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Commentary & Perspective | ||||||||
Commentary & Perspective on In this prospective, randomized clinical trial, Billote et al. evaluated the efficacy of preoperative autologous blood donation in reducing the need for allogeneic transfusion in patients undergoing unilateral primary total hip replacement. Randomized clinical trials are relatively uncommon in the orthopaedic literature and should be encouraged as the practice of evidence-based medicine has been recognized as optimal medical care. Historically, from the mid-to-late 1970s into the 1980s, patients were encouraged to deposit autologous blood prior to undergoing total hip arthroplasty—first, because of the risk of acquiring hepatitis from homologous transfusion and later, because of the fear of acquiring AIDS (Acquired Immune Deficiency Syndrome) from allogeneic transfusion. Many studies, including our own1, demonstrated a reduction in the use of homologous blood transfusions following total hip replacement when autologous blood programs were implemented. In the 1990s, as cost-containment measures were implemented, in medicine in general and in the performance of total hip replacements specifically, the cost-effectiveness of autologous blood donation came into question, especially with documentation that large amounts of predeposited autologous blood had been wasted. In addition, concern has arisen that in the population with predonation hemoglobin levels of 110 to 130 g/L, predeposit autologous programs may contribute to preoperative anemia and to the potential for increased postoperative transfusion needs in some patients2. After retrospectively demonstrating no differences in postoperative transfusion rates between autologous donors and nondonors following total hip replacement in their patient population3, the authors performed a prospective, randomized study to evaluate the efficacy of preoperative autologous donation as a method for decreasing allogeneic transfusion in a select group of patients undergoing primary total hip replacement. These patients had preoperative hemoglobin levels greater than or equal to 120 g/L. The authors found that there was no need for homologous blood transfusion in either the donor or the nondonor group. Thirty-four (41%) of eighty-two autologous units were wasted. The study was well designed, implemented, and analyzed. Its weakness lies in the omission of the number of patients who underwent total hip arthroplasty during the entire study period, including those who did and those who did not meet the inclusion criteria; hence, we can question the generalizability of the authors' findings. However, in this group of relatively healthy patients who had preoperative hemoglobin levels >120 g/L and no significant medical comorbidities, no blood transfusions were required. On the basis of these findings, surgeons should be comfortable in informing their patients who are undergoing total hip replacement and meet these criteria that the need for blood transfusion during or following the procedure is unlikely. Billote et al. should be congratulated on this contribution to evidence-based medicine. *The author did not receive grants or outside funding in support of the research or preparation of this manuscript. He did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated. References 1. Thomson JD, Callaghan JJ, Savory CG, Stanton RP, Pierce RN. Prior deposition of autologous blood in elective orthopaedic surgery. J Bone Joint Surg Am. 1987;69:320-4. | ||||||||
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