Figure - available via license: CC BY-NC-SA
Content may be subject to copyright.
Source publication
Background
Perioperative blood loss and postoperative pain following total knee arthroplasty prevent early mobilisation of patients. The Enhanced Recovery Protocol (ERP) followed for patients in our institute aims at reducing post operative pain, blood loss and length of stay.
Materials and Methods
50 consecutive patients that underwent ERP follow...
Context in source publication
Context 1
... the patients had posterior stabilised knee prosthesis (Maxim®, Biomet, Inc. Warsaw, IN, USA) inserted by single surgeon (NMG). All patients had local anaesthetic infiltrated according to the regime 4 described in Table 3. Tourniquet was released before closure, and haemostasis obtained. ...Citations
... This study is in contrast with the finding that a solution of bupivacaine with epinephrine similar to the one used in the current study reduce blood loss in total knee arthroplasty [18]. Generally, solutions containing adrenaline were found to reduce perioperative blood loss in total knee arthroplasty [10,19,20], with some exceptions [11,17]. ...
This study evaluates the effect of local infiltration analgesia with bupivacaine and adrenaline on perioperative blood loss in total hip arthroplasty. Patients who had primary total hip arthroplasty were retrospectively assigned to two groups. One group had 100 ml of bupivacaine/adrenaline solution injected into periarticular soft tissues at the end of the procedure. There were 55 patients in the infiltrated hip group and 44 patients in the not infiltrated group. Patients’ hemoglobin level (Hb), hematocrit (HTC), red blood count (RBC), platelet count (PLT) and International Normalized Ratio (INR) as well as the need for blood transfusions were compared statistically between groups preoperatively and postoperatively. There were no significant differences between Hb, HTC or RBC levels as well as the rate and amount of blood transfusions on the 1 st , 4 th postoperative days or at patients’ discharge between infiltrated and not infiltrated groups. This study does not support the hypothesis that the use of local infiltration analgesia with adrenaline may reduce perioperative blood loss in total hip arthroplasty.
... In recent years, the concept of enhanced recovery after surgery (ERAS) has been widely used in TKA. The ERAS protocols can make patients' perioperative management much easier: patients with TKA have better recovery, less blood loss, less pain, and shorter hospital stay but do not increase the mortality of compilations [1][2][3][4]. ...
Background:
With the use of tranexamic acid and control of the blood pressure during the operation, total knee arthroplasty (TKA) without tourniquet can be achieved. There is no exact standard for the control level of blood pressure during no tourniquet TKA. We explored the optimal level of blood pressure control during no tourniquet TKA surgery with the use of tranexamic acid in this study.
Methods:
Patients underwent TKA were divided into three groups: the mean intraoperative systolic blood pressure in group A was < 90 mmHg, 90-100 mmHg in group B, > 100 mmHg in group C. Total blood loss (TBL), intraoperative blood loss, hidden blood loss, transfusion rate, maximum hemoglobin drop, operation time, and postoperative hospitalization days were recorded.
Results:
Two hundred seventy-eight patients were enrolled, 82 in group A, 105 in group B, and 91 in group C. Group A (663.3 ± 46.0 ml) and group B (679.9 ± 57.1 ml) had significantly lower TBL than group C (751.7 ± 56.2 ml). Group A (120.2 ± 18.7 ml) had the lowest intraoperative blood loss than groups B and C. Group C (26.0 ± 4.1 g/l) had the largest Hb change than groups A and B. Group A (62.3 ± 4.7 min) had the shortest operation time. The incidence rate of postoperative hypotension in group A (8, 9.8%) was significantly greater than groups B and C. No significant differences were found in other outcomes.
Conclusion:
The systolic blood pressure from 90 to 100 mmHg was the optimal strategy for no tourniquet primary TKA with tranexamic acid.
... This rising number of TKAs and an emerging trend towards enhanced recovery after TKA has prompted surgeons to seek safer perioperative management strategies, including effective blood management [20]. Blood loss after TKA is estimated to be approximately 1000 mL to 1500 mL, leading to anemia in about 10% to 38% of patients [6,11,13,14,18,19,41,43]. In patients who undergo bilateral TKA, the estimated total blood loss and the frequency of anemia are higher than in those with unilateral TKA, leading to at least a threefold increase in the use of allogenic blood transfusion [25,35]. ...
Background:
Tranexamic acid (TXA) is efficacious for reducing blood loss and transfusion use in patients who undergo bilateral TKA, and it is administered intravenously alone, intraarticularly alone, or as a combination of these. However, it is unclear whether combined intravenous (IV) and intraarticular TXA offers any additional benefit over intraarticular use alone in patients undergoing bilateral TKA.
Questions/purposes:
The purposes of our study was to determine (1) whether combined IV and intraarticular TXA reduces blood loss and blood transfusion use compared with intraarticular use alone and (2) whether the frequency of adverse events is different between these routes of administration in patients who undergo simultaneous or staged bilateral TKA.
Methods:
Between April 2015 and May 2017, one surgeon performed 316 same-day bilateral TKAs and 314 staged bilateral TKAs. Of those, 98% of patients in each same-day TKA (310) and staged bilateral TKA (309) groups were eligible for this randomized trial and all of those patients agreed to participate and were randomized. The study included four groups: simultaneous TKA with intraarticular TXA only (n = 157), simultaneous TKA with IV and intraarticular TXA (n = 153), staged TKA with intraarticular TXA only (n = 156), and staged TKA with IV and intraarticular TXA (n = 155). There were no differences in demographic data among the intraarticular alone and IV plus intraarticular TXA groups of patients who underwent simultaneous or staged bilateral TKA in terms of age, proportion of female patients, BMI, or preoperative hematologic values. The primary outcome variables were total blood loss calculated based on patient blood volume and a drop in the hemoglobin level and administration of blood transfusion. The secondary outcomes of this study were a decrease in the postoperative hemoglobin level; the proportion of patients with a hemoglobin level lower than 7.0, 8.0, or 9.0 g/dL; and the frequencies of symptomatic deep vein thrombosis, symptomatic pulmonary embolism, wound complications, and periprosthetic joint infection.
Results:
Total blood loss with intraarticular TXA alone in patients undergoing simultaneous bilateral TKA and those undergoing staged procedures was not different from the total blood loss with the combined IV plus intraarticular TXA regimen (1063 mL ± 303 mL versus 1004 mL ± 287 mL, mean difference 59 mL [95% CI -7 to 125]; p = 0.08 and 909 ml ± 283 ml versus 845 ml ± 278 ml; mean difference 64 mL [95% CI 1 to 127]; p = 0.046, respectively). The use of blood transfusions between intraarticular alone and combined IV and intraarticular TXA was also not different among patients undergoing simultaneous (0% [0 of 152] versus 1%; p = 0.149) and staged TKA (1% [1 of 155] versus 0% [0 of 153]; p = 0.98). Furthermore, the frequency of symptomatic thromboembolic events, wound complications, and periprosthetic joint infections was low, without any differences among the groups with the numbers available.
Conclusion:
Because there was no difference between intraarticular alone and combined intraarticular plus IV regimen of TXA administration, we recommend that IV and intraarticular TXA should not be used in combination. Moreover, other studies have found no differences between intraarticular and IV TXA used alone, and hence to avoid potential complications associated with systemic administration, we recommend that intraarticular alone is sufficient for routine TKA.
Level of evidence:
Level I, therapeutic study.
... With the aging population, there has been a marked increase in the number of joint arthroplasty in recent years. However, TKA was associated with major bleeding ranging from 460 to 920 ml [3][4][5]. Postoperative anemia may cause many adverse events, including increased mortality and morbidity and prolonged hospitalization due to transfusion-related needs. Several effective strategies have been used for the perioperative blood management, including hemostatic agent administration, hypothermic anesthesia, tourniquet and minimally invasive procedures [6,7]. ...
Background
The efficacy of modified Robert Jones bandage in primary total knee arthroplasty (TKA) is controversial. On the basis of randomized controlled trials (RCTs), this systematic review and meta-analysis was conducted to evaluate the modified Robert Jones bandage in TKA.
Methods
The electronic databases of EMBASE, PubMed, Web of Science and Cochrane Library were searched from the inception to November 2018 for all relevant English studies. The outcome measurements consisted of total blood loss, hemoglobin decline, transfusion rates, pain score, range of motion, length of hospitalization, knee circumference difference, and adverse effects. Data were analyzed using STATA 14.0 software (The Cochrane Collaboration, Oxford, United Kingdom).Quality assessment was conducted according to the Cochrane Handbook for systematic review of interventions.
Results
A total of 5 randomized controlled trials (RCTs) were included in the systematic review and meta-analysis. The present meta-analysis indicated that there were no significant differences in terms of total blood loss, hemoglobin decline, transfusion rates, pain score, range of motion, length of hospitalization, knee circumference difference, or adverse effects.
Conclusions
Although published articles have shown improved outcome of blood loss, pain, and knee swelling after application of a modified Robert Jones bandage, our study suggest the use of modified Robert Jones bandage may not be necessary after primary TKA.
... [1] It has been estimated that more than 500,000 total joint arthroplasties are performed annually in China. [2] However, the process is associated with perioperative major blood loss with an average volume of 560 to 1474 ml in TKA [3][4][5] and 655 to 1520 mL in THA [6][7][8] which delays rehabilitation, functional recovery, and hospital discharge. ...
Background:
To assess the effectiveness and safety of intravenous aminocaproic acid for blood management after total knee and hip arthroplasty.
Methods:
Electronic databases: PubMed (1950.1-2018.8), EMBASE (1974.1-2018.8), the Cochrane Central Register of Controlled Trials (CENTRAL, 2017.10), Web of Science (1950.1-2018.8), and CNKI (1980.1-2018.8) were systematically searched for clinical controlled trials comparing intravenous aminocaproic acid and placebo after joint arthroplasties. Heterogeneity was assessed using the chi-square test and I-square statistic. The meta-analysis was performed using STATA 12.0 (College Station, TX).
Results:
Six studies with 756 patients were included. Our meta-analysis revealed that there were significant differences between aminocaproic acid and placebo in terms of total blood loss (SMD = -0.673, 95% CI: -0.825 to -0.520, P <.001), hemoglobin reduction (SMD = -0.689, 95% CI: -0.961 to -0.418, P <.001), drain output (SMD = -2.162, 95% CI: -2.678 to -1.646, P <.001) and transfusion rates (RD = -0.210, 95% CI: -0.280 to -0.141, P <.001).
Conclusion:
Aminocaproic acid results in a significant reduction of total blood loss, postoperative hemoglobin decline and transfusion requirement in patients undergoing arthroplasties. Due to the limited quality of the evidence currently available, the results of our meta-analysis should be treated with caution.
... 19 Dhawan et al in their consecutive study found female predominance in both group but average age 72 for males and 69 for females in group 1(NON ERP) and in group 2 (ERP) average age for male and female was 71 years, which is different from our study. 20 Hertog et al in their randomized prospective study had predominace of female in both groups and average age of 68.25 in control group and 66.58 in fast track group. 21 The minimum length of stay of our study was 4 days and maximum length of stay was 9 days for group I with mean length of stay 5.69. ...
p class="abstract"> Background: Comparison of functional outcome at three month follow up using knee society score in patients undergoing total knee replacement by ERP and Non ERP.
Methods: In this prospective study of 29 patients in group (II) who underwent total knee arthroplasty using Enhanced recovery protocol and compared with 29 patients in control group (I) whose data was obtained from hospital database in Lilavati Hospital & Research Centre, Mumbai.
Results: The majority of the patients were from the age group of 61-70 years in both group I & II. There was female predominance in our study. The mean length of stay for group I was 5.69 days and for group II 3.28 days. The average knee clinical score in group I was pre op 33.52 which improved to an average post-op score of 82.62 at 3 months and for group II it improved from 34.21 to 84.66 at 3 months. The average pre-op knee functional score was 43.28 which improved to an average post-op score of 85.00 at 3 months in study group II. The average pre-op Knee Society Score was 77.14 which improved to an average post-op score of 169.66 at 3 months follow up for group II.
Conclusions: The results of the present study showed that patients who underwent TKA using ERP protocol has reduced length of stay in hospital, significantly improved KSS proving TKA as an effective procedure that is associated with substantial functional improvement.</p
Background
Short-stay joint replacement programmes are used in many countries but there has been little scrutiny of safety outcomes in the literature. We aimed to systematically review evidence on the safety of short-stay programmes versus usual care for total hip (THR) and knee replacement (KR), and optimal patient selection.
Methods
A systematic review and meta-analysis. Randomised controlled trials (RCTs) and quasi-experimental studies including a comparator group reporting on 14 safety outcomes (hospital readmissions, reoperations, blood loss, emergency department visits, infection, mortality, neurovascular injury, other complications, periprosthetic fractures, postoperative falls, venous thromboembolism, wound complications, dislocation, stiffness) within 90 days postoperatively in adults ≥ 18 years undergoing primary THR or KR were included. Secondary outcomes were associations between patient demographics or clinical characteristics and patient outcomes. Four databases were searched between January 2000 and May 2023. Risk of bias and certainty of the evidence were assessed.
Results
Forty-nine studies were included. Based upon low certainty RCT evidence, short-stay programmes may not reduce readmission (OR 0.95, 95% CI 0.12–7.43); blood transfusion requirements (OR 1.75, 95% CI 0.27–11.36); neurovascular injury (OR 0.31, 95% CI 0.01–7.92); other complications (OR 0.63, 95% CI 0.26–1.53); or stiffness (OR 1.04, 95% CI 0.53–2.05). For registry studies, there was no difference in readmission, infection, neurovascular injury, other complications, venous thromboembolism, or wound complications but there were reductions in mortality and dislocations. For interrupted time series studies, there was no difference in readmissions, reoperations, blood loss volume, emergency department visits, infection, mortality, or neurovascular injury; reduced odds of blood transfusion and other complications, but increased odds of periprosthetic fracture. For other observational studies, there was an increased risk of readmission, no difference in blood loss volume, infection, other complications, or wound complications, reduced odds of requiring blood transfusion, reduced mortality, and reduced venous thromboembolism. One study examined an outcome relevant to optimal patient selection; it reported comparable blood loss for short-stay male and female participants (p = 0.814).
Conclusions
There is low certainty evidence that short-stay programmes for THR and KR may have non-inferior 90-day safety outcomes. There is little evidence on factors informing optimal patient selection; this remains an important knowledge gap.
Background
Hidden blood loss (HBL) unrecognized by the usual practice of assessing intraoperative loss and postoperative drainage comprises a considerable proportion of total blood loss (TBL) during primary total knee arthroplasty (TKA). However, HBL has not been adequately investigated in hybrid TKA (uncemented femur, cemented tibia). The purpose of this study was to clarify the amount and influential factors of HBL in hybrid TKA.
Methods
A consecutive series of 151 knees in 137 patients with knee osteoarthritis who underwent hybrid TKA were retrospectively evaluated. We examined the correlations between HBL and various factors of concern for their effects on TBL, including age, sex, body weight (BW), body height, body mass index, operation time, tourniquet time, and visible blood loss (VBL) in three periods (intraoperative: VBL1; until 3 h postoperatively: VBL2; from 3 h to 1 day postoperatively: VBL3).
Results
Median (interquartile range) HBL and TBL were 528 (388, 711) mL and 725 (582, 926) mL, respectively. HBL relative to TBL (H/T) was 73%. There were weak correlations between HBL and BW (r = 0.249, p = 0.002) and between HBL and VBL3 (r = −0.261, p = 0.001). Multivariate analyses confirmed a positive correlation between HBL and BW (β = 0.296, p < 0.001) and a negative correlation between HBL and VBL3 (β = −0.270, p < 0.001).
Conclusions
Hybrid TKA showed comparable values of HBL and H/T to those reported for cemented TKA. Therefore, management strategies for HBL in hybrid TKA can follow the same protocols used for cemented TKA. High BW and low VBL3 may be predictors of postoperative HBL in hybrid TKA.
