Abstract
Background:
Hemi hip arthroplasty is one treatment option for femoral neck fractures; however, there has been limited evidence on factors associated with blood transfusions following hemi hip arthroplasty. Hence, the aim of this study was to identify the predictors of blood transfusion after hemi hip arthroplasty, which could lead to the establishment of proper guidelines for management protocols.
Materials and Methods:
This study was a retrospective cohort study, conducted in a single center of 323 femoral neck fracture patients having undergone hemi hip arthroplasty. Peri-operative factors and demographic data were extracted from the electronic medical records, from 2007 to 2019. A predictive model was developed by logistic regression (LR), and adjusted by multivariate logistic regression.
Result:
One hundred and twenty-six (39%) patients received blood transfusions. On multivariate analysis, those of a female gender (odds ratio (OR) 2.00, p = 0.037), having a body mass index lower than 18.5 kg/m2 (OR 2.40, p = 0.028), lower preoperative hemoglobin levels (OR 0.52, p < 0.001) and given general anesthesia (OR 2.07, p = 0.028) were shown to be significantly associated with a higher risk of requiring a blood transfusion.
Conclusion:
The authors recommend that preparation of blood components coupled with the utilization of blood conserving methods for high risk patients, as studies have stated, in addition to the consideration of spinal anesthesia; if patients have no contraindication, should be implemented.
Keywords: blood transfusion, hemi hip arthroplasty, femoral neck fracture, risk factor, hip replacement
Introduction
Hemi hip arthroplasty is an option for treatment of a femoral neck fracture. Although, there have been improvements in surgical techniques as well as patient care protocols for decreasing blood loss in the last decade, there are still a number of patients that require post-operative blood transfusions. Femoral neck fracture patients, whom require blood transfusions, usually require an allogenic blood transfusion, which increases the rate of infection.1 Other problems occurring from blood transfusions are: acute transfusion reactions, transfusion-associated circulatory overload and transfusion-related acute lung injury.2
There are methods which apply for reducing blood loss and blood transfusions in hemi hip arthroplasty. Intraoperative cell saver blood replacement is an option, but this method increases the cost of patient care. There has been a study stating that: cell saver blood replacement is not a cost effective option, and not recommended for application in all cases of femoral neck fractures.3 There was also a study demonstrating that intra-articular tranexamic acid injection during the hip hemi-arthroplasty is effective in reducing blood transfusions, without increasing the risk of thrombosis.4
Additionally, there are many studies reporting on the risk factors of post-operative blood transfusions after total hip arthroplasty (THA). Female gender, high American Society of Anesthesiologists (ASA) and lower preoperative hemoglobin (Hb) were associated with a high rate of blood transfusions.5,6 However, there has been no report on the predictors of blood transfusions in hemi hip arthroplasty that have less intraoperative bleeding compared with THA. Moreover, patients who have had hemi hip arthroplasty were usually older and less active than patients who had THA. This present study was conducted to evaluate the risk factors for post-operative blood transfusion after hemi hip arthroplasty in a single center that utilized the same surgical techniques and patient care protocols.
Material and Methods
This study was a retrospective study conducted at a tertiary hospital; from January, 2007 to May, 2019. The primary outcome was the requirement of post-operative allogenic blood transfusion. A total of 323 femoral neck patients having undergone hemi hip arthroplasty were recruited. The exclusion criteria were: patients who had pathological fractures from tumor or infection, patients who had multiple fractures and patients with incomplete data. This study was approved by the local Ethics Committee and Institutional Review Board.
The posterior approach was used for all patients; wherein: the hip capsule and short external rotator were sutured back through the bone, with a suction drain being placed prior to wound closure. The drain was then removed on day 2 after the operation; however, patients were able to ambulate on the day after their operation. In cases of DVT prophylaxis, aspirin was used for venous thromboembolism (VTE) prophylaxis. Cefazolin was used for prophylaxis of surgical site infection. In cases of a cefazolin or penicillin allergy, patients were administered clindamycin instead.
Criteria for allogenic blood transfusion were postoperative hematocrit below 30 percent, or when the patient had anemic symptoms. The following factors were evaluated as potential factors that might affect allogenic blood transfusion requirements.
Patient demographic data; gender, age, body mass index (BMI), ASA, co-morbidity, pre-operative hemoglobin, pre-operative hematocrit, Garden classification, preoperative anticoagulation.
Perioperative and postoperative data; type of anesthesia, operative time, intraoperative blood loss, type of prosthesis, deep venous thrombosis (DVT) prophylaxis, length of stay, tranexamic and post-operative NSAIDs, was collected and reviewed.
All data were obtained from electronic medical records. The Garden classification was evaluated with picture archiving and communication system (PACS), from both hip antero-posterior view and lateral cross table views.
Statistical Analysis
Patient demographic data; such as: gender, ASA classifications, co-morbidity, preoperative anticoagulant, type of anesthesia, type of prosthesis, postoperative anticoagulant, was compared between the allogenic blood transfused group and non-blood transfused group, using chi-square. Rank sum test was used to compare age. BMI, preoperative hematocrit and hemoglobin were assessed with independent t-test, while Garden classification was evaluated with Fisher exact test.
Multivariate logistic regression analysis was used to estimate the impact of potential predictors associated with allogenic blood transfusions. All statistical analyses were conducted in R, version 3.1.0 (R Foundation for statistical computing, Vienna, Austria). A P value < 0.05 was used to define a statistical significance.
Results
The demographic data of 323 femoral neck fracture patients is summarized in Table 1. Thirty-nine percent of patients had allogenic blood transfusions. The results revealed that: patients within the blood transfusion group had a higher proportion of female gender, lower BMI, higher ASA class, lower preoperative hemoglobin levels and hematocrit compared with the non-blood transfusion group (P < 0.05).
Table 1.
Patient Demographics.
| Factors | Total (n = 323) | Transfusion (n = 126) | Nontransfusion (n = 197) | p value |
|---|---|---|---|---|
| Gender* | 0.011Ψ | |||
| Male | 91 (100) | 25 (27.5) | 66 (72.5) | |
| Female | 232 (100) | 101 (43.5) | 131 (56.5) | |
| Age† (y) | 79 (70.5,85) | 78 (69.5,83.8) | 79 (71,85) | 0.449 |
| BMI‡ | 21.8 (3.8) | 21 (3.8) | 22.3 (3.7) | 0.006Ψ |
| ASA* | 0.013Ψ | |||
| I | 15 (100) | 4 (26.7) | 11 (73.3) | |
| II | 219 (100) | 76 (34.7) | 143 (65.3) | |
| III | 89 (100) | 46 (51.7) | 43 (48.3) | |
| Co-morbidity* | ||||
| DM | 60 (100) | 28 (46.7) | 32 (53.3) | 0.23 |
| MI | 24 (100) | 6 (25) | 18 (75) | 0.213 |
| CVA | 49 (100) | 19 (38.8) | 30 (61.2) | 1 |
| Hb‡ (g/dL) | 11.3 (1.8) | 10.3 (1.6) | 11.9 (1.6) | < 0.001Ψ |
| Hct‡ (%) | 34.2 (4.9) | 31.6 (4.4) | 35.9 (4.4) | < 0.001Ψ |
| Garden classificationa | 0.70 | |||
| I | 21 (100) | 7 (33.3) | 14 (66.67) | |
| II | 9 (100) | 5 (55.56) | 4 (44.44) | |
| III | 57 (100) | 24 (42.11) | 33 (57.89) | |
| IV | 236 (100) | 93 (39.41) | 143 (60.59) | |
| Duration† (days) | 9 (5,21) | 9 (5,24) | 10 (6,20) | 0.988 |
| Preoperative anticoagulant* | 24 (100) | 11 (45.8) | 13 (54.2) | 0.621 |
*chi-square, † Ranksum, ‡ independent t-test, aFisher exact test.
Ψp value < 0.05.
Intraoperative and post-operative data is summarized in Table 2. Patients who were given spinal anesthesia had a lower rate of blood transfusions compared with patients who had general anesthesia (P < 0.02). Patients in the blood transfusion group had higher intraoperative blood loss greater than those in the non-transfusion group (P < 0.01). The length of stay was shorter for patients who did not receive blood transfusions (P < 0.001).
Table 2.
Perioperative Factors.
| Factors | Total (n = 323) | Transfusion (n = 126) | Nontransfusion (n = 197) | p value |
|---|---|---|---|---|
| Type of anesthesia* | 0.002Ψ | |||
| General anesthesia | 79 (100) | 43 (54.4) | 36 (45.6) | |
| Spinal anesthesia | 244 (100) | 83 (34) | 161 (66) | |
| Operative time† (min) | 130 (89.5,160) | 135 (105,160) | 123 (85,155) | 0.068 |
| Intraoperative blood loss† (mL) | 250 (150,400) | 300 (200,500) | 200 (150,350) | 0.01Ψ |
| Type of prosthesis* | 0.546 | |||
| Cemented | 231 (100) | 93 (40.3) | 138 (59.7) | |
| Cementless | 92 (100) | 33 (35.9) | 59 (64.1) | |
| Postoperative anticoagulant* | 206 (100) | 79 (38.3) | 127 (61.7) | 0.838 |
| Length of stays† (days) | 5 (4,7) | 6 (4,9) | 5 (4,7) | < 0.001Ψ |
| Tranxenamic used* | 42 (100) | 18 (42.9) | 24 (57.1) | 0.718 |
| Postoperative NSAIDs* | 145 (100) | 52 (35.9) | 93 (64.1) | 0.351 |
*chi-square, † Ranksum, aFisher exact test.
Ψp value < 0.05.
Multivariate analysis revealed a significant relationship between patients who had allogenic-blood transfusions and the following factors (Table 3). Female patients had a lower incidence of blood transfusions compared with male patients (Female: OR 2; 95% CI, 1.04-3.83; P = 0.037). Patients with a BMI ≤ 18.5 were more likely to receive blood transfusions compared with patients with a BMI 18.5-22.9 (OR 2.40; 95% CI, 1.10-5.25; P = 0.028). Patients with high preoperative hemoglobin were less likely to receive a blood transfusion (OR 0.52; 95% CI, 0.42-0.63; P < 0.001). General anesthesia patients were more likely to receive blood transfusions in comparison to spinal anesthesia patients (OR 2.07; 95% CI, 1.08-3.96; P = 0.028). However, there were no significant relationships between patients who had allogenic-blood transfusions in concerns to: age, ASA classification, type of prosthesis, tranxenamic acid use and preoperative anticoagulant.
Table 3.
Multivariate LR Analysis of Blood Transfusion in Related Factors.
| Factors | OR | 95% CI | p value |
|---|---|---|---|
| Gender | |||
| Male | 1.00 | Ref | |
| Female | 2.00 | 1.04-3.83 | 0.037* |
| Age | 0.98 | 0.96-1.01 | 0.145 |
| BMI | |||
| <18.5 | 2.40 | 1.10-5.25 | 0.028* |
| 18.5-22.9 | 1.00 | Ref | |
| 23.0-24.9 | 1.05 | 0.44-2.50 | 0.907 |
| 25.0-29.9 | 0.77 | 0.31-1.88 | 0.56 |
| ≥30.0 | 0.57 | 0.07-4.41 | 0.59 |
| ASA | |||
| I | 1.00 | Ref | |
| II | 0.79 | 0.19-3.23 | 0.741 |
| III | 1.4 | 0.30-6.40 | 0.668 |
| Hb | 0.52 | 0.42-0.63 | <0.001* |
| Type of anesthesia | |||
| General anesthesia | 2.07 | 1.08-3.96 | 0.028* |
| Spinal anesthesia | 1.00 | Ref | |
| Type of prosthesis | |||
| Cemented | 1.05 | 0.55-2.00 | 0.891 |
| Cementless | 1.00 | Ref | |
| Tranxenamic used | 0.86 | 0.38-1.93 | 0.719 |
| Preoperative anticoagulant | 1.22 | 0.44-3.36 | 0.700 |
*p value < 0.05.
Discussion
Allogenic blood transfusions after joint replacement is of increasing concern; due to the recent evidences demonstrating that: patients who received blood transfusions had a higher rate of complications, such as postoperative infection, fluid over load, increase duration of hospital stay and worse surgical and medical outcomes.7,8 There have been many studies reporting on the risk factors of blood transfusions in total hip arthroplasty.9-12 However, there is, to our knowledge, no report on the risk factors for blood transfusions in hemi hip arthroplasty in femoral neck fractures, which are less invasive and generally performed on older aged patients, compared with THA.
This study underlines that there were many factors associated with blood transfusions after hemi hip arthroplasty. There was 39 percent of patients who received an allogenic blood transfusion after surgery. Additionally, this study had comparable rates of transfusions compared with previous reports in THA, that have reported in their systematic reviews for THA patients using a standard drain without autologous re-transfusion. These showed the transfusion rate to be ranging from 19-48 percent.13 However, in this study the transfusion rate was quite high compared to previous studies. This may have been a result of the study being conducted in hemi hip arthroplasty, which usually involves patients of an older age and co-morbidity, compared to THA patients. An additional reason was that this study contained a low threshold for blood transfusion.
Logistic regression analysis, in our study, demonstrated many patient factors as well as other associated factors that were related with blood transfusions. In this study it was established that female patients had a higher rate of blood transfusions compared with male patients. However, prior studies in THA had various results regarding this aspect. There are many studies indicating that female patients are at risk for blood transfusions in THA.5,6,11,12,14 However, Grosflam reported higher blood transfusions in male patients.15 Contrary, Ogbemudia found that sex is not a predictor for blood transfusions.16 Lower BMI was a factor that increased the chances of a blood transfusion in our study. This study, which has also been supported by other studies in THA,17,18 discovered that: an underweight patient (BMI < 18.5) was a significant, related factor for blood transfusion. In contrast to our result, there were many studies stating that: BMI or weight were not predictive factors for blood transfusion.5,11,14,16
Preoperative hemoglobin levels, or hematocrit, were stated to be strong predictors for blood transfusion. Our study had the same results as previous data, which reported that a lower preoperative hemoglobin level and hematocrit was associated with a higher risk of blood transfusion in THA. 5,11,12,14,19,20 The intraoperative factor associated with blood transfusion was the type of anesthesia. Our study concluded that: patients who had spinal anesthesia had a lower chance of requiring a transfusion. The results in our hemi hip arthroplasty patients concurred with the results of previous meta-analysis in THA patients; which stated that: patients under spinal block were less likely to require a blood transfusion than patients under general anesthesia (OR = 0.26).21
In our study, the length of stay was shorter in patients who didn’t a receive blood transfusion (P < 0.001). Smeets reported a study in hip fracture patients who were treated by hip arthroplasty or internal fixation. This study revealed that patients who received blood transfusions had a significantly longer hospital stay adjoined with more postoperative cardiac complications.22 Another study in THA patients, by Browne, also reported that: THA patients who had blood transfusions had longer lengths of stay and higher mortality.20
The limitation of this study was that our protocol used lower thresholds for blood transfusion than other studies. Our center was using 30 percent of hematocrit, which is a historical rule proposed for improving outcomes in surgical patients with poor anesthesia risk.23 However, nowadays many surgeons consider the use of restrictive transfusion threshold of hemoglobin concentration 7g/dl, which is also as safe and as effective as a liberal transfusion strategy.24 So, further studies evaluating factors for blood transfusions, by using a restrictive transfusion threshold would be of interest.
Conclusions
In conclusion, this study reveals that: female gender, lower BMI, a lower preoperative hemoglobin level and general anesthesia, were factors associated with the risk of a blood transfusion; in the context of hemi-hip arthroplasty in femoral neck fractures. Our study concluded that the factors that surgeons could modify, so as to decrease the risk of a blood transfusion in this group of patients, was the use of spinal anesthesia. The authors, therefore, recommend prior preparation of blood components, or consider blood conserving methods for high risk patients, as described, in addition to considering spinal anesthesia if the patient has no contraindication.
Acknowledgments
The authors wish to thank Andrew Jonathan Tait for his assistance in proofreading the English of this report.
Authors’ Note: This article does not contain any studies involving any human participants, or procedure’s performed on participants by any of the authors. This study was approved by the Ethics Committee and Institutional Review Board of the Faculty of Medicine, Prince of Songkla University (EC 62-156-11-1). This study was a retrospective study. Consent was waived by the ethics committee. The hospital gave permission to extract information from the database. The datasets generated during the current study are available from the corresponding author upon reasonable request.
Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Funding for this research was provided by the Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand (grant number 62-156-11-1).
ORCID iD: Varah Yuenyongviwat, MD 
https://orcid.org/0000-0003-0338-7733
References
- 1. Taneja A, El-Bakoury A, Khong H, et al. Association between allogeneic blood transfusion and wound infection after total hip or knee arthroplasty: a retrospective case-control study. J Bone Jt Infect. 2019;4:99–105. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2. Shaw RE, Johnson CK, Ferrari G, et al. Balancing the benefits and risks of blood transfusions in patients undergoing cardiac surgery: a propensity-matched analysis. Interact Cardiovasc Thorac Surg. 2013;17:96–102. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3. Faraj AA, Raghuvanshi M. The role of postoperative blood recovery for patients with femoral neck fracture. Acta Orthop Belg. 2006;72:11–14. [PubMed] [Google Scholar]
- 4. Liu W, Hui H, Zhang Y, Lin W, Fan Y. Intra-articular tranexamic acid injection during the hip hemi-arthroplasty in elderly patients: a retrospective study. Geriatr Orthop Surg Rehabil. 2018;9:2151459318803851. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5. Huang Z, Huang C, Xie J, et al. Analysis of a large dataset to identify predictors of blood transfusion in primary total hip and knee arthroplasty. Transfusion (Paris). 2018;58:1855–1862. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6. Yoshihara H, Yoneoka D. Predictors of allogeneic blood transfusion in total hip and knee arthroplasty in the United States, 2000-2009. J Arthroplasty. 2014;29:1736–1740. [DOI] [PubMed] [Google Scholar]
- 7. Bierbaum BE, Callaghan JJ, Galante JO, Rubash HE, Tooms RE, Welch RB. An analysis of blood management in patients having a total hip or knee arthroplasty. J Bone Joint Surg Am. 1999;81:2–10. [DOI] [PubMed] [Google Scholar]
- 8. Saleh A, Small T, Chandran Pillai ALP, Schiltz NK, Klika AK, Barsoum WK. Allogenic blood transfusion following total hip arthroplasty: results from the nationwide inpatient sample, 2000 to 2009. J Bone Joint Surg Am. 2014;96: e155. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9. Hart A, Khalil JA, Carli A, Huk O, Zukor D, Antoniou J. Blood transfusion in primary total hip and knee arthroplasty. Incidence, risk factors, and thirty-day complication rates. J Bone Joint Surg Am. 2014;96:1945–1951. [DOI] [PubMed] [Google Scholar]
- 10. Parvizi J, Chaudhry S, Rasouli MR, et al. Who needs autologous blood donation in joint replacement? J Knee Surg. 2011;24:25–31. [DOI] [PubMed] [Google Scholar]
- 11. Salt E, Wiggins AT, Rayens MK, et al. Risk factors for transfusions following total joint arthroplasty in patients with rheumatoid arthritis. J Clin Rheumatol Pract Rep Rheum Musculoskelet Dis. 2018; 24: 422–426. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12. Wong S, Tang H, de Steiger R. Blood management in total hip replacement: an analysis of factors associated with allogenic blood transfusion. ANZ J Surg. 2015;85:461–465. [DOI] [PubMed] [Google Scholar]
- 13. Spahn DR. Anemia and patient blood management in hip and knee surgery: a systematic review of the literature. Anesthesiology. 2010; 113: 482–495. [DOI] [PubMed] [Google Scholar]
- 14. Walsh M, Preston C, Bong M, Patel V, Di Cesare PE. Relative risk factors for requirement of blood transfusion after total hip arthroplasty. J Arthroplasty. 2007;22:1162–1167. [DOI] [PubMed] [Google Scholar]
- 15. Grosflam JM, Wright EA, Cleary PD, Katz JN. Predictors of blood loss during total hip replacement surgery. Arthritis Care Res Off J Arthritis Health Prof Assoc. 1995;8:167–173. [DOI] [PubMed] [Google Scholar]
- 16. Ogbemudia AE, Yee SY, MacPherson GJ, Manson LM, Breusch SJ. Preoperative predictors for allogenic blood transfusion in hip and knee arthroplasty for rheumatoid arthritis. Arch Orthop Trauma Surg. 2013;133:1315–1320. [DOI] [PubMed] [Google Scholar]
- 17. Aderinto J, Brenkel IJ. Pre-operative predictors of the requirement for blood transfusion following total hip replacement. J Bone Joint Surg Br. 2004;86:970–973. [DOI] [PubMed] [Google Scholar]
- 18. Salido JA, Marín LA, Gómez LA, Zorrilla P, Martínez C. Preoperative hemoglobin levels and the need for transfusion after prosthetic hip and knee surgery: analysis of predictive factors. J Bone Joint Surg Am. 2002;84:216–220. [DOI] [PubMed] [Google Scholar]
- 19. Hatzidakis AM, Mendlick RM, McKillip T, Reddy RL, Garvin KL. Preoperative autologous donation for total joint arthroplasty. An analysis of risk factors for allogenic transfusion. J Bone Joint Surg Am. 2000;82:89–100. [DOI] [PubMed] [Google Scholar]
- 20. Browne JA, Adib F, Brown TE, Novicoff WM. Transfusion rates are increasing following total hip arthroplasty: risk factors and outcomes. J Arthroplasty. 2013;28:34–37. [DOI] [PubMed] [Google Scholar]
- 21. Mauermann WJ, Shilling AM, Zuo Z. A comparison of neuraxial block versus general anesthesia for elective total hip replacement: a meta-analysis. Anesth Analg. 2006;103:1018–1025. [DOI] [PubMed] [Google Scholar]
- 22. Smeets SJM, Verbruggen JPAM, Poeze M. Effect of blood transfusion on survival after hip fracture surgery. Eur J Orthop Surg Traumatol. 2018;28:1297–1303. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23. Wang JK, Klein HG. Red blood cell transfusion in the treatment and management of anaemia: the search for the elusive transfusion trigger. Vox Sang. 2010;98:2–11. [DOI] [PubMed] [Google Scholar]
- 24. Hébert PC, Wells G, Blajchman MA, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med. 1999;340:409–417. [DOI] [PubMed] [Google Scholar]