Blood loss in trochanteric fractures: multivariate analysis comparing dynamic hip screw and Gamma nail

The effects of three different low-molecular-weight heparins on blood loss after intramedullary nailing of trochanteric fractures

PURPOSE

The purpose of this study was to compare the effects of reviparin, dalteparin and enoxaparin on intraoperative blood loss in patients with trochanteric fracture treated with intramedullary nailing.

MATERIALS AND METHODS

This retrospective multicenter study included 100 patients with trochanteric fracture who were divided into three groups according to the low-molecular-weight heparin administered. In all cases, a short third generation Gamma nail was used for osteosynthesis. Complete blood count and number of red blood cell transfusions (RBC) were evaluated.

RESULTS

The mean value of postoperative haemoglobin level was lower in the enoxaparin group compared to the reviparin group, with significant difference (p = 0.001; 95% CI 4.1-18.87). Patients in the dalteparin group received more RBC transfusions compared to the reviparin and enoxaparin group (p = 0.048).

CONCLUSION

The use of enoxaparin and dalteparin in hip fracture patients can result in lower postoperative haemoglobin levels and more RBC transfusions compared to reviparin.

Anticoagulants and fracture morphology have a significant influence on total blood loss after proximal femur fractures

INTRODUCTION

Blood loss after proximal femoral fractures is an important risk factor for postoperative outcome and recovery. The purpose of our study was to investigate the total blood loss depending on fracture type and additional risks, such as anticoagulant use, to be able to recognize vulnerable patients depending on planned surgery and underlying comorbidities.

MATERIALS AND METHODS

A retrospective single center study including 1478 patients treated operatively for a proximal femoral fracture between January 2016 and June 2020 at a level I trauma center. Patient data, surgical procedure, time to surgery, complications and mortality were assessed. Lab data including hemoglobin and transfusion rates were collected. The Mercuriali formula was implemented to calculate total blood loss. Linear regression was performed to identify influencing factors.

RESULTS

One thousand four hundred seventy-eight mainly female patients were included in the study (mean age: 79.8 years) comprising 667 femoral neck fractures, 704 pertrochanteric- and 107 subtrochanteric fractures. Nearly 50% of the cohort were on anticoagulants or anti- platelet therapy. At time of admission average hemoglobin was 12.1 g/l. Linear regression proved fracture morphology, age, BMI, in-house mortality and anticoagulant use to have crucial influence on postoperative blood loss. Femoral neck fractures had a blood loss of 1227.5 ml (SD 740.4 ml), pertrochanteric fractures lost 1,474.2 ml (SD 830 ml) and subtrochanteric femoral fractures lost 1902.2 ml (SD 1,058 ml).

CONCLUSIONS

Hidden blood loss is underestimated. Anticoagulant use, fracture type, gender and BMI influence the total blood loss. Hemoglobin levels should be monitored closely. Within 48 h there was no increased mortality, so adequate time should be given to reduce anticoagulant levels and safely perform surgery.

Methods of Quantifying Intraoperative Blood Loss in Orthopaedic Trauma Surgery: A Systematic Review

OBJECTIVES

To collect and present the recently published methods of quantifying blood loss (BL) in orthopaedic trauma.

DATA SOURCES

A systematic review of English-language literature in PubMed, Cochrane Library, and Scopus databases was conducted according to the PRISMA guidelines on articles describing the methods of determining BL in orthopaedic trauma published since 2010.

STUDY SELECTION

English, full-text, peer-reviewed articles documenting intraoperative BL in an adult patient population undergoing orthopaedic trauma surgery were eligible for inclusion.

DATA EXTRACTION

Two authors independently extracted data from the included studies. Articles were assessed for quality and risk of bias using the Cochrane Collaboration's tool for assessing risk of bias and ROBINS-I.

DATA SYNTHESIS

The included studies proved to be heterogeneous in nature with insufficient data to make data pooling and analysis feasible.

CONCLUSIONS

Eleven methods were identified: 6 unique formulas with multiple variations, changes in hemoglobin and hematocrit levels, measured suction volume and weighed surgical gauze, transfusion quantification, cell salvage volumes, and hematoma evacuation frequency. Formulas included those of Gross, Mercuriali, Lisander, Sehat, Foss, and Stahl, with Gross being the most common (25%). All formulas used blood volume estimation, determined by equations from Nadler (94%) or Moore (6%), and measure change in preoperative and postoperative blood counts. This systematic review highlights the variability in BL estimation methods published in current orthopaedic trauma literature. Methods of quantifying BL should be taken into consideration when designing and evaluating research.

Pre-Emptive Antifibrinolysis: Its Role and Efficacy in Hip Fracture Patients Undergoing Total Hip Arthroplasty

BACKGROUND

We aimed to determine the efficacy of pre-emptive antifibrinolysis with tranexamic acid (TXA) in decreasing hidden blood loss (HBL) in the elderly hip fracture patients.

METHODS

Ninety-six elderly hip fracture patients receiving hip arthroplasty were randomized to receive 100 mL of normal saline (group A) or 1.5 g of TXA (group B) intravenously q12 hours from postadmission day 1 (PAD1) to the day before surgery. Both groups were treated with 1.5 g of TXA q12 hours from postoperative day 1 (POD1) to POD3. HBL was calculated by formulas and recorded as the primary outcome.

RESULTS

In overall analyses, no difference was found in HBL, while the decline of hemoglobin (ΔHb), allogeneic blood transfusion (ABT) rate, fibrinogen degradation product (FDP-on PAD2, PAD3, POD1, and POD2), and d-dimer (D-D-on PAD2, PAD3, and POD1) were lower in group B. In subgroup analyses for patients receiving intervention within 72 hours of injury, group B had lower postoperative HBL, ΔHb, ABT rate, FDP, and D-D levels (on PAD2, PAD3, POD1, and POD2). For patients receiving intervention over 72 hours after injury, no difference was detected in perioperative HBL, ΔHb, and ABT rate between the 2 groups. The FDP and D-D levels were lower in group B on PAD2 and PAD3. No difference was found in coagulation parameters, wound complications, venous thromboembolism rate, and 90-day mortality in all analyses.

CONCLUSION

Early administration (within 72 hours of injury) of multidose of TXA is effective in reducing perioperative HBL in elderly hip fracture patients. Delayed use (over 72 hours after injury) of TXA was not beneficial.

In Silico Finite Element Modeling of Stress Distribution in Osteosynthesis after Pertrochanteric Fractures

A stabilization method of pertrochanteric femur fractures is a contentious issue. Here, we assess the feasibility of rapid in silico 2D finite element modeling (FEM) to predict the distribution of stresses arising during the two most often used stabilization methods: gamma nail fixation (GNF) and dynamic hip screw (DHS). The modeling was based on standard pre-surgery radiographs of hip joints of 15 patients with pertrochanteric fractures of type A1, A2, and A3 according to the AO/OTA classification. The FEM showed that the stresses were similar for both GNF and DHS, with the medians ranging between 53-60 MPa and consistently lower for A1 than A3 fractures. Stresses also appeared in the fixation materials being about two-fold higher for GNF. Given similar bone stresses caused by both GNF and DHS but shorter surgery time, less extensive dissection, and faster patient mobilization, we submit that the GNF stabilization appears to be the most optimal system for pertrochanteric fractures. In silico FEM appears a viable perioperative method that helps predict the distribution of compressive stresses after osteosynthesis of pertrochanteric fractures. The promptness of modeling fits well into the rigid time framework of hip fracture surgery and may help optimize the fixation procedure for the best outcome. The study extends the use of FEM in complex orthopedic management. However, further datasets are required to firmly position the FEM in the treatment of pertrochanteric fractures.

Quality of life, walking ability and change of living situation after trochanteric femur fracture in geriatric patients-Comparison between sliding hip screw and cephalomedullary nails from the registry for geriatric trauma

BACKGROUND

There is no well-established gold standard for treating trochanteric femur fractures in the elderly. The two common treatment options are cephalomedullary nails (CMN) and sliding hip screws (SHS). In this study, treatment using CMN and SHS were compared for a cohort of patients older than 70 years of age: The main outcomes were quality of life and main residence after surgery.

METHODS

In this retrospective study we analyzed 24,919 patients from 100 hospitals, treated between 2016 and 2019 and documented in the Registry for Geriatric Trauma. The impact of CMN vs. SHS on the walking ability, quality of life (QoL), living situation, mortality, and revision rate were analyzed. To analyze the change of the living situation, the main residence 120 days after surgery for patients, who lived in their own home before fracture, was described for both groups.

FINDINGS

A total of 10,995 patients could be included of which 10,436 patients were treated with CMN and 369 patients with SHS. 120 days postoperative the QoL differed significantly (p = 0.020) in favor of treatment using CMN. 26% of the SHS group who lived at home prior to surgery had to reside in a nursing home after surgery, whereas the rate was only 18% in the CMN group (p < 0.001). No significant difference in the mortality rate nor a difference in the walking ability 120 days postoperative were found. CMN were implanted more promptly (median: 13.9 vs. 18.4 hours; p < 0,001). No differences were found concerning the revision rate between the two groups, neither during inpatient treatment (p = 0.723) nor during the 120 day follow-up period (p = 0.524).

INTERPRETATION

There might be a benefit for geriatric patients with trochanteric femur fractures to be treated with a proximal femur nail in regard to a higher QoL and a reduced institutionalization rate. Mortality or revision rate was not affected by the chosen implant.

Investigation of perioperative blood loss of femoral shaft fractures treated with intramedullary nail or locking compression plate

INTRODUCTION

Femoral shaft fractures (FSFs) are associated with significant blood loss, resulting in anemia and hemorrhagic shock. However, there has been limited data for the blood loss of FSFs during the whole perioperative period. Our primary aim is to quantify the blood loss associated with FSFs treated with intramedullary nail or locking compression plate fixation, as well as to identify the relative affecting factors for perioperative hidden blood loss (HBL).

PATIENTS AND METHODS

131 consecutive patients with FSFs were enrolled in the retrospective study between January 2009 and January 2020, including 90 cases for intramedullary nail (Nail group) and 41 cases for locking compression plate fixation (Plate group). Demographics and perioperative data were collected and analyzed. Total blood loss (TBL), visible blood loss (VBL), HBL, and percentage of HBL (PHBL) were calculated based on hematocrit (Hct) changes.

RESULTS

There was a large drop of hemoglobin (Hb) during the perioperative time. Of all 131 patients, the average HBL was 1445.5 ± 443.2 mL, accounting for 78.7% of TBL (1815.1 ± 446.3 mL). TBL and HBL in Nail group were 1886.1 ± 438.6 mL and 1546.0 ± 424.7 mL; while TBL and HBL in Plate group were 1659.5 ± 427.9 mL and 1225.1 ± 405.7 mL. The differences between the two groups were statistically significant (p = 0.007, p < 0.001, respectively). Besides, statistical significance (p< 0.05, p< 0.05, respectively) was also reported in HBL between Type-A and Type-C, and between Type-B and Type-C (1395.8 ± 444.8 mL vs. 1651.6 ± 495.7 mL; and 1411.2 ± 383.4 mL vs. 1651.6 ± 495.7 mL, respectively).

CONCLUSIONS

Patients of FSFs had significant TBL and HBL, the amount of which was much larger than that observed intra-operatively. Moreover, two readily available preoperative factors for nail fixation and Type-C were associated with a higher likelihood of more HBL. Therefore, it was argued that regular perioperative monitoring and timely blood transfusion were crucially important for patients to avoid possible risks of anemia and facilitate recovery.

The efficacy and safety of tranexamic acid in the treatment of intertrochanteric fracture: an updated meta-analysis of 11 randomized controlled trials

This meta-analysis was performed to investigate the efficacy and safety of tranexamic acid (TXA) in the elderly patients undergoing intertrochanteric fracture surgery from the current literatures. The electronic literature database of PubMed, Embase and Cochrane library were searched in October 2019. The intraoperative blood loss, hidden blood loss, postoperative drainage and total blood loss, postoperative hemoglobin, length of stay, transfusion rate, mortality rate, thromboembolic events and wound complications were extracted. Stata 14.0 software was used for our meta-analysis. A total of 11 RCTs (3 new RCTs in 2019) with 1202 patients met our inclusion criteria. This meta-analysis showed that administration of TXA can reduce intraoperative blood loss (P = 0.009), hidden blood loss (P = 0.000), total blood loss (P = 0.000), length of stay (P = 0.003), transfusion rate (P = 0.000) and the occurrence of wound complications (P = 0.006). Furthermore, administration of TXA was associated with an increase in the postoperative Hb level at day 1, 2 and 3 (P = 0.000, P = 0.000 and P = 0.000, respectively) after surgery. However, no significant difference was found between the TXA group and control group regarding the occurrence of thromboembolic events (P = 0.978, including deep vein thrombosis, P = 0.850; pulmonary embolism, P = 0.788; cerebrovascular accident, P = 0.549; myocardial infarction, P = 0.395) and mortality rate (P = 0. 338). Our meta-analysis suggested that administration of TXA is effective in reducing intraoperative blood loss, hidden blood loss, total blood loss, length of stay, transfusion rate, wound complications and enhancing postoperative Hb without increasing the risk of thromboembolic events and mortality rate in intertrochanteric fracture surgery. More large multi-center and high-quality RCTs are required for further research.

Superior Gluteal Artery Bleed After Cephalomedullary Nail Fixation

Background: Hip fracture is a common orthopedic condition that leads to many hospitalizations each year. Intertrochanteric femur fractures are commonly treated with cephalomedullary nail fixation. Superior gluteal artery bleed is a rare complication of cephalomedullary nail fixation, especially when the trochanteric approach is used.

Case Report: A 63-year-old male presented to the emergency department with a right intertrochanteric femur fracture after a fall from standing height. Cephalomedullary nail fixation was performed without any complications during the operation. The patient's postoperative course was complicated by decreasing hemoglobin levels despite blood transfusions. Superior gluteal artery bleed with a large hematoma was discovered on postoperative day 4. The bleed was embolized, and the patient was stabilized and discharged.

Conclusion: We found only 1 published report of a superior gluteal artery bleed associated with nail placement. During the operative procedure, guidewire placement requires careful consideration because of the risk of vascular damage. Superior gluteal artery injury, although rare, should be considered in patients with unstable hemoglobin levels after nail placement.

Effect of types of proximal femoral fractures on physical function such as lower limb function and Activities of Daily Living

OBJECTIVES

This study aimed to assess physical function such as lower limb function and Activities of Daily Living after surgery for proximal femoral fractures ( unstable medial femoral neck fracture and trochanteric fracture).

METHODS

This study enrolled 68 patients with proximal femoral fractures. Isometric knee extension strength (IKES), the Japanese Orthopedic Association (JOA) hip score, and the number of days required to develop straight leg raising, transfer, and T-caneassisted gait abilities to become independent were assessed. Patients were classified based on the types of proximal femoral fractures, namely unstable medial femoral neck fracture (bipolar hip arthroplasty [BHA] group), stable trochanteric fracture (S group), and unstable trochanteric fracture (US group).

RESULTS

IKES and the JOA hip score were significantly better in the BHA group than in the S and US groups. IKES and the JOA hip score were significantly worse in the US group than in the BHA and S groups. Both transfer and T-cane-assisted gait abilities of patients in the BHA and S groups were indifferent. However, all physical functions were significantly worse in the US group.

CONCLUSIONS

Our study results suggested that physical therapists plan the different rehabilitation program for the patients with proximal femoral fractures who were classified into three types, namely unstable medial femoral neck fracture, stable trochanteric fracture, and unstable trochanteric fracture, instead of two types.

Unstable intertrochanteric fractures are associated with a greater hemoglobin drop during the perioperative period: a retrospective case control study

Background

With an increase in the elderly population, the occurrence of hip fractures, femoral neck fractures, and intertrochanteric fractures (ITFs) is also increasing. It is important to establish effective perioperative methods that would help reduce the morbidity and mortality rates associated with ITFs. The purpose of this study was to determine the effects of ITFs according to the AO classification for perioperative hemoglobin drop.

Methods

Seventy-six patients with ITFs classified as AO 31-A1 or A2 and fixated with intramedullary nails participated in this retrospective cohort study. Medical records of these patients were retrospectively reviewed from September 2016 to August 2018. The perioperative hemoglobin drop was chosen as the main outcome measure and calculated as the difference between pre- and postoperative hemoglobin levels. Multivariate linear regression analysis was performed and included the following variables: AO classification (A1.1-A2.1 [stable] vs. A2.2-A2.3 [unstable]), time interval between injury and surgery, age, body mass index, and the use of anticoagulants.

Results

Among the 76 patients who met the inclusion criteria, a significantly higher hemoglobin drop was observed in the AO 31 A2.2-A2.3 (unstable) group than in the AO 31 A1.1-A2.1 (stable) group (p = 0.04). The multivariate analysis also showed a greater hemoglobin drop in the unstable group (p < 0.05).

Conclusions

Patients with unstable ITFs exhibited a greater hemoglobin drop and a hidden blood loss was suspected around the fracture site. We believe that this should be taken into consideration when presurgical blood transfusion is being planned for patients with unstable ITFs, to reduce associated postoperative complications, especially in patients with severe anemia or high risk of mortality.

Identifying a clinical decision tool to predict discharge disposition following operative treatment of hip fractures in the United States

BACKGROUND

Post-discharge management following operative treatment of hip fractures continues to be performed on a case-by-case basis, with no uniform guidelines dictating management. Predicting discharge to post-acute care (PAC) facilities (i.e. skilled nursing facilities and inpatient rehabilitation facilities) can assist preoperative planning and potentially decrease length of stay secondary to disposition issues. The goal of this study was to develop a nomogram using easily identified variables to preoperatively predict discharge disposition following operative treatment of hip fractures.

METHODS

Using the National Surgical Quality Improvement Program database, patients who underwent surgical intervention for hip fractures between 2012 and 2015 were identified. A multivariable logistic regression model was used to identify risk factors for discharge to a PAC facility, and a predictive nomogram was created based on these results.

RESULTS

From 2012 to 2015, 33,371 hip fractures were identified: 13,336 (40%) femoral neck fractures, and 20,035 (60%) intertrochanteric femur fractures. Of the patients identified, 26,082 (78.2%) were discharged to a PAC while the remainder were discharged home with or without home health. 70% of patients were female and 92.4% were Caucasian. When accounting for comorbidities, using the American Society of Anesthesiologists (ASA) classification system, 6,122 patients (18.4%) had 'Mild Systemic Disease' (ASA 2), 20,872 (62.6%) patients had 'Severe Systemic Disease' (ASA 3), and 6,006 (18.1%) had 'Life Threatening Disease' (ASA 4/5). The majority of patients were brought in from a 'Home' setting, while 10.4% of patients were admitted from a 'Long-Term Care' setting. After controlling for confounding variables, older age and increasing ASA class were predictive of an increased risk of discharge to a PAC. Diabetes, dyspnea, congestive heart failure, and chronic obstructive pulmonary disease were not associated with an increased risk of discharge to a PAC.

DISCUSSION

Discharge disposition following operative treatment of hip fractures can be reliably predicted using a nomogram with commonly identified preoperative variables.

LEVEL OF EVIDENCE

Level III, Retrospective Cohort Design, Observational Study.

Safety and efficacy of tranexamic acid with epinephrine for prevention of blood loss following surgery for trochanteric femoral fractures

OBJECTIVE

This study aimed to determine whether the local administration of tranexamic acid (TXA) combined with diluted epinephrine (DEP) reduces blood loss and the need for transfusions compared with the administration of TXA alone following surgery for trochanteric femoral fractures.

METHODS

Hundred patients were enrolled in this study. In the target group (TXA/DEP group: n=50; 19 men and 31 women, mean age 72.5±11.1 years), the surgical sites were injected with 35 mL normal saline mixed with 3 g of TXA with 0.2 mg of DEP at a 1:200,000 dilution (TXA/DEP) immediately after musculoaponeurotic closure. In the control group (TXA group: n=50; 22 men and 28 women; mean age: 70.5±12.2 years), the surgical site was injected with 35 mL normal saline containing 3 g of TXA alone. The main outcome measures were postoperative hemoglobin (Hb) levels, hematocrit, drainage volume, and total blood loss (TBL); the secondary measures included transfusion requirements and perioperative complications.

RESULTS

The mean Hb levels among patients in theTXA/DEP group were significantly lower than among those in the TXA group, measured on postoperative day 1 at 101.0±14.1 g/L vs. 106.9±10.5 g/L and day 3 as 104.2±8.2 g/L vs. 108.5±9.1 g/L, respectively (p<0.05). Drainage volume from the surgical site and TBL measured on postoperative day 2 were also significantly reduced in the TXA/DEP group vs. the TXA group, measured at 71.4±26.0 mL vs. 82.5±24.6 mL and 343.6±148.0 mL vs. 419.6±165.4 mL, respectively (p<0.05). Furthermore, 11 patients (22%) from the TXA group and 15 (30%) from the TXA/DEP group received blood transfusions; the mean number of transfusion events (1.2±0.4 vs. 1.9±0.7) and the amount of blood transfused (1.7±0.5 Units vs. 2.9±1.0 Units) was also markedly reduced in the TXA/DEP group (p<0.05). Two cases in the TXA/DEP group and three in the TXA group were diagnosed with deep vein thrombosis, a difference that did not reach statistical significance (p>0.05).

CONCLUSION

Local administration of TXA with DEP reduced blood loss and limited the need for blood transfusions after surgery for trochanteric femoral fracture without increasing the risk of perioperative complications. Our study indicates that the local administration of TXA/DEP is safe and more effective than the administration of TXA alone in treating trochanteric femoral fractures.

LEVEL OF EVIDENCE

Level III, Therapeutic study.

Risk of Arterial Injury During Hip Internal Fixation

BACKGROUND

Injury to femoral arterial vessels is a risk with internal fixation of the hip. Understanding the anatomy of proximate vessels, particularly medial vessels not directly visualized, may reduce intraoperative and postoperative complications.

METHODS

We analyzed 47 patients (29 men and 18 women) using a computed tomographic (CT) angiogram of the lower limbs. The mean age of our patients was 69 years (range, 46 to 88 years). The distance from the tip of the greater trochanter to the profunda femoris and its perforators within 5 mm of the medial femoral shaft was measured along the length of the expected placement of typical dynamic hip screw constructs and other proximal femoral fracture fixation methods.

RESULTS

All patients were found to have 2 perforator vessels within 5 mm of the medial femoral shaft along the line of dynamic hip screw insertion (up to 200 mm from the tip of the greater trochanter). The first perforator was found at a mean distance of 112.6 mm (median, 110 mm) in women and at 123.4 mm (median, 122 mm) in men (p = 0.0066) from the tip of the greater trochanter. The second perforator appeared at a mean distance of 159.7 mm (median, 159 mm) in women and 178.9 mm (median, 180 mm) in men (p = 0.0028) from the tip of the greater trochanter.

CONCLUSIONS

Surgeons should be aware of the presence of 2 arteries within 5 mm of the medial femoral shaft during femoral internal fixation procedures. We suggest avoiding the overdrilling of the medial cortex and the insertion of overlong screws along the femoral shaft from 110 to 120 mm in women and 120 to 130 mm in men (as measured from the tip of the greater trochanter) to prevent vascular injury during proximal femoral fracture fixation.

CLINICAL RELEVANCE

This article can assist orthopaedic surgeons in planning for procedures involving internal fixation of the hip and may reduce vascular complications from such procedures.

Tranexamic acid can reduce blood loss in patients undergoing intertrochanteric fracture surgery: A meta-analysis

BACKGROUND

This meta-analysis aimed to assess whether administration tranexamic acid (TXA) could reduce blood loss and transfusion requirements in patients undergoing intertrochanteric fracture surgery.

METHODS

We performed an electronic search of PubMed (1950-October 2018), EMBASE (1974-October 2018), the Cochrane Library (October 2018 Issue 3), the Google database (1950-October 2018), and the Chinese Wanfang database (1950-October 2018). Studies were included in accordance with Population, Intervention, Comparison, Outcomes, and Setting (PICOS) including criteria. Intertrochanteric fracture patients prepared for surgery were selected. Administration with TXA and the placebo or no interventions were considered as an intervention and comparators, respectively. Measures related to total blood loss, blood loss in drainage, hemoglobin on postoperative day were analyzed. A fixed/random-effects model was used according to the heterogeneity assessed by the I statistic. Data analysis was performed using Stata 12.0 software.

RESULTS

A total of five RCTs with 584 patients (TXA group = 289, control group = 298) were included in the meta-analysis. Based on the results, administration of TXA was associated with a reduction in total blood loss, blood loss in drainage, need for transfusion, length of hospital stay, and occurrence of hematoma (P < .05). Administration of TXA increased the hemoglobin level at 3 days after surgery (P < .05). There were no significant differences between the two groups in terms of the occurrence of deep venous thrombosis, pulmonary embolism, or infection (P > .05).

CONCLUSION

Administration of TXA is associated with reduced total blood loss, postoperative hemoglobin decline, and transfusion requirements in patients with intertrochanteric fractures. Additional high-quality RCTs should be conducted in the future.