Healio
Healio
October 01, 2006
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Blood Loss After Navigation-assisted Minimally Invasive Total Knee Arthroplasty

Abstract

The following study evaluated blood loss in patients undergoing navigation-assisted minimally invasive total knee arthroplasty. The study included 100 patients divided into two groups. Group A consisted of patients with an immediate drain release, and group B consisted of patients with a 1-hour delayed drain release after surgery. The surgeon used a mini-midvastus approach with the OrthoPilot navigation system. The mean blood drainage was 465 mL in group A and 409 mL in group B. The mean hemoglobin loss was 2.59 g/dL in group A and 2.43 g/dL in group B.

Total knee arthroplasty (TKA) leads to considerable blood loss after surgery and may also result in need for frequent transfusions. Allogenic transfusions have been associated with the risk of infection, allergic reaction, and immunocompromise. Thus, blood loss should be minimized during and after surgery to decrease transfusion-associated risks.

Despite thorough stanching, conventional TKAs cause bleeding from the minute vessels of resected soft tissues and bones. To minimize the need for patient blood transfusions, various techniques, such as tourniquets, minimal incisions, diathermy coagulation, sealing the intramedullary femoral canal with autologous bone, and fibrin tissue adhesives, are used during surgery to reduce bleeding.1-4 Recently, computer navigation-assisted surgery and drain-clamping methods were introduced.5,6 The authors performed image-free, navigation system-assisted, minimally invasive TKAs and compared blood loss and transfusion administration between patients with immediate drain release (group A) and patients with 1-hour delayed drain release (group B) after surgery. The investigation was intended to discover methods in which blood loss and the need for subsequent transfusions could be minimized.

Materials and Methods

A randomized prospective study was conducted between January 2005 and March 2005. The study included 100 patients who underwent image-free, navigation system-assisted, minimally invasive TKA using the OrthoPilot 4.08 (B. Braun Aesculap, Tuttlingen, Germany). Patients were divided into two groups: group A (n=50), which included patients who had an immediate drain release, and group B (n=50), which included patients who had a 1-hour delayed drain release. Hemoglobin levels, hematocrit counts and platelet counts before and after surgery, postoperative blood loss and transfusion amounts were compared and analyzed using t tests.

Patients with abnormal platelet counts, prothrombin times, and partial prothrombin times were excluded from the study. Patients with illnesses that could affect blood loss and test results, such as liver cirrhosis or chronic renal failure and heart disease, which are treated with anticoagulant medication, were also excluded from this study. In addition, patients who underwent simultaneous bilateral TKAs were excluded, because blood loss amounts would be affected. Physicians advised patients taking nonsteroid anti-inflammatory drugs to stop taking the medication 7 days before surgery. Each group comprised 1 man and 49 women. The mean age was 67.9 years (range: 53-91 years) in group A and 68.1 years (range: 52-79 years) in group B. In group A, diagnoses included 47 patients with degenerative osteoarthritis and 3 patients with osteonecrosis. In group B, diagnoses included 46 patients with degenerative osteoarthritis and and 3 patients with osteonecrosis. In group B, diagnoses included 46 patients with degenerative osteoarthritis and 4 patients with osteonecrosis. No significant differences were observed in hemoglobin levels or in hematocrit counts and platelet counts between the two groups before surgery (Table 1).

table 1

A single surgeon performed all operations and applied a tourniquet (with pressure equivalent to 200 mm/Hg systolic blood pressure) on the proximal thigh. The mini-midvastus approach was used through a midline skin incision between 8 and 12 cm long. The synovial membrane was not resected, and the suprapatellar pouch was preserved. The OrthoPilot TKA 4.08 was used for image-free, navigation system-assisted TKA (Figure). All patients had unilateral primary TKA using cemented prostheses. After drainage tubes were inserted, synovial membranes were sutured before skin closure. The tourniquet was released after skin closure, and compression dressing was applied. The knee joint was raised to approximately 30° flexion, and ice packs were applied to the knee for approximately 24 hours.

The amount of drained blood, preoperative and postoperative hemoglobin levels, vital signs, and amount of transfusions were measured, compared, and analyzed between the two groups. The amount of drained blood was measured at 24 and 48 hours after surgery, and the drainage tubes were removed 48 hours after surgery.

Statistical analyses were performed using the data management system, SPSS for Windows Release 12.0, and distribution was performed using the Kolmogorov-Smirnov test. Student t tests were performed to analyze parametric data, and Mann-Whitney U tests were used for nonparametric data, using a confidence interval of 95%.

figure

Figure: For MIS TKA, navigation-assisted TKA was easier and more comfortable than the conventional method.

Results

Mean blood loss drainage was measured and compared between both groups. Blood loss drainage in the early phase (up to 24 hours after the tourniquet was removed) was 330.4 mL in group A. Blood loss drainage in group B was 275.4 mL, which is significantly less (P=.021) than the mean in group A. The mean amount of blood loss during the delayed phase (24-48 hours) was 134.5 mL in group A and 133.7 mL in group B, revealing no statistical significant difference (P=.943). The total amount of blood loss drainage was 464.9 mL in group A and 409.1 mL in group B, showing no significant difference (P=.117) (Table 2). The mean preoperative hemoglobin level in group A was 13.36 g/dL (range: 10.4-16.3 g/dL), and the mean postoperative hemoglobin level in group A was 10.77 g/dL (range: 8.7-12.8 g/dL). The mean preoperative hemoglobin level in group B was 12.8 g/dL (range: 10.8-15.8 g/dL), and the mean postoperative hemoglobin level in group B was 10.37 g/dL (range: 8.8-12.6 g/dL). The mean loss of hemoglobin was 2.59 g/dL in group A and 2.43 g/dL in group B (Table 3). Significant differences between the groups in the reduction of postoperative hemoglobin levels were not observed. Blood transfusions were not administered because neither group met the criteria for transfusion.

table 2

table 3

Discussion

Total knee arthroplasties often require blood transfusions. Major blood loss threatens life, causes general weakness, delays wound healing, and increases risks of infection. Thus, various methods have been suggested for reducing blood loss. Soft tissue hemostases are required to reduce blood loss during surgery. Nevertheless, stopping blood loss from minute vessels and resected bone surface and stopping intramedullary hemorrhage would be difficult. There is much debate about reducing blood loss by releasing the tourniquet and performing hemostatic procedures on soft tissues before wound closure.7,8 This study examined whether a reduction in blood loss could decrease the number of transfusions. The criteria for what necessitates a transfusion may differ depending on country or hospital, but whether to administer a transfusion always depends on the patient’s condition and disorder.9-12

The authors established criteria for transfusion to include patients with hemoglobin levels of 8.0 g/dL and patients with hemoglobin levels of 8 to 9 g/dL, accompanied by unstable vital signs. Also, if transfusion were necessary, the amount of blood would be 2 pints. In this study, however, no patients had a hemoglobin level of 8 g/dL in either group A (immediate drain release after surgery, 50 patients) or group B (1-hour delayed drain release after surgery; 50 patients). Four patients in group A and 3 patients in group B had hemoglobin levels of 8 to 9 g/dL with stable vital signs. Based on the authors’ criteria, no transfusions were administered.

Conventionally performed TKAs cause substantial tissue injuries, because large skin incisions (15-20 cm) are made, which can lead to heavy blood loss and extended hospital stays after surgery. In contrast, minimally invasive TKA requires an incision approximately 8 to 12 cm long and results in reduced tissue damage, blood loss, and pain, shorter hospital stays; and faster wound healing. Minimally invasive TKA also has cost and rehabilitation advantages.

Cameron13 believe that securing an operation field is the most important factor in surgery and minimally invasive TKA. Unsatisfactory field views increase the chances of inaccurate osteotomy and prosthesis positioning, which can lead to complications.Cameron13 also insist that sufficient traction and exposure within the operation field are difficult to obtain in patients with severe bone deformity in the knee joint and in obese patients, explaining the limitations of TKA by means of minimal incisions.Thus, in an effort to attain restoration of a precise mechanical axis of the lower extremities and accurate alignment of a prosthesis, these authors incorporated a computer-assisted navigation system to countermeasure the surgical inaccuracy inaccuracy—the disadvantage of a MIS procedure.14-20 Furthermore, navigation system-assisted TKA does not require securing intermedullary space during surgery, which should diminish osteogenic hemorrhage. Kalairajah et al5 reported that computer-assisted surgery reduces blood loss and the need for subsequent transfusions compared with a conventional method. Niloy et al21 reported that the amount of blood loss and need for transfusions in group B after TKA surgery were significantly lower than in group A.

In this study, with respect to the early phase after surgery, blood loss and the need for transfusions in group B were significantly lower than blood loss and the need for transfusions in group A. No statistically significant differences were observed between the two groups in the amount of delayed blood loss and total blood loss, however.

Conclusion

There were no statistically significant differences observed in the total amount of blood drainage and hemoglobin loss between group A and group B. Transfusions were not administered in either group. Navigation-assisted, minimally invasive TKA could present an effective and safe method for reducing blood loss and preventing blood transfusion in patients undergoing TKA.

References

  1. Ko PS, Tio MK, Tang YK, et al. Sealing the intramedullary femoral canal with autologous bone plug in total knee arthroplasty. J Arthroplasty. 2003; 18:6-9.
  2. Levy O, Martinowitz U, Oran A, et al. The use of fibrin tissue adhesive to reduce blood loss and the need for transfusion after total knee arthroplasty. A prospective, randomized, multicenter study. J Bone Joint Surg Am. 1999; 81:1580-1588.
  3. Tria AJ Jr, Coon TM. Minimal incision total knee arthroplasty: early experience. Clin Orthop Relat Res. 2003;416:185-190.
  4. Vandenbussche E, Duranthon LD, Couturier M, et al. The effect of tourniquet use in total knee arthroplasty. Int Orthop. 2002; 26:306-309.
  5. Kalairajah Y, Simpson D, Cossey AJ, et al. Blood loss after total knee athroplasty: effects of computer-assisted surgery. J Bone Joint Surg Br. 2005; 87:1480-1482.
  6. Yamada K, Imaizumi T, Uemura M, et al. Comparison between 1-hour and 24-hour drain clamping using diluted epinephrine solution after total knee arthroplasty. J Arthroplasty. 2001; 16:458-462.
  7. Burkart BC, Bourne RB, Rorabeck CH. The efficacy of tourniquet release in blood conservation after total knee arthroplasty. Clin Orthop Relat Res. 1994; 299:147-152.
  8. Widman J, Iscacson J. Surgical haemostasis after tourniquet release does not reduce blood loss in knee replacement. A prospective randomized study of 81 patients. Acta Orthop Scand. 1999; 70:268-270.
  9. Boralessa H, Boralessa H, Contreras M, et al. Effectiveness of a protocol to improve transfusion practice in knee replacement surgery. Vox Sang. 2002; 82:213.
  10. Bottner F, Pavone V, Johnson T, et al. Blood management after bilateral total knee arthroplasty. Clin Orthop Relat Res. 2003; 410:254-261.
  11. Isbister JP. Decision making in perioperative transfusion. Transfus Apher Sci. 2002; 27:19-28.
  12. Keating EM, Ritter MA. Transfusion options in total joint arthroplasty. J Arthroplasty. 2002; 17:125-128.
  13. Cameron HU. Mini-incisions: visualization is key. Orthopedics. 2002; 25:473.
  14. Bathis H, Perlick L, Tingart M, et al. Alignment in total knee arthroplasty. A comparison of computer-assisted surgery with conventional technique. J Bone Joint Surg Br. 2004; 86:682-687.
  15. Chauhan SK, Scott RG, Breidahl W, Beaver RJ. Computer-assisted knee arthoplasty versus a conventional jig-based technique. A randomised, prospective trial. J Bone Joint Surg Br. 2004; 86:372-377.
  16. Delp SL, Stulberg DS, Davies B, et al. Computer assisted knee replacement. Clin Orthop Relat Res. 1998; 354:49-56.
  17. Jenny JY, Boeri C. Computer assisted implantation of total knee prostheses: a case control comparative study with classical instrumentation. Computer Aided Surg. 2001; 6:217-220.
  18. Saragaglia D, Picard F, Chaussard C, et al. Computer-assisted knee arthoplasty: comparison with a conventional procedure. Results of 50 cases in a prospective randomized study. Rev Chir Orthop Reparatrice Appar Mot. 2001; 87:18-28.
  19. Seon JK, Song EK: The accuracy of lower extremity alignment in a total knee arthroplasty using computer-assisted navigation system. J Korean Orthop Assoc. 2004; 39:566-571.
  20. Sparmann M, Wolke B, Czupalla H, et al. Positioning of total knee arthroplasty with and without navigation support: a prospective, randomised study. J Bone Joint Surg Br. 2003; 85:830-835.
  21. Roy N, Smith M, Anwar M, Elsworth C. Delayed release of drain in total knee replacement reduces blood loss: a prospective randomised study. Acta Orthop Belg. 2006; 72:34-38.

Authors

Drs Eum, Lee, Hwang and Park are from the Department of Orthopedic Surgery, Yellin Keun (BigOS) Hospital, Daegu, Korea.