Advanced age (P=.019), low pre-operative hemoglobin value (P<.001), and failure to receive tranexamic acid (P<.001) were associated with increased risk of postoperative transfusion. A preoperative hemoglobin value of 12.5 g/dL was identified as the optimal cutoff for predicting postoperative transfusion requirements across all patients, with a sensitivity of 84.8% and a specificity of 76.4%. Preoperative anemia remains predictive of transfusion following TKA despite current antifibrinolytics. Patients with a preoperative hemoglobin value of less than 12.5 g/dL who are not receiving intravenous tranexamic acid are particularly at risk and should be considered for blood conservation programs. [Orthopedics. 2019; 42(2):103-109.].

When Should Complete Blood Count Tests Be Performed in Primary Total Hip Arthroplasty Patients?

BACKGROUND

Routine laboratory studies are often obtained following total hip arthroplasty (THA). Moreover, laboratory studies are often continued daily until the patient is discharged regardless of medical management. The purpose of this study was to investigate the use of routine complete blood count (CBC) tests following THA. Secondarily, the purpose was to identify patient factors associated with abnormal postoperative lab values.

METHODS

This retrospective review identified 352 patients who underwent primary THA at a single institution from 2012 to 2014. Preoperative and postoperative CBC values were collected along with demographic data, use of tranexamic acid (TXA), and transfusion rates. Logistic regression models were used to identify factors associated with an abnormal postoperative lab and risk of transfusion.

RESULTS

Of the 352 patients, 54 patients were transfused (15.3%). Patients who underwent transfusion had a significantly lower preoperative hemoglobin (Hb; 12.0 g/dL) compared to patients who did not undergo transfusion (13.5 g/dL; P < .001). Patients who did not receive TXA were 3.7 times more likely to receive a transfusion. No patients received medical intervention based on the outcome of postoperative platelet or white blood counts. A Hb value below 11.94 g/dL for patients who are anemic preoperative or did not receive TXA predicted transfusion after postoperative day 1.

CONCLUSION

Under value-based care models, cost containment while maintaining high-quality patient care is critical. Routine postoperative CBC tests in patients with a normal preoperative Hb who receive TXA do not contribute to actionable information. Patients who are anemic before THA or do not receive TXA should at minimum obtain a CBC on postoperative day 1.