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Hourlier H, Fennema P. An observational study of an adjusted patient blood management protocol intended to lower rates of transfusion following total knee arthroplasty in patients with preoperative anemia. J Orthop Surg Res 2023; 18:918. [PMID: 38041115 PMCID: PMC10693030 DOI: 10.1186/s13018-023-04404-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 11/24/2023] [Indexed: 12/03/2023] Open
Abstract
BACKGROUND Patients with preoperative anemia have a higher risk of requiring blood transfusion after major orthopedic surgery due to increased blood loss and closer transfusion thresholds. Various patient blood management (PBM) policies aim to reduce transfusion rates. This observational study aimed to investigate blood loss and evaluate the effectiveness of an adjusted surgical PBM protocol in patients with anemic chronic disease (ACD) undergoing elective total knee arthroplasty (TKA). METHODS A consecutive cohort of patients underwent elective unilateral TKA with an adjusted PBM protocol. The protocol consisted of epoetin (EPO) alfa therapy prescribed by the surgeon, routine administration of tranexamic acid (TXA), and standardized postoperative pharmacologic prophylaxis for thromboembolism. The performance of this PBM protocol was analyzed in patients with a baseline hemoglobin level of less than 12 g/dl. Hemoglobin levels were controlled at admission, on postoperative day (POD) 1, and on POD 7 ± 1. A bleeding index (BI-7) was used as an estimate of blood loss up until POD 7. Multiple linear regression was used to assess whether there were any differences in BI-7 between ACD- and ACD + patients. RESULTS A total of 751 patients with complete hemoglobin monitoring were included in the study. Of these patients, 68 (9.1%) had a baseline hemoglobin concentration of less than 12 g/dl (ACD group). In this group, 28 patients (41.2%) received preoperative EPO therapy. The mean adjusted BI-7 for the study population was 3.0 (95% CI, 2.9 to 3.0) g/dl in the ACD- group and 2.3 (95% CI, 2.0-2.6) g/dl in the ACD + group. The difference in BI-7 was statistically significant (difference, 0.6 [95% CI: 0.3 to 0.9] g/dl, p < 0.001). No major complications occurred in the ACD + group, whereas there were three complications in the ACD- group (p = 1.00). CONCLUSIONS ACD patients undergoing TKA did not have an increased risk of bleeding or bleeding complications with the use of the adjusted PBM protocol. None of ACD patients required transfusion. ACD patients undergoing TKA experienced significantly less blood loss than patients with no preoperative anemia with the use of the adjusted PBM. We now consider the use of EPO in ACD patients with no nutritional deficiencies undergoing TKA at a baseline hemoglobin level of 11 g/dl. However, this should be validated in larger cohorts with a higher prevalence of ACD patients.
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Affiliation(s)
- Hervé Hourlier
- Department of Orthopaedic Surgery, Polyclinique de La Thiérache, Rue du Dr Koral, 59212, Wignehies, France.
- Centre Hospitalier de Fourmies, 59610, Fourmies, France.
| | - Peter Fennema
- AMR Advanced Medical Research GmbH, Männedorf, Switzerland
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LiBrizzi CL, Sabharwal S, Forsberg JA, Leddy L, Doung YC, Morris CD, Levin AS. Does the Use of Negative Pressure Wound Therapy and Postoperative Drains Impact the Development of Surgical Site Infections?: A PARITY Trial Secondary Analysis. J Bone Joint Surg Am 2023; 105:34-40. [PMID: 37466578 DOI: 10.2106/jbjs.22.01185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
BACKGROUND Surgical site infections (SSIs) represent a major complication following oncologic reconstructions. Our objectives were (1) to assess whether the use of postoperative drains and/or negative pressure wound therapy (NPWT) were associated with SSIs following lower-extremity oncologic reconstruction and (2) to identify factors associated with the duration of postoperative drains and with the duration of NPWT. METHODS This is a secondary analysis of the Prophylactic Antibiotic Regimens in Tumor Surgery (PARITY) trial, a multi-institution randomized controlled trial of lower-extremity oncologic reconstructions. Data were recorded regarding the use of drains alone, NPWT alone, or both NPWT and drains, including the total duration of each postoperatively. We analyzed postoperative drain duration and associations with tourniquet use, intraoperative thromboprophylaxis or antifibrinolytic use, incision length, resection length, and total operative time, through use of a linear regression model. A Cox proportional hazards model was used to evaluate the independent predictors of SSI. RESULTS Overall, 604 patients were included and the incidence of SSI was 15.9%. Postoperative drains alone were used in 409 patients (67.7%), NPWT alone was used in 15 patients (2.5%), and both postoperative drains and NPWT were used in 68 patients (11.3%). The median (and interquartile range [IQR]) duration of drains and of NPWT was 3 days (IQR, 2 to 5 days) and 6 days (IQR, 4 to 8 days), respectively. The use of postoperative drains alone, NPWT alone, or both drains and NPWT was not associated with SSI (p = 0.14). Increased postoperative drain duration was associated with longer operative times and no intraoperative tourniquet use, as shown on linear regression analysis (p < 0.001 and p = 0.03, respectively). A postoperative drain duration of ≥14 days (hazard ratio [HR], 3.6; 95% confidence interval [CI], 1.3 to 9.6; p = 0.01) and an operative time of ≥8 hours (HR, 4.5; 95% CI, 1.7 to 11.9; p = 0.002) were independent predictors of SSI following lower-extremity oncologic reconstruction. CONCLUSIONS A postoperative drain duration of ≥14 days and an operative time of ≥8 hours were independent predictors of SSI following lower-extremity oncologic reconstruction. Neither the use of postoperative drains nor the use of NPWT was a predictor of SSI. Future research is required to delineate the association of the combined use of postoperative drains and NPWT with SSI. LEVEL OF EVIDENCE Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Christa L LiBrizzi
- Division of Orthopaedic Oncology, Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Samir Sabharwal
- Division of Orthopaedic Oncology, Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jonathan A Forsberg
- Division of Orthopaedic Oncology, Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Lee Leddy
- Department of Orthopaedic Surgery, The Medical University of South Carolina, Charleston, South Carolina
| | - Yee-Cheen Doung
- Department of Orthopaedics and Rehabilitation, Oregon Health & Science University, Portland, Oregon
| | - Carol D Morris
- Division of Orthopaedic Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY
| | - Adam S Levin
- Division of Orthopaedic Oncology, Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
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Value of closed suction drainage in arthroscopic and minimally invasive surgery of the ankle joint: a prospective randomised study. Arch Orthop Trauma Surg 2023; 143:657-663. [PMID: 34401935 DOI: 10.1007/s00402-021-04107-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 07/27/2021] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Closed suction drainage is an established procedure in arthroscopic surgery. It is intended to reduce the retention of wound and irrigation fluids, which form the basis for postoperative swelling, pain, and infection. However, currently, there is no scientific review of the actual benefit of this procedure. METHODS Between 2020 and 2021, 84 patients (53 males, 31 females; mean age: 42 years) were prospectively randomised into this study. The patients underwent arthroscopic surgery of the ankle joint with (group A) or without (group B) insertion of a closed suction drain (42 patients per group). Assessments included upper ankle swelling using the figure-of-eight-20 method, pain preoperatively and 48 h postoperatively, and unexpected events within 6 weeks postoperatively. RESULTS The measurements performed 48 h postoperatively showed a mean circumferential increase of 1.38 cm (1.48 and 1.28 cm in groups A and B, respectively; p > 0.05) in all patients. The mean pain at rest, assessed using the visual analogue scale (maximum 10 points), was 2.7 and 2.4 in groups A and B, respectively (p > 0.05). Overall, two minor complications occurred: residual swelling in group A and persistent limitation of movement in group B. The average length of hospital stay was 2.4 days (p > 0.05). CONCLUSIONS Based on the available data, the routine insertion of a closed suction drainage at the upper ankle does not offer any objective benefit and must be considered obsolete. From both a medical and an economic point of view, the decision to conduct this procedure should be justified on an individual basis. LEVEL OF EVIDENCE Level I, prospective randomised trial.
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Migliorini F, Pintore A, Eschweiler J, Oliva F, Hildebrand F, Maffulli N. Factors influencing the outcomes of minimally invasive total hip arthroplasty: a systematic review. J Orthop Surg Res 2022; 17:281. [PMID: 35585545 PMCID: PMC9118783 DOI: 10.1186/s13018-022-03168-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Accepted: 05/09/2022] [Indexed: 12/01/2022] Open
Abstract
Introduction The present systematic review investigated possible factors which may influence the surgical outcome of minimally invasive surgery for total hip arthroplasty (MIS THA). Methods In January 2022, the Embase, Google Scholar, PubMed, and Scopus databases were accessed. All the clinical trials investigating the clinical outcome of MIS THA were considered.
Results Data from 9486 procedures were collected. Older age was moderately associated with greater Visual Analogue Scale (VAS) (P = 0.02) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) (P = 0.009) at last follow-up, and shorter surgical duration (P = 0.01). Greater body mass index (BMI) at baseline was moderately associated with greater cup anteversion (P = 0.0009), Oxford Hip Score (OHS) at last follow-up (P = 0.04), longer surgical duration (P = 0.04), increased leg length discrepancy (P = 0.02), and greater rate of infection (P = 0.04). Greater VAS at baseline was weakly associated with greater VAS at last follow-up (P < 0.0001), total estimated blood lost (P = 0.01), and lower value of Harris Hip Score (HHS) (P = 0.0005). Greater OHS at baseline was associated with greater post-operative VAS (P = 0.01). Greater WOMAC at baseline was associated with lower cup anteversion (P = 0.009) and greater VAS (P = 0.02). Greater HHS at baseline was associated with shorter hospitalisation (P = 0.001). Conclusion Older age and greater BMI may represent negative prognostic factors for MIS THA. The clinical outcome is strongly influenced by the preoperative status of patients.
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Affiliation(s)
- Filippo Migliorini
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany.
| | - Andrea Pintore
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081, Baronissi, SA, Italy
| | - Joerg Eschweiler
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Francesco Oliva
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081, Baronissi, SA, Italy
| | - Frank Hildebrand
- Department of Orthopaedic, Trauma, and Reconstructive Surgery, RWTH University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Nicola Maffulli
- Department of Medicine, Surgery and Dentistry, University of Salerno, Via S. Allende, 84081, Baronissi, SA, Italy.,School of Pharmacy and Bioengineering, Keele University School of Medicine, Thornburrow Drive, Stoke on Trent, England, UK.,Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Queen Mary University of London, Mile End Hospital, 275 Bancroft Road, London, E1 4DG, England, UK
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Hourlier H, Fennema P. Application of an adjusted patient blood management protocol in patients undergoing elective total hip arthroplasty: towards a zero-percent transfusion rate in renal patients-results from an observational cohort study. J Orthop Surg Res 2021; 16:697. [PMID: 34838063 PMCID: PMC8627010 DOI: 10.1186/s13018-021-02846-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Accepted: 11/15/2021] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Renal patients are at high risk of blood transfusion following major orthopaedic surgery. A variety of patient blood management (PBM) policies have been proposed to reduce the rate of transfusions. The aim of this observational study was to assess the performance of an adjusted PBM protocol in patients with chronic kidney disease (CKD) undergoing elective total hip arthroplasty (THA). METHODS A total of 1191 consecutive patients underwent elective unilateral THA and took part in an adjusted PBM protocol. The PBM protocol consisted of epoetin (EPO) alfa therapy prescribed by the surgeon, routine administration of tranexamic acid (TXA), an avascular approach to the hip and postoperative prophylaxis of thromboembolism. The performance of this PBM protocol was analysed in patients with a glomerular filtration rate (GFR) below or above 60 ml/min/1.73 m2 at baseline. Haemoglobin levels were controlled at admission, on postoperative day (POD) 1 and on POD 7 ± 1. A bleeding index (BI) was used as a proxy for blood loss. RESULTS In total, 153 patients (12.9%) presented with a modification of diet in renal disease value below 60 at baseline. Of these, 20 (13.1%) received EPO therapy and 120 (78.4%) received TXA. None of the patients received allogenic blood transfusions during the first perioperative week. The mean BI for the entire study population was 2.7 (95% CI 2.6, 2.8). CKD did not exert a significant impact on the BI (p = 0.287). However, it was found that both TXA and EPO therapy significantly lowered the BI (difference, - 0.3, p < 0.001). There were no thromboembolic complications in renal patients who received TXA and/or EPO therapy. CONCLUSIONS A zero-percent transfusion rate during the first perioperative week is attainable in patients with stage 3 or stage 4 CKD undergoing contemporary elective THA. With the use of a pragmatic blood-sparing protocol, patients with renal dysfunction did not have an increased risk of bleeding and did not have an increased incidence in the rate of perioperative blood transfusions.
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Affiliation(s)
- Hervé Hourlier
- Department of Orthopaedic Surgery, Polyclinique de la Thiérache, Rue du Dr Koral, 59212, Wignehies, France.
| | - Peter Fennema
- AMR Advanced Medical Research, Männedorf, Switzerland
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Cao G, Yang X, Xu H, Yue C, Huang Z, Zhang S, Quan S, Yao J, Yang M, Pei F. Association between preoperative hemoglobin and postoperative moderate and severe anemia among patients undergoing primary total knee arthroplasty: a single-center retrospective study. J Orthop Surg Res 2021; 16:572. [PMID: 34565418 PMCID: PMC8474733 DOI: 10.1186/s13018-021-02727-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 09/13/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Postoperative moderate and severe anemia (PMSA) has been a serious perioperative complication in primary total knee arthroplasty (TKA). However, the ideal cutoff values to predict PMSA is still undetermined. The aim of this study was (1) to identify the risk factors associated with PMSA and (2) to establish the cutoff values of preoperative hemoglobin (HB) associated with increased PMSA in primary TKA. METHODS We identified 474 patients undergoing primary TKA and separated those in which PMSA (HB was less than 110 g/L on postoperative day 1 and 3) was developed from those without PMSA. Multivariate logistic regression model was used to identify independent risk factors for PMSA. Area under the receiver-operator curve (AUC) was used to determine the best-supported preoperative HB cutoff across all the patients. RESULTS The PMSA rate in primary TKA was 53.2%. Significant risk factors were lower preoperative HB (OR [odds ratio] = 1.138, 95% CI [confidence interval] = 1.107-1.170, p < 0.001) and more intraoperative blood loss (OR = 1.022, 95% CI 1.484-4.598, p < 0.001). A preoperative HB cutoff value that maximized the AUC was 138.5 g/L for men (sensitivity: 79.4%, specificity: 75.0%) and 131.5 g/L for women (sensitivity: 74.7%, specificity: 80.5%), respectively. CONCLUSION We should recognize and consider the related risk factors to establish specific, personalized risk assessment for PMSA, including preoperative HB and intraoperative blood loss. Of these, preoperative HB was a referable tool to predict PMSA in primary TKA.
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Affiliation(s)
- Guorui Cao
- Department of Knee Injury (2), Luoyang Orthopedic Hospital of Henan Province, Orthopedic Hospital of Henan Province, Luoyang, 471000, Henan Province, People's Republic of China
| | - Xiuli Yang
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, No. 87 Guoxue Road, Chengdu, 610041, Sichuan Province, People's Republic of China
| | - Hong Xu
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, No. 87 Guoxue Road, Chengdu, 610041, Sichuan Province, People's Republic of China
| | - Chen Yue
- Department of Knee Injury (2), Luoyang Orthopedic Hospital of Henan Province, Orthopedic Hospital of Henan Province, Luoyang, 471000, Henan Province, People's Republic of China
| | - Zeyu Huang
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, No. 87 Guoxue Road, Chengdu, 610041, Sichuan Province, People's Republic of China
| | - Shaoyun Zhang
- Department of Orthopedics, The Third Hospital of Mianyang, Sichuan Mental Health Center, Mianyang, 621000, Sichuan Province, People's Republic of China
| | - Songtao Quan
- Department of Knee Injury (2), Luoyang Orthopedic Hospital of Henan Province, Orthopedic Hospital of Henan Province, Luoyang, 471000, Henan Province, People's Republic of China
| | - Junna Yao
- Department of Knee Injury (2), Luoyang Orthopedic Hospital of Henan Province, Orthopedic Hospital of Henan Province, Luoyang, 471000, Henan Province, People's Republic of China
| | - Minglu Yang
- Department of Knee Injury (2), Luoyang Orthopedic Hospital of Henan Province, Orthopedic Hospital of Henan Province, Luoyang, 471000, Henan Province, People's Republic of China
| | - Fuxing Pei
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, No. 87 Guoxue Road, Chengdu, 610041, Sichuan Province, People's Republic of China.
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