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Transfusions and blood loss in total hip and knee arthroplasty: A prospective observational study

Authors:
  • Inst. of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden

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Background There is a high prevalence of blood product transfusions in orthopedic surgery. The reported prevalence of red blood cell transfusions in unselected patients undergoing hip or knee replacement varies between 21% and 70%. We determined current blood loss and transfusion prevalence in total hip and knee arthroplasty when tranexamic acid was used as a routine prophylaxis, and further investigated potential predictors for excessive blood loss and transfusion requirement. Methods/materials In total, 193 consecutive patients undergoing unilateral hip (n = 114) or knee arthroplasty (n = 79) were included in a prospective observational study. Estimated perioperative blood loss was calculated and transfusions of allogeneic blood products registered and related to patient characteristics and perioperative variables. Results Overall transfusion rate was 16% (18% in hip patients and 11% in knee patients, p = 0.19). Median estimated blood loss was significantly higher in hip patients (984 vs 789 mL, p < 0.001). Preoperative hemoglobin concentration was the only independent predictor of red blood cell transfusion in hip patients while low hemoglobin concentration, body mass index, and operation time were independent predictors for red blood cell transfusion in knee patients. Conclusions The prevalence of red blood cell transfusion was lower than previously reported in unselected total hip or knee arthroplasty patients. Routine use of tranexamic acid may have contributed. Low preoperative hemoglobin levels, low body mass index, and long operation increase the risk for red blood cell transfusion.
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... Orthopaedic surgeries, specifically total joint arthroplasty, can lead to excessive bleeding and thus high transfusion rates [52][53][54]. In 2015, it was reported that the prevalence of blood transfusions for THA cases varied widely from 20-71% and the estimated blood loss following THA was almost 1000 mL [52,[55][56][57]. ...
... Orthopaedic surgeries, specifically total joint arthroplasty, can lead to excessive bleeding and thus high transfusion rates [52][53][54]. In 2015, it was reported that the prevalence of blood transfusions for THA cases varied widely from 20-71% and the estimated blood loss following THA was almost 1000 mL [52,[55][56][57]. It is widely accepted that blood transfusions are associated with risks of acute transfusion reactions, haemolysis, transfusion-related acute lung injury, graft vs. host, and transfusion-transmitted infections [58]. ...
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Purpose Concerns persist that trainee participation in surgical procedures may compromise patient care and potentiate adverse events and costs. We aimed to analyse the potential impact and consequences of surgical trainee involvement in total hip arthroplasty (THA) procedures in terms of surgical efficacy, patient safety, and functional outcomes. Methods We systematically reviewed Medline/PubMed, EMBASE, the Cochrane library, and Scopus databases in October 2021. Eligible studies reported a direct comparison between THA cases performed with and without trainee involvement. Results Eighteen publications met our eligibility criteria and were included in our study. The included studies reported on 142,450 THAs completed on 142,417 patients. Specifically, 48,155 and 94,295 surgeries were completed with and without trainee involvement, respectively. The mean operative times for procedures with (n = 5,662) and without (n = 14,763) trainee involvement were 106.20 and 91.41 min, respectively. Mean overall complication rates were 6.43% and 5.93% for THAs performed with (n = 4842) and without (n = 12,731) trainees. Lastly, the mean Harris Hip Scores (HHS) for THAs performed with (n = 442) and without (n = 750) trainee participation were 89.61 and 86.97, respectively. Conclusion Our systematic review confirmed previous studies’ reports of increased operative time for THA cases with trainee involvement. However, based on the overall similar complication rates and functional hip scores obtained, patients should be reassured concerning the relative safety of trainee involvement in THA. Future prospective studies with higher levels of evidence are still needed to reinforce the existing evidence.
... Our study also reported lower estimated blood loss compared to TKA and longer operative time compared to conventional UKA and TKA. We found our blood loss to 3 Applied Bionics and Biomechanics be minimal and much less in comparison to commonly accepted numbers for perioperative blood loss in TKA of 0.5 L to 1.5 L [35,36]. This is concurrent with other studies and is due to the less invasive nature of the surgery [37]. ...
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Purpose: While unicompartmental knee arthroplasty (UKA) has demonstrated benefits over total knee arthroplasty (TKA) in selected populations, component placement continues to be challenging with conventional surgical instruments, resulting in higher early failure rates. Robotic-arm-assisted UKA (RA-UKA) has shown to be successful in component positioning through preop planning and intraop adjustability. The purpose of this study is to assess the 5-year clinical outcomes of medial RA-UKA. Methods: This study was a retrospective review of a single-center prospectively maintained cohort of 133 patients (146 knees) indicated for medial UKA from 2009 to 2013. Perioperative data and 2- and 5-year Knee injury Osteoarthritis Outcome Score (KOOS), Western Ontario and McMaster Universities Osteoarthritis Score (WOMAC), and Forgotten Joint Score (FJS) outcome measures were collected. Five-year follow-up was recorded in 119 patients (131 knees). Results: Mean follow-up was 5.1 ± 0.2 years. Mean age and BMI were 68.0 ± 8.1 years and 29.3 ± 4.7 kg/m2, respectively. At 2-year follow-up, mean KOOS, WOMAC, and FJS were 71.5 ± 15.3, 14.3 ± 7.9, and 79.1 ± 25.8, respectively. At 5-year follow-up, mean KOOS, WOMAC, and FJS were 71.6 ± 15.2, 14.2 ± 7.9, and 80.9 ± 25.1, respectively. Mean change in KOOS and WOMAC was 34.6 ± 21.4 and 11.0 ± 13.6, respectively (p < 0.001 and p < 0.001). For patient satisfaction at last follow-up, 89% of patients were very satisfied/satisfied and 5% were dissatisfied. For patient activity expectations at last follow-up, 85% met activity expectations, 52% were more active than before, 25% have the same level of activity, 23% were less active than before, and 89% were walking without support. All patients returned to driving after surgery at a mean 15.2 ± 9.4 days. Survivorship was 95% (95% CI 0.91-0.98) at 5 years. One knee (1%) had a patellofemoral revision, two knees (1.3%) were revised to different partial knee replacements, and five knees (3.4%) were converted to TKA. Conclusion: Overall, medial RA-UKA demonstrated improved patient-recorded outcomes, high patient satisfaction, met expectations, and excellent functional recovery. Midterm survivorship was excellent. Longitudinal follow-up is needed to evaluate long-term outcomes of robotic-arm-assisted UKA procedures.
... Despite the agreement for risk factors for blood transfusions in primary THA between the present machine learning study and prior retrospective work [21,36,37], there are differences in research findings with regards to the threshold for pre-operative hematocrit. The threshold for low pre-operative hematocrit (< 36%) as identified in this present machine learning study is higher than that of previous retrospective studies (< 30%). ...
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Background Despite advancements in total hip arthroplasty (THA) and the increased utilization of tranexamic acid, acute blood loss anemia necessitating allogeneic blood transfusion persists as a post-operative complication. The prevalence of allogeneic blood transfusion in primary THA has been reported to be as high as 9%. Therefore, this study aimed to develop and validate novel machine learning models for the prediction of transfusion rates following primary total hip arthroplasty. Methods A total of 7265 consecutive patients who underwent primary total hip arthroplasty were evaluated using a single tertiary referral institution database. Patient charts were manually reviewed to identify patient demographics and surgical variables that may be associated with transfusion rates. Four state-of-the-art machine learning algorithms were developed to predict transfusion rates following primary THA, and these models were assessed by discrimination, calibration, and decision curve analysis. Results The factors most significantly associated with transfusion rates include tranexamic acid usage, bleeding disorders, and pre-operative hematocrit (< 33%). The four machine learning models all achieved excellent performance across discrimination (AUC > 0.78), calibration, and decision curve analysis. Conclusion This study developed machine learning models for the prediction of patient-specific transfusion rates following primary total hip arthroplasty. The results represent a novel application of machine learning, and has the potential to improve outcomes and pre-operative planning. Level of evidence III, case–control retrospective analysis.
... However, blood loss during THA can be high, leading to the need for allogeneic blood transfusion (ABT). Traditionally, transfusion rates during THA have been reported to be up to 26%, with an average of 18% (2)(3)(4)(5). However, with increased attention to blood conservation and the use of tranexamic acid (TXA) the transfusion rate has dropped to around 10% (6)(7)(8). ...
Article
Background: Blood conservation and reduction in the need for allogeneic blood transfusion (ABT) has been a subject of importance in total hip arthroplasty. There are a number of well-recognized parameters that influence blood loss during total hip arthroplasty (THA). The role of surgical approach on blood loss and the rate of ABT during THA is not well studied. The hypothesis of this study was that blood loss and the need for ABT is lower with direct anterior (DA) approach. Methods: In a case-control retrospective cohort study, we analyzed 1,524 primary THAs performed at a single institution by seven fellowship-trained surgeons between January 2015 to March 2017. All patients received THA using either the modified direct lateral (DL) or direct anterior (DA) approach using a standard operating table. The overall ABT rate was 10.2% (155/1,524) in the cohort. Demographic, surgical, and postoperative data were extracted and analyzed. Logistic regression was used to identify independent risk factors for transfusion. Results: Higher preoperative hemoglobin (p<0.001), use of DA approach (p<0.016) and administration of tranexamic acid TXA, (p=0.024) were identified as independent factors which reduced the odds of ABT. Operative time (p<0.001) was associated with an increased odd of ABT, while age, BMI and type of anesthesia were not statistically significant. Conclusion: Based on the findings of this study, direct anterior approach for THA appears to be protective against blood loss and reduced ABT rate, when controlling for confounding variables.
... [4] In our series, the mean operative time (140 min) and mean intraoperative blood loss (1400 ml) are comparable with other studies. [5][6][7] The challenges encountered and possible solutions related to different complex hips of our series are discussed one by one. ...
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Background: Total hip arthroplasty (THA) surgery for complex primary hips are challenging not only for its technical difficulties but also for increased risk of complications, thus requiring detailed planning to ensure successful operation. This paper aims to present the pattern of complex primary hips presenting for total hip replacement and the challenges and complications. Materials and Methods: This was a retrospective study in which records of patients who had THA from 2015 to 2019 were analyzed for the demography, pattern of complex primary hip, and the surgical challenges and complications. Outcome of follow-up results was analyzed by clinical (Harris Hip Score) and radiological evaluation at 6 weeks, 3 months, and 2 years. Results: One hundred THAs were done during the study period, out of which 42 THAs in 29 patients (16 unilateral and 13 bilateral THAs) were of complex primary hip. Majority of them were of ankylosing spondylitis (38.1%) followed by posttraumatic avascular necrosis of femoral head (23.8%). The main difficulties were related to soft-tissue contracture, completely fused hip, and removal of hardware in old operated hip fracture. Postoperatively, majority of the patients had anemia (7 patients, 16.6%), followed by postoperative dislocation in 2 patients (4.7%). Outcome of follow-up results was analyzed by clinical (Harris Hip Score) and radiological evaluation at 6 weeks, 3 months, and 2 years, and the overall outcome was satisfactory in 95% of the patients. Conclusion: Complex THA is challenging and needs to assess properly and to be done meticulously. The surgical exposure and subsequent placement of components can be significant challenges in complex THA which can be tackled by using proper instrumentation and modular implants. With proper surgical technique, proper instrumentation, and proper implantation, one can expect good-to-excellent results even in complex THA.
... Some authors found that low pre-operative hemoglobin, long operative time, BMI more than 30, and general anesthesia were major predictors of blood transfusion needs after TKA. [40][41][42] TQ use was reported to be associated with a higher risk of developing VTE complications following TKA. [43] However, our results showed no difference in the incidence of thromboembolism complications with or without TQ use. ...
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Introduction 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 significant decreases in hemoglobin (Hgb), even if their Hgb is above restrictive transfusion thresholds. The purpose of this study is to determine whether the difference between preoperative and postoperative Hgb values (Delta) correlates with 90 day readmission in patients who did not receive perioperative transfusions. Methods A retrospective review of primary unilateral TJA between 2015 – 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 6,791 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% vs. 3.68%; p = 0.020). When constructing ROC curves, a cutoff value of 3.20 resulted in an AUC of 0.595 [0.486 - 0.704]. In patients with cardiovascular disease, a cutoff value of 3.10 resulted in an AUC of 0.626 [0.466 - 0.787]. Conclusion The magnitude of Hgb change is 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 greater physiologic reserve.
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Introduction:Main population of total knee arthroplasty are elderly group which contained of risks from procedure and medical condition. The amount of blood loss in TKA vary in different studies. Blood loss from TKA may cause the change of hemodynamic status, risked to cardiovascular morbidity or mortality. Allogenic blood transfusion, associated with many immunological and transfusion complications, increased cost of surgery. Factors associated with blood loss should controlled to decreased blood loss and complications. Objectives:Determination of risk factors for blood loss is a significant step toward blood management. This study is also used calculated blood loss, which more accurate than visible blood loss. Methods:Medical records of 517 patients who underwent TKA from 2011 to 2016 were examined, blood loss was calculated by Gross' formula. Pearson 's correlation and multiple regression analyses were performed to identify factors associated to blood loss. Results:The mean calculated blood loss decreased yearly from 602.94ml to 107.78ml in 2016. There is “zero” transfusion in 2016. Radivac drain, patellar resurfacing, modified Robert Jones bandage and higher postoperative pain score related to increased blood loss after TKA according to Pearson's correlation. Multiple regression analysis revealed significant independent predictors related to blood loss are radivac drain, intravenous tranexamic acid, postoperative pain score and body mass index. Conclusions :Awareness in low BMI patient, avoid radivac drain, routine using of intravenous tranexamic acid and good postoperative pain control can reduce blood loss and transfusion for a patient undergoing TKA.
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UPDATE The print version of this article has errors that have been corrected in the online version of this article. In the Materials and Methods section, the sentence that reads as "During the study period, our institution offered preoperative autologous blood donation to all patients who were scheduling for total joint arthroplasty with a hemoglobin level of no less than 11 mg/dL or a hematocrit level of at least 33%." in the print version now reads as "During the study period, our institution offered preoperative autologous blood donation to all patients who were scheduling for total joint arthroplasty with a hemoglobin level of no less than 11 g/dL or a hematocrit level of at least 33%." in the online version. In Table III, the footnote that reads as "The values are given as the estimate and the standard error in milligrams per deciliter." in the print version now reads as "The values are given as the estimate and the standard error in grams per deciliter." in the online version. Despite advances in surgical and anesthetic techniques, lower-extremity total joint arthroplasty is associated with considerable perioperative blood loss. As predictors of perioperative blood loss and allogenic blood transfusion have not yet been well defined, the purpose of this study was to identify clinical predictors for perioperative blood loss and allogenic blood transfusion in patients undergoing total joint arthroplasty. From 2000 to 2008, all patients undergoing unilateral primary total hip or knee arthroplasty who met the inclusion criteria were enrolled in the study. Perioperative blood loss was calculated with use of a previously validated formula. The predictors of perioperative blood loss and allogenic blood transfusion were identified in a multivariate analysis. Eleven thousand three hundred and seventy-three patients who underwent total joint arthroplasty, including 4769 patients who underwent total knee arthroplasty and 6604 patients who underwent total hip arthroplasty, were evaluated. Multivariate analysis indicated that an increase in blood loss was associated with being male (263.59 mL in male patients who had undergone total hip arthroplasty and 233.60 mL in male patients who had undergone total knee arthroplasty), a Charlson Comorbidity Index of >3 (293.99 mL in patients who had undergone total hip arthroplasty and 167.96 mL in patients who had undergone total knee arthroplasty), and preoperative autologous blood donation (593.51 mL in patients who had undergone total hip arthroplasty and 592.30 mL in patients who had undergone total knee arthroplasty). In patients who underwent total hip arthroplasty, regional anesthesia compared with general anesthesia reduced the amount of blood loss. The risk of allogenic blood transfusion increased with the amount of blood loss in the patients who underwent total hip arthroplasty (odds ratio, 1.43 [95% confidence interval, 1.40 to 1.46]) and the patients who underwent total knee arthroplasty (odds ratio, 1.47 [95% confidence interval, 1.42 to 1.51]), but the risk of blood transfusion increased with the Charlson Comorbidity Index only in patients who underwent total knee arthroplasty (odds ratio, 3.2 [95% confidence interval, 1.99 to 5.15]). The risk of allogenic blood transfusion decreased with preoperative autologous blood donation in patients who underwent total hip arthroplasty (odds ratio, 0.01 [95% confidence interval, 0.01 to 0.02]) and patients who underwent total knee arthroplasty (odds ratio, 0.02 [95% confidence interval, 0.01 to 0.03]). This study identified some clinical predictors for blood loss in patients undergoing total joint arthroplasty that we believe can be used for implementing more effective blood conservation strategies. Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Despite attempts to minimize exposure to allogeneic blood, there are little data on recent nationwide trends in transfusion following total hip arthroplasty (THA) and no consensus on indications. The purpose of this study was to examine the rate, predictors, and inpatient outcomes associated with transfusion after primary THA. This retrospective cohort study analyzed the data collected from US Nationwide Inpatient Sample (NIS) for each year during the period 2005-2008 to assess the trends in transfusion in patients who underwent elective primary THA. Logistic regression models were used to evaluate the predictive risk factors for blood transfusion. The University Hospital Consortium (UHC) database was also queried to examine the variability in rates of transfusion at different academic medical centers. A total of 129,901 patients were identified in the NIS database. The transfusion rates following THA consistently increased from 18.12% in 2005 to 21.21% in 2008 (P<0.0001). Hospitals in the Northeast and Midwest region had the highest and lowest rates of transfusion, respectively. Significant risk factors for blood transfusion were female gender (odds ratio, OR 2.1), age above 85 (OR 2.9), African-American race (OR 1.7), Medicare payor status (OR 1.6), being at a hospital in the Northeast Region (OR 1.4), the presence of preoperative anemia (OR 1.6), having at least one comorbidity (OR 1.3), and a high Charlson Index score (OR 2.2). Patients receiving blood transfusions had increased in-hospital mortality, longer lengths of stay, and higher total charges compared to non-transfused patients (P<0.001). The UHC database demonstrated that transfusion rates vary widely across different institutions from <5% to >80%. The incidence of blood transfusion has recently increased following total hip arthroplasty and there is great variability in practice. We identified several patient risk factors along with the morbidity and mortality independently associated with transfusion following THA. Further work is needed to standardize the approach to blood conservation and minimize exposure to allogenic blood.
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PURPOSE: Several observational studies in head and neck cancer have reported that allogenic blood transfusion is associated with increased postoperative complications, increased risk of tumor recurrence, and worse prognosis. The aim of this study was to identify preoperative and intraoperative factors predicting blood transfusion in patients undergoing surgery for oral and oropharyngeal cancer. PATIENTS AND METHODS: We conducted a retrospective cohort study of patients undergoing tumor resection and free flap reconstruction for locally advanced oral and oropharyngeal squamous cell carcinoma between 2000 and 2008. The primary outcome variable was perioperative exposure to allogenic blood transfusion. Univariate and multivariate logistic regression models were used to determine predictors of blood transfusion. RESULTS: A cohort of 142 participants was found eligible. In a multivariate model, Charlson score ≥1 (OR, 5.2; 95% CI, 1.4 to 19.3; P = .01), preoperative hemoglobin levels ≤12 g/dl (OR, 4.4; 95% CI, 1.2 to 16.2; P = .03), bone resection (OR, 5.1; 95% CI, 1.5 to 17.8; P = .01), and osseous free tissue transfer (OR, 8.8; 95% CI, 1.0 to 74.8; P = .046) were independently associated with an increased risk of blood transfusion. CONCLUSION: Our study identified patient- and surgery-related factors predicting a higher risk of exposure to allogenic blood transfusion. This readily available preoperative information could be used to better stratify patients according to their transfusion risk and may thereby guide blood conservation strategies in high-risk patients.
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The efficacy of an integrated autotransfusion regimen, including pre-donation and perioperative salvage of autologous blood, was prospectively evaluated in 2884 patients undergoing total hip (n = 2016) or knee arthroplasty (n = 480), and hip revision (n = 388) with either balanced general, regional, or integrated epidural/general anaesthesia. Allogenic concentrated red blood cells were transfused in the presence of symptomatic anaemia or when haemoglobin concentration was < 6 g dL−1 (10 g dL−1 in patients affected by cerebrovascular or coronary artery disease) after all salvaged and pre-donated autologous blood had been transfused. A total of 278 patients (9.6%) received allogenic blood. Risk factors for allogenic blood transfusion were: preoperative haemoglobin concentration < 10 g dL−1 (after autologous blood pre-donations) (Odds ratio: 8.7; 95% CI: 6.5–16.8; P = 0.004), hip revision versus hip or knee arthroplasty (Odds ratio: 5.8; 95% CI: 3.9–8.5; P = 0.0001) and inability in obtaining the number of pre-donations required by the Maximum Surgery Blood Order on Schedule (Odds ratio: 3.4; 95% CI: 2.7–4.1; P = 0.0001). The incidence of perioperative complications, including wound infection and haematoma, as well as myocardial ischaemia, respiratory failure and thromboembolic complications, was higher in those patients requiring allogenic blood transfusion (29.8%) than that observed in patients receiving only autologous blood (6.6%) (P = 0.0005); while the mean time duration from surgical procedure to patient discharge from the orthopaedic ward was shorter in those patients not receiving allogenic blood transfusion (12 days; 25–75th percentiles: 8–14 days) than in those patients who required perioperative transfusion with allogenic blood (15 days; 25–75th percentiles: 10–17 days) (P = 0.0005). In conclusion, this prospective study highlighted the clinical relevance of applying an extensive and integrated autotransfusion regimen in order to reduce allogenic blood transfusion and associated complications in patients undergoing major joint replacement.