Hidden blood loss and its risk factors after hip hemiarthroplasty for displaced femoral neck fractures: a cross-sectional study

Use of an Artificial Intelligence Device for Evaluating Blood Loss in Complex Major Orthopaedic Surgery Procedures

BACKGROUND

An artificial intelligence algorithm that analyzes the pulse oximeter waveform in the fingertip can be used to determine the compensatory reserve index (CRI) in trauma patients. This measurement shows the remaining cardiovascular capacity and is known to be more specific and sensitive in detecting blood loss than are routine vital signs. We hypothesized that the CRI measurement could predict loss of reserve cardiovascular capacity in patients undergoing major orthopaedic surgery, and therefore could help in their management.

METHODS

A total of 304 patients undergoing lower extremity arthroplasty consented to participate in waveform monitoring. Pulse oximeter waveforms were sensed with a fingertip probe and processed with a tablet computer that remained with the patient during surgery and recovery in the hospital. The CRI, systolic blood pressure, and heart rate were evaluated throughout the postoperative period.

RESULTS

The CRI measurement identified a group of patients who were significantly more likely to require transfusions and emergency medical care (P = .000021). Patients who had morbid obesity were especially likely to have low CRI results and a high percentage of clinical events. A CRI of 0.40 or more was evaluated retrospectively as the criterion for withholding transfusion in 54 patients, but that group had a significantly higher incidence of transfusion later in treatment than did the cohort as a whole. The systolic blood pressure and heart rate were not useful in predicting the need for transfusion until late in treatment.

CONCLUSIONS

This study suggests that the CRI measurement can identify patients at risk for transfusion and the need for urgent medical care and may aid in the management of blood loss and transfusion in major orthopedic surgery.

Hidden blood loss and its risk factors after hip reconstruction in children

OBJECTIVE

There were few reports in the literature regarding hidden blood loss following surgery for developmental dysplasia of the hip in children. This study aimed to evaluate the volume of hidden blood loss and its risk factors among children undergoing hip reconstruction for developmental dysplasia of the hip.

METHODS

A retrospective analysis of clinical data from 42 patients (58 hips), who underwent Pemberton and femoral osteotomies between March 2020 and March 2023, was conducted. Serial complete blood count assays were conducted on the day of admission and four days post-surgery. Preoperative and postoperative hematocrit levels were documented to calculate hidden blood loss utilizing the Gross formula. Pearson and Spearman correlation analyses, along with multivariable linear regression, were employed to ascertain associations between patient characteristics and hidden blood loss.

RESULTS

The mean hidden blood loss was recorded as 283.06 ± 271.05 mL, constituting 70.22% of the total blood loss. Multiple linear regression analysis identified weight and surgical duration as independent risk factors contributing to hidden blood loss.

CONCLUSIONS

A relevant amount of postoperative hidden blood loss occurs after Pemberton osteotomy and femoral osteotomy for developmental dysplasia of the hip. Surgeons should be aware that patients who require blood transfusions and have longer surgical durations are at a higher risk of developing more hidden blood loss. Therefore, attention should be given to hidden blood loss to ensure patient safety during the perioperative period for those undergoing Pemberton and femoral osteotomies.

LEVEL OF EVIDENCE

IV.

Establishment and validation of a nomogram to predict postoperative anemia after total hip arthroplasty

BACKGROUND

Anemia is a common complication of total hip arthroplasty (THA). In this study, we evaluated the preoperative risk factors for postoperative anemia after THA and developed a nomogram model based on related preoperative and intraoperative factors.

METHODS

From January 2020 to May 2023, 927 THA patients at the same medical center were randomly assigned to either the training or validation cohort. The correlation between preoperative and intraoperative risk factors and postoperative anemia after THA was evaluated using univariate and multivariate logistic regression analysis. A nomogram was developed using these predictive variables. The effectiveness and validation for the clinical application of this nomogram were evaluated using the concordance index (C-index), receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis (DCA).

RESULTS

Through univariate and multivariate logistic regression analysis, 7 independent predictive factors were identified in the training cohort: Lower body mass index (BMI), extended operation time, greater intraoperative bleeding, lower preoperative hemoglobin level, abnormally high preoperative serum amyloid A (SAA) level, history of cerebrovascular disease, and history of osteoporosis. The C-index of the model was 0.871, while the AUC indices for the training and validation cohorts were 84.4% and 87.1%, respectively. In addition, the calibration curves of both cohorts showed excellent consistency between the observed and predicted probabilities. The DCA curves of the training and validation cohorts were high, indicating the high clinical applicability of the model.

CONCLUSIONS

Lower BMI, extended operation time, increased intraoperative bleeding, reduced preoperative hemoglobin level, elevated preoperative SAA level, history of cerebrovascular disease, and history of osteoporosis were seven independent preoperative risk factors associated with postoperative anemia after THA. The nomogram developed could aid in predicting postoperative anemia, facilitating advanced preparation, and enhancing blood management. Furthermore, the nomogram could assist clinicians in identifying patients most at risk for postoperative anemia.

Social determinants of health in patients undergoing hemiarthroplasty: are they associated with medical complications, healthcare utilization, and payments for care?

INTRODUCTION

Social determinants of health (SDOH) have previously been shown to impact orthopedic surgery outcomes. This study assessed whether greater socioeconomic disadvantage in patients undergoing hemiarthroplasty following femoral neck fracture was associated with differences in (1) medical complications, (2) emergency department (ED) utilization, (3) readmission rates, and (4) payments for care.

METHODS

A US nationwide database was queried for hemiarthroplasties performed between 2010 and 2020. Area Deprivation Index (ADI), a validated measure of socioeconomic disadvantage reported on a scale of 0-100, was used to compare two cohorts of greater and lesser deprivation. Patients undergoing hemiarthroplasty from high ADI (95% +) were 1:1 propensity score matched to a comparison group of lower ADI (0-94%) while controlling for age, sex, and Elixhauser Comorbidity Index. This yielded 75,650 patients evenly distributed between the two cohorts. Outcomes studied were 90-day medical complications, ED utilizations, readmissions, and payments for care. Multivariate logistic regression models were utilized to calculate odds ratios (ORs) of the relationship between ADI and outcomes. p Values < 0.05 were significant.

RESULTS

Patients of high ADI developed greater medical complications (46.74% vs. 44.97%; OR 1.05, p = 0.002), including surgical site infections (1.19% vs. 1.00%; OR 1.20, p = 0.011), cerebrovascular accidents (1.64% vs. 1.41%; OR 1.16, p = 0.012), and respiratory failures (2.27% vs. 2.02%; OR 1.13, p = 0.017) compared to patients from lower ADIs. Although comparable rates of ED visits (2.92% vs. 2.86%; OR 1.02, p = 0.579), patients from higher ADI were readmitted at diminished rates (10.57% vs. 11.06%; OR 0.95, p = 0.027). Payments were significantly higher on the day of surgery ($7,570 vs. $5,974, p < 0.0001), as well as within 90 days after surgery ($12,700 vs. $10,462, p < 0.0001).

CONCLUSIONS

Socioeconomically disadvantaged patients experience increased 90-day medical complications and payments, similar ED utilizations, and decreased readmissions. These findings can be used to inform healthcare providers to minimize disparities in care.

LEVEL OF EVIDENCE

III.

[Efficacy and safety of multiple-dose intravenous tranexamic acid for reducing blood loss in complex tibial plateau fractures: A prospective randomized controlled trial]

Objective

To investigate the efficacy and safety of multiple-dose intravenous tranexamic acid (TXA) for reducing blood loss in complex tibial plateau fractures with open reduction internal fixation by a prospective randomized controlled trial.

Methods

A study was conducted on patients with Schatzker type Ⅳ-Ⅵ tibial plateau fractures admitted between August 2020 and December 2022. Among them, 88 patients met the selection criteria and were included in the study. They were randomly allocated into 3 groups, the control group (28 cases), single-dose TXA group (31 cases), and multiple-dose TXA group (29 cases), using a random number table method. There was no significant difference ( P>0.05) in terms of age, gender, body mass index, the Schatzker type and side of fracture, laboratory examinations [hemoglobin (Hb), activated partial thromboplastin time (APTT), prothrombin time (PT), fibrinogen (Fib), international normalized ratio (INR), D-dimer, and interleukin 6 (IL-6)], and preoperative blood volume. The control group received intravenous infusion of 100 mL saline at 15 minutes before operation and 3, 6, and 24 hours after the first administration. The single-dose TXA group received intravenous infusion of 1 g TXA (dissolved in 100 mL saline) at 15 minutes before operation, followed by an equal amount of saline at each time point after the first administration. The multiple-dose TXA group received intravenous infusion of 1 g TXA (dissolved in 100 mL saline) at each time point. The relevant indicators were recorded and compared between groups to evaluate the effectiveness and safety of TXA, including hospital stays, operation time, occurrence of infection; the occurrence of lower extremity deep vein thrombosis, intermuscular vein thrombosis, and pulmonary embolism at 1 week after operation; the lowest postoperative Hb value and Hb reduction rate, the difference (change value) between pre- and post-operative APTT, PT, Fib, and INR; D-dimer and IL-6 at 24 and 72 hours after operation; total blood loss, intraoperative blood loss, hidden blood loss, drainage flow during 48 hours after operation, and postoperative blood transfusion.

Results

① TXA efficacy evaluation: the lowest Hb value in the control group was significantly lower than that in the other two groups ( P<0.05), and there was no significant difference between the single- and multiple-dose TXA groups ( P>0.05). The Hb reduction rate, total blood loss, intraoperative blood loss, drainage flow during 48 hours after operation, and hidden blood loss showed a gradual decrease trend in the control group, single-dose TXA group, and multiple-dose TXA group. And differences were significant ( P<0.05) in the Hb reduction rate and drainage flow during 48 hours after operation between groups, and the total blood loss and hidden blood loss between control group and other two groups. ② TXA safety evaluation: no lower extremity deep vein thrombosis or pulmonary embolism occurred in the three groups after operation, but 3, 4, and 2 cases of intermuscular vein thrombosis occurred in the control group, single-dose TXA group, and multiple-dose TXA group, respectively, and the differences in the incidences between groups were not significant ( P>0.05). There was no significant difference in the operation time between groups ( P>0.05). But the length of hospital stay was significantly longer in the control group than in the other groups ( P<0.05); there was no significant difference between the single- and multiple-dose TXA groups ( P>0.05). ③ Effect of TXA on blood coagulation and inflammatory response: the incisions of the 3 groups healed by first intention, and no infections occurred. The differences in the changes of APTT, PT, Fib, and INR between groups were not significant ( P>0.05). The D-dimer and IL-6 in the three groups showed a trend of first increasing and then decreasing over time, and there was a significant difference between different time points in the three groups ( P<0.05). At 24 and 72 hours after operation, there was no significant difference in D-dimer between groups ( P>0.05), while there was a significant difference in IL-6 between groups ( P<0.05).

Conclusion

Multiple intravenous applications of TXA can reduce perioperative blood loss and shorten hospital stays in patients undergoing open reduction and internal fixation of complex tibial plateau fractures, provide additional fibrinolysis control and ameliorate postoperative inflammatory response.

Influencing factors of hidden blood loss after primary total hip arthroplasty through the posterior approach: a retrospective study

BACKGROUND

Total hip arthroplasty (THA) is an excellent treatment for the end-stage hip disease, and perioperative blood management strategies have been effectively applied to this procedure. However, many patients still experience anemia after the operation, which is usually overlooked by orthopedic surgeons due to the hidden blood loss (HBL) in the perioperative period. Therefore, the objective of this study was to evaluate HBL in patients undergoing primary THA using the posterior approach and to explore its influencing factors.

METHODS

A retrospective analysis of 707 patients who underwent primary THA through the posterior approach was conducted in our hospital from January 2020 to January 2022. By applying Gross's and Nadler's formula, the HBL was calculated. Six quantitative variables (age, body mass index, surgical duration, albumin loss, preoperative hemoglobin, and hemoglobin loss) as well as four qualitative variables (gender, American Society of Anesthesiologists class, major preoperative diagnosis, and hypertension) of patients were analyzed using multivariate linear regression.

RESULTS

The HBL was recorded at 700.39 ± 368.59 mL. As a result of multivariate linear regression analysis, it was determined that body mass index, surgical duration, and hemoglobin loss were all significant risk factors for HBL, whereas preoperative hemoglobin was considered a protective factor. It has been demonstrated that HBL is not significantly correlated with age, albumin loss, gender, ASA class, or major preoperative diagnosis, but it also did not differ from HBL by hypertension.

CONCLUSIONS

Hidden blood Loss (HBL) in patients after primary total hip arthroplasty (THA) using the posterior approach is large and significant. When optimizing the perioperative management of THA, orthopedic surgeons should keep in mind HBL and its influencing factors, especially for patients with high body mass indexes, long surgical durations, and low preoperative hemoglobin levels.

TRIAL REGISTRATION

This study was registered in the Chinese Clinical Trial Registry (ChiCTR2100053888) in 02/12/2021, http://www.chictr.org.cn .

Pharmacological interventions for the prevention of bleeding in people undergoing definitive fixation or joint replacement for hip, pelvic and long bone fractures

BACKGROUND

Pelvic, hip, and long bone fractures can result in significant bleeding at the time of injury, with further blood loss if they are treated with surgical fixation. People undergoing surgery are therefore at risk of requiring a blood transfusion and may be at risk of peri-operative anaemia. Pharmacological interventions for blood conservation may reduce the risk of requiring an allogeneic blood transfusion and associated complications.

OBJECTIVES

To assess the effectiveness of different pharmacological interventions for reducing blood loss in definitive surgical fixation of the hip, pelvic, and long bones.

SEARCH METHODS

We used a predefined search strategy to search CENTRAL, MEDLINE, PubMed, Embase, CINAHL, Transfusion Evidence Library, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform (ICTRP) from inception to 7 April 2022, without restrictions on language, year, or publication status. We handsearched reference lists of included trials to identify further relevant trials. We contacted authors of ongoing trials to acquire any unpublished data.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of people who underwent trauma (non-elective) surgery for definitive fixation of hip, pelvic, and long bone (pelvis, tibia, femur, humerus, radius, ulna and clavicle) fractures only. There were no restrictions on gender, ethnicity, or age. We excluded planned (elective) procedures (e.g. scheduled total hip arthroplasty), and studies published since 2010 that had not been prospectively registered. Eligible interventions included: antifibrinolytics (tranexamic acid, aprotinin, epsilon-aminocaproic acid), desmopressin, factor VIIa and XIII, fibrinogen, fibrin sealants, and non-fibrin sealants.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial eligibility and risk of bias, and extracted data. We assessed the certainty of the evidence using GRADE. We did not perform a network meta-analysis due to lack of data.

MAIN RESULTS

We included 13 RCTs (929 participants), published between 2005 and 2021. Three trials did not report any of our predefined outcomes and so were not included in quantitative analyses (all were tranexamic acid versus placebo). We identified three comparisons of interest: intravenous tranexamic acid versus placebo; topical tranexamic acid versus placebo; and recombinant factor VIIa versus placebo. We rated the certainty of evidence as very low to low across all outcomes. Comparison 1. Intravenous tranexamic acid versus placebo Intravenous tranexamic acid compared to placebo may reduce the risk of requiring an allogeneic blood transfusion up to 30 days (RR 0.48, 95% CI 0.34 to 0.69; 6 RCTs, 457 participants; low-certainty evidence) and may result in little to no difference in all-cause mortality (Peto odds ratio (Peto OR) 0.38, 95% CI 0.05 to 2.77; 2 RCTs, 147 participants; low-certainty evidence).  It may result in little to no difference in risk of participants experiencing myocardial infarction (risk difference (RD) 0.00, 95% CI -0.03 to 0.03; 2 RCTs, 199 participants; low-certainty evidence), and cerebrovascular accident/stroke (RD 0.00, 95% CI -0.02 to 0.02; 3 RCTs, 324 participants; low-certainty evidence).  We are uncertain if there is a difference between groups for risk of deep vein thrombosis (Peto OR 2.15, 95% CI 0.22 to 21.35; 4 RCTs, 329 participants, very low-certainty evidence), pulmonary embolism (Peto OR 1.08, 95% CI 0.07 to 17.66; 4 RCTs, 329 participants; very low-certainty evidence), and suspected serious drug reactions (RD 0.00, 95% CI -0.03 to 0.03; 2 RCTs, 185 participants; very low-certainty evidence). No data were available for number of red blood cell units transfused, reoperation, or acute transfusion reaction. We downgraded the certainty of the evidence for imprecision (wide confidence intervals around the estimate and small sample size, particularly for rare events), and risk of bias (unclear or high risk methods of blinding and allocation concealment in the assessment of subjective measures), and upgraded the evidence for transfusion requirement for a large effect.  Comparison 2. Topical tranexamic acid versus placebo We are uncertain if there is a difference between topical tranexamic acid and placebo for risk of requiring an allogeneic blood transfusion (RR 0.31, 95% CI 0.08 to 1.22; 2 RCTs, 101 participants), all-cause mortality (RD 0.00, 95% CI -0.10 to 0.10; 1 RCT, 36 participants), risk of participants experiencing myocardial infarction (Peto OR 0.15, 95% CI 0.00 to 7.62; 1 RCT, 36 participants), cerebrovascular accident/stroke (RD 0.00, 95% CI -0.06 to 0.06; 1 RCT, 65 participants); and deep vein thrombosis (Peto OR 1.11, 95% CI 0.07 to 17.77; 2 RCTs, 101 participants).  All outcomes reported were very low-certainty evidence. No data were available for number of red blood cell units transfused, reoperation, incidence of pulmonary embolism, acute transfusion reaction, or suspected serious drug reactions. We downgraded the certainty of the evidence for imprecision (wide confidence intervals around the estimate and small sample size, particularly for rare events), inconsistency (moderate heterogeneity), and risk of bias (unclear or high risk methods of blinding and allocation concealment in the assessment of subjective measures, and high risk of attrition and reporting biases in one trial). Comparison 3. Recombinant factor VIIa versus placebo   Only one RCT of 48 participants reported data for recombinant factor VIIa versus placebo, so we have not presented the results here.

AUTHORS' CONCLUSIONS

We cannot draw conclusions from the current evidence due to lack of data. Most published studies included in our analyses assessed the use of tranexamic acid (compared to placebo, or using different routes of administration).  We identified 27 prospectively registered ongoing RCTs (total target recruitment of 4177 participants by end of 2023). The ongoing trials create six new comparisons: tranexamic acid (tablet + injection) versus placebo; intravenous tranexamic acid versus oral tranexamic acid; topical tranexamic acid versus oral tranexamic acid; different intravenous tranexamic acid dosing regimes; topical tranexamic acid versus topical fibrin glue; and fibrinogen (injection) versus placebo.

Anticoagulants and fracture morphology have a significant influence on total blood loss after proximal femur fractures

INTRODUCTION

Blood loss after proximal femoral fractures is an important risk factor for postoperative outcome and recovery. The purpose of our study was to investigate the total blood loss depending on fracture type and additional risks, such as anticoagulant use, to be able to recognize vulnerable patients depending on planned surgery and underlying comorbidities.

MATERIALS AND METHODS

A retrospective single center study including 1478 patients treated operatively for a proximal femoral fracture between January 2016 and June 2020 at a level I trauma center. Patient data, surgical procedure, time to surgery, complications and mortality were assessed. Lab data including hemoglobin and transfusion rates were collected. The Mercuriali formula was implemented to calculate total blood loss. Linear regression was performed to identify influencing factors.

RESULTS

One thousand four hundred seventy-eight mainly female patients were included in the study (mean age: 79.8 years) comprising 667 femoral neck fractures, 704 pertrochanteric- and 107 subtrochanteric fractures. Nearly 50% of the cohort were on anticoagulants or anti- platelet therapy. At time of admission average hemoglobin was 12.1 g/l. Linear regression proved fracture morphology, age, BMI, in-house mortality and anticoagulant use to have crucial influence on postoperative blood loss. Femoral neck fractures had a blood loss of 1227.5 ml (SD 740.4 ml), pertrochanteric fractures lost 1,474.2 ml (SD 830 ml) and subtrochanteric femoral fractures lost 1902.2 ml (SD 1,058 ml).

CONCLUSIONS

Hidden blood loss is underestimated. Anticoagulant use, fracture type, gender and BMI influence the total blood loss. Hemoglobin levels should be monitored closely. Within 48 h there was no increased mortality, so adequate time should be given to reduce anticoagulant levels and safely perform surgery.

Combination effect of intraoperative and postoperative intravenous tranexamic acid in hip hemiarthroplasty. A propensity score matched analysis

BACKGROUND

Tranexamic acid (TXA) has been proven to reduce perioperative blood loss and the incidence of allogeneic blood transfusion in total joint arthroplasty (TJA). However, there is limited literature on the use of TXA in patients undergoing hip hemiarthroplasty. Furthermore, combination effect of intraoperative and postoperative intravenous TXA has not been investigated extensively. The purpose of this study was to evaluate this combination effect on hip hemiarthroplasty by a propensity score matched analysis (PSMA).

METHODS

This is a retrospective cohort study involving hip hemiarthroplasty for femoral neck fracture. All patients received 1g intraoperative intravenous TXA. One group also received 1g intravenous TXA 6h after surgery, while the other group did not. Perioperative blood loss, the incidence of allogeneic blood transfusion and venous thromboembolism (VTE) were collected and compared.

RESULTS

209 patients who underwent unilateral hip hemiarthroplasty were included. PSMA resulted in 66 matched pairs in each group. There were no significant differences in perioperative blood loss on postoperative day (POD) # 1, 3, 5 (637.2 ± 285.9 versus 653.6 ± 305.5, 726.6 ± 274.2 versus 676.3 ± 313.2, 795.5 ± 291.2 versus 759.9 ± 328.4), the incidence of allogeneic blood transfusion (9.1% versus 12.1%) and VTE (1.5% versus 1.5%) between the two groups (P value> 05) for up to one year.

CONCLUSION

Intraoperative and postoperative intravenous TXA have no combination effect on reducing perioperative blood loss, the incidence of allogeneic blood transfusion and VTE in patients undergoing hip hemiarthroplasty.

Methods of Quantifying Intraoperative Blood Loss in Orthopaedic Trauma Surgery: A Systematic Review

OBJECTIVES

To collect and present the recently published methods of quantifying blood loss (BL) in orthopaedic trauma.

DATA SOURCES

A systematic review of English-language literature in PubMed, Cochrane Library, and Scopus databases was conducted according to the PRISMA guidelines on articles describing the methods of determining BL in orthopaedic trauma published since 2010.

STUDY SELECTION

English, full-text, peer-reviewed articles documenting intraoperative BL in an adult patient population undergoing orthopaedic trauma surgery were eligible for inclusion.

DATA EXTRACTION

Two authors independently extracted data from the included studies. Articles were assessed for quality and risk of bias using the Cochrane Collaboration's tool for assessing risk of bias and ROBINS-I.

DATA SYNTHESIS

The included studies proved to be heterogeneous in nature with insufficient data to make data pooling and analysis feasible.

CONCLUSIONS

Eleven methods were identified: 6 unique formulas with multiple variations, changes in hemoglobin and hematocrit levels, measured suction volume and weighed surgical gauze, transfusion quantification, cell salvage volumes, and hematoma evacuation frequency. Formulas included those of Gross, Mercuriali, Lisander, Sehat, Foss, and Stahl, with Gross being the most common (25%). All formulas used blood volume estimation, determined by equations from Nadler (94%) or Moore (6%), and measure change in preoperative and postoperative blood counts. This systematic review highlights the variability in BL estimation methods published in current orthopaedic trauma literature. Methods of quantifying BL should be taken into consideration when designing and evaluating research.

Risk factors analysis and nomogram construction for blood transfusion in elderly patients with femoral neck fractures undergoing hemiarthroplasty

INTRODUCTION

Elderly patients with femoral neck fractures (FNFs) undergoing hemiarthroplasty usually have poor physical condition. The main aim of this study was to identify risk factors for blood transfusion in these patients and construct a nomogram to intuitively predict the requirement of transfusion. The secondary purpose was to examine the relationship between blood transfusion and complications within 30 days post-operatively. Our hypothesis was that chronic kidney disease (CKD) and hypoalbuminemia may increase the requirement of transfusion.

METHODS

Data of 414 elderly patients undergoing hemiarthroplasty for FNFs were retrospectively collected. Univariate and multiple regression analysis were performed to identify independent risk factors for blood transfusion, which were used to construct a nomogram subsequently. The discrimination and calibration of the nomogram model were assessed with concordance index (C-index), the area under receiver operating characteristic curve (AUC), and calibration curve. Furthermore, the complications of blood transfusion within 30 days post-operatively were also analyzed.

RESULTS

Out of 414 patients, 127 (30.7%) received a blood transfusion. Independent risk factors for blood transfusion included CKD, hypoalbuminemia, pre-operative anaemia, general anaesthesia, higher American Society of Anesthesiologists score, more intraoperative blood loss, and longer surgical time. Increased hidden blood loss, deep vein thrombosis, superficial wound infection, and prolonged hospital stays were more common in transfused patients. The C-index of the nomogram model was 0.848 (95% CI = 0.811-0.885), and the AUC value was 0.859. The calibration curve showed a good consistency between the actual transfusion and the predicted probability.

DISCUSSION

We observed a transfusion rate of 30.7% in elderly FNF patients undergoing hemiarthroplasty. CKD and hypoalbuminemia were firstly identified as independent risk for blood transfusion. In addition, blood transfusion can increase the occurrence of early post-operative complications.

CONCLUSION

Targeted pre-operative intervention, such as optimizing CKD and correcting hypoalbuminemia is essential and highly regarded.

Low serum calcium is associated with perioperative blood loss and transfusion rate in elderly patients with hip fracture: a retrospective study

Background

To investigate whether hypocalcemia influenced total blood loss and transfusion rate in elderly patients with hip fracture.

Methods

From our hip fracture database, patients were consecutively included between January 2014 and December 2020. Serum calcium level was corrected for albumin concentration, and hypocalcaemia was defined as corrected calcium < 2.11 mmol/L. Hemoglobin and hematocrit were obtained on admission day and postoperative day, and blood transfusions were collected. According to the combination formulas of Nadler and Gross, the total blood loss of each patient was calculated. Risk factors were further analyzed by multivariate linear regression.

Results

A total of 583 consecutive elderly hip fracture patients were finally included (mean age 79.32 ± 8.18 years, 68.61% female). On admission, the mean serum corrected calcium level was 2.17 ± 0.14 mmol/L, and the prevalence of hypocalcemia was 33.11% (95% CI: 29.42–37.02). When comparing patients with normal calcium, hypocalcemia patients exhibited a higher blood transfusion rate (7.69% vs 16.06%, P < 0.05), and significantly larger total blood loss (607.86 ± 497.07 ml vs 719.18 ± 569.98 ml, P < 0.05). Multivariate linear regression analysis showed that male, anemia on admission, time from injury to hospital, intertrochanteric fracture, blood transfusion and hypocalcemia were independently associated with increased total blood loss (P < 0.05).

Conclusion

Hypocalcemia is common in elderly patients with hip fracture, and significantly associated with more total blood loss and blood transfusion. The other risk factors for increased total blood loss are male, anemia on admission, time from injury to hospital, intertrochanteric fracture, and blood transfusion.

Level of evidence

Level III, retrospective study.

"Damage Control" Fixation of Displaced Femoral Neck Fractures in High-Risk Elderly Patients: A Feasibility Case Series

OBJECTIVES

To assess the outcomes of patients who underwent closed reduction and percutaneous pinning (CRPP) with cannulated screws for treatment of a displaced femoral neck fracture (DFNF) as they were deemed too high risk to undergo hemiarthroplasty (HA).

DESIGN

Prospective cohort study.

SETTING

One urban academic medical center.

PATIENTS/PARTICIPANTS

Sixteen patients treated with CRPP and 32 risk-level-matched patients treated with HA.

INTERVENTION

CRPP for patients with DFNFs who were deemed too ill to undergo HA. The concept being that CRPP would aid in pain control and facilitate mobilization and if failed, the patient could return electively after medical optimization for conversion to arthroplasty.

MAIN OUTCOME MEASUREMENTS

Complications, readmissions, mortality, inpatient cost, and functional status.

RESULTS

The CRPP cohort had a greater incidence of exacerbations of chronic medical conditions or new onset of acute illness and an elevated mean American Society of Anesthesiologist score. There were no differences in discharge location, length of stay, major complication rate, ambulation before discharge, or 90-day readmission rate. Patients undergoing CRPP were less likely to experience minor complications including a significantly decreased incidence of acute blood loss anemia. Three patients (18.7%) in the CRPP cohort underwent conversion to HA or THA. There was no difference in inpatient, 30-day, or 1-year mortality.

CONCLUSION

In the acutely ill patients with DFNFs, "damage control" fixation with CRPP can be safely performed in lieu of HA to stabilize the fracture in those unable to tolerate anesthesia or the sequelae of major surgery. Patients should be followed closely to evaluate the need for secondary surgery.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of Levels of Evidence.

Association between admission serum calcium and hemoglobin in older patients with hip fracture: a cross-sectional study

PURPOSE

Serum calcium ion is an essential cofactor in the coagulation cascade, and low calcium concentration is associated with more bleeding in many diseases. This study aimed to describe the prevalence of hypocalcaemia, and investigate the correlation between calcium and hemoglobin (Hb) level in older patients with hip fracture.

METHODS

From our established hip fracture database, patients were consecutively included between January 2014 and December 2020. Serum calcium concentration was corrected for albumin level, and hypocalcaemia was defined as corrected calcium below the lower limit of reference range (< 2.11 mmol/L), and further sub-grouped into mild hypocalcaemia (1.90-2.11 mmol/L) and severe hypocalcaemia (< 1.90 mmol/L). Pearson correlation, scatter plots and partial correlation analyses were performed to evaluate the associations between various factors and Hb level.

RESULTS

A total of 1032 older patients with hip fracture were finally included (mean age 79.2 years, 66.0% female). At admission, the mean serum corrected calcium and Hb levels were 2.14 mmol/L and 11.0 g/dL. Overall, the prevalence of hypocalcaemia and anemia were 39.5% and 71.6%, respectively. After adjusting for all variables, low serum calcium concentration was positively associated with low Hb level in the total study (partial correlation r = 0.13, P < 0.001), as well as in patients with femur neck fracture (partial correlation r = 0.16, P = 0.001) and intertrochanteric fracture (partial correlation r = 0.13, P = 0.003).

CONCLUSION

Hypocalcaemia was common in older patients with hip fracture, and independently and positively associated with low Hb level. Further study on causal relationship between calcium and Hb level in older patients with hip fracture is necessary.

The efficacy of intravenous tranexamic acid administration at induction in definitive hip fracture surgery: Is there a role?

Tranexamic acid (TXA) is a cheap and powerful drug that has several uses in surgery and is well established in elective orthopaedic surgery. At present, limited small studies have looked into its role in the acute hip fracture. Transfusion in the geriatric population presents risks and increased costs to healthcare systems around the world. Our retrospective study looks at the role of TXA administration at induction for both intracapsular fracture requiring hemiarthroplasty and our preferred method of fixation of extracapsular fracture by intramedullary nail (IM nail). We show a statistically significant reduction in the number of patients requiring transfusion as well as mean haemoglobin (Hb) drop in those undergoing hemiarthroplasty. This was not replicated in those undergoing IM nail fixation. Both groups showed no increase in 1-year mortality or thromboembolic events following TXA administration. These results support the use of TXA for hemiarthroplasty for intracapsular hip fractures over the age of 60.

OBJECTIVES

The aim of this pre and post interventional study looks at the effects of intravenous administration of tranexamic acid on induction for elderly patients undergoing hemiarthroplasty or intramedullary nail fixation for hip fractures.

DESIGN

Pre and post interventional, randomised observational study SETTING: Large hip fracture unit, Level 2 Trauma Centre, single centre PATIENTS: Two arms of the study looking at those aged above the age of 60 undergoing hemiarthroplasty and intramedullary nail fixation without and with tranexamic acid on induction.

RESULTS

12.1% of hemiarthroplasties required post-operative transfusion without tranexamic acid compared to 2.6% of those with tranexamic acid (n=15 vs n=3 respectively, p=0.006). Equally, the mean Hb drop in g/L is reduced in those with tranexamic acid compared to those without (mean Hb = 14.6 vs 17.7 respectively, p=0.034). This was not replicated in the IM nail group between those without and those with tranexamic acid (n=31 vs n=20 respectively, p= 0.16). The mean Hb drop in g/L was not statistically significant in the tranexamic acid arm compared to without (mean Hb = 19.2 vs mean Hb = 21.9, p=0.11). Gross reporting of thromboembolic events did not demonstrate an increase in the number of those with DVT, PE, MI or stroke. 1-year mortality was not statistically significant in either hemiarthroplasty or IM nail fixation following tranexamic acid administration.

CONCLUSIONS

Tranexamic acid both statistically significantly reduces the number of patients requiring transfusion post hemiarthroplasty and also the value of mean Hb drop without appearing to increase in thromboembolic events or 1 year mortality rates. This does not appear to be emulated in the IM nail fixation although both thrombotic events and 1-year mortality rates are also not affected by administration of TXA. We propose that TXA has a role in hemiarthroplasty surgery in reducing post-operative transfusions.

LEVEL OF EVIDENCE

Level 3 - retrospective cohort study.

Does patient positioning influence blood loss and transfusion rate in hip replacement for femoral neck fractures? A single-centre, retrospective chart review

Background

We compared blood loss and transfusion frequency between the lateral decubitus and the supine position in patients undergoing hip replacement surgery due to femoral neck fractures.

Methods

We retrospectively included femoral neck fracture patients treated with either hemi (HA) or total hip arthroplasty (THA). We included a total of 626 patients, of which 313 patients underwent surgery in the lateral decubitus position and 313 patients in the supine position. Preoperative and day 1 postoperative blood measures including hemoglobin (Hb), hematocrit (Hct), and red blood cell count (RBC) were evaluated, as well as transfusion records analyzed.

Results

The following decrease of laboratory parameters between pre- and 1st day postoperative measures was noted: RBC: -0.77 G/L (± 0.5 G/L, median = -0.80 G/L; range: -0.50 – -1.10 G/L); Hct: -7.08 % (± 4.7 %, range: -4.70 – -9.90 G/L); Hb: -2.36 g/dL (± 1.6 g/dL, range: -1.50. – -3.40 g/dL). We did not observe significant differences in transfusion frequency between the two study cohorts (p = 0.735 for THA, p = 0.273 for HA). No influence of patient positioning on Hb-decrease, Hct-decrease, or RBC-decrease was noted in our two-way ANOVA models with consideration of implant type and fixation technique (F(3,618) = 1.838, p = 0.139; F(3,618) = 2.606, p = 0.051; F(3,618) = 1.407, p = 0.240).

Conclusions

We did not observe  significant differences in perioperative blood values and transfusion rates in association with patient positioning in patients undergoing hip replacement surgery for femoral neck fractures.

Level of evidence

Level III, retrospective cohort study.

Perioperative Hidden Blood Loss in Elderly Cervical Spondylosis Patients With Anterior Cervical Discectomy Fusion and Influencing Factors

Introduction:

To analyze the perioperative hidden blood loss (HBL) and its influencing factors in elderly cervical spondylosis patients treated with anterior cervical discectomy fusion (ACDF).

Materials and Methods:

From January 2017 to December 2018, 128 elderly cervical spondylosis patients (age > 65 y) treated with ACDF were selected. The patients’ height, weight, duration of symptoms, previous medical history and other basic information were routinely recorded. The hemoglobin (Hb), hematocrit (Hct) and blood coagulation function preoperative and the next day postoperative were recorded. The operation time, surgical bleeding, ASA classification, fixation method, total drainage and the time for extraction of drainage tube were recorded. The total blood loss (TBL) was calculated according to the Gross’s formula, and HBL was calculated based on TBL, total drainage and surgical bleeding. The statistical analysis of HBL was performed, and then influential factors were further analyzed by multivariate linear regression analysis and t test.

Results:

The mean surgical bleeding was 102.70 ± 46.78 mL and HBL was 487.98 ± 255.96 mL. HBL accounted for 67.61 ± 5.20% of TBL. According to the multiple linear regression analysis, the gender (P = 0.047), operation time (P = 0.000), fixation method (P = 0.014) and international normalized ratio (INR) (P = 0.003) influenced the amount of HBL. Body mass index (BMI) (P = 0.624), hypertension (P = 0.977), diabetes (P = 0.528), blood type (P = 0.577), ASA classification (P = 0.711), duration of symptoms (P = 0.661), preoperative cobb angle (P = 0.152), number of surgical level (P = 0.709), intramedullary hyperintensity (P = 0.967), drainage time (P = 0.294), postoperative drainage volume (P = 0.599), prothrombin time (PT) (P = 0.674), activated partial thromboplastin time (APTT) (P = 0.544) and thrombin time (TT) (P = 0.680) had no correlation with the amount of HBL.

Conclusions:

There was obvious HBL during the perioperative period of ACDF in elderly cervical spondylosis patients. The male patients, longer operation time, fusion with titanium plate and cage and high INR were independent risk factors for HBL.

Orthogeriatric Management: Improvements in Outcomes during Hospital Admission Due to Hip Fracture

Hip fractures are an important socio-economic problem in western countries. Over the past 60 years orthogeriatric care has improved the management of older patients admitted to hospital after suffering hip fractures. Quality of care in orthogeriatric co-management units has increased, reducing adverse events during acute admission, length of stay, both in-hospital and mid-term mortality, as well as healthcare and social costs. Nevertheless, a large number of areas of controversy regarding the clinical management of older adults admitted due to hip fracture remain to be clarified. This narrative review, centered in the last 5 years, combined the search terms "hip fracture", "geriatric assessment", "second hip fracture", "surgery", "perioperative management" and "orthogeriatric care", in order to summarise the state of the art of some questions such as the optimum analgesic protocol, the best approach for treating anemia, the surgical options recommendable for each type of fracture and the efficiency of orthogeriatric co-management and functional recovery.

An analysis of perioperative hidden blood loss in femoral intertrochanteric fractures: bone density is an important influencing factor

Background

To explore the influencing factors of perioperative hidden blood loss in intertrochanteric fractures.

Method

We undertook a retrospective analysis from January 2016 to October 2019. Clinical data of 118 patients with intertrochanteric fractures were included. Hidden blood loss was calculated from the haematocrit changes before and after surgery using the Gross equation based on height, weight, and haematocrit (HCT) changes before and after surgery. Patients’ gender, age, presence of underlying diseases, fracture types, anaesthesia methods, time from injury to surgery, administration of antiplatelet drugs within 6 months before surgery, use of anticoagulant drugs after surgery, and bone density were statistically analysed. Factors having an effect on hidden blood loss were screened out. Then, hidden blood loss was used as the dependent variable, and each influencing factor was used in turn as the independent variable. Multivariate linear regression analysis was employed to analyse the related risk factors that affect hidden blood loss during the perioperative period of patients with intertrochanteric fractures.

Result

The apparent blood loss during the operation was 203.81 ±105. 51 ml, and the hidden blood loss was 517.55±191.47 ml. There were significant differences in the hidden blood loss of patients with different fracture types (stable vs unstable), anaesthesia methods (general anaesthesia vs intraspinal anaesthesia), antiplatelet or postoperative anticoagulant drugs, and bone densities (P< 0.05). 05). Multiple linear regression analysis showed that internal fixation, age, fracture type, anaesthesia method, anticoagulant application, and bone density were related risk factors that affected hidden blood loss during the surgical treatment of intertrochanteric fractures.

Conclusion

Hidden blood loss is the main cause of perioperative blood loss in intertrochanteric fractures, and the risk factors for hidden blood loss include internal fixation, fracture type (e.g., unstable), anaesthesia (e.g., intraspinal), and use of anticoagulant drugs. Specifically, we found that low bone density was a risk factor for hidden blood loss. It is not reliable to use apparent blood loss as the basis for fluid replacement and transfusion. We must fully consider the existence of hidden blood loss and intervene as soon as possible to prevent complications.

Level of evidence

III

Comparison of the effectiveness and safety of intravenous and topical regimens of tranexamic acid in complex tibial plateau fracture: a retrospective study

Background

Previous studies have demonstrated the effectiveness and safety of tranexamic acid (TXA) in orthopedic surgery. However, no study has investigated TXA in complex tibial plateau fracture surgery. Therefore, the purpose of this study was to confirm the safety and effectiveness of i.v. (intravenous) TXA and topical TXA.

Material and methods

This was a retrospective analysis of prospectively collected data. The control group received an equal amount of placebo (physiological saline solution); the i.v. group received 1.0 g TXA by intravenous injection before the tourniquet was inflated and before the surgical incision was closed, and the topical group received 3.0 g TXA in 75 mL of physiological saline solution 5 min prior to the final tourniquet release. Perioperative blood loss, vascular events, wound complications, and adverse reactions were compared among the three groups. The pain, knee function, and quality of life (QoL) assessments were based on their corresponding scoring systems.

Results

Baseline data were comparable for all groups. The i.v. group showed the best results for total blood loss (TBL) and hidden blood loss (HBL) (424.5 ± 49.4 mL and 219.3 ± 33.4 mL, respectively, all P values < 0.001). Patients in the i.v. group had lesser real Hb decrease than those in the control group (0.9 vs 1.5, P<0.001) and topical group (0.9 vs 1.2, P = 0.026). The blood coagulation level as measured using fibrinolysis (D-dimer) was lower in the i.v. group than in the control and topical groups on POD1 and POD3; however, this difference was not significant; the fibrin-degradation products also showed a similar trend. Patients in the topical group experienced less pain than those in the control group on POD2, POD4, and PO6W. The VAS pain score was 3.6 vs. 4.4 (POD2, P<0.05), 2.8 vs 3.3 (POD4, P<0.05), and 2.1 vs. 2.6 (PO6W, P<0.001) in the topical group vs control group, respectively. No significant differences were identified in vascular events, wound complications, adverse reactions, knee function, and QoL among the three groups.

Conclusion

To our knowledge, this is the first study that showed both i.v. TXA and topical TXA are safe and effective for complex tibial plateau fractures. The i.v. regimen effectively reduced blood loss during the perioperative period, whereas patients under the topical regimen had less vascular events, wound complications, and a lower incidence of adverse reactions compared to those in the i.v. group.

Trial registration

The trial was registered in the Chinese Clinical Trial Registry (ChiCTR-TRC-1800017754, retrospectively registered from 2018 to 01-01).

Incidence, Risk Factors, and Nomogram of Transfusion and Associated Complications in Nonfracture Patients following Total Hip Arthroplasty

The incidence, risk factors, and associated complications of perioperative transfusion in nonfracture patients following total hip arthroplasty (THA) are unclear. The aim of the present research was to study the predictors of transfusion risk in nonfracture patients following THA and develop a nomogram. One thousand six hundred and thirty-five patients who underwent THA due to nonfracture disease in our institution between September 2013 and July 2017 were included. Independent predictors of transfusion were identified by univariate, LASSO, and multivariate analyses. A nomogram was established based on independent predictors. In addition, a prospective cohort was used to validate the nomogram. The area under the receiver operating characteristic curve was utilized to evaluate the discrimination of the nomogram. Calibration and decision curve analyses were established to evaluate the nomogram. In addition, the association between perioperative transfusion and 30- and 90-day complications was studied. The incidence of transfusion was 15.78%, and 10 independent predictors were confirmed. The areas under the curve of the nomogram were 0.834 and 0.867 in the training and validation cohorts, respectively. Moreover, the area under the curve of the nomogram was significantly higher than that of any single predictor in both the training and validation cohorts. Calibration curve and decision curve analyses in both the training and validation cohorts showed good performance of the nomogram. In addition, perioperative transfusion was identified as an independent risk factor for both 30- and 90-day complications. Generally, ten transfusion-related factors for nonfracture patients following THA were identified. A validated nomogram was established, and several adverse events were confirmed to be associated with transfusion.

Analysis of hidden blood loss and its influential factors in myomectomy

OBJECTIVE

This study was performed to quantify hidden blood loss (HBL) and explore its influential factors in myomectomy.

METHODS

Two hundred nine patients who underwent myomectomy by laparotomy or laparoscopy from 1 January 2017 to 31 December 2018 were analyzed. Each patient's estimated blood volume and total blood loss (TBL) were calculated by the Nadler formula and Gross formula, respectively. The HBL was calculated by subtracting the visible blood loss (VBL) from the TBL. A multivariate linear stepwise analysis was applied to identify the influential factors of HBL in myomectomy.

RESULTS

The mean perioperative VBL and estimated TBL during myomectomy were 137.81 ±104.43 and 492.24 ± 225.00 mL, respectively. The mean HBL was 354.39 ± 177.69 mL, which accounted for 71.52% ± 15.75% of the TBL and was two to three times higher than the VBL. The duration of surgery, number of removed leiomyomas, and location of removed leiomyomas were independent risk factors for HBL in myomectomy.

CONCLUSIONS

HBL accounted for a significant percentage of TBL in myomectomy. A full understanding of the HBL in perioperative blood management may improve patients' postoperative rehabilitation.

Does perioperative use of tranexamic acid in hip fracture patients increase the risk of venous thromboembolism and reduce the need for postoperative transfusions?

Perioperative tranexamic acid use is a popular choice among many surgeons for reducing surgical blood loss and its sequelae. While there is evidence in the literature that tranexamic acid use is effective in reducing blood loss in surgery for patients with hip fractures, there is less information on whether it leads to thromboembolic complications. We undertook a retrospective study in patients with hip fractures at two local hospitals to investigate if there was an increased risk of venous thromboembolism in patients who received tranexamic acid, and whether it reduced perioperative blood loss and the need for transfusion. We found that tranexamic acid used in patients undergoing hip fracture surgery reduced the drop in postoperative haemoglobin and the need for postoperative blood transfusion but was not associated with an increased risk of venous thromboembolism.

Supercapsular percutaneously-assisted total hip (SuperPath) versus posterolateral total hip arthroplasty in bilateral osteonecrosis of the femoral head: a pilot clinical trial

Background

The supercapsular percutaneously-assisted total hip arthroplasty (SuperPath) was proposed to be minimally invasive and tissue sparing with possible superior postoperative outcomes to traditional approaches of total hip arthroplasty (THA). Here, we compared the short-term outcomes of staged THA with the SuperPath or through posterolateral approach (PLA) for bilateral osteonecrosis of the femoral head (ONFH).

Methods

Patients with bilateral late-stage ONFH were prospectively recruited from our department from March 2017 to March 2018. Staged bilateral THAs with one side SuperPath and the other side PLA were performed consecutively in the same patients with right and left hips alternating within approaches. The average time interval between the staged THAs was 3 months. Perioperative status (operation time, incision length, intraoperative blood loss, soft tissue damage, and length of hospital stay) and postoperative function (range of motion, pain, and hip function) were recorded and compared between the SuperPath and PLA approaches within 12-month postoperatively.

Results

Four male patients (age, 51.00 ± 4.54; BMI, 21.49 ± 1.73) with bilateral alcohol-induced ONFH (Ficat III/IV) were followed up over 12 months postoperatively. Compared with the PLA, the SuperPath yielded shorter incision length (7.62 vs. 11.12 cm), longer operation time (103.25 vs. 66.50 min), more blood loss (1108.50 vs. 843.50 ml), deficient abduction angle of the acetabular cup (38.75° vs. 44.50°), and inferior early-term hip function (Harris hip score, 72.50 vs. 83.25) at 12-month postoperatively. Soft tissue damage, length of hospital stay, postoperative pain, postoperative range of motion, and 12-month patient satisfaction were comparable between both approaches.

Conclusion

The SuperPath may be a minimally invasive technique but the present study shows less favorable short-term outcomes than PLA for total hip arthroplasty in osteonecrosis of the femoral head. More investigations are required to provide convincing favorable evidences of the SuperPath over other traditional THA approaches.

Trial registration information

The trial was retrospectively registered in https://www.researchregistry.com (No. Researchregistry4993) on July 04, 2019. The first participant was enrolled on March 13, 2017.

Hidden blood loss after hip hemiarthroplasty using the superPATH approach: A retrospective study

OBJECTIVE

The purpose of this study was to compare perioperative hidden blood loss after hip hemiarthroplasty via the SuperPATH approach and the conventional posterior approach (the Moore approach).

PATIENTS AND METHODS

From January 2015 to January 2017, 130 patients (80.7 ± 6.0 years) with displaced femoral neck fracture (Garden type III or IV) undergoing hip hemiarthroplasty were included in this study. As a non-randomisation study, Fifty-two patients (SuperPATH group) were operated using the SuperPATH approach, and 78 patients (Moore group) were operated with the conventional posterior approach (Moore approach). The demographic and relevant clinical information of the patients were collected. According to the combination formulas of Nadler, Gross and Sehat, the hidden blood loss (HBL) of each patient was calculated. Student's t-test for independent samples was used to compare the normally distributed variables and the Mann-Whitney U test was used to compare variables not following a normal distribution.

RESULTS

The visible blood loss (VBL) in the SuperPATH group was 123.7 ± 47.5 ml, the hidden blood loss (HBL) was 1084.1 ± 816.8 ml and the HBL% was 82.7 ± 16.5%. In the Moore group, the VBL was 303.6 ± 139.6 ml, the HBL was 700.2 ± 563.8 ml and the HBL% was 61.5 ± 23.8%. The patients in the SuperPATH group had more HBL and HBL% (P < 0.05). However, no significant difference was observed of total blood loss (TBL) between the two groups (P = 0.125).

CONCLUSIONS

HBL should not be ignored in patients who underwent hip hemiarthroplasty for displaced femoral neck fractures, as it is a significant portion of TBL. Compared with the conventional approach, the SuperPATH approach had a greater amount of HBL. A better understanding of HBL after hip hemiarthroplasty may help surgeons improve clinical assessment and ensure patient safety.