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Data-driven pre-operative hemoglobin strata predict blood transfusion and surgical complication risk after total
Jeremy Clements1, Victor Shen1, David Tan1
1Department of Orthopaedic Surgery, The George Washington University School of Medicine and Health Sciences, Washington, DC, USA.
Background:
Pre-operative anemia is associated with post-operative surgical complications and blood transfusions after total shoulder arthroplasty (TSA). However, hemoglobin thresholds have not been well identified. This study aimed to create data-driven pre-operative hemoglobin levels that characterize the risk of blood transfusion and other medical and surgical complications.
Methods:
Patients who underwent TSA with a hemoglobin value recorded 1 month before surgery were identified from the TriNetX database. Stratum-specific likelihood ratio (SSLR) analysis defined pre-operative hemoglobin cutoffs associated with increased 90-day postoperative blood transfusions for men and women. The additional outcomes included 90-day medical complications, such as blood transfusion, major complications, wound infection, or dehiscence, and 2-year surgical outcomes, including all-cause revision, periprosthetic joint infection (PJI), and mechanical loosening.
Results:
The SSLR analysis identified 4 hemoglobin strata with increased 90-day blood transfusion for men (<12, 12-13, 13-14.5, and >14.5 g/dL) and 5 hemoglobin strata for women (<10, 10-11, 11-12, 12-13, and >13 g/dL). When comparing against the highest-value strata, there were sequential, significant increases in risk for 2-year PJI, 90-day major complications, and 90-day infection/wound disruption, progressing down the hemoglobin strata for both cohorts.
Conclusion:
The SSLR analysis characterized the likelihood of 90-day blood transfusions associated with hemoglobin strata, ranging from 0.24 to 4.65 for men and from 0.23 to 8.11 for women, where intermediate strata had an LR close to 1, thus minimally changing the likelihood of transfusion. After matching, we observed a progressive increase in 90-day major medical complications (up to 1.84 and 2.2 times for men and women, respectively), 90-day infection/wound disruption (up to 3.14 and 3.71 times for men and women, respectively), and 2-year PJI (up to 2.36 and 4.94 times for men and women, respectively). These findings indicate that progressively lower pre-operative hemoglobin is associated with a stepwise increase in post-operative TSA complication risk.
