Predictors of perioperative blood loss in total joint arthroplasty

The evolution of anesthetic management for total knee arthroplasty (TKA) patients: A hospital network experience

Introduction

In the face of an ongoing opioid epidemic and an aging population, the utilization of a successful multimodal pain regimen in patients undergoing total knee arthroplasty (TKA) is vital. This study looks to explore the effect of different types of anesthesia in addition to a multimodal pain regimen on post-operative outcomes after undergoing TKA.

Materials and methods

From January 2016 to December 2022, 783 charts of patients undergoing an elective TKA were reviewed. Patients undergoing primary, isolated, and unilateral TKA procedures were included. Patients were grouped into three study arms: 1) general anesthesia (GA); 2) general anesthesia with a local anesthetic adductor canal block (GA + ACB); 3) spinal anesthesia with local anesthetic adductor canal block (SA + ACB). Patients who received other anesthesia types or received ACB utilizing liposomal bupivacaine were excluded.

Results

Of the 420 included patients, 63 patients received GA, 148 GA + ACB, and 209 SA + ACB. Patients in the SA + ACB group had a shorter LOS compared to both the GA + ACB and GA groups (p < 0.01. The SA + ACB group had the lowest daily average OME requirement (p < 0.01). Finally, patients in the SA + ACB group had the lowest average total cost of $11,683.91 (p < 0.01).

Discussion

Spinal anesthesia with adductor canal block is effective in decreasing opioid usage and improving postoperative outcomes after TKA. Surgeons and anesthesiologists should look to utilize this anesthetic option along with a multimodal regimen when deciding how to best manage postoperative pain after TKA procedures.

Level of evidence

Level III.

J-shaped association of operation duration and blood transfusion risk in patients undergoing primary total knee arthroplasty

PURPOSE

Blood transfusion is a common perioperative complication of primary total knee arthroplasty (TKA) that can lead to adverse outcomes, prolonged hospital stays, and increased medical costs. The purpose of our study was to explore the risk factors for blood transfusion and to establish whether operation duration is independently related to blood transfusion risk in patients undergoing primary TKA after adjusting for other covariates.

METHODS

This was a secondary analysis of data from a retrospective cohort study involving patients who underwent primary TKA in Singapore. The patients' baseline data, comorbidity, and surgical characteristics were collected. The independent variable was operation duration and the dependent variable was blood transfusion events. Patients were divided into three groups according to operation durations (90 and 120 min). Univariate logistic regression was used to explore the risk factors associated with blood transfusion after primary TKA. Multivariate analysis was used to assess the independent effect of operation duration on blood transfusion risk after adjusting for other covariates. Additionally, we performed subgroup analyses to identify specific groups, test the robustness of the relationships, and explore whether there were interactions between the different variables. Furthermore, restricted cubic splines (RCS) were used to identify the relationship between the two variables.

RESULTS

A total of 2,562 patients were included in the study, of whom 136 (5.61%) had a transfusion event. Operation durations were 95.55 ± 36.93 and 83.86 ± 26.29 min for blood transfused and non-transfused patients, respectively. Univariate logistic regression analysis showed that age, BMI, ASA status, Hb level, OSA, CHF, creatinine level > 2 mg/dL, and anaesthesia type were risk factors for blood transfusion. After adjusting for all covariates, multivariate logistic regression models showed that operation duration was positively associated with blood transfusion risk (odds ratio [OR] = 1.87, 95% CI = 1.174-2.933, P = 0.007). Compared to patients with an operation duration of less than 90 min, those with an operation duration of more than 120 min had a 2.141-fold increased risk of blood transfusion (OR = 2.141, 95% CI = 1.035-4.265, P = 0.035). Stratified analysis results showed that the association persisted in patients aged > 50 years, Chinese, BMI > 30 kg/m 2, Hb level > 11 g/dL, ASA status levels 2 and 3, general anaesthesia, and unilateral primary TKA. A non-linear (P-non-linear = 0.30) and J-shaped relationship was identified. The risk of transfusion increased as the operation duration decreased or exceeded the inflection point (73.2 min).

CONCLUSION

Our study demonstrated a non-linear and J-shaped relationship between operation duration and blood transfusion events in patients undergoing primary TKA. Blood transfusion risk was the lowest when the operation duration was 73.2 min. A shorter operation duration implies irregular surgical procedures and incomplete intraoperative haemostasis, leading to increased perioperative blood loss and blood transfusion. These results will be useful for clinical decision-making.

Can local infiltration analgesia supplemented with tranexamic acid reduce blood loss during total knee arthroplasty?

PURPOSE

The aim of this study was to investigate the efficacy of TXA supplemented with local infiltration analgesia (LIA) for reducing blood loss in patients undergoing total knee replacement.

MATERIALS

A retrospective study of 530 individuals with a mean age of 71.44 years was performed after posterior stabilized total knee arthroplasty. Patients were divided into three groups according to the method of bleeding control: I - patients without an additional bleeding protocol (control group); II - patients receiving IV TXA (TXA group); and III - patients receiving the exact TXA protocol plus intraoperative local infiltration analgesia (TXA + LIA group). Blood loss was measured according to the maximal decrease in Hb compared to the preoperative Hb level.

RESULTS

The mean hospitalization duration was 7.02 (SD 1.34) days in the control group, 6.08 (SD 1.06) days in the TXA group, and 5.56 (SD 0.79) in the TXA + LIA group. The most significant decrease in haemoglobin was found in the control group, which was an average of 30.08%. The average decrease in haemoglobin was 25.17% (p < 0.001) in the TXA group and 23.67% (p < 0.001) in the TXA + LIA group. A decrease in the rate of allogeneic blood transfusions was observed: 24.4% in the control group, 9.9% in the TXA group, and 8% in the TXA + LIA group (p < 0.01).

CONCLUSIONS

Compared to the separate administration of tranexamic acid, the combination of perioperative administration with local infiltration analgesia significantly reduced blood loss in patients after total knee replacement.

Topical Use of Low-dose Tranexamic Acid Has no Effect on Drainage Volume after Medial Open Wedge High Tibial Osteotomy: A Case Control Study

OBJECTIVE

Many studies reported that tranexamic acid (TXA) was effective in reducing surgical blood loss in the perioperative period of medial open wedge high tibial osteotomy (MOWHTO). However, few studies focused on the simple topical use of TXA in MOWHTO, and the modality and dosage of topical use of TXA varied. The purpose of this study was to observe the effect of topical use of low-dose TXA on drainage volume after MOWHTO, and to analyze the related influencing factors.

METHODS

Data of patients who underwent MOWHTO combined with arthroscopic knee surgery in our department from January 2019 to September 2021 were retrospectively analyzed. A total of 105 patients (38 males and 67 females, aged 57.7 ± 7.5 years) were included in this study who received topical TXA or no TXA. The patients were divided into three groups: control group (39 cases), 0.5 g TXA group (40 cases), 1 g TXA group (26 cases). Postoperative drainage volume, wound healing, incidence of hematoma and deep venous thrombosis (DVT) were observed and analyzed in the three groups. The effects of gender, hypertension and diabetes on postoperative drainage volume were analyzed using a t-test. The correlation between age, body mass index (BMI), osteotomy gap and postoperative drainage volume were analyzed using the Pearson correlation coefficient.

RESULTS

The average postoperative drainage volume of the control group was 259.54 ± 226.33 mL, that of the 0.5 g TXA group was 277.18 ± 177.68 mL, and that of the 1 g TXA group was 229.15 ± 219.93 mL. There was no statistically significant difference in postoperative drainage volume among the three groups (F = 0.423, p = 0.656). There was no local hematoma and wound infection in the three groups. The wound fat liquefaction was found in one patient of the control group. The incidence of DVT was 38.9% (7/18) and 57.1% (8/14) in the control group and 0.5 TXA group, respectively. There was no significant difference in the incidence of DVT between the above two groups (p = 0.476). The average postoperative drainage volume of male patients in the three groups was higher than that of female patients, and the differences were statistically significant (p < 0.05). There was no correlation between age, BMI, osteotomy gap and postoperative drainage volume in the three groups (p > 0.05).

CONCLUSION

Topical use of low-dose TXA has no significant effect on drainage volume after MOWHTO. The drainage volume after MOWHTO in male patients was more than that in female patients. Topical administration of low-dose TXA does not increase postoperative complications, such as DVT and hematoma.

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.

Effectiveness, safety and indications of acute normovolemic haemodilution in total knee arthroplasty

Total knee arthroplasty (TKA) is the most cost-effective, and potent method for the treatment of end-stage knee osteoarthritis. Acute normovolemic haemodilution (ANH) can effectively replace the need for allogeneic transfusions due to the high amount of bleeding during TKA. However, more studies are needed to prove the efficacy and safety of ANH and to clarify its indications in the field of knee replacement. Medical records from June 1, 2019 to June 1, 2021 were searched and grouped according to inclusion and exclusion criteria.

PART I

58 patients with ANH during TKA were selected as the ANH group (n = 58), and 58 patients with allogeneic transfusion were chosen as the control group (n = 58).

PART II

Patients with anaemia were divided into the ANH group (n = 18) and the control group (n = 12).

PART I

The postoperative inflammatory index and serum albumin in the ANH group were significantly lower than those in the control group. No significant difference was observed in the theoretical loss of red blood cells, postoperative renal function, liver function, cardiac function and biochemical ion index between the two groups. The effective rate of ANH in the normal haemoglobin group was significantly lower than that in the anaemia group.

PART II

In patients with anaemia, the theoretical loss of red blood cells in patients with ANH was less than that in the control group. The postoperative inflammation, renal function, liver function and cardiac function in the ANH group were better than those in the control group, and no significant difference was noted in biochemical ions and nutritional status indicators. This paper shows that ANH not only can replace allogeneic transfusion in TKA, especially in patients with anaemia, but also has lower inflammatory indicators than allogeneic transfusion. From a security perspective, the body's tolerance to ANH is within the body's compensation range.

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.

Postoperative Hemodynamics of Total Knee Arthroplasty Unaffected by Cementless Approach under Contemporary Patient Blood Management Protocol: A Propensity Score-Matched Study

(1) Background: A cementless total knee arthroplasty (TKA) is a recent and an increasingly popular innovation that enhances porous fixation surfaces. However, the lack of cemented sealing of an exposed resected bone has raised concerns about the potential for greater blood loss. The goals of this study were to determine if a cementless approach impacts post-TKA hemodynamics and to identify risk factors for blood loss in instances of cementless (vs. cemented) TKAs under a contemporary patient blood management (PBM) protocol. (2) Methods: We recruited 153 consecutive patients undergoing unilateral TKAs between 2019 and 2023. All enrollees received cementless or cemented prostheses of the same design (cementless, 87; cemented, 66). After propensity score matching for demographics, there were 46 patients in each group. We then compared blood loss metrics (total [TBL] and estimated [EBL]), drainage volumes, hemoglobin (Hb) levels, and transfusion rates by group. (3) Results: Post-TKA hemodynamics (i.e., TBL, EBL, drainage, Hb level, and transfusion rate) of cementless (n = 46) and cemented (n = 46) TKA groups did not differ significantly. In addition, the proportions of patients with Hb drops > 3.0 g/dL were similar for the two groups. A logistic regression analysis revealed that only preoperative Hb and EBL during the early postoperative period were predictive of a substantial fall in Hb levels. The fixation method was not associated with Hb decline > 3.0 g/dL by postoperative Day 3. (4) Conclusion: The cementless TKA has no impact on customary post-TKA hemodynamics and is not associated with greater TKA-related blood loss when implementing a contemporary PBM protocol.

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.

Safety and Efficacy of Tranexamic Acid in Total Ankle Arthroplasty

Tranexamic acid has been shown to significantly reduce blood loss in patients undergoing total knee arthroplasty and total hip arthroplasty. However, there is a paucity of data regarding its safety and efficacy in total ankle arthroplasty. The purpose of this study was to determine whether tranexamic acid use in patients with total ankle arthroplasty affects blood loss or overall complication rate. A retrospective chart review was conducted for 64 patients who underwent total ankle arthroplasty with (n = 32) and without (n = 32) intraoperative tranexamic acid from 2014 to 2023 at a single academic medical center. Recorded blood loss, pre-to-postoperative hemoglobin changes, hidden blood loss, and complication rates were recorded and compared. There was no statistically significant difference in recorded blood loss, total calculated blood loss, pre-to-postoperative hemoglobin difference, hidden blood loss, or overall complications between the groups (all, P > .05). A lower rate of wound complications was observed in the tranexamic acid group, but the difference between each group was not statistically significant (P > .05). Tranexamic acid did not decrease blood loss during total ankle arthroplasty, as measured in our study. Tranexamic acid was not associated with any increase in overall complications. Based on our findings, tranexamic acid may be a safe intervention in total ankle arthroplasty, but further studies are needed to better elucidate its clinical impact.Level of Evidence: Level 3.

No Blood Loss Increase in Cementless vs. Cemented Fixation Following Bilateral Total Knee Arthroplasty: A Propensity Score Matching Study

Background and Objectives: Recent advancements in three-dimensional printing technology have enhanced the biologic fixation of cementless total knee arthroplasty (TKA), therefore increasing the utilization of newer-generation cementless implants. However, the lack of sealing and tamponade effect of cement on the resected bone surface after cementless TKA raises concerns regarding the potential for greater blood loss compared to cemented TKA. The aim of this study was to (1) compare blood loss and transfusion rates between cementless and cemented TKAs and (2) identify the risk factor for higher blood loss in patients who underwent 1-week-interval staggered bilateral (SB) TKA. Materials and Methods: This retrospective, propensity-matched study included 54 cementless and 53 cemented SB TKAs performed by a single surgeon from 2019 to 2023 with a single implant that has similar design features in both cementless and cemented implants. All patients underwent 1-week-interval SB TKA and received the same patient blood management (PBM) and rehabilitation protocol. The estimated total blood loss (TBL), transfusion rate, and total hemoglobin drop were assessed. Patients were categorized according to TBL into average TBL and higher TBL groups. Univariate and multiple logistic regression analyses were performed to identify risk factors for higher blood loss. Results: There was no difference in TBL between cementless and cemented TKA groups (1233 ± 299 and 1282 ± 309 mL, respectively; p > 0.05). In addition, no between-group differences in the transfusion rate and mean total hemoglobin drop were observed. The logistic regression analyses revealed that whether TKA was cementless or cemented was not associated with higher blood loss; rather, the only identified risk factor was the pre-TKA patient blood volume (odd ratio 1.001, 95% confidence interval 1.000-1002, p = 0.026). Conclusions: Contemporary cementless fixation does not increase blood loss or transfusion rates compared to cemented fixation in patients undergoing 1-week-interval staggered bilateral TKA.

Predisposing factors for allogeneic blood transfusion in patients with rheumatoid arthritis undergoing primary unilateral total knee arthroplasty

BACKGROUND

To determine the incidence and identify the predisposing factors for allogeneic blood transfusion (ABT) in patients with rheumatoid arthritis (RA) undergoing primary unilateral total knee arthroplasty (TKA).

METHODS

A total of 702 patients with RA who underwent primary unilateral TKA between 2003 and 2022 at a single center, were retrospectively enrolled. Patients were stratified into the ABT and non-ABT groups. Data on patient demographics, laboratory parameters, and disease- and surgery-related parameters were collected from chart reviews and compared between the ABT and non-ABT groups. Multivariate logistic regression analysis was conducted to identify the possible factors associated with postoperative ABT.

RESULTS

A total of 173 (24.6%) patients underwent ABT after surgery. Significant risk factors for ABT included the degree of flexion contracture [odds ratio (OR) = 1.018, P = 0.005] and thickness of insertion (OR = 1.170, P = 0.014). Conversely, body mass index (OR = 0.937, P = 0.018), preoperative hemoglobin level (OR = 0.973, P < 0.001), and intraoperative use of tranexamic acid (TXA) (OR = 0.119, P < 0.001) were associated with a lower risk of ABT in TKA.

CONCLUSION

We identified the significant risk and protective factors for ABT during TKA in patients with RA. This information could be helpful in optimizing perioperative blood management strategies during these surgeries.

Comparison of Blood Loss with the Use of Intravenous and Intraarticular Tranexamic Acid Versus Isolated Intraarticular in Primary Knee Arthroplasty

Objective  The objective of this work is to compare blood loss during primary knee arthroplasty with the use of intravenous and intraarticular (IV + IA) tranexamic acid versus intraarticular (IA) tranexamic acid alone. Methods  This is a randomized, double-blind clinical trial. Patients with indication for primary total knee arthroplasty were recruited in a specialized clinic, where they were operated by the same surgeon, always using the same surgical technique. Thirty patients were allocated in the IV + IA tranexamic acid group and 30 patients in the IA tranexamic acid group, according to randomization. Blood loss was compared through hemoglobin, hematocrit, drain volume, and blood loss estimation (Gross and Nadler calculus). Results  After collection, data from 40 patients were analyzed, 22 in the IA group and 18 in the IV + IA group. There were 20 losses due to collection error. Between groups IA and IV + IA, there were no significant differences in 24 hours between hemoglobin levels (10.56 vs. 10.65 g/dL; F 1.39  = 0.63, p  = 0.429), erythrocyte (3.63 vs. 3.73 million/mm 3 ; F 1.39  = 0.90, p  = 0.346); hematocrit (32.14 vs. 32.60%; F 1.39  = 1.39, p  = 0.240); drainage volume (197.0 vs. 173.6 mL; F 1.39  = 3.38 p  = 0.069); and estimated blood loss (1,002.5 vs. 980.1; F 1.39  = 0.09, p  = 0.770). The same occurred in comparisons conducted after 48 hours postoperatively. Time was a significant factor for the change of all outcome variables. However, the treatment did not modify the effect of time on these outcomes. No individual presented any thromboembolic event during the work period. Conclusions  The use of IV + IA tranexamic acid showed no advantage in reducing blood loss when compared to the use of IA tranexamic acid alone in primary knee arthroplasties. This technique proved to be safe, since no thromboembolic event occurred during the development of the work.

The safety of tranexamic acid administration in total knee arthroplasty: a population-based study from Taiwan

Tranexamic acid is an effective treatment to reduce blood loss. We performed a retrospective observational study to evaluate safety in unilateral total knee arthroplasty. We utilised Taiwan's national health insurance database to identify relevant patients and to retrieve information on peri-operative blood transfusions and tranexamic acid administration within 60 days of follow-up. We examined changes in the rate of transfusions and adverse events with respect to tranexamic acid administration using logistic regression. We observed a total of 226,719 knee arthroplasty cases during 2010-2019. Transfusion and tranexamic acid administration rates were 38.9% (88,258) and 42.9% (97,237), respectively. Tranexamic acid was associated with a 50% decrease in blood transfusions (RR: 0.50, 95%CI: 0.48-0.51). After propensity-score matching, tranexamic acid was not associated with pulmonary embolism; deep vein thromboembolism; artery vein thromboembolism; acute myocardial infarction; ischaemic stroke; or in-hospital mortality, but was significantly associated with acute kidney injury. Patients with existing chronic kidney disease suffered a high absolute risk of kidney injury irrespective of tranexamic acid administration (832 per 10,000, 95%CI 797-869). Tranexamic acid was also associated with surgical site infection. There was strong interaction between blood transfusion; tranexamic aid administration; and development of surgical site infection. In conclusion, tranexamic acid use was associated with decreased blood transfusion and was not associated with thromboembolic events. However, careful consideration is required before use in patients with pre-existing renal disease. Further, our observed interaction between patients given tranexamic acid who subsequently require transfusion requires careful consideration with respect to enhanced prophylaxis against surgical site infection.

Perioperative safety assessment of patients undergoing unilateral or bilateral hip replacements

Introduction

Due to the aging of the world population and the increase of obesity rate, it is expected that the number of joint replacement surgery will continue to increase in the next few years. This study evaluated the safety differences between unilateral and bilateral hip replacement surgeries.

Methods

The data for patients who underwent hip arthroplasty in 2021 and 2022 were examined. The data set included 68 patients who were grouped according to the type of hip replacement needed, sex, age, and body mass index. Total blood loss and operative time were the safety-related indicators used to compare the groups.

Results

Regardless of whether the unilateral replacement group was compared with the overall bilateral replacement group or separately with the staged and simultaneous bilateral replacement groups, simultaneous bilateral replacement surgeries were equally safe as the other types of hip replacements. The total blood loss and operative time for the simultaneous bilateral replacement group were not significantly different from those in the unilateral and staged bilateral replacement groups. For overweight patients, the operative time for simultaneous bilateral replacements was significantly shorter than that for unilateral replacements.

Conclusions

These findings suggest that for patients requiring bilateral hip replacements, the blood loss risk for patients undergoing simultaneous bilateral hip replacements was similar to that for patients undergoing either unilateral or staged bilateral hip replacements. Thus, simultaneous bilateral total hip replacement (THR) are safe and should be considered for candidate patients.

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.

Predisposing factors for allogeneic blood transfusion in patients with ankylosing spondylitis undergoing primary unilateral total hip arthroplasty: a retrospective study

BACKGROUND

The transfusion rate is relatively high in patients with ankylosing spondylitis (AS) undergoing total hip arthroplasty (THA). However, relevant studies focusing on the predisposing factors for transfusion with a large sample size are lacking. This study aimed to investigate the incidence of and risk factors for allogeneic blood transfusion in patients with AS undergoing primary unilateral THA.

METHODS

This retrospective study included 331 patients with AS who underwent primary unilateral THA between 2011 and 2021. Relevant parameters were collected through a chart review. Multivariate logistic regression analysis was conducted to identify possible factors associated with perioperative allogeneic blood transfusion.

RESULTS

A total of 113 (34.1%) patients received perioperative allogeneic blood transfusions. Factors related to receiving an allogeneic blood transfusion included prolonged operative duration (odds ratio [OR] per 10 min = 1.139, P = 0.047), increased estimated intraoperative blood loss (OR per 100 mL = 1.348, P < 0.001), and increased postoperative drainage volume (OR per 100 mL = 1.235, P = 0.024). A higher body mass index (BMI) (OR = 0.914, P = 0.012), perioperative tranexamic acid (TXA) use (OR = 0.166, P < 0.001), and a higher preoperative hemoglobin level (OR per 1 g/dL = 0.744, P = 0.004) decreased the risk of transfusion.

CONCLUSIONS

In patients with AS undergoing THA, prolonged operative duration, increased estimated intraoperative blood loss, and increased postoperative drainage volume were found to be risk factors for transfusion, whereas a higher BMI, perioperative TXA use, and a higher preoperative hemoglobin level were protective factors. These results may aid in developing a better perioperative management strategy, ultimately reducing the need for transfusion.

Prediction of red blood cell transfusion after orthopedic surgery using an interpretable machine learning framework

Objective

Postoperative red blood cell (RBC) transfusion is widely used during the perioperative period but is often associated with a high risk of infection and complications. However, prediction models for RBC transfusion in patients with orthopedic surgery have not yet been developed. We aimed to identify predictors and constructed prediction models for RBC transfusion after orthopedic surgery using interpretable machine learning algorithms.

Methods

This retrospective cohort study reviewed a total of 59,605 patients undergoing orthopedic surgery from June 2013 to January 2019 across 7 tertiary hospitals in China. Patients were randomly split into training (80%) and test subsets (20%). The feature selection method of recursive feature elimination (RFE) was used to identify an optimal feature subset from thirty preoperative variables, and six machine learning algorithms were applied to develop prediction models. The Shapley Additive exPlanations (SHAP) value was employed to evaluate the contribution of each predictor towards the prediction of postoperative RBC transfusion. For simplicity of the clinical utility, a risk score system was further established using the top risk factors identified by machine learning models.

Results

Of the 59,605 patients with orthopedic surgery, 19,921 (33.40%) underwent postoperative RBC transfusion. The CatBoost model exhibited an AUC of 0.831 (95% CI: 0.824-0.836) on the test subset, which significantly outperformed five other prediction models. The risk of RBC transfusion was associated with old age (>60 years) and low RBC count (<4.0 × 10¹²/L) with clear threshold effects. Extremes of BMI, low albumin, prolonged activated partial thromboplastin time, repair and plastic operations on joint structures were additional top predictors for RBC transfusion. The risk score system derived from six risk factors performed well with an AUC of 0.801 (95% CI: 0.794-0.807) on the test subset.

Conclusion

By applying an interpretable machine learning framework in a large-scale multicenter retrospective cohort, we identified novel modifiable risk factors and developed prediction models with good performance for postoperative RBC transfusion in patients undergoing orthopedic surgery. Our findings may allow more precise identification of high-risk patients for optimal control of risk factors and achieve personalized RBC transfusion for orthopedic patients.

¿Es seguro el ácido tranexámico en la cirugía de reemplazo total de rodilla de pacientes con enfermedad coronaria?

Introducción: El ácido tranexámico reduce la pérdida sanguínea y los requerimientos de transfusiones luego de un reemplazo total de rodilla. Una de sus contraindicaciones relativas son los antecedentes de colocación de prótesis intravasculares coronarias, por un supuesto aumento de eventos tromboembólicos. Materiales y Métodos: Análisis retrospectivo de pacientes sometidos a un reemplazo total de rodilla primario y de revisión que recibieron ácido tranexámico y tenían antecedente de colocación de prótesis intravascular coronaria. Se los comparó con un grupo sin estas prótesis. Se analizó la presencia de cualquier cambio clínico o electrocardiográfico de oclusión coronaria aguda, eventos tromboembólicos, el requerimiento de transfusión sanguínea y el nivel de hemoglobina pre y posoperatorio. Resultados: 57 pacientes (59 cirugías, 56 reemplazos primarios y 3 revisiones) con colocación de prótesis intravascular coronaria, al menos, un año antes de la artroplastia. Un paciente tuvo síntomas de síndromecoronario agudo y cambios en el electrocardiograma. No hubo diferencias en la cantidad de eventos tromboembólicos. Solo un paciente del grupo de control recibió una transfusión de glóbulos rojos. El sangrado relativo fue menor en el grupo coronario independientemente del uso crónico de aspirina y clopidogrel antes de la cirugía (2,09 vs. 3,06 grupo de control; p = 0,01). En pacientes del alto riesgo, el ácido tranexámico no se asoció con más eventos tromboembólicos. Conclusiones: El ácido tranexámico impresionó ser seguro y efectivo en nuestro grupo de pacientes con prótesis intravasculares coronarias; sin embargo, se necesita un estudio prospectivo con más casos para confirmar estos resultados

Acute Postoperative Anemia After Unilateral Primary Total Joint Arthroplasty: Restrictive Transfusion Thresholds are Safe for Discharge Regardless of Delta Hemoglobin

BACKGROUND

Primary unilateral total joint arthroplasty (TJA) is associated with acute postoperative anemia that may require blood transfusion. Clinicians may worry about discharging patients after surgery who experience substantial decreases in hemoglobin (Hgb), even if their Hgb is above restrictive transfusion thresholds. The purpose of this study was to determine whether differences between preoperative and postoperative Hgb values (Delta) correlate with 90-day readmission in patients who did not receive perioperative transfusions.

METHODS

A retrospective review of patients undergoing primary unilateral TJA between 2015 and 2020 was performed. The primary outcome was whether a specific cutoff delta Hgb was predictive of readmission within 90 days due to anemia-related causes. Secondary outcomes included the presence of acute postoperative anemia and transfusion during readmission.

RESULTS

Six thousand seven hundred and ninety one patients had a median delta Hgb of 2.80. In total, 268 patients (3.95%) were readmitted within 90 days postoperatively, with two patients requiring transfusion during readmission. A significantly higher rate of readmission was found in patients with cardiovascular disease (5.16% versus 3.68%; P = .020). When constructing receiver operating characteristic curves, a cutoff value of 3.20 resulted in an area under curve of 0.595 (0.486-0.704). In patients with cardiovascular disease, a cutoff value of 3.10 resulted in an area under curve of 0.626 (0.466-0.787).

CONCLUSION

The magnitude of Hgb change was not predictive of anemia-related readmission within 90 days in patients who did not receive a perioperative transfusion. Patients experiencing higher delta Hgb values but remaining above the transfusion threshold may have a greater physiologic reserve.

Bipolar Sealers and Tourniquet Use Have Similar Outcomes in Total Knee Arthroplasty

INTRODUCTION

The use of tourniquets and bipolar sealers are effective methods of hemostasis during total knee arthroplasty (TKA). However, their effect on perioperative patient outcomes is unknown. The purpose of this study is to compare the efficacy of tourniquet-less, tourniquet-less with use of a bipolar sealer, and tourniquet use on postoperative pain and surgical outcomes following TKA.

METHODS

A retrospective study of prospectively collected data of 120 primary TKA cases was conducted at an urban academic hospital. Primary outcomes were visual analog scale (VAS) scores and opioid consumption (in morphine milligram equivalents). Demographics, length of stay (LOS), perioperative complications, and change in Knee Injury and Osteoarthritis Outcome Score (ΔKOOS) were also collected. Patients were divided into cohorts based on the use of tourniquet-less with bipolar sealer (TRLB) (n = 40), tourniquet (TR) (n = 40), or tourniquet-less (TRL) (n = 40).

RESULTS

There were no differences in demographic data between each cohort. TRLB, TR and TRL had similar LOS (2.68 ± 1.63 vs 2.29 ± 1.27 vs 2.36 ± 1.42 days; p = 0.472) and VAS pain score on postoperative day 1 (4.68 vs 3.74 vs 3.63; p = 0.209). There were also no differences in opioid consumption at 2 weeks (p = 0.903), 1 month (p = 0.973), 3 months (p = 0.983), or 5 months (p = 0.983) post-operatively. TRLB and TR had comparable improvement in ΔKOOS from baseline to 12 weeks post-operatively (Δ16.58 ± 8.47 vs Δ23.92 ± 14.60; p = 0.254). Compared to the ΔKOOS of TRL (Δ5.19 ± 2.59), TRLB and TR had clinically and statistically greater ΔKOOS improvements (p = 0.009; p = 0.001). The TRL cohort also had a higher readmission rate than TRLB and TR (15% vs 0% vs 5%, p = 0.025).

CONCLUSION

Our findings demonstrate that both bipolar sealer and tourniquet use in TKA are associated with similar postoperative pain levels and LOS in comparison to tourniquet-less only TKA. However, bipolar sealer and tourniquet use may lead to better longer term improvement such as greater PRO score improvement and fewer readmissions.

The efficacy and safety of combined administration of intravenous and intra-articular tranexamic acid in total knee arthroplasty: An update meta-analysis

WHAT IS KNOWN AND OBJECTIVE

This study was performed to compare the efficacy and safety of combined administration of intravenous (IV) and intra-articular (IA) tranexamic acid (TXA) with IV or IA TXA alone in total knee arthroplasty (TKA).

METHODS

PubMed, Embase, Cochrane Library and Web of Science were searched for randomized controlled trials (RCTs) in July 2021. Total blood loss, transfusion rate, postoperative haemoglobin drop, drain output, deep venous thrombosis (DVT) and pulmonary embolism (PE) were pooled. Data were analyzed using Stata 14.0 software. The study protocol was registered with PROSPERO, number CRD42020186654.

RESULTS

Ten RCTs involving 1306 patients were included. Combined TXA group provided lower total blood loss (SMD -0.47; 95% CI -0.64 to -0.30; p < 0.001), postoperative haemoglobin drop (SMD -0.47; 95% CI -0.60 to -0.33; p < 0.001) and drain output (SMD -0.50; 95% CI -0.71 to -0.29; p = 0.009) compared with IV or IA TXA alone group. No significant difference was found in terms of transfusion rate (OR 0.53; 95% CI 0.23 to 1.23; p = 0.137) and DVT (OR 0.55; 95% CI 0.18 to 1.68; p = 0.293). PE data was provided by all 10 studies, but PE only occurred in one patient in IV TXA alone group.

WHAT IS NEW AND CONCLUSION

Combined administration of IV and IA TXA was relatively more effective in reducing total blood loss, transfusion rate, postoperative haemoglobin drop, and drain output after TKA. TXA may not increase the risk of DVT/PE, but it also needs to be monitored in clinical application.

Blood Management in Total Knee Arthroplasty: A Nationwide Analysis from 2011 to 2018

Both advances in perioperative blood management, anesthesia, and surgical technique have improved transfusion rates following primary total knee arthroplasty (TKA), and have driven substantial change in preoperative blood ordering protocols. Therefore, blood management in TKA has seen substantial changes with the implementation of preoperative screening, patient optimization, and intra- and postoperative advances. Thus, the purpose of this study was to examine changes in blood management in primary TKA, a nationwide sample, to assess gaps and opportunities. The American College of Surgeons National Surgical Quality Improvement Program database was used to identify TKA (n = 337,160) cases from 2011 to 2018. The following variables examined, such as preoperative hematocrit (HCT), anemia (HCT <35.5% for females and <38.5% for males), platelet count, thrombocytopenia (platelet count < 150,000/µL), international normalized ration (INR), INR > 2.0, bleeding disorders, preoperative, and postoperative transfusions. Analysis of variances were used to examine changes in continuous variables, and Chi-squared tests were used for categorical variables. There was a substantial decrease in postoperative transfusions from high of 18.3% in 2011 to a low of 1.0% in 2018, (p < 0.001), as well as in preoperative anemia from a high of 13.3% in 2011 to a low of 9.5% in 2016 to 2017 (p < 0.001). There were statistically significant, but clinically irrelevant changes in the other variables examined. There was a HCT high of 41.2 in 2016 and a low of 40.4 in 2011 to 2012 (p < 0.001). There was platelet count high of 247,400 in 2018 and a low of 242,700 in 201 (p < 0.001). There was a high incidence of thrombocytopenia of 5.2% in 2017 and a low of low of 4.4% in 2018 (p < 0.001). There was a high INR of 1.037 in 2011 and a low of 1.021 in 2013 (p < 0.001). There was a high incidence of INR >2.0 of 1.0% in 2012 to 2015 and a low of 0.8% in 2016 to 2018 (p = 0.027). There was a high incidence of bleeding disorders of 2.9% in 2013 and a low of 1.8% in 2017 to 2018 (p < 0.001). There was a high incidence of preoperative transfusions of 0.1% in 2011 to 2014 and a low of <0.1% in 2015 to 2018 (p = 0.021). From 2011 to 2018, there has been substantial decreases in patients receiving postoperative transfusions after primary TKA. Similarly, although a decrease in patients with anemia was seen, there remains 1 out 10 patients with preoperative anemia, highlighting the opportunity to further improve and address this potentially modifiable risk factor before surgery. These findings may reflect changes during TKA patient selection, optimization, or management, and emphasizes the need to further advance multimodal approaches for perioperative blood management of TKA patients. This is a Level III study.

A Comparison of Operative Time and Intraoperative Blood Volume Loss Between Stemless and Short‐stem Anatomic Total Shoulder Arthroplasty: A Single Institution's Experience

There has been increasing interest in the use of stemless humeral implants for total shoulder arthroplasty when compared with both short-stem (SS) and standard-length implants. Although evidence for decreased surgical time and blood loss exists for stemless versus standard-length stems, far less literature exists comparing these clinical parameters for stemless versus SS implants.

Peri-Articular Injection of Tranexamic Acid Reduce Blood Loss and Transfusion Requirement During Total Knee Arthroplasty: A Meta-analysis

Background

The aim of this meta-analysis was to evaluate the efficacy and safety of peri-articular injection of tranexamic acid (TXA) during total knee arthroplasty (TKA) from clinical controlled trials.

Method

Eligible scientific articles published prior to October 2021 were retrieved from the PubMed, Springer, ScienceDirect and Cochrane Library databases. The statistical analysis was performed with RevMan 5.1.

Result

2 RCTs and 3 non-RCTs met the inclusion criteria. Meta-analysis showed significant differences in terms of hemoglobin reduction (MD = -1.04, 95% CI: -1.33 to -.76, P < .00001), total blood loss (MD = -342.80.70, 95% CI: -437.52 to -248.08, P < .00001), drainage volume (MD = -297.24, 95% CI: -497.26 to -97.23, P = .004) and blood transfusion rate (OR = .30, 95% CI: .14 to .62, P = .001) were found in the control group. No postoperative infection and deep venous thrombosis were found between 2 groups.

Conclusion

Peri-articular injection of TXA can effectively decrease perioperative blood loss and blood transfusion rate without increasing the incidence of postoperative complications during TKA.

Transfusion Trends of Knee Arthroplasty in Korea: A Nationwide Study Using the Korean National Health Insurance Service Sample Data

Knee arthroplasties are strongly associated with blood transfusion to compensate for perioperative bleeding. The purpose of this study was to evaluate trends of transfusion associated with knee arthroplasties using nationwide data of the National Health Insurance Service-National Sample Cohort (NHIS-NSC). Using data from the nationwide claims database of the Health Insurance Review Assessment Service managed by the NHIS, 50,553 knee arthroplasties under three categories (total knee replacement arthroplasty, uni-knee replacement arthroplasty, and revision arthroplasty) from 2012 to 2018 were identified. Overall transfusion rate, transfusion count, proportion of each type of transfusion, and cost associated with each type of operation were investigated. Overall transfusion rate was 83.4% (5897/7066) in 2012, 82.7% (5793/7001) in 2013, 79.6% (5557/6978) in 2014, 75.9% (5742/7557) in 2015, 73.1% (6095/8337) in 2016, 68.2% (4187/6139) in 2017, and 64.6% (4271/6613) in 2018. The proportion of each type of transfusion was 1.8% for fresh frozen plasma, 0.5% for platelets, and 97.7% for red blood cells. The average cost of transfusion was $109.1 ($123 in 2012, $124 in 2013, $123.3 in 2014, $110.6 in 2015, $100 in 2016, $92.9 in 2017, and $90.1 in 2018). In this nationally representative study of trends in transfusion associated with knee arthroplasty, we observed significantly high rates of blood transfusion among patients undergoing knee arthroplasties. Although the overall rate of transfusion had declined, the allogeneic transfusion rate was still high from 2012 to 2018 in Korea. Thus, surgeons need to develop various patient blood management plans and minimize the use of allogeneic transfusion when performing knee arthroplasties.

Intravenous Ferric Carboxymaltose Improves Response to Postoperative Anemia Following Total Knee Arthroplasty: A Prospective Randomized Controlled Trial in Asian Cohort

Background: Ferric carboxymaltose (FCM) is an intravenous (IV) high-dose iron that is effective in the treatment of iron deficiency anemia. This study was performed to determine whether postoperative FCM infusion is effective at improving hemoglobin (Hb) responders, Hb and iron profiles, and the patient’s quality of life (QOL). Methods: A total of 110 patients with postoperative anemia, defined by a Hb < 10 g/dL within 3 days of unilateral primary TKA, between June 2018 and February 2020 were randomized into either the FCM or Control group. On postoperative day 3, the FCM group (55 patients) received IV FCM while the Control group (55 patients) did not. The Hb responders (Hb increase ≥ 2 g/dL compared to baseline), Hb level, iron profiles (ferritin, total iron-binding capacity (TIBC), transferrin saturation (TSAT)), and EQ-5D scores were compared at weeks 2, 4, and 8. Results: The FCM group demonstrated a significantly greater number of Hb responders (p < 0.001) and a higher Hb level (p = 0.008) at 2 weeks postoperative than did the Control group. The FCM group recovered its preoperative Hb level between 4 and 8 weeks. In contrast, the Control group did not recover its preoperative level until 8 weeks. The FCM infusion group also had higher serum ferritin, iron and TSAT, and lower TIBC levels than those of the Control group between 2 and 8 weeks (all p < 0.001). However, there was no significant difference in the postoperative transfusion rate (p = 0.741) or EQ-5D score between the two groups (all p > 0.05). Discussion: In postoperative anemia following TKA, IV FCM increases the Hb response and improves Hb and iron metabolism variables, however, it does not affect the transfusion rate or QOL.

Are Risk Factors for Postoperative Significant Hemorrhage following Total Knee Arthroplasty Potentially Modifiable? A Retrospective Cohort Study

Total knee arthroplasty (TKA) is the treatment of choice for end-stage osteoarthritis (OA) of the knee, because it alleviates pain and restores function of the knee. However, TKA-associated hemorrhage and subsequent anemia remain a concern. Most previous studies have defined meaningful postoperative bleeding as blood loss > 500 mL or hemoglobin (Hb) drop > 20 g/L. Therefore, we defined significant hemorrhage as a postoperative Hb drop more than 20 g/L in this study, and we investigated possible risk factors related to significant hemorrhage in TKA and whether these risk factors are modifiable. This retrospective study was conducted through a comprehensive review of the perioperative records of patients with OA of the knee who underwent TKA between January 2009 and December 2015 at our hospital. Patients were allocated into two groups: patients in Group A had their Hb drop ≤ 20 g/L; patients in Group B had their Hb drop > 20 g/L. Factors analyzed included sex, age, body mass index (BMI), the American Society of Anesthesiologists (ASA) classification, comorbidities, preoperative platelet count, use of tranexamic acid (TXA), operation time, and type of anesthesia. A total of 3350 patients met the criteria for analysis, with 1782 patients allocated to Group A and 1568 patients to Group B. Five independent risk factors for significant hemorrhage were identified: male sex (odds ratio(OR), 1.29; 95% confidence interval(CI), 1.08−1.53; p = 0.005), age (OR, 1.02; 95% CI, 1.01−1.03; p = 0.001), use of TXA (OR, 0.39; 95% CI, 0.34−0.45; p < 0.001), spinal anesthesia versus general anesthesia (OR, 0.71; 95% CI, 0.56−0.90; p = 0.004), and preoperative platelet count (OR, 0.96; 95% CI, 0.93−0.98; p = 0.001). Of these identified risk factors, preoperative platelet count, use of TXA, and spinal anesthesia are modifiable. These potentially modifiable risk factors need to be taken into consideration when making both the perioperative care and anesthesia plan by surgeons and anesthesiologists, especially in patients at risk of significant hemorrhage.

Association of Use of Tourniquets During Total Knee Arthroplasty in the Elderly Patients With Post-operative Pain and Return to Function

Objective

During total knee arthroplasty (TKA), tourniquet may negatively impact post-operative functional recovery. This study aimed at investigating the effects of tourniquet on pain and return to function.

Methods

Pubmed, Embase, and Cochrane Library were comprehensively searched for randomized controlled trials (RCTs) published up to February 15th, 2020. Search terms included; total knee arthroplasty, tourniquet, and randomized controlled trial. RCTs evaluating the efficacies of tourniquet during and after operation were selected. Two reviewers independently extracted the data. Effect estimates with 95% CIs were pooled using the random-effects model. Dichotomous data were calculated as relative risks (RR) with 95% confidence intervals (CI). Mean differences (MD) with 95% CI were used to measure the impact of consecutive results. Primary outcomes were the range of motion (ROM) and visual analog scale (VAS) pain scores.

Results

Thirty-three RCTs involving a total of 2,393 patients were included in this study. The mean age is 65.58 years old. Compared to no tourniquet group, the use of a tourniquet resulted in suppressed ROM on the 3rd post-operative day [MD, −4.67; (95% CI, −8.00 to −1.35)] and the 1st post-operative month [MD, −3.18; (95% CI, −5.92 to −0.44)]. Pain increased significantly when using tourniquets on the third day after surgery [MD, 0.39; (95% CI, −0.19 to 0.59)]. Moreover, tourniquets can reduce intra-operative blood loss [MD, −127.67; (95% CI, −186.83 to −68.50)], shorter operation time [MD, −3.73; (95% CI, −5.98 to −1.48)], lower transfusion rate [RR, 0.85; (95% CI, 0.73–1.00)], higher superficial wound infection rates RR, 2.43; [(5% CI, 1.04–5.67)] and higher all complication rates [RR, 1.98; (95% CI, 1.22–3.22)].

Conclusion

Moderate certainty evidence shows that the use of a tourniquet was associated with an increased risk of higher superficial wound infection rates and all complication rates. Therefore, the findings did not support the routine use of a tourniquet during TKA.

Association of Anesthesia Type with Postoperative Outcome and Complications in Patients Undergoing Revision Total Knee Arthroplasty

Revision total knee arthroplasty (TKA) is an increasingly common procedure and is effective in treating knee osteoarthritis, but it has higher complication rates than primary TKA. Anesthetic choice poses perioperative risk that has been extensively studied in primary TKA, showing favorable results for regional anesthesia compared with general anesthesia. The impact of anesthetic choice in revision TKAs is not well studied. A retrospective cohort study was conducted using the American College of Surgeons National Surgical Quality Improvement Program database. Patients who underwent revision TKAs between 2014 and 2017 were divided into three anesthesia cohorts: (1) general anesthesia, (2) regional anesthesia, and (3) combined general-regional anesthesia. Univariate and multivariate analyses were used to analyze patient characteristics and 30-day postoperative outcomes. Bonferroni correction was applied for post hoc analysis. In total, 8,820 patients were identified. Of whom, 3,192 patients underwent general anesthesia, 3,474 patients underwent regional anesthesia, and 2,154 patients underwent combined anesthesia. After multivariate analyses, regional anesthesia was associated with decreased odds for any complication (p = 0.008), perioperative blood transfusion (p < 0.001), and extended length of stay (p < 0.001) compared with general anesthesia. In addition, regional anesthesia was associated with decreased odds for perioperative blood transfusion (p < 0.001) and extended length of stay (p = 0.006) compared with combined anesthesia. However, following multivariate analysis, regional anesthesia was not associated with decreased odds of wound, pulmonary, renal, urinary tract, thromboembolic, and cardiac complications, and was not associated with return to operating room, extended length of stay, minor and major complications, and mortality. Retrospective analysis of a large surgical database suggests that patients receiving general anesthesia have increased likelihood for developing adverse postoperative outcomes relative to patients receiving regional anesthesia. Prospective and controlled trials should be conducted to verify these findings.

Predicting postoperative transfusion in elective total HIP and knee arthroplasty: Comparison of different machine learning models of a case-control study

BACKGROUND

Total joint arthroplasty (TJA) is a very successful orthopedics procedure but associates with a significantly high transfusion rate.

OBJECTIVE

In this study, we aimed to determine predictors of postoperative blood transfusion in patients undergoing elective hip and knee TJA patients and compare the accuracy of machine learning (ML) algorithms in predicting transfusion risk.

METHODS

We utilized data from 12,642 patients undergoing primary unilateral TJA. Risk factors and demographic information were extracted, and predictive models were developed using seven ML algorithms. The area under the receiver operating characteristic curve was used to measure the predictive accuracy of each algorithm.

RESULTS

The overall transfusion rate was 18.7%. Patient-related risk factors for transfusion included age 65-85 (Odds Ratio (OR): 1.175-1.222), female (OR: 1.246), American Society of Anesthesiologists grade Ⅱ or greater (OR: 1.264-2.758). Surgical factors included operation time (OR: 1.736), drain use (OR: 2.202) as well as intraoperative blood loss (OR: 7.895). Elevated preoperative Hb (OR: 0.615), Hct (OR: 0.800), BMI (≥24 kg/m2) (OR: 0.613-0.731) and tranexamic acid use (OR: 0.375) were associated with decreased risk of postoperative transfusion. The long short-term memory networks (LSTM) and random forest (RF) models achieved the highest predictive accuracy (p < 0.001).

CONCLUSION

The risk factors identified in the current study can provide specific, personalized postoperative transfusion risk assessment for a patient considering lower limb TJA. Furthermore, the predictive accuracies of LSTM and RF algorithms were significantly higher than the others, making them potential tools for future personalized preoperative prediction of risk for postoperative transfusion.

Effect of an Elevated Preoperative International Normalized Ratio on Transfusion and Complications in Primary Total Hip Arthroplasty with the Enhanced Recovery after Surgery Protocol

Objective

To verify whether an elevated preoperative international normalized ratio (INR) increases transfusion and complications independently in primary total hip arthroplasty (THA) with the management of an enhanced recovery after surgery (EARS) protocol.

Methods

We retrospectively reviewed the database of adults who underwent primary THA between 2014 and 2018 by the same surgeon. A total of 552 patients were assigned into three groups by preoperative INR class: INR ≤ 0.9, 0.9 < INR < 1.0, and INR ≥ 1.0. We regarded transfusion within 90 days during the same hospitalization as the primary outcome. We also included perioperative blood loss, maximum Hb drop, postoperative anaemia requiring medicine, and length of hospital stay (LOS) during the same hospitalization in the study. Complications and reoperation at 90 days and mortality at 90 days and 12 months were also included in the study. Univariable analyses were utilized to compare baselines and outcomes among the three groups. Multivariate logistic regressions were used to adjust for differences at baseline among the groups.

Results

All patients had an INR < 1.5 preoperatively and were managed with the ERAS protocol. Among them, 93 (16.8%) patients had INR ≤ 0.9, 268 (48.6%) patients had 0.9 < INR < 1.0, and 191 (34.6%) patients had INR ≥ 1.0. In the univariable analyses, as the INR increased, the transfusion rates increased from 1.08% for INR ≤ 0.9, to 1.12% for 0.9 < INR < 1.0 and to 5.76% for INR ≥ 1.0 (P < 0.05). The overall complication rate increased from 10.8% for INR ≤ 0.9, to 16.4% for 0.9 < INR < 1.0, and to 22.5% for INR ≥ 1.0 (P < 0.05). The length of stay (LOS) in the INR ≥ 1.0 group was 5.7 ± 2.2 days, which was significantly longer than that in the INR ≤ 0.9 group (4.7 ± 1.6 days, P = 0.000) and 0.9 < INR < 1.0 group (5.1 ± 2.0 days, P = 0.007). No statistical significance was detected among the groups regarding blood loss, maximum Hb drop, or the incidence of postoperative anaemia that required medicine. There was no significant difference in reoperation or mortality among the groups. When controlling for demographic and comorbidity characteristics, there was no statistically significant difference in the odds of transfusion during the same hospitalization or overall complications at 90 days among the groups (P > 0.05).

Conclusions

Elevated preoperative INR cannot increase transfusion or complication rates independently in primary THA with the management of the ERAS protocol. With the improvement in the ERAS protocol and the use of tranexamic acid (TXA), an INR < 1.5 is still a conventional safe threshold for THA surgery.

Clinical-Deep Neural Network and Clinical-Radiomics Nomograms for Predicting the Intraoperative Massive Blood Loss of Pelvic and Sacral Tumors

Background

Patients with pelvic and sacral tumors are prone to massive blood loss (MBL) during surgery, which may endanger their lives.

Purposes

This study aimed to determine the feasibility of using deep neural network (DNN) and radiomics nomogram (RN) based on 3D computed tomography (CT) features and clinical characteristics to predict the intraoperative MBL of pelvic and sacral tumors.

Materials and Methods

This single-center retrospective analysis included 810 patients with pelvic and sacral tumors. 1316 CT and CT enhanced radiomics features were extracted. RN1 and RN2 were constructed by random grouping and time node grouping, respectively. The DNN models were constructed for comparison with RN. Clinical factors associated with the MBL were also evaluated. The area under the receiver operating characteristic curve (AUC) and accuracy (ACC) were used to evaluate different models.

Results

Radscore, tumor type, tumor location, and sex were significant predictors of the MBL of pelvic and sacral tumors (P < 0.05), of which radscore (OR, ranging from 2.109 to 4.706, P < 0.001) was the most important. The clinical-DNN and clinical-RN performed better than DNN and RN. The best-performing clinical-DNN model based on CT features exhibited an AUC of 0.92 and an ACC of 0.97 in the training set, and an AUC of 0.92 and an ACC of 0.75 in the validation set.

Conclusions

The clinical-DNN and clinical-RN had good performance in predicting the MBL of pelvic and sacral tumors, which could be used for clinical decision-making.

Multimodality imaging of the paediatric flatfoot

Flatfoot is commonly encountered in the paediatric population and describes a spectrum of clinical and radiological presentations which encompass both normally developing and pathological feet. Flatfoot can be categorised as flexible or rigid, a distinction which has important implications when considering the potential underlying aetiology and treatment options, and therefore imaging is an important component of the diagnostic workup. Weight-bearing plain radiographs are established initial investigations, although the significance of a number of the commonly derived quantitative parameters in children remains unclear. CT and MRI are important additional imaging modalities reserved for the investigation of symptomatic cases or those in which an underlying structural abnormality is suspected, rigid flatfoot commonly falling into one of these two categories. We review and illustrate the multimodality imaging of the paediatric flatfoot, with reference to both qualitative and quantitative radiographic assessment and cross-sectional imaging appearances.

Study to estimate the average blood loss in different orthopedic procedures: A retrospective review

Background

In orthopedic surgery, bleeding is an inevitable side effect. The study's aim was to provide estimated blood loss values in various orthopedic procedures and take a step towards developing statistically reliable formulae. This can provide blood loss values in orthopedic surgery, which will be a very good tool for operative planning.

Materials and methods

We reviewed case notes of 282 patients in a UK based trauma center from December 2020 to March 2021,who had undergone a various orthopedic procedures. The results were analyzed using SPSS version 25.

Results

Most common fracture was neck of femur (37.5%)followed by intertrochanteric fractures(27.6%). Paired t-test was used, and there is good evidence (t281 = 14.957, p = 0.000) that intraoperative transfusions increased HB levels in patients (t281 = 14.957, p = 0.000) by an average of 1.331 points, with a 95% confidence interval of 1.156–1.506. As a result, the variation between the Pre-op and Post-op HB levels is statistically important but minimal. We can see that the mean blood loss is statistically different in different age groups (0.03) of patients and by the existence of co-morbids using analysis of variance (0.04). The average number of days spent in the hospital varies by surgical type (0.01) performed on patients.

Conclusion

Orthopedic surgery can be associated with high levels of blood loss. There is a significant relation between fracture form and age groups, change of wound dressing (COD), use of a tourniquet, and drain insertion, no connection was noted between gender and fracture types.

•

Bleeding is an unavoidable side effect of most surgical operations, including orthopaedic surgery.

•

There is a scarcity of literature that can provide us an estimate of how much blood will be lost during various orthopaedic operations.

•

Goal of the study was to offer estimated blood loss estimates in various orthopaedic operations.

•

There is a significant relationship between fracture type and age groups, change of wound dressing (COD), use of a tourniquet.

Predictive Factors for Blood Transfusion after Total Knee Arthroplasty

Objectives  The present paper aims to (1) verify the incidence and volume of blood transfusion among patients undergoing unilateral cemented total knee arthroplasty (TKA) in a single Brazilian reference center; (2) identify pre and perioperative variables to determine subjects with higher risk (i.e., predictive factors) for blood transfusion within 48 hours following surgery; (3) estimate the risk of blood transfusion during the first 48 hours after the procedure.

Methods  The initial sample consisted of all patients undergoing TKA from August 2010 to August 2013. After applying the exclusion criteria, 234 patients aged 30 to 83 years old and diagnosed with primary or secondary osteoarthritis due to rheumatoid arthritis remained in the study.

Results  Preoperative hemoglobin levels ≤ 12.3 g/dL and ischemia time ≥ 87 minutes were independent predictors for post-TKA blood transfusion, with a relative risk of 2.48 and 1.78, respectively. Approximately half of the TKA patients (51.3%) presenting these two variables required a blood transfusion.

Conclusion  The incidence of post-TKA blood transfusion was 33.7%. On average, each transfused patient received 480 mL of packed red blood cells. Preoperative hemoglobin levels ≤ 12.3 g/dL ( p  < 0.001) and ischemia time ≥ 87 minutes ( p  < 0.047) were independent predictors for blood transfusion in TKA using a pneumatic cuff, with a relative risk of 2.48 and 1.78, respectively. Age, gender, diagnosis, or body mass index were not considered independent predictors for the need for blood transfusion up to 48 hours after the procedure.

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.

Re-evaluating the necessity of routine laboratory tests after high tibial osteotomy surgery

BACKGROUND

To assess the utility of routine postoperative laboratory tests for patients undergoing high tibial osteotomy (HTO) surgery.

METHODS

The associations between clinical risk factors and postoperative clinical treatment were analyzed. Additionally, a logistic regression analysis was performed to detect independent risk factors for patients requiring postoperative clinical treatment.

RESULTS

A total of 482 patients with symptomatic isolated medial compartment osteoarthritis from January 2015 to May 2020 were included in the present study and underwent examination by the full set of postoperative laboratory tests within 3 days after HTO surgery. However, only a small proportion of the patients with anemia (3.9 %), hypoalbuminemia (4.1 %), and abnormal serum potassium levels (3.5 %) required clinical intervention after surgery. Binary logistic regression analysis showed that the body mass index (BMI), preoperative hemoglobin level, estimated blood loss and operative duration were independent risk factors for postoperative blood transfusion in patients who underwent HTO surgery, and factors associated with albumin supplementation were female sex and preoperative albumin level. In addition, these results indicated that preoperative potassium was potential risk factor for patients who required potassium supplementation postoperatively.

CONCLUSIONS

Based on the analysis, we conclude that routinely ordering postoperative laboratory tests after HTO surgery is unnecessary. However, for patients with identified risk factors, routine postoperative laboratory tests are still needed.

Significantly reducing blood loss via a peri-articular injection of tranexamic acid during total knee arthroplasty: a retrospective study

Background

The administration of an intra-articular injection (IAI) of tranexamic acid (TXA) has been demonstrated to be effective in reducing both blood loss and transfusion rate during total knee arthroplasty (TKA); however, few studies have reported the efficiency of a peri-articular injection (PAI) of TXA. We studied the efficiency of a PAI of TXA in reducing blood loss during TKA.

Methods

Fifty patients undergoing primary simultaneous bilateral TKA were enrolled in this retrospective study. The right knee received a PAI of 1 g of TXA (Group I), and the left knee received an IAI of 1 g of TXA (Group II). The clinical outcome measures were a change in blood loss from Hemovac drains and surgical time.

Results

The decrease in blood loss from the Hemovac was significantly lower in Group I (460.1 ± 36.79 vs. 576.0 ± 34.01, P < 0.001) than in Group II, and no significant difference in surgical times was observed. The blood transfusion rate in the present study was 16 %.

Conclusions

A PAI of TXA may reduce blood loss more efficiently than an IAI of TXA during TKA without increased complications such as surgical site infection, poor wound healing, skin necrosis, pulmonary embolism, and deep vein thrombosis.

Association between Type of Anesthesia and Risk of Blood Transfusion Events in Primary Unilateral Total Knee Arthroplasty: A Secondary Analysis Based on a Cohort Study in Singapore

This study evaluated whether the type of anesthesia independently related to risk of blood transfusion events in patients undergoing total knee arthroplasty (TKA) after adjusting for other covariates. This was a secondary analysis of a retrospective cohort study of patients undergoing primary unilateral TKA in Singapore. The independent variable was the type of anesthesia and the dependent variable was blood transfusion events. A multivariable logistic regression analysis was performed adjusting for variables that might affect the choice of anesthesia or blood transfusion events. Additional analyses examined this association by the subgroup analysis by using stratified multivariate logistic regression models. Of all 2,366 patients undergoing primary unilateral TKA, 120 (5.1%) developed blood transfusion events. Sixty-four (4.1%) of 1,560 patients with regional anesthesia (RA) developed blood transfusion events, compared with 56 (6.9%) of 806 patients with general anesthesia (GA; (p = 0.003). After adjusting for age, sex, preoperative hemoglobin, and other variables, patients who received RA had a decreased risk of blood transfusion events compared with those receiving GA (odds ratio [OR]: 0.53, 95% confidence interval [CI]: 0.35-0.81). This risk further decreased in male (OR: 0.20, 95% CI: 0.07-0.59) and participants whose operation time ≥ 90 minutes (OR: 0.39, 95% CI: 0.19-0.78). Our results indicated that patients receiving primary unilateral TKA who were managed with RA had a significantly decreased risk of blood transfusion events compared with those with GA, especially in male and participants whose operation time ≥ 90 minutes.

Tranexamic acid use in high-risk blood transfusion patients undergoing total hip replacement: a randomised controlled trial

INTRODUCTION

We hypothesised that a single preoperative intravenous dose of tranexamic acid (TXA) is effective in patients who undergo total hip arthroplasty (THA) and are at high risk of blood transfusion (preoperative haemoglobin level <13.0 g/dL).

METHODS

A prospective, randomised controlled study of 308 patients who underwent primary THA was conducted. 256 participants remained in the study and were divided into 2 major groups: high-risk group comprising 116 patients with preoperative Hb < 13.0 g/dL (57 of whom were treated with a 15 mg/kg intravenous bolus of TXA, and 59 of whom did not receive the medication) and low-risk group comprising 140 patients with Hb ⩾ 13.0 g/dL (71 of whom received the same dose of TXA, and 69 of whom did not). Participants were followed up at 3 weeks, 3 months, 6 months, and 1 year after surgery.

RESULTS

The use of TXA in both groups of patients significantly increased the levels of postoperative Hb and Ht. TXA protected high-risk patients from blood loss and from transfusion. In low-risk patients the use of TXA reduced blood loss but did not protect from blood transfusion. The median length of stay was significantly affected for high-risk patients. No thromboembolic event was recorded in either group.

CONCLUSIONS

TXA reduces intra- and postoperative bleeding, transfusion rates, and the length of hospital stays in patients with low preoperative Hb. The use of TXA in patients with normal preoperative Hb reduces blood loss but does not affect the transfusion rate.ClinicalTrials.gov Identifier: NCT03019198.

Tranexamic Acid Is Safe in Patients with a History of Coronary Artery Disease Undergoing Total Joint Arthroplasty

BACKGROUND

Tranexamic acid (TXA) is increasingly used to minimize blood loss during total joint arthroplasty (TJA). Although TXA has been shown to be highly effective in reducing operative blood loss, many surgeons believe that it places patients with coronary artery disease (CAD) or a history of coronary stents at an increased risk for myocardial infarction. The purpose of this study was to determine if TXA is safe to use in patients with a history of CAD or coronary stents.

METHODS

We performed a retrospective analysis at a single, tertiary academic medical center identifying consecutive total hip and knee arthroplasty cases over an 8-year period. From this cohort who received TXA intraoperatively, we identified patients with a history of CAD or coronary stents and determined the total myocardial infarction and venous thromboembolism (VTE) rates within a 90-day postoperative period. Chi-square analyses were used to identify differences in VTE rates between cohorts. A post hoc power analysis was also performed to determine whether our results were powered to detect a difference in VTE rates.

RESULTS

In the 26,808 identified at-risk patients, there were no postoperative myocardial infarctions. No significant differences were observed for VTE rates compared with the control cohort using either topical or intravenous TXA, with regard to CAD (0.29% compared with 0.76%; p = 0.09) or coronary stents (0% compared with 0.76%; p = 0.14). Moreover, there was no significant difference observed in VTE rates when administration was subcategorized into intravenous and topical methods with regard to CAD (0.13% compared with 0.72%; p = 0.12) or coronary stents (0% compared with 0%; p = 1.0).

CONCLUSIONS

In our series, topical and intravenous TXA were equally safe when used in patients with a history of CAD and coronary stents in comparison with the control cohort. With equal efficacy and risk of adverse events, we recommend intravenous TXA, which may enable easier institutional implementation.

LEVEL OF EVIDENCE

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

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.

Can an outpatient risk assessment tool predict who needs postoperative haemoglobin monitoring?

AIMS

Recent improvements in surgical technique and perioperative blood management after total joint replacement (TJR) have decreased rates of transfusion. However, as many surgeons transition to outpatient TJR, obtaining routine postoperative blood tests becomes more challenging. Therefore, we sought to determine if a preoperative outpatient assessment tool that stratifies patients based on numerous medical comorbidities could predict who required postoperative haemoglobin (Hb) measurement.

METHODS

We performed a prospective study of consecutive unilateral primary total knee arthroplasties (TKAs) and total hip arthroplasties (THAs) performed at a single institution. Prospectively collected data included preoperative and postoperative Hb levels, need for blood transfusion, length of hospital stay, and Outpatient Arthroplasty Risk Assessment (OARA) score.

RESULTS

A total of 504 patients met inclusion criteria. Mean age at time of arthroplasty was 65.3 years (SD 10.2). Of the patients, 216 (42.9%) were THAs and 288 (57.1%) were TKAs. Six patients required a blood transfusion postoperatively (1.19%). Transfusion after surgery was associated with lower postoperative day 1 Hb (median of 8.5 (interquartile range (IQR) 7.9 to 8.6) vs 11.3 (IQR 10.4 to 12.2); p < 0.001), longer length of stay (1 day (IQR 1 to 1) vs 2 days (IQR 2 to 3); p < 0.001), higher OARA score (median of 60.0 (IQR 40 to 75) vs 5.0 (IQR 0-35); p = 0.001), and total hip arthroplasty (p < 0.001). All patients who received a transfusion had an OARA score > 34; however, this did not reach statistical significance as a screening threshold.

CONCLUSION

Risk of blood transfusion after primary TJR was uncommon in our series, with an incidence of 1.19%. Transfusion was associated with OARA scores > 60. The OARA score, not American Society of Anesthesiologists grade, reliably identified patients at risk for postoperative blood transfusion. Selective Hb monitoring may result in substantial cost savings in the era of cost containment. Cite this article: Bone Joint J 2021;103-B(1):65-70.

Perioperative Blood Management Strategies for Patients Undergoing Total Hip Arthroplasty: Where Do We Currently Stand on This Matter?

Total hip replacement (THR) has proved to be a reliable treatment for the end stage of hip osteoarthritis. It is a common orthopaedic procedure with excellent results, but is associated with significant blood loss and high rates of allogeneic blood transfusion (ABT). The potential complications and adverse events after ABT, combined with the ongoing research, have resulted in multimodel, multidisciplinary blood management strategies adoption, aiming to reduce the blood loss and transfusion rates. Many reviews and meta-analyses have tried to demonstrate the best blood management strategies. The purpose of this study is to review any evidence-based blood conserving technique, dividing them in three stages: preoperative, intraoperative and postoperative.

Factors associated with blood loss in ankylosing spondylitis patients with hip involvement undergoing primary total hip arthroplasty: a cross-sectional retrospective study of 243 patients

Background

Total hip arthroplasty (THA) can cause considerable blood loss and perioperative transfusion in ankylosing spondylitis (AS) patients. This study aimed to identify the factors related to blood loss in AS patients with hip involvement undergoing THA.

Methods

We analyzed 243 AS patients with advanced hip involvement undergoing primary THA from 2012 to 2017. Bilateral THA was performed by a one-stage operation during one general anesthesia session. The patients were divided into three groups according to the grade of blood loss, as determined by the Advanced Trauma Life Support hypovolemic shock classification system. Ordinal logistic regression was used to identify factors associated with blood loss in the patients.

Results

The proportion of patients who were male, underwent bilateral THA, had a hip range of motion (ROM) = 0°, had a BASRI-hip score of 4, underwent iliopsoas and adductor release, and underwent autologous or allogenic transfusion increased significantly with the grade of blood loss, while that of the patients who received tranexamic acid (TXA) decreased significantly (P < 0.05). The preoperative hemoglobin (Hb) level, hematocrit level, and operating time also increased significantly with the grade of blood loss (P < 0.05). The ordinal logistic regression results identified the factors related to blood loss during THA in AS patients with hip involvement to be the male sex (odds ratio [OR] = 3.287; 95% confidence interval [CI] 1.022, 10.567), bilateral THA (OR = 13.896; 95% CI 4.950, 39.011), hip ROM = 0° (OR = 2.513; 95% CI 1.277, 4.946), an elevated erythrocyte sedimentation rate (ESR) level (OR = 3.042; 95% CI 1.320, 7.014), an elevated preoperative Hb level (OR = 1.043; 95% CI 1.017, 1.070), a long operating time (OR = 1.009; 95% CI 1.003, 1.016), and the administration of TXA (OR = 0.252; 95% CI 0.134, 0.472).

Conclusions

The male sex, bilateral THA, a hip ROM = 0°, an elevated ESR level, a high preoperative Hb level, and a long operating time are risk factors associated with blood loss in AS patients with hip involvement undergoing THA, while the administration of TXA is a protective factor. These results might help determine the risk of bleeding in the perioperative assessment and develop more efficient blood management strategies for THA in AS patients with hip involvement.

Comparison of oral versus intravenous tranexamic acid in total knee and hip arthroplasty: A GRADE analysis and meta-analysis

BACKGROUND

The efficacy and safety of oral tranexamic acid (TXA) remain controversial because of the small number of clinical studies. The aim of the present study was to compare the efficacy and safety of oral TXA with intravenous TXA in patients undergoing total hip arthroplasty and total knee arthroplasty in a systematic review and meta-analysis.

METHODS

We conducted a meta-analysis to identify randomized controlled trials (RCTs) involving oral and intravenous TXA in total hip arthroplasty and total knee arthroplasty up to December 2019 by searching databases including PubMed, Web of Science, Embase, the Cochrane Controlled Trials Register, the Cochrane Library China Biology Medicine, China National Knowledge Infrastructure, China Science and Technology Journal Database and Wanfang. The mean difference or standard mean difference was used to assess continuous outcomes such as hemoglobin (Hb) drop, total blood loss, drain blood loss, and length of hospital stay, with a 95% confidence interval. Relative risks with a 95% confidence interval were used to assess dichotomous outcomes such as transfusion rate and the incidence of deep venous thrombosis and calf muscular vein thrombosis. Review Manager was used for the meta-analysis.

RESULTS

Ten RCTs containing 1080 participants met the inclusion criteria. We found no significant differences in terms of the average Hb drop (P = .60), total blood loss (P = .60), transfusion rate (P = .99), drain blood loss (P = .91), length of hospital stay (P = .95), and the incidence of deep venous thrombosis (P = .55) and calf muscular vein thrombosis (P = .19) between oral and IV TXA.

CONCLUSIONS

Compared with the IV TXA, oral TXA has similar effects on reducing the Hb drop, total blood loss, transfusion rate, drain blood loss, and length of hospital stay without increasing the risk of calf muscular vein thrombosis and deep venous thrombosis. Furthermore, oral TXA is easy to access and administer, which decreases the workload of nurses and even delivers cost-saving benefits to the health care system. We thus conclude that oral TXA may be an optimal approach in total joint arthroplasty. However, more high-quality and multicenter RCTs are still needed to confirm our conclusions.

REGISTRATION

The current meta-analysis was registered on PROSPERO (International Prospective Register of Systematic Reviews), and the registration number was CRD42018111291.

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

Introduction/purpose

The purpose of this systematic review was to evaluate the effect of iron supplementation during total knee arthroplasty (TKA): (1) Is the iron supplementation necessary during TKA? (2) When is the optimal timing of iron supplementation? (3) Which is better, between orally and intravenously administered iron supplementation? And (4) What is the optimal dose of iron supplementation?

Materials and methods

A rigorous and systematic approach was used and each of the selected studies was evaluated for methodological quality. Data about study design, total number of cases enrolled, iron administration method, timing, and dose were extracted. Change in hemoglobin and transfusion rates were extracted to evaluate the effectiveness of iron supplementation.

Results

Eleven studies were included in the final analysis. Most of studies reported that hemoglobin change between iron and control group did not show any difference. Only one study reported that iron supplementation could reduce the decrease in hemoglobin. However, transfusion rate showed a decrease in the iron supplementation group compared with the control group. There was no clear consensus on the optimum timing and dose of iron supplementation and intravenously administered iron was more effective than orally administered iron, especially in anemic patients.

Conclusion

Iron supplementation is not clear as a way to raise hemoglobin levels after TKA, but an effective treatment for lowering transfusion rate, especially in patients with anemia. We could not determine the optimal timing and dose of the iron. Intravenously administered iron was similar to, or better than, orally administered iron for improving hemoglobin levels and transfusion rate.