Preoperative optimisation of anaemia for primary total hip arthroplasty: a systematic review

The 2009 NHS Blood and Transplant national comparative audit on blood use following primary total hip arthroplasty (THR) highlighted that preoperative anaemia was common and undertreated. They recommended that hospitals have a written policy for treating anaemia preoperatively. In our centre, we found that preoperative optimisation of anaemia, significantly reduced blood transfusion rate to <5%. The 2015 national audit showed that even though 48% of patients received tranexamic acid, 85% of patients required transfusion. By conducting a systematic review of literature on blood management for preoperative anaemia in primary THR; we aimed to validate the recommendations of the national audit and increase its awareness in the orthopaedic community.

A PubMed Search was performed to identify suitable literature limited to randomised controlled trials, cohort studies, meta-analyses and systematic reviews involving primary THR. We excluded any THRs performed for trauma and revision arthroplasty. Our exclusion criteria for the intervention was the use of autologous methods such as cell salvage techniques and preoperative autologous blood donation.

Analysis of 13 publications showed widespread study heterogeneity, which precluded meta-analysis. Preoperative blood management (PBM) interventions included the use of recombinant human erythropoietin and oral iron supplementation in 12/13 and 11/13 studies respectively. There were significant differences in transfusion rates between PBM and control groups in 12/13 studies.

The findings overwhelmingly support preoperative optimisation of anaemia. The main barrier to wider implementation remains the cost effectiveness. We recommend using our validated protocol, which has shown to significantly reduce transfusion rates, length of stay and remain cost effective.