[A strategy for reduction of blood loss in total hip joint endoprosthesis]

The aim of the work is to evaluate 42 patients with THA with the use of alternative approaches to blood transfusion.

In the period between 1 October 1998 and 1 October 2001, 42 primary total hip arthroplasties were performed, of which 16 were cemented and 26 cementless, in patients who refused blood transfusion due to religious or other reasons. The operated on group comprised 28 women and 14 men at average age of 57 (range, 38-76 years) with the indication of primary osteoarthritis in 24 patients and secondary osteoarthritis in 18 of them.

Preoperative and postoperative blood loss was carefully observed in all patients. In cooperation with an internist and hematologist we used preoperatively recombinant human erythropoietin, iron and other agents stimulating erythropoiesis in order to increase the preoperative hematocrit to 45-50%. Preoperative planning is based on a careful examination of radiographs mainly from the viewpoint of the size of components of the total hip replacement. The surgery is performed in a semilateral position of the patient in a slight Trendelenburg position from the anterolateral, strictly atraumatic approach with a consistent hemostasis, maintenance of normothermia intraoperatively, efficient reduction of the surgery duration and application of substitute solutions.

Average blood loss in cemented THA was 980 ml, of which 940 ml in men and 1000 ml in women. In the cementless THA it was 1180 ml, of this 1165 ml in men and 1205 ml in women. In case of the indication of primary osteoarthritis the average blood loss amounted to 1140 ml, of this 1125 ml in men and 1140 in women. In the secondary osteoarthritis the average value was 1215 ml, of which 1125 ml in men and 1180 ml in women. No statistically significant difference in the amount of the blood loss in relation to age was found. Preoperative hemoglobin ranged between 122-172 g/l, the postoperative range was 73-157 g/l. The average loss of hemoglobin in the cemented THA was 28.25 g/l and in the cementless THA 35 g/l. Preoperative average hematocrit was 43,375%, postoperative average was 31.3%. We used only some alternatives of the blood loss reduction. There occurred no case requiring termination of the surgery due to extreme blood loss.

The article analyses opinions and outcomes of different authors as concerns the use of alternatives in the blood loss reduction in extensive orthopaedic operations. Transfusion trigger is described as the threshold for blood transfusion in linkage to the concentration of hemoglobin in blood and level of hematocrit. Pharmacological and non-pharmacological alternatives of blood loss reduction are evaluated including both their benefits and disadvantages. Emphasis is put on the preoperative treatment by human recombinant erythropoietin and hematopoietics, a careful approach during THA with the reduction of the surgery duration and maintenance of normothermia intraoperatively.

The use of alternative procedures of blood loss reduction may be divided into three principles: 1. acceptable extent of anemia, 2. preoperative optimisation of the number of erythrocytes and the level of hemoglobin, 3. minimisation of bleeding during the surgery. By observation of these principles it is possible to reduce the use of blood transfusions in extensive orthopaedic operations.