Peter Earnshaw

Detection, evaluation, and management of preoperative anaemia in the elective orthopaedic surgical patient: NATA guidelines

Previously undiagnosed anaemia is common in elective orthopaedic surgical patients and is associated with increased likelihood of blood transfusion and increased perioperative morbidity and mortality. A standardized approach for the detection, evaluation, and management of anaemia in this setting has been identified as an unmet medical need. A multidisciplinary panel of physicians was convened by the Network for Advancement of Transfusion Alternatives (NATA) with the aim of developing practice guidelines for the detection, evaluation, and management of preoperative anaemia in elective orthopaedic surgery. A systematic literature review and critical evaluation of the evidence was performed, and recommendations were formulated according to the method proposed by the Grades of Recommendation Assessment, Development and Evaluation (GRADE) Working Group. We recommend that elective orthopaedic surgical patients have a haemoglobin (Hb) level determination 28 days before the scheduled surgical procedure if possible (Grade 1C). We suggest that the patients target Hb before elective surgery be within the normal range, according to the World Health Organization criteria (Grade 2C). We recommend further laboratory testing to evaluate anaemia for nutritional deficiencies, chronic renal insufficiency, and/or chronic inflammatory disease (Grade 1C). We recommend that nutritional deficiencies be treated (Grade 1C). We suggest that erythropoiesis-stimulating agents be used for anaemic patients in whom nutritional deficiencies have been ruled out, corrected, or both (Grade 2A). Anaemia should be viewed as a serious and treatable medical condition, rather than simply an abnormal laboratory value. Implementation of anaemia management in the elective orthopaedic surgery setting will improve patient outcomes.

Anterior Cruciate Ligament Injury and Radiologic Progression of Knee Osteoarthritis A Systematic Review and Meta-analysis

Background: Knee osteoarthritis after anterior cruciate ligament (ACL) injury has previously been reported. However, there has been no meta-analysis reporting the development and progression of osteoarthritis. Purpose: We present the first meta-analysis reporting on the development and progression of osteoarthritis after ACL injury at a minimum mean follow-up of 10 years, using a single and widely accepted radiologic classification, the Kellgren & Lawrence classification. Study Design: Meta-analysis. Method: Articles were included for systematic review if they reported radiologic findings of ACL-injured knees and controls using the Kellgren & Lawrence classification at a minimum mean follow-up period of 10 years. Appropriate studies were then included for meta-analysis. Results: Nine studies were included for systematic review, of which 6 studies were further included for meta-analysis. One hundred twenty-one of 596 (20.3%) ACL-injured knees had moderate or severe radiologic changes (Kellgren & Lawrence grade III or IV) compared with 23 of 465 (4.9%) uninjured ACL-intact contralateral knees. After ACL injury, irrespective of whether the patients were treated operatively or nonoperatively, the relative risk (RR) of developing even minimal osteoarthritis was 3.89 (P < .00001), while the RR of developing moderate to severe osteoarthritis (grade III and IV) was 3.84 (P < .0004). Nonoperatively treated ACL-injured knees had significantly higher RR (RR, 4.98; P < .00001) of developing any grade of osteoarthritis compared with those treated with reconstructive surgery (RR, 3.62; P < .00001). Investigation of progression to moderate or severe osteoarthritis (grade III or IV only) after 10 years showed that ACL-reconstructed knees had a significantly higher RR (RR, 4.71; P < .00001) compared with nonoperative management (RR, 2.41; P = .54). It was not possible to stratify for return to sports among the patients undergoing ACL reconstruction. Conclusion: Results support the proposition that ACL injury predisposes knees to osteoarthritis, while ACL reconstruction surgery has a role in reducing the risk of developing degenerative changes at 10 years. However, returning to sports activities after ligament reconstruction may exacerbate the development of arthritis.

Publication Trends in Knee Surgery: A Review of the Last 16 Years

The trends in the publication of articles regarding knee arthroplasty and soft tissue surgery were analysed with regard to geographical authorship, institutional funding and number of authors. Over 7500 articles from relevant journals with the highest impact factors according to the Thomson Reuters Journal Citation Report (2010) were evaluated from 1995 to 2010. The rate of publication increased by 16.9 per year for arthroplasty articles and by 13.9 per year for soft tissue surgery articles. The relative supremacy of the USA has declined over the 16 years, its share dropping from 72.2% to 39.2% for arthroplasty articles and from 61.7% to 36.6% for soft tissue surgery articles. The UK, Japan, South Korea and smaller countries in Asia and South America have become increasingly prolific.

Management of preoperative anaemia in patients undergoing elective surgery

Previously undiagnosed anaemia is commonly identified during preadmission testing in patients undergoing elective surgery. Anaemia in these patients and related perioperative therapy have been associated with increased morbidity (including increased rates of perioperative infection) and mortality. Clinical care pathways for patients in these settings have been developed by the Society for Blood Management (SABM) and the Network for the Advancement of Transfusion Alternatives (NATA). These consensus recommendations emphasize the following: (1) preadmission testing, including complete blood counts (CBC) that should occur as close as possible to 30 days before the scheduled surgery date; (2) any anaemia identified should be evaluated and managed before surgery; (3) evaluations and laboratory testing should be performed to rule out nutritional causes (particularly iron deficiency), chronic kidney disease and/or anaemia of inflammation and (4) management of anaemia should include consideration of IV iron therapy and/or therapy with erythropoiesis‐stimulating agents (ESA).

Erythropoietin provides a useful strategy for treating preoperative anemia in planned elective orthopedic surgery: an analysis of benefit in routine practice.

There is strong evidence that preoperative anemia that is not corrected can result in increased mortality and morbidity, particularly in patients who have cardiovascular disease. Major orthopedic surgery such as hip and knee replacement can require transfusion of significant quantities of allogeneic red blood cells (RBCs). This is problematic for several reasons. First, there is evidence that clinical outcome is prejudiced by blood transfusion. Infection risk is increased not only directly by contaminated blood products, but also by the indirect immunosuppressive effect of transfusion. Allergic reactions and incompatibility are further risks associated with blood transfusion. Second, health economics disfavor blood transfusion on the grounds of reduced supply of blood components and high costs of blood preservation. Recent progress in the development of a blood-based assay for prion infection by variant Creutzfeldt-Jakob disease (vCJD) may reduce infection risk, but correspondingly may further reduce the availability of RBCs for transfusion. There is therefore a pressing need to develop and evaluate alternative strategies for correcting preoperative anemia in patients who require major orthopedic surgery. In this regard, recombinant human erythropoietin (EPO) is a promising “blood-saving technique.” Our institution’s existing Healthcare Trust protocol evaluates patients individually for transfusion, rather than designating a formal hemoglobin (Hb) threshold. Blood management strategies are well established within our Trust, including preoperative screening and intraoperative and postoperative cell salvage. We developed a protocol to further reduce exposure to allogeneic blood transfusion by utilizing EPO in adult patients before elective major orthopedic surgery and thereby evaluate our ability to utilize EPO therapy in standard preoperative care, that is, outside the formal setting of a research study. EPO therapy was considered for patients with moderate anemia (Hb level, 10-13 g/dL) scheduled for planned primary total hip replacement (THR) or revision THR or total knee replacement (TKR). Data were also collected from one patient who received EPO regimens on two occasions before right acetabular revision procedure; in this case, EPO was utilized because of the patient’s religious objections to a blood transfusion. We excluded patients with clinically relevant diseases according to the discretion of the investigator. Importantly, we also excluded patients with trauma from our study. This protocol was for patients with physiologic or chronic anemia due to underlying disease such as renal impairment, diabetes, and chronic inflammation. Patients were assessed for Hb, ferritin, vitamin B12, and folate levels 21 days before surgery and weekly thereafter. Intravenous (IV) iron sucrose 200 mg was prescribed and administered concurrently with EPO for all patients who had ferritin levels of less than 100 ng/mL while oral iron (ferrous sulfate 200 mg bd until surgery) was prescribed for patients who had ferritin levels of more than 100 ng/mL to prevent EPO-associated iron deficiency. Patients with Hb levels of 10 to 13 g/dL were administered EPO in the form of epoetin beta 40,000 units (60,000 units if weight >90 kg) subcutaneously weekly. Two patients were included, at the clinical discretion of the investigator, who had initial Hb levels of 9.8 and 9.9 g/dL, respectively. The protocol encouraged weekly EPO from 21 days before surgery unless the Hb level was more than 14 g/dL. EPO was not administered on the day of surgery except in two patients who joined the study 14 days before surgery. All patients received postoperative thromboprophylaxis with enoxaparin 40 mg subcutaneously as per Healthcare Trust policy. We identified 30 episodes of care for 29 patients with a mean age of 73.4 years (range, 48-88 years) and pre-EPO mean Hb level of 11.3 g/dL. Twenty-two episodes of care achieved three EPO injections at weekly intervals, and eight episodes of care achieved only two EPO injections either because of practical barriers preventing attendance at clinic or because they were referred too late in the pathway to achieve three injections. All patients received IV iron sucrose except for one patient who had a ferritin level of more than 100 ng/mL and therefore received oral iron. The mean Hb level of all patient episodes on the day of surgery was 12.9 g/dL. For male patients, the post-EPO mean Hb level was 12.7 g/dL and 60% (n = 5) had Hb levels within the normal range according to World Health Organization criteria. For female patients, the post-EPO mean Hb level was 12.9 g/dL and 88% (n = 25) had Hb levels within normal range. Surgery without blood transfusion was performed in 90% (27 of 30) of episodes of care. Of the remaining three episodes, surgery was deferred because of cardiac history and the patient’s religious beliefs in two cases, respectively. Blood transfusion was required in only one episode of care, due to severe perioperative hemorrhage unrelated to treatment. Thus of 28 operations only one required a transfusion, which was for an unexpected complication. In addition, there were no instances of venous thromboembolism among the 30 episodes of care. A recent audit in our institution has established that blood transfusion is currently performed in a significant proportion of patients who undergo elective orthopedic surgery. This audit of 980 patients over 1 year identified that patients were transfused blood as follows: 37% of

Saw Cut Accuracy in Knee ArthroplastyâAn Experimental Case-ControlStudy

Introduction: Navigated TKA (Total Knee Arthroplasty) has heightened awareness of mal-alignment in conventional TKA, as well as providing an accurate means of measuring alignment intra-operatively. Debate as to the importance and significance of alignment versus knee balance continues. Aim: To assess cutting error, and examine the hypothesises: • ‘Slotted osteotomies are more accurate than non-slotted’ • ‘Second pass of the saw blade improves the accuracy of osteotomies’ Method: Three pairs of fresh frozen human knees were prepared, exposed, and positioned as for primary TKA. Standard cutting guides were used in conjunction with a clinical navigation system, and the error (difference between the achieved resection, and the planned resection) in each osteotomy was measured. A second, tidying, pass of the saw blade was made and the error re-measured. Cutting guides were used with a slotted and un-slotted technique in left and right knees respectively. A single experienced surgeon performed all 96 osteotomies. Results: Slotted tibial osteotomies are significantly more accurate in the sagittal (p=0.01) and coronal (p=0.04) planes. Second pass osteotomies reduce variability in femoral (p=0.07) and tibial (p=0.17) osteotomies. Discussion: The bone cutting process is prone to high levels of random error that can result in implant malalignment, and thus predispose to aseptic loosening. Navigated TKA gives the operating surgeon the opportunity to check each osteotomy, and correct any error where necessary. In conventional TKA the use of dual pass, slotted osteotomies should provide improved accuracy.

Erythropoietin provides a useful strategy for treating preoperative anemia in planned elective orthopedic surgery: an analysis of benefit in routine practice: LETTERS TO THE EDITOR

There is strong evidence that preoperative anemia that is not corrected can result in increased mortality and morbidity, particularly in patients who have cardiovascular disease. Major orthopedic surgery such as hip and knee replacement can require transfusion of significant quantities of allogeneic red blood cells (RBCs). This is problematic for several reasons. First, there is evidence that clinical outcome is prejudiced by blood transfusion. Infection risk is increased not only directly by contaminated blood products, but also by the indirect immunosuppressive effect of transfusion. Allergic reactions and incompatibility are further risks associated with blood transfusion. Second, health economics disfavor blood transfusion on the grounds of reduced supply of blood components and high costs of blood preservation. Recent progress in the development of a blood-based assay for prion infection by variant Creutzfeldt-Jakob disease (vCJD) may reduce infection risk, but correspondingly may further reduce the availability of RBCs for transfusion. There is therefore a pressing need to develop and evaluate alternative strategies for correcting preoperative anemia in patients who require major orthopedic surgery. In this regard, recombinant human erythropoietin (EPO) is a promising “blood-saving technique.” Our institution’s existing Healthcare Trust protocol evaluates patients individually for transfusion, rather than designating a formal hemoglobin (Hb) threshold. Blood management strategies are well established within our Trust, including preoperative screening and intraoperative and postoperative cell salvage. We developed a protocol to further reduce exposure to allogeneic blood transfusion by utilizing EPO in adult patients before elective major orthopedic surgery and thereby evaluate our ability to utilize EPO therapy in standard preoperative care, that is, outside the formal setting of a research study. EPO therapy was considered for patients with moderate anemia (Hb level, 10-13 g/dL) scheduled for planned primary total hip replacement (THR) or revision THR or total knee replacement (TKR). Data were also collected from one patient who received EPO regimens on two occasions before right acetabular revision procedure; in this case, EPO was utilized because of the patient’s religious objections to a blood transfusion. We excluded patients with clinically relevant diseases according to the discretion of the investigator. Importantly, we also excluded patients with trauma from our study. This protocol was for patients with physiologic or chronic anemia due to underlying disease such as renal impairment, diabetes, and chronic inflammation. Patients were assessed for Hb, ferritin, vitamin B12, and folate levels 21 days before surgery and weekly thereafter. Intravenous (IV) iron sucrose 200 mg was prescribed and administered concurrently with EPO for all patients who had ferritin levels of less than 100 ng/mL while oral iron (ferrous sulfate 200 mg bd until surgery) was prescribed for patients who had ferritin levels of more than 100 ng/mL to prevent EPO-associated iron deficiency. Patients with Hb levels of 10 to 13 g/dL were administered EPO in the form of epoetin beta 40,000 units (60,000 units if weight >90 kg) subcutaneously weekly. Two patients were included, at the clinical discretion of the investigator, who had initial Hb levels of 9.8 and 9.9 g/dL, respectively. The protocol encouraged weekly EPO from 21 days before surgery unless the Hb level was more than 14 g/dL. EPO was not administered on the day of surgery except in two patients who joined the study 14 days before surgery. All patients received postoperative thromboprophylaxis with enoxaparin 40 mg subcutaneously as per Healthcare Trust policy. We identified 30 episodes of care for 29 patients with a mean age of 73.4 years (range, 48-88 years) and pre-EPO mean Hb level of 11.3 g/dL. Twenty-two episodes of care achieved three EPO injections at weekly intervals, and eight episodes of care achieved only two EPO injections either because of practical barriers preventing attendance at clinic or because they were referred too late in the pathway to achieve three injections. All patients received IV iron sucrose except for one patient who had a ferritin level of more than 100 ng/mL and therefore received oral iron. The mean Hb level of all patient episodes on the day of surgery was 12.9 g/dL. For male patients, the post-EPO mean Hb level was 12.7 g/dL and 60% (n = 5) had Hb levels within the normal range according to World Health Organization criteria. For female patients, the post-EPO mean Hb level was 12.9 g/dL and 88% (n = 25) had Hb levels within normal range. Surgery without blood transfusion was performed in 90% (27 of 30) of episodes of care. Of the remaining three episodes, surgery was deferred because of cardiac history and the patient’s religious beliefs in two cases, respectively. Blood transfusion was required in only one episode of care, due to severe perioperative hemorrhage unrelated to treatment. Thus of 28 operations only one required a transfusion, which was for an unexpected complication. In addition, there were no instances of venous thromboembolism among the 30 episodes of care. A recent audit in our institution has established that blood transfusion is currently performed in a significant proportion of patients who undergo elective orthopedic surgery. This audit of 980 patients over 1 year identified that patients were transfused blood as follows: 37% of

Erythropoietin provides a useful strategy for treating preoperative anemia in planned elective orthopedic surgery

There is strong evidence that preoperative anemia that is not corrected can result in increased mortality and morbidity, particularly in patients who have cardiovascular disease. Major orthopedic surgery such as hip and knee replacement can require transfusion of significant quantities of allogeneic red blood cells (RBCs). This is problematic for several reasons. First, there is evidence that clinical outcome is prejudiced by blood transfusion. Infection risk is increased not only directly by contaminated blood products, but also by the indirect immunosuppressive effect of transfusion. Allergic reactions and incompatibility are further risks associated with blood transfusion. Second, health economics disfavor blood transfusion on the grounds of reduced supply of blood components and high costs of blood preservation. Recent progress in the development of a blood-based assay for prion infection by variant Creutzfeldt-Jakob disease (vCJD) may reduce infection risk, but correspondingly may further reduce the availability of RBCs for transfusion. There is therefore a pressing need to develop and evaluate alternative strategies for correcting preoperative anemia in patients who require major orthopedic surgery. In this regard, recombinant human erythropoietin (EPO) is a promising “blood-saving technique.” Our institution’s existing Healthcare Trust protocol evaluates patients individually for transfusion, rather than designating a formal hemoglobin (Hb) threshold. Blood management strategies are well established within our Trust, including preoperative screening and intraoperative and postoperative cell salvage. We developed a protocol to further reduce exposure to allogeneic blood transfusion by utilizing EPO in adult patients before elective major orthopedic surgery and thereby evaluate our ability to utilize EPO therapy in standard preoperative care, that is, outside the formal setting of a research study. EPO therapy was considered for patients with moderate anemia (Hb level, 10-13 g/dL) scheduled for planned primary total hip replacement (THR) or revision THR or total knee replacement (TKR). Data were also collected from one patient who received EPO regimens on two occasions before right acetabular revision procedure; in this case, EPO was utilized because of the patient’s religious objections to a blood transfusion. We excluded patients with clinically relevant diseases according to the discretion of the investigator. Importantly, we also excluded patients with trauma from our study. This protocol was for patients with physiologic or chronic anemia due to underlying disease such as renal impairment, diabetes, and chronic inflammation. Patients were assessed for Hb, ferritin, vitamin B12, and folate levels 21 days before surgery and weekly thereafter. Intravenous (IV) iron sucrose 200 mg was prescribed and administered concurrently with EPO for all patients who had ferritin levels of less than 100 ng/mL while oral iron (ferrous sulfate 200 mg bd until surgery) was prescribed for patients who had ferritin levels of more than 100 ng/mL to prevent EPO-associated iron deficiency. Patients with Hb levels of 10 to 13 g/dL were administered EPO in the form of epoetin beta 40,000 units (60,000 units if weight >90 kg) subcutaneously weekly. Two patients were included, at the clinical discretion of the investigator, who had initial Hb levels of 9.8 and 9.9 g/dL, respectively. The protocol encouraged weekly EPO from 21 days before surgery unless the Hb level was more than 14 g/dL. EPO was not administered on the day of surgery except in two patients who joined the study 14 days before surgery. All patients received postoperative thromboprophylaxis with enoxaparin 40 mg subcutaneously as per Healthcare Trust policy. We identified 30 episodes of care for 29 patients with a mean age of 73.4 years (range, 48-88 years) and pre-EPO mean Hb level of 11.3 g/dL. Twenty-two episodes of care achieved three EPO injections at weekly intervals, and eight episodes of care achieved only two EPO injections either because of practical barriers preventing attendance at clinic or because they were referred too late in the pathway to achieve three injections. All patients received IV iron sucrose except for one patient who had a ferritin level of more than 100 ng/mL and therefore received oral iron. The mean Hb level of all patient episodes on the day of surgery was 12.9 g/dL. For male patients, the post-EPO mean Hb level was 12.7 g/dL and 60% (n = 5) had Hb levels within the normal range according to World Health Organization criteria. For female patients, the post-EPO mean Hb level was 12.9 g/dL and 88% (n = 25) had Hb levels within normal range. Surgery without blood transfusion was performed in 90% (27 of 30) of episodes of care. Of the remaining three episodes, surgery was deferred because of cardiac history and the patient’s religious beliefs in two cases, respectively. Blood transfusion was required in only one episode of care, due to severe perioperative hemorrhage unrelated to treatment. Thus of 28 operations only one required a transfusion, which was for an unexpected complication. In addition, there were no instances of venous thromboembolism among the 30 episodes of care. A recent audit in our institution has established that blood transfusion is currently performed in a significant proportion of patients who undergo elective orthopedic surgery. This audit of 980 patients over 1 year identified that patients were transfused blood as follows: 37% of