Efficacy of intraoperative red blood cell salvage and autotransfusion in the treatment of acetabular fractures

Effect of different anesthetic modalities on postoperative delirium in elderly hip fractures: A meta-analysis

BACKGROUND

Previous findings on the effect of general versus spinal anesthesia on postoperative delirium in elderly people with hip fractures are somewhat controversial. This article included the latest randomized controlled study for meta-analysis to evaluate the effect of general anesthesia (GA) and spinal anesthesia (SA) on delirium after hip fracture surgery in the elderly, so as to guide the clinical.

METHODS

Cochrane Library, PubMed, Web Of Science, and Embase were searched from inception up to January 16, 2024. Randomized controlled trial (RCT) was included to evaluate the postoperative results of GA and SA in elderly patients (≥50 years old) undergoing hip fracture surgery. Two researchers independently screened for inclusion in the study and extracted data. Heterogeneity was assessed by the I²and Chi-square tests, and P < .1 or I² ≥ 50% indicated marked heterogeneity among studies. The Mantel-Haenszel method was used to estimate the combined relative risk ratio (RR) and the corresponding 95% confidence interval (CI) for the binary variables.

RESULTS

Nine randomized controlled trials were included. There was no significant difference (RR = 0.93, 95% CI = 0.774-1.111, P > .05) in the incidence of postoperative delirium between the GA group and the SA group. In intraoperative blood transfusion (RR = 1.0, 95% CI = 0.77-1.28, Z = 0.04, P = .971), pulmonary embolism (RR = 0.795, 95% CI = 0.332-1.904, Z = 0.59, P = .606), pneumonia (RR = 1.47, 95% CI = 0.75-2.87, P = .675), myocardial infarction (RR = 0.97, 95% CI = 0.24-3.86, Z = 0.05, P = .961), heart failure (RR = 0.80, 95% CI = 0.26-2.42, Z = 0.40, P = .961), urinary retention (RR = 1.42, 95% CI = 0.77-2.61, Z = 1.11, P = .267) were similar between the 2 anesthetic techniques.

CONCLUSION

There is no significant difference in the effect of GA and SA on postoperative delirium in elderly patients with hip fracture, and their effects on postoperative complications are similar.

Cost-Effectiveness of Cell Salvage in Trauma Blood Transfusions

INTRODUCTION

Despite the increasing amount of evidence supporting its use, cell salvage (CS) remains an underutilized resource in operative trauma care in many hospitals. We aim to evaluate the utilization of CS in adult trauma patients and associated outcomes to provide evidence-based recommendations.

METHODS

A systematic review was conducted using PubMed, Google Scholar, and CINAHL. Articles evaluating clinical outcomes and the cost-effectiveness of trauma patients utilizing CS were included. The primary study outcome was mortality rates. The secondary outcomes included complication rates (sepsis and infection) and ICU-LOS. The tertiary outcome was the cost-effectiveness of CS.

RESULTS

This systematic review included 9 studies that accounted for a total of 1119 patients that received both CS and allogeneic transfusion (n = 519), vs allogeneic blood transfusions only (n = 601). In-hospital mortality rates ranged from 13% to 67% in patients where CS was used vs 6%-65% in those receiving allogeneic transfusions only; however, these findings were not significantly different (P = .21-.56). Similarly, no significant differences were found between sepsis and infection rates or ICU-LOS in those patients where CS usage was compared to allogeneic transfusions alone. Of the 4 studies that provided comparisons on cost, 3 found the use of CS to be significantly more cost-effective.

CONCLUSIONS

Cell salvage can be used as an effective method of blood transfusion for trauma patients without compromising patient outcomes, in addition to its possible cost advantages. Future studies are needed to further investigate the long-term effects of cell salvage utilization in trauma patients.

Perioperative management of acetabular and pelvic fractures: evidence-based recommendations

PURPOSE

The American Academy of Orthopaedic Surgeons does not currently provide clinical practice guidelines for management of PAF. Accordingly, this article aims to review and consolidate the relevant historical and recent literature in important topics pertaining to perioperative management of PAF.

METHODS

A thorough literature review using PubMed, Cochrane and Embase databases was performed to assess preoperative, intraoperative and postoperative management of PAF fracture. Topics reviewed included: time from injury to definitive fixation, the role of inferior vena cava filters (IVCF), tranexamic acid (TXA) use, intraopoperative cell salvage, incisional negative pressure wound therapy (NPWT), intraoperative antibiotic powder use, heterotopic ossification prophylaxis, and pre- and postoperative venous thromboembolism (VTE) prophylaxis.

RESULTS

A total of 126 articles pertaining to the preoperative, intraoperative and postoperative management of PAF were reviewed. Articles reviewed by topic include 13 articles pertaining to time to fixation, 23 on IVCF use, 14 on VTE prophylaxis, 20 on TXA use, 10 on cell salvage, 10 on iNPWT 14 on intraoperative antibiotic powder and 20 on HO prophylaxis. An additional eight articles were reviewed to describe background information. Five articles provided information for two or more treatment modalities and were therefore included in multiple categories when tabulating the number of articles reviewed per topic.

CONCLUSION

The literature supports the use of radiation therapy for HO prophylaxis, early (< 5 days from injury) surgical intervention and the routine use of intraoperative TXA. The literature does not support the routine use of iNPWT or IVCF. There is inadequate information to make a recommendation regarding the use of cell salvage and wound infiltration with antibiotic powder. While the routine use of chemical VTE prophylaxis is recommended, there is insufficient evidence to recommend the optimal agent and duration of therapy.

Efficacy of Red Cell Salvage Systems in Open Acetabular Surgery

Over the past 50 years, treatment of displaced acetabular fractures has moved away from conservative treatment with bedrest to operative intervention to achieve anatomic reduction, stable fixation, and allow early range of motion of the hip. However, operative fixation is not without complications. Internal fixation of traumatic acetabular fractures has been coupled with large volume of blood loss both at the time of injury and surgery. This often results in the need for allogenic blood products, which has been linked to increase morbidity (Vamvakas and Blajchman, 2009). In an attempt to avoid the risk associated with allogenic blood transfusion numerous techniques and methods have been devised. Red blood cell salvage (CS) is an intraoperative blood salvage tool where blood is harvested from the operative field. It is washed to remove the plasma, white blood cells, and platelets. The red cells are resuspended in a crystalloid solution. If the hematocrit of the resuspended red blood cells is sufficient, it is transfused to the patient intravenously. The benefits of CS in major spine surgery, bilateral knee replacement, and revision hip surgery are well established (Goulet et al. 1989, Gee et al. 2011, Canan et al. 2013). However, literature reviewing the use of cell saver in orthopedic trauma surgery, specifically acetabular surgery is limited. Our institute performed a retrospective review of 63 consecutive operative acetabular fractures at a level one trauma center. Our study revealed that patients with blood loss of less than 400 mL were 13 times less likely to receive autologous blood, and patients with hemoglobin less than 10.5 were 5 times less likely to receive autologous transfusion (p < 0.05). We also found that no patients with a hemoglobin level less than 10.5 and EBL less than 400 mL received autologous blood return. Autologous blood transfusion had no effect on volume or rate of allogenic blood transfusion. We believed that if a patient's preoperative hemoglobin is less than 10.5 or expected blood loss is less than 400 mL, then CS should have a very limited role, if any, in the preoperative blood conservation strategy. We found ASA greater than 2, BMI greater than 24 and associated fracture type to be a risk factor for high blood loss.

The acetabular roof reinforcement plate for the treatment of displaced acetabular fractures in the elderly: results in 59 patients

INTRODUCTION

Open reduction and internal fixation is considered the gold standard of treatment for displaced acetabular fractures in younger patients. For elderly patients with osteoporotic bone quality, however, primary total hip arthroplasty (THA) with the advantage of immediate postoperative mobilization might be an option. The purpose of this study was to evaluate the clinical and radiological outcomes of surgical treatment of displaced osteoporotic acetabular fractures using the acetabular roof reinforcement plate (ARRP) combined with THA.

MATERIALS AND METHODS

Between 2009 and 2019, 84 patients were operated using the ARRP combined with THA. Inclusion criteria were displaced osteoporotic fractures of the acetabulum with or without previous hemi- or total hip arthroplasty, age above 65 years, and pre-injury ability to walk at least with use of a walking frame. Of the 84 patients, 59 could be followed up after 6 months clinically and radiographically. Forty-nine (83%) were primary fractures and 10 (17%) periprosthetic acetabular fractures.

RESULTS

The mean age was 80.5 years (range 65-98 years). The average time from injury to surgery was 8.5 days (range 1-28). Mean time of surgery was 167 min (range 100-303 min). Immediate postoperative full weight bearing (FWB) was allowed for 51 patients (86%). At the 6-month follow-up, all 59 patients except one showed bony healing and incorporation of the ARRP. One case developed a non-union of the anterior column. No disruption, breakage or loosening of the ARRP was seen. Additional CT scans performed in 18 patients confirmed bony healing. Twenty-six patients (44%) had regained their pre-injury level of mobility. Complications requiring revision surgery occurred in 8 patients. Five of them were suffering from a prosthetic head dislocation, one from infection, one from hematoma and one from a heterotopic ossification.

CONCLUSIONS

The ARRP has proven to provide sufficient primary stability to allow for immediate FWB in most cases and represents a valuable option for the surgical management of displaced acetabular fractures in this challenging patient group.

Ability of a Machine Learning Algorithm to Predict the Need for Perioperative Red Blood Cells Transfusion in Pelvic Fracture Patients: A Multicenter Cohort Study in China

Background: Predicting the perioperative requirement for red blood cells (RBCs) transfusion in patients with the pelvic fracture may be challenging. In this study, we constructed a perioperative RBCs transfusion predictive model (ternary classifications) based on a machine learning algorithm.

Materials and Methods: This study included perioperative adult patients with pelvic trauma hospitalized across six Chinese centers between September 2012 and June 2019. An extreme gradient boosting (XGBoost) algorithm was used to predict the need for perioperative RBCs transfusion, with data being split into training test (80%), which was subjected to 5-fold cross-validation, and test set (20%). The ability of the predictive transfusion model was compared with blood preparation based on surgeons' experience and other predictive models, including random forest, gradient boosting decision tree, K-nearest neighbor, logistic regression, and Gaussian naïve Bayes classifier models. Data of 33 patients from one of the hospitals were prospectively collected for model validation.

Results: Among 510 patients, 192 (37.65%) have not received any perioperative RBCs transfusion, 127 (24.90%) received less-transfusion (RBCs < 4U), and 191 (37.45%) received more-transfusion (RBCs ≥ 4U). Machine learning-based transfusion predictive model produced the best performance with the accuracy of 83.34%, and Kappa coefficient of 0.7967 compared with other methods (blood preparation based on surgeons' experience with the accuracy of 65.94%, and Kappa coefficient of 0.5704; the random forest method with an accuracy of 82.35%, and Kappa coefficient of 0.7858; the gradient boosting decision tree with an accuracy of 79.41%, and Kappa coefficient of 0.7742; the K-nearest neighbor with an accuracy of 53.92%, and Kappa coefficient of 0.3341). In the prospective dataset, it also had a food performance with accuracy 81.82%.

Conclusion: This multicenter retrospective cohort study described the construction of an accurate model that could predict perioperative RBCs transfusion in patients with pelvic fractures.

Hypotensive Anesthesia does not reduce Transfusion Rates during and after Acetabular Fracture Surgery

BACKGROUND

Acetabular fracture open reduction and internal fixation (ORIF) is generally associated with high intraoperative blood loss. Hypotensive anesthesia has been shown to decrease blood loss and intraoperative transfusion in total joint arthroplasty and posterior spinal fusion. In this study, we assessed the effect of reduction in intraoperative mean arterial pressures (MAPs) during acetabular fracture surgery on intraoperative blood loss and need for transfusion.

METHODS

Three hundred and one patients with acetabular fractures who underwent ORIF at an academic Level 1 trauma center were retrospectively reviewed. Patients were separated based on mean intraoperative MAPs (<60 mmHg, 60-70 mmHg, >70 mmHg). Thirteen patients had mean intraoperative MAP <60 mmHg, 95 had MAP 60-70 mmHg, and 193 had MAP >70 mmHg. Rates of intraoperative and postoperative allogeneic blood transfusion were compared.

RESULTS

Mean intraoperative MAPs were significantly different between groups (p < 0.0001). Time from injury to surgery, estimated blood loss, operative time and intraoperative IV fluids were comparable. The proportion of patients who received blood transfusion and mean units transfused intraoperatively and postoperatively were similar between groups. Mean differences in preoperative and postoperative hemoglobin and hematocrit were also similar. There was no difference in hospital length of stay or perioperative complications between the groups. Multivariate logistic regression analysis demonstrated that body mass index > 30 (p < 0.05) and anterior surgical approach (p < 0.01) were independently associated with intraoperative transfusion and an anterior surgical approach (p < 0.001) was independently associated with postoperative transfusion.

CONCLUSION

Decreased intraoperative MAP during acetabular fracture surgery does not reduce blood loss or need for transfusion. On the other hand, no increased end-organ ischemia was seen with hypotensive anesthesia.

LEVEL OF EVIDENCE

Therapeutic Level III.

Tranexamic acid does not affect intraoperative blood loss or in-hospital outcomes after acetabular fracture surgery

PURPOSE

Tranexamic acid (TXA) reduces need for transfusion in total joint arthroplasty, though findings in acetabular surgery are conflicting. We compared outcomes after acetabular fracture surgery with or without perioperative intravenous (IV) TXA administration.

METHODS

We performed a retrospective review of 305 patients with acetabular fractures that underwent open reduction and internal fixation (ORIF). Eighty-nine patients received TXA, and 216 did not. The primary outcome was rates of intraoperative and postoperative allogeneic blood transfusion.

RESULTS

Baseline demographics and characteristics were similar. Time from injury to surgery and estimated blood loss were comparable. Operative time (p < 0.01) and intraoperative IV fluids (p < 0.01) were greater in the non-TXA group. The proportion of patients who received blood transfusion and mean units transfused intraoperatively and postoperatively did not differ. Mean differences in preoperative and postoperative hemoglobin and hematocrit, hospital length of stay, and perioperative complications also did not differ. In a multivariable regression model, age 60-70 years, Charlson Comorbidity Index, Injury Severity Score, and fracture patterns likely to bleed were independently associated with intraoperative transfusion. Anterior surgical approaches and intraoperative transfusion requirement were independently associated with postoperative transfusion.

CONCLUSION

In this study, perioperative IV TXA did not decrease blood loss, need for transfusion, or improve in-hospital outcomes of acetabular fracture surgery. Age 60-70, CCI, ISS, and fracture patterns likely to bleed were independently associated with intraoperative transfusion. Anterior surgical approach and need for intraoperative transfusion were independently associated with postoperative transfusion. Further prospective trials are warranted to confirm these findings.

Tranexamic Acid Use in Open Reduction and Internal Fixation of Fractures of the Pelvis, Acetabulum, and Proximal Femur: A Randomized Controlled Trial

OBJECTIVE

To assess the safety and efficacy of tranexamic acid (TXA) use in fractures of the pelvic ring, acetabulum, and proximal femur.

DESIGN

Prospective, randomized controlled trial.

SETTING

Single Level 1 trauma center.

PATIENTS

Forty-seven patients were randomized to the study group, and 46 patients comprised the control group.

INTERVENTION

The study group received 15 mg/kg IV TXA before incision and a second identical dose 3 hours after the initial dose.

MAIN OUTCOME MEASUREMENTS

Transfusion rates and total blood loss (TBL) [via hemoglobin-dilution method and rates of venous thromboembolic events (VTEs)].

RESULTS

TBL was significantly higher in the control group (TXA = 952 mL, no TXA = 1325 mL, P = 0.028). The total transfusion rates between the TXA and control groups were not significantly different (TXA 1.51, no TXA = 1.17, P = 0.41). There were no significant differences between the TXA and control groups in inpatient VTE events (P = 0.57).

CONCLUSION

The use of TXA in high-energy fractures of the pelvis, acetabulum, and femur significantly decreased calculated TBL but did not decrease overall transfusion rates. TXA did not increase the rate of VTE. Further study is warranted before making broad recommendations for the use of TXA in these fractures.

LEVEL OF EVIDENCE

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

Intraoperative cell salvage use reduces the rate of perioperative allogenic blood transfusion in patients undergoing periacetabular osteotomy

Blood loss during periacetabular osteotomy (PAO) is variable, with losses ranging from 100 to 3900 ml in published series. Perioperative allogenic blood transfusion is frequently utilized although is associated with significant risk of morbidity. Cell salvage (CS) is a common blood conservation tool; however, evidence supporting its use with PAO is lacking. Our aim was to assess whether CS affects perioperative allogenic blood transfusion rate in patients undergoing PAO. The clinical records of 58 consecutive PAOs in 54 patients (median age 24.7 years, interquartile range 17.8-29.4 years) performed by a single surgeon between 1 January 2016 and 30 April 2018 were reviewed. Autologous blood pre-donation and surgical drains were not used. Due to variable technician availability, CS was intermittently used during the study period. PAOs were allocated into a CS group or no cell salvage group (NCS group), according to whether an intraoperative CS system was used. There was no significant difference in patient age, gender, body mass index, dysplasia severity, regional anesthetic technique, tranexamic acid administration, surgical duration or estimated blood loss (all P > 0.05) between the two groups. The CS group had a lower preoperative hemoglobin compared to the NCS group (median, 13.4 g/dl versus 14.4 g/dl, P = 0.006). The incidence of allogenic blood transfusion was significantly lower in the CS group compared to the NCS group (2.5% versus 33.3% patients transfused, P = 0.003). Multivariate modeling showed CS use to be protective against allogenic blood transfusion (P = 0.003), with an associated 80-fold reduction in the odds of transfusion (odds ratio, 0.01; 95th% CI, 0-0.57). To our knowledge, this is the first study to assess the effect of CS use on allogenic transfusion rate in patients undergoing PAO. Our results demonstrate CS to be a mandatory component of blood conservation for all patients undergoing PAO.

Effect of Tranexamic Acid on Transfusion: A Randomized Clinical Trial in Acetabular Fracture Surgery

OBJECTIVES

Given the increasing evidence that minimizing blood loss and limiting allogeneic transfusion can improve patient outcome, we are performing a randomized controlled trial of the use of tranexamic acid (TXA) during acetabular fracture surgery.

DESIGN

Prospective, multicenter, and randomized.

SETTING

Two level I trauma centers.

PARTICIPANTS

Eighty-eight patients underwent randomization, with 42 assigned to the TXA group and 46 assigned to the placebo group.

INTERVENTION

The use of TXA during acetabular fracture surgery.

MAIN OUTCOME MEASUREMENTS

The primary outcome was allogeneic blood transfusion. Secondary outcomes consisted of estimate blood loss (EBL) and venous thromboembolism (VTE).

RESULTS

The overall transfusion rate was 40.9% (36 of 88), and the average estimated blood loss was 635 mL. There were no significant differences between groups for transfusion incidence, number of units transfused, EBL, or incidence of VTE. There was no difference in transfusion rate for the TXA group (0.097). Transfusion was significantly more likely in cases with low preoperative hemoglobin levels, higher rates of intraoperative blood loss, and longer surgical times.

CONCLUSIONS

There was no significant difference in transfusion rate, EBL, or VTE for TXA versus placebo. Any potential benefit seems to be overwhelmed by other factors, specifically preoperative anemia and surgical time, which are highly variable in trauma surgery. These findings do not support the routine use of TXA in the setting of open reduction and internal fixation of acetabular fractures.

LEVEL OF EVIDENCE

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

Treatment of acetabular fractures in older patients-introduction of a new implant for primary total hip arthroplasty

BACKGROUND

Fractures of the acetabulum in younger patients are commonly treated by open reduction and internal fixation. For elderly patients, stable primary total hip arthroplasty with the advantage of immediate postoperative mobilization might be the adequate treatment. For this purpose, a sufficiently stable fixation of the acetabular component is required.

MATERIALS AND METHODS

Between August 2009 and 2014, 30 cases were reported in which all patients underwent total hip arthroplasty additionally to a customized implant designed as an antiprotrusion cage. Inclusion criteria were an acetabular fracture with or without a previous hemiarthroplasty, age above 65 years, and pre-injury mobility dependent on a walking frame at the most. The median age was 79.9 years (65-92), and of 30 fractures, 25 were primary acetabular fractures (83%), four periprosthetic acetabular fractures (14%), and one non-union after a failed ORIF (3%).

RESULTS

The average time from injury to surgery was 9.4 days (3-23) and 295 days for the non-union case. Mean time of surgery was 154.4 min (range 100 to 303). In 21 cases (70%), mobilization with full weight bearing was possible within the first 10 days. Six patients died before the follow-up examination 3 and 6 months after surgery, while 24 patients underwent radiologic examination showing consolidated fractures in bi-plane radiographs. In 9 patients, additional CT scan was performed which confirmed the radiographical results. 13 had regained their pre-injury level of mobility including the non-union case. Only one patient did not regain independent mobility. Four complications were recognized with necessary surgical revision (one prosthetic head dislocation, one pelvic cement leakage, one femoral shaft fracture, and one infected hematoma).

CONCLUSION

The presented cage provides the possibility of early mobilization with full weight bearing which represents a valuable addition to the treatment spectrum in this challenging patient group.

Cost Savings Opportunities in Perioperative Management of the Patients With Orthopaedic Trauma

Considerable opportunities for cost savings exist surrounding the perioperative management of patients with orthopaedic fracture and trauma. Scientific evidence is available to support each potential cost savings measure. Much of these data had been documented for years but has never been adhered to, resulting in millions of dollars in unnecessary testing and treatment. Careful attention to preoperative laboratory testing can save huge amounts of money and expedite medical clearance for injured patients. The use of a dedicated orthopaedic trauma operating room has been shown to improve resource utilization, decrease costs, and surgical complications. A variety of anesthetic techniques and agents can reduce operative time, recovery room time, and hospital lengths of stay. Strict adherence to blood utilization protocols, appropriate deep venous thrombosis prophylaxis, and multimodal postoperative pain control with oversight from dedicated hip fracture hospitalists is critical to cost containment. Careful attention to postoperative disposition to acute care and management of postoperative testing and radiographs can also be another area of cost containment. Institutional protocols must be created and followed by a team of orthopaedic surgeons, hospitalists, and anesthesiologists to significantly impact the costs associated with care of patient with orthopaedic trauma and fracture.

Operating Room Supply Costs in Orthopaedic Trauma: Cost Containment Opportunities

In the current health care environment, cost containment is more important than ever. Most physicians currently are unaware of the cost of operating room supplies. A large amount of waste occurs secondary to lack of knowledge and absence of physician incentives for cost saving. Many of the decisions for supply use can be based on good scientific evidence, which supports specific cost saving measures. Careful attention to blood utilization and use of tranexamic acid has the potential to save millions in the hip fracture treatment and arthroplasty treatments. Standardization of surgical preparation and draping can decrease costs and prevent costly surgical site infections. Following protocols and guidelines for bone graft and orthobiologics is critical. The clinical and legal repercussions of retained instruments and costs associated with dropped implants is a huge source of wasted health care dollars. Reprocessing programs for external fixators and tourniquets have been extremely successful. A myriad of opportunities for intraoperative cost savings exist that could be applied to nearly every orthopaedic surgery performed in the United States. It is incumbent on all surgeons to put aside the choices made out of habit and take part in reducing operating room waste for the benefit of hospitals, patients, and the health care system. When applied to the 5.3 million orthopaedic surgeries performed annually in the United States, billions of dollars could easily be saved with no adverse effect on patient care.

[Two-year experience with cell salvage in total hip arthroplasty]

BACKGROUND AND OBJECTIVE

The aim of this study was to determine the efficacy of the cell salvage system in total hip arthroplasty surgeries and whether the cell salvage system can reduce the allogeneic blood transfusion requirement in total hip arthroplasty patients.

METHODS

We reviewed retrospectively the medical records of patients who underwent hip arthroplasty surgeries between 2010 and 2012 in a university hospital. A total of 181 arthroplasty patients were enrolled in our study.

RESULTS

In the cell salvage group, the mean perioperative rate of allogeneic blood transfusion was significantly lower (92.53±111.88mL) than that in the control group (170.14±116.79mL; p<0.001). When the mean postoperative transfusion rates were compared, the cell salvage group had lower values (125.37±193.33mL) than the control group (152.22±208.37mL), although the difference was not statistically significant. The number of patients receiving allogeneic blood transfusion in the CS group (n=29; 43.2%) was also significantly lower than control group (n=56; 73.6%; p<0.05). In the logistic regression analysis, perioperative amount of transfusion, odds ratio (OR) -4.257 (95% CI -0.502 to 0.184) and operation time, OR: 2.720 (95% CI 0.001-0.004) were independent risk factors for the usage of cell salvage system.

CONCLUSION

Cell salvage is an effective strategy for reducing the need for allogeneic blood transfusion in the perioperative setting; it provides support to patient blood management interventions. Thus, we recommend the cell salvage system for use in total hip arthroplasty surgeries to reduce the need for allogeneic blood transfusion, if possible.

Cell Saver Use in Acetabular Surgery: Does Approach Matter?

OBJECTIVE

To determine if intraoperative autologous transfusion using a Cell Saver (CS) was routinely indicated for open reduction internal fixation (ORIF) of acetabular fractures, and if so, was there a difference between differing surgical approaches.

DESIGN

Retrospective single-center cohort study.

SETTING

University Level 1 trauma center.

PATIENTS/PARTICIPANTS

One hundred forty-five consecutive acetabular fractures using intraoperative autologous transfusion, either treated with an anterior ilioinguinal or a posterior-based Kocher-Langenbeck approach, were compared.

INTERVENTION

Use of CS in ORIF acetabular cases.

MAIN OUTCOME MEASUREMENTS

CS utilization and CS blood return for acetabular ORIF. Mean intraoperative blood loss between the 2 approaches.

RESULTS

CS blood was returned in 29 of the 145 total cases [23/65 anterior (ilioinguinal approach) and 6/80 posterior approach (Kocher-Langenbeck)]. Mean intraoperative blood loss was 786 mL for the anterior approach and 485 mL for the posterior approach. Subgroup analysis identified anterior approach as the only risk factor for elevated blood loss and CS blood return.

CONCLUSIONS

CS is not indicated for routine use when performing ORIF of the acetabulum. Use of the CS may be warranted with anterior approaches if large amounts of blood loss are anticipated.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

A growing problem: acetabular fractures in the elderly and the combined hip procedure

Acetabular fractures in the elderly are most frequently the result of low-energy trauma and present unique management challenges to orthopedic surgeons. Evaluation and treatment should be performed in a multidisciplinary fashion with early involvement of internal medicine subspecialists and geriatricians. Distinct fracture patterns and pre-existing osteoarthritis and osteoporosis necessitate careful preoperative planning. The role of total hip arthroplasty should also be considered when surgical treatment is indicated. The outcomes of acetabular fractures in the elderly have improved, but complications remain higher and results less satisfactory than in younger individuals. The lack of randomized controlled trials has limited the ability to establish an evidence-based treatment algorithm.

Two-year experience with cell salvage in total hip arthroplasty

BACKGROUND AND OBJECTIVE

The aim of this study was to determine the efficacy of the cell salvage system in total hip arthroplasty surgeries and whether the cell salvage system can reduce the allogeneic blood transfusion requirement in total hip arthroplasty patients.

METHODS

We reviewed retrospectively the medical records of patients who underwent hip arthroplasty surgeries between 2010 and 2012 in a university hospital. A total of 181 arthroplasty patients were enrolled in our study.

RESULTS

In the cell salvage group, the mean perioperative rate of allogeneic blood transfusion was significantly lower (92.53±111.88mL) than that in the control group (170.14±116.79mL; p<0.001). When the mean postoperative transfusion rates were compared, the cell salvage group had lower values (125.37±193.33mL) than the control group (152.22±208.37mL), although the difference was not statistically significant. The number of patients receiving allogeneic blood transfusion in the CS group (n=29; 43.2%) was also significantly lower than control group (n=56; 73.6%; p<0.05). In the logistic regression analysis, perioperative amount of transfusion, odds ratio (OR) -4.257 (95% CI -0.502 to 0.184) and operation time, OR: 2.720 (95% CI 0.001-0.004) were independent risk factors for the usage of cell salvage system.

CONCLUSION

Cell salvage is an effective strategy for reducing the need for allogeneic blood transfusion in the perioperative setting; it provides support to patient blood management interventions. Thus, we recommend the cell salvage system for use in total hip arthroplasty surgeries to reduce the need for allogeneic blood transfusion, if possible.

The use of blood cell salvage in acetabular fracture internal fixation surgery

OBJECTIVES

To determine if the routine use of intraoperative blood cell salvage in acetabular fracture internal fixation reduces the need for allogenic blood transfusion, is cost effective, and whether it is influenced by the acetabular fracture pattern.

DESIGN

A retrospective study.

SETTING

Tertiary pelvic and acetabular reconstructive center.

PATIENTS/PARTICIPANTS

Patients undergoing internal fixation for acetabular fractures.

RESULTS

Eighty consecutive patients were reviewed, comprising 26 elementary fracture (EF) and 54 associated fracture (AF) types. The mean volume of autologous blood transfused was 484 mL. The mean volume of 561 mL of autologous blood transfused in patients with AF types was significantly greater than the mean volume of 325 mL transfused in the EF group (P = 0.007). Additional allogenic blood transfusion was required in 5 (19%) patients with EFs and 15 (28%) patients with AFs (P = 0.418). The mean cost of the blood cell salvage and additional blood products in our study was $223 (£135) for all fracture types ($174/£105 for EF and $246/£149 for AF).When treating AF types, the mean cost of using blood cell salvage was $246 (£149) as compared with the mean predicted cost of not using blood cell salvage and transfusing the equivalent of 1.7 units of allogenic blood instead, which was $463 (£281). These distributions are significantly different (P = 0.01).

CONCLUSIONS

The use of blood cell salvage for internal fixation surgery for acetabular fracture is cost effective, particularly when treating AF types, and its routine use is advocated to limit the need for allogenic blood transfusion.

Clinical efficacy and cost effectiveness of intraoperative cell salvage in pelvic trauma surgery

INTRODUCTION

Pelvic acetabular injuries are associated with significant blood loss. This is compounded by multiple surgical interventions including definitive fracture fixation, which put patients at further risk of postoperative transfusion. We use intraoperative cell salvage routinely as a blood conservation strategy to address this issue. This is a prospective evaluation of the clinical efficacy and cost effectiveness of using intraoperative cell salvage in patients with pelvic acetabular injuries.

METHODS

Data were collected prospectively for all the patients who underwent pelvic acetabular fracture fixation at our institution. A total of 30 patients (25 men, 5 women) with a mean age of 41 years (range: 31-79 years) were assessed over a period of 10 months.

RESULTS

The mean preoperative and postoperative haemoglobin levels were 11.8g/dl and 9.9g/dl respectively. The mean intraoperative blood loss was 1,232.5ml (range: 150-2,693ml). The mean amount of blood salvaged and retransfused through a cell saver was 388ml. Of the 30 patients, 14 (47%) required transfusion after surgery and 26 units of blood were transfused. In terms of cost effectiveness, a total of £2,572 in 30 patients or £86 per patient were saved.

CONCLUSIONS

We found intraoperative cell salvage to be clinically efficacious and cost effective in patients with pelvic acetabular injuries.

Fractures of the acetabulum in elderly patients: an update

The incidence of acetabular fractures in elderly patients is increasing. Poor bone quality and concomitant diseases are the main features of these patients. Fracture patterns are marked by a high degree of variability in terms of patient and fracture characteristics. Preoperative planning with plain radiographs and computed tomography, including 3-dimensional reconstructions, is recommended. Treatment remains challenging because of precarious general health, severe osteopenia, comminution, and associated femoral head damage. Treatment options available include closed management, open reduction with internal fixation, percutaneous fixation in situ, and acute or staged total hip arthroplasty (THA) whether alone or combined with osteosynthesis. In the case of significant destruction of the articular cartilage, primary THA may provide the best solution. Whichever surgical method is chosen, the objective is rapid mobilisation of the patient on a walker or crutches. Late local complications that may occur after nonoperative or operative treatment include posttraumatic arthritis, nonunion, malunion, wound infection, dislocation, intrusive hardware, nerve palsy, and heterotopic bone formation. In this article an overview of the current trends in the management of acetabulum fractures in the elderly is presented.

Use of temporary partial intrailiac balloon occlusion for decreasing blood loss during open reduction and internal fixation of acetabular and pelvis fractures

Patients with pelvic and/or acetabular fractures can sustain significant blood loss at the time of their injury and during surgery. We report on the technique, effect on blood loss, and complications with the use of temporary partial intrailiac balloon occlusion during open reduction and internal fixation of pelvic and acetabular fractures in a series of patients refusing allogeneic blood products for philosophical or religious reasons. An intra-arterial balloon is positioned in the common iliac artery immediately preoperatively, ipsilateral to the fracture in the interventional radiography suite. This balloon is then periodically inflated and deflated throughout the case by the anesthesiologist to mitigate operative blood loss. For anterior approaches, average blood loss was significantly less for those patients operated with temporary partial intrailiac balloon occlusion compared with those without. For posterior approaches, blood loss was not significantly different. One complication occurred in a patient who developed an arterial thrombus requiring surgical removal by the vascular surgery service at the conclusion of the orthopaedic surgery. He had no further sequelae. Although not recommended for routine use in all pelvic and acetabular fractures, we feel the use of temporary partial intrailiac balloon occlusion merits further study and may be beneficial in reducing blood loss during anterior pelvic or acetabular procedures in those patients who are opposed to allogeneic blood products and cell saver or those who cannot tolerate an anticipated massive blood loss.

Role of quality improvement in prevention of inappropriate transfusions

PURPOSE

Many different methods are used to manage surgical bleeding and reduce transfusion. Techniques vary by institution, resulting in inconsistent outcomes. We reviewed the current literature on the quality and costs of transfusions, focusing on prevention and management of transfusions during surgery, and provide recommendations on future directions for quality improvement (QI).

DATA SOURCES

Ovid, PubMed, and Scopus.

STUDY SELECTION

Key words included QI, blood loss, transfusion, hemostasis, and costs. Inclusion criteria were English language, publication between 1999 and 2010, and primary end points of blood loss, transfusion, or hemostasis.

DATA EXTRACTION

A total of 1331 abstracts were reviewed; 43 met the inclusion criteria.

RESULTS

A variety of bleeding management (BM) techniques were identified, with multiple studies suggesting that algorithms combining pre-, peri-, and postoperative interventions have the greatest potential to minimize transfusions. Most studies assessing the economic impact of BM interventions excluded resources beyond blood acquisition cost and longer-term complications, which may underestimate transfusion costs and bias estimates of the cost-effectiveness of interventions. Despite consensus on avoiding inappropriate transfusions, little agreement exists on optimal use of interventions.

CONCLUSIONS

Multifaceted algorithms show promising results. Future QI should focus on reducing practice variation via evidence-based guidelines for effective use of BM interventions.

Cell salvage as part of a blood conservation strategy in anaesthesia

The use of intraoperative cell salvage and autologous blood transfusion has become an important method of blood conservation. The main aim of autologous transfusion is to reduce the need for allogeneic blood transfusion and its associated complications. Allogeneic blood transfusion has been associated with increased risk of tumour recurrence, postoperative infection, acute lung injury, perioperative myocardial infarction, postoperative low-output cardiac failure, and increased mortality. We have reviewed the current evidence for cell salvage in modern surgical practice and examined the controversial issues, such as the use of cell salvage in obstetrics, and in patients with malignancy, or intra-abdominal or systemic sepsis. Cell salvage has been demonstrated to be safe and effective at reducing allogeneic blood transfusion requirements in adult elective surgery, with stronger evidence in cardiac and orthopaedic surgery. Prolonged use of cell salvage with large-volume autotransfusion may be associated with dilution of clotting factors and thrombocytopenia, and regular laboratory or near-patient monitoring is required, along with appropriate blood product use. Cell salvage should be considered in all cases where significant blood loss (>1000 ml) is expected or possible, where patients refuse allogeneic blood products or they are anaemic. The use of cell salvage in combination with a leucocyte depletion filter appears to be safe in obstetrics and cases of malignancy; however, further trials are required before definitive guidance may be provided. The only absolute contraindication to the use of cell salvage and autologous blood transfusion is patient refusal.