Postoperative Blood Loss Prevention in Total Knee Arthroplasty

Abstract

Blood loss is a serious concern during lower extremity total joint arthroplasty with the estimated reduction in hemoglobin concentration known to vary between 2 and 4 g/dL after total knee arthroplasty (TKA). Allogeneic transfusions are commonly used to treat the acute blood loss and postoperative anemia to diminish the potential cardiovascular risks in up to 50% of such cases with a high volume of blood loss. However, these transfusions are associated with the risks of immunologic reactions, immunosuppression, and infection transmission. Multiple blood-saving strategies have been developed to minimize blood loss, to reduce transfusion rates, to decrease complications, and to improve outcomes in the postoperative period. Currently, there are no clear guidelines on the blood management strategies adopted to lessen the blood loss associated with TKA. The aim of this study was to review the literature and provide a broad summary of the efficacy and complications associated with several blood-saving measures that are currently used in the postoperative period. Evidence suggests that simple techniques such as limb elevation, cryotherapy, compression dressings, and drain clamping may reduce external drainage, however, whether these techniques lead to less allogeneic transfusions is currently debatable. Further research on using a combination of these strategies and their cost-effectiveness are needed.

Keywords

blood - management - postoperative - knee - arthroplasty

• References

• 1 Sehat KR, Evans RL, Newman JH. Hidden blood loss following hip and knee arthroplasty. Correct management of blood loss should take hidden loss into account. J Bone Joint Surg Br 2004; 86 (4) 561-565
• 2 Sehat KR, Evans R, Newman JH. How much blood is really lost in total knee arthroplasty? Correct blood loss management should take hidden loss into account. Knee 2000; 7 (3) 151-155
• 3 Lotke PA, Faralli VJ, Orenstein EM, Ecker ML. Blood loss after total knee replacement. Effects of tourniquet release and continuous passive motion. J Bone Joint Surg Am 1991; 73 (7) 1037-1040
• 4 Gombotz H, Rehak PH, Shander A, Hofmann A. Blood use in elective surgery: the Austrian benchmark study. Transfusion 2007; 47 (8) 1468-1480
• 5 Bierbaum BE, Callaghan JJ, Galante JO, Rubash HE, Tooms RE, Welch RB. An analysis of blood management in patients having a total hip or knee arthroplasty. J Bone Joint Surg Am 1999; 81 (1) 2-10
• 6 Pedersen AB, Mehnert F, Overgaard S, Johnsen SP. Allogeneic blood transfusion and prognosis following total hip replacement: a population-based follow up study. BMC Musculoskelet Disord 2009; 10: 167
• 7 Carson JL, Duff A, Poses RM , et al. Effect of anaemia and cardiovascular disease on surgical mortality and morbidity. Lancet 1996; 348 (9034) 1055-1060
• 8 Umlas J, Jacobson MS, Kevy SV. Survival and half-life of red cells salvaged after hip and knee replacement surgery. Transfusion 1993; 33 (7) 591-593
• 9 Rizzi L, Bertacchi P, Ghezzi LM, Bellavita P, Scudeller G. Postoperative blood salvage in hip and knee arthroplasty. A prospective study on cost effectiveness in 161 patients. Acta Orthop Scand 1998; 69 (1) 31-34
• 10 Newman JH, Bowers M, Murphy J. The clinical advantages of autologous transfusion. A randomized, controlled study after knee replacement. J Bone Joint Surg Br 1997; 79 (4) 630-632
• 11 Singh VK, Singh PK, Javed S, Kumar K, Tomar J. Autologous transfusion of drain contents in elective primary knee arthroplasty: its value and relevance. Blood Transfus 2011; 9 (3) 281-285
• 12 Sarkanović ML, Gvozdenović L, Savić D, Ilić MP, Jovanović G. Autologous blood transfusion in total knee replacement surgery. Vojnosanit Pregl 2013; 70 (3) 274-278
• 13 Park KH, Lee SR, Jin JM, Moon MS. The efficacy and safety of postoperative autologous transfusion of filtered shed blood and anticoagulant prophylaxis in total knee arthroplasty patients. Knee Surg Relat Res 2012; 24 (1) 14-18
• 14 Tellisi N, Kakwani R, Hulse N, Abusitta G, Ashammakhi N, Wahab KA. Autologous blood transfusion following total knee arthroplasty: is it always necessary?. Int Orthop 2006; 30 (5) 412-414
• 15 Ulrich SD, Kyle B, Johnson AJ, Zywiel MG, Mont MA. Strategies to reduce blood loss in lower extremity total joint arthroplasty. Surg Technol Int 2010; 20: 341-347
• 16 Mont MA, Low K, LaPorte DM, Hostin E, Jones LC, Hungerford DS. Reinfusion drains after primary total hip and total knee arthroplasty. J South Orthop Assoc 2000; 9 (3) 193-201
• 17 Biagini D, Filippucci E, Agnelli G, Pagliaricci S. Activation of blood coagulation in patients undergoing postoperative blood salvage and re-infusion of unwashed whole blood after total knee arthroplasty. Thromb Res 2004; 113 (3-4) 211-215
• 18 Ley JT, Yazer MH, Waters JH. Hemolysis and red blood cell mechanical fragility in shed blood after total knee arthroplasty. Transfusion 2012; 52 (1) 34-38
• 19 Hanlon L, Punzo A, Jones RA, Speroni KG. Comparison of cardiopulmonary complication rates in patients undergoing total knee arthroplasty and reinfusion of shed blood. Orthop Nurs 2011; 30 (5) 307-311
• 20 Muñoz M, Campos A, Merino I. Recovered hemoglobin and hemolysis in filtered or processed shed blood after total knee arthroplasty. Transfusion 2012; 52 (8) 1839-1841 , author reply 1841
• 21 Moonen AF, Knoors NT, van Os JJ, Verburg AD, Pilot P. Retransfusion of filtered shed blood in primary total hip and knee arthroplasty: a prospective randomized clinical trial. Transfusion 2007; 47 (3) 379-384
• 22 Peter VK, Radford M, Matthews MG. Re-transfusion of autologous blood from wound drains: the means for reducing transfusion requirements in total knee arthroplasty. Knee 2001; 8 (4) 321-323
• 23 Muñoz M, Ariza D, Campos A, Martín-Montañez E, Pavía J. The cost of post-operative shed blood salvage after total knee arthroplasty: an analysis of 1,093 consecutive procedures. Blood Transfus 2013; 11 (2) 260-271
• 24 Muñoz M, Kühlmorgen B, Ariza D, Haro E, Marroquí A, Ramirez G. Which patients are more likely to benefit from postoperative shed blood salvage after unilateral total knee replacement? An analysis of 581 consecutive procedures. Vox Sang 2007; 92 (2) 136-141
• 25 Dundon JM, Rymer MC, Johnson RM. Total patellar skin loss from cryotherapy after total knee arthroplasty. J Arthroplasty 2013; 28 (2) e5-e7
• 26 Gibbons CE, Solan MC, Ricketts DM, Patterson M. Cryotherapy compared with Robert Jones bandage after total knee replacement: a prospective randomized trial. Int Orthop 2001; 25 (4) 250-252
• 27 Kullenberg B, Ylipää S, Söderlund K, Resch S. Postoperative cryotherapy after total knee arthroplasty: a prospective study of 86 patients. J Arthroplasty 2006; 21 (8) 1175-1179
• 28 Adie S, Kwan A, Naylor JM, Harris IA, Mittal R. Cryotherapy following total knee replacement. Cochrane Database Syst Rev 2012; 9: CD007911
• 29 Cao L, Ablimit N, Mamtimin A , et al. [Comparison of no drain or with a drain after unilateral total knee arthroplasty: a prospective randomized controlled trial]. Zhonghua Wai Ke Za Zhi 2009; 47 (18) 1390-1393
• 30 Esler CN, Blakeway C, Fiddian NJ. The use of a closed-suction drain in total knee arthroplasty. A prospective, randomised study. J Bone Joint Surg Br 2003; 85 (2) 215-217
• 31 Adalberth G, Byström S, Kolstad K, Mallmin H, Milbrink J. Postoperative drainage of knee arthroplasty is not necessary: a randomized study of 90 patients. Acta Orthop Scand 1998; 69 (5) 475-478
• 32 Jenny JY, Boeri C, Lafare S. No drainage does not increase complication risk after total knee prosthesis implantation: a prospective, comparative, randomized study. Knee Surg Sports Traumatol Arthrosc 2001; 9 (5) 299-301
• 33 Zhang QD, Guo WS, Zhang Q, Liu ZH, Cheng LM, Li ZR. Comparison between closed suction drainage and nondrainage in total knee arthroplasty: a meta-analysis. J Arthroplasty 2011; 26 (8) 1265-1272
• 34 Al-Zahid S, Davies AP. Closed suction drains, reinfusion drains or no drains in primary total knee replacement?. Ann R Coll Surg Engl 2012; 94 (5) 347-350
• 35 Prasad N, Padmanabhan V, Mullaji A. Comparison between two methods of drain clamping after total knee arthroplasty. Arch Orthop Trauma Surg 2005; 125 (6) 381-384
• 36 Pornrattanamaneewong C, Narkbunnam R, Siriwattanasakul P, Chareancholvanich K. Three-hour interval drain clamping reduces postoperative bleeding in total knee arthroplasty: a prospective randomized controlled trial. Arch Orthop Trauma Surg 2012; 132 (7) 1059-1063
• 37 Raleigh E, Hing CB, Hanusiewicz AS, Fletcher SA, Price R. Drain clamping in knee arthroplasty, a randomized controlled trial. ANZ J Surg 2007; 77 (5) 333-335
• 38 Stucinskas J, Tarasevicius S, Cebatorius A, Robertsson O, Smailys A, Wingstrand H. Conventional drainage versus four hour clamping drainage after total knee arthroplasty in severe osteoarthritis: a prospective, randomised trial. Int Orthop 2009; 33 (5) 1275-1278
• 39 Roy N, Smith M, Anwar M, Elsworth C. Delayed release of drain in total knee replacement reduces blood loss. A prospective randomised study. Acta Orthop Belg 2006; 72 (1) 34-38
• 40 Madadi F, Mehrvarz AS, Madadi F, Boreiri M, Abachizadeh K, Ershadi A. Comparison of drain clamp after bilateral total knee arthroplasty. J Knee Surg 2010; 23 (4) 215-221
• 41 Ryu J, Sakamoto A, Honda T, Saito S. The postoperative drain-clamping method for hemostasis in total knee arthroplasty. Reducing postoperative bleeding in total knee arthroplasty. Bull Hosp Jt Dis 1997; 56 (4) 251-254
• 42 Chareancholvanich K, Siriwattanasakul P, Narkbunnam R, Pornrattanamaneewong C. Temporary clamping of drain combined with tranexamic acid reduce blood loss after total knee arthroplasty: a prospective randomized controlled trial. BMC Musculoskelet Disord 2012; 13: 124
• 43 Yamada K, Imaizumi T, Uemura M, Takada N, Kim Y. Comparison between 1-hour and 24-hour drain clamping using diluted epinephrine solution after total knee arthroplasty. J Arthroplasty 2001; 16 (4) 458-462
• 44 Tai TW, Yang CY, Jou IM, Lai KA, Chen CH. Temporary drainage clamping after total knee arthroplasty: a meta-analysis of randomized controlled trials. J Arthroplasty 2010; 25 (8) 1240-1245
• 45 Aksoy Y, Altinel L, Köse KC. The comparison of the effects of intraoperative bleeding control and postoperative drain clamping methods on the postoperative blood loss and the need for transfusion following total knee arthroplasty. Acta Orthop Traumatol Turc 2011; 45 (3) 190-194
• 46 Tai TW, Jou IM, Chang CW, Lai KA, Lin CJ, Yang CY. Non-drainage is better than 4-hour clamping drainage in total knee arthroplasty. Orthopedics 2010; 33 (3) 156-160
• 47 Calvo R, Martínez-Zapata MJ, Urrútia G , et al. Low- vs. high-pressure suction drainage after total knee arthroplasty: a double-blind randomized controlled trial. J Adv Nurs 2012; 68 (4) 758-766
• 48 Cheung KW, Chiu KH. Effect of drain pressure in total knee arthroplasty. J Orthop Surg (Hong Kong) 2006; 14 (2) 163-166
• 49 Li B, Wen Y, Liu D, Tian L. The effect of knee position on blood loss and range of motion following total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2012; 20 (3) 594-599
• 50 Ong SM, Taylor GJ. Can knee position save blood following total knee replacement?. Knee 2003; 10 (1) 81-85
• 51 Ma T, Khan RJ, Carey Smith R, Nivbrant B, Wood DJ. Effect of flexion/extension splintage post total knee arthroplasty on blood loss and range of motion—a randomised controlled trial. Knee 2008; 15 (1) 15-19
• 52 Johnson DP. Infection after knee arthroplasty. Clinical studies of skin hypoxia and wound healing. Acta Orthop Scand Suppl 1993; 252: 1-48
• 53 Madarevic T, Tudor A, Sestan B , et al. Postoperative blood loss management in total knee arthroplasty: a comparison of four different methods. Knee Surg Sports Traumatol Arthrosc 2011; 19 (6) 955-959
• 54 Charalambides C, Beer M, Melhuish J, Williams RJ, Cobb AG. Bandaging technique after knee replacement. Acta Orthop 2005; 76 (1) 89-94
• 55 Ogata K, Whiteside LA. Effects of external compression on blood flow to muscle and skin. Clin Orthop Relat Res 1982; (168) 105-107
• 56 Melhuish JM, Clark M, Williams R, Harding KG. The physics of sub-bandage pressure measurement. J Wound Care 2000; 9 (7) 308-310
• 57 Pinsornsak P, Chumchuen S. Can a modified Robert Jones bandage after knee arthroplasty reduce blood loss? A prospective randomized controlled trial. Clin Orthop Relat Res 2013; 471 (5) 1677-1681
• 58 Sundaram RO, Parkinson RW. Closed suction drains do not increase the blood transfusion rates in patients undergoing total knee arthroplasty. Int Orthop 2007; 31 (5) 613-616