Chemoprophylaxis without intra-articular wound drainage can replace autotransfusion in primary TKA

We compared outcomes in 2 groups undergoing total knee arthroplasty (TKA) with different blood-saving strategies (ie, chemoprophylaxis vs reinfusion). We hypothesized that chemoprophylaxis would lead to reduced blood loss and fewer transfusions, with no increase in associated complications. Group A was a prospective series of 91 consecutive cemented TKAs undertaken with chemoprophylaxis to reduce bleeding and blood allogeneic exposure. Group B consisted of 44 historical TKAs undertaken with postoperative reinfusion. With the exception of mean patient age (group A, 74.3 years; group B, 70.9 years; P=.006), there were no statistically significant differences between the 2 study groups.Mean total blood loss throughout the 7-day perioperative period was 1490 mL in group A and 1828 mL in group B. The rate of blood transfusion in group A was almost zero. In group B, 41 of 44 patients were administered blood intravenously. Despite the absence of autotransfusion, postoperative hemoglobin levels were significantly higher in group A than in group B. No major bleeding complications emerged in the immediate postoperative period in either group.Chemoprophylaxis proved superior to reinfusion at decreasing blood transfusion requirements in the routine daily setting of unilateral cemented primary TKA.     

Minimizing allogeneic blood transfusion in knee prosthesis implantation

The goal of blood management in orthopedic and trauma surgery is to minimize exposure to allogenic blood transfusion in elective surgical procedures. Pre-, intra- and postoperative techniques are available. In a retrospective study at our department we could show, that postoperative reinfusion in primary knee arthroplasty is an effective way to avoid allogenic blood transfusion. We evaluated two groups of totally 40 patients. Group I (20 patients) underwent collection of postoperative drainage blood and reinfusion (blood conservation system, CBC II ConstaVac, Stryker^® instruments), group II (20 patients) was treated without postoperative reinfusion. Group II required per patient 1,3 units of allogenic blood (totally 26 units), group I needed only 0,25 units of allogenic blood per patient (totally 5 units) by using the same guidelines for transfusion in both groups. There were similar preoperative and postoperativ hemoglobin and hematocrit levels in both groups. We recommend the use of postoperative reinfusion in addition with other blood saving techniques to reduce allogenic blood transfusion in primary knee arthroplasty.     

老年患者全膝和全髋关节置换术围手术期血红蛋白及红细胞压积的转归

 目的 探讨非输血老年患者全膝和全髋关节置换术围手术期血红蛋白及红细胞压积的自然转归及其与性别、手术类型之间的关系。方法 2012年9月至2013年2月接受全膝关节或全髋关节置换术的60岁以上骨关节炎患者107例,男54例,女53例;年龄60~82岁,平均69.4岁。检测术前、手术日、术后第1~7天,3周、6周、3个月、6个月的血红蛋白和红细胞压积,分析其变化趋势。将不同性别和手术类别各个时点的血红蛋白和红细胞压积进行比较,评价性别和手术类别对血红蛋白和红细胞压积转归的影响。结果 所有患者血红蛋白和红细胞压积均于术后至第4天出现明显下降,最低点出现在术后第4天,术后1周至3周,血红蛋白和红细胞压积回升最快,在术后6周至3个月逐渐恢复到术前水平。在下降和恢复过程的各个时点,男性与女性患者的血红蛋白、红细胞压积差异无统计学意义。全髋关节置换组术后第4天内血红蛋白下降多于全膝关节置换组,全髋关节置换组手术日红细胞压积下降多于全膝关节置换组,差异均有统计学意义,其他时点两组血红蛋白和红细胞压积下降值的差异无统计学意义。结论 全膝和全髋关节置换术后血红蛋白和红细胞压积的最低点出现在术后第4天,术后6~12周恢复。性别因素对围手术期失血及恢复无明显影响。全髋关节置换术后血红蛋白和红细胞压积下降多于全膝关节置换。     

Effect of training level on accuracy of digital templating in primary total hip and knee arthroplasty

The use of digital radiography and templating software continues to become more prevalent in orthopedics as the number of total hip arthroplasty (THA) and total knee arthroplasty (TKA) procedures increases every year. The purpose of this study was to evaluate the effect of training level on the accuracy of digital templating for primary THA and TKA. Digital radiographs of 97 patients undergoing primary THA (49 cases) and TKA (48 cases) were retrospectively templated using OrthoView digital planning software (OrthoView LLC, Jacksonville, Florida). Anteroposterior hip and lateral knee radiographs were digitally templated and compared with the actual size of the implants used intraoperatively. An implant sales representative, physician assistant, medical student (J.D.K.), resident (A.R.H.), and fellowship-trained arthroplasty surgeon (B.R.L.) templated all cases independently after a standardized orientation and were blinded to the actual component sizes used for surgery. The medical student, resident, and arthroplasty surgeon retemplated the same 97 cases 1 month later to determine intraobserver reliability. Digital templating was accurate in predicting the correct implant size in 33% of THAs and 54% of TKAs. In 73% of THAs and 92% of TKAs, digital templating was within 1 size of the actual implant used, and in 88% of THAs and 99% of TKAs, templating was within 2 sizes of the final components. In no cases did the templated implant size vary by >3 sizes from the final components. Interobserver reliability for templating THAs and TKAs showed good reliability as measured by intraclass correlation coefficient (ICC) (ICC(THA)=.70; ICC(TKA)=.86). Intraobserver reliability for templating THAs had excellent reliability for the resident and arthroplasty surgeon, with a kappa coefficient (κ) of 0.92, and good reliability for the medical student (κ=0.78). Intraobserver reliability for templating TKAs showed excellent reliability among all examiners (κ=0.90).     

Patient perspective survey of total hip vs total knee arthroplasty surgery

A 42-item survey was developed and administered to determine patient perception of and satisfaction with total hip arthroplasty (THA) vs total knee arthroplasty (TKA). A total of 153 patients who had both primary THA and TKA for osteoarthritis with 1-year follow-up were identified. Survey response rate was 72%. Patients were more satisfied with THA meeting expectations for improvement in function and quality of life (P < .05), whereas pain relief expectations were equivalent. Most patients (70.9%) reported that TKA required more physiotherapy. One-year Oxford score and improvement in Oxford score from preoperative to 1 year were superior for THAs (P = .000). Despite equivalent pain relief, THAs trend toward higher satisfaction compared with TKAs. THA is more likely to "feel normal" with greater improvement in Oxford score. Recovery from TKA requires more physiotherapy and a longer time to achieve a satisfactory recovery status. Patients should be counseled accordingly.     

Digital templating in primary total hip and knee arthroplasty

The use of digital radiography is becoming more prevalent in orthopedics. This transition impacts the ability to preoperatively plan for implants in total hip arthroplasty (THA) and total knee arthroplasty (TKA). This article reports on the clinical success of digital templating using the Advanced Case Plan (Stryker Imaging, Flower Mound, Texas) system in primary THA and TKA. Digital radiographs of 269 consecutive patients undergoing primary THA (93 cases) or TKA (176 cases) were templated using the Advanced Case Plan digital software package. A 25.4-mm metallic sphere was used as a calibrating marker. Anteroposterior hip and lateral knee radiographs were digitally templated preoperatively and compared to the actual size of the implants at the time of surgery. The accuracy of calibrating images using the metallic sphere was validated by measuring the diameter of femoral heads on 25 postoperative hip radiographs. Digital templating was accurate in predicting the correct implant size in 58.5% of THAs and 66% of TKAs. In 93% of THAs and 98.5% of TKAs, preoperative templating was within 1 size of the final implant. There were no cases in which the predicted implant size varied from the final components by >2 sizes. Calibrating the image using the metallic sphere marker was found to be highly accurate, predicting the correct femoral head size within 1.5 mm in all 25 cases (7 hemiarthroplasties and 18 THAs). Digital templating is an effective means for predicting the size of THA and TKA components, thus remaining a viable option as we transition into the modern era of digital radiography. Future studies will evaluate interobserver reliability and the impact of level of training on templating accuracy.     

Low-molecular-weight heparin and partial thromboplastin time-adjusted unfractionated heparin in thromboprophylaxis after total knee and total hip arthroplasty

Thromboprophylaxis with heparins after total hip arthroplasty (THA) and total knee arthroplasty (TKA) is well established. The aim of this study was to compare low-molecular-weight heparin (enoxaparin) with partial thromboplastin time (PTT)-adjusted, unfractionated heparin (heparin sodium). In a prospective study of THA and TKA 246 patients, physical examination and compression and duplex ultrasound were performed 1 day before and 7 and 14 days after surgery. One hundred thirty patients received 40 mg enoxaparin subcutaneously once per day. One hundred sixteen patients received 5,000 IU heparin sodium subcutaneously 3 times daily. As the PTT did not reach 40 seconds, the heparin sodium dosage was increased to 7,500 IU 3 times daily. The overall thrombosis rate was 4% (n = 10). In the enoxaparin group, the rate was 2.9% of the 70 THAs and 10% of the 60 TKAs. Thrombosis also occurred in the group that received heparin sodium: 1.8% of the THAs and 1.7% of the TKAs. For TKA, the difference between the 2 heparin groups was statistically significant. In the thromboprophylaxis of TKA, PTT-adjusted unfractionated heparins are superior to fixed doses of low-molecular-weight heparins.     

Transfusion of autologous blood from reinfusion systems in total knee arthroplasty

After total knee arthroplasty (TKA) the technique of wound management is not standardised. In this prospective study the efficacy of autologous blood reinfusion from the wound was investigated. One hundred patients (100 TKAs) were enrolled in this sequential cohort study. In one-half of the operations, a reinfusion system with suction and in the other half one wound drain without suction were used. Blood loss, transfusion requirements, range of motion, Insall scores and the incidence of complications were studied. The use of a reinfusion system did not decrease the homologous transfusion requirements. The blood loss in the group with a suction drainage system was significantly higher. Our experiences since May 2002 with one drain without suction in 787 consecutive TKAs confirm all findings of the current study.     

Blood loss and transfusion rates in bilateral total knee arthroplasty

From 1994 to 1998, we performed 170 bilateral total knee arthroplasties (TKAs) with cemented, posterior cruciate-substituting prostheses. Blood management included preoperative autologous donation, symptom-based transfusion, and autoreinfusion devices. Perioperative allogeneic transfusion rates for patients who donated 0, 1, 2, 3, or 4 units of blood were 40.00%, 0.00%, 3.70%, 0.00%, and 3.23%, respectively. Preoperative autologous donation >2 units also resulted in lower preoperative hemoglobin levels. For bilateral TKA, a protocol of 2 preoperative autologous donation units and reinfusion of postoperative drainage reduces anemia during the preoperative and postoperative periods.     

Shoulder Arthroplasties have Fewer Complications than Hip or Knee Arthroplasties in US Veterans

Total shoulder arthroplasties (TSA) are being performed more commonly for treatment of arthritis, although fewer than either hip (THA) or knee (TKA) arthroplasties. Total shoulder arthroplasty also provides general health improvements that are comparable to THA. One study suggests TSAs are associated with lower morbidity and mortality than THAs and TKAs. To confirm and extend that study, we therefore examined the association of patient characteristics (sociodemographics, comorbid illness, and other risk factors) with 30-day complications for patients undergoing TSAs, THAs, or TKAs. We used data from the Veterans Administration (VA) National Surgical Quality Improvement Program (NSQIP) for fiscal years 1999 to 2006. Sociodemographics, comorbidities, health behaviors, operative factors, and complications (mortality, return to the operating room, readmission within 14 days, cardiovascular events, and infections) were available for 10,407 THAs, 23,042 TKAs, and 793 TSAs. Sociodemographic features were comparable among groups. The mean operative time was greater for TSAs (3.0 hours) than for TKAs (2.2 hours) and THAs (2.4 hours). The 30-day mortality rates were 1.2%, 1.1%, and 0.4% for THAs, TKAs, and TSAs, respectively. The corresponding postoperative complication rates were 7.6%, 6.8%, and 2.8%. Adjusting for multiple risk factors, complications, readmissions, and postoperative stays were less for TSAs versus THAs and TKAs. In a VA population, TSAs required more operative time but resulted in shorter stays, fewer complications, and fewer readmissions than THAs and TKAs.     

In the Era of Tranexamic Acid,are Type and Screens for Primary Total Joint Arthroplasty Obsolete?

BackgroundAdvances in technique and perioperative blood management have improved transfusion rates following unilateral primary total joint arthroplasty and led some centers to change their preoperative blood ordering protocols. The purpose of this study is to determine whether deleting type and screens (T&S) from preoperative order sets was safe for patients undergoing primary total knee (TKA) and total hip arthroplasty (THA) and to identify patients who required allogenic blood transfusion.MethodsProspectively collected data were reviewed to identify any patient with a hemoglobin (Hgb) drawn within 30 days of surgery who received a transfusion following a unilateral primary TKA or THA.ResultsA total of 1255 patients met inclusion criteria. Of the total, 682 (54%) were TKAs and 573 (46%) were THAs. The mean preoperative Hgb was 11.5 g/dL with an average delta Hgb of 3.6 g/dL on postoperative day 1. No patient required an intraoperative transfusion. Fourteen patients (mean age and body mass index, 67.9 and 29.0) required a transfusion (1.1%) for postoperative blood loss anemia. Of those transfused, 13 (93%) of the patients underwent THA with the mean estimated blood loss of 378.6 mL. The total cost for a patient obtaining a T&S is $191.27.ConclusionIn our series, the risk of blood transfusion was rare (1.1%) and occurred only secondary to postoperative blood loss anemia. There were no cases of intraoperative complication requiring urgent or emergent blood transfusion. Removing T&S from standard order sets for patients undergoing primary TKA or THA appears to be a safe and cost-effective practice.     

Deep venous thrombosis after total hip or knee arthroplasty in a "low-risk" Chinese population

Scarcely any information has been published on deep vein thrombosis (DVT) in Chinese patients after total hip arthroplasty (THA) or total knee arthroplasty (TKA). However, generally, no prophylaxis is given to patients who do not have conventional high-risk factors because they are believed to be at "low risk." We performed a prospective study on 80 such "low risk" patients undergoing THA or TKA (58 TKA and 22 THA) without prophylaxis and performed duplex ultrasonography on both lower limbs 6 to 8 days after surgery. A total of 22 patients (27.5%) showed ultrasonographic evidence of DVT. Eighteen (31%) TKAs and 4 (18.1%) THAs were complicated by DVT. Three patients showed bilateral involvement, all of whom underwent TKA. Two patients had symptomatic pulmonary embolism. The sensitivity and positive predictive value of the clinical examination was 27.2% and 31.6%, respectively. This study showed that patients who are labeled "low risk" for DVT actually had a significant risk and suggests that the current practice of providing prophylaxis to only patients deemed at "high risk" should be revised.     

Stress and Strain During Total Joint Arthroplasty Are Not Impacted by Hand Dominance or Operative Laterality in Orthopedic Surgeons

BackgroundOrthopedic surgeons experience significant musculoskeletal pain and work-related injuries while performing total joint arthroplasty (TJA). We sought to investigate the impact of operative extremity and surgeon limb dominance on surgeon physiologic stress and energy expenditure during TJA.MethodsThis was a prospective cohort study conducted at a tertiary academic practice. Cardiorespiratory data was recorded continuously in 3 high-volume arthroplasty surgeons using a smart garment that measured heart rate (HR), HR variability, respiratory rate, minute ventilation, and energy expenditure (calories) during conventional total knee (TKA) and total hip arthroplasty (THA).ResultsSurgeon 1 and 2 (right-handed) performed 21 right TKAs, 10 left TKAs, 13 right THAs, and 10 left THAs. Surgeon 3 (left-handed) performed 6 right TKAs, 9 left TKAs, 16 right THAs, and 10 left THAs. While performing TKA or THA, limb laterality had no significant impact on operative time and no significant differences existed in HR, HR variability, respiratory rate, minute ventilation, or energy expenditure for any right-handed or left-handed surgeons, regardless of the operative limb laterality. While performing TKA, consistently standing on the side of hand dominance was associated with decreased strain and stress, compared to always standing on the operative side.ConclusionThis study suggests that surgeon hand dominance and operative limb laterality do not impact energy expenditure or physiologic strain during TJA. However, consistently standing on the side of hand dominance in TKA may lead to decreased physiologic strain and stress during surgery. Further study utilizing wearable technology during TJA may provide orthopedic surgeons with information about modifiable factors that contribute to differences in physiological parameters during surgery.     

Topical Tranexamic Acid Reduces Blood Loss and Transfusion Rates in Total Hip and Total Knee Arthroplasty

The objective of this study was to determine if tranexamic acid (TXA) applied topically reduced postoperative bleeding and transfusion rates after primary total hip arthroplasty (THA) and primary total knee arthroplasty (TKA). Two hundred and ninety consecutive patients from a single surgeon were enrolled. In TKA, TXA solution was injected into the knee after closure of the arthrotomy. In THA, the joint was bathed in TXA solution at three points during the procedure. In both THA and TKA the TXA solution was at a concentration of 3 g TXA per 100 mL saline. The mean blood loss was significantly higher in the non-TXA patients in both TKA and THA groups. Postoperative transfusions decreased dramatically with TXA, dropping from 10% to 0%, and from 15% to 1%, in the TKA and THA groups, respectively. Topical application of TXA significantly reduces postoperative blood loss and transfusion risk in TKA and THA.     

Reduction of blood loss using tranexamic acid in total knee and hip arthroplasties

There have been several attempts to reduce postoperative blood loss in patients undergoing total arthroplasty. Benoni et al. reported the usefulness of tranexamic acid in total knee arthroplasty (TKA). We investigated its effect in TKA and total hip arthroplasty (THA). Blood loss was significantly reduced in patients given tranexamic acid in both the TKA and THA groups, and no severe complications, such as venous or pulmonary thrombosis, were noted in any of the patients who received the agent. Administration of tranexamic acid seems to be useful for reducing postoperative blood loss in TKA and THA. Received: 26 May 1999     

Surgeon energy expenditure during total joint arthroplasty

Although there is extensive literature related to total hip arthroplasty (THA) and total knee arthroplasty (TKA), most of this research has been devoted to analyzing patient outcomes and complications. There are no published articles to date investigating the energy expenditure of the surgeon during these procedures. Using a SenseWear Pro(2) Armband, energy expenditure measured as energy expended during 22 primary THAs or TKAs by a single surgeon was recorded. Total hip arthroplasty required a greater expenditure of energy than TKA (P < .05). No significant trend was detected when comparing patient body mass index to the number of calories used by the surgeon. The physiologic demands placed upon the surgeon for various procedures should be recognized and is an additional factor to consider when determining procedure reimbursement.     

Does Time to Surgery Affect Outcomes for Periprosthetic Femur Fractures?

Background

Periprosthetic femur fractures around total hip (THA) and total knee (TKA) arthroplasties are difficult complications to manage. With native hip fractures, delay to fixation has been correlated with an increase in postoperative mortality. The effect of time to definitive fixation of periprosthetic femur fractures around THA and TKA is not well established. The aim of our study is to evaluate the effect of time to definitive fixation on postoperative length of stay and mortality for patients with periprosthetic femur fractures around THA and TKA.

Orthopedic Specialty Hospital Reasons for Transfer and Subsequent Outcomes

BackgroundSurgical specialty hospitals provide patients, surgeons, and staff with a streamlined approach to elective surgery but may not be equipped to handle all complications arising postoperatively. The purpose of this study is to evaluate the immediate postoperative and 90-day outcomes of patients who were transferred from a high-volume specialty hospital following primary total hip arthroplasty (THA) or total knee arthroplasty (TKA).MethodsAll patients who were admitted to one orthopedic specialty hospital for primary THA or TKA between January 2015 and December 2019, and subsequently transferred to a tertiary care hospital, were identified and propensity matched to nontransferred patients. Emergency department visits, complications, readmissions, mortality, and revisions within 90 days of surgery were identified for each group.ResultsThere were 26 TKAs (0.78%) and 20 THAs (0.48%) transferred, representing 0.62% of all primary THAs and TKAs performed over the study duration. Arrhythmia and chest pain were the most common reasons for transfer. Ninety-day readmissions were significantly higher in the transfer group (15.2% vs 4.3%, P = .020) with an odds ratio for readmission after transfer of 3.9 (95% confidence interval 1.3-12.4). Overall complications and orthopedic complications did not differ significantly, although transferred patients had a higher rate of medical complications (13.0% vs 2.2%, P = .008) with an odds ratio of 6.7 (95% confidence interval 1.6-28.2).ConclusionTransfer from a specialty hospital is rarely required following primary TKA and THA. Although not at increased risk for orthopedic complications, these transferred patients are at increased risk for readmissions and medical complications within the first 90 days of their care, necessitating increased vigilance.     

Safety of combined use of local anesthetic infiltration and reinfusion drains in total knee arthroplasty

Injection of local anesthetic during total knee arthroplasty (TKA) has been shown to aid postoperative pain relief. Reinfusion drains have also proven useful in decreasing allogenic blood transfusion. Combined use carries the risk of reinfusion of local anesthetic from drainage bag. We examined plasma ropivacaine concentrations from 20 patients undergoing TKA, who were treated with these 2 techniques. Samples were taken from a dedicated venous cannula and from the reinfusion drainage bag. The average amount of ropivacaine reinfused was 1.9 mg, a fraction of the injected dose (150 mg), and venous plasma concentrations reached peaks of 0.5 to 1.5 μg/mL, well below demonstrated levels of toxicity. Patients tolerated the treatment well, with no adverse outcomes. This study demonstrates the safety of combining these 2 techniques in TKA.     

Postoperative blood salvage and reinfusion after total joint arthroplasty

The purpose of this prospective study was to evaluate the safety of salvage and reinfusion of postoperative sanguineous wound drainage using the ConstaVac Blood Conservation System (Stryker, Kalamazoo, MI). A prospective analysis of 135 primary total hip and total knee arthroplasties was carried out. The collection time for reinfusion was limited to 6 hours, and suction pressure was kept to a minimum by using the lowest setting on the device. For all patients, no citrate-phosphate-dextrose anticoagulant was added to the reservoir. To evaluate the effect of reinfusion on hemostasis and the blood coagulation system, antithrombin III, fibrinogen, and d-dimer levels of 40 of 135 patients were measured before surgery and on the first and seventh days after the operation. The mean volume of reinfusion of postoperative drainage was 437 mL for the patients with total hip arthroplasties, 883 mL for those with total knee arthroplasties, and 1,713 mL for those with bilateral total knee arthroplasties. Ninety-nine of 135 patients underwent operations without homologous blood replacement. Transient chills with mild fever were seen in 2 patients during reinfusion. No complications related to air embolism, coagulopathy, renal failure, or sepsis were recognized in any of the patients. This study suggests that postoperative blood salvage and reinfusion appear to be safe and effective in patients undergoing primary total hip and knee arthroplasties.