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

Combining Innovative Techniques: Total Extraperitoneal Approach in Orthopedic Surgery (O-TEP) and Percutaneous Both Column Screw (BCS) Fixation Technique in a Geriatric Acetabular Fracture Case

The concepts of both column fixation corridor (BCFC) and both column screws (BCS) along with the orthopedic total extraperitoneal approach (O-TEP) are highly innovative approaches in orthopedic surgery. However, the orthopedic literature lacks sufficient studies on these topics, indicating a significant gap. This case report aims to highlight how combining these innovative techniques can facilitate the use of BCFC and BCS in the treatment of acetabular fractures with O-TEP, thereby enhancing the feasibility of endoscopic techniques. Furthermore, we aim to discuss the potential advantages of BCFC and BCS concepts when used in O-TEP.For this purpose, we present a case of a 74-year-old geriatric patient with a transverse acetabular fracture involving the posterior column. The quadrilateral surface was exposed using the O-TEP approach, and the fracture was reduced using a fully endoscopic approach. The fixation was achieved using BCS and a Magic screw through percutaneous screw placement.The patient's clinical condition was followed for at least 13 months. The clinical outcomes demonstrated the effectiveness of combining these innovative techniques in the treatment of acetabular fractures, with satisfactory healing and functional recovery observed.This case report illustrates that combining BCFC and BCS with the O-TEP approach can facilitate the treatment of acetabular fractures with minimally invasive techniques and enhance the feasibility of endoscopic procedures. These findings suggest potential advantages of using BCFC and BCS concepts in O-TEP, warranting further investigation and study.

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.

Preoperative Blood Loss of Isolated Acetabular Fractures

OBJECTIVE

To quantify preoperative blood loss in isolated acetabular fractures and identify any fracture or patient characteristics associated with increased blood loss or blood transfusion.

DESIGN

Retrospective cohort study.

SETTING

Two level 1 trauma centers.

PATIENTS/PARTICIPANTS

All patients with operative, isolated acetabular fractures from January 2010 to December 2018.

INTERVENTION

Operative management of an acetabular fracture.

MAIN OUTCOME MEASUREMENTS

Volume of preoperative blood loss and transfusion rates associated with isolated acetabular fracture patterns.

RESULTS

A total of 598 patients were included. The mean preoperative blood loss of all fractures was 1172.6 mL. The 3 fracture patterns with the greatest average preoperative blood loss were associated both column (1454.9 mL), T-type (1374.8 mL), and anterior column posterior hemitransverse fractures (1317.7 mL). The acetabular fracture pattern had a significant association with preoperative blood loss and preoperative transfusion. The timing from injury to surgery and body mass index were significantly associated with preoperative blood loss.

CONCLUSIONS

In conclusion, operatively treated isolated acetabular fractures surprisingly lose an average of greater than 1 liter of blood in the preoperative setting. Surgeons must carefully assess patient's physiology, ensuring they are adequately resuscitated before surgery and remain aware that increasing body mass index is associated with increased preoperative blood loss. However, as patients await surgery, unreduced acetabular fractures continue to contribute to ongoing blood loss beyond the first 24 hours from injury. We believe the best hemostasis after initial resuscitation is provided by surgical reduction and fixation, and we recommend a continued early surgical intervention to prevent continued bleeding from fracture surfaces.

LEVEL OF EVIDENCE

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

Optimising the use of cell salvage in revision hip arthroplasty

BACKGROUND

Intraoperative cell salvage is an established method to reduce the requirement for and the volume of allogenic blood transfusion but adds to the financial cost of performing surgery.

AIMS

The primary aim of this study was to determine which patients and what type of revision hip surgery benefit most from intraoperative cell salvage.

METHODS

This observational study included patients who underwent revision hip surgery performed by the senior author at a single orthopaedic unit. The cohort was divided into single and two-component revision groups; then, the transfusion requirement combined with analysis of patient factors was used to create a decision-making protocol.

FINDINGS

The two-component group had a significantly higher number of cases using cell salvage and a higher total transfusion volume. Patients who required postoperative allogenic blood transfusions had a higher mean age, were less likely to have received tranexamic acid and had a lower preoperative haemoglobin level.

CONCLUSION

Based on these results, a decision-making protocol was developed for when to use cell salvage in revision hip surgery.

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.

Autotransfusion in low-resource settings: a scoping review

INTRODUCTION

Globally, haemorrhage is the leading cause of both maternal mortality and preventable trauma death. For patients suffering from haemorrhage, prompt blood transfusion can be life-saving; however, safe and sufficient blood is often lacking in low-resource settings (LRS). Autotransfusion (AT), in which the patient's own blood is collected and transfused back, is an established alternative to donor blood transfusions, although one that is primarily performed with advanced AT systems. Research on basic AT in LRS is scarce. Therefore, we aimed to consolidate all available information on the current use of basic AT in LRS and to identify AT techniques and devices described for use in such settings.

DESIGN

Scoping review.

METHODS

We systematically searched four key databases: PubMed, Web of Science, Global Health and Cochrane Library as well as several grey literature databases and databases of relevant organisations. The final search was conducted on 22 April 2019. We included all types of studies referring to any information on basic AT used or sought to be used in LRS, published in English and dated after 31 December 2008. We synthesised the data from the included studies, results were charted or summarised narratively.

RESULTS

Some 370 records were reviewed, yielding 38 included documents. We found a paucity of scientific evidence as well as contradictory information on the extent of AT use and that AT use is largely undocumented. The most commonly described indications were haemoperitoneum (primarily among obstetric patients) and haemothorax. We identified three AT techniques used in LRS. Additionally, two new devices and one filter are described for potential use in LRS.

CONCLUSIONS

Basic AT is practiced for certain obstetric and trauma indications. However, context-specific studies are needed to determine the technique's safety and effectiveness. Extent of use is difficult to assess, but our results indicate that basic AT is not a widely established practice in LRS. Future research should address the bottlenecks hampering basic AT availability. New AT devices for use in LRS are described, but their utility and cost-effectiveness remain to be assessed.

Cell Salvage in Oncological Surgery, Peripartum Haemorrhage and Trauma

Oncological surgery, obstetric haemorrhage and severe trauma are the most challenging conditions for establishing clinical recommendations for the use of cell salvage. When the likelihood of allogeneic transfusion is high, the intraoperative use of this blood-saving technique would be justified, but specific patient selection criteria are needed. The main concerns in the case of oncological surgery are the reinfusion of tumour cells, thereby increasing the risk of metastasis. This threat could be minimized, which may help to rationalize its indication. In severe peripartum haemorrhage, cell salvage has not proven cost-effective, damage control techniques have been developed, and, given the risk of fetomaternal alloimmunization and amniotic fluid embolism, it is increasingly out of use. In trauma, bleeding may originate from multiple sites, coagulopathy may develop, and it should be evaluated whether re-transfusion of autologous blood collected from uncontaminated organ cavities would be feasible. General safety measures include washing recovered blood and its passage through leukocyte depletion filters. To date, no well-defined indications for cell salvage have been established for these pathologies, but with accurate case selection and selective implementation, it could become safe and effective. Randomized clinical trials are urgently needed.

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.

Early Operative Treatment of Acetabular Fractures Does Not Increase Blood Loss: A Retrospective Review

OBJECTIVES

To compare cell salvage (CS) volume, intraoperative blood loss, intraoperative blood transfusions, and operative time for acetabular fractures undergoing early (≤48 hours from admission) versus delayed fixation (>48 hours from admission).

DESIGN

Retrospective.

SETTING

Level one trauma center.

PATIENTS

One hundred thirty-one patients with unilateral acetabular fractures involving at least one column.

INTERVENTION

Open reduction and internal fixation performed through the anterior intrapelvic approach or posterior approach.

MAIN OUTCOME MEASUREMENTS

CS volume, estimated blood loss (EBL), intravenous fluids (IVFs), intraoperative packed red blood cells (PRBCs), and operative time.

RESULTS

Early versus delayed fixation through the posterior approach was associated with shorter operative times and less intraoperative PRBCs (140 vs. 301 mL, MD -161 mL, 95% confidence interval -25 to -296 mL) with no differences in CS, EBL, or IVF. Early versus delayed fixation through an anterior intrapelvic approach was more common in less severe fracture patterns with no differences in PRBCs, CS, EBL, or IVF. CS, through either approach, was successful in returning blood to 77% of patients for an average of 267 ± 168 mL (range, 105-900 mL).

CONCLUSIONS

Fixation of acetabular fractures within 48 hours of admission did not increase blood loss or intraoperative transfusions. CS was successful in returning an average of one unit of blood to a majority of patients.

LEVEL OF EVIDENCE

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

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.

Anterior subcutaneous internal fixator (INFIX) versus plate fixation for pelvic anterior ring fracture

The aim of this study was to compare the clinical outcomes in patients with unstable anterior pelvic ring fractures after treatment with anterior subcutaneous internal fixator (INFIX) or plate fixation. We performed a retrospective study from August 2015 to October 2017. A consecutive series of 74 patients who underwent surgical treatment of their anterior pelvic ring (35 treated with INFIX and 39 treated with plates) were studied. Data collected included patients’ demographic data, injury severity score (ISS), AO/OTA classification, injury mechanism, time to surgery, procedure time, and blood loss. The quality of postoperative reduction were assessed by postoperative radiographs using the Tornetta and Matta method. Functional outcome was evaluated using Majeed scoring system. In the INFIX group, ten patients developed LFCN paralysis, one patient suffered from superficial infection. Three screw loosening cases and two wound infection cases occurred in the plate group. INFIX is relatively minimally invasive and time-saving than the reconstruction plate in the treatment of anterior pelvic ring fracture. However, plate fixation increases the rate of anatomic reduction of the pelvic anterior ring fracture. Plates also provide a higher functional outcome compared with INFIX. INFIX is especially suitable in patients with urological injury, which can also decrease the wound infection rate.

30-day adverse events, length of stay and re-admissions following surgical management of pelvic/acetabular fractures

INTRODUCTION

Pelvic/acetabular fractures are associated with significant morbidity, mortality and cost to the society. We sought to utilize a national surgical database to assess the incidence and factors associated with prolonged length of stay (LOS), non-home discharge destination, 30-day adverse events and readmissions following surgical fixation of pelvic/acetabular fractures.

MATERIALS & METHODS

The 2011-2016 ACS-NSQIP database files were queried using CPT codes (27215, 27217, 27218, 27226, 27227, 27228) for patients undergoing open reduction/internal fixation (ORIF) for pelvic/acetabular fractures. Patients undergoing additional procedures for associated fractures (vertebral fractures, distal radius/ulna fractures or femoral neck/hip fractures) were excluded from the analysis to ensure that a relevant population of patients with isolated pelvic/acetabular injuries were included in the analysis. A total of 572 patients were included in the final cohort. Severe adverse events (SAE) were defined as: death, ventilator use >48 h, unplanned intubation, stroke, deep venous thrombosis, pulmonary embolism, cardiac arrest, myocardial infarction, acute renal failure, sepsis, septic shock, re-operation, deep SSI and organ/space SSI. Minor adverse events (MAE) included - wound dehiscence, superficial SSI, urinary tract infection (UTI) and progressive renal insufficiency. An extended LOS was defined as >75th centile (>9days).

RESULTS

Factors associated with AAE were partially dependent functional health status pre-operatively (p = 0.020), transfusion ≥1 unit of packed RBCs (p = 0.001), and ASA > II (p < 0.001). Experiencing a SAE was associated with congestive heart failure (CHF) pre-operatively [p = 0.005), total operative time >140 min (p = 0.034) and Hct <36 pre-operatively (p = 0.003). MAE was associated with transfusion≥1 unit of packed RBCs (p = 0.022) and ASA > II (p = 0.007). Patients with an ASA > II (p = 0.001), total operative time>140 min (p < 0.001) and Hct <36 (p = 0.006) were more likely to have a LOS >9 days. Male gender (p = 0.026), prior history of CHF (p = 0.024), LOS >9 days (p = 0.030) and >10% bodyweight loss in last 6 months before the procedure (p = 0.002) were predictors of 30-day mortality.

CONCLUSION

Patients with ASA grade > II, greater co-morbidity burden and prolonged operative times were likely to experience adverse events and have a longer length of stay. Surgeons can utilize this data to risk stratify patients so that appropriate pre-operative and post-operative medical optimization can take place.

The role of intraoperative cell salvage system on blood management in major orthopedic surgeries: a cost-benefit analysis

INTRODUCTION

The aim of this study was to compare the efficiency and cost of cell salvage systems with allogeneic blood transfusions in patients who had major elective orthopedic surgeries.

MATERIALS AND METHODS

Consecutive 108 patients who had intraoperative cell saver (CS) performed routinely constitute the study group. In control group, consecutive 112 patients who were operated without intraoperative CS were investigated. Hemoglobin (Hb) level less than 8 mg/dL was regarded as the absolute transfusion indication. The patients were evaluated for age, gender, body mass index, operation period, mean intraoperative estimated blood loss (EBL), postoperative hemovac drainage volume; preoperative, postoperative first day and discharge Hb levels, allogeneic blood transfusion (ABT) volume, hospitalization and cost parameters.

RESULTS

The mean intraoperative EBL was 507 mL in the study group and 576 mL in control group. The mean ABT was 300 mL in the study group and 715 mL in control group. In the study group, intraoperative EBL, ABT usage and hospitalization period were significantly lower compared with the control group (p = 0.009, p = 0.000 and p = 0.000; p < 0.05, respectively). The mean cost was 771 Turkish liras (TL) in the study group and 224 TL in control group. In the study group, the cost was significantly higher than the control group (p = 0.000). The postoperative first day Hb level was significantly higher in the study group (p = 0.010).

CONCLUSION

Although CS usage was determined to increase the costs in this study, it significantly decreases intraoperative and postoperative ABT requirements. We believe that the increase in cost may be neglected when the complications and prolonged hospitalization due to ABT usage were regarded.

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.

Flexible 3D laparoscopic assisted reduction and percutaneous fixation of acetabular fractures: Introduction to a new surgical option

The gold standard for fractures of the acetabulum is to perform an open reduction and internal fixation in order to achieve anatomical reduction. In a well-defined subset of patients, percutaneous techniques may be employed but achieving reduction by closed means can be challenging especially for fractures with large degrees of displacement. Such patient may include elderly patients who may not have the physiologic reserve to withstand open approaches. In our paper, we present a new option using laparoscopic assisted reduction of the acetabular fracture and percutaneous fixation. The young obese patient refused all forms of blood products transfusion and presented with a displaced transverse posterior wall fracture. While we do not recommend routine use of such technique and recognize its numerous limitations, we present it as an alternative strategy in a small subset of patients.

[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.

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.