Copyright © 2007 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
Stuart B. Goodman MD, PhD*,
Department of Orthopaedic Surgery, Stanford University, Stanford, California
Posted February 2007
Revision total hip surgery is often complex, and blood loss
may be substantial. Interventions that attempt to minimize blood loss during
revision procedures include preoperative autologous blood donation, preoperative
administration of erythropoietin, intraoperative and postoperative blood
salvage, specific anesthetic protocols such as controlled hypotension and
autotransfusion, and meticulous surgical technique1-5. Blood loss is
inevitable during revision procedures, however, and many patients require allogeneic
blood transfusion. This adds further risk to the patient, including
transmission of blood-borne diseases and transfusion reactions, as well as
additional financial costs.
Using a case-controlled study of ninety-four total patients
(forty-seven patients who received intraoperative blood salvage and forty-seven
patients who did not were carefully matched for age, sex, and eleven operative
variables), Bridgens and colleagues clearly demonstrate the utility of the
Haemonetics Cell Saver in mitigating the need for additional allogeneic blood. The
use of intraoperative blood salvage was associated with a median reduction in
allogeneic blood transfusion of 4 U. Surprisingly, the Cell Saver was found to
be easy to use and required no additional personnel to operate the device. Excluding
the initial financial burden of purchasing the device, the average savings per
patient in whom the Cell Saver was used became cost neutral if at least 1 U of
salvaged blood was reinfused.
Previous reports have documented the utility of
intraoperative blood salvage during hip replacement procedures and attempted to
devise algorithms to identify which patients would most benefit from the use of
an intraoperative blood salvage device3-5. The latter point is not
addressed in a comprehensive way in the study by Bridgens et al. because of the
relatively small number of patients and the fact that the vast majority of
patients in each group (85% in the control group and 87% in the intraoperative
cell-salvage group) underwent revision of both femoral and acetabular
components. Each revision hip replacement procedure has a unique combination of
factors that affect the complexity of the procedure. These include the surgical
approach, the type and degree of fixation of the excised components, whether
cemented or cementless techniques were previously used, the location and extent
of periprosthetic osteolysis, and the need for bone-grafting. A prospective
randomized study to delineate the effects of these different variables on blood
loss and the effects of blood salvage techniques would probably be unrealistic
to perform. Bridgens et al. are to be commended for matching many of these
variables to aid our understanding of how to preserve a precious resource and
optimize patient care.
*The author did not receive any outside funding or grants in
support of his research for or preparation of this work. Neither he nor a
member of his immediate family received payments or other benefits or a
commitment or agreement to provide such benefits from a commercial entity. No
commercial entity paid or directed, or agreed to pay or direct, any benefits to
any research fund, foundation, division, center, clinical practice, or other
charitable or nonprofit organization with which the author, or a member of his immediate
family, is affiliated or associated.
References
1. Semkiw LB, Schurman DJ, Goodman SB, Woolson ST. Postoperative blood salvage using the Cell Saver after total joint arthroplasty. J Bone Joint Surg Am. 1989;71:823-7.
2. Keating EM, Ritter MA. Transfusion options in total joint arthroplasty. J Arthroplasty. 2002;17:125-8.
3. Grosvenor D, Goyal V, Goodman S. Efficacy of postoperative blood salvage following total hip arthroplasty in patients with and without deposited autologous units. J Bone Joint Surg Am. 2000;82:951-4.
4. Zarin J, Grosvenor D, Schurman D, Goodman S. Efficacy of intraoperative blood collection and reinfusion in revision total hip arthroplasty. J Bone Joint Surg Am. 2003;85:2147-51.
5. Borghi B, Casati A. Incidence and risk factors for allogenic blood transfusion during major joint replacement using an integrated autotransfusion regimen. The Rizzoli Study Group on Orthopaedic Anaesthesia. Eur J Anaesthesiol. 2000;17:411-7.
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