SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA
w w w . r b o . o r g . b r
Original
Article
Blood
level
changes
in
total
knee
arthroplasty
with
and
without
a
tourniquet
夽
Marco
Felipe
Francisco
Honorato
de
Barros
∗,
Evandro
Junior
Christovam
Ribeiro,
Rafael
Gomes
Dias
HospitalRegionaldePresidentePrudente,PresidentePrudente,SP,Brazil
a
r
t
i
c
l
e
i
n
f
o
Articlehistory:
Received6September2016 Accepted4October2016 Availableonline21October2017
Keywords:
Kneereplacementarthroplasty Surgicalbloodloss
Bloodtransfusion Tourniquets
a
b
s
t
r
a
c
t
Objective:Toevaluatethedifferencebetweenthetotalbloodlossinpatientsundergoing primarytotalkneearthroplastywithandwithouttheuseoftourniquet.
Methods:Aretrospectivecohortstudy,withanalysisofmedicalrecordsofpatients under-goingprimarytotalkneearthroplastyin2015,withandwithouttheuseofatourniquet. Comparisonwasperformedofhemoglobin(HB)andhematocrit(HT)variationinthe com-pletebloodcount(CBC)duringthepre-andpost-operativeperiodbetweenthetwogroups.
Results:Therewere117patientsundergoingprimarytotalkneearthroplastyincluded, min-imumageof33andmaximumof86years,withameanof67years.64.1%ofthesurgeries usedatourniquetand35.9%didnot.ThemeanpreoperativeHBinGroup1was13.08and 12.97inGroup2(p=0.435).ThemeanpostoperativeHBinGroup1was11.64and10.93in Group2(p=0.016).ThevariationofHBinGroup1was1.44and2.04inGroup2(p=0.025). ThemeanpreoperativeHTinGroup1was38.96and39.01inGroup2(p=0.898).Themean postoperativeHTinGroup1was34.47and32.19inGroup2(p=0.005).ThevariationofHTin Group1was4.49and6.82inGroup2(p=0.001).Atotalof21patientsreceivedtransfusions RCC(redcellconcentrates),asaresultofHBbelow8g/dLorclinicalsymptoms,respectively, representingsevenofGroup1(9.3%oftotalintra-group)and14ofGroup2(33.3%oftotal intra-group),withp=0.001.
Conclusion: Inpatientsundergoingprimarytotalkneearthroplastyusinga tourniquet,a lowervarianceinthehematimetricindiceswasobservedandfewerbloodtransfusionswere necessary.
©2017PublishedbyElsevierEditoraLtda.onbehalfofSociedadeBrasileiradeOrtopedia eTraumatologia.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http:// creativecommons.org/licenses/by-nc-nd/4.0/).
夽
PaperdevelopedatHospitalRegionaldePresidentePrudente,Servic¸odeOrtopediaeTraumatologia,PresidentePrudente,SP,Brazil.
∗ Correspondingauthor.
E-mail:marcofelipebarros@hotmail.com(M.F.Barros). http://dx.doi.org/10.1016/j.rboe.2017.10.001
Variac¸ão
sanguínea
nas
artroplastias
de
joelho
com
e
sem
o
uso
de
garrote
Palavras-chave:
Artroplastiadojoelho Perdasanguíneacirúrgica Transfusãosanguínea Torniquetes
r
e
s
u
m
o
Objetivo: Avaliaradiferenc¸aentrea perdasanguíneatotalem pacientessubmetidos à artroplastiatotaldojoelhocomesemousodegarrote.
Métodos:Estudodecoorteretrospectivo,comanálisedosprontuáriosdepacientes submeti-dosaartroplastiaprimáriatotaldejoelhoem2015,comesemousodegarrote.Comparou-se avariac¸ãodehemoglobina(HB)ehematócrito(HT)nopré-epós-operatórioentreosdois grupos.
Resultados:Foramincluídos117pacientessubmetidosaartroplastiatotaldejoelhoprimária, idademínimade33emáximade86anos,commédiade67;em64,1%dascirurgias,foiusado garroteeem35,9%,não.Nopré-operatório,amédiadaHBnoGrupo1foide13,08;noGrupo 2,12,97(p=0,435).Nopós-operatório,amédiadaHBnoGrupo1foide11,64;noGrupo2, 10,93(p=0,016).Avariac¸ãodaHBnoGrupo1foide1,44;noGrupo2,de2,04(p=0,025). Nopré-operatório,amédiadoHTnoGrupo1foide38,96;noGrupo2,de39,01(p=0898). Nopós-operatório,amédiadoHTnoGrupo1foide34,47;noGrupo2,de32,19(p=0,005). Avariac¸ãodoHTnoGrupo1foide4,49;noGrupo2,de6,82(p=0,001).Dospacientes,21 receberamtransfusãodeCH(concentrac¸ãodehemácias),porHBabaixode8ousintomas clínicos,setedoGrupo1(9,3%dototalintragrupo)e14doGrupo2(33,3%dototalintragrupo) comp=0,001.
Conclusão: Nospacientessubmetidosaartroplastiatotaldejoelhoprimáriacomousode garrote,ocorreuumamenorvariânciadosíndiceshematimétricoseummenornúmerode transfusõessanguíneasfoinecessário.
©2017PublicadoporElsevierEditoraLtda.emnomedeSociedadeBrasileirade OrtopediaeTraumatologia.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction
Totalkneearthroplasty (TKA)isaprocedurewithexcellent resultsinthetreatmentofdegenerativediseasesoftheknee, butitisnotfreefromcomplications1;itisassociatedwitha greatlossofblood,whichcanreachvaluesequaltoorgreater than 1.5L, asituation inwhich blood transfusion becomes unavoidable.2
Complicationsdependonfactorsrelatedtothepatient,the environmentandthesurgicaltechnique.3Toreducethe num-berofbloodtransfusionsinTKA,somecarehasbeendescribed tominimizeperioperativeand postoperativebleeding,such asocclusionofthefemoralmillingholewithbonegraft,use ofpneumatictourniquetandsuctiondrain,improvementof surgicaltechnique,useoftranexamicacid,localinfusionwith norepinephrineand,morerecently,theplacementofgelwith plateletsintheoperativewound.4
Orthopedicpatientshavearelativelyhighcontributionto bloodconsumption.IntheUnitedKingdom,forexample,10% oftheunitsofredbloodcellconcentrategiveninhospitals areconsumedbyorthopedicpatients.Ofthese,40%areused inpatientsundergoingTKAortotalhiparthroplasty(THA).5
Theuseofhomologous bloodcomponents isassociated withanincreaseinmortalityandmorbidity.Risksassociated withhomologous transfusions includethe transmission of infectiousagents,andnon-infectiousrisks(Table1). Homol-ogoustransfusionsarenotrisk-freeandareassociatedwith adverseeventsin20%ofcasesandseverereactionsin0.5%.6
Table1–Infectiousandnoninfectiousrisksassociated tohomologousbloodtransfusions.6
Infectiousrisks Noninfectiousrisks
Virus(e.g.,human immunodeficiencyvirus)
Acutetransfusionalreaction
Bacteria(e.g.,Staphilococcus aureus)
Latetransfusionalreactions
Parasites(e.g.,malaria) Febrilenon-hemolyticreaction Prions Allergicreaction
Acutetransfusion-associatedlung lesion
Graft-versus-hostdisease Immunosuppression PosttransfusionalPurpura Transfusionmistakes
Inordertoreducethehigh rateofbloodtransfusionsin TKA,itisessentialtoadoptstrategiesthatleadtolessblood loss. Theuse of aperioperativetourniquet allowsthe sur-geontohavean exsanguinousfield untilthe placementof thecomponentsoftheprosthesis;itimprovesthetechnique ofcementation.Themomentofitswithdrawal,however,is controversialintheliterature;itcanbedoneintraoperatively, soonafterprosthesiscementingfordirecthemostasisofthe wound,orafterthesutureandplacementofacompressive dressing.4
Material
and
methods
Aretrospectiveanalysisofthemedicalrecordsof117patients undergoingunilateraltotalkneearthroplastywascarriedout bytheDepartmentofOrthopedicsandTraumatologyofour institutionfrom January2015toDecember2015.All proce-dureswereperformedbyateamofsurgeonsexperiencedin totalkneearthroplasty.
Inclusion criteria was considered for patients with gonarthrosisandindicationoftotalkneearthroplasty,withno hemoglobinandhematocritchanges,orblooddyscrasiainthe preoperativeexams.Patientsonmedicationthatcouldalter thebloodcoagulationsystemwereinstructedtosuspendthat medicationbeforethesurgicalprocedure,andallhadnormal coagulogramsonthedayoftheprocedure.
Thesurgicalprocedurewasperformedthroughamedial parapatellarapproach,followedbyeversionandlateral dis-locationofthepatella,resectionofthemenisciandanterior cruciateligament,femoraland tibialcutaccordingto stan-dardizedtechniqueforkneearthroplasties.Thefemoralcuts were performedwithan intramedullary guideand the tib-ial with an extramedullary guide. All the prostheses were cementedandthefemoralorificeobliteratedwithbonegraft. Aftertheprocedure,allthepatientsremainedhospitalizedin theward,newhematimetrictestswereperformed,aswellas antithromboembolismprophylaxis.
Patientsweredividedinto twogroups,Group1withthe useoftourniquet, andGroup 2withouttorniquet. Theuse ornotoftourniquetwasdeterminedbythesurgeon’s prefer-ence.Inordertoanalyzethestatisticalsignificanceofgeneral andspecificinformation,patientsweredividedintothosewho usedatourniquetduringsurgery(n=75)andthosewhodid not(n=42).Thechi-squaretestforqualitativevariables (gen-der,operatedside,anduse ofRCC)and Student’st-testfor quantitativevariables(HBandHTbeforeandaftersurgeryand theirvariations)witha95%confidenceintervalwereapplied toevaluatehematimetricvariance.Datawereanalyzedusing Bioestat5.3software.
Results
All117patientswereincludedinthestudy.Group1consisted of75(64.1%),andGroup2of42(35.9%).InGroup1,theage rangedfrom38to86years(mean67),andinGroup2between 33and82(mean67).Regardinggender,Group1had55women and20men,andGroup2had30womenand12men.InGroup 1,theRsidewas46andtheLsidewas29,inGroup2theR sidewas22andtheLsidewas20.Inthepreoperativeperiod themeanHBinGroup1was13.08,andinGroup2was12.97 (p=0.435).InthepostoperativeperiodthemeanHBinGroup 1was11.64,andinGroup2was10.93(p=0.016).TheHB varia-tioninGroup1was1.44,andinGroup2was2.04(p=0.025).In thepreoperativeperiodthemeanHTinGroup1was38.96,and inGroup2was39.01(p=0.898).Inthepostoperativeperiod, themeanHTinGroup1was34.47,andinGroup2was32.19 (p=0.000).TheHTvariationinGroup1was4.49,andinGroup 2was6.82(p=0.000).Ofthepatients,21receivedRCC transfu-sion(redblood cellsconcentration),forHBbelow8or with clinicalsymptoms; sevenfrom Group1(9.3% ofintragroup
total),and 14fromGroup2(33.3%ofintragrouptotal)with
p=0.001.ThegroupsaredetailedinTables2and3.
Discussion
Thefirsttotalkneearthroplasty(TKA)wasperformedin1974. Sincethen,it hasbeeninpermanent evolution;it changes andimproves,despitebeingoneofthetwomostsuccessful orthopedicproceduresinthehistoryofthespecialty, along withhiparthroplasty.7
According to Vane and Ganem,8 in trauma and major surgeries,suchasTKA,inwhichthereisacutebloodloss, oxy-genationisthemainindicatorforfluidresuscitation.Thus, transfusions can be made with homologous blood, whose donorisforeign totherecipient, orwithautologousblood, whenthedonorandrecipientarethesameperson.Inmost cases,transfusionwithhomologousbloodisthemostused.8
Theuse ofhomologousblood componentsisassociated with anincreasein mortalityand morbidity,and has high financialcostsinvolved.Hopewelletal.9analyzed32studies relatedtotheincreaseinmorbidityandmortalityfollowing bloodtransfusionsandconcludedthatpatientsreceivingred bloodcellsconcentratehadahigherincidenceof complica-tionsandmortalitythanthosewhousedotherhemodynamic compensationmethods.
Homologoustransfusionsarenotrisk-freeand are asso-ciatedwithadverseeventsinabout20%ofcases,andsevere reactionsin0.5%.Therisksassociatedwithhomologous trans-fusions include the transmission ofinfectious agents, and non-infectious risks(Table 1).6 Inorder toreduce the high homologousbloodconsumptionbypartofpatients undergo-ingthesesurgicalprocedures,itisessentialtoadoptstrategies withlessbloodlossthatcanleadtobloodtransfusion.
Several hospitals have different transfusion protocols. Some studies recommend transfusion if hemoglobin con-centrationfallsbelow10g/dL.TheConsensusDevelopment Conference in 1988 suggested that a hemoglobin level of lessthan8g/dLshouldbethetriggerforbloodtransfusion.5 However,adequateclinicaljudgmentisimperativetodecide whetheratransfusionisneededinsteadofadheringto labo-ratoryvaluesalone.5,10
Therearenumerousstudiesanalyzingbloodlossintotal kneearthroplasty,andcomparingmethodsthatleadtolower blood loss.Smith andHing11 conductedameta-analysisin which15studieswereincluded(1040totalkneereplacement proceduresin991patients)andevaluatedtheuseofa tourni-quetasameasureforlowerbloodloss.Intheirreviewthey foundthattotalkneereplacementwithatourniquetwas asso-ciatedwithasignificantreductioninintraoperativebloodloss comparedtosurgerythatdidnotusetourniquet.Therewere no significant differences intotal blood loss, postoperative blood lossmeasured fromdrainagesystems,blood transfu-sionrates,timeofsurgery,andhospitalstaylengthbetween thetwogroups.Significantheterogeneitywasobservedinall theseresults.
Table2–Patientsinwhomatourniquetwasused.
Age Gender Sideoperatedon Usedtourniquet HBPRE HBPOS HBvariation HTPRE HTPOS HTvariation
64 F Right Yes 3 10.6 2.4 39 31.4 7.60
74 F Right Yes 4.3 13.9 0.4 41.4 39.7 1.70
76 F Right Yes 11.1 12.8 −1.7 32.5 38.7 −6.20
79 F Left Yes 12.8 12 0.8 38.9 35.6 3.30
72 F Left Yes 13 11.8 1.2 36.8 33 3.80
68 F Right Yes 12.8 10.3 2.5 38 30.5 7.50
62 F Left Yes 12 10.5 1.5 35.7 30.7 5.00
71 F Right Yes 13.9 13.4 0.5 41 39.8 1.20
65 F Right Yes 13.3 10.6 2.7 38.7 32.2 6.50
47 M Right Yes 12.6 10.2 2.4 36.5 29.5 7.00
75 M Left Yes 14.8 14.7 0.1 42.5 42.2 0.30
72 F Right Yes 10.3 10.3 0 30.5 31.6 −1.10
68 F Left Yes 13.9 11.1 2.8 38.9 33.7 5.20
59 F Right Yes 13.6 12.5 1.1 42.7 36.5 6.20
60 F Left Yes 13.3 11.5 1.8 39.5 34.1 5.40
62 F Right Yes 14 10.9 3.1 41.9 33.1 8.80
69 M Right Yes 14.2 12.7 1.5 42.7 37.3 5.40
74 F Left Yes 12.3 11.9 0.4 36.9 35.7 1.20
66 M Right Yes 14.4 12.6 1.8 40.9 35.8 5.10
69 M Left Yes 15.2 14.5 0.7 44.8 41 3.80
60 M Left Yes 13.9 12.5 1.4 40 34.5 5.50
75 F Right Yes 11.9 11.5 0.4 34.6 33.5 1.10
64 F Left Yes 11.4 10.3 1.1 35.6 32.6 3.00
63 F Left Yes 14 13.4 0.6 40.4 38 2.40
71 M Right Yes 14.5 11.6 2.9 40.4 31.9 8.50
77 F Right Yes 13.9 12.6 1.3 40.3 36.8 3.50
52 F Right Yes 12.3 11.6 0.7 35.3 33.4 1.90
76 M Right Yes 12.9 12.1 0.8 41.1 39.3 1.80
59 F Left Yes 16.6 13.6 3 46.6 38.6 8.00
68 F Right Yes 13.1 12.5 0.6 38.2 32.1 6.10
71 F Right Yes 11.8 9.5a 2.3 34.6 27 7.60
65 F Left Yes 12.2 12 0.2 35.9 33.8 2.10
72 F Right Yes 12.8 11.1 1.7 38 32.1 5.90
71 F Left Yes 13.7 12.5 1.2 41 37.2 3.80
74 F Right Yes 14 11.7 2.3 42 35.3 6.70
62 M Left Yes 15 12.4 2.6 44.4 37.1 7.30
69 F Right Yes 15.3 12.6 2.7 46.4 39 7.40
59 F Left Yes 11.4 10.4 1 33.7 32.3 1.40
70 F Right Yes 12.5 11 1.5 36.9 33.3 3.60
77 F Right Yes 13.5 11.1 2.4 40 33.3 6.70
59 F Right Yes 13 12 1 37.9 36.9 1.00
65 F Right Yes 13.5 10.5 3 41.3 33.2 8.10
66 F Left Yes 14.5 14.4 0.1 42.8 42.5 0.30
67 F Left Yes 13.9 11.4 2.5 42.1 35.6 6.50
53 F Right Yes 13.7 11 2.7 40.4 32.4 8.00
57 M Right Yes 11.5 10.2 1.3 34.8 30.4 4.40
71 F Left Yes 12 10.5 1.5 36.4 32.6 3.80
73 F Right Yes 12.1 11.5 0.6 36.4 30.2 6.20
66 F Right Yes 10.4 9.9 0.5 33.7 29.3 4.40
49 F Left Yes 10.5 8.9a 1.6 35.5 30.8 4.70
69 M Right Yes 13.7 11.1 2.6 39.5 34 5.50
86 M Right Yes 12.7 12.1 0.6 38.7 37.9 0.80
65 M Right Yes 14.9 14.1 0.8 45.3 43.7 1.60
59 M Right Yes 13.3 12 1.3 38.7 35.9 2.80
63 M Left Yes 11.7 9.5a 2.2 37.2 31 6.20
59 F Right Yes 10.6 9.5a 1.1 32.5 30.2 2.30
66 F Left Yes 10.5 9.1a 1.4 33.4 27.8 5.60
74 M Right Yes 12.5 11.4 1.1 37.3 34.1 3.20
64 M Left Yes 13 12.1 0.9 39.1 32.4 6.70
38 M Right Yes 15.5 14 1.5 46.7 42.3 4.40
78 M Right Yes 15.6 14.2 1.4 45.3 42.5 2.80
64 F Left Yes 14.3 13.9 0.4 41.7 38.3 3.40
80 F Right Yes 10.8 8.8a 2 34.9 28.1 6.80
–Table2(Continued)
Age Gender Sideoperatedon Usedtourniquet HBPRE HBPOS HBvariation HTPRE HTPOS HTvariation
82 F Right Yes 12.1 11.2 0.9 37.2 34 3.20
70 F Left Yes 12.9 11 1.9 38.6 32.6 6.00
59 F Right Yes 13.1 9.6a 3.5 38.5 28.1 10.40
75 F Left Yes 12.3 10.4 1.9 36.3 29.3 7.00
72 F Left Yes 13.3 12.5 0.8 38.4 32 6.40
60 M Right Yes 14.3 13.4 0.9 43 37.4 5.60
39 F Right Yes 13.3 12.2 1.1 37.8 35.4 2.40
67 F Left Yes 12.3 10.6 1.7 36.3 31.3 5.00
70 F Right Yes 13.3 9.8 3.5 39.8 29.6 10.20
72 F Left Yes 12.4 12.2 0.2 39.4 38.3 1.10
62 F Right Yes 13.4 11.9 1.5 42.7 38.7 4.00
Averagestandarddeviation 13.08±1.32 11.64±1.41 1.44±0.96 38.96±3.51 34.47±3.89 4.49±2.80
a Receivedredbloodcellsconcentrate.
Table3–Patientsinwhomatourniquetwasnotused.
Age Gender Sideoperatedon Usedtourniquet HBPRE HBPOS HBvariation HTPRE HTPOS HTvariation
75 M Right No 14.7 13.6 1.1 42.5 39.3 3.20
56 M Right No 14.8 11.4 3.4 42.3 33 9.30
64 F Left No 9.8 8.8a 1 29.6 26.1 3.50
65 F Right No 11.8 10.5 1.3 36 32.1 3.90
69 F Left No 12.3 10.5 1.8 36.2 30.4 5.80
62 M Right No 13.5 12.4 1.1 40.2 36.5 3.70
71 F Right No 11.2 9.2a 2 37 29.5 7.50
65 M Right No 16 11.6 4.4 46.5 33.8 12.70
33 F Left No 12.5 11.3 1.2 40 34.2 5.80
73 M Left No 14.8 13.7 1.1 49.9 38.1 11.80
82 F Left No 12.9 9.4a 3.5 39.1 27.5 11.60
69 F Right No 10.5 9.2a 1.3 30.8 27.2 3.60
76 F Right No 11 9.3a 1.7 34.2 29.4 4.80
47 F Right No 15.8 13.4 2.4 44.5 38.5 6.00
47 F Left No 11.9 9.7a 2.2 37.3 28.8 8.50
67 F Right No 13.9 9.5a 4.4 39.9 27.3 12.60
66 F Right No 10.5 9.1a 1.4 32.5 28.3 4.20
70 F Left No 13.9 10.5 3.4 40.5 30.1 10.40
76 M Right No 15 13.1 1.9 42.5 38.4 4.10
64 F Right No 12.6 9a 3.6 36.3 26 10.30
62 F Right No 12.4 11.2 1.2 36.8 33.4 3.40
68 M Left No 13.4 13.4 0 37.9 31.1 6.80
74 F Left No 13.6 8.3a 5.3 40.1 24.2 15.90
72 F Right No 12.7 11.7 1 36 33.5 2.50
56 F Left No 12.8 11.2 1.6 39.3 34.5 4.80
61 F Right No 12.9 10.3 2.6 39.7 31.3 8.40
76 M Left No 12.7 11.6 1.1 39.6 35.7 3.90
60 M Right No 14.7 11.2 3.5 43.8 32.7 11.10
66 F Left No 12.7 12.7 0 39.1 30 9.10
79 F Left No 11.7 8.7a 3 36.6 28.1 8.50
77 M Left No 10.1 7.5a 2.6 33.6 24.4 9.20
69 F Left No 13.2 12.3 0.9 41.7 38.3 3.40
69 F Right No 13.7 12 1.7 42 37.3 4.70
67 F Left No 12.5 9.8 2.7 39.7 30 9.70
71 F Left No 11.2 9.2a 2 37 29.5 7.50
49 M Right No 14.2 12.3 1.9 41.8 36.2 5.60
68 F Right No 13.5 12.6 0.9 37.6 36.2 1.40
67 F Left No 11.1 9.5a 1.6 34.6 29.8 4.80
65 F Right No 13.5 12.3 1.2 40 37 3.00
72 F Left No 13.8 11.8 2 40.3 34.2 6.10
79 M Left No 14.7 12.6 2.1 41.5 36.6 4.90
74 F Right No 14.3 11.5 2.8 41.9 33.5 8.40
Averagestandarddeviation 12.97±1.52 10.93±1.63 2.04±1.17 39.01±3.95 32.19±4.18 6.82±3.37
preserving blood stock, however, is controversial. Vasconcelos4 observed that the removal of the intraoper-ative or postoperative tourniquet showed no difference in blood loss when comparing hemoglobin and hematocrit variationinthepreandpostoperativeperiod.
Conclusion
Inpatientsundergoingtotalkneearthroplastywiththeuse ofatourniquet,therewas alower varianceinthe hemati-metricrates,andalowernumberofbloodtransfusionswere necessary.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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