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Letters to the Editor to:

Scientific Articles:
Hari P. Bezwada, David G. Nazarian, David H. Henry, and Robert E. Booth, Jr.
Preoperative Use of Recombinant Human Erythropoietin Before Total Joint Arthroplasty
J Bone Joint Surg Am 2003; 85: 1795-1800 [Abstract] [Full text] [PDF]
*Letters to the Editor: Submit a response to this article

Electronic letters published:

[Read Letter to the Editor] Dr Bezwada and colleagues respond to Dr. Salot
Hari P. Bezwada, Nazarian, Henry, Booth   (18 December 2003)
[Read Letter to the Editor] Guidelines Regarding the Use of Erythropoietin Before Total Joint Arthroplasty
William H. Salot, M.D.   (4 December 2003)

Dr Bezwada and colleagues respond to Dr. Salot 18 December 2003
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Hari P. Bezwada,
Orthopaedic Surgeon
Pennsylvania Hospital,
Nazarian, Henry, Booth

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Re: Dr Bezwada and colleagues respond to Dr. Salot

hbezwada{at}yahoo.com Hari P. Bezwada, et al.

We appreciate the comments from Dr. Salot. We will respond to his points individually.

1) While it is true that the combination of recombinant human erythropoietin with preoperative autologous donation might not necessarily be in conformity with medicare regulations; Goodnough et al noted the ability to increase the amount of autologous donation with recombinant erythropoietin. Furthermore, peroperative autologous donation only leads to preoperative anemia, as noted by several authors. The combination of erythropoietin and preoperative autologous donation allows the patient to preoperatively donate without the development of a significant preoperative anemia.

2) This particular study did not address the issue of cost. While it is true that the combination of autologous blood and recombinant erythropoietin remains costly, this study addresses the issue of efficacy not cost. The selection of a hemoglobin of 140 g/l as an inclusion criteria was at the suggestion of our hematologist (DHH). This was a hemoglobin level selected for other cases in which erythropoietin was utilized.

3) While it is true that not many patients with a baseline hemoglobin of >130 g/l will require allogeneic transfusions. Previous studies have suggested that they have to be healthy patients, generally under 60 years of age, and be undergoing primary unilateral total joint arthroplasty. This study combined a large number of bilateral and revision arthroplasties. There should be no dispute that bilateral and revision arthroplasties have a greater allogeneic blood requirements than primary unilateral arthroplasty. A baseline hemoglobin of 140 g/l may not be sufficient to avoid allogeneic blood transfusions in bilateral and revision arthroplasties.
Guidelines Regarding the Use of Erythropoietin Before Total Joint Arthroplasty 4 December 2003
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William H. Salot, M.D.,
Orthopedist
Associated Orthopedists of Detroit, P.C.

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Re: Guidelines Regarding the Use of Erythropoietin Before Total Joint Arthroplasty

wsalot{at}earthlink.net William H. Salot, M.D.

To the Editor;

I was impressed by the efficacy of recombinant human erythropoietin when used with autologous blood donation to reduce the need for perioperative allogeneic blood transfusion in total joint arthroplasty. However, your readership should be aware that the protocol followed in this study was not in conformity with current Medicare guidelines.

These guidelines restrict the surgical use of recombinant erythropoietin to patients whose preoperative hemoglobin range lies between 100 g/L and 130 g/L, and who are not candidates for autologous blood donation. The authors’ selection of 140 g/L as the upper limit of preoperative hemoglobin, as well as their addition of autologous blood donation to the treatment regimen, if adopted by others, could lead to challenges of reimbursement for these expensive programs.

The use of 140 g/L as the upper limit of preop hemoglobin is puzzling, as a number of those patients between 130 g/l and 140 g/L probably need no preoperative treatment at all. Faris et al (1) demonstrated that patients whose hemoglobin was > 130g/L were only half as likely to require allogeneic blood in primary joint replacement as those with levels < 130g/L.

William H. Salot, M.D.

Associated Orthopedists of Detroit,P.C.

24715 Little Mack St.

St. Clair Shores, Michigan 48080

wsalot@earthlink.net

1) Faris,P.M., Spence, R.K., Larholt, K.M., Sampson, A.R., Frei, D. The predictive power of baseline hemoglobin for transfusion risk in surgery patients Orthopedics 1999 January:22 (1 suppl.) s 135-40