Aims. The aim of this study was to perform a systematic review of the evidence for the use of intraoperative cell salvage in patients undergoing revision hip arthroplasty, and specifically to analyze the available data in order to quantify any associated reduction in the use of allogenic blood transfusion, and the volume which is used. Methods. An electronic search of MEDLINE (PubMed), Embase, Scopus, and the Cochrane Library was completed from the date of their inception to 24 February 2022, using a search strategy and protocol created in conjunction with the PRISMA statement. Inclusion criteria were patients aged > 18 years who underwent revision hip arthroplasty when cell salvage was used. Studies in which pre-donated red blood cells were used were excluded. A meta-analysis was also performed using a random effects model with significance set at p = 0.05. Results. Of the 283 studies which were identified, 11 were included in the systematic review, and nine in the meta-analysis. There was a significant difference (p < 0.001) in the proportion of patients requiring allogenic transfusion between groups, with an odds ratio of 0.331 (95% confidence interval (CI) 0.165 to 0.663) associated with the use of cell salvage. For a total of 561 patients undergoing revision hip arthroplasty who were treated with cell salvage, 247 (44.0%) required allogenic transfusion compared with 418 of 643 patients (65.0%) who were treated without cell salvage. For those treated with cell salvage, the mean volume of allogenic blood which was required was 1.95 units (390 ml) per patient (0.7 to 4.5 units), compared with 3.25 units (650 ml) per patient (1.2 to 7.0 units) in those treated without cell salvage. The mean difference of -1.91 units (95% CI -4.0 to 0.2) in the meta-analysis was also significant (p = 0.003). Conclusion. We found a a significant reduction in the need for allogenic blood transfusion when cell salvage was used in patients undergoing revision hip arthroplasty, supporting its routine use in these patients. Further research is required to determine whether this effect is associated with types of revision arthroplasty of differing complexity. Cite this article: Bone Joint J 2023;105-B(10):1038–1044

Background. One-stage bilateral total hip arthroplasty (THA) is twice as invasive as unilateral THA. Therefore, increases in bleeding, postoperative anemia, and complications are a concern. The purpose of this study was to investigate hemoglobin values and the use of autologous and allogenic blood transfusion after one-stage bilateral THA. Methods. Twenty-nine patients (7 men and 22 women; 58 hips) were treated with one-stage bilateral THA. The mean age of subjects at the time of surgery was 60.6 years. The average body mass index for patients was 21.7 kg/m. 2. The diagnoses were secondary osteoarthritis due to developmental dysplasia of the hip (n=25) and avascular necrosis (n=4). All patients had donated 800 ml of autologous blood in 2 stages preoperatively (1 to 4 weeks apart). All patients took iron supplements starting from 5 weeks preoperatively. For all patients, the procedure was performed under general anesthesia in the lateral decubitus position via a posterolateral approach. Intra-operative blood salvage was not used. Suction drains were inserted subfascially. As a general rule, pre-donated autologous blood was transfused back to the patients intra- or post-operatively. Allogenic blood transfusion was performed when clinical symptoms of anemia occurred (hypotension, low urinary output, tachycardia, etc.) rather than using a preset blood threshold (hemoglobin level <8 g/dl). To determine changes in blood pressure following surgery until the next morning, systolic and diastolic blood pressure were measured at 3-hr intervals. Results. The mean duration of surgery was 67.4 min for the procedure on the side that was operated on first, 32.7 min to change to the other side, and 68.4 min for the procedure on the other side. The mean blood loss was 576.1 ml. Hemoglobin values at baseline, at the time of autologous blood donation, and on the first day after surgery were 13.2, 12.7, and 8.7 g/dl respectively. Hemoglobin values were significantly different between the 2 weeks before surgery and the first day after surgery. Systolic and diastolic blood pressure were the lowest 3–6 hrs postoperatively (mean, 86/55). Blood reinfusion using autologous blood was performed for all patients. The allogenic blood transfusion rate was 25.0% (range, 2–8 units). In terms of complications, one patient developed an arrhythmia on postoperative day 5. This was the patient for whom autologous blood donation could not be performed due to pre-existing anemia. This patient also had right-sided sciatic nerve palsy. Discussion. With respect to one-stage bilateral THA, Gie showed that allogenic blood transfusion rate with or without autologous blood donation was 42% and 87% respectively. The allogenic blood transfusion rate was 25.0% in our study. Establishing a procedure to perform surgery in a shorter time period may further reduce the rate of allogenic blood transfusion. Although not used herein, intraoperative blood salvage may also be considered. Conclusions. In one-stage bilateral THA, autologous blood donation is effective in managing perioperative anemia and reducing the rate of allogenic blood transfusion. Perioperative blood management based on individual patients' situations are important for the safe performance of one-stage bilateral THA

Background. In the literature are different data about the allogenic blood transfusion rate after total knee replacement. The common intention in orthopedic surgery is to reduce the requirement for allogenic blood transfusions by optimizing the blood management. The aim of this study is to determine the efficacy of the mechanical autotransfusion system OrthoPAT® to reduce the postoperative allogenic blood transfusion (ABT) rate. Method. According to the preliminary performed power analysis we did a prospective controlled study including 151 patients which were randomized in a group A (OrthoPAT® for intra- and postoperative blood salvage and retransfusion, n=76 patients) and a control group B (no retransfusion system was used, n=75 patients). All patients had a primary osteoarthritis of the knee and were operated on without use of a tourniquet. We implanted in all patients a cemented posterior stabilized total knee prosthesis design. In group A the autotransfusion system was used for 6 hours (intra- and postoperatively) and the collected blood was retransfused. The retransfused blood was anticoagulated, filtered and centrifuged to separate waste products. Red cells were washed with saline and reconcentrated to a high hematocrit. The preoperative data for cardiopathy, angiopathy, preoperative anemia or anticoagulant treatment showed no significant differences for group A and B. Because of missing data we finally were able to use the results of 140 patients: 70 group A and 70 in group B. The indications for a blood transfusion were influenced by the clinical symptoms of anemia, the hemoglobin value (hemoglobin < 8.0 g/dl) and the anamnesis of cardiovascular diseases. Evaluation was done with the medical history and the pre-/postoperative hemoglobin values and postoperative need of allogenic blood transfusion. Results. The two groups showed no significant differences relating to the demographic data or the medical history. 23 patients (33 %) of the retransfusion group who in mean received 281 ml of salvaged blood needed allogenic blood transfusion compared with 23 patients (33 %) of the control group B (p=0,999). The hemoglobin values of group A versus the control group showed after the donation of the salvaged blood a tendency to a higher hemoglobin value (p=0,062) but no longer at the third and fifth day postoperative. Conclusions. In this clinical observation the use of the autotransfusion system does not reduce the postoperative allogenic blood transfusion rate. At the third and fifth day postoperatively no significant differences of the hemoglobin values could be stated comparing group A with group B

Background: Patients undergoing total knee arthroplasty (TKA) frequently require allogenic blood transfusion. The incidence of blood transfusion varies between 1.4 and 24.5% in the published literature. Purpose of the study: In order to determine the incidence of allogenic blood transfusion in patients undergoing primary TKA at our centre, we performed retrospective analysis of prospectively collected data for all patients who underwent TKA between 1 April 2006 and 31 March 2008. Material and Methods: 1488 eligible patients were categorized into two groups: those who underwent TKA in year 2006 (group I, n= 647) and in year 2007 (group II, n = 841), respectively. Patients with haematological diseases, coagulation disorders or with a known malignancy or infection were excluded. Data were collected for haemoglobin levels (pre-operative, postoperative and predischarge), duration of operation, ASA grade, number of transfusions, use of tranexamic acid and suction drains with relevant clinical data including postoperative medical and surgical complications. Allogenic blood transfusions were administered according to hospital policy. The transfusion threshold was haemoglobin of 8g/dl or less or a symptomatic patient. Results: The two groups were similar with respect to age, gender, ASA, BMI, duration of operation, pre and post-op haemoglobin and tranexamic acid usage. A significantly greater proportion of patients in group I required allogenic blood transfusion when compared to group II. (4.2% vs. 1.2%, group I vs. group II, p < 0.001; respectively). In group I, the usage of suction drain was significantly greater when compared to group II (48% vs. 20%, group I vs. group II, p = 0.27 respectively). The medical complications in group I, included superficial wound infections (two patients), myocardial ischemia (one patient) and reversible acute renal failure (one patient), while in group II, one patient developed a superficial wound infection, which was treated with oral antibiotics. Conclusion: A low rate of allogenic blood transfusion can be achieved by using tranexamic acid and minimising insertion of suction drains. To the best of our knowledge, we report the lowest rate of allogenic blood transfusion for primary TKA. Our data have important implications in the management of patients undergoing TKA

Background: In the literature are different data about the allogenic blood transfusion rate after total knee replacement. The common intention in orthopedic surgery is to reduce the requirement for allogenic blood transfusions by optimizing the blood management. The aim of this study is to determine the efficacy of the mechanical autotransfusion system OrthoPAT (Haemonetics Corp., MA, USA) to reduce the postoperative allogenic blood transfusion rate. Method: According to the preliminary performed power analysis we did a prospective controlled study including 104 patients which were randomized in a group A (OrthoPAT for intra- and postoperative blood salvage and retransfusion, n = 52 patients) and a control group B (no retransfusion system was used, n = 52 patients) All patients had a primary osteoarthritis of the knee and were operated on without use of a tourniquet. We implanted in all patients a cemented posterior stabilized total knee prosthesis design (LPS-Flex Mobile, Zimmer, IN, USA). In group A the autotransfusion system was used for 6 hours (intra- and postoperatively) and the collected blood was retransfused. The retransfused blood is anticoagulanted, filtered and centrifuged to separate waste products. Red cells are washed with saline and reconcentrated to a high haematocrit. The preoperative data for cardiopathy, angiopathy, preoperative anemia or anticoagulant treatment showed no significant differences for group A and B. Because of missing data we finally were able to use the results of 98 patients: 48 group A and 50 in group B. The indications for a blood transfusion were influenced by the clinical symptoms of anemia, the hemoglobin value (hemoglobin < 8.0 g/dl) and the anamnesis of cardiovascular diseases. Evaluation was done with the medical history and the pre-/postoperative hemoglobin values, postoperative blood loss and postoperative need of allogenic blood transfusion. Results: The two groups showed no significant differences relating to the demographic data or the medical history. 16 patients (33 %) of the retransfusion group who in mean received 281 ml of salvaged blood needed allogenic blood transfusion compared with 22 patients (44 %) of the control group B (p = 0,306). The hemoglobin values of group A versus the control group showed after the donation of the salvaged blood a significant difference (p = 0,027) but no longer at the 3rd and 5th day postoperative. Conclusions: The use of the autotransfusion system seems to reduce the postoperative allogenic blood transfusion rate but not statistical significant. At the 3rd and 5th day postoperatively no significant differences of the hemoglobin values could be stated comparing group A with group B. For us this was a clue showing that the quality of the erythrocytes after the reclamation was reduced

Purpose: In order to determine the incidence of allogenic blood transfusion in patients undergoing primary total knee arthroplasty (TKA) at our centre, we performed a retrospective analysis of prospectively collected data for all patients who underwent TKA between 1 April 2006 and 31 March 2008. Methods and Results: In 2006/2007 there were 650 primary TKA patients (group 1) and in 2007/2008 this increased to 841 (group 2). Allogenic blood transfusions were administered according to hospital policy. The transfusion threshold was haemoglobin of 8g/dl or less or a symptomatic patient. For transfused patients data were collected for haemoglobin levels (pre-operative, post-operative and pre-discharge), duration of operation, ASA grade, number of transfusions, use of tranexamic acid and suction drains, and relevant clinical data including post-operative medical and surgical complications. In group 1 27 patients were transfused (group 1T) and in group 2 10 patients were transfused (group 2T). This was a significant reduction in allogenic blood transfusions (4.5% vs. 1.2%, p < 0.001). The two transfused groups were similar with respect to age, gender, ASA, BMI, duration of operation, pre- and post-operative haemoglobin and tranexamic acid usage. In group 1T, the usage of suction drains was greater than in group 2T (48% vs. 20%) although this was not statistically significant (p = 0.27). Conclusion: This study indicates that a low rate of allogenic blood transfusion can be achieved by using tranexamic acid and minimising insertion of suction drains. To the best of our knowledge, we report the lowest rate of allogenic blood transfusion for primary TKA. Our data have important implications in the management of patients undergoing TKA, particularly with respect to the need to cross-match all patients

Background: During total hip or knee replacement there is blood loss, wich often requires allogenic blood transfusions. The risks associated with this practice are well documented in the literature, and numerous strategies have been employed to conserve blood following total joint arthroplasty. The aim of this study is to determine the efficacy of an autologous retransfusion drain system to reduce the postoperative allogenic blood transfusion rate and the lack of adverse effects when using it. Method: We did a retrospective study of patients operated on hip and knee primary replacements during the first six months of 2008, which had a postoperative blood salvage and retransfusion (Bellovac ABT autotransfusion system-Astra Tech, Mölndal, Swedenn-), Group A, n=220 patients, and a control group, Group B, with patients operated on hip or knee replacements during the first six months of the year before, which had standard drainage system, n=177. In first group the drain was opened inmediatly after tourniquet release and the shed blood was returned to the patient after collecting up to 500 ml and no later than six hours after surgery. The pre-operative data for cardiopathy, angiopathy, preoperative anemia or anticoagulant treatment showed no significant differences for group A and B. We standardised the transfusion criteria in order to allow an accurate comparison between the two groups. Evaluation was done with the medical history and the pre-/postoperative hemoglobin values, postoperative blood loss and postoperative need of allogenic blood transfusion. Results: The two groups showed no significant differences relating to the demographic data or the medical history. 17 patients (7.7 %) of the retransfusion group needed allogenic blood transfusion compared with 16 patients (9 %) of the control group B (p > 0.05). The hemoglobin values of group A versus the control group showed after the donation of the salvaged blood a significant difference (p = 0,0007) but only in the subgroup of total knee replacement. Only three adverse events were observed when using the recuperator, which were not a risk for patients life and were solved with the cessation of postoperative reinfusion. Conclusions: The use of the autotransfusion system seems to reduce the postoperative allogenic blood transfusion rate but not statistical significant. Our study therefore confirms the safety of retransfusion drains

Introduction:. Intraoperative cell salvage involves the collection of blood directly from the operative field. The purpose of this study was to determine if its use reduces the need for postoperative allogenic blood transfusion, assess any adverse events and its effect on duration of postoperative stay in primary hip arthroplasty. Patients and Methods:. We prospectively examined the effect of intraoperative cell salvage on the need for postoperative allogenic blood transfusion. Between February 2009 and August 2010, a total of 77 patients who underwent primary total hip arthroplasty were included in the study, under the care of the senior author (KB). All patients had a diagnosis of osteoarthritis. Intraoperative cell salvage was used in 38 patients and not used in 39 patients. We prospectively collected data on patient demographics, ASA grade, preoperative and postoperative haematological features, number of units of packed red cells transfused and the volume of intraoperative reinfused cell salvaged blood. Total inpatient stay and any postoperative adverse events were recorded. Results:. No patients in the cell salvage group required postoperative allogenic blood transfusion compared to three patients (7.7%) in the conventional group. Postoperative decrease in haemoglobin was less in the cell salvage group (2.57 vs. 3.3 g/dL). The mean length of postoperative inpatient stay was shorter in the cell salvage group (5.1 vs. 6.41 days). Three patients in the cell salvage group had adverse events (1 UTI, 1 hyponatraemia, 1 colonic pseudo-obstruction). Three patients in the conventional group experienced adverse events (2 superficial wound infections, 1 DVT). An average of 361 mls of cell salvaged blood was reinfused (110–900 mls). Conclusions:. We have found that the use of intraoperative cell salvage in patients undergoing primary total hip arthroplasty reduces the need for post operative allogenic blood transfusion with no increase in adverse events when compared to conventional measures of blood preserving techniques

Intraoperative cell salvage involves the collection of blood directly from the operative field. The purpose of this study was to determine if its use reduces the need for postoperative allogenic blood transfusion, assess any adverse events and its effect on duration of postoperative stay in primary hip arthroplasty. We prospectively examined the effect of intraoperative cell salvage on the need for postoperative allogenic blood transfusion. Between February 2009 and August 2010, a total of 77 patients who underwent primary total hip arthroplasty were included in the study, under the care of the senior author (KB). All patients had a diagnosis of osteoarthritis. Intraoperative cell salvage was used in 38 patients and not used in 39 patients. We prospectively collected data on patient demographics, ASA grade, preoperative and postoperative haematological features, number of units of packed red cells transfused and the volume of intraoperative reinfused cell salvaged blood was. Total inpatient stay and any postoperative adverse events were recorded. No patients in the cell salvage group required postoperative allogenic blood transfusion compared to three patients (7.7%) in the conventional group. Postoperative decrease in haemoglobin was less in the cell salvage group (2.57 vs. 3.3 g/dL). The mean length of postoperative inpatient stay was shorter in the cell salvage group (5.1 vs. 6.41 days). Three patients in the cell salvage group had adverse events (1 UTI, 1 hyponatraemia, 1 colonic pseudo-obstruction). Three patients in the conventional group experienced adverse events (2 superficial wound infections, 1 DVT). An average of 361mls of cell salvaged blood was reinfused (110–900mls). We have found that the use of intraoperative cell salvage in patients undergoing primary total hip arthroplasty reduces the need for post operative allogenic blood transfusion with no increase in adverse events when compared to conventional measures of blood preserving techniques

Introduction: Reinfusion drains are used to minimise the need for allogenic blood transfusion, and its potential complications. Tranexamic acid {TA} is an antifibrinolytic agent that is used to decrease blood loss in total knee arthroplasty surgery. The effect of TA on reinfusion volume of drained blood has received little attention. The aim of our study is to measure the effect of TA on reinfusion volumes in primary total knee replacement {TKR}. Methods: A cohort of consecutive patients undergoing primary total knee replacement between November 2006 and January 2008 were studied. Each patient was operated upon by the same surgeon, and had the same pros-thesis inserted. Patients operated upon before June 2007 did not receive TA but had reinfusion drains, while those who underwent surgery after June 2007 received TA along with the reinfusion drain. We measured pre and post operative haemoglobin {Hb}, drainage volume and reinfusion volume. The need for allogenic blood transfusion was recorded. TA and non TA groups were compared. Results: Seventy patients were included in the study. There was no significant difference between the TA and non TA groups in pre operative Hb {13.2, 13.1g/dl} or post operative Hb {10.95, 10.9}. There was a significantly lower drainage volume {250 v 600ml} and subsequent reinfusion volume {100 v 465ml} in the TA group versus non TA groups respectively. There were no cases of thromboembolism or allogenic blood transfusion in either group. Conclusion: Tranexamic acid significantly decreased post operative blood loss and subsequent reinfusion volumes in TKR. TA and reinfusion drains greatly decrease the demand for allogenic blood transfusion. Drainage volume is so low when TA is used in routine primary TKR, that the need for reinfusion drains is questionable. TA is cost-effective compared to reinfusion drains in TKR

In a prospective randomised controlled trial, 51 patients who did not receive a bone plug during total knee replacement surgery were compared to 49 patients who received a bone plug. The primary outcome measure was the need for allogenic blood transfusion requirement and the secondary outcome was the post-operative blood loss and decline in haemoglobin levels. The patients had autologous re-transfusion from their closed drainage system. The two groups did not differ in the demographics. The mean intra-operative blood loss was slightly more in the no plug group (difference of 41.25 millilitres), which was not statistically significant. There was no statistically significant difference in total post-operative blood loss and drop in haemoglobin levels. Only one patient had two units of allogenic blood transfusion in the no bone plug group while none required allogenic blood in the bone plug group. There was no statistically significant difference in the amount of blood re-transfused from the drain between the two groups. Our findings did not show any statistically significant difference in post-operative blood loss, decline in haemoglobin levels and the need for allogenic blood transfusion in total knee replacement surgery

Allogenic blood transfusions are frequent sequellae of hip and knee arthroplasty with potentially deleterious consequences. A prospective collection of a comprehensive data set of 1,185 knee and 1,064 hip arthroplasty patients including primary and revision surgeries was completed with analysis of allogenic and predonated blood usage, blood salvage systems and costs. The most effective strategy in reducing allogenic blood transfusion is the use of a blood salvage system. The most expensive strategy is the use of blood salvage systems with predonation. The least expensive and least effective strategy is no predonation of blood and no blood salvaging system. The purpose of this study is to evaluate the usage, effectiveness and cost of blood salvage technologies in total hip and knee arthroplasty. The most effective strategy in reducing allogenic blood transfusion is the use of a blood salvage system. The most expensive strategy is the use of blood salvage systems with predonation. The least expensive and least effective strategy is no predonation of blood and no blood salvaging system. More than half of the predo-nated blood collected was never used. Blood loss in total hip and knee arthroplasty can have significant deleterious physiologic effects on patients. There are potential health risks with allogenic blood transfusion as well as patient anxiety toward allogenic transfusion. Recent advances in blood management provide additional options that need further evaluation. The lowest cost strategy was no predonation and no blood salvage system at an average of $30 per patient, but with a 14% incidence of allogenic transfusion. Pre-donation alone had a cost of $330 with a 12% transfusion rate. Predonated blood was wasted in 60% of knee arthroplasties and 48% of hip arthroplasties. The Consta Vac and OrthoPAT blood salvage systems had a cost of $110 and $365 with 5% and 7% transfusion rate, respectively. A prospective collection of a two-year comprehensive data set of 1,185 knee and 1,064 hip arthroplasty patients including both primary and revision surgeries was completed. Analysis of blood counts, allogenic and predonated blood usage, blood salvage systems, length of stay, demographics and costs were performed

Allogenic blood transfusions are frequent sequellae of hip and knee arthroplasty with potentially deleterious consequences. A prospective collection of a comprehensive data set of 1,185 knee and 1,064 hip arthroplasty patients including primary and revision surgeries was completed with analysis of allogenic and predonated blood usage, blood salvage systems and costs. The most effective strategy in reducing allogenic blood transfusion is the use of a blood salvage system. The most expensive strategy is the use of blood salvage systems with predonation. The least expensive and least effective strategy is no predonation of blood and no blood salvaging system. The purpose of this study is to evaluate the usage, effectiveness and cost of blood salvage technologies in total hip and knee arthroplasty. The most effective strategy in reducing allogenic blood transfusion is the use of a blood salvage system. The most expensive strategy is the use of blood salvage systems with predonation. The least expensive and least effective strategy is no predonation of blood and no blood salvaging system. More than half of the predonated blood collected was never used. Blood loss in total hip and knee arthroplasty can have significant deleterious physiologic effects on patients. There are potential health risks with allogenic blood transfusion as well as patient anxiety toward allogenic transfusion. Recent advances in blood management provide additional options that need further evaluation. The lowest cost strategy was no predonation and no blood salvage system at an average of $30 per patient, but with a 14% incidence of allogenic transfusion. Pre-donation alone had a cost of $330 with a 12% transfusion rate. Predonated blood was wasted in 60% of knee arthroplasties and 48% of hip arthroplasties. The Consta Vac and OrthoPAT blood salvage systems had a cost of $110 and $365 with 5% and 7% transfusion rate, respectively. A prospective collection of a two-year comprehensive data set of 1,185 knee and 1,064 hip arthroplasty patients including both primary and revision surgeries was completed. Analysis of blood counts, allogenic and predonated blood usage, blood salvage systems, length of stay, demographics and costs were performed

There is currently no consensus about the mean volume of blood lost during spinal tumour surgery and surgery for metastatic spinal disease. We conducted a systematic review of papers published in the English language between 31 January 1992 and 31 January 2012. Only papers that clearly presented blood loss data in spinal surgery for metastatic disease were included. The random effects model was used to obtain the pooled estimate of mean blood loss.

We selected 18 papers, including six case series, ten retrospective reviews and two prospective studies. Altogether, there were 760 patients who had undergone spinal tumour surgery and surgery for metastatic spinal disease. The pooled estimate of peri-operative blood loss was 2180 ml (95% confidence interval 1805 to 2554) with catastrophic blood loss as high as 5000 ml, which is rare. Aside from two studies that reported large amounts of mean blood loss (> 5500 ml), the resulting funnel plot suggested an absence of publication bias. This was confirmed by Egger’s test, which did not show any small-study effects (p = 0.119). However, there was strong evidence of heterogeneity between studies (I² = 90%; p < 0.001).

Spinal surgery for metastatic disease is associated with significant blood loss and the possibility of catastrophic blood loss. There is a need to establish standardised methods of calculating and reporting this blood loss. Analysis should include assessment by area of the spine, primary pathology and nature of surgery so that the amount of blood loss can be predicted. Consideration should be given to autotransfusion in these patients.

Cite this article: Bone Joint J 2013;95-B:683–8.

Purpose. This meta-analysis was designed to compare the effectiveness and safety of intravenous (IV) versus topical administration of tranexamic acid (TXA) in patients undergoing primary total knee arthroplasty (TKA) by evaluating the need for allogenic blood transfusion, incidence of postoperative complications, volume of postoperative blood loss, and change in hemoglobin levels. Materials and Methods. Studies were included in this meta-analysis if they assessed the allogenic blood transfusion rate, postoperative complications including pulmonary thromboembolism (PTE) or deep vein thrombosis (DVT), volume of postoperative blood loss via drainage, estimated blood loss, total blood loss, and change in hemoglobin before and after surgery in primary TKA with TXA administered through both the intravenous (IV) and topical routes.[Fig. 1]. Results. Ten studies were included in this meta-analysis.[Fig. 2] The proportion of patients requiring allogenic blood transfusion (OR 1.34, 95% CI: 0.63 to 2.81; P=0.45) [Fig. 3] and the proportion of patients who developed postoperative complications including PTE or DVT (OR 0.85, 95% CI: 0.41 to 1.77; P=0.66) did not significantly differ between the two groups. There was 52.3 mL less blood loss via drainage (95% CI: −50.74 to 185.66 ml; P=0.44),[Fig. 4] 21.5 mL greater estimated blood loss (95% CI: −98.05 to 55.12 ml; P=0.32), and 51.4 mL greater total blood loss (95% CI: −208.16 to 105.31 ml; P=0.52) [Fig. 5]in the topical TXA group as compared to the IV TXA group. The two groups were also similar in terms of the change in hemoglobin levels (0.02 g/dl, 95% CI: −0.36 to 0.39 g/dl; P=0.94). Conclusion. In primary TKA, there are no significant differences in the transfusion requirement, postoperative complications, blood loss, and change in hemoglobin levels between the intravenous and topical administration of TXA. For figures/tables, please contact authors directly.

Introduction:. Primary total knee arthroplasty (TKA) is associated with perioperative bleeding, and some patients will require allogenic blood transfusion during their inpatient admission. While blood safety has improved in the last several decades, blood transfusion still carries significant complications and costs. Transfusion indications and alternative methods of blood conservation are being explored. However, there is limited nationally representative data on allogenic blood product utilization among TKA patients, and its associated outcomes and financial burden. The purpose of this study was to use a national administrative database to investigate the trends in utilization and outcomes (i.e. in-hospital mortality, length of stay, admission costs, acute complications) of allogenic blood transfusion in primary TKA patients. Methods:. The Nationwide Inpatient Sample (NIS), the largest all-payer inpatient care database representing a 20% stratified sample of United States hospitals, was utilized. Primary TKA (ICD-9-CM 81.54) cases from 2000 to 2009 were retrospectively queried (n = 4,544,999; weighted national frequency). A total of 67,841 admissions were excluded (Figure 1). The remaining 4,477,158 cases were separated into two study cohorts: (1) patients transfused with allogenic blood products (red blood cells, platelets, serum) (n = 540,270) and (2) patients not transfused (n = 3,936,888). Multivariable regression and generalized estimating equations were used to examine the effect of transfusion on outcomes, adjusting for patient/hospital characteristics and comorbidity. Results:. During the study period, the overall allogenic blood transfusion rate in primary TKA patients was 12.1%. The rate increased ∼5% from 2000 to 2009, and stayed constant around 13% from 2006 to 2009. Transfusion rates were higher in older patients (80–89 yrs, 21.4%; ≥ 90 yrs, 30.7%), blacks (19.6%), females (14.0%), Medicare patients (14.6%), and Medicaid patients (14.4%). Transfused TKA patients had a greater percent of comorbidities than their non-transfused peers. The largest differences in comorbidity prevalence among transfused and non-transfused patients were: deficiency anemia (27.5% vs. 10.1%), renal failure (4.0% vs. 1.4%), chronic blood loss (3.7% vs. 1.4%), and coagulopathy (3.1% vs. 1.0%) (p < 0.001). Unadjusted trends show that from 2000 to 2009, in-hospital mortality rate decreased (Figure 2A), mean length of stay decreased (Figure 2B), and mean admission cost increased (Figure 2C) for both transfused and non-transfused patients following TKA. Adjusting for patient and hospital characteristics, transfused patients had a 22% (95% CI, 4%–43%) greater likelihood of in-hospital mortality (p = 0.013), 0.68 ± 0.02 days longer length of stay (p < 0.001), and $2,237 ± 76 increased admission costs (p < 0.001). Additionally, patients who received a transfusion had a greater adjusted risk of a postoperative infection (odds ratio, 2.35), pulmonary insufficiency (odds ratio, 1.60), and other complications (p < 0.001) (Figure 3). Conclusions:. The allogenic blood transfusion rate increased between 2000 and 2009 in the United States. Transfusion has a considerable burden on patients and healthcare institutions, increasing in-hospital mortality, length of stay, admission costs, and acute complications. Preoperative optimization strategies, transfusion criteria, and hemostatic agents for at-risk patients need to be further researched as possible ways to reduce transfusion occurrence and its effects

In recent years, reduction in the length of stay in patients undergoing UKA has gained considerable interest. This has led to development of ‘fast-track' and even day-case protocols aimed at decreasing length of stay (LOS), enhancing post-operative recovery and decreasing post-operative morbidity. One potential barrier to faster discharge and patient recovery is the need for post-operative haemoglobin checks and allogenic blood transfusion; which has been shown to increase LOS. Allogenic blood transfusion itself is not without risk, including immunological reactions, transfusion associated lung injury, infection and transmission of disease, thus reducing blood loss and the need for transfusion is imperative. Currently there is a knowledge gap regarding post-operative transfusion need and blood loss following UKA. We aimed to investigate blood loss and transfusion rates following UKA. Our primary aim was to evaluate the extent of post-operative transfusion need following UKA and identify which patients are at higher risk of needing transfusion. Following institutional approval, a retrospective analysis of all patients undergoing unicompartmental knee arthroplasty (UKA) at our level one academic university hospital was conducted. Operative records of all patients undergoing primary UKA were reviewed between March 2016 and March 2019. Patients' pre-operative haemoglobin and haematocrit, BMI, co-morbidities, application of tourniquet, tourniquet time, administration of Tranexamic Acid, need for post-operative blood transfusion, hospital length of stay, complications and re-admission were all recorded. Blood loss was estimated using the post-operative haematocrit. A total number of 155 patients were included. There were 70 females (45%) and 85 males (55%). The mean age was 66±10 years. Median pre-op blood volume was 4700mls (IQR; 4200–5100). Median blood loss was 600 mls (IQR; 400–830). Mean pre-op Haemoglobin was 135±14g/L and mean post-op Haemoglobin was 122±13g/L. No patient had a post-op Haemoglobin under 80g/L (Range 93–154). No patients in our study needed transfusion. A further comparison group of high-blood loss and low-blood loss patients was included in analysis. High-blood loss patients were defined as those losing greater than 20% of their pre-operative blood volume whilst low-blood loss patients were defined as those losing ≤20% of their blood volume. Results of these groups are presented in Table 3. No significance was found between the two groups in patient's demographics and in terms of intra-operative factors including TXA usage (p=0.68) and tourniquet time (p=0.99). There was no difference in terms of post-operative complications (p=1.0), length of stay (p=0.36) or readmission rates (p=0.59). The results of our study indicated that post-operative haemoglobin and haematocrit check proved unnecessary in all of our patients and could have been omitted from post-operative routines. We conclude that routine post UKA check of haemoglobin and haematocrit can be avoided and be saved for special circumstances depending on patient's physiology

There is an increasing body of evidence that allogenic blood transfusion is harmful and blood itself is a valuable resource not to be dispensed lightly. Therefore, a review was undertaken into the need for allogenic blood transfusion following primary unilateral hip arthroplasty in our unit. An initial audit was performed retrospectively on 191 consecutive patients, revealing that 73 of the 191 (38%) received allogenic blood either intra-operatively or postoperatively. Guidelines were drawn up, then implemented, with the assisistance of the anaesthetic and haematology departments. The threshold for transfusion was a post-operative haemoglobin of less than 8g/dL. A trial period of 2 months was used to study the impact of these guidelines. No patients were excluded at the outset due to age or co-morbidity. During this period 96 patients were identified for inclusion in the study, of which only 19 (20%) required blood transfusion. In order to ensure these guidelines were not unsafe we compared the length of hospital stay following surgery in both groups of patients as a surrogate measure of postoperative complications. There was no significant difference between the lengths of stay in each groups. The conclusion was drawn that these new guidelines are not detrimental to the patient, and roughly halve the need for allogenic blood transfusion

Revision total hip replacement is often associated with significant blood loss and subsequent transfusion. Intra-operative cell salvage is one approach to minimising this allogenic transfusion. We carried out a retrospective study of 158 consecutive revision THRs carried out by one surgeon between June 2003 and September 2006 in the Southern General Hospital, Glasgow. In the study group (79 patients, operated upon after October 2005) Intra-operative cell salvage was routinely used for all cases. In the control group (79 patients, operated upon before October 2005) Intra-operative cell salvage was not available. Data was collected on transfusion of salvaged blood, transfusion of allogenic blood, operation type, indication for surgery, complications and length of hospital stay. Results showed a 53% reduction (p=0.002) in the number of units of allogenic blood transfused in the study group compared with the control group. (1.59 units per case compared with 3.41 units). In the study group 51% of patients received allogenic blood transfusion, compared with 68% of patients in the control group, a relative reduction of 17% (p=0.02). There was no difference between the two groups regarding haemoglobin drop and length of hospital stay. Data regarding complications yielded no significant results due to small cohort size. We conclude that intra-operative cell salvage leads to a significant reduction in allogenic blood transfusion with subsequent implications upon cost, resource management, and patient safety and should be used for all patients undergoing revision hip arthroplasty

The February 2015 Hip & Pelvis Roundup. 360 . looks at: Hip arthroplasty in Down syndrome; Bulk femoral autograft successful in acetabular reconstruction; Arthroplasty follow-up: is the internet the solution?; Total hip arthroplasty following acetabular fracture; Salvage arthroplasty following failed hip internal fixation; Bone banking sensible financially and clinically; Allogenic blood transfusion in arthroplasty