Blood Management Strategies in Total Knee Arthroplasty

Total knee arthroplasty is one of the most cost-effective and reliable orthopedic procedure to treat end-stage knee arthritis. In addition, the demand for this procedure has been increasing with an accelerating rate[1] due to inclusion of previously excluded patient populations such as younger patients and those who have higher body mass indices, including super-obese patients.[2] However, one of the major concerns with this procedure is its potential for marked perioperative blood loss. With estimations that total knee arthroplasty procedures will increase from currently approximately 500,000 to 3.75 million by 2030, the need for enhanced blood management strategies is evident.[1]

It has been estimated that mean perioperative blood loss is approximately 1,500 mL per case, which is often associated with a concomitant decline in hemoglobin of greater than 3 g/dL.[3] The subsequent resultant anemia from the procedure can potentially lead to inadequate tissue oxygenation and decreased vitality.[4] This perioperative blood loss also often results in high rates of allogeneic blood transfusions, which can be greater than 30% following total knee arthroplasty.[5] [6]

Although allogeneic transfusions are currently associated with a low complication rates due to enhanced screening methods, they are not without risks.[3] [7] Some transfusion reactions can occur, such as infections, allergic phenomena, fevers, and acute immune hemolytic reactions; however, other problems can take weeks to manifest, such as transfusion-related acute lung injury, iron overload, delayed hemolytic reaction, or graft-versus-host disease.[8] [9] [10] [11] Furthermore, preoperative anemia and blood transfusions have been demonstrated to prolong hospitalization periods and increase patient morbidity and mortality.

These concerns have prompted an evaluation for more efficacious and safer methods for blood management strategies, which are aimed at improving clinical outcomes following total knee arthroplasty. The major interventional points for blood management can be substratified into pre-, intra-, and postoperative strategies. Specifically, preoperative strategies covered in this issue include preoperative autologous blood donation, iron therapy, and erythropoietin use; intraoperative strategies include acute normovolemic hemodilution, hypotensive anesthesia, tourniquets, bipolar sealants, blood salvage systems, femoral plugs, computer-assisted surgery, patient-specific instrumentation, antifibrinolytics, fibrin, thrombin, and vasoconstrictors; and postoperative strategies include cryotherapy, drain clamping, suction drains, and compression dressing. Although it has been demonstrated that many of these methods may be effective at optimizing pre- and postoperative anemia and potentially reducing the need for allogeneic transfusions, there is conflicting evidence regarding the efficacy and safety of some of these practices. Additionally, there are economic implications to the healthcare system which should be considered with the use of these measures that may prevent more widespread use.

It has proven to be challenging and often impractical to apply the same practices for blood management to each patient undergoing total knee arthroplasty. Instead, an orthopedic surgeon must tailor blood management strategies to ensure individualistic treatment to account for a plethora of medical comorbidities and a multitude of cultural beliefs. For example, Jehovah's Witness patients usually refuse blood transfusion or its constituents due to their religious conviction; however, many surgeons may not be familiar with the limitations of standard blood management strategies in these patients. Respecting the desires of informed competent patients such as the Witnesses requires a high standard of ethics and professionalism. Although physicians may face challenges in providing care in such cases, reduced blood loss surgeries with established management protocols result in successful outcomes in this patient population. Such protocols may potentially emphasize the importance of a team approach to optimize these patients perioperatively, including changing the classical triggers for transfusion.[12] [13]

In this special section on blood management strategies in the Journal of Knee Surgery, we aim to examine the various practices currently being used for total knee arthroplasty and assess their reported clinical efficacy, as well as related complications. The purpose of this review was to help practicing orthopedic surgeons regarding blood management strategies for patients undergoing total knee arthroplasty.

• References

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