The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 89, Issue 2

Scientific Articles | February 01, 2007

Intraoperative Red Blood-Cell Salvage in Revision Hip Surgery: A Case-Matched Study

J.P. Bridgens, MRCS¹; C.R. Evans, FRCS(Tr&Orth)²; P.M.S. Dobson, FRCA¹; A.J. Hamer, MD, FRCS(Orth)¹

¹ Department of Trauma and Orthopaedics, Northern General Hospital, Herries Road, Sheffield S5 7AU, United Kingdom. E-mail address for J.P. Bridgens: jpbridgens@doctors.org.uk
² Department of Trauma and Orthopaedics, Robert Jones and Agnes Hunt Orthopaedic Hospital, Oswestry, Shropshire SY10 7AG, United Kingdom

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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received 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, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

A commentary is available with the electronic versions of this article, on our web site () and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM).

Investigation performed at the Lower Limb Arthroplasty Unit, Northern General Hospital, Sheffield, United Kingdom

The Journal of Bone and Joint Surgery, Incorporated

J Bone Joint Surg Am, 2007 Feb 01;89(2):270-275. doi: 10.2106/JBJS.F.00492

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Abstract

Background: Revision hip arthroplasty is commonly associated with substantial blood loss and the subsequent need for transfusion. This leads to an increased risk of blood-borne infection and hemolytic reactions. The purpose of this study was to demonstrate whether the use of intraoperative red blood-cell salvage in revision hip arthroplasty reduces the overall rate of allogeneic transfusion.

Methods: Forty-seven patients who had undergone revision hip arthroplasty with the use of intraoperative cell salvage were identified. A computer database was used to individually match these patients, for age, sex, and eleven operative variables, to control patients who had undergone revision hip arthroplasty in the same unit without intraoperative cell salvage. Data gathered included the total allogeneic transfusion requirement for each patient, preoperative and postoperative hemoglobin levels, and operative time.

Results: The total allogeneic transfusion requirement was significantly lower in the group that had intraoperative cell salvage than in the control group (median, 2 compared with 6 U of packed red blood cells, p = 0.0006), with a median reduction in allogeneic transfusion of 4 U. There was no significant difference in preoperative or postoperative hemoglobin levels between the groups.

Conclusions: The use of intraoperative cell salvage significantly lowered the allogeneic transfusion requirement, which can lead to substantial cost savings. To our knowledge, this is the first study in which the use of intraoperative red blood-cell salvage in revision hip arthroplasty was evaluated by matching patients on the basis of age, sex, and operative variables.

Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

Figures in this Article

Revision hip arthroplasty can be associated with substantial blood loss and the subsequent need for blood transfusion¹. Serious complications of allogeneic blood transfusion occur at a rate of one in 67,000². These complications include the transmission of blood-borne infections and hemolytic reactions. In the United Kingdom, emerging evidence of transfusion-transmitted variant Creutzfeldt-Jakob disease led the Department of Health to exclude all donors who had previously received a transfusion, thus reducing the donor base^2,3. Additional preparation such as leukodepletion has meant a rise in the cost of allogeneic blood⁴. These factors have increased interest in methods that can reduce the need for allogeneic transfusion^2,5. There is also an increasing emphasis on the role of blood conservation as a part of good orthopaedic surgical practice.

Effective blood conservation should encompass preoperative, intraoperative, and postoperative measures. In the case of revision hip arthroplasty, the often substantial intraoperative blood loss means conservation at this stage is particularly important.

Intraoperative cell salvage and subsequent autologous transfusion have been in routine use since the mid 1970s⁶. Red blood cells are salvaged from the operative field and washed before being resuspended in saline solution. They are then reinfused into the patient in the intraoperative and postoperative period. The technique has been used for a variety of orthopaedic operations in which substantial blood loss is likely, including hip and knee arthroplasty as well as pelvic and spinal surgery⁷. Intraoperative cell salvage cannot be used when a patient has an infection, but it can be used with irrigants such as hydrogen peroxide or chlorhexidine provided that the wound is adequately lavaged after the use of those irrigants². Blood derived with intraoperative cell salvage has been shown to have a high rate of erythrocyte viability⁸. There have been suggestions that it may have a positive immunostimulatory effect and might reduce the risk of postoperative infections^9,10.

A number of factors, such as the use of cement and segmental bone-grafting, have been shown to influence blood loss in revision hip surgery^11,12. Previous studies of intraoperative cell salvage have demonstrated that revision of both components (femoral and acetabular) is associated with increased blood loss^6,13.

The purpose of our study was to examine whether the use of intraoperative cell salvage in revision hip surgery lowers the rate of allogeneic blood transfusion.

Materials and Methods

Materials and Methods | Results | Discussion | References

Forty-seven patients in whom intraoperative cell salvage had been used during revision hip surgery were identified. All of the surgical details for these patients had been prospectively entered into a computer database (Access; Microsoft UK, Reading Berkshire, United Kingdom) kept within the lower limb arthroplasty unit. The decision to use intraoperative cell salvage for each patient was made by the surgeon and anesthetist on the basis of the potential blood loss.

Intraoperative cell salvage was carried out with use of a Haemonetics Cell Saver 5 (Haemonetics UK, Leeds, United Kingdom). Recovery of blood from the surgical field and washing were done according to the manufacturer's recommendations. Blood was most often reinfused toward the end of the operation or in the recovery room. The Cell Saver equipment was provided by the Blood Transfusion Service, which also initially provided the disposable components used with this device. The Cell Saver was found to be easy to use, and operating department practitioners were trained to operate it. This meant that no extra staff had to be employed.

Forty-seven control patients who had also undergone revision hip arthroplasty, prior to the introduction of intraoperative cell salvage, were identified as historical controls. In order to ensure that our study and control groups were comparable, each control patient was individually matched to a study patient on the basis of age, sex, and eleven operative variables (Table I). These variables were chosen to be indicative of the general complexity of the operation and the potential for intraoperative blood loss. Matching was done by creating database queries, which meant that patients could be matched for a far larger number of variables than would be possible with other methods. This also meant that there was no need to refer to patient notes, which allowed us to avoid a potential source of bias. Use of the database made it possible to match patients for the exact prosthesis type that had been inserted or removed.

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TABLE I Operative Variables Used for Matching Patients

Surgical approach

Femoral grafting (massive allograft) (yes/no)

Type of femoral prosthesis removed

Type of femoral prosthesis inserted

Type of acetabular prosthesis removed

Type of acetabular prosthesis inserted

Cement used in femur (yes/no)

Cement used in acetabulum (yes/no)

2nd stage due to previous infection (yes/no)

Operating surgeon

Mode of failure

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TABLE I Operative Variables Used for Matching Patients

Surgical approach

Femoral grafting (massive allograft) (yes/no)

Type of femoral prosthesis removed

Type of femoral prosthesis inserted

Type of acetabular prosthesis removed

Type of acetabular prosthesis inserted

Cement used in femur (yes/no)

Cement used in acetabulum (yes/no)

2nd stage due to previous infection (yes/no)

Operating surgeon

Mode of failure

All operations took place from 1999 to 2003 at one hospital, and all were carried out by one of four arthroplasty consultants or by fellows supervised by one of those consultants. All patients underwent sterile revision hip surgery.

The quantity of filtered blood that was reinfused in the patients who had had intraoperative cell salvage was recorded. The total allogeneic transfusion requirement for each patient during his or her hospital stay (maximum, thirty days) was recorded as well. The preoperative and postoperative hemoglobin concentrations were noted, with the postoperative level considered to be the first laboratory result obtained postoperatively. The operating time was also recorded for all patients.

The department's routine guidelines on blood transfusion were followed for all patients. Patients received a transfusion either when they were symptomatic or when the hemoglobin level was <90 g/L. This level is higher than that currently recommended in the British Orthopaedic Association guidelines, which refer to primary arthroplasties². Thromboprophylaxis with low-molecular-weight heparin was used for all patients in both groups in line with the department's guidelines at that time. The anesthetic technique was not standardized, although most patients in both groups were anesthetized by one of a small number of anesthetists specializing in major orthopaedic anesthesia. More than 75% of the patients in both groups (thirty-six patients who had intraoperative cell salvage and thirty-seven in the control group) had combined epidural and general anesthesia, and the majority of the remaining patients had general anesthesia only.

Statistical Analysis

Analysis was carried out with use of a PC statistical package (SPSS, Chicago, Illinois). Normality was assessed with use of the Kolmogorov-Smirnov test. The primary outcome measure was the total allogeneic blood transfusion requirement. These data were not normally distributed and thus were analyzed with the Mann-Whitney U test. Previously, other authors have used parametric methods to express their results although the data have commonly not been normally distributed. In order to allow comparison with previous studies, the mean values for our data are also included. The adequacy of the matching of the groups was analyzed with use of the chi-square test. The preoperative and discharge hemoglobin levels were normally distributed, and were analyzed with use of an unpaired two-tailed t test. A post hoc power analysis showed that the study had a 90% power to detect a >2.2-U difference in the amount of transfused blood between the groups. Significance was assumed at the p < 0.05 level. The analysis was carried out on the basis of advice from the Sheffield University Statistical Services Unit.

Results

Materials and Methods | Results | Discussion | References

Ninety-four patients were included in the study, with forty-seven in each group (intraoperative cell salvage and control) (Table II). There were no differences between the groups in terms of age, sex, or duration of the operation. As shown in Table III, the groups were well matched for all of the operative variables except for the operating surgeon (consultant or fellow). They were not well matched for the operating surgeon because the operations in the control group took place when fewer arthroplasty fellows were on staff. The data on matching for operative variables was further analyzed to find out how many patients in each group had undergone revision of both components or a single component. There was no significant difference between the groups with regard to this factor, with 87% of the patients who had intraoperative cell salvage and 85% of the patients in the control group having undergone revision of both components (p = 0.68, chisquare test).

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TABLE II Demographic Details, Duration of Operation, Hemoglobin Levels, and Total Allogeneic Transfusion Requirement for the Ninety-six Patients in the Study^*

	Intraoperative Cell Salvage (N = 47)	Control Group (N = 47)	P Value
Mean age (yr)	64.7 ± 12.9	64.3 ± 11.2	0.86 (t test)
Male (no.)	20	24	0.23 (chi-square test)
Female (no.)	27	23
Mean duration of operation (min)	216 ± 72.6	229 ± 81.9	0.3 (t test)
Mean volume of red blood cells reinfused (mL)	590 ± 363	—
Mean hemoglobin level (g/L)
Preop.	133 ± 13	132 ± 13	0.87 (t test)
Postop.	101 ± 10	106 ± 11	0.06 (t test)
Total allogeneic transfusion requirement (U)
Median	2 (0-22)	6 (0-14)	0.0006 (Mann-Whitney U test)
Mean	2.6 ± 3.13	6.4 ± 4.5

The mean values are given with the standard deviation, and the median value is given with the range.

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TABLE II Demographic Details, Duration of Operation, Hemoglobin Levels, and Total Allogeneic Transfusion Requirement for the Ninety-six Patients in the Study^*

	Intraoperative Cell Salvage (N = 47)	Control Group (N = 47)	P Value
Mean age (yr)	64.7 ± 12.9	64.3 ± 11.2	0.86 (t test)
Male (no.)	20	24	0.23 (chi-square test)
Female (no.)	27	23
Mean duration of operation (min)	216 ± 72.6	229 ± 81.9	0.3 (t test)
Mean volume of red blood cells reinfused (mL)	590 ± 363	—
Mean hemoglobin level (g/L)
Preop.	133 ± 13	132 ± 13	0.87 (t test)
Postop.	101 ± 10	106 ± 11	0.06 (t test)
Total allogeneic transfusion requirement (U)
Median	2 (0-22)	6 (0-14)	0.0006 (Mann-Whitney U test)
Mean	2.6 ± 3.13	6.4 ± 4.5

The mean values are given with the standard deviation, and the median value is given with the range.

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TABLE III Matching of Operative Variables

	No. of Patients
Operative Variable	Intraoperative Cell Salvage	Control	P Value (Chi-Square Test)
Approach			0.53
Anterolateral	0	2
Extended trochanteric osteotomy	7	7
Lateral to femoral shaft	4	3
Posterior	19	21
Trochanteric osteotomy	17	14
Femoral grafting (massive allograft)			1.0
Yes	2	2
No	45	45
Femoral prosthesis removed			0.57
None removed^*	4	4
Cement only†	8	11
Implant	35	32
Femoral prosthesis inserted			0.95
None inserted^*	4	4
Cement only†	2	2
Implant	41	43
Acetabular prosthesis removed			0.2
None removed^*	5	7
Cement only†	8	12
Implant	34	28
Acetabular prosthesis inserted			0.63
None inserted^*	2	3
Cement only†	1	2
Implant	44	42
Cement used in femur			0.35
Yes	35	32
No	12	15
Cement used in acetabulum			0.5
Yes	37	35
No	10	12
2nd stage due to previous infection			0.32
Yes	9	12
No	38	35
Operating surgeon			<0.001
Consultant	28	41
Fellow	19	6
Mode of failure			0.66
Acetabular erosion	3	2
Aseptic loosening	29	28
Dislocation	2	1
Implant failure	1	2
Infection	9	12
Periprosthetic fracture	3	2

^*"None removed" and "none inserted" refer to cases in which either no prosthesis was in situ (e.g., in a revision of a hemiarthroplasty) or in which only one side was revised. †"Cement only" refers to the insertion or removal of cement beads or a spacer as used in a first or second-stage revision, respectively.

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TABLE III Matching of Operative Variables

	No. of Patients
Operative Variable	Intraoperative Cell Salvage	Control	P Value (Chi-Square Test)
Approach			0.53
Anterolateral	0	2
Extended trochanteric osteotomy	7	7
Lateral to femoral shaft	4	3
Posterior	19	21
Trochanteric osteotomy	17	14
Femoral grafting (massive allograft)			1.0
Yes	2	2
No	45	45
Femoral prosthesis removed			0.57
None removed^*	4	4
Cement only†	8	11
Implant	35	32
Femoral prosthesis inserted			0.95
None inserted^*	4	4
Cement only†	2	2
Implant	41	43
Acetabular prosthesis removed			0.2
None removed^*	5	7
Cement only†	8	12
Implant	34	28
Acetabular prosthesis inserted			0.63
None inserted^*	2	3
Cement only†	1	2
Implant	44	42
Cement used in femur			0.35
Yes	35	32
No	12	15
Cement used in acetabulum			0.5
Yes	37	35
No	10	12
2nd stage due to previous infection			0.32
Yes	9	12
No	38	35
Operating surgeon			<0.001
Consultant	28	41
Fellow	19	6
Mode of failure			0.66
Acetabular erosion	3	2
Aseptic loosening	29	28
Dislocation	2	1
Implant failure	1	2
Infection	9	12
Periprosthetic fracture	3	2

The use of intraoperative cell salvage led to a median reduction in allogeneic transfusion of 4 U. This result was highly significant (p = 0.0006). Figure 1 shows that the majority of patients treated with intraoperative cell salvage received 0, 1, or 2 U of allogeneic blood, and eleven patients needed no allogeneic transfusion. Most patients in the control group required =6 U, and only one patient needed no allogeneic transfusion. Further analysis of the data showed that, in the group with intraoperative cell salvage, the transfusion requirement was 2.8 U for patients who had a revision of both components compared with 1.2 U for those who had a revision of a single component, whereas the values were 6.55 U compared with 5.6 U, respectively, in the control group. These differences were not significant. There was no difference in hemoglobin levels, either preoperatively or at the time of discharge, between the groups.

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Fig 1: Number of allogeneic units received by patients in each group. ICS = intraoperative cell salvage.

Discussion

Materials and Methods | Results | Discussion | References

Previous studies have shown that use of intraoperative cell salvage in revision hip surgery reduces the allogeneic transfusion requirement^{6,7,11,12,14-16}. Because revision hip surgery can encompass a wide range of procedures, ranging from a single-stage revision of both components with use of a massive allograft to a simple acetabular liner exchange, we wanted to ensure the equivalence of the operative procedures in our two groups. As far as we are aware, this is the first study comparing two groups of patients matched in this way.

In 1989, Wilson reported that intraoperative autologous transfusion had resulted in a 42% reduction in the allogeneic transfusion requirement in a similar, but not casematched, study of 100 revision total hip arthroplasties⁶. In 1990, McMurray et al. showed that use of intraoperative cell salvage in revision hip operations reduced the allogeneic transfusion requirement by approximately 2 U¹⁴. In 1992, Elawad and Fredin evaluated (as part of a larger study of intraoperative cell salvage) fifty-five patients who had undergone a revision operation with intraoperative cell salvage and compared them with an age and gender-matched control group of the same size¹⁵. The intraoperative cell salvage reduced the average allogeneic transfusion requirement from 2026 to 1026 mL (an approximately 3-U reduction).

As the combined use of transfusion of predeposited autologous blood and postoperative blood salvage from drains has increased, it has been more difficult for investigators to specifically assess the effect of intraoperative cell salvage alone on the need for additional allogeneic transfusion^12,13,15,16. In 2003, Zarin et al. evaluated the effect of intraoperative cell salvage on net blood loss¹³, which may be more difficult to relate to clinical practice than reduction in allogeneic transfusion. They used statistical techniques to control for perioperative factors. By specifically matching patients for these factors, we avoided the need for such techniques.

In our study, we found a 59% reduction in the mean volume of allogeneic blood transfused into patients for whom intraoperative cell salvage had been used. This greater difference in our study, compared with that reported in previous studies, may be due to the similarity of the groups compared in our study and the fact that a larger proportion of patients had revision of both components. Sixty percent (thirty) of the fifty patients in Wilson's study⁶ had both components revised compared with 87% (forty-one) of the forty-seven patients in the cell-salvage group in our study. Our finding that 23% (eleven) of the forty-seven patients who had had intraoperative cell salvage required no allogeneic transfusion is similar to the findings in other studies⁶.

The efficiency of the Cell Saver device in our study appears to be similar to that in previously reported studies. Zarin et al.¹³ reported that patients who had undergone a revision of both components had a mean of 519 mL of salvaged red blood cells reinfused as compared with 616 mL in our study.

A cost analysis of the results of this study was carried out in our unit. With use of prices at 2005 levels, the cost of 1 U of red blood cells was £131.80 and the cost of using the Cell Saver 5 (including the cost of the disposable components but excluding the initial capital outlay) was £94 regardless of the amount of blood salvaged. The average saving per patient was £406.84 with the use of the Cell Saver 5, with cost becoming neutral if =1 U of blood was reinfused. The initial outlay to buy the Haemonetics Cell Saver 5 was £11,000, which was equivalent to the money saved by its use in twenty-seven revision operations. Its use may therefore be more applicable to larger hospital units.

We concluded that intraoperative cell salvage in revision hip arthroplasty can be cost effective for the institution in which it is used as well as in that it conserves blood supplies for other uses. Patients benefit from the reduced risk of blood-borne infection and transfusion reactions. Intraoperative cell salvage is now used routinely in hip revisions at our institution. ?

References

Materials and Methods | Results | Discussion | References

Woolson ST, Marsh JS, Tanner JB. Transfusion of previously deposited autologous blood for patients undergoing hip-replacement surgery. J Bone Joint Surg Am.1987;69: 325-8.69325 1987 [PubMed]

British Orthopaedic Association. Blood conservation in elective orthopaedic surgery. April 2005. . Accessed 2006 Oct 7.
http://www.boa.ac.uk/site/showpublications.aspx?ID=59

United Kingdom Department of Health Press Release. Update on precautions to protect blood supply. Reference number 2004/0270. July 2004. . Accessed 2006 Oct 7.
http://www.dh.gov.uk/PublicationsAndStatistics/PressReleases/PressReleasesNotices/fs/en?CONTENT_ID=4086160&chk=9/Ni4w

United Kingdom Department of Health Press Release. Government accepts advice on leucodepletion from spongiform encephalopathy advisory committee. Reference number 98/295. July 1998. . Accessed 2006 Oct 7.
http://www.dh.gov.uk/PublicationsAndStatistics/PressReleases/PressReleasesNotices/fs/en?CONTENT_ID=4024937&chk=5qfCXY

Dixon S, James V, Hind D, Currie CJ. Economic analysis of the implementation of autologous transfusion technologies throughout England. Int J Technol Assess Health Care.2005;21: 234-9.21234 2005 [PubMed]

Wilson WJ. Intraoperative autologous transfusion in revision total hip arthroplasty. J Bone Joint Surg Am.1989;71: 8-14.718 1989 [PubMed]

Goulet JA, Bray TJ, Timmerman LA, Benson DR, Bargar WL. Intraoperative autologous transfusion in orthopaedic patients. J Bone Joint Surg Am.1989;71: 3-8.713 1989

Colwell CW Jr, Beutler E, West C, Hardwick ME, Morris BA. Erythrocyte viability in blood salvaged during total joint arthroplasty with cement. J Bone Joint Surg Am.2002;84: 23-5.8423 2002 [PubMed][CrossRef]

Gharehbaghian A, Haque KM, Truman C, Evans R, Morse R, Newman J, Bannister G, Rogers C, Bradley BA. Effect of autologous salvaged blood on postoperative natural killer cell precursor frequency. Lancet.2004;363: 1025-30.3631025 2004 [PubMed][CrossRef]

Newman JH, Bowers M, Murphy J. The clinical advantages of autologous transfusions. A randomized, controlled study after knee replacement. J Bone Joint Surg Br.1997;79: 630-2.79630 1997 [PubMed][CrossRef]

Semkiw LB, Schurman DJ, Goodman SB, Woolson ST. Postoperative blood salvage using the Cell Saver after total joint arthroplasty. J Bone Joint Surg Am.1989;71: 823-7.71823 1989

Law JK, Wiedel JD. Autotransfusion in revision total hip arthroplasties using uncemented prostheses. Clin Orthop Relat Res.1989;245: 145-9.245145 1989

Zarin J, Grosvenor D, Schurman D, Goodman S. Efficacy of intraoperative blood collection and reinfusion in revision total hip arthroplasty. J Bone Joint Surg Am.2003;85: 2147-51.852147 2003 [PubMed]

McMurray MR, Birnbaum MA, Walter NE. Intraoperative autologous transfusion in primary and revision total hip arthroplasty. J Arthroplasty.1990;5: 61-5.561 1990 [CrossRef]

Elawad AA, Fredin H. Intraoperative autotransfusion in hip arthroplasty. A retrospective study of 214 cases with matched controls. Acta Orthop Scand.1992;63: 369-72.63369 1992 [PubMed][CrossRef]

Elawad AA, Ohlin AK, Berntorp E, Nilsson IM, Fredin H. Autologous blood transfusion in revision hip arthroplasty. A prospective, controlled study of 30 patients. Acta Orthop Scand.1992;63: 373-6.63373 1992 [PubMed][CrossRef]

Topics

hemorrhage ; blood cells ; infection ; transfusion ; hemoglobin measurement ; matching ; cell saver ; operative procedure on hip

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J.P. Bridgens, C.R. Evans, P.M.S. Dobson, A.J. Hamer; Intraoperative Red Blood-Cell Salvage in Revision Hip SurgeryA Case-Matched Study. The Journal of Bone & Joint Surgery. 2007 Feb;89(2):270-275.

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