Effectiveness of iron supplementation in the perioperative management of total knee arthroplasty: a systematic review

Postoperative Intravenous Iron Supplementation Increases Hemoglobin Level in Total Knee Arthroplasty

Iron supplementation provides iron storage and facilitates effective production of hemoglobin. The purpose of this study was to investigate the effect of early postoperative intravenous (IV) iron supplementation in different types of total knee arthroplasty (TKA) surgery. We retrospectively analyzed 863 patients who underwent TKA between September 2017 and September 2021. The IV iron (I) and non-IV iron (NI) groups were compared. Hemoglobin responders, defined as patients who showed a change in hemoglobin level of ≥2 g/dL at 6 weeks of surgery compared to the baseline immediate postoperative hemoglobin level, were identified and they were compared with the nonresponders. After logistic regression analysis, the patients were classified according to the type of surgery (unilateral TKA, staged bilateral TKA, and simultaneous bilateral TKA). A subgroup analysis was performed according to the comorbidity as Charlson Comorbidity Index (CCI). The type of surgery and the rate of hemoglobin responders differed between the I and NI groups. The surgery type and iron supplementation significantly affected the hemoglobin responder in the logistic regression model. In each surgery type, hemoglobin drop in the I group was generally lower in the second and sixth weeks than that in the NI group. It was also effective in reducing hemoglobin drop on the first day of the second surgery in staged bilateral TKA. In addition, the number of hospital days was lower in the IV iron supplementation group who underwent a staged bilateral TKA. CCI did not affect hemoglobin responder, hemoglobin drop, and transfusion rate in both the I and NI groups. Postoperative IV iron supplementation affected the outcome of hemoglobin responders. In addition, it reduced early postoperative hemoglobin drop. However, iron supplementation did not affect the transfusion rate, complications, and clinical outcome, regardless of the type of surgery. LEVEL OF EVIDENCE:  Level III, case-control study.

Comparison of blood loss between intra-articular microporous polysaccharide hemospheres powder and tranexamic acid following primary total knee arthroplasty

Total knee arthroplasty (TKA) is associated with substantial blood loss and tranexamic acid (TXA) effectively reduces postoperative bleeding. Although it is known that there is no difference between intravenous or intra-articular (IA) injection, the general interest is directed towards topical hemostatic agents regarding thromboembolic events in high-risk patients. This study aimed to compare the blood conservation effects of IA MPH powder and TXA in patients undergoing primary TKA. We retrospectively analyzed 103 patients who underwent primary TKA between June 2020 and December 2021. MPH powder was applied to the IA space before capsule closure (MPH group, n = 51). TXA (3 g) was injected via the drain after wound closure (TXA group, n = 52). All patients underwent drain clamping for three postoperative hours. The primary outcome was the drain output, and the secondary outcomes were the postoperative hemoglobin (Hb) levels during the hospitalization period and the perioperative blood transfusion rates. An independent Student's t-test was used to determine differences between the two groups. The drain output in the first 24 h after surgery was significantly higher in the MPH group than in the TXA group. The postoperative Hb levels were significantly lower in the MPH group than in the TXA group. In patients with simultaneous bilateral TKA, there was a significant difference in the blood transfusion volumes and the rates between groups. It is considered that IA MPH powder cannot replace IA TXA because of an inferior efficacy in reducing blood loss and maintaining postoperative Hb levels in the early postoperative period after primary TKA. Moreover, in the case of simultaneous bilateral TKA, we do not recommend the use of IA MPH powder because it was notably less effective in the field of transfusion volume and rate.

A Decline in Overutilization of Transfusion after Total Knee Arthroplasty Using Pharmacological Agents for Patient Blood Management in South Korea: An Analysis Based on the Korean National Health Insurance Claims Database from 2008 to 2019

Background

This study aimed to evaluate the annual trends of transfusion rates and utilization of blood management agents in total knee arthroplasty (TKA) based on the operation type and to analyze the risk factors of transfusion after TKA.

Methods

Using the Korean National Insurance claims database of 797,106 primary and revision TKAs between January 2008 and October 2019, data on the patients' characteristics, comorbidities, utilization of transfusion, and blood management agents were collected. The patients were categorized into three groups based on the operation type: primary, revision, and simultaneous bilateral TKA. The transfusion rate and utilization of blood management agents (intraoperative tranexamic acid [TXA] and preoperative iron supplements) were compared, and the risk factors for transfusion were evaluated.

Results

After excluding the inaccurate data, 730,554 arthroplasties (636,292 primary, 10,540 revision, and 41,861 simultaneous bilateral TKAs) were identified. The transfusion rates of primary, revision, and simultaneous bilateral TKAs in 2019 were 64.0%, 67.7%, and 68.9%, respectively, which were significantly decreased compared with 83.2%, 88.0%, and 92.5% in 2008, respectively (p < 0.001). Conversely, the utilization of intraoperative TXA and preoperative iron supplements was significantly increased from 4.6% and 13.8%, respectively, in 2008 to 52.4% and 27.0%, respectively, in 2019 (p < 0.001). The utilization of intraoperative TXA and preoperative iron supplements significantly lowered the risk of transfusion after TKA (odds ratio [OR], 0.20; p < 0.001 and OR, 0.71; p < 0.001).

Conclusions

The transfusion rate after TKA decreased gradually from 83.5% to 64.5% between 2008 and 2019 in South Korea corresponding with the increased utilization of blood management agents. Therefore, consistent attention to patient blood management should be emphasized to reduce the transfusion rate after TKA.

Effect of recombinant human erythropoietin combined with iron sucrose on postoperative hemoglobin in patients undergoing artificial joint replacement

With the aging of the population, an increasing number of elderly patients are opting for artificial joint replacement, leading to the exploration of various rapid rehabilitation programs in the perioperative period. In this study, we aimed to investigate the effectiveness of combining recombinant human erythropoietin and iron sucrose in altering the range and trend of postoperative hemoglobin in patients undergoing arthroplasty. Specifically, we will examine whether this combination can effectively alter the rise and fall of postoperative haemoglobin, identify the inflection point of haemoglobin change or recovery after arthroplasty, and assess the effect of treatment on serum iron in postoperative blood. We conducted a retrospective study of 138 patients who underwent unilateral total joint arthroplasty by the same surgeon in the same hospital before July 2022. The results of this study may provide valuable insights for the development of effective rehabilitation programs for patients undergoing arthroplasty.

Effects of intraoperative or postoperative administration of intravenous iron supplements on hemoglobin recovery in patients with total knee arthroplasty: A systematic review and meta-analysis

BACKGROUND

The objectives of the researchers are as follows: First, to investigate whether intraoperative or postoperative administration of Intravenous (IV) iron supplements in patients undergoing primary total knee arthroplasty (TKA) can contribute to the hemoglobin recovery during the postoperative period (between 4 and 8 weeks after surgery). Second, to examine whether the administration of IV iron supplements during or immediately after TKA in patients undergoing primary TKA can reduce the need for allogenic blood transfusion during hospitalization.

METHODS

Articles published between January 1, 1990, and June 30, 2023 were searched in PubMed, Cochrane, and Embase. The population, intervention, comparison, and outcome of this study are as follows; Population: Patients undergoing primary total knee arthroplasty; Intervention: Administration of IV iron supplements during or immediately after surgery; Comparison: Non-administration of IV iron supplements; Outcome: Degree of hemoglobin recovery (between 4 and 8 weeks after surgery) and the need for blood transfusion during hospitalization.

RESULTS

There was a statistically significant difference in the amount of change in hemoglobin between iron supplementation group and non-iron supplementation group. The effect size were -0.44 (95% confidence interval: -0.69 to -0.19, P value < .001) in all patients. This means that the amount of change in hemoglobin were significantly reduced in the iron supplementation group than in the non-iron supplementation group. There was a statistically significant difference for post-operative transfusion rate between 2 groups. The effect size were 0.28 (95% confidence interval: 0.10-0.81, P value = .02) in all patients. This means that the post-operative transfusion rate was significantly less in the iron supplementation group than in the non-iron supplementation group.

CONCLUSION

The administration of IV iron supplements during or after TKA surgery increases hemoglobin recovery between 4 and 8 weeks after surgery and reduces the need for allogeneic blood transfusion during hospitalization.

Total joint replacement in ambulatory surgery

Total joint arthroplasty is one of the most commonly performed surgical procedures in the United States, and projected numbers are expected to double in the next ten years. From 2018 to 2020, total hip and knee arthroplasty were removed from the United States' Center for Medicare and Medicaid Services "inpatient-only" list, accelerating this migration to the ambulatory setting. Appropriate patient selection, including age, body mass index, comorbidities, and adequate social support, is critical for successful ambulatory total joint arthroplasty. General anesthesia and neuraxial anesthesia are both safe and effective anesthetic choices, and recent studies in this population have found no difference in outcomes. Multimodal analgesia, including acetaminophen, nonsteroidal anti-inflammatory drugs, local infiltration analgesia, and peripheral nerve blocks, is the foundation for adequate pain control. Common reasons for "failure to launch" include postoperative urinary retention, postoperative nausea and vomiting, inadequate analgesia, and hypotension.

The Association of Intravenous Iron Administered the Day before Total Knee Arthroplasty with Postoperative Anemia and Functional Recovery

Background and Objectives: Total knee arthroplasty (TKA) involves blood loss, increasing the risk of postoperative anemia and delayed functional recovery. Intravenous (IV) iron supplementation limits postoperative anemia; however, the effectiveness of IV iron, administered one day before TKA, on postoperative anemia and functional recovery has scarcely been studied. Materials and Methods: We conducted a retrospective cohort study with propensity score matching using two consecutive groups of patients who underwent TKA using tranexamic acid: the iron group received 500 mg ferric derisomaltose intravenously one day before surgery (n = 46); the non-iron group did not (n = 46). Hemoglobin (Hb) level was determined at postoperative days (PODs) 2, 4, 6, 14, and 30. Ferritin, transferrin saturation (TSAT), and functional iron deficiency anemia (IDA) rate were measured at PODs 2, 4, 6, and 14. Length of hospital stay and transfusion rate were also evaluated. Results: The iron group had higher Hb levels at PODs 6, 14, and 30 and higher ferritin and TSAT at PODs 2, 4, 6, and 14. The functional IDA rate was significantly higher in the non-iron group at PODs 2, 4, 6, and 14. Length of hospital stay was significantly shorter in the iron group; however, the rate of transfusion did not differ between the two groups. Conclusions: IV iron administered one day before TKA was associated with postoperative anemia recovery and length of hospital stay; however, it did not lower the postoperative transfusion rate.

The natural course of hemoglobin levels after allogenic blood transfusion in total knee arthroplasty

We retrospectively investigated the natural course of hemoglobin levels after allogenic blood transfusion in total knee arthroplasty. All patients were treated according to the same clinical pathway, and blood tests were performed on the same day. All blood tests were done on pre-op, immediate post-op, midnight of op day, 1st, 2nd, 3rd, 5th, 7th, and 11th day after surgery. Of the total 593 cases, a total of 197 cases (33.2%) were performed within 3 days of surgery. Hemoglobin level was significantly lowest on the 3rd day after surgery and tended to increase afterwards in the non-transfusion group. In the case of blood transfusion on the day of surgery, the hemoglobin level showed an increase on the next day and then showed a minimum value on the fifth day of surgery and then increased. The same pattern was identified when blood transfusion was done on the 1st and 2nd day of surgery. However, when blood transfusion was done on the 3rd day, the hemoglobin level showed a steady increase afterwards. The hemoglobin level of total knee arthroplasty patients with no blood transfusion was the lowest on the 3rd day after surgery and increased afterwards. If blood transfusion was done within 2 days after surgery, the hemoglobin level was the lowest on the 5th day after surgery and increased afterwards. If blood transfusion was done on the 3rd day after surgery, the hemoglobin level increased afterwards.

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.

Effect of intraoperative intravenous ferric derisomaltose supplementation on reduction of postoperative anemia and transfusion in chronic kidney disease patients after total knee replacement

Total knee replacement (TKR) is associated with a large amount of bleeding; therefore, the prevalence of postoperative anemia is high. In particular, patients with chronic kidney disease (CKD) are more vulnerable to postoperative anemia than are healthy individuals. Accordingly, the effect of intraoperative intravenous ferric derisomaltose (FDI) supplementation on postoperative anemia and blood transfusion volume reduction in patients with CKD was studied. Patients who underwent unilateral TKR between January 2019 and December 2020 were retrospectively reviewed. In analyzing the data, the patients fell into the CKD group (n = 85) and the non-CKD group (n = 106). Each group was divided into a group using FDI and a non-FDI group, and classified into 4 groups. The postoperative hemoglobin level for each postoperative day (POD) was determined as the primary outcome. In addition, the patient transfusion rate, volume of transfusion, and length of hospital stay were set as secondary study outcomes during the period from surgery to discharge. There was no statistically significant difference in hemoglobin levels on PODs 0, 1, 2, 7, and 14 in the CKD group. In the CKD group, the transfusion volume of the FDI group was 0.58 ± 0.91 units per person, which was statistically significantly lower than 1.28 ± 1.28 units of the non-FDI group (P = .01). In the CKD group, the transfusion rate of the FDI group was 30.2%, which was statistically significantly lower than that of the non-FDI group, which was 56.3% (P = .02). This study showed that intravenous FDI supplementation after TKR in CKD patients did not reduce postoperative anemia but was an effective and safe treatment to reduce transfusion volume and transfusion rate. There was no statistically significant difference in hemoglobin levels on POD 0, 1, 2, 7, and 14 in the non-CKD group. In the non-CKD group, the transfusion volume of the FDI group was 0.46 ± 0.88 units per person, which was lower than the 0.56 ± 0.91 units of the non-FDI group, but it was not statistically significant (P = .59). In the non-CKD group, the transfusion rate of the FDI group was 23.0%, which was lower than that of the non-FDI group, which was 31.3%, but it was not statistically significant (P = .37).

Effect of Sequential Intravenous and Oral Tranexamic Acid on Hemoglobin Drop After Total Knee Arthroplasty: A Randomized Controlled Trial

BACKGROUND

Tranexamic acid (TXA) is typically discontinued on the day of total knee arthroplasty (TKA). However, bleeding may persist for several days. We sought to determine whether sequential administration of intravenous (IV) and oral TXA could reduce hemoglobin (Hb) drop more than IV TXA alone. We also wanted to determine whether the use of additional oral TXA increased the rate of complications of deep vein thrombosis (DVT) or symptomatic pulmonary embolism (PE).

METHODS

This prospective, randomized controlled trial included 141 patients. We compared the Hb drop, estimated blood loss (EBL), and transfusion rate of patients receiving IV TXA alone (group IV, n = 48) to those of patients who received IV TXA followed by oral TXA for 2 days (group 2D, n = 46) or 5 days (group 5D, n = 47). IV TXA was administered 10 minutes prior to the tourniquet release and 3 hours after the first IV TXA administration. Computed tomography (CT) was performed on postoperative day 6 to identify radiographic evidence of DVT. We also assessed the prevalence of symptomatic DVT and PE.

RESULTS

There were no differences in maximal Hb drop, Hb drops measured at each time point, EBL, or transfusion rate among the 3 groups. The mean maximal Hb drop was 3.5 g/dL in group IV, 3.2 g/dL in group 2D, and 3.4 g/dL in group 5D. The mean EBL was 999.9 mL in group IV, 886.4 mL in group 2D, and 972.5 mL in group 5D. One patient in each group required a transfusion. There were no differences in the prevalence of radiographic evidence of DVT or symptomatic DVT. Symptomatic DVT occurred in 3 patients in group IV and 2 patients in group 5D. One patient in group IV developed a symptomatic PE.

CONCLUSIONS

Although there was no increase in the complication rate, the sequential administration of oral TXA for up to 5 days after IV TXA did not decrease Hb drop. Therefore, our findings suggest that sequential use of oral and IV TXA is not recommended.

LEVEL OF EVIDENCE

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

Modifiable Individual Risks of Perioperative Blood Transfusions and Acute Postoperative Complications in Total Hip and Knee Arthroplasty

BACKGROUND

The primary aim of this study was to identify modifiable patient-related predictors of blood transfusions and perioperative complications in total hip and knee arthroplasty. Individual predictor-adjusted risks can be used to define preoperative treatment thresholds.

METHODS

We performed this retrospective monocentric study in orthopaedic patients who underwent primary total knee or hip arthroplasty. Multivariate logistic regression models were used to assess the predictive value of patient-related characteristics. Predictor-adjusted individual risks of blood transfusions and the occurrence of any perioperative adverse event were calculated for potentially modifiable risk factors.

RESULTS

3754 patients were included in this study. The overall blood transfusion and complication rates were 4.8% and 6.4%, respectively. Haemoglobin concentration (Hb, p < 0.001), low body mass index (BMI, p < 0.001) and estimated glomerular filtration rate (eGFR, p = 0.004) were the strongest potentially modifiable predictors of a blood transfusion. EGFR (p = 0.001) was the strongest potentially modifiable predictor of a complication. Predictor-adjusted risks of blood transfusions and acute postoperative complications were calculated for Hb and eGFR. Hb = 12.5 g/dL, BMI = 17.6 kg/m², and eGFR = 54 min/mL were associated, respectively, with a 10% risk of a blood transfusion, eGFR = 59 mL/min was associated with a 10% risk of a complication.

CONCLUSION

The individual risks for blood transfusions and acute postoperative complications are strongly increased in patients with a low preoperative Hb, low BMI or low eGFR. We recommend aiming at a preoperative Hb ≥ 13g/dL, an eGFR ≥ 60 mL/min and to avoid a low BMI. Future studies must show if a preoperative increase of eGFR and BMI is feasible and truly beneficial.

Characterization of wild-type and STAT3 signaling-suppressed mesenchymal stem cells obtained from hemovac blood concentrates

Background

Venous blood drained from the knee joint after total knee arthroplasty (TKA) using a hemovac line is a potential source of bone marrow components, including stem cells, from the cutting surface of cancellous bones of the knee joint. However, the function of mesenchymal stem cells (MSCs) in patients with osteoarthritis (OA-MSCs) can be disrupted by inflammation of the joint. Further, to override the invasive nature of the currently used methods to obtain stem cells, their functional modification is necessary for therapeutic applications.

Methods

The effects of signal transducer and activator of transcription 3 (STAT3) signaling suppression on MSCs (iSTAT3-MSCs) were evaluated by comparative analyses of the characteristics of OA-MSCs and iSTAT3-MSCs from 20 patients who underwent TKA.

Results

OA-MSCs and iSTAT3-MSCs were adherent, with fibroblast-like appearance and high rates of expression of MSC-specific markers, including CD73, CD90, and CD105 (>90%). Both OA-MSCs and iSTAT3-MSCs were able to differentiate into osteogenic, adipogenic, and chondrogenic cells; however, iSTAT3-MSCs showed higher levels of osteogenic and chondrogenic differentiation markers than OA-MSCs. Additionally, the anti-inflammatory and chondroprotective cytokine levels were higher in iSTAT3-MSCs than in OA-MSCs.

Conclusions

These findings indicate that iSTAT3-MSCs after TKA are potentially effective for stem cell therapy in the context of bone and cartilage disorders.

Natural course of hemoglobin level after total knee arthroplasty and the benefit of tranexamic acid injection in the joint

We retrospectively investigated the natural course of hemoglobin (Hb) level after total knee arthroplasty (TKA) and identified the benefit of tranexamic acid injection at the operation field for unilateral TKA patients who have not received blood transfusions.There were 115 cases conducted by a surgeon who performed TKA without injecting tranexamic acid and 62 cases by another surgeon with injection. During 2-weeks of hospitalization, Hb level was checked on the day of surgery and 1, 2, 3, 5, 7, 11 days after surgery.Regardless of whether whom the operator was and tranexamic acid was injected or not, the same natural course of Hb level after TKA was observed. The lowest value of Hb was shown at postoperative day 3, after which it tended to recover. In repeated measures analysis of variance test, mean difference from preoperative Hb level showed a statistically significant difference between tranexamic acid injected and noninjected groups (P = .01). In post hoc test, the differences from preoperative Hb levels were significantly lower at all measurements in surgeon with injection of tranexamic acid.When deciding whether to transfuse after TKA, it should be noted that the patient tends to show the lowest Hb level on postoperative day 3. Also, the authors emphasize that tranexamic acid injection in the joint at the operation field is an effective method to reduce the loss of Hb after TKA.