In 1962, Sir John Charaley introduced the modern concept of total hip arthroplasty (THA).1 Initially, the technique was indicated for older patients with disabling arthritis of the hip and for whom the only alternative was a resection arthroplasty. The excellent results reported by Charnley in the early 1970s resulted in widespread acceptance of THA. Additionally, the use of polymethylmethacrylate (PMMA) for component fixation and polyethylene for bearing surfaces has revolutionized arthroplasty. Now the procedure is being offered to younger and more active patients. As a result of this and of the increasing number of total hip replacements performed, there is a rising need for revision operations resulting from mechanical failure, loosening, and wear of the components and significant bone loss resulting from osteolysis triggered by debris particles. Thus, in hips with failed arthroplasties, we are now seeing some of the most challenging reconstruction problems in the history of orthopedic surgery. It is this bone loss from the femur and pelvis that makes revision THA such a challenging undertaking.
Not all THA revisions are created equal. Less difficult revisions require only the exchange of a modular acetabular polyethylene and femoral head to repair excessive wear. These revisions are done before osteolysis becomes severe and before the components are loosened from the bone. More complex cases require revision of both components along with extensive allografting of the pelvis and the femur and may take several hours of surgery to complete. Despite the great variability, most revision THAs involve greater exposure of bone and soft tissues, require increased operating room time, and involve higher levels of surgical complexity than primary arthroplasties. Because of these factors, revision THA typically results in greater perioperative blood loss.
For revision THA, the average total blood loss has been reported to be approximately 4.0 units ±2.1 units,2 and the average perioperative transfusion rate has been estimated at 2.9 units ± 2.3 units.2 These averages are based on revision operations of various complexities. At our institution, we perform many complicated hip revision operations and, therefore, tend to see higher than average blood loss and transfusion rates. Occasionally, revision operations are more complicated than anticipated, and require more surgical time and blood loss than expected. Even if predonated autologous blood is available in such cases, the need for allogeneic blood transfusion may still arise. Bierbaum estimated that revision THA has a 21% rate of breakthrough transfusion (the need for allogeneic blood in addition to predonated autologous blood).3
Although the risk of allogeneic blood transfusion is not limited to the risk of transfusion-transmitted human immunodeficiency virus (HTV), this is what most concerns our patients. Although the risks of transmitting HTV and other disease-causing viruses (e.g., hepatitis B and C, cytomegalovirus, Epstein-Barr virus) have diminished with improved blood testing, physicians continue to be concerned about these risks, as well as the risks of transfusion reactions, alloimmunization, and immunomodulation.4"6
A separate but emerging concern is the progressive shortage of blood. It is projected that by the year 2030, there will be a shortage of 4 million units of red blood cells (RBCs).7 Currently, in Los Angeles County, frequent severe blood shortages have threatened to limit the scheduling of elective surgery. It is these concerns and the greater anticipated blood loss that make blood management such a challenge in revision hip arthroplasty.
BLOOD MANAGEMENT OPTIONS
Management Goals. The goals of blood management in revision THA are to reduce blood loss and the dependence on allogeneic blood transfusion. Achieving these goals will optimize patient outcomes. The strategy to reduce the need for allogeneic blood should include knowing the patient's risk of perioperative bleeding. A thorough bleeding history should be obtained from the patient, which, together with determinations of clotting times and related tests, should reveal any patient-specific problems that may lead to excessive blood loss. Additionally, 1 week prior to surgery the patient should be instructed to stop taking anticoagulation medications, nonsteroidal anti-inflammatory drugs, aspirin, and any medication containing aspirin.
Reducing Perioperative Blood Loss. In addition to patient screening and limitation of certain medications, another blood management strategy is to reduce perioperative blood loss. Reducing surgical time is one way to accomplish this. Careful preoperative planning and preparation of implants will decrease waiting and decision-making time intraoperatively. In addition, a welltrained and experienced staff will increase the efficiency of the operating room and markedly decrease the length of the procedure.
To reduce perioperative blood loss, it is also imperative to maintain meticulous hemostasis during surgery. Coagulation techniques, such as electrocautery, and ligation of vessels before cutting should be used whenever possible. Exposed cancellous bone bleeds readily and should be packed when surgical work is not focused in that area. Occasional use of bone wax can also help decrease bone bleeding. Antifibrinolytie agents that help control bleeding are also available;8 however, our experience with these is limited.
In addition to careful hemostasis, several additional techniques for reducing perioperative bleeding are available, including hypotensive epidural anesthesia,9,10 normovolemic hemodilution,1 U2 and intraoperative blood salvage.13,14 By lowering the blood pressure, hypotensive epidural anesthesia reduces bleeding and improves visualization at the surgical site.9 An added benefit of epidural anesthesia is that the epidural catheter can be left in place postoperatively for administering pain control medications. We use this method for nearly all revision and primary hip arthroplasties.
Acute normovolemic hemodilution involves diluting the blood by removing whole blood from the patient at the beginning of the surgery and replacing it with colloid or crystalloid fluid.11 Therefore, blood lost during surgery has a lower concentration of RBCs. The whole blood removed early in the operation is transfused either at the end of surgery when blood loss has diminished, or during the surgical procedure if the patient requires it. One disadvantage to this method is that it increases total surgical time and, if performed routinely, can slow down the schedule of a high-volume practice. Nevertheless, from our experience, this technique is effective at reducing perioperative blood loss. Although it is contraindicated for patients with coronary artery disease, renal disease, pulmonary disease, or significant hepatic disease, normovolemic hemodilution remains an excellent option for select cases, especially when combined with preoperative administration of recombinant human erythropoietin (Epoetin alfa).
In intraoperative blood salvage, we require a threshold volume of 400 mL to 500 mL of salvaged blood to begin reinfusion. Thus, intraoperative blood salvage is not necessary for primary arthroplasty when blood loss is reduced by hypotensive epidural anesthesia and when predonated autologous blood is available.15 In revision arthroplasty, metal, polyethylene, and PMMA debris generated by the removal of failed components may taint the collected blood and clog the suction recovery device.16 In addition, frequent irrigation of the surgical site may dilute and damage the recovered RBCs. Thus, the yield and quality of salvaged blood are often unsatisfactory. Another disadvantage of intraoperative blood salvage is that the possibility of infection at the site of a failed arthroplasty (or anywhere) prohibits the reinfusion of the collected blood. Usually, infection is detected before surgery in the preoperative work-up or is obvious from the surgical wound appearance. Intraoperative analyses of fluids and tissue sections can also reveal infection, but occasionally these analyses are not complete until after surgery, in which case transfusion of infected blood would already have begun. A final disadvantage to intraoperative blood salvage is the cost of the specialized equipment and of the trained personnel required to operate it. Nevertheless, despite all these drawbacks, intraoperative blood salvage is used in select revision cases in which excessive blood loss is expected. Additionally, when combined with other methods to reduce perioperative blood loss, "closed circuit" blood collection and reinfusion is especially useful for Jehovah's Witness patients.
Blood collected from surgical wound drains postoperatively can also be used for reinfusion.17 However, in primary arthroplasty, many surgeons do not routinely use drains. In revision cases, we will use a drain if there is concern that the patient will develop a postoperative hematoma. The risk associated with unwashed blood, and the cost of washing collected blood, have prevented the routine use of postoperative blood salvage.
Reducing Allogeneic Transfusion. Traditional transfusion criteria have recommended transfusing a unit of blood when the patient's hemoglobin (Hb) decreases to 10 g/dL or when the hematocrit (HCT) decreases to 33%. It is now recognized, however, that most patients can tolerate lower Hb levejs 18.19 Transfusion, even in elderly patients, often can be delayed until Hb levels decrease to 8 g/dL.20 It is best to avoid arbitrary transfusion "triggers" such as Hb or HCT levels and instead, focus on the physiologic response to anemia. Relaxing the transfusion "trigger" criteria can reduce patient exposure to allogeneic blood. To thoroughly evaluate the need for transfusion, patients should be monitored for their ability to tolerate blood loss throughout the surgery and during the postoperative period, as many patients require postoperative blood transfusions.
For revision THA, preoperative autologous blood donation (PAD) is the standard of care.21 For most revision THAs, we ask patients to predonate 4 units of autologous blood (if they are capable of doing so). For less-complicated revisions, we ask for fewer units of autologous blood.22 To donate blood preoperatively, patients generally should have Hb levels > 11 g/dL (HCT >33%). One unit of blood can be donated every 5 to 7 days. During this time, supplemental iron is administered to facilitate erythropoiesis. Preexisting anemia, multiple medical problems, and a poor erythropoietic response to phlebotomy may preclude or limit the use of PAD in some patients, especially the elderly. Other considerations include the cost associated with the drawing and storing of blood23 and the large volume of autologous blood that is not used. In a series of 9482 primary and revision total joint arthroplasty cases (hips and knees), 45% of autologous blood was wasted.3 Nevertheless, because most of our patients fear the risks of allogeneic blood transfusion and request the option to donate autologous blood, PAD continues to be a standard part of our practice.
Recently, Epoetin alfa has been demonstrated to be effective in reducing the need for allogeneic blood in elective orthopedic surgery patients.24" 26 Epoetin alfa increases the preoperative Hb, HCT, and reticulocyte count2426 by increasing erythropoiesis. Patients who enter surgery with more RBCs are better able to tolerate blood loss. Combining Epoetin alfa with PAD may also help patients who have an inadequate erythropoietic response to phlebotomy.27 Currently, we are conducting a clinical trial in revision THA patients to compare PAD with Epoetin alfa. While data are preliminary, our study thus far has revealed higher preoperative and discharge Hb levels in the Epoetin alfa group. A full statistical analysis will be completed when all the data have been collected.
The blood management goals in revision hip arthroplasty are to reduce perioperative blood loss and to reduce the need for allogeneic blood transfusion. To achieve these goals, the orthopedic surgeon should be aware of all the blood management techniques available and apply them appropriately to each patient.
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