Abstract
Despite several blood management strategies available, blood transfusion rates following total hip arthroplasty remain high. Therefore, this study evaluated transfusion rates following bilateral hip arthroplasty via direct anterior approach using a multimodal blood loss management approach for 213 consecutive patients. All patients received standard surgical and post-operative procedures, with allogenic transfusion performed if hemoglobin was less than 8.0 g/dL with persistent clinical symptoms. Thirty-two patients (15%) required transfusion, with those patients significantly older and had lower pre-operative hemoglobin compared to non-transfusion patients. This transfusion rate was much lower than previous literature and could be an appropriate, multimodal blood loss management strategy.
Keywords: One-stage bilateral total hip arthroplasty, Transfusion, Blood loss management, Direct anterior approach
1. Introduction
One-stage bilateral total hip arthroplasty (BTHA) has several proposed advantages over a two-staged procedure, including shorter operating time under only a single anesthetic event and shorter recovery time.1, 2, 3, 4, 5, 6 The safety and efficacy of one-stage BTHA has been demonstrated in the literature with low incidence of perioperative complications.7,8 However, concerns regarding increased blood loss and blood transfusion requirements persist, as a recent study of 347 consecutive BTHAs demonstrated a greater than 6 times increase in transfusion rate with one-stage compared to two stage BTHA.9 Multiple strategies have be utilized to mitigate allogenic transfusions and associated risks, such as erythropoietin use (EPO),10 preoperative autologous donation (PAD)11,12 and cell salvage.13,14 Although these procedures may reduce the incidence of allogenic transfusions, autologous transfusion rates ranged from 33% to 90% of patients.15,16 Autologous transfusions have been associated with additional complication risks, including electrolyte imbalance, air or fat embolism, and acute lung or renal injury.17 The optimal strategy or combination of strategies to reduce blood loss and need for allogenic transfusions is not yet clearly defined.
To mitigate these complication risks, a variety of blood management strategies have been suggested to limit intraoperative blood loss and subsequently decrease the incidence of transfusions. These include hypotensive anesthesia and regional anesthesia,18 tranexamic acid (TXA)19, 20, 21, 22 and bipolar sealant technologies.23 Previous research has identified each of these strategies as effective methods for decreasing intraoperative blood loss and/or transfusion rates, without the added risk factors associated with transfusions. However, these studies are commonly heterogenous in their blood management strategies, evaluate small cohorts of patients and, in some cases, lack adequate description of their blood management strategies. Additionally, these studies often evaluate hip arthroplasty without regard to surgical approach. The current study site utilizes these simple intraoperative techniques simultaneously to control bleeding for all patients undergoing one stage BTHA via DAA. Therefore, the purpose of this study was to define current blood management protocol used at the current study site and to evaluate the transfusion rates in a large unselected consecutively performed cohort of one stage DAA BTHA.
2. Materials and methods
This retrospective, institutional review board approved analysis included a consecutive cohort of unselected patients having undergone primary one stage BTHA via DAA between May 2013 and October 2019 at a multi-specialty community hospital. All patients met the standard indications for primary BTHA and patients were not excluded from surgery based on demographic or comorbidity status. Revision THA or those performed for femoral neck fractures were not included.
All surgeries were performed by an experienced, fellowship trained orthopedic surgeon using the DAA as described by Matta et al.24 with a specialized fracture table (Hana®, Mizuho OSI, Union City, CA) and intraoperative fluoroscopy. All patients underwent the same DAA THA procedure, with the left hip arthroplasty performed and completed first as part of the standard protocol. Once completed and closed, the operating room was prepared to complete the right hip and a new instrument set was prepared. The time between ending the left hip and starting the right hip surgery is approximately 30–40 min. Due to the high volume nature at the study site, the senior surgeon routinely performed a unilateral knee arthroplasty while the right hip was being prepared for surgery.
Prior to surgery, all patients received appropriate antibiotic prophylaxis dosed by body weight and given 1000 mg of acetaminophen, unless contraindicated. Patients did not undergo autologous donation prior to surgery nor did they receive medications to increase red blood cell concentration such as EPO prior to surgery. Either a paravertebral or a quadratus lumborum block at the discretion of the performing anesthesiologist was given prior to induction, with a max dose (divided in half) containing bupivacaine 0.5% (20 cc), epinephrine (100mcg) and Clonidine (1mcg/kg). All patients received a pericapsular injection with a max dose (divided in half) of bupivacaine 0.15% (1 cc/kg) and toradol (30 mg). Surgery was performed under general anesthesia as the preferred method and spinal anesthesia was utilized at the discretion of the anesthesiologist. All patients received 1 g of intravenous TXA prior to incision and before closure of the arthrotomy.
A bipolar sealant device (Aquamantys™ Bipolar Sealer, Medtronic, Minneapolis, MN) was used to treat the circumflex vessels and branches extending laterally into the tensor fascia latae before incising the vessels. The bipolar sealant was also used to treat bleeding in the saddle region of the lateral femoral neck and release of the capsule near the inferior medial femoral neck area. The femoral neck was cut in situ with a reciprocating saw and bone wax was then placed over the cut proximal femur to minimize bleeding. The bipolar sealant was used to treat the foveal contents before removal with electrocautery and the branch of the obturator vessel if bleeding was encountered. Following acetabular reaming, topical TXA was placed in the wound and sponges were used to tamponade acetabular bleeding while the acetabular component was being readied. A solid acetabular cup was used in nearly 100% of cases and implanted with fluoroscopic guidance. A broach only technique was used following removal of the bone wax. Following implantation of the final implants, the capsule was closed using interrupted braided suture. The fascia over the tensor fascia latae was closed using a running barbed suture and the subcutaneous layer closed with either interrupted braided suture or a running barbed suture. Final wound closure was completed using either monocryl and dermabond or a zipper method (ZipLine® Medical, Silicon Valley, CA). Dressings consisted of gauze and paper tape over the incision area only. No patient received a Foley catheter, thromboembolic stockings or a wound drain. Red cell salvage suction technologies were not used for any patient. Upon wound closure, each patient was given dexamethasone (4 mg) intravenously to control post-operative nausea.
Immediate post-operative pain was managed with intravenous hydromorphone (0.2 mg) as deemed necessary by post anesthesia staff. After the patient was fully awake, acetaminophen (1000 mg) was given for primary pain management. Break through pain was treated with tramadol (50 mg) or oxycodone (5 mg) only upon patient request until discharge as needed. Post-operative nausea was symptomatically treated with anti-emetics as needed. Intermittent mechanical foot compression was used for all patients until discharge and deep vein thrombosis chemoprophylaxis included aspirin (325 mg) for six week unless contraindicated. Patients who were on pre-operative anticoagulation for other medical reasons were allowed to restart the same medication on post operative day one. Patients with a history of thrombosis or similar events were preferentially given low molecular weight heparin (40 mg subcutaneously daily for 10 days) or 10 mg of rivaroxaban for 21 days following surgery.
All patients were seen by a physical therapist and a dedicated orthopedic acute care nurse practitioner (ACNP) to determine discharge disposition. Immediate full, unrestricted weight bearing was allowed as tolerated. Discharge criteria included the ability to walk 50 feet with an assistive device, adequate pain and nausea control, hemodynamic stability, and, if stairs were present in the home environment, successfully navigation one flight of stairs. If patients could not prove safe, independent function the patient was kept overnight and discharged when safe function could be demonstrated. Transfer to an acute care rehabilitation facility or skilled nursing facility was arranged if the patient could not demonstrate safe, independent post-operative function within one to two days.
Prior to each physical therapy session, patients were evaluated for orthostatic hypotension or other signs of symptomatic anemia. The criteria for allogenic blood transfusion was symptomatic anemia defined as hemoglobin less than 8.0 g/dL associated with persistent orthostatic hypotension, tachycardia, hypoxia unaffected by fluid resuscitation or medication management (such as holding antihypertensive medications or narcotic medications) which interfered with physical therapy participation. The experienced dedicated ACNP responsible for medical management of all arthroplasty patients, along with the orthopedic team input ultimately decided on transfusion requirements for each patient based on the above criteria and medical comorbidities and risk factors.
Patient demographics were collected for each patient at the time of surgery, including age, body mass index, and American Society of Anesthesiologists’ (ASA) classification. Preoperative comorbidities were also grouped by system, including cardiac, renal and hepatic conditions. Cardiac conditions included diagnosed coronary artery disease, mitral valve prolapse, cardiac stent, or previous transient ischemic attack. Renal conditions only included diagnosed chronic renal insufficiency. Liver conditions included hepatitis B or C and fatty liver disease. Perioperative data reviewed included any adverse events during or immediately following surgery, estimated blood loss (EBL), surgical time, transfusions required, hospital length of stay and discharge disposition. Hemoglobin and hematocrit values were obtained preoperatively within 30 days prior to surgery, immediately postoperatively in the post anesthesia care unit and every morning during hospitalization until discharge. Perioperative complications were defined as any wound or systemic complication arising within six weeks following surgery. Complications were recorded from emergency room visits, readmissions or self-reported at six week follow-up visit.
Data were separated by the presence or absence of post-operative transfusion requirement. Descriptive statistics for all outcome variables, including mean, standard deviation and ranges, were determine for each group. Independent t-tests (continuous variables) and Chi-square tests (categorical variables) were performed to determine differences between groups. All statistical tests were performed using SPSS v25, with a significance level of p < 0.05.
3. Results
Of the 213 patients (426 hips), 31 (14.6%) required allogenic blood transfusion. Results were subdivided into these two groups: requiring transfusion (T group) and not requiring transfusion (NT group). Patient demographics were similar between groups and are presented in Table 1. There were no significant differences in the presence of cardiac, renal or hepatic disease and no difference in the long term, pre-operative use of anti-coagulants. Additionally, average length of stay was longer in the T group at 3.26 days compared to 2.06 days in the NT group (p < 0.001).
Table 1.
Patient demographics and descriptive variables - mean (SD)/%.
| Transfusion (N = 31) | No Transfusion (N = 182) | p-value | |
|---|---|---|---|
| Age (years) | 66.84 (8.8) | 63.34 (10.4) | 0.079 |
| BMI (kg/m^2) | 25.89 (5.2) | 26.76 (5.3) | 0.402 |
| Gender | |||
| Male | 29.0% | 45.1% | 0.069 |
| Female | 71.0% | 54.9% | |
| ASA | |||
| 1 | 0.0% | 3.8% | 0.680 |
| 2 | 58.1% | 58.2% | |
| 3 | 41.9% | 37.4% | |
| 4 | 0.0% | 0.5% | |
| Comorbidity | |||
| Heart | 12.9% | 11.0% | 0.475 |
| Kidney | 6.5% | 3.8% | 0.386 |
| Liver | 6.5% | 4.4% | 0.442 |
| Pre-Op Meds | |||
| Aspirin | 16.1% | 12.6% | 0.627 |
| Anti-Coag | 0.0% | 2.2% | |
| Post-Op Meds | |||
| Aspirin | 71.0% | 71.4% | 0.940 |
| Anti-Coag | 25.8% | 26.4% | |
| Disposition | |||
| Home | 38.7% | 57.7% | 0.116 |
| Inpatient RF | 58.1% | 41.2% | |
| SNF | 3.2% | 1.1% | |
| LOS (days) | 3.26 (1.3) | 2.06 (1.1) | <0.001 |
N = number of patients; SD = standard deviation.
BMI = body mass index.
ASA = American Society of Anesthesiologists.
LOS = length of stay; RF = rehabilitation facility.
SNF = short term nursing facility.
Anti-Coag = anticoagulation.
Mean intraoperative EBL was 435.5 mL and 379.8 mL in the T and NT groups, respectively (p = 0.002), although surgical time was not significantly different (p = 0.256) (Table 2). There was no significant difference in intraoperative blood pressure (p > 0.062), fluids given (p = 0.392) and no intraoperative transfusions were required.
Table 2.
Operative variables - mean (SD)/%.
| Transfusion (N = 31) | No Transfusion (N = 182) | p-value | |
|---|---|---|---|
| Anesthesia | |||
| General | 87.1% | 91.2% | 0.328 |
| Spinal | 12.9% | 8.8% | |
| Intraoperative | |||
| Mode Systolic | 104.2 (10.6) | 100.5 (9.9) | 0.062 |
| Mode Diastolic | 56.3 (9.3) | 52.6 (7.8) | 0.086 |
| Peak Systolic | 147.4 (15.9) | 147.2 (21.7) | 0.953 |
| Peak Diastolic | 83.0 (14.4) | 83.9 (10.4) | 0.984 |
| EBL (cc) | 435.5 (101.8) | 379.8 (90.1) | 0.002 |
| Fluids Given | 1525.8 (525.3) | 1447.5 (460.3) | 0.392 |
| Surigcal Time (min) | 166.3 (32.6) | 172.3 (26.5) | 0.256 |
SD = standard deviation; N = number of patients.
EBL = estimated blood loss; cc = cubic centimeters.
min = minute.
The average pre-operative hemoglobin and hematocrit was significantly lower in the T group compared to the NT group (p < 0.001) (Table 3). Hemoglobin and hematocrit remained lower in the T group patients compared to the NT group at both the immediate post-operative and for the lowest drawn values during the hospital stay (p < 0.001). The average pre-discharge hemoglobin and hematocrit remained lower in the T group compared to the NT group (p < 0.001).
Table 3.
Perioperative hemoglobin and hematocrit - mean (SD)/%.
| Transfusion (N = 32) | No Transfusion (N = 181) | p-value | |
|---|---|---|---|
| Pre-Operative | |||
| Hgb (g/dL) | 12.3 (1.9) | 13.8 (1.5) | <0.001 |
| Hct (%) | 37.3 (5.2) | 41.2 (4.8) | <0.001 |
| Post-Op | |||
| Immediate Hgb (g/dL) | 10.0 (1.5) | 12.0 (1.5) | <0.001 |
| Immediate Hct (%) | 29.9 (4.7) | 35.7 (4.3) | <0.001 |
| Lowest Hgb (g/dL) | 8.1 (0.9) | 10.4 (1.6) | <0.001 |
| Lowest Hct (%) | 24.0 (2.6) | 30.7 (4.6) | <0.001 |
| Pre-Discharge | |||
| Hgb (g/dL) | 9.3 (1.1) | 10.6 (1.5) | <0.001 |
| Hct (%) | 27.6 (3.1) | 31.2 (4.5) | <0.001 |
SD = standard deviation; N = number of patients.
Hgb = hemoglobin; Hct = hematocrit; g/dL = grams per deciliter.
Immediate = first post-operative draw.
Lowest = lowest post-operative draw during total hospital stay.
Post-operative orthostatic hypotension was more commonly reported in the T group (64.5%) compared to the NT group (30.8%) (p < 0.001) (Table 4). Although not significant, patients in the T group more commonly experienced post-operative vomiting compared to the NT group (12.9% and 4.4%, respectively) (p = 0.078). However, there was no difference in systemic (p = 0.100) or wound (p > 0.85) complications occurring within the first 90-days post-operatively.
Table 4.
Post operative complications within 90 Days.
| Required Transfusion (N = 31) | No Transfusion (N = 182) | p-value | |
|---|---|---|---|
| Orthostatic Hypotension | 64.5% | 30.8% | <0.001 |
| Post-Operative Vomiting | 12.9% | 4.4% | 0.078 |
| Deep Infection | 0.0% | 0.0% | 1.000 |
| Superficial Infection | 0.0% | 0.5% | 0.854 |
| Death | 0.0% | 0.0% | 1.000 |
| Pulmonary Embolism | 0.0% | 0.0% | 1.000 |
| Deep Vein Thrombosis | 0.0% | 0.0% | 1.000 |
N = number of patients.
4. Discussion
Perioperative blood loss is a significant concern for one-stage BTHA, as blood transfusions introduce significant health risks, including blood-borne infections, hemolytic transfusion reactions, transfusion related acute lung injury and other disruptions to the host's immune system.11 Reducing transfusion requirements when performing one stage BTHA continues to be problematic, as approximately 26.6% of DAA BTHA patients have been reported to require a transfusion.25 Many strategies are currently available to decrease allogenic transfusion rates, with perhaps the most common strategy being the use of cell salvage systems. Although previous research evaluating the cell salvage system report low allogenic transfusion rates, autologous transfusion rates ranged from 33% to 90% of patients.15,16 In the current study, the implementation of multiple intraoperative blood loss management strategies resulted in required transfusions in only 14.6% of DAA BTHA patients. Based on these results, the use these strategies to reduce the amount of intraoperative blood loss may be an effective strategy to decrease the incidence of autogenic or allogenic transfusion.
In an effort to control intraoperative and post-operative bleeding, the current study site uses TXA at multiple time points during all DAA BTHAs. It is generally accepted that TXA administered to arthroplasty patients is effective in limiting blood loss and decreasing the incidence of required transfusion but the administration route is still controversial.26,27 In the current study, patients received pre- and intra-operative intravenous TXA, which has been shown to be an effective method of administration to decrease transfusion rates. Topical TXA was also used in the current study following reaming and during wound closure. Although topical TXA alone may not decrease transfusion rates, its use in combination with intravenous TXA may provide further protection against transfusion.27
In addition to TXA, a bipolar sealer was used in the current study throughout the procedure to control small and larger vessel bleeding. The effectiveness of the bipolar sealant remains inconclusive,23 but its use during DAA unilateral total hip arthroplasty has been shown to decrease intraoperative blood loss and transfusion rate.28 When combined with other blood management strategies, such as TXA, the individual contribution of the bipolar sealant may no longer be significant.29 Although a general conclusion on the effectiveness of the individual strategies cannot be made, the bipolar sealer was used in combination with TXA in the current study, to provide added control over intraoperative blood loss.
The final strategy implemented in the current study was the use of hypotensive general anesthesia supplemented with regional nerve blocks. Hypotensive general anesthesia alone may not decrease intraoperative blood loss,30 however, regional nerve blocks have been reported to decrease both intraoperative blood loss and transfusion rates.31 The use of both strategies in the current study resulted in mean intraoperative systolic pressures of approximately 100 mmHg in both the transfused and non-transfused groups. As previously mentioned, the individual contributions of these strategies cannot be determined. However, a previous study, including a small cohort of DAA BTHAs, EBL was 473 mL and 23% of patients required allogenic transfusion following DAA BTHA, in which TXA and general anesthesia was used.32 Compared to results of the current study, the addition of a regional block and bipolar sealer resulted in a mean EBL of less than 400 mL and a transfusion rate of 15%. The regional block administered in the current study could have attributed to the low intraoperative blood pressure, limiting overall blood loss which subsequently decreased the transfusion rate. Further studies should evaluate the relationship.
A potential confounding factor in the current study was the significantly lower pre-operative hemoglobin and hematocrit levels in patients requiring transfusions. This is of interest since only four patients in the T group had pre-existing diagnoses of anemia. Patients who were transfused were significantly older than the NT group. It has been well documented that hemoglobin levels steadily decline with age for both genders,33 which may be supported in the current study. Based on these results, perhaps a definable age or preoperative hemoglobin level can help identify high transfusion risk patients, allowing for pre-operative screening and treatment for anemia to occur several months prior to surgery.
There are a few limitations for the current study. First, all procedures were completed by the same arthroplasty surgeon, performing approximately 800 arthroplasties per year. Additionally, these procedures were completed in a small, tertiary hospital setting with consistent operating room and anesthesiology teams. The consistency and high volume in which these procedures were performed may limit the generalizability to all surgical sites. Secondly, this was a retrospective chart review for all BTHAs in the given time frame. Although the standard of care was relatively stable over the study period, small changes to staff and procedures could have occurred. Finally, clinical indications for blood transfusion were described in the methods but, ultimately, the determination for transfusion involved clinical judgment by the hospital staff. The guidelines and clinical judgement may be difficult to generalize for all settings and may influence the differences in transfusion rate.
5. Conclusion
The results from this study suggest the implementation of blood loss management strategies during DAA BTHAs may result in a lower risk of allogenic blood transfusion than previously reported in literature. While further studies will be necessary to determine the influence of individual blood management strategies, the use of intravenous and topical TXA, bipolar sealant and regional anesthetic blocks may mitigate intraoperative blood loss, resulting in lower incidence of transfusions. These strategies provide an effective and efficient multimodal approach to blood loss management during DAA BTHA, which is critical to decreasing the risk of autogenic or allogenic transfusion and their respective associated risk factors.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Declaration of competing interest
No authors have conflict of interests to report.
References
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