Blood transfusion rates following shoulder arthroplasty in a high volume UK centre and analysis of risk factors associated with transfusion

Increasing severity of preoperative anemia is associated with higher postoperative medical and surgical complications after primary shoulder arthroplasty

BACKGROUND

Anemia is a major cause of morbidity worldwide and compounds numerous medical conditions. Studies have found associations between anemia and both medical and surgical complications after shoulder arthroplasty (SA); however, most of these studies have used commercially available national databases with limited information on outcomes and typically short-term follow-up. Our study sought to evaluate the midterm outcomes of primary SA at a single institution when stratified by the degree of preoperative anemia.

METHODS

Between 2000 and 2020, 5231 primary SA (477 hemiarthroplasties, 2091 anatomic total SA, and 2335 reverse SA) with preoperative hematocrit values available and a minimum follow-up of 2 years were collected from a single-institution joint registry database. The severity of anemia was subclassified as no anemia (hematocrit >39% for males, >36% for females; n = 4194 [80.2%]), mild anemia (hematocrit 33%-39% for males, 33%-36% for females; n = 742 [14.2%]), and moderate-to-severe anemia (hematocrit <33% for both males and females; n = 295 [5.6%]). The mean follow-up time for the entire cohort was 5.9 years (range, 2-22 years). Medical and surgical complications, reoperations, revisions, and implant survivorship were assessed.

RESULTS

SA with moderate-to-severe anemia had the highest rate of nonfatal and nontransfusion medical complications (5.1%) relative to the nonanemic (1.2%; P < .001) and mild anemic groups (1.5%; P < .001). Similarly, SA with moderate-to-severe anemia had the highest rate of surgical complications (19.3%) compared with mild anemia (14.3%; P = .044) and no anemia (11.6%; P < .001). Postoperative transfusion was most frequent in the moderate-to-severe anemia cohort (40.3%) compared with the mild anemia (14.2%; P < .001) and nonanemic groups (2.5%; P < .001). Furthermore, SA who received postoperative transfusions had a higher risk of nonfatal medical complications (8.2% vs. 1.0%; P < .001), 90-day mortality (1.5% vs. 0.03%; P = .001), and surgical complications (19.5% vs. 12.0%; P < .001) when compared with those without transfusion.

CONCLUSIONS

Moderate-to-severe anemia (hematocrit <33% for both males and females) was identified in approximately 5.6% of patients who underwent SA at a single institution and was associated with increased medical and surgical complications. Patients who received postoperative transfusions presented elevated rates of medical complications, 90-day mortality, and surgical complications. Health care teams should be aware of these risks in order to provide more individualized medical optimization and postoperative monitoring.

Low complication rate following reverse total shoulder arthroplasty at 90-days follow-up - A systematic review

IMPORTANCE

As reverse total shoulder arthroplasty (RTSA) has become an increasingly common procedure, rates of post-operative complications leading to potential hospital readmission are of greater importance. No previous systematic reviews have focused exclusively on post-operative complications and mortality rates at 90 days post RTSA.

OBJECTIVES

The purpose of this study was to review complication, readmission, and mortality rates within 90 days post RTSA.

EVIDENCE REVIEW

Two independent reviewers performed a literature search using the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines using PubMed, Embase, and Web of Science databases. Only studies reporting on outcomes of RTSA at 90-days follow-up specifically were considered for inclusion.

FINDINGS

Our search included 79,037 shoulders (62.1 ​% female) from a total of 15 studies with an average age of 72.4 ​± ​5.8 years. The overall 90-day re-admission rates were reported in nine studies as 6.1 ​% (4205/69,127) following RTSA. Additionally, a total of five studies reported the overall 90-day mortality rate as 1.1 ​% (19/1733). The overall pooled rate of medical complications was 3.9 ​% (2998/77,826) as reported in 13 studies, at 90-days post-RTSA, with the occurrence of anaemia being the most commonly reported outcomes as 2.9 ​% (1013/34,385) in six studies. The overall rate of surgical complications was 1.1 ​% reported in 13 studies (1327/77,826), with the pooled rate of surgical revisions of 1.5 ​% (607/40,563) at 90-days follow-up. A total of 8, 5, and 3 studies reported rates of dislocation, requirement for closed reduction and glenoid loosening as 0.9 ​% (344/37,995), 0.6 ​% (7/1180), and 0.3 ​% (30/9115) respectively at 90-days following RTSA.

CONCLUSIONS AND RELEVANCE

This study established that the overall rates of mortality and medical and surgical complications are low in the short-term following RTSA, with only 6 ​% of patients requiring re-admission in the first 90 days.

LEVEL OF EVIDENCE

IV - Systematic Review of all levels of evidence.

Impact of Resident Involvement on 30-Day Postoperative Outcomes in Orthopedic Shoulder Surgery

The literature concerning resident involvement in shoulder surgery is limited. The purpose of this study was to examine whether resident involvement across all orthopedic shoulder surgeries is associated with adverse 30-day outcomes. Utilizing the American College of Surgeons National Surgical Quality Improvement Program database, patients who underwent shoulder surgery with or without a resident present were analyzed. Independent t-test and chi-square or Fischer's exact test were used appropriately. A logistic regression model was used to calculate adjusted odds ratios. This study examined 5,648 patients: 3,455 patients in the "Attending alone" group and 2,193 in the "Attending and resident in the operating room" group. Resident presence in the operating room was not associated with increased complications, except for bleeding transfusions (OR 1.71, CI 1.32-2.21, P ≤ 0.001). This study demonstrates that resident involvement in orthopedic shoulder surgery does not present an increased risk for 30-day complications when compared to surgeries performed with the attending surgeon alone.

Early morbidity and mortality after one-stage bilateral shoulder arthroplasty

PURPOSE

One-stage bilateral shoulder arthroplasty has the advantage of requiring a single hospital stay and a single anaesthesia. The topic has been little reported, unlike one stage bilateral hip and knee arthroplasty, which have demonstrated their interest. The aim of the present study was to determine peri- and early post-operative morbidity and mortality after this procedure. The study hypothesis was that peri- and early post-operative morbidity and mortality in one stage bilateral shoulder arthroplasty is low in selected patients and that satisfaction is high.

METHODS

A single-centre retrospective study assessed peri- and early post-operative morbidity and mortality in one stage bilateral shoulder arthroplasty. Twenty-one patients, aged < 80 years, with ASA score ≤ 3, were consecutively operated on between 1999 and 2020. Indications comprised primary osteoarthritis, aseptic osteonecrosis, inflammatory arthritis, massive rotator cuff tear, and dislocation fracture, involving both shoulders.

RESULTS

There were no early deaths. The complication rate was 10% (4/21 cases). No prosthesis dislocation or sepsis was reported. Mean blood loss was 145 ± 40 cc, mean surgery time 164 ± 63 min, and mean hospital stay five ± four days. Only one patient required postoperative transfusion. Functional results at six months showed significantly improved range of motion and good patient satisfaction.

CONCLUSIONS

One-stage bilateral shoulder arthroplasty was feasible in selected patients. Mortality was zero, and morbidity was low. Surgery time was reasonable and required no repositioning. Postoperative home help is indispensable for patient satisfaction during rehabilitation.

The Obesity Paradox: A Nonlinear Relationship Between 30-Day Postoperative Complications and Body Mass Index After Total Shoulder Arthroplasty

BACKGROUND

An inverse relationship coined the "obesity paradox" has been propositioned, in which body mass index (BMI) may be contradictorily protective in patients undergoing surgery or treatment of chronic disease. This study sought to investigate the BMI associated with the lowest rate of medical complications after total shoulder arthroplasty (TSA).

METHODS

The American College of Surgeons National Surgical Quality Improvement Project database was queried to identify adults who underwent elective primary TSA between January 2012 and December 2020. Thirty-day postoperative medical complications were extracted, which included death, readmission, pneumonia, pulmonary embolism, renal failure, and cardiac arrest, among others. BMI was classified into five categories (underweight [BMI <18.5 kg/m 2 ], normal weight [BMI ≥18.5 and <25 kg/m 2 ], overweight [BMI ≥25 and <30 kg/m 2 ], obese [BMI ≥30 and <40 kg/m 2 ], and morbidly obese [BMI ≥40 kg/m 2 ]). We examined the risk of any 30-day postoperative complications and BMI categorically and on a continuous basis using multivariable logistic regression controlling for age, sex, procedure year, and comorbidities.

RESULTS

Of the 31,755 TSAs, 84% were White, 56% were female, and the average age of patients was 69.2 ± 9.3 years. Thirty-day postoperative medical complications occurred in 4.53% (n = 1,440). When assessed on a continuous basis, the lowest risk was in patients with a BMI between 30 and 35 kg/m 2 . Underweight individuals (BMI <18.5 kg/m 2 ) had the highest postoperative complication rates overall. The probability of medical complications increased with age and was greater for female patients.

CONCLUSION

The relationship between BMI and complication risk in TSA is nonlinear. A BMI between 30 and 35 kg/m 2 was associated with the lowest risk of medical complications after TSA, and BMI<18.5 kg/m 2 had the highest risk overall, indicating some protective aspects of BMI against 30-day medical complications. Thus, obesity alone should not preclude patients from TSA eligibility, rather surgical candidacy should be evaluated in the context of patients' overall health and likelihood of benefit from TSA.

LEVEL OF EVIDENCE

III, Retrospective Comparative Study.

Risk factors for postoperative transfusion in diabetic patients following total shoulder arthroplasty

Background

Diabetes has been reported as a risk factor for postoperative transfusion following total shoulder arthroplasty (TSA). However, the risk factors specific to diabetic patients that increase their likelihood of postoperative blood transfusion remains understudied. The purpose of the study was to investigate the risk factors that are associated with 30-day postoperative transfusion among diabetic patients who undergo TSA.

Methods

The American College of Surgeons National Surgical Quality Improvement Program database was queried for all patients who underwent TSA between 2015 and 2020. Both patients with and without diabetes were divided into cohorts based on 30-day postoperative transfusion requirement. Bivariate logistic regression was used to compare patient demographics and comorbidities. Multivariate logistic regression, adjusted for all significant patient demographics and comorbidities, was used to identify the characteristics independently associated with postoperative transfusion.

Results

A total of 4376 diabetic patients remained after exclusion criteria, with 4264 (97.4%) patients who did not require postoperative transfusion and 112 (2.6%) patients who did require postoperative transfusion. On multivariate analysis, female gender (odds ratio [OR] 2.43, 95% confidence interval [CI] 1.52-3.89; P < .001), American Society of Anesthesiologists ≥3 (OR 2.46, 95% CI 1.10-5.48; P = .028), bleeding disorder (OR 2.94, 95% CI 1.50-5.76; P = .002), transfusion prior to surgery (OR 12.19, 95% CI 4.25-35.00; P < .001), preoperative anemia (OR 8.76, 95% CI 5.47-14.03; P < .001), and operative duration ≥129 minutes (OR 4.05, 95% CI 2.58-6.36; P < .001) were found to be independent risk factors for postoperative transfusion among diabetic patients. Our nondiabetic cohort included 19,289 patients, with 341 (1.8%) requiring postoperative transfusion. On Multivariate analysis, we found similar risk factors for transfusion to our diabetic population, as well as age ≥75 (OR 1.80, 95% CI 1.37-2.35; P < .001) and dependent functional status (OR 2.16, 95% CI 1.40-3.32; P < .001) to be independent risk factors for postoperative transfusion among nondiabetic patients.

Conclusion

Female gender, American Society of Anesthesiologists ≥3, bleeding disorder, transfusion prior to surgery, preoperative anemia, and operative duration ≥129 minutes were independently associated with postoperative transfusion following TSA in diabetic patients. These findings encourage physicians to carefully assess patients with diabetes preoperatively to minimize adverse outcomes.

Risk factors for postoperative blood transfusion after shoulder arthroplasty

Purpose

To identify the effect of surgical indication, patient factors, and perioperative characteristics on transfusion after shoulder arthroplasty (SA).

Methods

Shoulder arthroplasties for osteoarthritis (OA) (N = 47), rotator cuff arthropathy (RCA) (N = 50), fracture (N = 76), revision (N = 66), and periprosthetic joint infection (PJI) (N = 35) performed at a single institution during a 6-year period were included. All other indications were excluded. Patient-based and surgical risk factors, including surgical indication, for postoperative allogeneic red blood cell transfusion were assessed with multivariate logistic regression analysis.

Results

A total of 274 SAs were included; transfusions were performed in 2% (2/97) of primary SAs for OA or RCA. Increased transfusion rates occurred in PJI (23%, p = 0.0006) and fracture (18%, p = 0.0018) cases. The mean preoperative hemoglobin (Hgb) was 12.2 ± 2.2 with PJI, 12.0 ± 2.1 with fracture, and 13.3 ± 1.6 g/dL for all other SAs. Independent risk factors for transfusion included lower preoperative hemoglobin (p < 0.001), PJI indication (p = 0.008), and fracture indication (p = 0.02), with no difference for fracture greater or less than 4 weeks old (p = 0.53).

Conclusion

Risk factors for allogeneic red blood cell transfusion after SA were low preoperative hemoglobin and procedures for PJI or fracture.Level of Evidence: Level III, retrospective case-control study.

Risk Factors for Blood Transfusions in Primary Anatomic and Reverse Total Shoulder Arthroplasty for Osteoarthritis

BACKGROUND

The purpose of this study was to determine risk factors for blood transfusion in primary anatomic and reverse total shoulder arthroplasty (TSA) performed for osteoarthritis.

METHODS

Patients who underwent anatomic or reverse TSA for a diagnosis of primary osteoarthritis were identified in a national surgical database from 2005 to 2018 by utilizing both CPT and ICD-9/ICD-10 codes. Univariate analysis was performed on the two transfused versus non-transfused cohorts to compare for differences in comorbidities and demographics. Independent risk factors for perioperative blood transfusions were identified via multivariate regression models.

RESULTS

305 transfused and 18,124 nontransfused patients were identified. Female sex (p<0.001), age >85 years (p=0.001), insulin-dependent diabetes mellitus (p=0.001), dialysis dependence (p=0.001), acute renal failure (p=0.012), hematologic disorders (p=0.010), disseminated cancer (p<0.001), ASA ≥ 3 (p<0.001), and functional dependence (p=0.001) were shown to be independent risk factors for blood transfusions on multivariate logistic regression analysis.

CONCLUSION

Several independent risk factors for blood transfusion following anatomic/reverse TSA for osteoarthritis were identified. Awareness of these risk factors can help surgeons and perioperative care teams to both identify and optimize high-risk patients to decrease both transfusion requirements and its associated complications in this patient population. Level of Evidence: III.

Clinical Effectiveness of Intraoperative Tranexamic Acid Use in Shoulder Surgery: A Systematic Review and Meta-analysis

BACKGROUND

Tranexamic acid (TXA) is widely used across surgical specialties to reduce perioperative bleeding. It has been shown to be effective in spinal surgery and lower limb arthroplasty. Among all languages, there are no systematic reviews or meta-analyses investigating its clinical effectiveness for all types of shoulder surgery.

PURPOSE

To investigate the clinical effectiveness of TXA in all types of shoulder surgery, including open and arthroscopic procedures. To investigate the effect of TXA on bleeding and non-bleeding-related outcomes.

STUDY DESIGN

Systematic review and meta-analysis.

METHODS

A protocol for the study was designed and registered with PROSPERO (CRD42020185482). The literature search included the MEDLINE, Embase, PsycINFO, and Cochrane Library databases. All randomized controlled trials evaluating the use of TXA against placebo, in all types of shoulder surgery, were included. Assessments were undertaken for risk of bias and certainty of evidence. The primary outcome was total blood loss. Secondary outcomes included those not directly related to bleeding. Data from comparable outcomes were pooled and analyzed quantitatively or descriptively, as appropriate.

RESULTS

Eight randomized controlled trials were included in the systematic review, and data from 7 of these studies were pooled in the meta-analysis. Pooled analysis demonstrated a significant reduction in 2 of 3 outcomes measuring perioperative bleeding with TXA compared with controls: estimated total blood loss (mean difference, -209.66 mL; 95% CI, -389.11 to -30.21; P = .02) and postoperative blood loss as measured by drain output (mean difference, -84.8 mL; 95% CI, -140.04 to -29.56; P = .003). Hemoglobin reduction was reduced but not statistically significant (mean difference, -0.33 g/dL; 95% CI -0.69 to 0.03; P = .07). This result became significant with sensitivity analysis excluding arthroscopic procedures.

CONCLUSION

This systematic review and meta-analysis indicated that TXA was effective in reducing blood loss in shoulder surgery. Larger randomized controlled trials with low risk of bias for specific surgical shoulder procedures are required.

CLINICAL RELEVANCE

TXA can be used across shoulder surgery to reduced perioperative blood loss. The use of TXA may have other beneficial features, including reduced postoperative pain and reduced operative time.

A single dose of tranexamic acid reduces blood loss after reverse and anatomic shoulder arthroplasty: a randomized controlled trial

BACKGROUND

Hematoma formation and the need for blood transfusions are commonly reported complications after shoulder arthroplasty. Tranexamic acid (TXA) has been widely used in hip and knee arthroplasty to decrease perioperative blood loss. The role of TXA is still being established in shoulder arthroplasty.

MATERIALS AND METHODS

We conducted a double-blind randomized controlled trial comparing intravenous TXA vs. placebo in 60 patients undergoing primary anatomic or reverse shoulder arthroplasty. Of these patients, 29 received a placebo whereas 31 received a single dose of 2 g of intravenous TXA. Patient demographic characteristics, as well as drain tube output, blood loss, hematoma formation, transfusion requirement, length of hospital stay, and pain score, were recorded. Patients were followed up for 12 weeks to assess for complications.

RESULTS

Patients who received TXA had a lower drain tube output at all time points: 41 mL vs. 133 mL at 6 hours, 75 mL vs. 179 mL at 12 hours, and 94 mL vs. 226 mL at 24 hours (P < .001 for all). They also had a higher postoperative hemoglobin (Hb) level (12.3 g/dL vs. 11.4 g/dL, P = .009), lower change in Hb level (1.7 g/dL vs. 2.3 g/dL, P = .011), lower total Hb loss (0.078 g vs. 0.103 g, P = .042), lower blood volume loss (0.55 L vs. 0.74 L, P = .021), higher postoperative hematocrit level (36.7% vs. 34.6%, P = .020), and lower hematocrit change (5.4% vs. 7.6%, P = .022). There was no significant difference in pain score or length of hospital stay, and no patients required a transfusion.

CONCLUSION

A single dose of 2 g of intravenous TXA decreases blood loss and drain tube output in primary anatomic and reverse arthroplasty of the shoulder. No differences were detected in the occurrence of complications, need for transfusion, pain score, or length of hospital stay. With the mounting evidence now available, patients undergoing elective primary shoulder arthroplasty should be given intravenous TXA to decrease perioperative blood loss.

Inconclusive evidence for the efficacy of tranexamic acid in reducing transfusions, postoperative infection or hematoma formation after primary shoulder arthroplasty: A meta-analysis with trial sequential analysis

BACKGROUND

Tranexamic acid efficacy on clinically relevant adverse outcomes in patients undergoing shoulder arthroplasty has been contradictory. The aim of this review was to analyze whether tranexamic acid administration could decrease transfusions, infection and hematoma formation in patients undergoing shoulder arthroplasty.

METHODS

PubMed, EMBASE, and the Cochrane Library were searched up to May 2019 for randomized controlled trials comparing tranexamic acid to placebo in shoulder arthroplasty. Random-effect models were performed to meta-analyze the evidence. Trial sequential analysis was used to calculate and to establish the conclusiveness of the evidence derived from the meta-analysis.

RESULTS

Four randomized controlled trials comprising 375 patients were included. Meta-analysis showed no effect of tranexamic acid on transfusion rate (RR = 0.48 (adjusted 95% CI 0.05 to 3.85)). The possible effect of tranexamic acid on hematoma formation or infection rates after shoulder arthroplasty is non-estimable with the current evidence. The sample size necessary to reliably determine if tranexamic acid decreases transfusions, infection rates and hematoma formation is not available from the current literature as determined by the trial sequential analysis.

DISCUSSION

While tranexamic acid has proven its efficacy in decreasing blood loss in shoulder arthroplasty, this meta-analysis of randomized controlled trials clarifies that there is currently no conclusive evidence for a positive effect of tranexamic acid upon transfusion rate, infection rates or hematoma formation in patients undergoing primary shoulder arthroplasty.

The use of intra-operative tranexamic acid in shoulder surgery: Protocol for a systematic review and meta-analysis

INTRODUCTION

Blood loss is an important consideration in all types of shoulder surgery. Excessive bleeding is associated with increased morbidity. Tranexamic acid (TXA) is an antifibrinolytic agent. It has been demonstrated to be effective in reducing blood loss across multiple surgical specialties. The aim of this systematic review and meta-analysis is to review the literature evaluating clinical outcomes associated with the use of TXA in shoulder surgery.

METHODS

The study protocol was designed and registered prospectively on PROSPERO (International prospective register for systematic reviews). Literature search will include the MEDLINE, EMBASE, PsycINFO, and Cochrane Library databases. Randomised controlled trials (RCTs) evaluating the use of TXA against placebo, in all types of shoulder surgery, will be included. Our primary outcome is total blood loss (ml). Secondary outcomes include patient-reported outcome measures (PROMs), adverse events, and number of blood transfusions required. Risk of bias will be assessed within each study using The Cochrane Risk of Bias Tool 2.0 and the Jadad score. Inconsistency and bias across included studies will be assessed statistically. Data from comparable outcomes will be pooled and analysed quantitatively or descriptively as appropriate.

ETHICS AND DISSEMINATION

No ethical clearances required for this study. This systematic review and meta-analysis will be published in a peer-reviewed journal. It will be presented a various national and international conferences.