Blood transfusion and drainage catheter clamping are associated with ecchymosis formation at the surgical site after total knee arthroplasty: an analysis of 102 unilateral cases

Background

Many previous studies have focused on the postoperative complication of postoperative knee pain, infection, knee prosthesis loosening, periprosthetic fractures, and so on. There have been few studies focused on postoperative ecchymosis formation surrounding the wound of the TKA site. A certain degree of effect on the early functional recovery of the patients may occur due to the mental stress caused by the ecchymosis, which raises doubts regarding the success of the surgery. Therefore, it is particularly important to understand the risk factors for postsurgical ecchymosis formation after TKA, and specific measures for preventing ecchymosis should be taken. In this study, we reviewed the record of patients who received TKAs in our hospital, and a comprehensive analysis and assessment was conducted regarding 15 clinical factors causing postsurgical ecchymosis formation.

Methods

The records of 102 patients who received unilateral TKAs between January 2007 and May 2010 were retrospectively analyzed. Patients were divided into two groups based on the occurrence of ecchymosis.

Results

Of the 102 patients, 14 (13.7%) developed ecchymosis. Blood transfusion and drainage catheter clamping during the first few postoperative hours had a significant impact on the development of ecchymosis (p < 0.05). There was no difference in age, BMI, operation time, pre- and postoperative platelet count, and length of postoperative anticoagulant therapy between the two groups. Multivariate logistic regression revealed major risk factors for ecchymosis were postoperative blood transfusion (odds ratio (OR) = 15.624) and drainage catheter clamping (OR 14.237) (both, p < 0.05).

Conclusion

Blood transfusion and drainage catheter clamping after TKA due to excessive blood suction were associated with higher risks for ecchymosis formation surrounding the surgical site.     

Allogeneic blood transfusion reduction by risk-based protocol in total joint arthroplasty

Purpose

To evaluate the effect of a preoperative protocol that triages patients awaiting total joint arthroplasty to one of four strategies designed to mitigate the risk of allogeneic blood transfusion (ABT) based on a priori transfusion risk on perioperative exposure to allogeneic blood.

Methods

We compared the transfusion experiences of a historical control series of 160 subjects with a study group of 160 subjects treated by protocol. Protocol subjects with hemoglobin (Hb) 100-129 g·L^?1 were given erythropoietin, dosed by weight. Subjects with Hb 130-139 g·L^?1 underwent preoperative autologous blood harvest and perioperative re-infusion as deemed clinically necessary. Subjects with Hb >139 g·L^?1 received no special intervention, unless they were aged >70 yr and weighed < 70 kg, in which case they received oral iron and folate supplementation.

Results

The relative risk of ABT in the Study group was 0.68 (95% confidence interval 0.54-0.85). The Control group received 104 units of allogeneic blood and the Study group received 35 units (P = 0.0007). These differences cannot be explained by differences in transfusion risk or autologous units transfused. There was no worsening of anemia or its consequences in the Study group.

Conclusion

A simple protocol based on easily obtained preoperative clinical indices effectively targets interventions that mitigate the risk of ABT.     

Epsilon Aminocaproic Acid to Reduce Blood Loss and Transfusion After Total Hip and Total Knee Arthroplasty

Background

Total hip and knee arthroplasty (THA and TKA) are associated with significant blood loss and some patients require postoperative blood transfusion. While tranexamic acid has been studied extensively among this population, we tested the hypothesis that epsilon aminocaproic acid (EACA) can reduce blood loss and transfusion after joint arthroplasty.

Bone Wax Is Effective in Reducing Blood Loss After Total Knee Arthroplasty

Background

Total knee arthroplasty (TKA) is associated with major blood loss and blood transfusion is often required. This study aimed to evaluate the efficacy of bone wax in reducing blood loss and transfusion rates after TKA.

Can tranexamic acid and hydrogen peroxide reduce blood loss in cemented total knee arthroplasty?

Introduction

The use of tourniquet in total knee arthroplasty (TKA) has resulted in negligible intra-operative blood loss but notable post-operative blood loss, creating the ideal scenario for using topical haemostatic agents intra-operatively. Recently, medical adjuvants including tranexamic acid (TXA) and hydrogen peroxide (H₂O₂) have been introduced. The aim of this study was to evaluate the effectiveness of intra-articular TXA and H₂O₂ in reducing blood loss during TKA.

Materials and methods

Fifty patients, who underwent a primary TKA with 1,500 mg of intra-articular TXA between May 2011 and December 2011, were compared with two matching cohorts of 50 patients each who underwent TKA with 100 ml of 3 % H₂O₂ wash and TKA without any TXA or H₂O₂. All surgeries were performed by two senior surgeons. The total blood loss was calculated by the hemoglobin balance method.

Results

The pre-operative serum hemoglobin levels were 13.1 ± 1.3, 13.1 ± 1.3 and 13.0 ± 1.2 g/dl (p > 0.05); while the drop in serum hemoglobin levels post-operatively was 2.0 ± 0.7, 2.4 ± 0.9 and 2.7 ± 0.8 g/dl for the TXA, H₂O₂ and Control groups, respectively (p < 0.001). The total amount of blood loss was 596 ± 449, 710 ± 279 and 760 ± 228 ml, respectively (p = 0.046). There was no difference in the duration of surgery between the three groups (p > 0.05).

Conclusions

This study showed that intra-articular TXA reduced blood loss during TKA without significantly increasing the duration of surgery. We cannot justify H₂O₂ wash as an alternative to intra-articular TXA to reduce blood loss during TKA.     

Targeted Preoperative Autologous Blood Donation in Total Knee Arthroplasty Reduces the Need for Postoperative Transfusion

Background

Preoperative donation of autologous blood has been widely used to minimize the potential risk of allogeneic transfusions in total knee arthroplasty. A previous study from our center revealed that preoperative autologous donation reduces the allogeneic blood exposure for anemic patients but has no effect for non-anemic patients.

Questions/Purposes

The current study investigates the impact of a targeted blood donation protocol on overall transfusion rates and the incidence of allogeneic blood transfusions.

Methods

Prospectively, 372 patients undergoing 425 unilateral primary knee replacements were preoperatively screened by the Blood Preservation Center between 2009 and 2012. Anemic patients with a hemoglobin level less than 13.5 g/dL were advised to donate blood, while non-anemic patients did not donate.

Results

Non-anemic patients who did not donate blood required allogeneic blood transfusions in 5.9% of the patients. The overall rate of allogeneic transfusion was significantly lower for anemic patients who donated autologous blood (group A, 9%) than those who did not donate (group B, 33%; p?<?0.001). Donating autologous blood did increase the overall transfusion rate of anemic patients to 0.84 per patient in group A compared to 0.41 per patient in group B (p?<?0.001).

Conclusion

This investigation confirms that abandoning preoperative autologous blood donation for non-anemic patients does not increase allogeneic blood transfusion rates but significantly lowers overall transfusion rates.     

Periarticular Injection of Tranexamic Acid Reduces Blood Loss and the Necessity for Allogeneic Transfusion After Total Knee Arthroplasty Using Autologous Transfusion: A Retrospective Observational Study

Background

This study aimed to examine the influence of a periarticular injection of tranexamic acid (TXA) on blood loss after a total knee arthroplasty (TKA) in patients who received an autologous blood transfusion.

Safety of Liver Resection for Hepatocellular Carcinoma After Sorafenib Therapy: A Multicenter Case-Matched Study

Background

Liver resection can be considered in some hepatocellular carcinoma (HCC) patients who received sorafenib. The lack of clinical data about safety of resection after sorafenib treatment led us to assess its potential impact on perioperative course in a multicentric study.

Methods

From 2008 to 2011, a total of 23 HCC patients who underwent liver resection after treatment with sorafenib (sorafenib group) were compared with 46 HCC patients (control group) matched for age, gender, underlying liver disease, tumor characteristics and type of resection. Patients received sorafenib for a median duration of 1 (range 0.2–11) months and drug was interrupted at least 7 days before surgery. End points were intraoperative (operative time, vascular clamping, blood loss and transfusion), and postoperative outcomes focusing on recovery of liver function.

Results

In the sorafenib group, HCC was developed on F4 cirrhosis in 48 % and the rate of major resection was 44 %. Surgical procedure duration (280 vs. 240 min), transfusion rate (26 vs. 15 %), blood loss (400 vs. 300 mL) and vascular clamping (70 vs. 74 %) were similar in the two groups. Mortality was zero in the sorafenib group and one (2.1 %) in the control group (p = 1.000). The incidence of postoperative complications was 44 % in the sorafenib group and 59 % in the control group (p = 0.307). Recovery of liver function was similar in the two groups in terms of prothrombin time (90 vs. 81 %, p = 0.429) and bilirubin level (16 vs. 24 μmol/L, p = 102) at postoperative day 5.

Conclusions

No adverse effect of preoperative administration of sorafenib was observed during and immediately after liver resection for HCC.     

Preoperative predictors for allogenic blood transfusion in hip and knee arthroplasty for rheumatoid arthritis

Introduction

To identify the preoperative predictors of requirement for postoperative allogenic blood transfusion following hip and knee joint arthroplasty.

Materials and methods

We analysed the retrospective data on patients with rheumatoid arthritis who had undergone either total hip or knee arthroplasty at a single university teaching hospital. Factors of age, sex, procedure type, preoperative haemoglobin, blood transfusion data, comorbidities and body mass index were investigated for association with postoperative allogenic blood after hip or knee arthroplasty.

Results

Three hundred and forty nine cases of patients with rheumatoid arthritis were reviewed. 21 % (n = 72) required allogenic blood transfusion. The only significant predictive preoperative factors associated with postoperative blood transfusion were a low preoperative haemoglobin (Hb) level (p < 0.001), procedure of total hip arthroplasty (p = 0.008), a previous history of myocardial infarction (p = 0.038) and previous allogenic blood transfusion (p = 0.03). A preoperative haemoglobin <120 g/l was associated with a tenfold increase in transfusion requirement. All patients with a preoperative Hb level <90 g/l were transfused.

Conclusions

The ability to identify those within this high-risk group who are likely to receive blood transfusion allows for an informed, appropriate and cost effective approach to blood management strategies.     

Pre-operative autologous blood donation versus no blood donation in total knee arthroplasty: a prospective randomised trial

Purpose

During total knee arthroplasty (TKA) blood loss can be significant and in spite of all techniques for reducing blood loss there is still a significant possibility for blood transfusions. For blood loss management during TKA, pre-operative autologous blood donation (PABD) is still a standard of care. In this prospective randomised study we have evaluated the efficacy of PABD in patients undergoing TKA to answer the question whether there is any need for autologous blood donations during TKA and, if yes, for which group of patients.

Methods

Patients were randomised to three groups. In group 1 patients did not donate autologous blood, in group 2 patients donated 1 dose 72 hours prior to TKA and in group 3 patients donated autologous blood 14 days prior to TKA. In all patients haemoglobin, haematocrit, thrombocyte and reticulocyte values, iron concentrations (Fe, unsaturated iron binding capacity, total iron binding capacity), activated partial thromboplastin time, prothrombin time, and intra-operative and post-operative blood loss were measured and compared.

Results

With PABD there was no reduction in allogeneic blood transfusions and a large number of taken doses of autologous blood was discarded, which significantly increased the cost of treatment for these patients. For patients undergoing TKA, PABD can provoke iatrogenic anaemia and thereby increase the likelihood of the need for allogeneic blood transfusion.

Conclusions

Results of our study showed that PABD in non-anaemic patients is not justified and is not economically feasible.     

The Efficacy of Combined Use of Rivaroxaban and Tranexamic Acid on Blood Conservation in Minimally Invasive Total Knee Arthroplasty a Double-Blind Randomized,Controlled Trial

Background

Tranexamic acid (TXA) was reportedly to decrease postoperative blood loss after standard total knee arthroplasty (TKA). However, the blood-conservation effect of TXA in minimally invasive TKA, in particular, receiving a direct oral anticoagulant was unclear. The aim of the study was to investigate the efficacy of combined use of TXA and rivaroxaban on postoperative blood loss in primary minimally invasive TKA.

Diabetes mellitus increases the incidence of deep vein thrombosis after total knee arthroplasty

Introduction

Many patients undergoing total knee arthroplasty (TKA) have diabetes mellitus, which may increase the risk of deep vein thrombosis (DVT) after TKA. We therefore assessed whether diabetes mellitus increased the incidence of DVT within 14 days after TKA.

Materials and methods

The incidence of DVT within 14 days of surgery was compared in diabetic and non-diabetic patients undergoing TKA in our hospital between June 2011 and February 2013. The relationships between diabetes mellitus and DVT were analyzed.

Results

Of the 358 enrolled patients, 70 (19.6 %) had diabetes and 288 (80.4 %) did not. DVT occurred within 14 days in 198 patients, 52 of 70 (74.3 %) in the diabetes group and 146 of 288 (50.7 %) in the non-diabetes group (p = 0.012). DVT of the contralateral leg was observed in 16 and 50 patients, respectively (p = 0.452). Logistic regression analysis showed that the risk of DVT was 2.71-fold higher in patients with than without diabetes mellitus (95 % CI 1.183–6.212, p = 0.018). There were no significant differences in age, gender, hypertension, BMI, duration of surgery, intra-operative blood loss, and duration of tourniquet between the two groups.

Conclusions

The incidence of DVT 14 days after TKA was significantly higher in patients with than without diabetes.     

Multimodal Nutritional Management in Primary Total Knee Arthroplasty: A Randomized Controlled Trial

Background

This study aims at evaluating the effectiveness of a new multimodal nutritional management (MNM) on albumin (ALB) transfusion, the incidence of electrolyte disorders, blood loss, perioperative levels of ALB and electrolyte, length of hospital stay (LOH), and complications in patients following total knee arthroplasty without tourniquet.

Late Tourniquet Release and Drain Clamping Reduces Postoperative Blood Loss in Total Knee Arthroplasty

Background

Many studies have investigated the effect of tourniquet release time and closed suction drainage in total knee arthroplasty (TKA). However, controversy remains as to the advisability of preclosure tourniquet release and the advisability of closed suction drain use following total knee arthroplasty.

Questions/Purposes

The aim of the study was to investigate if there is a benefit of performing tourniquet release after skin closure, along with drain clamping, for the first 6h following TKA.

Methods

Ninety-six patients underwent TKA between May 2009 and April 2010. Fourteen of these were excluded because of systemic diseases and simultaneous bilateral TKA. Twenty-nine of these were excluded due to use of a patellar component and posterior cruciate ligament (PCL)-sacrificing systems. Thus, 53 patients that underwent PCL-retaining cemented TKA were reviewed retrospectively. In the control group (group C), the tourniquet was released before skin closure, an attempt at hemostasis was made, and a compressive bandage was applied. The drain was not clamped in these patients. The test group of 23 patients (group T) had tourniquet release after skin closure and after the compressive bandage was applied. The drain was clamped for the first 6h after surgery. The two groups were compared as to the amount of drained blood, postoperative change in hemoglobin, postoperative complications, and knee function.

Results

We found that drained blood and hemoglobin drop were significantly lower in group T compared with group C. There was no difference regarding postoperative complications and knee function.

Conclusion

We conclude that tourniquet release after skin closure and compressive dressing followed by 6h of drain clamping reduces postoperative blood loss in TKR surgery.     

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.

The use of pneumatic tourniquet in total knee arthroplasty: a meta-analysis

Background

Pneumatic tourniquet use in total knee arthroplasty (TKA) is always a controversial issue. The aim of the present study is to assess the effectiveness and safety of its use in patients receiving primary unilateral TKA, and to explore the most safe and effective protocols.

Materials and methods

This review was based on cochrane methodology for conducting meta-analysis. Only randomized controlled trials (RCTs) were eligible for this study. The participants were adults who had undergone primary unilateral TKA. The Review Manager Database (RevMan version 5.0, The Cochrane Collaboration 2008) was used to analyze the dates of the selected studies.

Results

Thirteen RCTs involving 859 patients were included in this analysis. The use of tourniquet could significantly reduce operation time (mean difference ?5.01 min, P = 0.003), intraoperative blood loss (mean difference ?201.85 ml, P < 0.00001) and total blood loss volumes (mean difference ?125.03 ml, P = 0.61). But postoperative (mean difference 45.99 ml, P = 0.68) were slightly increased in that situation. With respect to surgical complications, a tendency of increasing risk ratio was observed for tourniquet group.

Conclusions

Our results indicate that tourniquet application could reduce surgical time, intraoperative blood loss and total blood loss, but increases postoperative total blood loss. With respect to postoperative complications, DVT and surgical site infection rates are relatively augmented in the tourniquet group.