Commentary & Perspective

Commentary & Perspective on
"Clinical Factors Associated with an Increased Risk of Perioperative Blood Transfusion in Nonanemic Patients Undergoing Total Hip Arthroplasty"
by Enrico Pola, MD, et al.

Commentary & Perspective by
Stuart B. Goodman, MD, PhD*,
Department of Orthopaedic Surgery, Stanford University Medical Center, Stanford, California

Optimal blood management for total hip replacement should facilitate rapid, safe mobilization and rehabilitation of the patient and minimize the complications of anemia and transfusion. Furthermore, care must be provided at a reasonable cost. Preoperative autologous donation, pharmacologic stimulation of erythropoiesis, special intraoperative considerations regarding anesthesia, and intraoperative and postoperative blood salvage have been shown to minimize the need for allogeneic blood transfusion^1,2,3.

The study by Pola et al. identified four clinical factors that identify the patient at risk for perioperative blood transfusion after total hip replacement. In nonanemic patients, the presence of two of the four factors, including age >75 years, female gender, body-mass index <27, and hypertension, are associated with an increased risk of blood transfusion. With this knowledge, the surgeon and anesthesiologist may better counsel the patient preoperatively about the different treatment options for blood management. The strengths of the study are that it is prospective, well documented, and it employs specific criteria for perioperative blood transfusion.

There are several caveats to this study that should be mentioned. The study population was rather small and included ninety-four patients, of whom only seventeen were male. Fifty-four additional patients were excluded from the study because of various medical conditions. The need for perioperative allogeneic blood transfusion in the nonanemic patients in this series was quite high (28%). The patients received a cementless, primary total hip replacement under general anesthesia, and none of the patients donated autologous blood prior to surgery.

Despite the above limitations, the study by Pola and colleagues is valuable in that it allows the patient and clinical team to identify patients at risk for transfusion and to discuss issues regarding blood management in a more comprehensive manner prior to surgery.

*The author did not receive grants or outside funding in support of his 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. Hepinstall MS, Colwell CW Jr, Macaulay WB. Blood conservation in primary total hip arthroplasty. J South Orthop Assoc. 2003;12:95-102.
2. Rosencher N, Kerkkamp HE, Macheras G, Munuera LM, Menichella G, Barton DM, Cremers S, Abraham IL; OSTHEO Investigation. Orthopedic Surgery Transfusion Hemoglobin European Overview (OSTHEO) study: blood management in elective knee and hip arthroplasty in Europe. Transfusion. 2003;43:459-69.
3. Keating EM, Ritter MA. Transfusion options in total joint arthroplasty. J Arthroplasty. 2002;17(4 Suppl 1):125-8.

Copyright © 2004 by the The Journal of Bone and Joint Surgery, Inc.