Routine Preoperative Group Crossmatching and Postoperative Check Hemoglobin Is not Necessary in Patients Undergoing Total Knee Arthroplasty

Abstract

This study aims to find out if routine preoperative group crossmatch and postoperative check hemoglobin for total knee arthroplasty (TKA) patients is necessary. A retrospective analysis was performed on patients who underwent unilateral TKAs for osteoarthritis from January 1, 2004 to December 31, 2014. The main outcome measures were postoperative hemoglobin levels and transfusion requirements. Patients' demographics, comorbidities, laboratory results, and surgical details were analyzed. A total of 955 TKAs were included in this study (males = 207, females = 748; mean age = 66.1 years, standard deviation [SD] = 7.7). A total of 79 (8.27%) cases required postoperative blood transfusion, and the crossmatch-transfusion ratio was 17.5. Significant predictors for postoperative transfusion included lower preoperative hemoglobin levels (p < 0.001) and advanced age (p < 0.001). Receiver operating characteristic (ROC) curve and Youden's Index analyses identified the preoperative hemoglobin cut-off value for females to be 12.1 g/dL (relative risk (RR): 5.65, p < 0.001) in predicting postoperative blood transfusion requirement, and 12.4 g/dL (RR: 11.71, p < 0.001) for males. For age, the identified cut-off value was 68 years (RR: 3.18, p < 0.001). The largest decline in hemoglobin levels was noted on postoperative day (POD) 3 (31.8%), and smallest on POD 1 (18.8%). The postoperative transfusion requirements in TKA are low and do not justify routine perioperative blood investigations. However, these investigations should be reserved for patients with the identified risk factors, in particular advancing age (68 years and above) and lower preoperative hemoglobin (below or equal to 12.1 and 12.4 g/dL for females and males, respectively). In the event that postoperative hemoglobin level needs to be checked, it should be performed beyond the first POD.

Keywords

knee arthroplasty - group crossmatch - transfusion - hemoglobin - risk factor

Note

This study was performed in accordance with the ethical standards of our institutional review board and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Publication History

Received: 22 August 2019

Accepted: 01 March 2020

Article published online:
30 April 2020

• References

• 1 Kane RL, Saleh KJ, Wilt TJ, Bershadsky B. The functional outcomes of total knee arthroplasty. J Bone Joint Surg Am 2005; 87 (08) 1719-1724
• 2 Forbes. aging populations will challenge healthcare systems all over the world. Accessed July 10, 2019 at: https://www.forbes.com/sites/williamhaseltine/2018/04/02/aging-populations-will-challenge-healthcare-systems-all-over-the-world/#3658fa542cc3 2018
• 3 ABIM Foundation. Choosing Wisely® recommendations. Accessed July 10, 2019 at: http://www.choosingwisely.org/wp-content/uploads/2015/01/Choosing-Wisely-Recommendations.pdf
• 4 Bass AR, Rodriguez T, Hyun G. et al. Myocardial ischaemia after hip and knee arthroplasty: incidence and risk factors. Int Orthop 2015; 39 (10) 2011-2016
• 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 (01) 2-10
• 6 Pepe M. The Statistical Evaluation of Medical Tests for Classification and Prediction. Oxford: Oxford University Press; 2003: 28
• 7 Murphy WG. The sex difference in haemoglobin levels in adults - mechanisms, causes, and consequences. Blood Rev 2014; 28 (02) 41-47
• 8 Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 2007; 89 (04) 780-785
• 9 Carroll AE. The high costs of unnecessary care. JAMA 2017; 318 (18) 1748-1749
• 10 United Nations. World population ageing. Accessed July 10, 2019 at: https://www.un.org/en/development/desa/population/publications/pdf/ageing/WPA2017_Highlights.pdf
• 11 Friedman BA, Oberman HA, Chadwick AR, Kingdon KI. The maximum surgical blood order schedule and surgical blood use in the United States. Transfusion 1976; 16 (04) 380-387
• 12 Wells AW, Mounter PJ, Chapman CE, Stainsby D, Wallis JP. Where does blood go? Prospective observational study of red cell transfusion in north England. BMJ 2002; 325 (7368): 803
• 13 Cook SS, Epps J. Transfusion practice in central Virginia. Transfusion 1991; 31 (04) 355-360
• 14 Mathoulin-Pélissier S, Salmi LR, Verret C, Demoures B. , & RECEPT investigators. Blood transfusion in a random sample of hospitals in France. Transfusion 2000; 40 (09) 1140-1146
• 15 Reilly TJ, Gradisar Jr IA, Pakan W, Reilly M. The use of postoperative suction drainage in total knee arthroplasty. Clin Orthop Relat Res 1986; (208) 238-242
• 16 Ballantyne A, Walmsley P, Brenkel I. Reduction of blood transfusion rates in unilateral total knee arthroplasty by the introduction of a simple blood transfusion protocol. Knee 2003; 10 (04) 379-384
• 17 Alghamdi S, Gonzalez B, Howard L. et al. Reducing blood utilization by implementation of a type-and-screen transfusion policy a single-institution experience. Am J Clin Pathol 2014; 141 (06) 892-895
• 18 British Committee for Standards in Haematology. Guidelines for implementation of a maximum surgical blood order schedule. Accessed July 10, 2019 at: http://www.bcshguidelines.com/documents/maximum_surgical_blood_order_scehdule_1990.pdf
• 19 Mintz PD, Nordine RB, Henry JB, Webb WR. Expected hemotherapy in elective surgery. N Y State J Med 1976; 76 (04) 532-537
• 20 Boral LI, Henry JB. The type and screen: a safe alternative and supplement in selected surgical procedures. Transfusion 1977; 17 (02) 163-168
• 21 Vuille-Lessard E, Boudreault D, Girard F, Ruel M, Chagnon M, Hardy JF. Postoperative anemia does not impede functional outcome and quality of life early after hip and knee arthroplasties. Transfusion 2012; 52 (02) 261-270
• 22 Bong MR, Patel V, Chang E, Issack PS, Hebert R, Di Cesare PE. Risks associated with blood transfusion after total knee arthroplasty. J Arthroplasty 2004; 19 (03) 281-287
• 23 Prasad N, Padmanabhan V, Mullaji A. Blood loss in total knee arthroplasty: an analysis of risk factors. Int Orthop 2007; 31 (01) 39-44
• 24 Noticewala MS, Nyce JD, Wang W, Geller JA, Macaulay W. Predicting need for allogeneic transfusion after total knee arthroplasty. J Arthroplasty 2012; 27 (06) 961-967
• 25 Maempel JF, Wickramasinghe NR, Clement ND, Brenkel IJ, Walmsley PJ. The preoperative levels of haemoglobin in the blood can be used to predict the risk of allogenic blood transfusion after total knee arthroplasty. Bone Joint J 2016; 98-B [phone]
• 26 Lim E, Miyamura J, Chen JJ. Racial/ethnic-specific reference intervals for common laboratory tests: a comparison among Asians, Blacks, Hispanics, and White. Hawaii J Med Public Health 2015; 74 (09) 302-310
• 27 Lindman IS, Carlsson LV. Extremely low transfusion rates: contemporary primary total hip and knee arthroplasties. J Arthroplasty 2018; 33 (01) 51-54
• 28 Gonzalez-Porras JR, Colado E, Conde MP, Lopez T, Nieto MJ, Corral M. An individualized preoperative blood saving protocol can increase preoperative haemoglobin levels and reduce the need for transfusion in elective total hip or knee arthroplasty. Transfus Med 2009; 19 (01) 35-42
• 29 Smith DL. Anemia in the elderly. Iron disorders institute guide to anemia. Natl Heart Lung Blood Inst 2009; 9: 96-103
• 30 American Academy of Orthopaedic Surgeons. 2014 Annual meeting proceedings. Trends in total knee arthroplasty in the U.S.: understanding the shift to a younger demographic. Accessed July 10, 2019 at: http://aaos2014.conferencespot.org/55844-aaosb-1.927211/t-003-1.932388/f-025-1.934257/paper662-1.934345 2014
• 31 Kurtz SM, Lau E, Ong K, Zhao K, Kelly M, Bozic KJ. Future young patient demand for primary and revision joint replacement: national projections from 2010 to 2030. Clin Orthop Relat Res 2009; 467 (10) 2606-2612
• 32 Nagra NS, van Popta D, Whiteside S, Holt EM. An analysis of postoperative hemoglobin levels in patients with a fractured neck of femur. Acta Orthop Traumatol Turc 2016; 50 (05) 507-513