Perioperative Blood Management Strategies for Total Knee Arthroplasty

Lower Blood Loss with Bicruciate-Retaining Total Knee Arthroplasty Compared with Bicruciate-Stabilized Total Knee Arthroplasty

Total knee arthroplasty (TKA) is a common surgical procedure to treat end-stage knee osteoarthritis. This study compared blood loss volume and other clinical outcomes between bicruciate-retaining (BCR) and bicruciate-stabilized (BCS) TKA. Ninety-seven participants who underwent unilateral TKA were enrolled. The BCS-TKA and BCR-TKA groups comprised 78 and 19 participants, respectively. Blood loss was calculated using preoperative and postoperative hematocrit values, height, weight, and sex. Measurements were taken immediately after surgery, on days 1 and 7, and total blood loss was calculated up to day 7. Operation time, range of motion at 7 and 14 days postoperatively, blood transfusion requirement, and postoperative complications such as infection, hematoma, and deep vein thrombosis were compared between the groups. Blood loss was comparable between groups at all time points (125.7 vs. 105.4 mL, 57.9 vs. 43.5 mL, and 68.2 vs. 41.7 mL for immediate, day 1, and day 7 postoperatively, respectively; all p > 0.05) except for total blood loss, which was significantly lower in the BCR group compared with the BCS group (190.7 vs. 251.1 mL; p < 0.05). The BCR group also had a longer operation time than the BCS group (131.2 vs. 112.4 minutes; p < 0.05). No other significant differences were observed in other outcomes. Total blood loss up to 7 days postoperatively was significantly lower in the BCR group than in the BCS group despite a longer operation time. This may be attributed to the reduced bone resection and greater soft tissue preservation, including the anterior cruciate and posterior cruciate ligaments, in the BCR technique.

Comparative analysis of acute blood loss anemia in robotic assisted vs. manual instrumented total knee arthroplasty

Introduction

Robotic assisted total knee arthroplasty has become an increasingly popular technique over the past several years. Manual total knee arthroplasty can be associated with acute blood loss anemia. Instrumentation of the femoral canal with the alignment guide may in part contribute to this blood loss. Because the femoral canal is not entered during robotic assisted total knee arthroplasty, the blood loss may be lower compared to that seen in manual total knee arthroplasty. The purpose of this study was to determine if acute blood loss is greater in manually instrumented total knee arthroplasty versus robotic assisted total knee arthroplasty.

Materials and methods

This retrospective cohort study was performed in a large tertiary academic hospital network by two fellowship trained surgeons. Patients underwent either robotic assisted or manually instrumented total knee arthroplasty and were assessed for postoperative acute blood loss anemia, defined as hemoglobin <13 g/dL for males or <12 g/dL for females plus a 2 g/dL drop from preoperative levels, as well as postoperative drop in hemoglobin.

Results

A total of 75 patients were included in each study arm. There was no significant difference (p > 0.05) in postoperative hemoglobin in robotic assisted (2.1 g/dL) compared to manually instrumented total knee arthroplasty (2.1 g/dL). There was no significant difference in the incidence of postoperative acute blood loss anemia between robotic assisted (45 %) and manually instrumented total knee arthroplasty (39 %). Higher BMI and increased age were protective against postoperative drop in hemoglobin. These protective effects were not significant when controlling for confounding variables. Surgical time was significantly longer for robotic assisted (99 min) versus manually instrumented total knee arthroplasty (86 min) (p < 0.001).

Conclusions

There is no significant difference in acute blood loss when comparing patients undergoing robotic assisted and manually instrumented total knee arthroplasty.

Comparison of Mean Postoperative Hemoglobin Concentrations in Patients Undergoing Total Knee Arthroplasty With Intravenous Versus Intraarticular Administration of Tranexamic Acid

BACKGROUND

 Total knee arthroplasty (TKA) may result in significant blood loss, but it is an effective and affordable treatment for severe osteoarthritis in the knees. While intravenous (IV) tranexamic acid (TXA) is a commonly used technique, intraarticular (IA) TXA has just recently started to gain traction in joint replacement procedures. The purpose of this research was to examine the mean postoperative hemoglobin concentration in order to assess the effectiveness of TXA administered IV vs IA after TKA.

OBJECTIVE

To assess the effectiveness of intraarticular TXA against intravenous administration.

MATERIALS AND METHODS

The six-month randomized controlled experiment was started from October 5, 2022, to April 4, 2023, at "the Orthopedics Department of Sir Ganga Ram Hospital in Lahore". The experiment included 60 patients undergoing TKA, ranging in age from 30 to 70. All members of the surgical team, including the supervisor (a consultant surgeon), assistants, and researchers, were present throughout the surgery. A high, thigh tourniquet was employed in every case, and a medial parapatellar technique was performed as well. Before the tourniquet was inflated, individuals in the intravenous group received 1 g of TXA intravenously 15-30 minutes beforehand. In the IA group, the "patient received an injection of 2 g of TXA in a 20 mL solution" straight into the joint after the prosthesis was implanted and secured. Data were analyzed using SPSS (version 26), with numerical data (age, BMI, surgical length, and hemoglobin levels) presented as mean ± SD and categorical factors (gender, American Society of Anesthesiologists (ASA) class, anatomical side) shown as frequency and percentage. The mean postoperative hemoglobin levels were compared between groups using an independent sample t-test, with data stratified by various factors and p ≤ 0.05 considered significant.

RESULTS

There were 60 patients in this study, ranging in age from 30 to 70. The mean±SD age was 48.73±10.35 years. Patients' mean BMI was 25.51±4.48 kg/m², with representation across underweight, normal, overweight, and obese categories. The procedure took 173.10±32.61 minutes. The overall postoperative hemoglobin concentration was significantly higher in the IA TXA group (12.12±1.32 g/dL) compared to the IV TXA group (11.11±1.10 g/dL), with a p-value of 0.02. Additionally, when stratified by age, the IA TXA group consistently demonstrated higher postoperative hemoglobin levels across all age brackets, with significant differences observed in the 51-60 years (p = 0.001) and 61-70 years (p = 0.011) groups. Gender-based comparisons showed that IA TXA was associated with higher postoperative hemoglobin levels for both males (p < 0.05) and females (p < 0.05) compared to IV TXA.

CONCLUSION

This study demonstrates that IA administration of TXA is more effective in maintaining higher postoperative hemoglobin concentrations compared to IV TXA in patients undergoing TKA. The IA TXA group consistently achieved significantly higher hemoglobin levels across various age groups and both genders, indicating superior efficacy in reducing blood loss associated with TKA. These findings suggest that IA TXA could be a preferable alternative to IV TXA for enhancing postoperative hemoglobin recovery and potentially improving patient outcomes in knee arthroplasty procedures.

Early ambulation after total knee arthroplasty: a retrospective single-center study

PURPOSE

Early ambulation is an important step in accelerating post-joint replacement surgery recovery. However, there is limited research on populations who are unable to walk immediately after the operation. The purpose of this study was to determine the factors influencing postoperative ambulation in total knee arthroplasty (TKA) patients.

METHODS

Primary TKA patients were included in this retrospective study. All patients were divided into two groups. Patients who began walking within 24 h were categorized as the early ambulation group, while patients who began walking after 24 h were classified as the late ambulation group. Recorded demographic data included age, gender, body mass index (BMI), clinical diagnosis, and comorbidities. Hematological parameters potentially affecting patients' preoperative physical condition were also documented. Additionally, intraoperative metrics such as surgical time, surgical side, tourniquet time, intraoperative blood loss, the placement of drains, and prosthetic model were recorded.

RESULTS

A total of 453 patients (79.0% female, 21.0% male) were included in this study. The average age of all patients was 68.5±7.9 years, ranging from 36 to 87 years, with an average BMI of 27.2±9.9 kg/ m 2 . The mean postoperative ambulation time was 1.6 days, with a range of 0-4 days. In univariate group comparisons, an increase in postoperative time to ambulation was significantly associated with a history of heart disease ( P < 0.001 ), stroke history ( P = 0.003 ), and prior surgeries ( P = 0.003 ). Patients who delayed ambulation also exhibited significantly higher coagulation-related parameters including PT ( P < 0.001 ), APTT ( P = 0.002 ), TT ( P = 0.039 ) before surgery compared to those who mobilized early. Furthermore, prolonged surgical time ( P = 0.030 ), increased intraoperative blood loss ( P < 0.001 ), and the placement of intraoperative drains ( P < 0.001 ) also significantly extended the time to postoperative ambulation. However, after multivariate logistic regression analysis, only PT (OR 1.86, 95% CI 1.32 - 2.61, P < 0.001 ), TT (OR 1.30, 95% CI 1.09 - 1.55, P = 0.004 ) intraoperative blood loss (OR 1.01, 95% CI 1.00 - 1.01, P = 0.008 ) and the placement of intraoperative drains (OR 11.39, 95% CI 6.59 - 19.69, P < 0.001 ) were identified as predictive factors for late ambulation in patients after TKA.

CONCLUSION

In this study, preoperative coagulation function, intraoperative blood loss and the placement of intraoperative drains were factors contributing to delay ambulation time. Therefore, it is believed that properly improving preoperative coagulation function, effective intraoperative hemostasis, and reducing the placement of drains have a positive impact on early postoperative ambulation in patients undergoing TKA.

Impact of intra- and extramedullary alignment on blood loss in total knee arthroplasty: a retrospective study

BACKGROUND

There is a scarcity of scientific data regarding the correlation between alignment techniques during total knee arthroplasty (TKA) and blood loss as well as transfusion rates. This study's hypothesis posited that intramedullary-aligned (IM) TKA exhibits higher blood loss and transfusion rates when contrasted with extramedullary-aligned (EM) TKA.

METHODS

We conducted a retrospective examination of 883 patients who underwent total knee arthroplasty (TKA) in 2021 at a solitary orthopedic center in Germany. These patients were divided into two groups based on their tibial alignment technique: extramedullary alignment and intramedullary tibial alignment.

RESULTS

In the intramedullary tibial alignment (IM) group, we observed a blood loss of 0.91 L, while in the extramedullary tibial alignment (EM) group, the blood loss was 0.89 L. These values did not demonstrate a significant difference (p = 0.69). Transfusion rates were 0.99% in the IM group and 0.21% in the EM group, and there was no significant distinction between them (Chi-squared test: p > 0.05).

CONCLUSION

We observed no statistically significant variance in blood loss between the IM and EM groups. Likewise, there was no substantial disparity in transfusion rates between these groups. It can be concluded that the selection of a knee arthroplasty system incorporating either intramedullary tibial alignment or extramedullary alignment does not significantly impact blood loss.

Evaluating the Efficacy and Safety of Combined Administration of Systemic and Topical Tranexamic Acid in Total Knee Arthroplasty

Introduction

Tranexamic acid (TXA) is an antifibrinolytic agent, thatagent that reduces substantial blood loss in total knee arthroplasty (TKA) surgeries without increasing the risk of thromboembolic complications. The purpose of our study was to assess the effectiveness and safety of the combined use of intravenousIV and topical TXAtranexamic acid in uncomplicated primary Total knee Arthroplasty (TKA) without complications.

Materials and Methods

In this prospective study, we enrolled 61 patients who underwent unilateral primary TKR and were randomly divided into two groups: Group I received intravenous (IV) TXA and Group II received both IV and intraarticular (IA) TXA. Patients assigned to Group I received IV TXA preoperatively 30 mins before surgery and postoperatively at 3 and 6 hours after surgery, whereas in the combined group, in addition to IV doses, topical TXA was applied as mop 2 g of TXA diluted in 30 mL of isotonic sodium chloride solution) intraarticularly for about 5 minutes before closing the arthrotomy. We measured total blood loss (TBL), ) and mean reduction in haemoglobin (Hb) levels as primary outcomes. Transfusion rates, incidence of thromboembolic events (TE), and other adverse effects as secondary outcomes. Total blood loss TBL and Hb drops was were noted on the 3rd post-operative day. All the patients were followed-up for 6 months to note the incidence of deep venous thrombosisDVT and Thromboembolic Events (TE). An Iindependent t-test was used to evaluate between--group differences. P < 0.05 as is the cut-off for statistically significant differences.

Results

The Total blood loss (TBL) in Group I was 780.05 ± 158.05 mL, compared to 660.80 ± 156.45 mL in Group II. (P < 0.001). The Hb drop was significantly lower in IV TXA group (2.3 ± 0.37) than the combined TXA group (1.40 ± 0.32). Furthermore, both groups required no transfusions. No thromboembolic complications was were noted postoperatively and at 6 6-month follow-up.

Conclusion

TXATranexamic acid in total knee replacement surgery effectively decreases blood loss and significantly reduces the need for blood transfusions. Based on our study, the combined use of intravenous (IV) and IAintraarticular TXA in total knee replacement was found to be superior in reducing blood loss and significantly reducing the need for blood transfusions in TKA.

Associations of preoperative anemia and postoperative hemoglobin values with hospital costs in total knee arthroplasty (TKA)

BACKGROUND

Total knee arthroplasty are among the most frequently conducted surgeries, due to an aging society. Since hospital costs are subsequently rising, adequate preparation of patients and reimbursement becomes more and more important. Recent literature revealed anemia as a risk factor for enhanced length of stay (LOS) and complications. This study analyzed whether preoperative hemoglobin (Hb) and postoperative Hb were associated with total hospital costs and general ward costs.

METHODS

The study comprised 367 patients from a single high-volume hospital in Germany. Hospital costs were calculated with standardized cost accounting methods. Generalized linear models were applied to account for confounders, such as age, comorbidities, body mass index, insurance status, health-related quality of life, implant types, incision-suture-time and tranexamic acid.

RESULTS

Preoperative anemic women had 426 Euros higher general ward costs (p < 0.01), due to increased LOS. For men, 1 g/dl less Hb loss between the preoperative value and the value before discharge reduced total costs by 292 Euros (p < 0.001) and 161 Euros fewer general ward costs (p < 0.001). Total hospital costs were reduced by 144 Euros with 1 g/dl higher Hb on day 2 postoperatively for women (p < 0.01).

CONCLUSION

Preoperative anemia was associated with increased general ward costs for women and Hb loss with decreasing total hospital costs for men and women. Cost containment, especially reduced utilization of the general ward, may be feasible with the correction of anemia for women. Postoperative Hb values may be a factor for adjustments of reimbursement systems.

LEVEL OF EVIDENCE

Retrospective cohort study, III.

Risk factors for blood transfusion and postoperative anaemia following total knee arthroplasty

Aims

Blood transfusion and postoperative anaemia are complications of total knee arthroplasty (TKA) that are associated with substantial healthcare costs, morbidity, and mortality. There are few data from large datasets on the risk factors for these complications.

Methods

We retrospectively reviewed the records of TKA patients from a single tertiary care institution from February 2016 to December 2020. There were a total of 14,901 patients in this cohort with a mean age of 67.9 years (SD 9.2), and 5,575 patients (37.4%) were male. Outcomes included perioperative blood transfusion and postoperative anaemia, defined a priori as haemoglobin level < 10 g/dl measured on the first day postoperatively. In order to establish a preoperative haemoglobin cutoff, we investigated a preoperative haemoglobin level that would limit transfusion likelihood to ≤ 1% (13 g/dl) and postoperative anaemia likelihood to 4.1%. Risk factors were assessed through multivariable Poisson regression modelling with robust error variance.

Results

In multivariable analyses, each gram of tranexamic acid reduced transfusion likelihood by 39% (adjusted risk ratio (ARR) 0.61 (95% confidence interval (CI) 0.47 to 0.78)). Risk factors associated with an increased risk of transfusion included operating time (ARR 2.07 (95% CI 1.54 to 2.77)) and drain use (ARR 1.73 (95% CI 1.34 to 2.24)).

Conclusion

In this study, we found that increased tranexamic acid dosing, decreased operating time, and decreased drain use may reduce transfusions following TKA. We also established a single preoperative haemoglobin cutoff of 13 g/dl that could help minimize transfusions and reduce postoperative complete blood counts.

Blood Loss in Primary Unilateral Total Knee Arthroplasty with Limited Tourniquet Application: A Randomized Controlled Trial

Background

Tourniquet application in total knee arthroplasty (TKA) has many benefits and may have a role in the incidence of perioperative complications. Our aims were to examine the safety of applying a tourniquet for a limited amount of time during primary unilateral TKA (specifically, during cementation and final component fixation only) and to compare perioperative complications between the limited-application group and the full-application group.

Methods

We conducted a randomized controlled study of 62 patients undergoing primary unilateral TKA. Patients were randomly allocated to either the limited or full tourniquet application. The follow-up period was 6 months. We evaluated intraoperative, postoperative, total, and hidden blood loss as the primary outcome measures and clearance of the surgical field, operative duration, and perioperative complications as the secondary outcome measures.

Results

We found a significant difference in surgical field clearance between the groups. There was no significant difference in total, hidden, or postoperative blood loss between the groups. Mean intraoperative blood loss was significantly lower in the full-application group than in the limited-application group (171.742 ± 19.710 versus 226.258 ± 50.290 mL; p = 0.001). Perioperative complications, including allogeneic blood transfusion rates, did not significantly differ between the groups.

Conclusions

Limited tourniquet application is safe to use in primary unilateral TKA and does not increase the incidence of perioperative complications or total blood loss when compared with a standard, full-time tourniquet application.

Level of Evidence

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

Indicators and medical tests to identify lower limb swelling causes after total knee arthroplasty: a Delphi study with multidisciplinary experts

BACKGROUND

Lower limb swelling after total knee arthroplasty (TKA) hinders surgical effectiveness. The poor results of studies on swelling interventions are due to the lack of a classification of swelling causes through appropriate medical tests. A gold standard is missing. This study aimed to clarify the causes of TKA postoperative swelling and how to identify them through indicators and medical tests by consulting a wide range of experts from multiple disciplines.

METHOD

The Delphi method was used. A first draft of the index was prepared based on a systematic search of the literature. A total of 11 experts from several disciplines were invited to evaluate the rationality of the indicators and suggest modifications. After two rounds of consultation, the experts reached a consensus, and the consultation was stopped.

RESULTS

The response rate of the 11 experts was 100%, and the authoritative Cr was 0.896. Kendall's W values for opinion coordination of the two rounds of consultation were 0.262 and 0.226, respectively (P < 0.001). Among the final indicators, there were 4 primary indicators for swelling cause classification (inflammatory response, poor venous return, joint hematoma, muscle damage, and healing), 19 secondary and 19 tertiary indicators.

CONCLUSION

The indications obtained by systematic literature review and multidisciplinary expert consultation are reliable and scientific. Multiple causes of lower extremity swelling after TKA were identified. Blood test indicators can reflect an inflammatory response, suggest poor venous return, and reflect muscle damage and healing progress. Ultrasound scans are needed to identify underlying thrombotic or valvular problems, joint hematomas, and muscle damage. These tests help clinicians and researchers determine the cause of swelling after TKA and take appropriate management.

Effectiveness of Robotic Arm-Assisted Total Knee Arthroplasty on Transfusion Rate in Staged Bilateral Surgery

The transfusion rate in staged bilateral total knee arthroplasty (TKA) remains high despite the application of blood management techniques. The potential of robotic arm-assisted TKA (R-TKA) in reducing the transfusion rate in staged bilateral surgery has not yet been investigated. Therefore, we aimed to evaluate the effectiveness of R-TKA on transfusion reduction compared with conventional TKA (C-TKA) in staged bilateral surgery. This retrospective study involved two groups of patients who underwent 1-week interval staged bilateral TKA-the C-TKA group and the R-TKA group-using MAKO SmartRobotics (Stryker, Kalamazoo, MI, USA). Each group comprised 53 patients after propensity score matching and was compared in terms of nadir hemoglobin (Hb) level and transfusion rate after each stage of surgery. Both groups showed no significant differences in the propensity-matched variables of age, sex, body mass index, American Society of Anesthesiologists physical status score, and preoperative Hb level. The R-TKA group showed a significantly higher nadir Hb level than the C-TKA group after the second TKA (p = 0.002). The transfusion rate was not significantly different between the two groups after the first TKA (p = 0.558). However, the R-TKA group showed a significantly lower transfusion rate in the TKA (p = 0.030) and overall period (p = 0.023) than the C-TKA group. Patients who undergo staged bilateral R-TKA have lower transfusion rate than those who undergo C-TKA. R-TKA may be effective in minimizing unnecessary allogeneic transfusions in staged bilateral surgery.

Comparison of clinical outcomes of VISIONAIRE patient-specific instrumentation with conventional instrumentation in total knee arthroplasty: a systematic literature review and meta-analysis

INTRODUCTION

Malalignment and resulting complications are major challenges in total knee arthroplasty (TKA) which patient-specific instrumentation (PSI) is proposed to alleviate. Previous PSI meta-analyses of TKA outcomes typically do not differentiate between PSI systems and assess relatively few outcomes, so the value of their findings is limited. VISIONAIRE™ cutting guides (Smith + Nephew Inc., Memphis, TN, USA) is a PSI system based on preoperative magnetic resonance and X-ray imaging. A systematic literature review (SLR) and meta-analysis, focussed specifically on VISIONAIRE, were conducted to assess TKA accuracy, intraoperative outcomes, and postoperative outcomes, compared with conventional instrumentation (CI).

MATERIALS AND METHODS

The SLR was performed using PubMed, Embase, and Google Scholar databases to identify relevant studies published until March 2022. Depending on statistical heterogeneity, meta-analyses were performed for outcome measures with fixed effect (I2 < 50%) or random-effects models (I2 ≥ 50%). Dichotomous outcomes were reported as odds ratios and continuous outcomes were reported as mean differences. Descriptive analyses were performed for outcomes not amenable to meta-analysis.

RESULTS

Outcomes for VISIONAIRE versus CI were reported in 25 studies. Compared with CI, VISIONAIRE reduced odds of mechanical outliers by 40% (p < 0.0001), with no statistically significant differences in odds of overall coronal, sagittal, or rotational plane component outliers. VISIONAIRE improved surgical efficiency (operating room, turnover, and tourniquet times reduced by 7.3% (p = 0.02), 42% (p = 0.022), and 15.9% (p = 0.01), respectively), lowering the odds of blood transfusion by 53% (p = 0.01) and shortening patients' hospital stays (11.1% reduction; p < 0.0001). There were no significant differences between groups in incidence of postoperative complications and (descriptively analyzed) return-to-function outcomes.

CONCLUSION

Options for PSI in TKA differ substantially, and it is important to assess the outcomes of individual systems. The current findings suggest that VISIONAIRE guides can lead to improved alignment accuracy and surgical efficiency compared with CI, without compromising postoperative safety and return-to-function outcomes.

Prevention of surgical site infection: a ten-step approach

Surgical site infection (SSI) is a common cause of morbidity and mortality in patients undergoing surgery. Similarly, periprosthetic joint infection (PJI), is a major cause of failure after total joint arthroplasty (TJA). As the annual volume of TJA procedures is projected to rise, so will the rate of subsequent SSI and PJI. Currently, prevention has been identified as the single most important strategy for combating SSI/PJI. Hence, the present article will serve as a summary of an evidence-based ten-step approach for SSI/PJI prevention that may help orthopedic surgeons with their infection prevention strategies.

The impact of surgical trainee involvement in total knee arthroplasty: a systematic review of surgical efficacy, patient safety, and outcomes

PURPOSE

Trainee involvement in patient care has raised concerns about the potential risk of adverse outcomes and harming patients. We sought to analyze the impact and potential consequence of surgical trainee involvement in total knee arthroplasty (TKA) procedures in terms of surgical efficacy, patient safety, and functional outcomes.

METHODS

We systematically reviewed Medline/PubMed, EMBASE, the Cochrane library, and Scopus databases in April 2021. Eligible studies reported on the impact of trainee participation in TKA procedures performed with and without such involvement.

RESULTS

Twenty-three publications met our eligibility criteria and were included in our study. These studies reported on 132,624 surgeries completed on 132,416 patients. Specifically, 23,988 and 108,636 TKAs were performed with and without trainee involvement, respectively. The mean operative times for procedures with (n = 19,573) and without (n = 94,581) trainee involvement were 99.77 and 85.05 min, respectively. Both studies that reported data on cost of TKAs indicated a significant increase (p < 0.001) associated with procedures completed by teaching hospitals compared to private practices. Mean overall complication rates were 7.20% and 7.36% for TKAs performed with (n = 9,386) and without (n = 31,406) trainees. Lastly, the mean Knee Society Scale (KSS) knee scores for TKAs with (n = 478) and without (n = 806) trainee involvement were similar; 82.81 and 82.71, respectively.

CONCLUSION

Our systematic review concurred with previous studies that reported trainee involvement during TKAs increases the mean operative time. However, the overall complication rates and functional outcomes were similar. Larger studies with a better methodology and higher level of evidence are still needed for a resolute conclusion.

Anemia and formation of deep vein thrombosis before operation in patients with knee osteoarthritis: a cross-sectional study

BACKGROUND

Preoperative anemia is a common complication in knee osteoarthritis (KOA) patients. However, the association between anemia and preoperative deep vein thrombosis (DVT) in osteoarthritis patients remains unknown. The aim of this study was to investigate such association.

METHODS

In this retrospective study, we included 1005 KOA patients undergoing total knee arthroplasty (TKA) in our hospital. According to preoperative hemoglobin levels, the patients were divided into anemia group and non-anemia group. According to the results of Doppler ultrasonography for the lower extremities, the patients were divided into DVT group and non-DVT group. A logistic model was established through propensity score matching (PSM), with anemia before TKA as the dependent variable, DVT-related variable as the covariate, and 0.03 as the Caliper value. The anemia group and non-anemia group were matched at a 1:1 ratio and 310 successfully matched. After matching, logistic regression analysis was used to evaluate the correlation between preoperative anemia and DVT in KOA patients.

RESULTS

In this study, 342 cases (33.6%) had preoperative anemia and 73 cases (7.2%) had DVT before TKA. After matching, 46 DVT cases (7.42%) were found. By using binary logistic regression after PSM, we found that the risk for preoperative DVT formation in TKA patients with preoperative anemia increased by 1.97 times [95% (CI 1.05-3.69)], P = 0.035.

CONCLUSION

Preoperative anemia is considered as an independent risk factor for the formation of preoperative DVT in KOA patients.

TRIAL REGISTRATION

ChiCRT2100054844.

Efficacy of immediate postoperative intravenous iron supplementation after staged bilateral total knee arthroplasty

BACKGROUND

Approximately 26% of patients undergoing major orthopedic elective procedures have preoperative anemia. This study aimed to investigate the effect of intravenous (IV) iron supplementation on the hemoglobin (Hb) level after staged bilateral total knee arthroplasty (TKA) in patients with or without preoperative anemia.

METHODS

We retrospectively analyzed 418 patients who underwent staged bilateral TKA (1 week interval). The iron group (n = 220) received IV iron isomaltoside immediately after each TKA. The no-iron group (n = 198) was recommended to receive transfusion if postoperative anemia was diagnosed between the first and second TKA. Preoperative anemia was present in 42 (21.2%) and 50 (22.7%) patients in the no-iron and iron groups, respectively. Demographic data, preoperative and postoperative Hb levels, Hb level change (preoperative minus postoperative 6-week Hb level), and blood drainage amount were compared between groups.

RESULTS

The transfusion rate was lower in the iron group than in the no-iron group (96.5% vs. 58.6%, P < 0.001). Overall, the demographic data, preoperative and postoperative 6-week Hb levels, Hb level change, and blood drainage amount were not significantly different between the two groups. Among patients with preoperative anemia, the iron group showed lower Hb level change (0.6 ± 0.9 vs. 0.1 ± 1.1, P = 0.016).

CONCLUSION

Patients with preoperative anemia treated with IV iron showed lower Hb level change than did those without IV iron treatment. Despite the lower transfusion rate, the iron group showed similar postoperative 6-week Hb level and Hb level change to the no-iron group.

Tourniquet application in primary total knee arthroplasty for osteoarthritis: A systematic review and meta-analysis of randomized controlled trials

Objective

The aim of this study was to identify the influence of a tourniquet on the blood loss, transfusion requirement, swelling, pain, knee function, range of motion (ROM), operation time, bone cement mantle thickness, and complications in patients operated with total knee arthroplasty (TKA).

Methods

Two authors independently retrieved PubMed, Embase, and CENTRAL to identify eligible randomized controlled trials (RCTs) evaluating the effectiveness of a tourniquet in TKA. Fixed- (I ²< 50%) or random-effects (I ²> 50%) models were selected to perform meta-analysis according to the value of I ². Mean difference (MD) and risk ratio were selected as the effect sizes for continuous and dichotomous variables, respectively.

Results

A total of 29 RCTs, involving 2,512 operations (1,258 procedures with a tourniquet and 1,254 procedures without a tourniquet), were included, and 18 outcomes were compared. Tourniquet application could significantly decrease intraoperative blood loss (MD = -138.72 ml, p < 0.001), shorten operation duration (MD = -1.77 min, p < 0.001), and increase cement mantle thickness (MD = 0.17 mm, p < 0.001). However, it was significantly associated with increased postoperative pain intensity, decreased full ROM/flexion ROM/extension ROM, poorer knee function, increased knee swelling, and increased length of hospital stay (LOS) at several follow-up points (p < 0.050). No significant difference was found for postoperative draining volume, total blood loss, transfusion rate, change of Hb level, and risks of deep venous thrombosis and all complications.

Conclusions

Tourniquet application could only decrease the intraoperative blood loss but has no effectiveness on the total blood loss and transfusion requirement. On the contrary, it has a reverse effect on the pain score, knee function, ROM, swelling, and LOS.

A novel predictive model of hospital stay for Total Knee Arthroplasty patients

Objective

This study aimed to explore the main risk factors affecting Total Knee Arthroplasty (TKA) patients and develop a predictive nomogram of hospital stay.

Methods

In total, 2,622 patients undergoing TKA in Singapore were included in this retrospective cohort study. Hospital extension was defined based on the 75% quartile (Q3) of hospital stay. We randomly divided all patients into two groups using a 7:3 ratio of training and validation groups. We performed univariate analyses of the training group, in which variables with P-values < 0.05 were included and then subjected to multivariate analysis. The multivariable logistic regression analysis was applied to build a predicting nomogram, using variable P-values < 0.01. To evaluate the prediction ability of the model, we calculated the C-index. The ROC, Calibration, and DCA curves were drawn to assess the model. Finally, we verified the accuracy of the model using the validation group and by also using the C-index. The ROC curve, Calibration curve, and DCA curve were then applied to evaluate the model in the validation group.

Results

The final study included 2,266 patients. The 75% quartile (Q3) of hospital stay was six days. In total, 457 (20.17%) patients had hospital extensions. There were 1,588 patients in the training group and 678 patients in the validation group. Age, Hb, D.M., Operation Duration, Procedure Description, Day of Operation, Repeat Operation, and Blood Transfusion were used to build the prediction model. The C-index was 0.680 (95% CI: 0.734-0.626) in the training group and 0.710 (95% CI: 0.742-0.678) for the validation set. The calibration curve and DCA indicated that the hospital stay extension model showed good performance in the training and validation groups.

Conclusion

To identify patients' risk factors early, medical teams need to plan a patient's rehabilitation path as a whole. Its advantages lie in better resource allocation, maximizing medical resources, improving the functional recovery of patients, and reducing the overall cost of hospital stay and surgery, and will help clinicians in the future.

Clinical Outcomes and Experience of a Multiyear Consecutive Case Series of Total Knee Arthroplasty Procedures Conducted with a Bipolar Sealer System for Hemostasis

Maximizing hemostasis during total knee replacement procedures remains a key challenge in current practice. Bipolar sealer technology achieves intraoperative hemostasis through tissue sealing and coagulation with adjustable radio frequency energy and a saline-irrigated tip. Optimal surgical site hemostasis is important to avoid potential complications such as hemarthrosis, wound drainage, increased pain, delayed discharge, and readmissions. The aim of this study is to evaluate the safety and effectiveness of the bipolar sealer device in primary knee replacement in the largest consecutive series to date. A consecutive, treatment-control series of subjects who underwent a primary total knee arthroplasty (TKA) utilizing a bipolar sealer for hemostasis, one subgroup with concomitant tranexamic acid (TXA) administration (n = 1599) and one subgroup without TXA administration (n = 3582), compared with a control group of primary TKA under tourniquet only (n = 667). Statistical analyses were performed through two-tailed unpaired t-tests. There was less total postoperative drain output and a lower overall transfusion rate in the bipolar sealer group (807ml ± 428) (2.5%) than the tourniquet only group (1290 ± 658, p = 0.001) (8.4%, p = 0.0001), respectively. Drainage output in bipolar sealer + TXA (450 ± 297 ml) was lower than the other two groups (bipolar sealer 807 ± 428 mL, p = 0.0001; tourniquet only 1290 ± 658 ml, p = 0.0001). The bipolar sealer group had a higher hematocrit at postoperative day 1 (POD1) (bipolar sealer: 33.1 ± 4.3 cc, tourniquet only: 32.5 ± 4.3 cc, p = 0.001) and at discharge (POD2, bipolar sealer: 31.5 ± 3.7 cc, tourniquet only: 30.2 ± 3.9 cc, p = 0.0001). There were zero reported serious adverse events related to hemostasis management in any group. The bipolar sealer system is a safe and effective instrument to achieve intraoperative hemostasis during primary TKA. The bipolar sealer group required significantly fewer postoperative blood product transfusions and maintained a higher hematocrit concentration at the time of discharge compared with subjects treated solely with tourniquet mediated hemostasis. Addition of TXA to local hemostasis methods may further reduce blood loss and transfusion requirements. LEVEL OF EVIDENCE:  This is a Level III study.

Total Knee Arthroplasty After Genicular Nerve Radiofrequency Ablation: Reduction in Prolonged Opioid Use Without Increased Postsurgical Complications

Genicular nerve radiofrequency ablation (GNRFA) is an increasingly used nonsurgical treatment modality for patients with advanced knee osteoarthritis. Previous studies have demonstrated this to be an effective and safe method to decrease pain and increase functionality in this patient population. The purpose of this study was to compare 2-year postoperative complication rates and rates of prolonged postoperative opioid usage between patients undergoing total knee arthroplasty (TKA) after previous GNRFA and those undergoing TKA alone.

The Application of Platelet-Rich Plasma for Patients Following Total Joint Replacement: A Meta-Analysis of Randomized Controlled Trials and Systematic Review

Background

The clinical efficacy of platelet-rich plasma (PRP) in the treatment of total joint replacement (TJR) remains inconclusive. In this paper, systematic review and meta-analysis was adopted to assess the efficacy of using PRP for the treatment of TJR.

Methods

A comprehensive search of Medline, Embase, and Cochrane library databases for randomized controlled trial (RCT) articles recording data of PRP for TJR was conducted from inception to February 2022. Outcomes concerned were pain, range of motion (ROM), WOMAC score, length of hospital stay (LOS), hemoglobin (Hb) drop, total blood loss, wound healing rate, and wound infection. The methodological quality of the included RCTs was evaluated by using the Cochrane Risk of Bias Tool 2.0 (RoB 2.0). The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) was utilized to assess the level of evidence for the outcomes. Subgroup analysis was conducted according to the type of TJR.

Results

Ten RCTs were included in the meta-analysis. In the TKA subgroup, the available data demonstrated that there were significant differences in the outcomes of pain and Hb drop, while it was the opposite of ROM, WOMAC score, LOS, total blood loss, wound healing rate, and wound infection. In the THA subgroup, no significant differences could be seen between two groups in the outcomes of LOS and wound infection. However, the PRP group gained a higher wound healing rate in the THA subgroup.

Conclusion

The application of PRP did not reduce blood loss but improved the wound healing rate. However, more prospective and multicenter studies are warranted to confirm these results.

Enhanced recovery after surgery for major orthopedic surgery: a narrative review

Background

With increasing interest in enhanced recovery after surgery (ERAS), the literature on ERAS in orthopedic surgery is also rapidly accumulating. This review article aims to (1) summarize the components of the ERAS protocol applied to orthopedic surgery, (2) evaluate the outcomes of ERAS in orthopedic surgery, and (3) suggest practical strategies to implement the ERAS protocol successfully.

Main body

Overall, 17 components constituting the highly recommended ERAS protocol in orthopedic surgery were identified. In the preadmission period, preadmission counseling and the optimization of medical conditions were identified. In the preoperative period, avoidance of prolonged fasting, multimodal analgesia, and prevention of postoperative nausea and vomiting were identified. During the intraoperative period, anesthetic protocols, prevention of hypothermia, and fluid management, urinary catheterization, antimicrobial prophylaxis, blood conservation, local infiltration analgesia and local nerve block, and surgical factors were identified. In the postoperative period, early oral nutrition, thromboembolism prophylaxis, early mobilization, and discharge planning were identified. ERAS in orthopedic surgery reduced postoperative complications, hospital stay, and cost, and improved the patient outcomes and satisfaction with accelerated recovery. For successful implementation of the ERAS protocol, various strategies including the standardization of care system, multidisciplinary communication and collaboration, ERAS education, and continuous audit system are necessary.

Conclusion

The ERAS pathway enhanced patient recovery with a shortened length of stay, reduced postoperative complications, and improved patient outcomes and satisfaction. However, despite the significant progress in ERAS implementation in recent years, it has mainly focused on major surgeries such as arthroplasty. Therefore, further efforts to apply, audit, and optimize ERAS in various orthopedic surgeries are necessary.

A single-center experience with head-to-toe microsurgical reconstruction in bloodless medicine patients

Patients who decline blood transfusions, including members of the Jehovah's Witness faith, often face challenges when they require or desire prolonged operations such as free tissue transfer (FTT). This study aims to outline our institution's experience with treating bloodless medicine patients and offers the first anatomically comprehensive evaluation of FTT in this population. All patients undergoing FTT from 2017 to 2020 at a single institution were retrospectively reviewed. Patients who declined blood products were selected. Outcomes of interest include flap success, operative complications, and changes to hemoglobin measurements. Ten patients undergoing 11 FTT procedures were identified. Average age was 62.4 years (SD 7.6). Most patients were female (n = 9) and Black (n = 8). Average body mass index was 31.3 (SD 5.6), American Society of Anesthesiologists Physical Status was 2.9 (SD 0.5), and Charlson Comorbidity Index was 3.8 (SD 1.1). Sites of FTT reconstruction were breast (6), lower extremity (3), and scalp (2). Average operative time was 390 min (SD 85.1), with an average estimated blood loss of 170 mL (SD 100.4). The difference between preoperative hemoglobin to first postoperative hemoglobin measurement averaged 2.2 g/dL (SD 1.4). Average patient follow-up was 12 months (SD 7.8). Flap success occurred in 10 cases. One patient with flap failure was successfully reconstructed with a second procedure. Despite a small, heterogeneous cohort, our success rate in this highly comorbid population indicates that FTT can be performed effectively for patients who cannot use blood products. Bloodless medicine protocols are beneficial to providers serving patients with transfusion restrictions and systems that strive to limit transfusion volume and risk.

Tranexamic acid is beneficial for blood management of high tibial osteotomy: a randomized controlled study

INTRODUCTION

The purpose of this study was to investigate whether TXA can effectively reduce blood loss after HTO and related complications and to evaluate its safety.

MATERIALS AND METHODS

From March 2016 to March 2018, 100 patients who underwent medial opening wedge HTO in the Department of Orthopedics, the second affiliated hospital of xi'an jiaotong university, with an average age of 52.8 ± 3.2 years, were randomly divided into the TXA group (using intravenous TXA) and the control group (using the same amount of normal saline), with 50 patients in each group. The postoperative wound drainage volume, decrease in hemoglobin and hematocrit value, total blood loss, wound healing, blood transfusion, deep venous thrombosis (DVT) and pulmonary embolism (PE) were compared between the two groups.

RESULTS

The drainage volume on the first postoperative day and the total drainage volume of the TXA group were significantly lower compared with those of the control group (145.7 vs 264.5 ml, 282.3 vs 413.2 ml, P < 0.05). The decreases in the hemoglobin and hematocrit values on the postoperative first, second and fifth days were lower in the TXA group than those in the control group (1.4 VS 3.5, 2.6 vs 3.3, 1.9 vs 2.9 g, P < 0.05; 3.3 vs 5.5, 5.0 vs 9.1, 3.8 vs 7.2%, P < 0.05), and the mean total blood loss was also lower in the TXA group than that in the control group (477.9 vs 834.6 ml, P < 0.05). In the control group, 1 patient had wound hematoma requiring additional paracentesis and pressure dressing, 1 patient had superficial wound infection requiring additional debridement, and 1 patient had postoperative blood transfusion compared to none in the TXA group (P > 0.05). There was no symptomatic DVT or PE in either of the groups.

CONCLUSION

Intravenous TXA can effectively and safely reduce blood loss and bleeding-related complications after HTO and was beneficial for the blood management of HTO.

Thrombotic activation before and after total hip arthroplasty. A prospective cohort study

BACKGROUND

Total hip arthroplasty (THA) causes acute blood loss. It may lead to a deficiency in coagulation factors, which, in turn, may lead to increased bleeding during the postoperative period.

METHODS

Thirty patients (18 women) with a mean age of 67 years (range: 63-72 years) participated in this prospective diagnostic study. THA was performed without tranexamic acid administration in the perioperative period. Activities of clotting factors II, VIII, X, and fibrinogen concentration were evaluated before surgery, 6 hours after the procedure, 2, 4, and 6 days after the operation. All laboratory tests were performed using ACL TOP 500 CTS analyzer.

RESULTS

No thromboembolic complications were noted during hospitalization. Mean fibrinogen concentration was 366 mg/dL before surgery, which decreased to 311 mg/dL 6 hours after the operation and peaked at 827 mg/dL on the 4th day after the procedure. Activities of factors II and X decreased on the second and fourth days after surgery. Although the activity of factor VIII decreased after the procedure, it remained within the normal range. Increased baseline fibrinogen concentrations were observed in 6 out of 30 (20%) patients. Mean blood loss was 1332 mL (range, 183-2479 mL) and did not correlate with changes in clotting factor activities.

CONCLUSIONS

In patients undergoing THA, fibrinogen acts as an acute-phase protein. Activities of clotting factors II and X normalize within 6 days, and although the activity of factor VIII decreases, it remains within the normal range.

TRIAL REGISTRATION

The study was pre-registered May 1st, 2020 on ClinicalTrials.gov.

Blood loss and transfusion risk in robotic-assisted knee arthroplasty: A retrospective analysis

BACKGROUND

The purpose of this study was to compare total blood loss and the risk of receiving a blood transfusion in robotic-assisted total knee arthroplasty (TKA) and unicompartmental knee arthroplasty (UKA) against conventional jig-based techniques.

METHODS

Robotic TKA (n = 50) and UKA (n = 50) patients were matched to contemporary controls for TKA (n = 50) and UKA (n = 50) and retrospectively analysed.

RESULTS

Robotic TKA patients experienced 23.7% less blood loss compared to conventional TKA patients (911.0 ml vs 1193.7 ml, p < 0.01), and were associated with an 83% relative risk reduction of receiving a transfusion (2% of patients vs 12%, p = 0.02). Robotic UKA patients did not demonstrate less blood loss compared to corresponding controls (821.7 ml vs 854.7 ml, p = 0.69). Both UKA groups received no transfusions.

CONCLUSIONS

Robotic surgical systems in TKA reduces blood loss and lowers the risk of requiring a blood transfusion. In UKA, robotic-assisted arthroplasty did not reduce blood loss compared to conventional arthroplasty.

Perioperative Management of Chronic Antithrombotic Agents in Elective Hip and Knee Arthroplasty

Total hip and knee arthroplasty are common major orthopedic operations being performed on an increasing number of patients. Many patients undergoing total joint arthroplasty (TJA) are on chronic antithrombotic agents due to other medical conditions, such as atrial fibrillation or acute coronary syndrome. Given the risk of bleeding associated with TJAs, as well as the risk of thromboembolic events in the post-operative period, the management of chronic antithrombotic agents perioperatively is critical to achieving successful outcomes in arthroplasty. In this review, we provide a concise overview of society guidelines regarding the perioperative management of chronic antithrombotic agents in the setting of elective TJAs and summarize the recent literature that may inform future guidelines. Ultimately, antithrombotic regimen management should be patient-specific, in consultation with cardiology, internal medicine, hematology, and other physicians who play an essential role in perioperative care.

Topical co-delivery of platelet rich fibrin and tranexamic acid does not decrease blood loss in primary total knee arthroplasty compared to the standard of care: a prospective, randomized, controlled trial

PURPOSE

The purpose of this study was to evaluate the efficacy of intra-operative co-administration of tranexamic acid (TA) and platelet rich fibrin (PRF) using a proprietary co-delivery system on the amount of blood loss, early functional outcomes and wound complications after primary total knee arthroplasty (TKA). The intervention was compared to the standard of care (combined intravenous & topical TA) in a prospective, randomized, blinded setting.

METHODS

80 patients undergoing primary cemented TKA without tourniquet were prospectively randomized into control (combined intravenous and topical TA) and PRF (intra-venous TA and co-delivery of topical PRF and TA) groups after informed consent. Total blood loss, drainage blood loss, knee range of motion, VAS pain scores, length of stay and wound complications were analysed. Data collection was performed in a double blind manner on days 1, 3 and 21.

RESULTS

There was no statistically significant difference in drainage blood loss (550 ml vs. 525 ml, p = 0.643), calculated total blood loss on day 1 (401 ml vs. 407 ml, p = 0.722), day 3 (467 ml vs 471 ml, p = 0.471) and day 21 (265 ml vs. 219 ml, p = 0.082) between the PRF and control groups respectively. The PRF group had a small but statistically significant increase in median knee extension in the early post-operative period, however this difference evened out at 3 weeks. No significant difference could be demonstrated between the PRF and control groups in length of stay, VAS pain scores, narcotic usage, wound complications and knee flexion at all time points.

CONCLUSIONS

The topical co-delivery of PRF and TA does not significantly decrease blood loss in primary TKA compared to the standard of care. Slightly better active knee extension in the first 3 postoperative days can be achieved, however this benefit is not clinically relevant.

LEVEL OF EVIDENCE

I, Therapeutic study.

Changes in perioperative hemoglobin and hematocrit in patients undergoing total knee arthroplasty: a prospective observational study of optimal timing of measurement

Objective

This study was performed to depict the patterns of change in the perioperative hemoglobin (Hb) concentration and hematocrit (Hct) and to identify the optimal timing of Hb and Hct measurement in patients undergoing total knee arthroplasty (TKA).

Methods

This prospective observational study involved 302 consecutive patients who underwent TKA. The patients were kept in hospital for 1 full week postoperatively. Hb and Hct measurements were performed preoperatively and on days 1 to 7 postoperatively and then during clinic visits at 1, 3, and 6 months postoperatively.

Results

The Hb concentration and Hct decreased during the first few days postoperatively and reached a nadir on postoperative day 4 and 3, respectively; they then recovered in the following days. Significant differences in the Hb concentration and Hct were detected between the preoperative period and day 1, between days 1 and 2, between days 2 and 3, between day 7 and 1 month, and between 1 and 3 months. A significant difference in the Hct was also detected between 3 and 6 months.

Conclusion

The optimal timing of Hb and Hct measurement is on postoperative day 3 or 4. This timing accurately reflects ongoing hidden blood loss to better guide blood transfusions.

Does intraoperative transfusion during total knee arthroplasty reduce the need for transfusion after surgery?: A preliminary retrospective cohort study

OBJECTIVES

After total knee arthroplasty (TKA), many patients experience anemia due to blood loss. To prevent postoperative anemia and allogeneic blood transfusion after TKA, we used prophylactic allogeneic or autologous blood transfusion intraoperatively. This study evaluated the effects of prophylactic transfusion during TKA.

MATERIALS AND METHODS

This retrospective cohort study included 579 patients receiving scheduled unilateral TKA. We allocated the patients into three groups, the prophylactic allogeneic transfusion (Group AL), prophylactic autologous transfusion (Group AT), and no prophylactic transfusion with intra-articular tranexamic acid administration (GroupC) groups. After propensity score matching, we compared the rate of postoperative allogeneic blood transfusions until three days after TKA, postoperative hemoglobin and hematocrit levels until four days after TKA, and the side effects in each groups.

RESULTS

The postoperative allogeneic blood transfusion rates were statistically higher in group AL and AT than in group C (18.2% and, 18.9% vs 2.3%, respectively; P<0.000). The postoperative hemoglobin and hematocrit levels were statistically lower in group Auto than in group C (P<0.0001), but the levels in group AL were not different from those of group C (P=0.493 vs. P=0.384 respectively). In addition, the side effects were statistically higher in group AL and AT than in group C.

CONCLUSION

Prophylactic intra-operative transfusions did not reduce the rates of allogeneic transfusions and produced more side effects and hypotension after surgery than intra-articular tranexamic acid administration with no prophylactic transfusion in patients undergoing TKAs.

Postoperative Intravenous Iron Supplementation Does Not Improve Hemoglobin Level and Transfusion Rate Following Staged Bilateral Total Knee Arthroplasty

BACKGROUND

We determined whether postoperative intravenous (IV) iron supplementation could reduce transfusion rate in patients undergoing staged bilateral total knee arthroplasty (TKA). Furthermore, we examined whether hemoglobin (Hb) levels and iron profile differed between patients with and without postoperative IV iron supplementation.

METHODS

This retrospective, comparative cohort study included 126 patients who underwent primary staged bilateral TKA during a single hospitalization. The second TKA was performed at a week's interval. Group iron (n = 65) received IV iron immediately after each surgery, while patients in group no-iron (n = 61) received no iron after surgery. Transfusion rate, change in Hb levels, and iron profile including serum iron, ferritin, total iron binding capacity, and transferrin saturation were evaluated preoperatively; on postoperative days 1, 2, and 4 after the first TKA; and postoperative days 1, 2, 4, and 7, 6 weeks, and 3 months after the second TKA.

RESULTS

There were no significant differences in Hb levels and transfusion rate following staged bilateral TKA between patients with and without postoperative IV iron supplementation although serum iron profiles were improved in patients with IV iron supplementation.

CONCLUSION

Postoperative IV iron supplementation immediately after acute blood loss caused by TKA was not effective in improving the transfusion rate. Therefore, surgeons should use protocols other than postoperative IV iron supplementation for reducing the transfusion rate in patients undergoing staged bilateral TKA in a single hospitalization.

LEVEL OF EVIDENCE

III.

Does tourniquet use decrease blood loss following primary total knee arthroplasty in Jehovah's Witness patients?

OBJECTIVES

This study aims to investigate the use of multiple blood management strategies and the effect of tourniquet on the estimated blood loss (EBL) in Jehovah's Witness (JW) patients who underwent primary total knee arthroplasty (TKA).

PATIENTS AND METHODS

Twenty-two self-reported JW patients (9 males, 13 females; mean age 66.8±8.6 years; range, 51 to 83 years) who underwent primary TKA between January 2014 and January 2020 in our institution were retrospectively reviewed. A standard blood management protocol that consisted of hypotensive anesthesia, local and systemic administration of tranexamic acid (TXA) and intraoperative cell salvage was applied to all patients. Patients were divided into two groups: with (n=11) and without (n=11) tourniquet use. The EBL was calculated according to Meunier's formula. Hemoglobin (Hgb), hematocrit (Hct), and EBL on the first and third postoperative days were compared statistically.

RESULTS

There was no significant difference between groups regarding postoperative Hgb (p=0.801 and p=0.767), Hct (p=0.617 and p=0.895), Hgb decline (p=0.311 and p=0.822), and EBL (p=0.067 and p=0.284) at first and third postoperative days. None of the patients required blood transfusion. No wound complication or symptomatic deep vein thrombosis was seen during the hospital stay.

CONCLUSION

Combined use of hypotensive anesthesia, intravenous administration of TXA, intraoperative periarticular injection, and cell salvage seem to be sufficient in controlling the blood loss in JW patients during TKA. Additional tourniquet use may not further decrease the EBL.

Tranexamic acid or epsilon-aminocaproic acid in total joint arthroplasty? A randomized controlled trial

AIMS

Antifibrinolytic agents, including tranexamic acid (TXA) and epsilon-aminocaproic acid (EACA), have been shown to be safe and effective for decreasing perioperative blood loss and transfusion following total hip arthroplasty (THA) and total knee arthroplasty (TKA). However, there are few prospective studies that directly compare these agents. The purpose of this study was to compare the benefits of intraoperative intravenous TXA with EACA.

PATIENTS AND METHODS

A total of 235 patients (90 THA and 145 TKA) were enrolled in this prospective, randomized controlled trial at a single tertiary-care referral centre. In the THA cohort, 53.3% of the patients were female with a median age of 59.8 years (interquartile range (IQR) 53.3 to 68.1). In the TKA cohort, 63.4% of the patients were female with a median age of 65.1 years (IQR 59.4 to 69.5). Patients received either TXA (n = 119) or EACA (n = 116) in two doses intraoperatively. The primary outcome measures included change in haemoglobin level and blood volume, postoperative drainage, and rate of transfusion. Secondary outcome measures included postoperative complications, cost, and length of stay (LOS).

RESULTS

TKA patients who received EACA had greater drainage (median 320 ml (IQR 185 to 420) vs 158 ml (IQR 110 to 238); p < 0.001), increased loss of blood volume (891 ml (IQR 612 to 1203) vs 661 ml (IQR 514 to 980); p = 0.014), and increased haemoglobin change from the preoperative level (2.1 ml (IQR 1.7 to 2.8) vs 1.9 ml (IQR 1.2 to 2.4); p = 0.016) compared with patients who received TXA. For the THA cohort, no statistically significant differences were observed in any haematological outcome measure. One patient in the EACA group required transfusion. No patient in the TXA group required transfusion. There were no statistically significant differences in number or type of postoperative complications or LOS for either THA or TKA patients regardless of whether they received TXA or EACA.

CONCLUSION

For hip and knee arthroplasty procedures, EACA is associated with increased perioperative blood loss compared with TXA. However, there is no significant difference in transfusion rate. While further prospective studies are needed to compare the efficacy of each agent, we currently recommend orthopaedic surgeons to select their antifibrinolytic based on cost and regional availability. Cite this article: Bone Joint J 2019;101-B:1093-1099.

Multiple asystole events in a patient undergoing total knee arthroplasty - a case report

Background

Unexpected cardiac arrest in patients during surgery is associated with high mortality. Reasons are often multifactorial and unclear.

Case presentation

This case report describes a patient who developed reversible asystole during knee surgery under general anaesthesia. All diagnostic cardiac examinations were unremarkable. After surgery, the patient showed no further symptoms.

Conclusion

To prevent cardiac arrest due to non-cardiac reasons, patients with a high risk for asystole caused by vasovagal reflex or by pain need to be identified. Preoperative conditions such as hypovolemia need to be improved prior to surgery, and additional monitoring should be used. Further investigations to determine the influence of non-cardiac disease and long-term medication are necessary.

Blood loss of total knee arthroplasty in osteoarthritis: an analysis of influential factors

BACKGROUND

Total knee arthroplasty is regarded as the most effective treatment for severe knee osteoarthritis. The influential factors of blood loss in total knee arthroplasty remain controversial. The study aims to explore the influential factors of blood loss in total knee arthroplasty comprehensively.

MATERIAL AND METHODS

Three hundred and four osteoarthritis patients undergoing unilateral primary total knee arthroplasty were enrolled. Demographic characteristics, laboratory results, surgical protocol, and hemostatic and anticoagulation drugs were collected. Estimation of blood loss was calculated using the Gross equation. Multivariable stepwise linear regression analysis was performed to find out the influential factors.

RESULTS

Total blood loss reached the biggest volume (1346 ± 671 mL) in the post-operative third day. Hidden blood loss reached 465 ± 358 mL. Gender, tranexamic acid, prosthesis type, and drainage were proven to be positively correlated with the total blood loss (all P < 0.05). Male appeared to suffer more surgical blood loss than female. Posterior cruciate stabilizing prosthesis might lead to more surgical blood loss than posterior cruciate retaining prosthesis. Tranexamic acid could effectively reduce total blood loss while drainage might increase bleeding. Gender and anticoagulation drugs were correlated with hidden blood loss (both P < 0.05). Low molecular weight heparin resulted in less hidden blood loss than rivaroxaban.

CONCLUSIONS

Posterior cruciate retaining prosthesis and topical use of tranexamic acid were preferred to reduce total blood loss. Drainage was not recommended due to the risk of increasing bleeding. Low molecular weight heparin was recommended to prevent venous thrombosis.

Intravenous and intraarticular tranexamic acid plus epinephrine for the man-agement of blood loss after cemented total knee arthroplasty: a case-control study

BACKGROUND

Tranexamic acid (TXA) is efficiently used to control blood loss during total knee arthroplasty (TKA). The role of intraarticular epinephrine needs further clarification. Limited data exist, concerning the combined use of intravenous and intraarticular TXA plus epinephrine in the intraoperative management of blood loss in patients undergoing TKA.

METHODS

This study aimed to evaluate the safety and efficacy of intravenous and intraarticular TXA plus epinephrine in the intraoperative blood management in primary TKA. In this case-control study, 204 patients undergoing primary cemented TKA were enrolled. One hundred two patients received one gr TXA intravenously and intraarticular injection of a mixture containing 500 mg TXA and 0.6 mg epinephrine. They compared to a historical control group comprised of 102 patients that received the same drug combination without epinephrine. The two groups were comparable concerning age, sex, the grade of osteoarthritis, and preoperative hemoglobin and hematocrit.

RESULTS

The epinephrine group had significantly higher postoperative hemoglobin (11.70 vs 10.75, p <0.001) and hematocrit (35.70 vs 32.25, p <0.001) compared to the control group at the first postoperative day. The epinephrine group received fewer transfusions, not reaching statistical significance (p =0.110), compared to the control group during hospitalization. The rate of complications was similar between the groups. The combined use of TXA and epinephrine was positively associated with a smaller postoperative hemoglobin drop.

CONCLUSION

The combination of intravenous and intraarticular TXA plus epinephrine was safe and reduced the drop of hemoglobin at the first postop day but not significantly the rate of transfusions, in patients undergoing primary TKA. Future higher-level of evidence studies are needed to validate these results. HIPPOKRATIA 2018, 22(2): 86-90.