Simultaneous Bilateral Total Hip Arthroplasty With Contemporary Blood Management is Associated With a Low Risk of Allogeneic Blood Transfusion

Perioperative patient blood management in one-stage bilateral calcar-guided short stem hip arthroplasty

BACKGROUND

Total hip arthroplasty is the standard treatment for end stage osteoarthritis of the hip joint. In Germany about 180.000 procedures are performed every year. While most surgeries are performed unilaterally there is an increasing number of single-stage bilateral (SSBL) hip arthroplasties performed. The goal of this study was to demonstrate the safety of SSBL-procedures in terms of blood loss and blood transfusion rates using specific perioperative protocols.

METHODS

Data were collected from 469 patients who underwent one-stage bilateral hip arthroplasty in a single institution, between 2020 and 2023. The current study included patients who were operated on using a minimal-invasive anterolateral approach with a cementless calcar-guided short stem hip prosthesis. The patient's age, sex, comorbidities, medication and preoperative laboratory parameters were gathered as well as the intraoperative blood loss, postoperative hemoglobin levels, blood transfusions and the perioperative administration of tranexamic acid.

RESULTS

Out of 469 patients who underwent SSBL hip arthroplasty, nine (1.9%) required blood transfusions after surgery. In total, 14 red blood cell concentrates (RBC) were transfused (0.029 RBCs per patient). The use of tranexamic acid significantly reduced the need for RBCs (p-value 0.018). Female sex, older age (> 76 years), low body mass index and body weight as well as lower preoperative hemoglobin levels were associated with an increased risk of RBC transfusion.

DISCUSSION

This study demonstrated that SSBL hip arthroplasty, when combined with a minimally invasive approach (anterolateral in supine position), cementless short stem implants, and optimized blood management (including the use of tranexamic acid), is a safe procedure in terms of blood loss and transfusion risk.

Direct Anterior vs. Posterior Approach in Simultaneous Bilateral Total Hip Arthroplasty: A Meta-Analysis

Simultaneous bilateral total hip arthroplasty (SimBTHA) offers benefits such as reduced hospital stay and costs for patients with bilateral hip disease. However, the optimal surgical approach remains uncertain. This study aimed to compare the perioperative outcomes of SimBTHA performed via the direct anterior approach (DAA) versus the posterior approach (PA). A systematic review and meta-analysis were conducted, including studies reporting outcomes of SimBTHA using DAA and PA. The primary outcome was the incidence of allogeneic blood transfusions, while secondary outcomes included blood loss and surgical complications, such as dislocations, periprosthetic fractures, and infections. Six studies were included, analyzing 944 patients, with 372 undergoing SimBTHA via DAA and 572 via PA. No significant difference was observed in the number of allogeneic blood transfusions between the two approaches (RR = 1.04; 95% CI: 0.76 to 1.43; p=0.63). DAA was associated with significantly lower blood loss compared to PA (MD = -31.51 mL; 95% CI: -43.07 to -19.94 mL; p=0.07). However, there was no significant difference in the rates of surgical complications between the two groups (RR = 0.63; 95% CI: 0.32 to 1.26; p=0.12). While DAA showed a benefit in reducing blood loss, it did not demonstrate superiority over PA regarding transfusion rates or surgical complications. These findings highlight the need for further randomized controlled trials with standardized methodologies and longer follow-up periods to better assess the optimal approach for SimBTHA.

Perioperative Hematological Outcomes of Simultaneous Double Total Joint Arthroplasty for Hemophilic Arthritis of the Hip and Knee: A Retrospective Study

BACKGROUND

Double total joint arthroplasty (TJA) can reduce repeat hospitalizations and total coagulation factors usage in hemophilic arthritis (HA) patients who have multiple joint involvement, but the risk of perioperative adverse events with double TJA must be considered.

METHODS

We reviewed 50 patients who had hemophilia A, including 26 single TJA (STJA) (13 total knee arthroplasty [TKA] and 13 total hip arthroplasty [THA]) and 24 simultaneous double TJA (Sim-DTJA) (including 10 bilateral TKAs, 10 bilateral THAs, and four patients who had simultaneous THA and TKA). Length of hospitalization, blood loss, total exogenous coagulation factor VIII (FVIII) usage, perioperative FVIII levels, perioperative activated partial thromboplastin time, perioperative transfusion rates, and postoperative complications were assessed and compared.

RESULTS

Perioperative FVIII levels and activated partial thromboplastin time were not different between Sim-DTJA and STJA. Total blood loss (1,216.0 ± 450.4 mL) and hidden blood loss (1,020.0 ± 419.9 mL) were slightly higher in Sim-DTJA than in STJA (1,062.0 ± 371.8 mL and 929.9 ± 351.6 mL, respectively) (P = 0.192, P = 0.416, respectively). The length of hospitalization between the Sim-DTJA (10.6 ± 1.8 days) and the STJA (10.4 ± 1.7 days) was not different (P = 0.802). The perioperative FVIII usage was 30,063 ± 6,466 international unit for Sim-DTJA and 26,077 ± 12,524 international unit for STJA (P = 0.008). No postoperative adverse events and prosthesis-related complications were reported in any of the patients. The two cohorts had no perioperative transfusion of erythrocyte and platelets.

CONCLUSION

In HA patients who had multiple joint involvements, Sim-DTJA can achieve clinical efficacy without significantly increasing perioperative blood loss, length of hospitalization, and postoperative complications.

Comparison of Perioperative Outcomes and Early Complications Between a Direct Anterior Approach or Posterolateral Approach in Simultaneous Bilateral Total Hip Arthroplasty: A Retrospective Study

Background: Controversies remain on the best surgical approaches for unilateral total hip arthroplasty (THA). There are little data on simultaneous bilateral THA via direct anterior approach (SimBDAA-THA) or posterolateral approach (SimBPA-THA). Purpose: We sought to assess differences in perioperative outcomes and early medical and surgical complications between SimBDAA-THA and SimBPA-THA. Methods: This retrospective study involved patients who underwent either SimBDAA-THA in a supine position (n = 73) or SimBPA-THA in a lateral position (n = 162) at our institution from January 2015 to November 2021. The 2 groups were compared in terms of clinical and demographic characteristics, surgical parameters, and complications during 6-months of follow-up. Results: There were no differences in clinical and demographic characteristics between the 2 groups prior to surgery. Simultaneous bilateral THA via direct anterior approach significantly shortened the length of both the operation (117.50 ±19.42 vs 143.97 ± 32.20 min) and the hospitalization (140.64 ± 43.22 vs 156.24 ± 56.64 h) but increased perioperative loss of hemoglobin (3.28 ± 1.01 vs 3.21 ± 2.26 g/dL). There were no significant differences between the two groups in transfusion rate; levels of interleukin-6, C-reactive protein or creatine kinase; or complications. Conclusion: This retrospective study of patients at a single institution found minimal differences in perioperative outcomes or early medical and surgical complications between SimBDAA-THA and SimBPA-THA except operative time and length of hospitalization. Larger studies with longer follow-up should be conducted to identify whether a direct anterior approach is superior to a posterolateral one.

Comparison of simultaneous versus staged bilateral total hip arthroplasty via the direct anterior approach: A propensity score matched analysis

PURPOSE

It remains unclear whether simultaneous bilateral total hip arthroplasty (SimBTHA) or staged bilateral total hip arthroplasty (StaBTHA) is clinically superior. No study has compared these two procedures matching surgical approach and patient background. This study aimed to clarify the differences between SimBTHA using direct anterior approach (SimBTHA-DAA) and StaBTHA using the direct anterior approach (StaBTHA-DAA).

METHODS

Patients who underwent THA between 2012 and 2020 were enrolled, resulting in a total of 1658 hips of 1388 patients. After propensity score matching for patient background, 204 hips of 102 patients (51 patients in each group) were examined. Clinical and radiographic outcomes, complications, intraoperative blood loss and blood transfusions (BT) were evaluated. In complications, we evaluated periprosthetic fractures, pulmonary embolism, deep venous thrombosis, surgical site infection and dislocation.

RESULTS

At the final follow-up, clinical and radiographic outcomes and complications were not significantly different between the groups. Intraoperative blood loss was equivalent for SimBTHA and the sum in the first- and second-stage StaBTHA. The total-BT rate was significantly higher for SimBTHA-DAA than for StaBTHA-DAA (p < .0001). The allogeneic BT rate was significantly higher in SimBTHA-DAA in the supine position (32.3%) than in StaBTHA-DAA (8.3%) (p = .007). However, no patient who received autologous BT required allogeneic BT.

CONCLUSIONS

Clinical and radiographic outcomes were equivalent between SimBTHA-DAA and StaBTHA-DAA. The allogeneic BT rate was significantly higher in SimBTHA-DAA than in StaBTHA-DAA. Autologous BT reduced the use of allogeneic BT in SimBTHA-DAA. Auto-BT may be useful for avoiding allo-BT in SimBTHA.