Currently, more than 1 million total hip and knee arthroplasties are performed annually in the United States.1 By the year 2030, the projected annual demand for total knee arthroplasty (TKA) and total hip arthroplasty (THA) is expected to increase to 3.5 million and 500,000, respectively.2 Until recently, one of the major concerns after total joint arthroplasty (TJA) was the risk of significant blood loss necessitating transfusion of blood products.3 More recently, the wide-spread use of tranexamic acid (TXA) during the perioperative period has significantly decreased the incidence of postoperative bleeding and transfusion rates after TJA.4–13
Obtaining serial daily complete blood counts (CBCs) is common practice during inpatient hospitalization after TJA. However, with decreasing blood product transfusion rates and hospital length of stay along with the rising popularity of outpatient TJA, the practice of routinely obtaining daily postoperative CBCs beyond the first postoperative day for all primary TJA patients may be unnecessary.
In anticipation of reimbursement shifting from a fee-for-service model to a more quality-based model, developing new strategies that improve outcomes and patient satisfaction while also containing and minimizing costs are necessary. As the number of THAs and TKAs performed annually continues to increase exponentially, eliminating unnecessary laboratory testing may be an area of targeted cost savings to the health care system.
The utility and cost-effectiveness of obtaining routine daily postoperative CBCs in primary TJA patients who receive perioperative tranexamic acid (TXA) has not been investigated previously. The current study was undertaken to (1) identify both preoperative and postoperative day 1 hemoglobin level that placed patients at an increased risk of requiring a blood transfusion during their inpatient hospital stay after primary TKA or THA and (2) estimate the potential cost savings if the CBCs obtained for patients at low risk for postoperative blood transfusion were eliminated. Secondary objectives were to analyze the average increase in leukocytosis and decrease in platelet count during the postoperative inpatient hospitalization and to identify any potential subgroups of patients at increased risk for transfusion.
Materials and Methods
This retrospective study received approval from the institutional review board of the authors' hospital. The medical records of all consecutive patients older than 18 years who underwent primary unilateral TKA or THA performed by the senior author (E.S.W.) between October 2014 and September 2017 were identified using the database of the authors' institution. Patients with preexisting hematologic disorders, intraoperative blood transfusion, postoperative drains, and discharge prior to postoperative day 2 were excluded. Patients who did not receive perioperative TXA and those without documented preoperative and consecutive postoperative CBCs also were excluded.
Patient age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) score, and medical comorbidities were collected. The Charlson Comorbidity Index (CCI) was calculated for each patient.14,15 Procedural data including type of arthroplasty (TKA or THA), laterality of procedure, length of postoperative stay, and postoperative deep venous thrombosis (DVT) prophylaxis were recorded along with pre- and postoperative CBC values. The date and time of all blood transfusions as well as the number of units transfused also were documented.
All TJA patients received perioperative TXA (1 g at the time of incision and 1 g at the time of wound closure) unless they had a history of vascular stent placement, cerebrovascular accident (CVA) or transient ischemic attack (TIA), DVT, pulmonary embolism (PE), or color blindness. For patients with any of these relative contraindications to intravenous TXA, topical TXA (2 g of TXA mixed with 100 mL of normal saline) was applied at the conclusion of the procedure.
All patients received mechanical and pharmacologic DVT prophylaxis. The patients in this study who were at low risk for DVT received aspirin 325 mg twice daily (89 patients). Patients who were at high risk of developing postoperative DVT were prescribed rivaroxaban 10 mg daily (13 patients), warfarin (2 patients), apixaban 2.5 mg twice daily (1 patient), apixaban 5 mg twice daily (1 patient), or apixaban 5 mg twice daily and clopidogrel 75 mg daily (1 patient). Mechanical DVT prophylaxis for all patients consisted of both sequential compression devices and thromboembolism deterrent stockings on bilateral lower extremities.
All TKAs were performed through a medial parapatellar approach with the use of a thigh tourniquet. The approach used for THAs was either a modified Hardinge approach or a muscle-sparing anterior approach.16 Patients received a blood transfusion if their hemoglobin level was less than 7 g/dL or if they were symptomatic with a postoperative hemoglobin level between 7 g/dL and 8 g/dL. No patients received a postoperative transfusion if their hemoglobin level was greater than 8 g/dL.
Statistical analysis was performed using SAS version 9.2 (SAS Institute Inc, Cary, North Carolina). Fisher exact test was used to examine the association between categorical variables, and Student t test was used to compare transfusion group differences in continuous variables. Logistic regression models were developed to predict the probability of receiving a blood transfusion by using preoperative and postoperative day 1 values in separate models. The probability indicated by the model was used to determine a reasonable cutoff point that had the highest sensitivity value while also being clinically relevant. P<.05 was considered significant.
Between October 2014 and September 2017, a total of 129 primary unilateral TKAs and THAs were performed by the senior author. Twenty-one patients were excluded for the following reasons: discharge prior to postoperative day 2 (13 patients), use of a postoperative drain (5 patients), intraoperative transfusion (2 patients), and idiopathic thrombocytopenic purpura (1 patient). This left a total of 108 cases that satisfied the study's inclusion and exclusion criteria. Patient demographics and procedural data are provided in Table 1. A total of 45 THAs were performed using a modified Hardinge approach, and 12 THAs were performed using a muscle-sparing anterior approach.
Patient Demographics and Procedural Data
In the 30-day postoperative period, a total of 10 patients either presented to the emergency department for evaluation or required readmission (Table 2). None of these visits or readmissions were related to transfusion. One patient underwent incision and drainage with polyethylene liner exchange for surgical wound dehiscence 22 days after TKA. Four patients presented with chief complaints related to their operative extremity; 1 patient was treated with oral antibiotics for a superficial cellulitis at the surgical incision, and the remaining 3 patients did not require any intervention. The remaining 5 patients were readmitted for medical issues unrelated to their recent TJA.
Emergency Department Visits and Readmissions Within 30-Day Postoperative Period
Of the 108 patients included in this study, 9 patients (8.3%) required a blood transfusion postoperatively. Mean intraoperative blood loss was 788.89 mL (95% confidence interval [CI], 259.59–688.31 mL) for the transfusion group and 234.23 mL (95% CI, 172.25–296.22 mL; P<.0001) for the nontransfusion group. No significant association was found between postoperative blood transfusion and age, sex, BMI, ASA, procedure, laterality, medical comorbidities, DVT prophylactic agent, or CCI (P>.05).
Mean preoperative hemoglobin level was 13.4 g/dL compared with 10.6 g/dL on postoperative day 1. The mean minimum postoperative hemoglobin value in patients who did not receive a postoperative transfusion was 2.89 g/dL greater than for patients who received a transfusion (P<.0001). White blood cell count (WBC) and platelet count were not significantly different between patients who received a transfusion and those did not receive a transfusion (P=.1 and P=.75, respectively). The mean increase in leukocytosis for all patients undergoing primary TKA or THA was 3.6×103/µL. Mean decreases in hemoglobin, hematocrit, and platelet count for all patients were 3.3 g/dL, 10.1%, and 64×103/µL, respectively. Postoperative changes in WBC, hemoglobin, hematocrit, and platelet count are displayed in Figure 1.
Daily changes in laboratory values for study patients. All values are given as means, with vertical bars indicating confidence intervals. Abbreviations: POD, postoperative day; WBC, white blood cell count.
Logistic regression analysis indicated preoperative and postoperative day 1 hemoglobin levels were strong predictors of patients receiving a blood transfusion during the inpatient hospital stay (area under the curve, 0.845 and 0.943, respectively). A preoperative hemoglobin level of 12.5 g/dL or lower was predictive of a patient receiving a blood transfusion during the inpatient hospital stay (sensitivity 88.9% and specificity 73.7%). Eight of 34 patients (23.5%) with a preoperative hemoglobin value of 12.5 g/dL or lower required a postoperative transfusion. Only 1 patient with a preoperative hemoglobin value greater than 12.5 g/dL required a blood transfusion for a hemoglobin level of 7.7 g/dL on postoperative day 1. With a threshold postoperative day 1 hemoglobin level of 10 g/dL or less, the sensitivity and specificity of receiving a transfusion were 100% and 68.7%, respectively. Nine of 39 patients (23.1%) with a postoperative day 1 hemoglobin level of 10 g/dL or less required a blood transfusion postoperatively. None of the 61 patients who had both a preoperative hemoglobin level greater than 12.5 g/dL and a postoperative hemoglobin level greater than 10.0 g/dL required a transfusion postoperatively (Figure 2).
Flow chart showing the number of patients in relation to preoperative and postoperative day 1 (POD#1) threshold hemoglobin (Hb) criteria and whether a transfusion was administered. Abbreviations: THA, total hip arthroplasty; TKA, total knee arthroplasty.
Approximately 248 CBCs were drawn postoperatively on the patients included in this study (108 patients×2.3 days). An estimated 140 CBCs were drawn after postoperative day 1 (108 patients×1.3 days). According to the 2017 Centers for Medicare & Medicaid Services Clinical Laboratory Fee Schedule, the cost of a single CBC with differential in the inpatient setting is $10.66. If the 61 patients with both a preoperative hemoglobin value greater than 12.5 g/dL and a postoperative day 1 hemoglobin value greater than 10.0 g/dL did not have routine serial CBCs drawn after postoperative day 1, a total of 79 CBCs (61 patients×1.3 days) could have been eliminated, thereby resulting in a savings of $845 to the hospital system. Using the above-mentioned criterion for predicting a transfusion trigger, this could have resulted in a 56% reduction in CBCs ordered after the first postoperative day.
There has been a strong focus on increasing the value of TJA by optimizing outcome and decreasing costs. Obtaining routine daily postoperative CBCs after uncomplicated TJA in the inpatient setting is common practice among many orthopedic surgeons.
The results of the current study demonstrate preoperative and postoperative day 1 hemoglobin values can serve as strong predictors of a patient's likelihood of requiring a postoperative blood transfusion after primary TJA. In the current patient cohort, preoperative hemoglobin levels of 12.5 g/dL or less and postoperative day 1 hemoglobin levels of 10.0 g/dL or less had a respective sensitivity of 88.9% and 100% for predicting a blood transfusion during a patient's inpatient stay. The current authors used this information to stratify patients as “high risk” if their preoperative or postoperative day 1 hemoglobin values were below the thresholds of 12.5 g/dL and 10.0 g/dL, respectively, or as “low risk” if both preoperative and postoperative day 1 hemoglobin values were greater than these thresholds.
Shaner et al17 recently investigated the utility of obtaining routine postoperative laboratory studies after partial knee arthroplasty. Of 322 inpatient partial knee replacements, only 5 inpatient medical interventions (1.6%) were required despite 408 CBCs and basic metabolic panels being obtained in the study population. Interestingly, all 5 medical interventions involved abnormalities in the basic metabolic panels. The authors concluded that routinely obtaining postoperative blood work after partial knee replacement is neither necessary nor cost-effective. The results and conclusions reported by Shaner et al17 are consistent with the findings of the current study.
A secondary objective of the current study was to analyze the potential cost savings that could be achieved by eliminating routine blood work in low-risk patients. The authors determined that 79 CBCs after postoperative day 1 could have been eliminated in 61 patients if their preoperative and postoperative day 1 hemoglobin values had been used as threshold criteria for likelihood of requiring transfusion. This could have resulted in a 56% decrease in the number of CBCs ordered after postoperative day 1, for a cost savings of $845. Furthermore, the true cost savings likely is underestimated as hospital staff work hours and time spent collecting and processing specimens is unaccounted for in this analysis. The annual cost savings also is dependent on volume and would be significantly greater in a higher volume center or if multiple surgeons were to adhere to this protocol.
In the current study, a statistically significant difference was observed in the intraoperative blood loss between the transfusion and nontransfusion groups. The mean blood loss in the transfusion and nontransfusion groups was 788.89 mL and 234.23 mL (P<.0001), respectively. This represents a positive association between the risk of transfusion and intraoperative blood loss.
No significant association was observed between specific medical comorbidities and receiving a postoperative transfusion. This is in contrast to what is commonly reported in the literature, with multiple medical comorbidities, female sex, and increasing age being documented as risk factors for allogenic blood transfusion after TKA or THA.18–21 However, Bini et al22 also did not establish a strong relationship between increasing age and blood transfusions after THA.
In the current study, the mean increase in WBC count after primary THA or TKA was 3.6×103/µL. This is similar to the findings of Deirmengian et al23 who reported a 38% incidence of postoperative leukocytosis with an average WBC change of 3×103/µL in more than 13,000 patients who underwent primary TKA or THA. The WBC count traditionally has been used as a surrogate marker for infection, although its utility in the diagnosis of an acute prosthetic joint infection is not well established.23,24 Deirmengian et al23 reported a sensitivity of 79% and a specificity of 46% when using WBC count to diagnose early deep prosthetic joint infection. In concordance with the current findings, daily postoperative CBCs for monitoring changes in leukocytosis during inpatient hospitalization is also likely unnecessary because an average increase of 3.6×103/µL is part of the normal postsurgical stress/inflammatory response.
This study had several limitations. First, the number of patients in the study was relatively small, and all of the patients underwent surgery by a single surgeon. However, the current findings are consistent with those of other authors who reported similar transfusion rates to the 8% found in the current study cohort. 10,25–30 In addition, the current authors' threshold preoperative hemoglobin level of 12.5 g/dL is consistent with recent findings reported by Bini et al.22 In their study, Bini et al22 found a preoperative hemoglobin of less than 13 g/dL to be a risk factor for reaching a postoperative transfusion trigger of 8 g/dL after TKA. The current authors believe their results are validated based on similar findings from other higher-powered studies.
Second, the senior author (E.S.W.) used an anterior muscle-sparing approach in 12 patients.16 Only 1 patient with a preoperative hemoglobin greater than 12.5 g/dL met the transfusion trigger postoperatively. This patient's postoperative day 1 hemoglobin was 7.7 g/dL, and the patient underwent THA through an anterior approach. Several authors have documented a higher blood loss and complication rate with direct muscle-sparing approaches to the hip.31–34
The authors believe the current study supports stratifying patients into either a high-risk or low-risk group based on the aforementioned preoperative and postoperative hemoglobin thresholds. This could potentially identify patients who would benefit from daily CBC blood draws and eliminate unnecessary testing. In addition, with a growing number of TJAs being performed in ambulatory surgical centers, these data can be used to help surgeons identify which patients are candidates for outpatient TJA.
This study supports stratifying patients into a high-risk or low-risk group based on their preoperative and postoperative day 1 hemoglobin values. With the projected exponential increase in TJA during the next few decades, eliminating unnecessary daily CBCs in low-risk patients after primary TJA should be considered and represents a potential area where cost savings could be achieved.
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Patient Demographics and Procedural Data
|Characteristic||Total Patients (N=108)||Not Transfused (n=99)||Transfused (n=9)||P|
|Age, mean±SD (range), y||69.7±10.6 (45–90)||69.5±10.6 (45–90)||72.0±12.0 (52–86)||.4971|
| Male||37 (34%)||33 (33%)||4 (44%)|
| Female||71 (66%)||66 (67%)||5 (56%)|
|BMI, mean±SD (range), kg/m2||31.0±4.3 (17–39)||31.1±4.4 (17–39)||30.1±3.8 (25–36)||.4911|
|LOS, mean±SD (range), d||2.3±0.6 (2–4)||2.3±0.6 (2–4)||2.8±0.7 (2–4)|
| THA||57 (53%)||51 (52%)||6 (67%)|
| TKA||51 (47%)||48 (48%)||3 (33%)|
| Right||58 (54%)||52 (53%)||6 (67%)|
| Left||50 (46%)||47 (47%)||3 (33%)|
Emergency Department Visits and Readmissions Within 30-Day Postoperative Period
|Patient No.||Procedure||Postoperative Day||Encounter||Reason/Complaint|
|4||TKA||7||ED visit||Knee effusion/pain|
|31||TKA||12||ED visit||Knee pain|
|41||TKA||7||Admission||Acute kidney injury, urinary retention|
|22||Admission||Atrial fibrillation with RVR|
|61||THA||25||ED visit||RLE cellulitis|
|79||THA||4||Admission||Right lacunar infarct presenting as LLE weakness|
|26||Admission||Gastrointestinal bleed, syncope|
|106||TKA||22||Admission||Surgical wound dehiscence|
|127||THA||2||ED visit||Surgical wound drainage|