Date Published: July 1, 2012
Publisher: Hindawi Publishing Corporation
Author(s): Lawrence A. Delasotta, Ashwin V. Rangavajjula, Michael L. Frank, Jamie L. Blair, Fabio R. Orozco, Alvin C. Ong.
Introduction. To evaluate the efficacy of epoetin-α prior to revision total knee arthroplasty, we hypothesized that epoetin-α will reduce blood transfusion. Methods. Eighty-one patients were compared in this retrospective review; twenty-eight patients received our dosing regimen. All patients were mildly anemic. Epoetin-α to control (1 : 2) patient matching occurred so that one of two attending surgeons, gender, BMI, complexity of surgery, ASA score, and age were similar between groups. The clinical triggers for blood transfusion during or after the procedure were determined based on peri- and postoperative hemoglobin levels, ASA score, and/or clinical symptoms consistent with anemia. Blood salvage was not used. Results. Blood transfusion and length of stay were lower in the study group. None of the patients who received epoetin-α underwent transfusion. Hemoglobin increased from 11.97 to 13.8, preoperatively. Hemoglobin at day of surgery and time of discharge were higher. Gender, BMI, ASA score, total and hidden blood losses, calculated blood loss, preop PLT, PT, PTT, and INR were similar between groups. One Epogen patient had an uncomplicated DVT (3.6%). Conclusions. Epoetin-α may have a role in the mildly anemic revision knee patient. It may also decrease patient length of stay allowing for earlier readiness to resume normal activities and/or meet short-term milestones. A randomized study to evaluate the direct and indirect costs of such a treatment methodology in the mildly anemic revision patient may be warranted.
Revision knee arthroplasty (TKA) is known to cause substantial blood loss. It also increases blood transfusions throughout the perioperative period . Losses can typically range from 1 to 1.5 L (~3.85 ± 1.4 g hgb) [2–4]. Furthermore, revisions may require as much as 3 to 4 units of transfused blood . Since substantial blood loss increases the need for transfusion and may extend length of stay, we are interested in the effect of preoperative epoetin-α on the revision knee patient.
Following Institutional Review Board (IRB) approval, we performed this retrospective analysis. Between January 2007 and May 2010 there were 81 patients who met our inclusion and exclusion criteria (see below); twenty-eight of these patients electively received epoetin-α. All patients received a revision knee surgery for prosthesis wear out and/or loosening. All surgical procedures were elective. The following cases were excluded from the study: subjects with pre-operative Hb values less than 10 g/dL or greater than 13 g/dL, patients with hematological diseases or coagulation disorders, a history of prior deep venous thrombosis or a pulmonary embolus, periprosthetic infection, and subjects who received a postoperative drain. We defined mildly anemic patients as those with an Hb level at or below 13 g/dL and at or above 10 g/dL [11, 12]. Any patient, during pre-operative evaluation, who had an Hb level of <9 g/dL, was referred to a hematologist for further evaluation. A total of 81 mildly anemic patients who met our study criteria had revision knee surgery from January 2007 to May 2010. The records of these 81 patients were reviewed and no differences in demographic data between cohorts for age (64.4 versus 63.7 yrs), gender (75% versus 75%), or BMI (32.5 versus 35.9 kg/m2) were found. The following patient blood values were similar: preoperative PT (11.0 versus 10.5), preoperative PTT (32.7 versus 29.2), preoperative INR (1.06 versus 1.056), and preoperative platelet count (237,360 versus 263,070 per mm3) (P > 0.05) (Table 1).
While preoperative hemoglobin levels are a known risk factor for peri- and postoperative transfusion needs in knee arthroplasty [15–17], this is the first study to assess the effect of preoperative epoetin-α use on the mildly anemic revision knee patient. We report that our patients did not require transfusion, had higher postoperative and discharge hemoglobin levels, and had a shorter length of stay. Epoetin-α successfully increased the preoperative hemoglobin levels (from 11.97 g/dL to 13.93 g/dL, resp.). One patient had a deep venous thrombosis (3.6%), postoperatively.