Commentary & Perspective on
"Preoperative Hemogloblin Levels and the Need for Transfusion After Prosthetic Hip and Knee Surgery.
Analysis of Predictive Factors"
By Jose A. Salido, MD et al.

Commentary & Perspective by
Christopher R. Ferrante, MD*, and Paul A. Lotke, MD*,
Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA

In this issue of The Journal, Salido et al. report a study of the factors that predict the need for a blood transfusion after total knee arthroplasty (TKA) and total hip arthroplasty (THA). This study and several other previous reports^1-3 have sought to identify which patients would need blood transfusion. With use of these data we can determine the best methods of blood replacement. These may include the use of predonated autogenous blood, erythropoietin administration, or postoperative blood salvage.

Salido et al. retrospectively reviewed 370 procedures in 296 patients over a five-year period and used univariate and multivariate analyses to determine which factors had a significant effect on the need for postoperative transfusion. Independent variables included preoperative hemoglobin level, age, gender, type of surgery, weight, and height and did not include the intraoperative estimate of blood loss and duration of surgery, as these are not of any predictive value.

The authors concluded that the most important variable in determining the postoperative need for blood transfusion was the preoperative hemoglobin level. Stratification on the basis of preoperative hemoglobin levels showed that there was a high relative risk for transfusion that increased as preoperative hemoglobin levels decreased. Weight was also found to be an independent predictor of the need for a transfusion. Height and gender were not significant factors, according to the multivariate analysis.

The conclusions of the article are intuitive and confirm those of prior reports, adding to the evidence that the preoperative hemoglobin level can be effectively used to predict the need for transfusion and/or alternative strategies of blood management. Currently the most common of these strategies include the use of predonated autologous blood^1,3,4, treatment with human recombinant erythropoetin², and postoperative blood salvage⁵. Use of predonated autologous blood is the most common method of blood management in patients who have undergone a total joint replacement.

Bierbaum et al.¹ showed, in a logistic regression analysis involving 9482 patients undergoing hip or knee arthroplasty, that the most important predictors of transfusion of allogenic blood were a low baseline hemoglobin level (<130 g/L) and the lack of predonated autologous blood. As has been noted in many studies involving the use of predonated autologous blood, 45% of their units were not used. In contrast, Lotke et al.⁴ found that patients who received transfusion of all of the predonated autologous blood units in the recovery room had fewer nonsurgical complications, such as dysrythmias and myocardial events. It is generally recognized that the heart is the principal organ at risk from an acute loss of red blood-cell mass. The immediate transfusion of predonated autologous blood, especially in high-risk or elderly patients, may reduce this risk.

Hatzidakis et al.³ defined other predictors of allogenic transfusion, including revision total hip arthroplasty, revision total knee arthroplasty, and bilateral total knee arthroplasty, as well as low preoperative levels of hemoglobin.

Most authors now agree that hemoglobin levels >130 g/L in patients younger than sixty-five years of age may indicate a relatively low risk of need for a transfusion after a primary total hip or total knee arthroplasty. These data serve as a guide to the physician in choosing appropriate blood management strategies for patients undergoing total joint replacement and also allow those patients to make an informed decision with regard to the need to predonate their blood.

*The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. Commercial entities (J and J, Osteonics) paid or directed, or agreed to pay or direct, benefits to a research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

References

1. 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;81:2-10.
2. Faris PM, Ritter MA, Abels RI. The effects of recombinant human erythropoietin on perioperative transfusion requirements in patients having a major orthopaedic operation. The American Erythropoietin Study Group. J Bone Joint Surg Am. 1996;78:62-72.
3. Hatzidakis AM, Mendlick MR, McKillip T, Reddy RL, Garvin KL. Preoperative autologous donation for total joint arthroplasty. An analysis of risk factors for allogenic transfusion. J Bone Joint Surg Am. 2000;82:89-100.
4. Lotke PA, Barth P, Garino JP, Cook EF. Predonated autologous blood transfusions after total knee arthroplasty: immediate versus delayed administration. J Arthroplasty. 1999;14:647-50.
5. Grosvenor D, Goyal V, Goodman S. Efficacy of postoperative blood salvage following total hip arthroplasty in patients with and without deposited autologous units. J Bone Joint Surg Am. 2000;82:951-4.