Primary and revision total hip replacement in patients who are Jehovah's Witnesses

Treating Osteoarthritis in Jehovah's Witness Patients

This article addresses the challenges surrounding hip and knee osteoarthritis (OA) treatment in Jehovah's Witnesses (JWs), focusing on the complexities arising from their refusal of blood products and transfusions. Acknowledging the heightened risk of blood loss anemia during joint replacement surgery, this review explores documented strategies that enable safe elective joint arthroplasty in JW patients, emphasizing comparable initial diagnostic methods and non-operative treatments up until the pre-operative stage. Special considerations should be taken in the perioperative and intraoperative stage. Despite these challenges, safe arthroplasty is feasible with satisfactory outcomes through a combination of careful preoperative optimization, blood saving protocols, and cultural sensitivity.

Bloodless Total Hip Arthroplasty in Jehovah's Witness Patients: Contemporary Strategies and Outcomes

BACKGROUND

Reported blood transfusion rates in total hip arthroplasty (THA) range between 3 and 22%. Jehovah's Witnesses (JW) do not accept blood transfusions and make conscience decisions to accept blood derivatives. This study reports on strategies and outcomes for bloodless THA.

METHODS

All JW patients undergoing primary THA at our institution between 2011 and 2022 were included in this study (94 of 110 THA). The indications for THA were osteoarthritis (92%), femoral neck fracture (6%), rheumatoid arthritis (1%), and failed open reduction and internal fixation (1%). Strategies used to optimize outcomes included erythropoietin, tranexamic acid, cell savers, intrailiac artery tourniquets, and minimizing phlebotomy.

RESULTS

The mean estimated blood loss was 201.2 ± 122.2 mL. Preoperative hemoglobin (Hgb) levels were 13.4 ± 1.4 g/dL, which decreased to 11.0 ± 1.3 g/dL on postoperative day 1 (POD1, P < 0.001), 10.3 ± 1.5 g/dL on POD2 (P = 0.001), and 9.8 ± 1.1 g/dL on POD3 (P = 0.171). The use of tranexamic acid significantly decreased Hgb drop on POD1 (P = 0.04). Subgroup analysis showed that preoperatively anemic patients (closed circuit, Hgb < 12 g/dL) had significantly less Hgb drop postoperatively (P = 0.003). No patients met the recommended transfusion threshold (Hgb < 7 g/dL). There were two 90-day readmissions due to falls. There was zero 90-day mortality.

CONCLUSIONS

A THA can be safely performed on JW patients. Preoperatively anemic patients had a decreased Hgb drop postoperatively. JW patients make a conscious decision to accept blood derivatives, which may be present in medications including erythropoietin. We recommend maintaining an Hgb above 11 g/dL prior to surgery, as a Hgb drop of 3.1 g/dL can be expected. These findings highlight the efficacy of a multimodal approach to optimizing bloodless primary THAs.

Revision Total Hip Arthroplasty in Jehovah's Witnesses at a Public Hospital: Practical Recommendations for a Low-Resource Setting

Revision total hip arthroplasty (THA) is a major reconstructive procedure traditionally associated with significant blood loss. Jehovah’s Witnesses (JW) do not accept blood or blood product transfusions because of their religious beliefs. When confronted with a JW patient requiring a complex arthroplasty procedure, surgeons face moral and ethical questions and may be reluctant to perform surgery. A successful outcome depends on several factors including surgical and anesthetic expertise, a range of revision implants, and a multimodal blood management protocol. While these resources are readily available in a developed country, in many of the developing Caribbean islands, the healthcare system is underfunded and under-resourced.

Here, we describe our experience performing a revision THA on a JW patient in the Caribbean. Through this case report, we aim to illustrate our approach to blood management by exploring the fundamental elements that were employed in a low-resource setting. We believe that the extrapolation of these crucial principles to the broader category of primary arthroplasty in the general population can be used to reduce the rate of blood transfusion, increase access to surgery, and improve outcomes.

Life-Threatening Pancreatitis in Jehovah's Witness Patients With Severe Anemia Treated Without Transfusions and by Interventional Radiology Techniques

Blood transfusions in anemic patients frequently are used for critically ill patients as a life-saving therapeutic maneuver. Jehovah's Witness (JW) patients typically refuse blood transfusions due to religious beliefs. Numerous clinical reports, in a wide spectrum of medical specialties, have shown no greater morbidity or mortality in JW patients or others who refused transfusions compared to those patients who accept transfusions. We report our experience with two JW patients who presented with severe anemia and life-threatening pancreatitis. Despite undergoing percutaneous drainages by interventional radiology (IR) for complex pancreatic collections (and other IR drainages), neither patient suffered any adverse effect from the IR procedures, even though they refused blood transfusions. Our experience suggests that IR procedures also may be successful with this more limited blood product protocol.

A protocol avoiding allogeneic transfusion in joint arthroplasties

INTRODUCTION

Arthroplasties of hip and knee are associated with blood loss, which may lead to adverse patient outcome. Performing arthroplasties in Jehovah's Witness patients who do not accept transfusion has been a matter of concern. We developed a protocol, which avoids transfusion in arthroplasties of Jehovah's Witness patients, and evaluated the feasibility and safety of the protocol.

MATERIALS AND METHODS

The target of preoperative hemoglobin was more than 10 g/dL. When preoperative hemoglobin was lower than 10 g/dL, 4000 U erythropoietin (3 times a week) and 100 mg iron supplement (every day) were administered until the hemoglobin reached 10 g/dL. When the preoperative hemoglobin was higher than 10 g/dL, 4000 U erythropoietin and 100 mg iron supplement were administered once, before operation. During the operation, cell saver was used. Postoperatively, erythropoietin and iron supplements were administered until the hemoglobin reached 10 g/dL, similar to the preoperative protocol. We evaluated the feasibility of our protocol, perioperative complications and hematologic changes.

RESULTS

From 2002 to 2014, 186 Witness patients visited our department. In 179 patients (96.2 %), 77 total knee arthroplasties, 69 bipolar hemiarthroplasties and 33 total hip arthroplasties were performed. The mean hemoglobin level was 12.3 g/dL preoperatively, 9.4 g/dL on postoperative day 3 and 10.3 g/dL on postoperative day 7. One patient died immediately after the arthroplasty and the remaining 178 patients survived.

CONCLUSIONS

Total joint arthroplasty could be done without transfusion using this protocol in most of our patients. The rates of infection and mortality were similar with known infection and mortality rates of arthroplasties. In patients who do not want allogeneic transfusions, our protocol is a safe alternative to perform joint arthroplasties.

Massive Blood Transfusion during Revision Total Hip Arthroplasty under Combined Spinal Epidural Anaesthesia

Revision total hip arthroplasty (THA) is an orthopaedic surgery that is known to be associated with excessive bleeding. The rates of mortality and morbidity are high in patients with massive haemorrhage. The patient in this study was administered blood products with high fresh frozen plasma/red blood cell (RBC) suspension ratio and high platelet/RBC suspension ratio without waiting for haemostasis test results. This study suggests that this approach might prove beneficial in reducing the incidence of intra- and postoperative complications. this study presents our experience with a patient who underwent THA and required a transfusion that was three times her estimated total blood volume. The patient was successfully managed with close monitoring of haemorrhage and timely administration of blood and blood products before hypotension and loss of consciousness occurred.

Is total hip arthroplasty a successful and safe procedure in Jehovah's Witnesses? Mean five-year results

Total hip arthroplasty (THA) can be challenging in Jehovah's Witnesses because of the potential for blood loss. Because these patients will not accept blood transfusions, multiple strategies to prevent blood loss have been developed. The purpose of this study was to report implant survivorship, clinical outcomes, radiographic outcomes, morbidity, and mortality of Jehovah's Witnesses undergoing primary THA. Databases from two institutions were reviewed to identify 53 patients (55 hips) who were Jehovah's Witnesses and had a primary total hip arthroplasty. There were 27 women and 26 men who had a mean age of 63 years (range 35-94 years), and a mean follow-up of 63 months (range 24-120 months). All Jehovah's Witnesses had a comprehensive perioperative blood management strategy employed by a coordinated medical and surgical team. Mean post-operative Harris Hip Scores were 86 points, and implant survivorship was 97%. There were two aseptic revisions for osteolysis and component loosening. There were no mortalities, and three minor surgical and two minor medical complications occurred during the study. Excellent clinical outcomes were found for Jehovah's Witness undergoing total hip arthroplasty using a comprehensive blood management protocol. We believe that the use of a specialised blood management protocol involving a team approach to preoperative evaluation, appropriate anaesthesia, and surgical and postoperative management was responsible for minimising complications. Total hip arthroplasty is safe and efficacious in this patient group if proper preoperative safeguards are utilised.

Revision total hip arthroplasty in Jehovah's Witnesses

Revision total hip arthroplasty (THA) is associated with greater blood loss than primary THA. Jehovah's Witnesses will not accept transfusions of blood or blood products and are thus at an increased risk for complications due to perioperative anemia. The purpose of this study was to report the clinical outcomes, radiographic outcomes, morbidity, and mortality of Jehovah's Witnesses who were medically optimized and underwent revision THA. Databases from 2 institutions were reviewed to identify 10 patients (11 THAs) who were Jehovah's Witnesses undergoing revision THA with a minimum 24-month follow-up. At most recent follow-up, all patients were doing well clinically, with Harris Hip Scores greater than 80 points. Radiographic evaluation demonstrated well-positioned components and no progressive radioluciencies. No major perioperative medical or surgical complications occurred in patients undergoing THA. Revision THA for aseptic causes results in good clinical outcomes in patients who are preoperatively optimized before undergoing surgery.

Erythropoietin use and abuse

Recombinant human erythropoietin (rhEPO) is arguably the most successful therapeutic application of recombinant DNA technology till date. It was isolated in 1977 and the gene decoded in 1985. Since then, it has found varied applications, especially in stimulating erythropoiesis in anemia due to chronic conditions like renal failure, myelodysplasia, infections like HIV, in prematurity, and in reducing peri-operative blood transfusions. The discovery of erythropoietin receptor (EPO-R) and its presence in non-erythroid cells has led to several areas of research. Various types of rhEPO are commercially available today with different dosage schedules and modes of delivery. Their efficacy in stimulating erythropoiesis is dose dependent and differs according to the patient's disease and nutritional status. EPO should be used carefully according to guidelines as unsolicited use can result in serious adverse effects. Because of its capacity to improve oxygenation, it has been abused by athletes participating in endurance sports and detecting this has proved to be a challenge.

Blood management for hip reconstruction surgery

Blood conservation techniques are well established and have significant benefits. We review the current literature on these techniques and their applicability to hip reconstruction surgery and offer a suitable strategy to minimize allogeneic red cell transfusion.

Strategies for blood management in orthopaedic and trauma surgery

Several aspects of the management of an orthopaedic surgical patient are not directly related to the surgical technique but are nevertheless essential for a successful outcome. Blood management is one of these. This paper considers the various strategies available for the management of blood loss in patients undergoing orthopaedic and trauma surgery.

Right trisectionectomy of the liver for intrahepatic cholangiocarcinoma with bile duct invasion in a Jehovah's Witness

Intrahepatic cholangiocarcinoma (ICC) is well known to have a very poor prognosis. Aggressive surgical strategies in the treatment of ICC, including major hepatectomy, have been reported to afford patients the best chance for significant survival. Recent advancements in surgical techniques concerning live donor liver transplantation have dramatically improved the results of major hepatectomy. However, surgical treatment of biliary malignancy is complex and is known to increase the likelihood of blood transfusion. We describe a Jehovah's Witness patient with ICC and concomitant bile duct invasion who had a successful right trisectionectomy with bile duct resection, lymph node dissection, and Rouxen-Y hepatico-jejunostomy without blood transfusion. A multidisciplinary preparation was crucial in obtaining this positive outcome. Importantly, bloodless liver transection techniques with inflow clamping, meticulous dissection, and hemostasis should be utilized for major hepatectomy in a Jehovah's Witness. The success of this case may alert clinicians to consider a hepatectomy as a possible option in the treatment of ICC in a Jehovah's Witness.

Meeting the clinical challenge of care for Jehovah’s Witnesses1 1Editor’s Note: This article represents the current position of the Watch Tower Society on the use of blood components and fractions in the care of patients who are Jehovah’s Witnesses

Quality patient care entails more than simply biomedical interventions. Respect for the wishes, values, and preferences of patients are important elements of quality care. Unique aspects of the beliefs of Jehovah's Witnesses may present physicians with ethical and clinical conflicts. Witnesses believe that allogeneic blood transfusion (ie, whole blood, red blood cells, white cells, platelets, and plasma) and preoperative autologous blood deposit (PAD) are prohibited by several Biblical passages. This article reviews the Witness position on medical care, blood components, and fractions, placing these and related interventions into categories that may help physicians to individualize clinical management plans and meet the challenge of caring for patients who are Jehovah's Witnesses. It includes an overview of cost, safety, efficacy, and medicolegal issues related to patient care using transfusion-alternative strategies.

Recombinant erythropoietin in clinical practice

The introduction of recombinant human erythropoietin (RHuEPO) has revolutionised the treatment of patients with anaemia of chronic renal disease. Clinical studies have demonstrated that RHuEPO is also useful in various non-uraemic conditions including haematological and oncological disorders, prematurity, HIV infection, and perioperative therapies. Besides highlighting both the historical and functional aspects of RHuEPO, this review discusses the applications of RHuEPO in clinical practice and the potential problems of RHuEPO treatment.

Rapid sequence quadruple joint replacement in a rheumatoid Jehovah's Witness

We report the case of a wheelchair-bound rheumatoid Jehovah's Witness who underwent rapid sequence, staged, simultaneous ipsilateral hip and knee replacements. Using perioperative erythropoietin and postoperative blood salvage, all four joints were reconstructed without homologous blood transfusion. One year following surgery, the patient has achieved an independent functional status, and all four replaced joints remain painless.

The theory and practice of bloodless surgery

The application of blood conservation strategies to minimise or avoid allogeneic blood transfusion is seen internationally as a desirable objective. Bloodless surgery is a relatively new practice that facilitates that goal. However, the concept is either poorly understood or evokes negative connotations. Bloodless surgery is a term that has evolved in the medical literature to refer to a peri-operative team approach to avoid allogeneic transfusion and improve patient outcomes. Starting as an advocacy in the early 1960s, it has now grown into a serious practice being embraced by internationally respected clinicians and institutions. Central to its success is a coordinated multidisciplinary approach. It encompasses the peri-operative period with surgeons, anaesthetists, haematologists, intensivists, pathologists, transfusion specialists, pharmacists, technicians, and operating room and ward nurses utilising combinations of the numerous blood conservation techniques and transfusion alternatives now available. A comprehensive monograph on the subject of bloodless surgery along with detailed coverage of risks and benefits of each modality (some modalities are discussed in more detail elsewhere in this issue) is beyond the scope of this article. Accordingly, a brief overview of the history, theory and practice of bloodless surgery is presented, along with the clinical and institutional management requirements.