Variation in Use of Blood Transfusion in Primary Total Hip and Knee Arthroplasties

Development and Validation of a Machine Learning Algorithm to Predict the Risk of Blood Transfusion after Total Hip Replacement in Patients with Femoral Neck Fractures: A Multicenter Retrospective Cohort Study

OBJECTIVE

Total hip arthroplasty (THA) remains the primary treatment option for femoral neck fractures in elderly patients. This study aims to explore the risk factors associated with allogeneic blood transfusion after surgery and to develop a dynamic prediction model to predict post-operative blood transfusion requirements. This will provide more accurate guidance for perioperative humoral management and rational allocation of medical resources.

METHODS

We retrospectively analyzed data from 829 patients who underwent total hip arthroplasty for femoral neck fractures at three third-class hospitals between January 2017 and August 2023. Patient data from one hospital were used for model development, whereas data from the other two hospitals were used for external validation. Logistic regression analysis was used to screen the characteristic subsets related to blood transfusion. Various machine learning algorithms, including logistic regression, SVA (support vector machine), K-NN (k-nearest neighbors), MLP (multilayer perceptron), naive Bayes, decision tree, random forest, and gradient boosting, were used to process the data and construct prediction models. A 10-fold cross-validation algorithm facilitated the comparison of the predictive performance of the models, resulting in the selection of the best-performing model for the development of an open-source computing program.

RESULTS

BMI (body mass index), surgical duration, IBL (intraoperative blood loss), anticoagulant history, utilization rate of tranexamic acid, Pre-Hb, and Pre-ALB were included in the model as well as independent risk factors. The average area under curve (AUC) values for each model were as follows: logistic regression (0.98); SVA (0.91); k-NN (0.87) MLP, (0.96); naive Bayes (0.97); decision tree (0.87); random forest (0.96); and gradient boosting (0.97). A web calculator based on the best model is available at: (https://nomo99.shinyapps.io/dynnomapp/).

CONCLUSION

Utilizing a computer algorithm, a prediction model with a high discrimination accuracy (AUC > 0.5) was developed. The logistic regression model demonstrated superior differentiation and reliability, thereby successfully passing external validation. The model's strong generalizability and applicability have significant implications for clinicians, aiding in the identification of patients at high risk for postoperative blood transfusion.

Hospital variation in quality indicators for patient blood management in total knee and hip arthroplasty: a retrospective cohort study

BACKGROUND

Anaemia, blood loss, and blood transfusion are critical aspects of patient care in major orthopaedic surgery. We assessed hospital adherence to guideline-recommended Patient Blood Management (PBM) care, analysed variations between hospitals, and validated two composite indicators of hospital PBM performance in patients undergoing total knee arthroplasty (TKA) or total hip arthroplasty (THA).

METHODS

This retrospective cohort study included all primary TKA and THA procedures performed during 2021 across 39 hospitals in Spain. We assessed hospital adherence to key guideline-recommended PBM interventions using nine individual quality indicators and two types of composite quality indicators (cQIs): opportunity-based (cQI1) and all-or-none (cQI2). We validated these cQIs by analysing their associations with the adjusted total transfusion index using linear regression.

RESULTS

We included 8561 patient episodes from 33 hospitals in the analysis. Delivery of PBM care was similar for TKA and THA. Patients received 62% of the analysed PBM interventions and only 12% of patients underwent the full PBM pathway. Higher hospital cQIs scores were associated with a lower adjusted total transfusion index, both in TKA and THA. The greatest association was found for cQI1 in THA patients (β=-1.18 [95% confidence interval -2.00 to -0.36]; P=0.007).

CONCLUSIONS

Hospital adherence to guideline-recommended patient blood management care in total hip and knee arthroplasty was suboptimal and varied across centres. Using data that are widely available in hospitals, quality indicators and composite scores could become valuable tools for patient blood management monitoring and comparisons between healthcare organisations.

Evaluation of efficacy and safety of perioperative tranexamic acid during Primary Total Knee Arthroplasty: A randomized, Clinical trial

Background

Primary total knee arthroplasty (TKA) is the gold standard treatment for degenerative joint disease, but it carries a significant risk of blood loss that may require transfusion. Various techniques are implemented to reduce the possibility of the need for allogeneic blood transfusion (ABT). To this end, this study aims to assess the effectiveness of tranexamic acid (TXA) in decreasing blood loss following primary TKA.

Materials and methods

This study is a randomized controlled study of 100 cases of primary total knee arthroplasty conducted in Damascus from July 2021 to September 2022, followed up with every patient for six months. The patients were randomized into two groups. We compared intraoperative, postoperative, total, and hidden blood loss and perioperative complications.

Results

We observed a statistically significant difference between the two groups in total calculated, hidden, and postoperative blood loss. However, this difference does not seem clinically significant, as we didn't find a significant difference in allogeneic blood transfusion between the groups. Regarding complications, the TXA group had five cases of superficial wound infection and six cases of deep venous thrombosis. In contrast, the control group had eight cases of superficial wound infection and five cases of deep venous thrombosis.

Conclusion

Our study suggests that the role of TXA in primary unilateral total knee arthroplasty in the hands of an experienced surgeon might be overrated. The reduced blood loss did not seem to have clinical importance and didn't affect the transfusion rates.

Postoperative Prevalence and Risk Factors for Serum Hypokalemia in Patients with Primary Total Joint Arthroplasty

OBJECTIVE

Regular monitoring of serum potassium after a total joint arthroplasty (TJA) is a form of routine examination that can help detect abnormal serum potassium levels and reduce the incidences of adverse events that may occur on account of postoperative hypokalemia. Previous studies rarely discussed hypokalemia after joint replacement. In the present study, our primary goal was to investigate the incidence and possible risk factors of hypokalemia after a total hip and knee replacement procedure was performed.

METHODS

This study included patients who underwent a unilateral total knee or hip arthroplasty in our department between April 2017 and March 2018. Serum potassium levels pre and post operation were collected and retrospectively analyzed. The differences in age, gender, body mass index (BMI), history of diseases, red blood cell (RBC), hemoglobin, hematocrit, glomerular filtration rate, ejection fraction, blood glucose, urine creatinine, urea nitrogen, intraoperative blood loss, operation time, drainage, preoperative potassium, surgery type, were compared between those patients diagnosed with hypokalemia and their non-hypokalemia at different times post surgery. Thereafter, the risk factors of postoperative hypokalemia patients were analyzed using statistical procedure multiple logistic regression model.

RESULTS

The risk of hypokalemia after TJA was 53.1%, while, that on the first, third, and fifth day after operation was 12.5%, 40.7%, and 9.6% respectively. The serum potassium level on the first, third, and fifth postoperative days was 3.84 ± 0.32, 3.59 ± 0.34, and 3.80 ± 0.32 mmol/l, respectively. However, the level on the third day appeared to be the lowest (p = 0.015) of them all. The independent risk factors for hypokalemia after a total hip and knee replacement were the level of preoperative serum potassium concentration (p = 0.011), preoperative red blood cells counts (p = 0.027), and history of diabetes (p = 0.007).

CONCLUSION

Regular monitoring of serum potassium concentration should be performed post TJA. We need to pay more attention to the patient's preoperative potassium levels along with their red blood cell counts especially in patients diagnosed with type 2 diabetes mellitus.

Postoperative Hemodynamics of Total Knee Arthroplasty Unaffected by Cementless Approach under Contemporary Patient Blood Management Protocol: A Propensity Score-Matched Study

(1) Background: A cementless total knee arthroplasty (TKA) is a recent and an increasingly popular innovation that enhances porous fixation surfaces. However, the lack of cemented sealing of an exposed resected bone has raised concerns about the potential for greater blood loss. The goals of this study were to determine if a cementless approach impacts post-TKA hemodynamics and to identify risk factors for blood loss in instances of cementless (vs. cemented) TKAs under a contemporary patient blood management (PBM) protocol. (2) Methods: We recruited 153 consecutive patients undergoing unilateral TKAs between 2019 and 2023. All enrollees received cementless or cemented prostheses of the same design (cementless, 87; cemented, 66). After propensity score matching for demographics, there were 46 patients in each group. We then compared blood loss metrics (total [TBL] and estimated [EBL]), drainage volumes, hemoglobin (Hb) levels, and transfusion rates by group. (3) Results: Post-TKA hemodynamics (i.e., TBL, EBL, drainage, Hb level, and transfusion rate) of cementless (n = 46) and cemented (n = 46) TKA groups did not differ significantly. In addition, the proportions of patients with Hb drops > 3.0 g/dL were similar for the two groups. A logistic regression analysis revealed that only preoperative Hb and EBL during the early postoperative period were predictive of a substantial fall in Hb levels. The fixation method was not associated with Hb decline > 3.0 g/dL by postoperative Day 3. (4) Conclusion: The cementless TKA has no impact on customary post-TKA hemodynamics and is not associated with greater TKA-related blood loss when implementing a contemporary PBM protocol.

Predicting Factors for Blood Transfusion in Primary Total Knee Arthroplasty Using a Machine Learning Method

INTRODUCTION

Acute blood loss anemia requiring allogeneic blood transfusion is still a postoperative complication of total knee arthroplasty (TKA). This study aimed to use machine learning models for the prediction of blood transfusion after primary TKA and to identify contributing factors.

METHODS

A total of 2,093 patients who underwent primary TKA at our institution were evaluated using data extracted from the hospital quality improvement database to identify patient demographics and surgical variables that may be associated with blood transfusion. A multilayer perceptron neural network (MPNN) machine learning algorithm was used to predict risk factors for blood transfusion and factors associated with increased length of stay. Statistical analyses including bivariate correlate analysis, Chi-Square test, and Student t-test were performed for demographic analysis and to determine the correlation between blood transfusion and other variables.

RESULTS

The results demonstrated important factors associated with transfusion rates, including preoperative hemoglobin level, preoperative creatinine level, length of surgery, simultaneous bilateral surgeries, tranexamic acid usage, American Society of Anesthesiologists Physical Status score, preoperative albumin level, ethanol usage, preoperative anticoagulation medications, age, and TKA type (conventional versus robotic-assisted). Patients who underwent a blood transfusion had a markedly greater length of stay than those who did not. The MPNN machine learning model achieved excellent performance across discrimination (AUC = 0.894).

DISCUSSION

The MPNN machine learning model showed its power as a statistical analysis tool to predict the ranking of factors for blood transfusion. Traditional statistics are unable to differentiate importance or predict in the same manner as a machine learning model.

CONCLUSION

This study demonstrated that MPNN for the prediction of patient-specific blood transfusion rates after TKA represented a novel application of machine learning with the potential to improve preoperative planning for treatment outcomes.

Does the accelerometer-based navigation system reduce blood loss and transfusion in one-stage sequential bilateral total knee arthroplasty? A randomized double-blind controlled trial

BACKGROUND

Total knee arthroplasty (TKA) is associated with significant blood loss and postoperative transfusion. The accelerometer-based navigation (ABN) system guides the bone cutting plane without breaching the intramedullary canal, which may reduce bleeding. This study aimed to investigate blood loss and transfusion compared between the ABN system and the conventional procedure in patients undergoing one-stage sequential bilateral TKA (SBTKA).

METHODS

A total of 66 patients scheduled for SBTKA were randomly allocated to either the ABN or conventional group. Postoperative hematocrit (Hct) level, drainage blood loss, transfusion rate, and amount of packed red cell transfusion were collected. Total red blood cell (RBC) loss was then calculated for the primary outcome.

RESULTS

The mean calculated total RBC loss in the ABN and conventional group was 669.7 and 630.0 mL, respectively (p = 0.572). There was no significant difference between groups for other evaluated outcome parameters, including postoperative Hct level, drainage blood loss, or packed red cell transfusion volume. All patients in the conventional group required postoperative blood transfusion while 96.8% of patients in the ABN group were transfused.

CONCLUSIONS

The total RBC loss and volume of packed red cells transfusion were not significant difference between interventions, which suggest no benefit of the ABN system in reducing blood loss and transfusion in patients undergoing SBTKA.

TRIAL REGISTRATION

The protocol of this study was registered in the Thai Clinical Trials Registry database no. TCTR20201126002 on 26/11/2020.

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.

Artificial neural networks for the prediction of transfusion rates in primary total hip arthroplasty

BACKGROUND

Despite advancements in total hip arthroplasty (THA) and the increased utilization of tranexamic acid, acute blood loss anemia necessitating allogeneic blood transfusion persists as a post-operative complication. The prevalence of allogeneic blood transfusion in primary THA has been reported to be as high as 9%. Therefore, this study aimed to develop and validate novel machine learning models for the prediction of transfusion rates following primary total hip arthroplasty.

METHODS

A total of 7265 consecutive patients who underwent primary total hip arthroplasty were evaluated using a single tertiary referral institution database. Patient charts were manually reviewed to identify patient demographics and surgical variables that may be associated with transfusion rates. Four state-of-the-art machine learning algorithms were developed to predict transfusion rates following primary THA, and these models were assessed by discrimination, calibration, and decision curve analysis.

RESULTS

The factors most significantly associated with transfusion rates include tranexamic acid usage, bleeding disorders, and pre-operative hematocrit (< 33%). The four machine learning models all achieved excellent performance across discrimination (AUC > 0.78), calibration, and decision curve analysis.

CONCLUSION

This study developed machine learning models for the prediction of patient-specific transfusion rates following primary total hip arthroplasty. The results represent a novel application of machine learning, and has the potential to improve outcomes and pre-operative planning.

LEVEL OF EVIDENCE

III, case-control retrospective analysis.

Rotational Thromboelastometry Predicts Transfusion Requirements in Total Joint Arthroplasties

The frequency of red blood cell (RBC) transfusions is high in total joint arthroplasties, and the hemorrhagic risk is associated with both surgery- and patient-related factors. This study aims to assess the ability of rotational thromboelastometry (ROTEM) to identify patients at high risk for transfusion and excessive bleeding. A prospective observational study was conducted including 206 patients who underwent total knee or hip arthroplasties. Assessment of the coagulation status was performed preoperatively and immediately postoperatively using ROTEM analysis and conventional coagulation tests. The number of RBC transfusions and the postoperative hemoglobin drop were recorded. ROTEM findings were compared between transfused and nontransfused patients, and also between patients with and without excessive bleeding. Higher values of postoperative FIBTEM maximum clot firmness (MCF) were associated with lower risks of transfusion (odds ration [OR]: 0.66, 95% confidence interval [CI]: 0.57-0.78, p<0.001) and excessive bleeding (OR: 0.58, 95% CI: 0.36-0.94, p=0.028). A postoperative FIBTEM MCF value ≤10mm had 80.1% (95% CI: 73.1-85.9%) sensitivity with 75.5% (95% CI: 60.4-87.1%) specificity to predict transfusion requirements, and 70.5% (95% CI: 63.6-76.8%) sensitivity with 88.8% (95% CI: 51.7-99.7%) specificity to predict excessive bleeding. The estimated average probability of transfusion in patients with FIBTEM MCF values of 0 to 4mm is 86.3%. ROTEM assay demonstrated high predictive ability for transfusion and excessive bleeding. Identification of patients at risk for transfusion could allow blood banks to ensure adequate blood supply, while also more intense blood-salvaging strategies could be implemented in these patients.

The impact of surgical trainee involvement in total knee arthroplasty: a systematic review of surgical efficacy, patient safety, and outcomes

PURPOSE

Trainee involvement in patient care has raised concerns about the potential risk of adverse outcomes and harming patients. We sought to analyze the impact and potential consequence of surgical trainee involvement in total knee arthroplasty (TKA) procedures in terms of surgical efficacy, patient safety, and functional outcomes.

METHODS

We systematically reviewed Medline/PubMed, EMBASE, the Cochrane library, and Scopus databases in April 2021. Eligible studies reported on the impact of trainee participation in TKA procedures performed with and without such involvement.

RESULTS

Twenty-three publications met our eligibility criteria and were included in our study. These studies reported on 132,624 surgeries completed on 132,416 patients. Specifically, 23,988 and 108,636 TKAs were performed with and without trainee involvement, respectively. The mean operative times for procedures with (n = 19,573) and without (n = 94,581) trainee involvement were 99.77 and 85.05 min, respectively. Both studies that reported data on cost of TKAs indicated a significant increase (p < 0.001) associated with procedures completed by teaching hospitals compared to private practices. Mean overall complication rates were 7.20% and 7.36% for TKAs performed with (n = 9,386) and without (n = 31,406) trainees. Lastly, the mean Knee Society Scale (KSS) knee scores for TKAs with (n = 478) and without (n = 806) trainee involvement were similar; 82.81 and 82.71, respectively.

CONCLUSION

Our systematic review concurred with previous studies that reported trainee involvement during TKAs increases the mean operative time. However, the overall complication rates and functional outcomes were similar. Larger studies with a better methodology and higher level of evidence are still needed for a resolute conclusion.

A novel predictive model of hospital stay for Total Knee Arthroplasty patients

Objective

This study aimed to explore the main risk factors affecting Total Knee Arthroplasty (TKA) patients and develop a predictive nomogram of hospital stay.

Methods

In total, 2,622 patients undergoing TKA in Singapore were included in this retrospective cohort study. Hospital extension was defined based on the 75% quartile (Q3) of hospital stay. We randomly divided all patients into two groups using a 7:3 ratio of training and validation groups. We performed univariate analyses of the training group, in which variables with P-values < 0.05 were included and then subjected to multivariate analysis. The multivariable logistic regression analysis was applied to build a predicting nomogram, using variable P-values < 0.01. To evaluate the prediction ability of the model, we calculated the C-index. The ROC, Calibration, and DCA curves were drawn to assess the model. Finally, we verified the accuracy of the model using the validation group and by also using the C-index. The ROC curve, Calibration curve, and DCA curve were then applied to evaluate the model in the validation group.

Results

The final study included 2,266 patients. The 75% quartile (Q3) of hospital stay was six days. In total, 457 (20.17%) patients had hospital extensions. There were 1,588 patients in the training group and 678 patients in the validation group. Age, Hb, D.M., Operation Duration, Procedure Description, Day of Operation, Repeat Operation, and Blood Transfusion were used to build the prediction model. The C-index was 0.680 (95% CI: 0.734-0.626) in the training group and 0.710 (95% CI: 0.742-0.678) for the validation set. The calibration curve and DCA indicated that the hospital stay extension model showed good performance in the training and validation groups.

Conclusion

To identify patients' risk factors early, medical teams need to plan a patient's rehabilitation path as a whole. Its advantages lie in better resource allocation, maximizing medical resources, improving the functional recovery of patients, and reducing the overall cost of hospital stay and surgery, and will help clinicians in the future.

Intraoperative allogeneic transfusion is associated with postoperative delirium in older patients after total knee and hip arthroplasty

Objective

To determine whether intraoperative transfusion of allogeneic or autologous blood is associated with an increased incidence of postoperative delirium (POD) after total knee arthroplasty (TKA) and total hip arthroplasty (THA).

Methods

The medical records of 1,143 older (≥65 years old) patients who received an intraoperative blood transfusion while undergoing total knee or hip arthroplasty at the First Medical Center of Chinese PLA General Hospital from 2014 to 2019 were reviewed; of these patients, 742 (64.92%) received allogeneic blood, while 401 (35.08%) received autologous blood. Patients who received autologous transfusion were paired with those received allogeneic transfusion using 1:1 propensity score matching method. The primary outcome was POD. The secondary outcomes were postoperative complications, including heart failure, deep vein thrombosis, myocardial infarction, stroke, and lung infection. Multivariable nominal logistic regression was used to identify any independent associations between intraoperative blood transfusions and POD, and secondary postoperative complications, respectively.

Results

Postoperative delirium occurred in 6.6% (49/742) of patients who had received an allogeneic blood transfusion and in 2.0% (8/401) of patients who had received an autologous blood transfusion. It is noteworthy that the multivariable logistic regression demonstrated a significant association between intraoperative allogeneic blood transfusion and POD (odds ratio [OR]: 4.11; 95% confidence interval [CI]: 1.95-9.77; p < 0.001). After PSM, Allogeneic transfusion was also the strongest predictor for POD (OR: 4.43; 95% CI: 2.09-10.58; p < 0.001).

Conclusions

In the patients who had received THA or TKA, intraoperative allogeneic blood transfusions were associated with an increased risk of POD.

Immediate haemoglobin testing in association with a dedicated anaemia clinic: Effectiveness for primary total knee replacement patients

INTRODUCTION

Preoperative anaemia is associated with higher transfusion rates, increased hospital stays and poorer outcomes. Addressing preoperative anaemia is a crucial pillar of Patient Blood Management. Conventionally, patients are listed for surgery and then screened for anaemia in the pre-assessment clinic, followed by referral to their general practitioner. This process involves substantial delays, and poorly treated anaemia often results in perioperative transfusions. We assessed our pathway of immediate haemoglobin testing at the time of listing in conjunction with a dedicated preoperative anaemia clinic for detecting and treating anaemia in primary total knee replacement patients.

MATERIALS AND METHODS

We compared transfusion rates between anaemic patients undergoing a primary total knee replacement who were treated in this pathway with those who were not. We reviewed the preoperative haemoglobin levels, transfusion rates and treatment for all primary total knee arthroplasty patients over three years amounting to 2296.

RESULTS

Transfusion rates were significantly lower in the group treated in this pathway compared to those who were not. The treated group also had significantly higher preoperative haemoglobin levels.Discussion and conclusion: Immediate haemoglobin testing in association with a dedicated preoperative anaemia clinic is effective at detecting and treating anaemia in primary total knee replacement patients and reduces transfusion requirements.

Reducing transfusion in hip arthroplasty: tranexemic acid diminishes influence of anesthesia administered

BACKGROUND

The risk of transfusion following total hip arthroplasty (THA) continues to be problematic. The best choice of anesthesia (spinal vs general) and impact of tranexamic acid (TXA) use in reducing transfusions following surgery remain unclear. Therefore, the purpose of this study was to compare rates of blood transfusion following THA via the anterior approach using three different anesthesia protocols with and without TXA.

MATERIALS AND METHODS

This retrospective review included 1399 patients (1659 hips), receiving spinal anesthesia (SA) without (248 patients) and with TXA (77 patients), general anesthesia (GA) without (151 patients) and with TXA (171) and general anesthesia with paravertebral block (GA-PVB) and TXA (748 patients). All procedures were performed by a single surgeon. Chi-Squared tests and logistic regression were performed to evaluate the rate and risks of transfusion between groups.

RESULTS

Without TXA, transfusion rate with GA (24.5%) was higher than SA (13.4%) (p = 0.004). With TXA, there was no difference in transfusion rates between GA (4.6%), SA (3.9%) or GA-PVB (4.0%). The multivariable regression revealed bilateral (Odds Ratio (OR): 6.473; p < 0.001), female (OR: 2.046; p = 0.004), age (OR: 1.028; p = 0.012) and pre-operative anemia (OR: 2.604; p < 0.001) as increasing the risk of transfusion while use of TXA (OR: 0.168; p < 0.001) significantly reduced transfusion risk.

CONCLUSION

The use of TXA during THA via the anterior approach removed the influence of anesthesia type regarding risk of transfusion. The use of TXA may reverse presumed disadvantages of GA alone, potentially facilitating rapid discharge following surgery.

Intravenous Ferric Carboxymaltose Improves Response to Postoperative Anemia Following Total Knee Arthroplasty: A Prospective Randomized Controlled Trial in Asian Cohort

Background: Ferric carboxymaltose (FCM) is an intravenous (IV) high-dose iron that is effective in the treatment of iron deficiency anemia. This study was performed to determine whether postoperative FCM infusion is effective at improving hemoglobin (Hb) responders, Hb and iron profiles, and the patient’s quality of life (QOL). Methods: A total of 110 patients with postoperative anemia, defined by a Hb < 10 g/dL within 3 days of unilateral primary TKA, between June 2018 and February 2020 were randomized into either the FCM or Control group. On postoperative day 3, the FCM group (55 patients) received IV FCM while the Control group (55 patients) did not. The Hb responders (Hb increase ≥ 2 g/dL compared to baseline), Hb level, iron profiles (ferritin, total iron-binding capacity (TIBC), transferrin saturation (TSAT)), and EQ-5D scores were compared at weeks 2, 4, and 8. Results: The FCM group demonstrated a significantly greater number of Hb responders (p < 0.001) and a higher Hb level (p = 0.008) at 2 weeks postoperative than did the Control group. The FCM group recovered its preoperative Hb level between 4 and 8 weeks. In contrast, the Control group did not recover its preoperative level until 8 weeks. The FCM infusion group also had higher serum ferritin, iron and TSAT, and lower TIBC levels than those of the Control group between 2 and 8 weeks (all p < 0.001). However, there was no significant difference in the postoperative transfusion rate (p = 0.741) or EQ-5D score between the two groups (all p > 0.05). Discussion: In postoperative anemia following TKA, IV FCM increases the Hb response and improves Hb and iron metabolism variables, however, it does not affect the transfusion rate or QOL.

Blood Management Following Total Joint Arthroplasty in an Aging Population: Can We Do Better?

BACKGROUND

To evaluate the transfusion rates for octogenarians and nonagenarians following total knee and hip arthroplasty (TKA, THA), we compared transfusion rates and associated risk factors among sexagenarians, septuagenarians, octogenarians, and nonagenarians.

METHODS

This retrospective cohort study included 13,603 sexagenarians, 9796 septuagenarians, 2706 octogenarians, and 158 nonagenarians that received a primary, unilateral THA or TKA between 2016 and 2020 at a high-volume institution. Using multivariable logistic regression analysis, the study analyzed risk factors for postoperative transfusions including use of tranexamic acid (TXA) and compared preoperative and postoperative hemoglobin (Hgb) levels and the drop in Hgb.

RESULTS

Nonagenarians had significantly higher transfusion rates (THA 25.5%, TKA 26.7%) than octogenarians (THA 9.9%, TKA 9.2%), septuagenarians (THA 3.3%, TKA 4.5%), and sexagenarians (THA 1.9%, TKA 2.9%) (P < .01). Significant risk factors for transfusion requirement following THA were American Society of Anesthesiologists level III (odds ratio [OR] 5.3, P < .01) and American Society of Anesthesiologists level IV (OR 8.0, P = .01), nonuse of TXA (intravenous: OR 0.3, P < .01; topical: OR 0.5, P < .01), lower preoperative Hgb levels (OR 0.4, P < .01), longer duration of surgery (OR 1.0, P < .01), and hepatopathy (OR 3.1, P < .01). Significant risk factors following TKA were nonuse of TXA (intravenous: OR 0.3, P < .01; topical: OR 0.5, P < .01; combined: OR 0.2, P < .01), lower preoperative Hgb levels (OR 0.4, P < .01), and longer surgery time (OR 1.0, P < .01).

CONCLUSION

The strongest independent risk factors for increased transfusion rates among octogenarians and nonagenarians were lack of TXA application and lower preoperative Hgb levels. Routine TXA application and preoperative patient optimization are recommended to reduce transfusion rates in patients aged 80+.

Current Guidelines and Practice Recommendations to Prevent Hospital-Acquired Conditions After Major Orthopaedic Surgeries

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In 2016, a total of 48,771 hospital-acquired conditions (HACs) were reported in U.S. hospitals. These incidents resulted in an excess cost of >$2 billion, which translates to roughly $40,000 per patient with an HAC.

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Current guidelines for the prevention of venous thromboembolism and surgical site infection consist primarily of antithrombotic prophylaxis and antiseptic technique, respectively.

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The prevention of catheter-associated urinary tract infection (CA-UTI) and in-hospital falls and trauma is done best via education. In the case of CA-UTI, this consists of training staff about the indications for catheters and their timely removal when they are no longer necessary, and in the case of in-hospital falls and trauma, advising the patient and family about the patient's fall risk and communicating the fall risk to the health-care team.

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Blood incompatibility is best prevented by implementation of a pretransfusion testing protocol. Pressure ulcers can be prevented via patient positioning, especially during surgery, and via postoperative skin checks.

Blood transfusion and venous thromboembolism trends and risk factors in primary and aseptic revision total hip and knee arthroplasties: A nationwide investigation of 736,061 cases

BACKGROUND

Over the last years, new transfusion guidelines and pharmaceuticals have been introduced in primary and revision total hip and knee arthroplasty (P-THA, P-TKA, R-THA, R-TKA). In the US, a substantial decrease in transfusions has been observed in recent years. Little data exists on the subject in Europe. In this context we aimed to analyze: (1) Is there also a significant decrease in blood transfusion for these procedures in Germany? (2) Which patient and hospital related factors are associated with the risk of blood transfusion? (3) Is there a trend in complications, especially venous thromboembolism and stroke events that can be linked to tranexamic acid use?

HYPOTHESIS

There is a significant trend in decreasing blood transfusions in hip and knee arthroplasty.

METHODS

Using nationwide healthcare insurance data for inpatient hospital treatment, 736,061 cases treated between January 2011 and December 2017 were included (318,997 P-THAs, 43,780 R-THAs, 338,641 P-TKAs, 34,643 R-TKAs). Multivariable logistic regression was used to model the odds of transfusion as a function of the year of surgery. Adjusted odds ratios (OR) and 95% confidence intervals (CI) were calculated.

RESULTS

In each cohort the odds of transfusion decreased over time (2017 vs. 2011 (reference): P-THA: OR 0.42 (95%CI: 0.39-0.45), P-TKA: OR 0.41 (95%CI: 0.37-0.46), R-THA: OR 0.52 (95%CI: 0.47-0.58), R-TKA: OR 0.53 (95%CI: 0.46-0.61). Patient-related risk factors for blood transfusion included older age, female gender, lower Body Mass Index, comorbidities such as renal failure, cardiac arrhythmia, congestive heart failure, valvular disease, coagulopathy, depression, and antithrombotic medication prior to surgery. Venous thromboembolism or stroke events did not increase over the study period.

DISCUSSION

The incidence of blood transfusions in primary and revision TKA and THA decreased over the study period. This may be due to new transfusion guidelines and the introduction of novel pharmaceuticals such as tranexamic acid. A further improved patient blood management and a focus on vulnerable patient groups might lead to a further future reduction of transfusions, especially in R-THA.

LEVEL OF EVIDENCE

III; comparative observational study.

An insight into the utilization of allogenic blood transfusion and factors affecting blood transfusion in total knee replacement surgery in a tertiary care hospital in Eastern India

BACKGROUND:

Significant blood loss and requirement of allogenic blood transfusion during or after total knee replacement (TKR) have been reported. Incidence of blood transfusion in TKR is highly variable and depends on several factors. We investigated the blood utilization in patients undergoing TKR in our hospital and depicted the important risk factors that determine the need of allogenic blood transfusion in primary unilateral TKR.

MATERIALS AND METHODS:

The study included 1241 consecutive patients undergoing primary unilateral total knee arthroplasty. All the surgeries were performed by a single surgical team of orthopedists following standard procedure. Patient and disease details were obtained from patient file and hospital information system. Compatibility test was performed in blood bank before blood reservation following mandatory guidelines. Details of test, blood issue, and blood transfusion were documented in the blood bank.

RESULTS:

Of 1241 enrolled patients, 1069 (86.2%) were female. The median age of patients was 66 years with mean preoperative hemoglobin of 9.9 g/dL. Allogenic blood transfused was needed in 223 (17.9%) patients. Diabetes mellitus, hypertension, thyroid disorders, and chronic heart diseases were the major comorbid conditions. Risk factors such as gender, American Society of Anesthesiologists score, preoperative hemoglobin, and intraoperative and postoperative blood losses were significantly associated with blood transfusion.

CONCLUSION:

The risk factors determining blood transfusion in TKR vary between studies, however, all centers should establish standard operating procedures describing the surgical procedure and transfusion support in TKR. In addition, each center may develop specific blood management strategy to rationalize blood transfusion in TKR and overall successful care in TKR.

Association between Type of Anesthesia and Risk of Blood Transfusion Events in Primary Unilateral Total Knee Arthroplasty: A Secondary Analysis Based on a Cohort Study in Singapore

This study evaluated whether the type of anesthesia independently related to risk of blood transfusion events in patients undergoing total knee arthroplasty (TKA) after adjusting for other covariates. This was a secondary analysis of a retrospective cohort study of patients undergoing primary unilateral TKA in Singapore. The independent variable was the type of anesthesia and the dependent variable was blood transfusion events. A multivariable logistic regression analysis was performed adjusting for variables that might affect the choice of anesthesia or blood transfusion events. Additional analyses examined this association by the subgroup analysis by using stratified multivariate logistic regression models. Of all 2,366 patients undergoing primary unilateral TKA, 120 (5.1%) developed blood transfusion events. Sixty-four (4.1%) of 1,560 patients with regional anesthesia (RA) developed blood transfusion events, compared with 56 (6.9%) of 806 patients with general anesthesia (GA; (p = 0.003). After adjusting for age, sex, preoperative hemoglobin, and other variables, patients who received RA had a decreased risk of blood transfusion events compared with those receiving GA (odds ratio [OR]: 0.53, 95% confidence interval [CI]: 0.35-0.81). This risk further decreased in male (OR: 0.20, 95% CI: 0.07-0.59) and participants whose operation time ≥ 90 minutes (OR: 0.39, 95% CI: 0.19-0.78). Our results indicated that patients receiving primary unilateral TKA who were managed with RA had a significantly decreased risk of blood transfusion events compared with those with GA, especially in male and participants whose operation time ≥ 90 minutes.

Perioperative Blood Transfusions Are Associated with a Higher Incidence of Thromboembolic Events After TKA: An Analysis of 333,463 TKAs

BACKGROUND

Given the morbidity, mortality, and financial burden associated with venous thromboembolism (VTE) after TKA, orthopaedic providers continually seek to identify risk factors associated with this devastating complication. The association between perioperative transfusion status and VTE risk has not been thoroughly explored, with previous studies evaluating this relationship being limited in both generalizability and power.

QUESTIONS/PURPOSES

Therefore, we sought to determine whether perioperative transfusions were associated with an increased risk of (1) pulmonary embolism (PE) or (2) deep vein thrombosis (DVT) after primary TKA in a large, multi-institutional sample.

METHODS

The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was implemented for our analysis. The definitions of complications, such as DVT and PE, and risk adjustment validation is monitored by the central ACS NSQIP office to ensure participating hospitals are adhering to the same guidelines to log patients. Additionally, both preoperative and intraoperative/72 hour postoperative transfusion status is included for all patients. Therefore, ACS NSQIP was determined to be the most appropriate database for our analysis. All patients who underwent primary TKA between 2011 and 2018 were identified using Current Procedural Terminology code 27447. Primary TKAs designated as "non-elective" were excluded, thereby providing a cohort composed solely of patients undergoing unilateral primary elective TKA for further analysis. The final analysis included 333,463 patients undergoing TKA (mean age 67 ± 9 years, 62% female). Preoperative transfusions were received by < 0.01% (48 of 333,463) of the patients, while 4% (14,590 of 333,463) received a transfusion within the interim between the start of surgery up to 72 hours postoperatively. All missing values were imputed through multiple imputation by chained equation to avoid variable availability-based selection and the subsequent listwise deletion-associated bias in the estimate of parameters. A multivariable logistic regression analysis was conducted using variables identified in a univariate model to calculate adjusted odds ratios and 95% confidence intervals for risk factors associated with symptomatic DVT and/or PE. For variables that maintained significance in the multivariable model, an additional model without confounders was used to generate fully adjusted ORs and 95% CIs. A propensity score matched comparison between recipients versus nonrecipients (1:1) of transfusion (preoperative and intraoperative/72 hours postoperative) was then conducted to evaluate the independent association between DVT/PE development and patients' transfusion status. Significance was determined at a p value < 0.05.

RESULTS

Adjusted multivariable regression analysis accounting for patient age, sex, race, BMI, American Society of Anesthesiologists (ASA) class and baseline comorbidities demonstrated the absence of an association between preoperative (OR 1.75 [95% CI 0.24 to 12.7]; p = 0.58) or intraoperative/72 hours postoperative (OR 1.12 [95% CI 0.93 to 1.35]; p = 0.23) transfusions and higher odds of developing PE. Similar findings were demonstrated after propensity score matching. Although multivariable regression demonstrated the absence of an association between preoperative transfusion and the odds of developing DVT within the 30-day postoperative period (OR 1.85 [95% CI 0.43 to 8.05]; p = 0.41), intraoperative/postoperative transfusion was associated with higher odds of DVT development (OR 3.68 [95% CI 1.14 to 1.53]; p < 0.001) relative to transfusion naïve patients. However, this significance was lost after propensity score matching.

CONCLUSION

After controlling for various potential confounding variables such as ASA Class, age, anesthesia type, and BMI, the receipt of an intra- or postoperative transfusion was found to be associated with an increased risk of DVT. Our findings should encourage orthopaedic providers to strictly adhere to blood management protocols, further tighten transfusion eligibility, and adjust surgical approach and implant type to reduce the incidence of transfusion among patients with other DVT risk factors. Additionally, our findings should encourage a multidisciplinary approach to VTE prophylaxis and prevention, as well as to blood transfusion guideline adherence, among all providers of the care team.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Predictors for blood loss and transfusion frequency to guide blood saving programs in primary knee- and hip-arthroplasty

Endoprosthetic surgery can lead to relevant blood loss resulting in red blood cell (RBC) transfusions. This study aimed to identify risk factors for blood loss and RBC transfusion that enable the prediction of an individualized transfusion probability to guide preoperative RBC provision and blood saving programs. A retrospective analysis of patients who underwent primary hip or knee arthroplasty was performed. Risk factors for blood loss and transfusions were identified and transfusion probabilities computed. The number needed to treat (NNT) of a potential correction of preoperative anemia with iron substitution for the prevention of RBC transfusion was calculated. A total of 308 patients were included, of whom 12 (3.9%) received RBC transfusions. Factors influencing the maximum hemoglobin drop were the use of drain, tranexamic acid, duration of surgery, anticoagulation, BMI, ASA status and mechanical heart valves. In multivariate analysis, the use of a drain, low preoperative Hb and mechanical heart valves were predictors for RBC transfusions. The transfusion probability of patients with a hemoglobin of 9.0–10.0 g/dL, 10.0–11.0 g/dL, 11.0–12.0 g/dL and 12.0–13.0 g/dL was 100%, 33.3%, 10% and 5.6%, and the NNT 1.5, 4.3, 22.7 and 17.3, while it was 100%, 50%, 25% and 14.3% with a NNT of 2.0, 4.0, 9.3 and 7.0 in patients with a drain, respectively. Preoperative anemia and the insertion of drains are more predictive for RBC transfusions than the use of tranexamic acid. Based on this, a personalized transfusion probability can be computed, that may help to identify patients who could benefit from blood saving programs.

Awareness of performance on outcomes after total hip and knee arthroplasty among Dutch orthopedic surgeons: how to improve feedback from arthroplasty registries

Background and purpose - The Netherlands Registry of Orthopedic Implants (LROI) uses audit and feedback (A&F) as the strategy to improve performance outcomes after total hip and knee arthroplasty (THA/TKA). Effectiveness of A&F depends on awareness of below-average performance to initiate improvement activities. We explored the awareness of Dutch orthopedic surgeons regarding their performance on outcomes after THA/TKA and factors associated with this awareness.Methods - An anonymous questionnaire was sent to all 445 eligible Dutch orthopedic surgeons performing THA/TKA. To assess awareness on own surgeon-group performance, they were asked whether their 1-year THA/TKA revision rates over the past 2 years were below average (negative outlier), average (non-outlier), above average (positive outlier) in the funnel plot on the LROI dashboard, or did not know. Associations were determined with (1) dashboard login at least once a year (yes/no); (2) correct funnel-plot interpretation (yes/no) and; (3) recall of their 1-year THA/TKA revision rate (yes/no).Results - 44% of respondents started the questionnaire, 158 THA and 156 TKA surgeons. 55% of THA surgeons and 55% of TKA surgeons were aware of their performance. Surgeons aware of their performance more often logged in on the LROI dashboard, more often interpreted funnel plots correctly, and more often recalled their revision rate. 38% of THA and 26% of TKA surgeons scored "good" on all 3 outcomes.Interpretation - Only half of the orthopedic surgeons were aware of their performance status regarding outcomes after THA/TKA. This suggests that to increase awareness, orthopedic surgeons need to be actively motivated to look at the dashboard more frequently and educated on interpretation of funnel plots for audit and feedback to be effective.

Effectiveness of iron supplementation in the perioperative management of total knee arthroplasty: a systematic review

Introduction/purpose

The purpose of this systematic review was to evaluate the effect of iron supplementation during total knee arthroplasty (TKA): (1) Is the iron supplementation necessary during TKA? (2) When is the optimal timing of iron supplementation? (3) Which is better, between orally and intravenously administered iron supplementation? And (4) What is the optimal dose of iron supplementation?

Materials and methods

A rigorous and systematic approach was used and each of the selected studies was evaluated for methodological quality. Data about study design, total number of cases enrolled, iron administration method, timing, and dose were extracted. Change in hemoglobin and transfusion rates were extracted to evaluate the effectiveness of iron supplementation.

Results

Eleven studies were included in the final analysis. Most of studies reported that hemoglobin change between iron and control group did not show any difference. Only one study reported that iron supplementation could reduce the decrease in hemoglobin. However, transfusion rate showed a decrease in the iron supplementation group compared with the control group. There was no clear consensus on the optimum timing and dose of iron supplementation and intravenously administered iron was more effective than orally administered iron, especially in anemic patients.

Conclusion

Iron supplementation is not clear as a way to raise hemoglobin levels after TKA, but an effective treatment for lowering transfusion rate, especially in patients with anemia. We could not determine the optimal timing and dose of the iron. Intravenously administered iron was similar to, or better than, orally administered iron for improving hemoglobin levels and transfusion rate.

Development and validation of a nomogram to predict perioperative blood transfusion in patients undergoing total knee arthroplasty

Background

The need for a transfusion is one of the adverse events following total knee arthroplasty (TKA), and accurately predicting this need remains challenging for arthroplasty surgeons. The purpose of the present research is to study the preoperative predictors of transfusion risk in patients following TKA and develop a nomogram.

Methods

The nomogram was developed based on a training set of 5402 patients who underwent TKA at the Affiliated Hospital of Qingdao University between September 2013 and November 2018. The independent predictors of transfusion were identified by univariate, LASSO, and binary logistic regression analyses. Then, a nomogram was established based on these independent predictors. The area under the curve (AUC), calibration curve, and decision curve analysis (DCA) were selected to evaluate the nomogram. The results were validated using an independent set of 1116 patients who underwent TKA between December 2018 and September 2019. In addition, we also carried out subgroup analyses in the training and testing sets based on the independent predictors.

Results

Five independent predictors were identified by multivariate analysis and were used to establish the nomogram. The AUCs of the nomogram were 0.884 (95% CI: 0.865–0.903) and 0.839 (95% CI, 0.773–0.905) in the training and testing sets, respectively. In both the training and testing sets, the calibration curve indicated that the prediction by the nomogram was highly consistent with the actual observation, and the DCA indicated that the nomogram had a favorable level of clinical usefulness. In addition, the AUC of the nomogram was significantly higher than the AUC of any independent predictor for predicting transfusion risk following TKA, and the subgroup analysis showed good performance in 20 subgroups.

Conclusion

Lower preoperative Hb levels, simultaneous bilateral TKA, lower BMI, older age, and coronary heart disease were identified as independent predictors of postoperative transfusion in patients following TKA. A nomogram incorporating the above five predictors could accurately predict the transfusion risk.

Between-Hospital Variation in Revision Rates After Total Hip and Knee Arthroplasty in the Netherlands: Directing Quality-Improvement Initiatives

BACKGROUND

Variation in 1-year revision rates between Dutch hospitals after primary total hip and knee arthroplasty (THA and TKA) may direct quality-improvement initiatives if this variation accurately reflects true hospital differences. The aim of the present study was to assess the extent of variation, both overall and for specific indications, as well as the statistical reliability of ranking hospitals.

METHODS

All primary THAs and TKAs that were performed between January 2014 and December 2016 were included. Observed/expected (O/E) ratios regarding 1-year revision rates were depicted in a funnel plot with 95% control limits to identify outliers based on 1 or 3 years of data, both overall and by specific indication for revision. The expected number was calculated on the basis of patient mix with use of logistic regression models. The statistical reliability of ranking hospitals (rankability) on these outcomes indicates the percentage of total variation that is explained by "true" hospital differences rather than chance. Rankability was evaluated using fixed and random effects models, for overall revisions and specific indications for revision, including 1 versus 3 years of data.

RESULTS

The present study included 86,468 THAs and 73,077 TKAs from 97 and 98 hospitals, respectively. Thirteen hospitals performing THAs were identified as negative outliers (median O/E ratio, 1.9; interquartile range [IQR], 1.5-2.5), with 5 hospitals as outliers in multiple years. Eight negative outliers were identified for periprosthetic joint infection; 4, for dislocation; and 2, for prosthesis loosening. Seven hospitals performing TKAs were identified as negative outliers (median O/E ratio, 2.3; IQR, 2.2-2.8), with 2 hospitals as outliers in multiple years. Two negative outlier hospitals were identified for periprosthetic joint infection and 1 was identified for technical failures. The rankability for overall revisions was 62% (moderate) for THA and 46% (low) for TKA.

CONCLUSIONS

There was large between-hospital variation in 1-year revision rates after primary THA and TKA. For most outlier hospitals, a specific indication for revision could be identified as contributing to worse performance, particularly for THA; these findings are starting points for quality-improvement initiatives.

Long-Term Sustainability of a Quality Initiative Program on Transfusion Rates in Total Joint Arthroplasty: A Follow-Up Study

BACKGROUND

There are significant variations in transfusion rates among institutions performing total joint arthroplasty. We previously demonstrated that implementation of an educational program to increase awareness of the American Association of Blood Banks' transfusion guidelines led to an immediate decrease in transfusion rates at our facilities. It remained unclear how this initiative would endure over time. We report the long-term success and sustainability of this quality program.

METHODS

We reviewed the Michigan Arthroplasty Collaborative Quality Initiative data from 2012 through 2017 of all patients undergoing primary hip and knee arthroplasty at our institutions for preoperative and postoperative hemoglobin level, transfusion status, and number of units transfused and transfusions outside of protocol to identify changes surrounding our blood transfusion educational initiative. We calculated the transfusions prevented and cost implications over the course of the study.

RESULTS

We identified 6645 primary hip and knee arthroplasty patients. There was a significant decrease in transfusion rate and overall transfusions in each group when compared to pre-education values. Subgroup analysis of TKA and THA independently showed significant decreases in both transfusion rate and overall transfusions. Over the final 3 years of the study, only 2 patients were transfused outside of the American Association of Blood Banks protocol. We estimate prevention of 519 transfusions over the study period.

CONCLUSION

Application of this quality initiative was an effective means of identifying opportunities for quality improvement. The program was easily initiated, had significant early impact, and has been shown to be sustainable.

The incidence and risk factors for allogenic blood transfusion in total knee and hip arthroplasty

Background

Excessive blood loss in total joint arthroplasty (TJA) usually leads to an allogenic blood transfusion, which may cause adverse outcomes, prolonged length of hospitalization, and increased costs. The purpose of this study was to determine the incidence and risk factors for intraoperative and postoperative allogenic transfusion in patients undergoing primary unilateral total knee and hip arthroplasty (TKA and THA).

Methods

We conducted a retrospective study and enrolled consecutive patients undergoing primary unilateral TKA and THA at our institution between January 2010 and July 2014 (n = 1534). Information about allogenic transfusion was collected from medical records to determine the incidence. We performed univariate analysis and multivariate logistic regression analysis to identify the independent risk factors.

Results

Total, intraoperative, and postoperative transfusion rates were 17.9%, 7.9%, and 11.3%, respectively. The preoperative lower level of hemoglobin (Hb) (P < 0.001) and increased amount of intraoperative blood loss (P < 0.001) were independently associated with transfusion in TKA. The independent risk factors for transfusion in THA were female (P = 0.023), preoperative lower Hb level (P < 0.001), prolonged operation time (P < 0.001), and increased intraoperative blood loss (P < 0.001).

Conclusions

Given the high prevalence and potential risk of transfusion in TJA, interventions for identified risk factors should be used during the perioperative period.

Perioperative allogenic blood transfusion increases the incidence of postoperative deep vein thrombosis in total knee and hip arthroplasty

Background

Excessive blood loss caused by total joint arthroplasty (TJA) often increases the requirement for blood transfusion, which is associated with adverse outcomes. The purpose of this study was to determine the relationship between perioperative transfusion and postoperative DVT in TJA.

Methods

This retrospective study reviewed medical records of 715 patients, who consecutively underwent primary unilateral total knee arthroplasty (TKA) or total hip arthroplasty (THA) at our institution between September 2015 and March 2017. Demographic, clinical and surgical parameters were introduced into the univariate analysis to find risk factors for DVT within postoperative 30 days. In order to identify if allogenic blood transfusion was independently associated with DVT, a multivariate logistic regression analysis was conducted to adjust for gender, age, body mass index (BMI), diagnosis, and type of surgery.

Results

The incidence of perioperative allogenic blood transfusion was 12.4% (n = 89). Fifty-seven patients (8.0%) developed DVT after surgery. Univariate analysis demonstrated that there were differences between DVT group and non-DVT group in gender (P = 0.045), age (P < 0.001), BMI (P = 0.026), primary diagnosis (P = 0.001), type of surgery (P < 0.001), and transfusion rates (P = 0.040). After adjustment by using multivariate logistic regression analysis, transfusion appeared to be the independent risk factor for DVT in TJA (P = 0.001; OR = 3.9, 95%CI 1.8–8.4).

Conclusion

We found that perioperative allogenic blood transfusion was significantly associated with DVT following TJA. In order to reduce the risk of DVT and other adverse outcomes, methods to decrease transfusion rates should be used in clinical practice.

General vs Spinal Anesthesia for Revision Total Knee Arthroplasty: Do Complication Rates Differ?

BACKGROUND

The incidence of both primary total knee arthroplasty (TKA) and revision TKA is increasing. Data from primary arthroplasty patients suggest a risk reduction with the use of spinal anesthesia when compared with general anesthesia. However, the same relationship has not been examined in the revision knee arthroplasty patient.

METHODS

This is a retrospective cohort study using the American College of Surgeons-National Surgical Quality Improvement database. Patients undergoing revision TKA with either spinal or general anesthesia were identified from the database. Baseline characteristics were compared, and ultimately patients were matched using coarsened exact matching. Multivariate analysis was then performed on matched cohorts controlling for baseline patient and operative characteristics. This model was used to look for any differences in rates of complications, operative time, length of stay, and readmission.

RESULTS

Patients undergoing revision TKA with general anesthesia had increased risk of several postoperative complications, even after controlling for baseline patient characteristics. Specifically, there were significantly increased rates of the following: unplanned readmission (OR = 1.43, 95% confidence interval [CI] = 1.18-1.72, P < .001), nonhome discharge (OR = 1.60, 95% CI = 1.46-1.76, P < .001), transfusion (OR = 1.63, 95% CI = 1.41-1.88, P < .001), deep surgical site infection (OR = 1.43, 95% CI = 1.01-2.03, P = .043), and extended length of stay (OR = 1.22, 95% CI = 1.11-1.34, P < .001). General anesthesia was additionally associated with increased operative time.

CONCLUSION

General anesthesia is associated with increased risk of numerous postoperative complications in patients undergoing revision TKA. This study is retrospective in nature, and while causality cannot be definitively determined, the results suggest that spinal anesthesia is preferential to general anesthesia in the revision TKA patient.

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.].

Decline in allogeneic blood transfusion usage in total hip arthroplasty patients: National Inpatient Sample 2009 to 2013

INTRODUCTION

Although total hip arthroplasty (THA) is an effective treatment for end-stage arthritis, it is also associated with substantial blood loss that may require allogeneic blood transfusion. However, these transfusions may increase the risk of certain complications. The purpose of our study is to evaluate: (i) the incidence/trends of allogeneic blood transfusion; (ii) the associated risk factors and adverse events; and (iii) the discharge disposition, length of stay (LOS), and costs for these patients between 2009 and 2013.

METHODS

The National Inpatient Sample database was used to identify 1,542,366 primary THAs performed between 2009 and 2013. Patients were stratified based on demographics, economic data, hospital characteristics, comorbidities, and whether or not allogeneic transfusion was received. Logistic regression was performed to evaluate the risk factors for transfusion and postoperative complications.

RESULTS

From 2009 to 2013, allogeneic transfusions were used in 16.9% of primary THAs, with a declining annual incidence. Except for obesity, all comorbidities were associated with increased likelihood of receiving a transfusion. Allogeneic transfusion patients were more likely to experience surgical site infections or pulmonary complications (p<0.001 for all). These patients were more likely to be discharged to a short-term care facility (p<0.001). Additionally, they had a greater mean LOS (p<0.001) and higher median hospital costs and charges when compared to their non-transfused counterparts.

CONCLUSIONS

While the observed decline in allogeneic transfusion usage is encouraging, further efforts should focus on preoperative patient optimisation. Given the projected increase in demand for primary THAs, orthopaedic surgeons must be familiar with safe and effective blood conservation protocols.

Are Allogeneic Transfusions Decreasing in Total Knee Arthroplasty Patients? National Inpatient Sample 2009-2013

BACKGROUND

Allogeneic transfusions are commonly used for substantial blood loss in total knee arthroplasty (TKA), but have been associated with adverse effects and increased costs. The purpose of this study is to provide a detailed description of (1) trends of allogeneic blood transfusion; (2) risk factors and adverse events; and (3) discharge disposition, length-of-stay (LOS), and cost/charge analysis for primary TKA patients who received an allogeneic blood transfusion from 2009-2013.

METHODS

A cohort of 3,217,056 primary TKA patients was identified from the National Inpatient Sample database from 2009-2013. Demographic, clinical, economic, and discharge data were analyzed for patients who received allogeneic blood products, and for those who did not receive any type of blood transfusion. Other parameters analyzed include risk factors, adverse events, discharge disposition, and costs/charges.

RESULTS

There was a significant decline in use of allogeneic transfusion from 2009-2013 incidence (13.9%-7.3%; P < .001). All comorbidities examined were associated with significantly increased risk of receiving allogeneic transfusion with exception of patients with AIDS, metastatic cancer, and peptic ulcer disease. Allogeneic transfusion was associated with worse outcomes during hospitalization. Patients also had a greater likelihood of discharge to short-term care, greater LOS, and greater median costs/charges. Among TKA patients who received an allogeneic transfusion, costs varied based on hospital ownership and characteristics, primary-payer, region, and bed-size.

CONCLUSION

Given the poor outcomes and higher costs associated with allogeneic transfusions, efforts must be undertaken to minimize this risky practice. With the projected increase in demand for TKAs, orthopedists must understand effective blood management strategies.

Does blood transfusion type affect complication and length of stay following same-day bilateral total knee arthroplasty?

Same-day Bilateral Total Knee Arthroplasty (BTKA) safety is still controversial. The aim of this study was to examine the association of blood transfusion type (pure autologous, pure allogeneic, and combined) with complication and prolonged length of stay (PLOS) following same-day BTKA. 649 consecutive patients were retrospectively identified over a two-year period. Pure allogeneic transfusions were associated with increased odds of minor complication when compared to patients who had pure autologous transfusions. No association was found between blood transfusion type and major complication or PLOS. Our results suggest that blood transfusion type may be influential in minor complication after BTKA.

Extremely Low Transfusion Rates: Contemporary Primary Total Hip and Knee Arthroplasties

BACKGROUND

Considerable blood loss which requires transfusion is frequently reported after total hip and knee arthroplasties (THA and TKA). The purpose of this study is to review the transfusion rates in contemporary THA and TKA with optimized perioperative protocols including minimized surgical trauma and optimal perioperative patient care.

METHODS

This retrospective study included 1442 consecutive patients receiving either a primary THA or a TKA from the same high-volume surgeon between January 2008 and December 2015. Demographics and surgical data were collected from patients' journals. Estimated blood loss, decline in hemoglobin, and use of transfusion were registered.

RESULTS

One (0.0013%) THA and 3 (0.0044%) TKAs required blood transfusion postoperatively. Average measured bleeding was 253 mL ± 142 and 207 mL ± 169 in THA and TKA, respectively. Average decline in hemoglobin was 23.5 g/L ± 11.4 and 22.9 g/L ± 11.6 for THA and TKA, respectively.

CONCLUSION

In contemporary THA and TKA, perioperative protocols and patient optimization can decrease the rate of blood transfusion to near zero.

Hospital variation in allogeneic transfusion and extended length of stay in primary elective hip and knee arthroplasty: a cross-sectional study

OBJECTIVES

Outcomes in total hip and knee arthroplasty (THA and TKA), such as allogeneic transfusions or extended length of stay (LoS), can be used to compare the performance of hospitals. However, there is much variation in these outcomes. This study aims to rank hospitals and to assess hospital differences of two outcomes in THA and TKA: allogeneic transfusions and extended LoS, and to additionally identify factors associated with these differences.

DESIGN

Cross-sectional medical record review study.

SETTING

Data were gathered in 23 Dutch hospitals.

PARTICIPANTS

1163 THA and 986 TKA patient admissions.

OUTCOMES

Hospitals were ranked based on their observed/expected (O/E) ratios regarding allogeneic transfusion and extended LoS percentages (extended LoS was defined by postoperative stay >4 days). To assess the reliability of these rankings, we calculated which percentage of the existing variation was based on differences between hospitals as compared with random variation (after adjustment for variation in patient characteristics). Associations between hospital-specific factors and O/E ratios were used to explore potential sources of differences.

RESULTS

The variation in O/E ratios between hospitals ranged from 0 to 4.4 for allogeneic transfusion, and from 0.08 to 2.7 for extended LoS. Variation in transfusion could in 21% be explained by hospital differences in THA and 34% in TKA. For extended LoS this was 71% in THA and 78% in TKA. Better performance (low O/E ratios) in transfusion was associated with more frequent tranexamic acid (TXA) use in TKA (R=-0.43, p=0.04). Better performance in extended LoS was associated with more frequent TXA use in THA (R=-0.45, p=0.03) and TKA (R=-0.65, p<0.001) and local infiltration analgesia (LIA) in TKA (R=-0.60, p=0.002).

CONCLUSIONS

Ranking hospitals based on allogeneic transfusion is unreliable due to small percentages of variation explained by hospital differences. Ranking based on extended LoS is more reliable. Hospitals using TXA and LIA have relatively fewer patients with transfusions and extended LoS.