How to Optimize Revision Cases to Decrease Transfusions

A team from George Washington University and MedStar Georgetown Orthopaedic Institute in Washington, D.C., has looked into risk factors associated with blood transfusion in patients undergoing revision total hip arthroplasty for mechanical failure.

Their study, “Risk Factors for Blood Transfusion in Revision Total Hip Arthroplasty for Mechanical Failure,” appears in the April 2020 edition of The Journal of Hip Surgery.

Co-author Safa Cyrus Fassihi, M.D., a fourth year orthopedic resident at George Washington University, described the genesis of the study to OTW, “We initially explored this topic because of the high transfusion requirements associated with revision total hip arthroplasty. Unlike primary total hip arthroplasty, revision total hip arthroplasty often requires operative techniques that elicit a significant amount of blood loss (i.e., extended trochanteric osteotomy). Since revision total hip arthroplasty for mechanical failure is largely performed on an elective basis and allows for patient optimization preoperatively, we felt it would be prudent to identify risk factors for postoperative transfusion in this patient population and correct these risk factors where possible.”

A total of 8,469 revision total hip arthroplasty patients were included; 1,863 (22.0%) received blood transfusions within 72 hours after surgery. The authors wrote, “A multi-institutional surgical registry was queried for all patients who underwent revision total hip arthroplasty for mechanical failure from 2005 to 2016. Patients were divided into transfused and nontransfused cohorts and underwent univariate analysis for differences in demographic features, preoperative comorbidities, and operative variables.”

Dr. Fassihi explained to OTW, “While a host of risk factors were found to affect risk for blood transfusion following revision total hip arthroplasty for mechanical failure, the most significant were increased operative time, sepsis (systemically, not surgical site), open wounds, and, of course, baseline anemia (which could have been corrected for such elective procedures). Interestingly, smoking, obesity, and isolated acetabular component revision were protective against blood loss.”

“These findings can alter clinical practice by ensuring that in patients undergoing dual-component revision total hip arthroplasty with baseline anemia, open wounds, or high anticipated case complexity (which often translates into increased operative time), proper preoperative optimization is done. This may require sending them to consulting services (i.e., hematology) or their primary care provider and delaying surgery until the patient is adequately optimized. There is significant morbidity associated with revision total hip arthroplasty, and transfusions have been shown to increase this morbidity, so it is important to avoid such situations in cases that are truly elective, such as these.”