Computer navigation has no beneficial effect on blood loss and transfusion in sequential bilateral total knee Arthroplasty

BACKGROUND

Bilateral total knee arthroplasty is associated with significant blood loss. Postoperative anaemia retards patients recovery, and blood transfusion increases the risk for major complications including infection. While strategies like hypotensive anaesthesia, tranexamic acid, bone wax and so on are useful to conserve blood, navigation has also shown to decrease blood loss and transfusion in unilateral knee arthroplasty. The aim of this study was to compare the blood loss and transfusion in sequential bilateral knee arthroplasty performed with or without navigation.

MATERIALS AND METHODS

A retrospective case control cohort study of sequential bilateral knee arthroplasties was performed between 2 groups of 77 patients each, group N operated with navigation and group M operated without navigation. Both groups were matched for age, sex and body mass index. All patients were operated with similar surgical technique. The two cohorts were compared for blood loss calculated by three reliable methods.

RESULTS

The preoperative haemoglobin (Hb) in group N was 12.83 ± 1.32 and group M was 12.58 ± 1.33 ( p = 0.24). The postoperative Hb taken day 4 before any blood transfusions was 8.60 ± 1.24 in group N and 8.54 ± 1.16 in group M ( p = 0.75). The average fall in Hb was 4.23 ± 1.08 in group N and 4.04 ± 1.19 in group M ( p = 0.31). There was no difference in blood loss between group N and M in all three methods; Gross equation ( p = 0.56), Hb dilution ( p = 0.24) and Hb balance ( p = 0.20). Need for blood transfusion was similar in group N and M ( p = 0.56).

CONCLUSION

Blood loss and transfusion are equivalent in sequential bilateral total knee arthroplasty perform with or without navigation.

A prospective, randomized, comparative study of intravenous alone and combined intravenous and intraarticular administration of tranexamic acid in primary total knee replacement

Background

Studies on the use of tranexamic acid (TXA) to improve clinical outcomes after joint arthroplasty have reported contrasting results between intravenous (IV) TXA alone and combined IV and intraarticular (IA) administration. We compared the effectiveness of the 2 methods in providing higher postoperative hemoglobin (Hb) levels in patients undergoing primary total knee arthroplasty (TKA).

Methods

A total of 100 TKA patients were randomly assigned to receive either IV TXA alone (group 1) or combined IV and topical IA TXA (group 2). Hb and hematocrit levels were measured before and after surgery. The amount of drained blood and transfused blood for the 2 groups was compared.

Results

The Hb level was significantly higher at postoperative day 4, together with a positive, albeit not significant, trend toward less postoperative blood loss in the group that received combined IV and IA TXA. No postoperative infections or deep venous thrombosis events occurred.

Conclusions

This study reinforces evidence that, as compared to IV TXA alone, combined IV and IA administration of TXA has a synergic effect, leading to higher postoperative Hb levels without influencing drug safety in TKA patients.

Blood loss in trochanteric fractures: multivariate analysis comparing dynamic hip screw and Gamma nail

INTRODUCTION

Anaemia in patients with trochanteric fracture is associated with increased morbidity and mortality and it is an independent risk factor for functional mobility of patients. Several authors have reported the blood loss following operative treatment comparing different fixation systems but few authors have evaluated many associated variables that could influence the perioperative blood loss.

PURPOSE

To evaluate the blood loss in patients that had their trochanteric fracture stabilized with dynamic hip screw (DHS) or Gamma nail. Multivariate analysis of different variables that can influence blood loss was carried out (type of fracture, antiaggregant or anticoagulant therapy, time to surgery). The hypothesis was that there is no difference in terms of blood loss in patients with trochanteric fracture treated with DHS or Gamma nail considering all these variables.

MATERIALS & METHODS

Perioperative blood loss was evaluated in 417 consecutive patients treated for trochanteric fracture with DHS or Gamma nail between January 2010 and March 2013. The perioperative blood loss was calculated using the Lisander formula modified by Foss-Kehlet based on pre- and post-operative haemoglobin values and transfusion rates. Univariate and multivariate analysis were performed integrating the following variables: type of fracture (A1 vs A2), antiaggregant/anticoagulant therapy vs no therapy, time to surgery (<24 vs >24 hours from trauma), type of implant (DHS vs Gamma nail).

RESULTS

A significant blood loss (p <0.05) was observed between A1 and A2 fracture types (1247ml vs 1796.7ml), antiaggregant/anticoagulant therapy and no therapy (1592.7ml vs 1470.2ml), time-to-surgery <24 and >24 hours from trauma (1584.4ml vs 1323.9ml), DHS and Gamma nail (894.7ml vs 1720.6ml). At multivariate analysis, in the A1 fracture groups the DHS showed a significant lower blood loss compared to Gamma nail (p < 0.05).

CONCLUSIONS

According to the perioperative blood loss, DHS should be used in A1 fractures while Gamma nail can be taking in account for the unstable A2 fractures.

No Effect of a Bipolar Sealer on Total Blood Loss or Blood Transfusion in Nonseptic Revision Knee Arthroplasty-A Prospective Study With Matched Retrospective Controls

BACKGROUND

Postoperative anemia is frequent after revision of total knee arthroplasty (TKA) with reported transfusion rates up to 83%. Despite increased efforts of reducing blood loss and enhancing fast recovery within the fast-track setup, a considerable transfusion rate is still evident. The aim of this study was therefore to evaluate the effect of a bipolar sealer on blood loss and transfusion in revision TKA.

METHODS

In this single-center prospective cohort study with retrospective controls, 51 patients were enrolled in a fast-track setup for revision TKA without the use of a tourniquet. Twenty-five prospectively enrolled patients received treatment with both a bipolar sealer and electrocautery, whereas 26 patients had received treatment with a conventional electrocautery only in the retrospective group.

RESULTS

No significant differences were found neither for calculated blood loss, with 1397 (standard deviation, ± 452) mL in the bipolar sealer group vs 1452 (SD, ± 530) mL in the control group (P = .66), nor for blood transfusion rates of 53% and 46% (P = .89), respectively. Four controls were readmitted within 90 days follow-up.

CONCLUSION

The use of a bipolar sealer in a TKA revision setting without the use of a tourniquet did not reduce blood loss or blood transfusion rates.

Combined Intra-Articular and Intravenous Tranexamic Acid Reduces Blood Loss in Total Knee Arthroplasty: A Randomized, Double-Blind, Placebo-Controlled Trial

BACKGROUND

In total knee arthroplasty, both intravenous (IV) and intra-articular (IA) administration of tranexamic acid (TXA) have been shown to reduce blood loss in several randomized controlled trials, although routine use of systemic TXA is considerably more common. However, to our knowledge, the additional benefit of IA administration of TXA when combined with IV administration, without the use of a tourniquet, has not been previously investigated. Thus, the aim of this study was to evaluate whether combined IV and IA administration of TXA reduced total blood loss compared with IV-only administration of TXA.

METHODS

In this randomized, double-blind, placebo-controlled trial, 60 patients scheduled for total knee arthroplasty were randomized to one of two interventions. The TXA IV and IA group received combined administration of TXA consisting of 1 g administered intravenously preoperatively and 3 g diluted in 100 mL of saline solution administered intra-articularly after closure of the capsule. The TXA IV and placebo group received 1 g of TXA administered intravenously only and 100 mL of saline solution administered intra-articularly. IA TXA was administrated through a needle. The primary outcome was the 24-hour calculated blood loss. Secondary outcomes were blood loss on postoperative day 2, thromboembolic complications, and transfusion rate. Blood loss was calculated by hemoglobin differences using the Gross formula.

RESULTS

Data on the primary outcome were available for all 60 included patients. Baseline characteristics were comparable between the allocation groups. The mean 24-hour blood loss (and standard deviation) was 466 ± 313 mL in the TXA IV and IA group compared with 743 ± 358 mL in the TXA IV and placebo group; treatment effect (difference), 277 mL (95% confidence interval [CI], 103 to 451 mL) (p = 0.002). Second-day blood loss was 644 ± 382 mL in the TXA IV and IA group compared with 1017 ± 519 mL in the TXA IV and placebo group; treatment effect, 373 mL (95% CI, 132 to 614 mL) (p = 0.003). No thromboembolic complications were observed within 90 days postoperatively.

CONCLUSIONS

The combined administration of IV and IA TXA resulted in a clinically relevant reduction in blood loss of 37% compared with IV TXA alone both at 24 hours postoperatively and on postoperative day 2. No thromboembolic complications were observed.

LEVEL OF EVIDENCE

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

Tranexamic acid decreases external blood loss but not hidden blood loss in total knee replacement

BACKGROUND

Total knee arthroplasty (TKA) is often carried out using a tourniquet and shed blood is collected in drains. Tranexamic acid decreases the external blood loss. Some blood loss may be concealed, and the overall effect of tranexamic acid on the haemoglobin (Hb) balance is not known.

METHODS

Patients with osteoarthrosis had unilateral cemented TKA using spinal anaesthesia. In a double-blind fashion, they received either placebo (n=24) or tranexamic acid 10 mg kg(-1) (n=27) i.v. just before tourniquet release and 3 h later. The decrease in circulating Hb on the fifth day after surgery, after correction for Hb transfused, was used to calculate the loss of Hb in grams. This value was then expressed as ml of blood loss.

RESULTS

The groups had similar characteristics. The median volume of drainage fluid after placebo was 845 (interquartile range 523-990) ml and after tranexamic acid was 385 (331-586) ml (P<0.001). Placebo patients received 2 (0-2) units and tranexamic acid patients 0 (0-0) units of packed red cells (P<0.001). The estimated blood loss was 1426 (1135-1977) ml and 1045 (792-1292) ml, respectively (P<0.001). The hidden loss of blood (calculated as loss minus drainage volume) was 618 (330-1347) ml and 524 (330-9620) ml, respectively (P=0.41). Two patients in each group developed deep vein thrombosis.

CONCLUSIONS

Tranexamic acid decreased total blood loss by nearly 30%, drainage volume by approximately 50% and drastically reduced transfusion. However, concealed loss was only marginally influenced by tranexamic acid and was at least as large as the drainage volume.

Fever and autologous blood retransfusion after total knee arthroplasty: a prospective study of 40 autotransfusion events in 21 patients

The commonest adverse reaction of autotransfusion of drain blood is an increase in temperature, probably due to a cytokine-mediated inflammatory reaction. We recorded body temperature in 21 patients operated on with a total knee prosthesis prospectively during the first 18 postoperative hours. The patients had been given an autotransfusion of autologous filtered drain blood (40 events) within the first 8-9 hours. They all had hypothermia at the end of operation, with a continuous increase in temperature during the first 12 hours whereafter the temperature slowly fell. No additional increase in temperature was seen during the first 2 hours after an autologous retransfusion. Autotransfusion of filtered drain blood within the first 8 postoperative hours after arthroplasty thus did not seem to cause an additional increase in temperature above that due to spontaneous recovery after postoperative hypothermia and surgical trauma.

Increased interleukin-6 in collected drainage blood after total knee arthroplasty: an association with febrile reactions during retransfusion

We determined interleukin-6 (IL-6) concentrations in collected shed drainage blood intended for retransfusion in a prospective study in 81 patients after total knee replacement. We found large increases in IL-6 levels, averaging 6.5 (SD 3.9) ng/mL, in shed blood collected in the first 6 postoperative hours. 3 patients had febrile reactions after collected blood was retransfused. The IL-6 levels in the drainage blood of these patients were very high (9.6-13.4 ng/mL). In the blood collected after 6 hours, IL-6 concentrations increased to 47 (SD 33) ng/mL (p < 0.001). These results suggest a relation between increased interleukin-6 concentrations in shed drainage blood and the occurrence of febrile reactions after retransfusion of such blood.

Some characteristics of blood shed into the Solcotrans postoperative orthopaedic drainage/reinfusion system

OBJECTIVE

To assess the suitability of blood shed into the Solcotrans orthopaedic autotransfusion system as a source of autologous blood for transfusion.

DESIGN

Blood samples were taken from patients after surgery and from shed blood within the Solcotrans units.

SETTING

Surgery was performed at a public hospital.

PATIENTS

All six patients underwent total knee replacements.

MAIN OUTCOME MEASURES

Measurements were made of haemoglobin, haematocrit, platelets, pH, potassium, plasma haemoglobin, fibrinogen, D-dimer, plasminogen activator, thromboplastin and fibrinopeptide A. The non-activated partial thromboplastin time was estimated. Shed blood was compared with homologous whole blood to assess the thrombogenic potential of shed blood in vitro.

RESULTS

The haemoglobin and haematocrit levels of the shed blood were significantly lower than venous blood (P = 0.008). Levels of potassium in shed blood were normal although there was significant haemolysis. Shed blood was depleted of clotting factors, with increased levels of D-dimer (16-128 g/L). Activation of the coagulation pathway within the shed blood was shown by a shortened non-activated partial thromboplastin time (90-120 s), and detectable levels of thromboplastin. Propionibacterium acnes was isolated from one of the units.

CONCLUSION

Reinfusion of large volumes of shed blood should probably be avoided, but use of the Solcotrans orthopaedic transfusion system in conjunction with other autologous transfusion practices can reduce the patient's requirement for homologous blood.