Effectiveness of autologous fibrin tissue adhesive in reducing postoperative blood loss during total hip arthroplasty: a prospective randomised study of 100 cases

Outcomes following gel-based autologous chondrocyte implantation for articular cartilage defects of the knee

BACKGROUND

Gel-based autologous chondrocyte implantation (GACI) enables a simpler and more effective delivery of chondrocytes with reproducible three-dimensional structural restoration of the articular cartilage surface. There is limited documentation of medium-term outcomes. This study assessed safety and effectiveness of GACI for treatment of cartilage defects of the knee.

METHODS

This multicentric retrospective study was conducted across eight hospitals in India. Patients who had undergone GACI (CARTIGROW®) between 2008 and 2014 for the treatment of focal articular cartilage defects of the knee (mean defect size 4.5 ± 5.8 cm2) in limbs with normal alignment were analyzed. Primary outcomes were changes in Lysholm Knee Scoring Scale score, and Knee Outcome Sports Activity Scale (SAS).

RESULTS

A total of 107 patients (110 knee joints) with mean age 31.0 ± 10.5 years were included. The mean follow-up was 9.8 ± 1.5 years (range 7.85-13.43). Majority had osteochondritis dissecans (n = 51; 46.4%). The mean Lysholm Knee Scoring Scale score (81.23 ± 13.21 vs. 51.32 ± 17.89; p < 0.0001) and SAS score (80.93 ± 8.26 vs. 28.11 ± 12.28; p < 0.0001) improved significantly at follow-up as compared to pre-operative. Magnetic Resonance Observation of Cartilage Repair Tissue score in 39 patients at minimum 2 years follow-up was 84.5 ± 4.3. Among 30 patients who were playing sports before treatment, 17 patients (56.7%) could return to the same or higher level of sports post-transplantation. No major intra-operative or post-operative complications were noted. Four patients warranted revision surgery.

CONCLUSION

GACI is an effective treatment option for large focal articular cartilage defects of the knee with a low complication rate and revision rate and significant improvement in functional scores.

Gel-Based Autologous Chondrocyte Implantation (GACI) in the Chondral Defects of the Knee: An Observational Study

Introduction

Gel-based autologous chondrocyte implantation (GACI) is known to have superior results when compared to conventional autologous chondrocyte implantation (ACI) in terms of delivery of chondrocytes to the articular cartilage surface with reproducible three-dimensional structural restoration. This study aims to evaluate the short-term outcomes of gel-based autologous chondrocyte implantation (GACI) for the treatment of large focal articular cartilage defects of the knee.

Methods

This was a prospective observational study among 25 patients who underwent GACI. Primary outcome measures included Lysholm Knee Scoring Scale and IKDC score and secondary outcome measures included MRI assessment of cartilage repair using MOCART.

Results

Mean age of the population was 39.8 ± 7.5 years. The study found a highly significant improvement in both Lysholm knee score (pre-op: 45.1 to post-op: 72.4) and IKDC score (pre-op: 36.7 to post-op: 78.5) (p < 0.001) at the final follow-up of 24 months, even with the mean defect size being 4.5 ± 5.8 cm2. Postoperative MRI showed a mean MOCART score improvement from 39.4 to 67.4 at the final follow-up. No major complications were observed.

Conclusion

GACI is an effective and safe treatment option for large focal articular cartilage defects around the knee, with significant improvement in functional scores and low revision rates at medium-term follow-up.

Prevention of postoperative anemia in hip hemiarthroplasty for femoral neck fractures: comparison between local haemostatic agents

BACKGROUND

Tranexamic acid and fibrin sealant have been shown to be effective in reducing the need for transfusion after hip fracture surgery.

OBJECTIVE

The aim of this study was to evaluate the efficacy of local haemostatic agents to reduce the need of postoperative transfusion in elederly patients after hip hemiarthroplasty.

METHODS

All patients admitted to our institution with a diagnosis of proximal femur fracture from September 2018 to March 2021 were involved. Inclusion criteria were: diagnosis of femoral neck fracture, classified as AO 31B2-3, surgical treatment with hip hemiarthroplasty, hemoglobinemia on admission > 8 gr/dL. Patients were divided in four groups.

RESULTS

EVICEL was used on 25 patients, TRANEX was used on 52 patients, standard hemostatic care was used on 73 patients, while post-surgical drain was used on 21 patients. 3 patients were transfused in the EVICEL group while 26 patients were transfused in the control group (p 0,0404), there was also statistical significant difference in the need of perioperative transfusion between EVICEL group and drain group with 10 patients transfused (p 0,0102). Statistical significant differences was found about haemoglobin variation in the first post-operative day between TRANEX group and control group (p 0,000155) and between TRANEX group and drain group (p 0,013) and also between TRANEX group and control group in the third post-operative day (p 0,0004).

CONCLUSION

This study demonstrates that the use of both fibrin sealant or TXA can reduce total blood loss and the need of transfusions in geriatric population with intracapsular femur fracture.

Efficacy and safety of CARTIGROW® in patients with articular cartilage defects of the knee joint: a four year prospective studys

Introduction

Research shows autologous chondrocyte implantation (ACI) is a promising treatment for articular cartilage lesions. In this study, we assessed mid-term efficacy and safety of gel-based ACI or autologous adult live cultured chondrocytes (CARTIGROW®) implantation in patients with cartilage defects of the knee joint.

Methods

In this prospective, open-label study, patients (19–38 years) with focal, international cartilage repair society grade III or IV articular cartilage defects of the knee joint were enroled at four centres across India from April 2015 to September 2015. Punch biopsy was conducted to harvest cartilage, from which chondrocytes were isolated and cultured, and the characterised chondrocytes were implanted into the cartilage defect. Key efficacy outcomes were assessed by quantitative changes in international knee documentation committee (IKDC), visual analogue scale (VAS) scores, and qualitative changes in magnetic resonance imaging at six months and four years from baseline.

Results

Of the14 patients enroled in the study, all patients completed the six month follow-up and 11 completed the four year follow-up. The IKDC score improved significantly from 32.84 ± 9.25 at baseline to 67.49 ± 13.03 at six months (mean difference [MD] 34.66 ± 13.00, p < 0.0001) and to 60.18 ± 10.33 at four years (MD 28.21 ± 15.14, p = 0.0001). The VAS score reduced from 72.00 ± 14.40 at baseline to 16.64 ± 17.03 at six months (MD 55.36 ± 24.50, p < 0.0001) and further to 12.72 ± 9.05 at four years (MD 62.09 ± 10.66, p < 0.0001). All patients showed improvement on MRI of the knee joint. No adverse events were reported.

Conclusion

Autologous adult live cultured chondrocytes (CARTIGROW®) implantation showed good mid-term efficacy in patients with cartilage defects of the knee joint with no side-effects.

Bone Marrow Aspirate Matrix: A Convenient Ally in Regenerative Medicine

The rise in musculoskeletal disorders has prompted medical experts to devise novel effective alternatives to treat complicated orthopedic conditions. The ever-expanding field of regenerative medicine has allowed researchers to appreciate the therapeutic value of bone marrow-derived biological products, such as the bone marrow aspirate (BMA) clot, a potent orthobiologic which has often been dismissed and regarded as a technical complication. Numerous in vitro and in vivo studies have contributed to the expansion of medical knowledge, revealing optimistic results concerning the application of autologous bone marrow towards various impactful disorders. The bone marrow accommodates a diverse family of cell populations and a rich secretome; therefore, autologous BMA-derived products such as the “BMA Matrix”, may represent a safe and viable approach, able to reduce the costs and some drawbacks linked to the expansion of bone marrow. BMA provides —it eliminates many hurdles associated with its preparation, especially in regards to regulatory compliance. The BMA Matrix represents a suitable alternative, indicated for the enhancement of tissue repair mechanisms by modulating inflammation and acting as a natural biological scaffold as well as a reservoir of cytokines and growth factors that support cell activity. Although promising, more clinical studies are warranted in order to further clarify the efficacy of this strategy.

Fibrin sealant reduces need for transfusions after hip hemiarthroplasty for femoral neck fractures

INTRODUCTION

Every year more than 300,000 proximal femur fractures are diagnosed. Their number will double within 30 years. In femoral neck fractures treated with hip hemiarthroplasty 90-days mortality is 29.5-51.6%. Haemorrhage is one amongst other complications that is associated with increasing postoperative mortality. Transfusion rate in these patients ranges from 25.7% to 39%. Blood transfusions expose to complications. Fibrin sealants are useful in reducing perioperative need for transfusions, total blood loss, blood loss from drainage. The aim of this study is to assess whether the use of a fibrin sealant during hip hemiarthroplasty implant reduces the need for transfusion.

PATIENT AND METHODS

All patients admitted with a proximal femur fracture from September 2018 to May 2019 were reviewed. Inclusion criteria were: femoral neck fracture AO 31B2-3, hip hemiarthroplasty. Exclusion criteria were: previous surgery on the affected hip, coagulation disorders, hematopoietic disorders. Patients were divided in fibrin sealant group and control group. All patients underwent partial hip replacement through a posterolateral approach. 4 ml of fibrin sealant (EVICEL, Omrix Biopharmaceuticals, Diegem, Belgium) were sprayed on the soft tissues of patients included in the fibrin sealant group. Primary outcome of our study was need for perioperative transfusion. Secondary outcomes were: mean red blood cell transfused volume, variations in haematocrit and haemoglobin and total blood volume loss.

RESULTS

Eighty-one consecutive patients were enrolled. EVICEL was used on 19 patients, standard haemostatic care on 62 patients. Two patients were transfused in the fibrin sealant group, 22 in the control group (p 0,0371). Mean transfused volume was 21,05 ml in the fibrin sealant group and 116,16 ml in the control group (p 0,0017). No significant difference could be found in haematocrit and haemoglobin variation and total blood loss.

DISCUSSION

A reduction in transfusional need with the use of fibrin sealants was reported in studies on total hip arthroplasty and was confirmed by our study.

CONCLUSION

EVICEL reduces need for transfusion in patients undergoing hip hemiarthroplasty for a femoral neck fracture. It must be held among the options when a stricter control on transfusional requirement is needed.

The Effect of Single High-Dose Preoperative Intravenous Tranexamic Acid Administration to Reduce Blood Loss in Patients with Primary Total Knee Replacement

Objectives:

This study aimed to analyze the efficacy of single-dose tranexamic acid (TA) 20 mg/kg preoperatively to reduce blood loss in patients undergoing total knee replacement (TKR).

Methods:

A total of 387 patients (82 males, 305 females) undergoing TKR between January 2014 and December 2018 were included in the study. The T + group was administrated intravenous (iv) TA 20 mg/kg 20 min before the skin incision. We determined perioperative blood loss, the amount of drainage postoperative 24 h, the amount of drainage after postoperative 24–48 h, total volume of drains, total volume of blood loss, postoperative hemoglobin and hematocrit levels, and amount of total blood transfusion.

Results:

In terms of demographic data, no statistically significant difference was observed between the groups. Perioperative blood loss and total volume of blood loss was found statistically higher in T − group compared to T + group. Postoperatively, the mean hemoglobin and hematocrit levels of T − group were statistically significantly lower than T + group.

Conclusion:

A single 20 mg/kg iv TA administration before TKR reduces bleeding during surgery and within 24 h postoperatively.

Prevention of postoperative bleeding in hip fractures treated with prosthetic replacement: efficacy and safety of fibrin sealant and tranexamic acid. A randomised controlled clinical trial (TRANEXFER study)

INTRODUCTION

We assessed the efficacy of fibrin sealant (FS) and tranexamic acid (TXA) administered topically in patients with a hip fracture treated with prosthetic replacement.

MATERIALS AND METHODS

Parallel, multicentre, open label, randomised, clinical trial. We compared three interventions to reduce blood loss: (1) 10 ml of FS, (2) 1 g of topical TXA, both administered at the end of the surgery, and (3) usual haemostasis (control group). The main outcome was blood loss collected in drains. Other secondary variables were total blood loss, hidden blood loss, transfusion rate, average hospital stay, complications, adverse events, and mortality.

RESULTS

A total of 158 patients were included, 56 in the FS group, 52 in the TXA group, and 50 in the control group. The total amount of blood collected in drains was lower in the TXA group (148.6 ml, SD 122.7 in TXA; 168.2 ml, SD 137.4 in FS; and 201.5 ml, SD 166.5 in control group) without achieving statistical significance (p = 0.178). The transfusion rate was lower in the TXA group (32.7%), compared with FS group (42.9%) and control group (44.0%), without statistical significance (p = 0.341). There were no complications or adverse effects related to the evaluated interventions.

CONCLUSIONS

The use of TXA and FS administered topically prior to surgical closure in patients with a sub-capital femoral fracture undergoing arthroplasty did not significantly reduce either postoperative blood loss or transfusion rate, compared with a group that only received usual haemostasis.

Comparative efficacy and safety of different hemostatic methods in total hip arthroplasty: a network meta-analysis

BACKGROUND

It is unclear which kind of interventional therapy is the best when reducing blood loss in patients prepared for total hip arthroplasty (THA). We performed this network meta-analysis to rank the best intervention arm for blood loss control in THA patients.

METHODS

We searched electronic databases about randomized controlled trials (RCTs) to compare three treatments (topical tranexamic acid (TXA), intravenous TXA, and topical fibrin sealant (FS)) versus placebo for the people prepared for THA. Traditional and network meta-analyses were performed. The quality assessment was conducted using Cochrane Collaboration's tool. The network meta-analysis was conducted using Stata 13.0 software.

RESULTS

Finally, a total of 32 RCTs were included in this network meta-analysis. Topical TXA, intravenous TXA, and topical FS significantly decreased the need for transfusion and total blood loss when compared with placebo. And intravenous TXA ranks the first hemostasis agent for reducing the need for transfusion and total blood loss. There was no significant difference between these three treatments (intravenous TXA, topical TXA, and topical FS) in the occurrence of deep venous thrombosis (DVT).

CONCLUSION

Intravenous TXA may be the best way to reduce the need for transfusion and total blood loss. More direct studies that focused on topical TXA versus FS are needed in the future.

The use of fibrin sealant during non-emergency surgery: a systematic review of evidence of benefits and harms

BACKGROUND

Fibrin sealants are used in different types of surgery to prevent the accumulation of post-operative fluid (seroma) or blood (haematoma) or to arrest haemorrhage (bleeding). However, there is uncertainty around the benefits and harms of fibrin sealant use.

OBJECTIVES

To systematically review the evidence on the benefits and harms of fibrin sealants in non-emergency surgery in adults.

DATA SOURCES

Electronic databases [MEDLINE, EMBASE and The Cochrane Library (including the Cochrane Database of Systematic Reviews, the Database of Abstracts of Reviews of Effects, the Health Technology Assessment database and the Cochrane Central Register of Controlled Trials)] were searched from inception to May 2015. The websites of regulatory bodies (the Medicines and Healthcare products Regulatory Agency, the European Medicines Agency and the Food and Drug Administration) were also searched to identify evidence of harms.

REVIEW METHODS

This review included randomised controlled trials (RCTs) and observational studies using any type of fibrin sealant compared with standard care in non-emergency surgery in adults. The primary outcome was risk of developing seroma and haematoma. Only RCTs were used to inform clinical effectiveness and both RCTs and observational studies were used for the assessment of harms related to the use of fibrin sealant. Two reviewers independently screened all titles and abstracts to identify potentially relevant studies. Data extraction was undertaken by one reviewer and validated by a second. The quality of included studies was assessed independently by two reviewers using the Cochrane Collaboration risk-of-bias tool for RCTs and the Centre for Reviews and Dissemination guidance for adverse events for observational studies. A fixed-effects model was used for meta-analysis.

RESULTS

We included 186 RCTs and eight observational studies across 14 surgical specialties and five reports from the regulatory bodies. Most RCTs were judged to be at an unclear risk of bias. Adverse events were inappropriately reported in observational studies. Meta-analysis across non-emergency surgical specialties did not show a statistically significant difference in the risk of seroma for fibrin sealants versus standard care in 32 RCTs analysed [n = 3472, odds ratio (OR) 0.84, 95% confidence interval (CI) 0.68 to 1.04; p = 0.13; I² = 12.7%], but a statistically significant benefit was found on haematoma development in 24 RCTs (n = 2403, OR 0.62, 95% CI 0.44 to 0.86; p = 0.01; I² = 0%). Adverse events related to fibrin sealant use were reported in 10 RCTs and eight observational studies across surgical specialties, and 22 RCTs explicitly stated that there were no adverse events. One RCT reported a single death but no other study reported mortality or any serious adverse events. Five regulatory body reports noted death from air emboli associated with fibrin sprays.

LIMITATIONS

It was not possible to provide a detailed evaluation of individual RCTs in their specific contexts because of the limited resources that were available for this research. In addition, the number of RCTs that were identified made it impractical to conduct independent data extraction by two reviewers in the time available.

CONCLUSIONS

The effectiveness of fibrin sealants does not appear to vary according to surgical procedures with regard to reducing the risk of seroma or haematoma. Surgeons should note the potential risk of gas embolism if spray application of fibrin sealants is used and not to exceed the recommended pressure and spraying distance. Future research should be carried out in surgery specialties for which only limited data were found, including neurological, gynaecological, oral and maxillofacial, urology, colorectal and orthopaedics surgery (for any outcome); breast surgery and upper gastrointestinal (development of haematoma); and cardiothoracic heart or lung surgery (reoperation rates). In addition, studies need to use adequate sample sizes, to blind participants and outcome assessors, and to follow reporting guidelines.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42015020710.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Comparison of topical and intravenous administration of tranexamic acid for blood loss control during total joint replacement: Review of literature

Purpose

Many randomised controlled trials and meta-analysis studies have presented the efficacy of tranexamic acid (TXA) without an increase of complications. However, questions still remain about the type of administration, optimal dose and secondary outcomes of TXA in total hip arthroplasty and total knee arthroplasty. The aim of this review is to summarise the existing information in literature concerning the pharmacological characteristics of TXA, forms, doses, types of application and contraindications for its use.

Methods

A literature review containing 63 articles from the PubMed data starting from the first description of tranexamic acid until now was made in trying to present the existing information in a simple and effective way.

Results

TXA leads to statistically significant reduction of peri and postoperative bleeding and in that way decreases blood transfusion rates and the infection risk. Topical and intravenous (IV) use of TXA revealed similar results, with no increase of deep venous thrombosis. Therefore, topical TXA could be a reasonable alternative in patients with contraindications for IV application of TXA.

Conclusions

Blood loss control with TXA, a synthetic analogue of the amino acid lysine, may be an excellent and safe alternative to allogeneic blood transfusion after total hip arthroplasty and total knee arthroplasty. Further studies are needed to establish the efficacy of combined IV and topical administration of TXA with regard to diminishing blood loss and reducing hospital stay.

The Translational Potential of this Article

This review briefly presents the pharmacological characteristics of TXA, forms, doses, types of application and contraindications for its use with regard to diminishing blood loss and reducing hospital stay for better therapeutic strategies in orthopaedics.

A Systematic Review and Meta-analysis of the Topical Administration of Fibrin Sealant in Total Hip Arthroplasty

Patients who undergo total hip arthroplasty (THA) may experience a large amount of blood loss. The objective of our study is to include randomized controlled trials (RCTs) and compare the clinical outcomes of fibrin sealant (FS) versus placebo after a THA. In October 2015, we searched the following databases: Medline, Embase, PubMed, the Cochrane Controlled Trials Register, Web of Science, the China National Knowledge Infrastructure, the China Wanfang database and Google Scholar. Finally, seven studies that included 679 patients met the inclusion criteria. The meta-analysis indicated that the topical administration of FS was associated with a reduction of the need for transfusion compared to the control group (P = 0.05). And topical FS will reduce total blood loss after THA (P = 0.0003) and blood loss in drainage (P = 0.002). However, there was no significant difference in terms of the intraoperative blood loss (P = 0.62) and the rate of deep venous thrombosis (DVT), fever, pain, anemia, hematoma and oozing. In conclusion, the use of FS in patients who are undergoing THA may reduce perioperative blood loss and attenuate the decrease in Hb. Furthermore, FS do not decrease the intraoperative blood loss without an increase in the risk of postoperative DVT, fever, pain, anemia, hematoma and oozing.

The efficiency and safety of fibrin sealant for reducing blood loss in primary total hip arthroplasty: A systematic review and meta-analysis

OBJECTIVE

Total hip arthroplasty (THA) is associated with substantial blood loss. The objective of present systematic review and meta-analysis is to provide evidence from randomized controlled trials (RCTs) on the efficiency and safety of administration of fibrin sealant (FS) for reducing blood loss in patients undergoing primary THA.

METHODS

Potential relevant studies were identified from electronic databases including Medline, PubMed, Embase, ScienceDirect, web of science and Cochrane Library. Gray academic studies were also identified from the reference list of included studies. There was no language restriction. Pooling of data was carried out by using RevMan 5.1.

RESULTS

Six randomized controlled trials (RCTs) met the inclusion criteria. Current meta-analysis indicated that there were significant differences in terms of total blood loss (MD = -153.77, 95% CI: -287.21 to -20.34, P = 0.02), postoperative hemoglobin level (MD = -0.25, 95% CI: -0.46 to -0.05, P = 0.02) and transfusion rate (RD = -0.12, 95% CI: -0.22 to -0.03, P = 0.01) between groups. No significant differences were found regarding the incidence of deep venous thrombosis (DVT) (RD = 0.00, 95% CI: -0.01to 0.01, P = 0.51) or other side effects.

CONCLUSION

Administration of fibrin sealant in total hip arthroplasty may reduce total blood loss, postoperative hemoglobin decline and transfusion requirements. Moreover, no adverse effect was related to FS. Due to the limited quality of the evidence currently available, higher quality RCTs are required.

Comparison between topical and intravenous administration of tranexamic acid in primary total hip arthroplasty

BACKGROUND

Tranexamic acid has been reported to be safer with topical administration than with intravenous administration in total knee arthroplasty. However, the most effective administration route of tranexamic acid in total hip arthroplasty remains controversial. This study compared the effectiveness of topical tranexamic acid administration with that of intravenous tranexamic acid administration in total hip arthroplasty.

METHODS

We retrospectively examined the medical records of 886 patients with osteoarthritis of the hip joint, who had undergone unilateral primary total hip arthroplasty. The patients were divided into a control group (n = 302; did not receive tranexamic acid), topical group (n = 265; topically administered 2 g tranexamic acid in 30 mL normal saline via drain tubes placed in the joint before wound closure along with posterior soft tissue repair), and intravenous group (n = 319; intravenously administered 1 g tranexamic acid before skin incision along with posterior soft tissue repair). Data on blood loss, hemoglobin levels, transfusion rates, and occurrence of deep vein thrombosis and pulmonary embolization were collected.

RESULTS

The mean operation times were approximately 40 min in all of the groups. The operation time and intra-operative blood loss were significantly lower in the control group than in the topical and intravenous groups. However, the post-operative blood loss, total blood loss, and decrease in the hemoglobin level were significantly higher in the control group than in the topical and intravenous groups. There were no significant differences in terms of blood loss and systemic complications between the tranexamic acid administration methods.

CONCLUSIONS

Tranexamic acid reduces both post-operative and total blood loss in total hip arthroplasty. Moreover, a lower amount of tranexamic acid can be used to reduce blood loss in total hip arthroplasty with intravenous tranexamic acid administration than with topical tranexamic acid administration. Therefore, we suggest that tranexamic acid should be intravenously administered pre-operatively and the posterior soft tissue should be repaired to decrease total hip arthroplasty-related complications.

Prospective randomised evaluation of a collagen/thrombin and autologous platelet haemostatic agent during cementless total hip arthroplasty

BACKGROUND

Total hip arthroplasty (THA) can be associated with substantial peri-operative blood loss which can negatively influence a patient's clinical outcome. Few haemostatic agents have been tested in THA. The aim of this study was to determine whether the use of a collagen/thrombin/ autologous platelet haemostatic agent would result in a significant decrease of blood transfusions for patients undergoing primary THA.

MATERIALS AND METHODS

THA patients meeting inclusion/exclusion criteria (n=109) were enrolled in this prospective, double-blind trial and randomised to a treatment arm (standard haemostatic methods plus haemostatic agent) or control arm (standard haemostatic methods only). The primary outcome was transfusion. Secondary outcome measures included peri-operative narcotic usage and post-operative haemoglobin levels, pain scores, function, and general health quality of life.

RESULTS

Transfusions were required by 5/60 (8.3%) patients in the treatment group and 7/49 (14.3%) in the control group (p=0.33). The mean number of units transfused was not significantly different between the treatment group (2.2±1.3) and the control group (1.6±0.5) (p=0.36). Haemoglobin values on post-operative days 1, 2, and 3 were significantly higher in the treatment group (p=0.002, 0.04, and 0.02, respectively). Hip Disability and Osteoarthritis Outcome Score and Short Form-12 scores were not different between the two groups.

DISCUSSION

In relatively healthy patients undergoing primary cementless THA there was no significant difference in number of transfusions or number of units transfused. It is unlikely that we will routinely use the investigated haemostatic agent to reduce blood loss in a healthy patient undergoing THA. The product may have some benefit in patients who refuse blood transfusions, have minimal ability to increase blood volume, are undergoing total joint revision, or have markedly low pre-operative haemoglobin levels, but this needs to be demonstrated.

Practice guidelines for perioperative blood management: an updated report by the American Society of Anesthesiologists Task Force on Perioperative Blood Management*

The American Society of Anesthesiologists Committee on Standards and Practice Parameters and the Task Force on Perioperative Blood Management presents an updated report of the Practice Guidelines for Perioperative Blood Management.

Supplemental Digital Content is available in the text.

Systematic review and meta-analysis of fibrin sealants for patients undergoing pancreatic resection

INTRODUCTION

Post-operative pancreatic fistula (POPF) is a common complication after partial pancreatic resection, and is associated with increased rates of sepsis, mortality and costs. The role of fibrin sealants in decreasing the risk of POPF remains debatable. The aim of this study was to evaluate the literature regarding the effectiveness of fibrin sealants in pancreatic surgery.

METHODS

A comprehensive database search was conducted. Only randomized controlled trials comparing fibrin sealants with standard care were included. A meta-analysis regarding POPF, intra-abdominal collections, post-operative haemorrhage, pancreatitis and wound infections was performed according to the recommendations of the Cochrane collaboration.

RESULTS

Seven studies were included, accounting for 897 patients. Compared with controls, patients receiving fibrin sealants had a pooled odds ratio (OR) of developing a POPF of 0.83 [95% confidence interval (CI): 0.6-1.14], P = 0.245. There was a trend towards a reduction in post-operative haemorrhage (OR = 0.43 (95%CI: 0.18-1.0), P = 0.05) and intra-abdominal collections (OR = 0.52 (95%CI: 0.25-1.06), P = 0.073) in those patients receiving fibrin sealants. No difference was observed in terms of mortality, wound infections, re-interventions or hospital stay.

CONCLUSION

On the basis of these results, fibrin sealants cannot be recommended for routine clinical use in the setting of pancreatic resection.

Fibrin sealants or cell saver eliminate the need for autologous blood donation in anemic patients undergoing primary total knee arthroplasty

INTRODUCTION

Reducing allogeneic blood transfusions remains a challenge in total knee arthroplasty. Patients with preoperative anemia have a particularly high risk for perioperative blood transfusions.

MATERIALS AND METHODS

176 anemic patients (Hb < 13.5 g/dl) undergoing total knee replacement were prospectively evaluated to compare the effect of a perioperative cell saver (26 patients), intraoperative fibrin sealants (5 ml Evicel, Johnson & Johnson Wound Management, Ethicon, Somerville, NJ) (45 patients), preoperative autologous blood donation (PABD) (21 patients), the combination of fibrin sealants and preoperative autologous blood donation (44) and no intervention (40 patients) on perioperative blood loss and transfusion requirements.

RESULTS

All protocols resulted in significant reduction of allogeneic blood transfusions. Transfusion rates were similar with the use of PABD (19%), Evicel (18%), and cell saver (19%), all significantly lower than the control group (38 %, p < 0.05). Combining Evicel with PABD resulted in significantly higher wastage of autologous units (p < 0.05) with no significant reduction in allogeneic transfusion rate (14%). The use of fibrin sealant resulted in a significant reduction of blood loss compared to the PABD group (603 vs. 810 ml, p < 0.005) as well as the control group (603 vs. 822 ml, p < 0.005).

CONCLUSIONS

While PABD proved to be the most cost-effective treatment option in anemic patients, fibrin sealants and cell saver show similar reduction in allogeneic transfusion rates compared to controls. The combination of fibrin sealants and PABD is not cost-effective and increases the number of wasted units.

Patterns of use of hemostatic agents in patients undergoing major surgery

BACKGROUND

Although a number of prohemostatic agents that are applied intraoperatively have been introduced to minimize bleeding, little is known about the patterns of use and the factors that influence use. We examined the use of hemostatic agents in patients undergoing major surgery.

METHODS

All patients who underwent major general, gynecologic, urologic, cardiothoracic, or orthopedic surgery from 2000-2010 who were recorded in the Perspective database were analyzed.

RESULTS

Among 3,633,799 patients, hemostatic agents were used in 30.3% (n = 1,102,267). The use of hemostatic agents increased from 28.5% in 2000 to 35.2% in 2010. Over the same period, the rates of transfusion declined for pancreatectomy (-14.4%), liver resection (-15.0%), gastrectomy (-11.7%), prostatectomy (-6.6%), nephrectomy (-4.6%), hip arthroplasty (-10.4%), and knee arthroplasty (-6.6%). Over the same time period, the transfusion rate increased for colectomy (6.0%), hysterectomy (3.7%), coronary artery bypass graft (8.4%), valvuloplasty (4.2%), lung resection (1.9%), and spine surgery (1.6%). Transfusion remained relatively stable for thyroidectomy (0.2%).

CONCLUSIONS

The use of hemostatic agents has increased rapidly even for surgeries associated with a small risk of transfusion and bleeding complications. In addition to patient characteristics, surgeon and hospital factors exerted substantial influence on the allocation of hemostatic agents.

Efficacy and safety of fibrin glue and tranexamic acid to prevent postoperative blood loss in total knee arthroplasty: a randomized controlled clinical trial

BACKGROUND

Postoperative blood loss in patients after total knee arthroplasty may cause local and systemic complications and influence clinical outcome. The aim of this study was to assess whether fibrin glue or tranexamic acid reduced blood loss compared with routine hemostasis in patients undergoing total knee arthroplasty.

METHODS

A randomized, single-center, parallel, open clinical trial was performed in adult patients undergoing primary total knee arthroplasty. Patients were divided into four groups. Group 1 received fibrin glue manufactured by the Blood and Tissue Bank of Catalonia, Group 2 received Tissucol (fibrinogen and thrombin), Group 3 received intravenous tranexamic acid, and Group 4 (control) had no treatment other than routine hemostasis. The primary outcome was total blood loss collected in drains after surgery. Secondary outcomes were the calculated hidden blood loss, transfusion rate, preoperative and postoperative hemoglobin, number of blood units transfused, adverse events, and mortality.

RESULTS

One hundred and seventy-two patients were included. The mean total blood loss (and standard deviation) collected in drains was 553.9 ± 321.5 mL for Group 1, 567.8 ± 299.3 mL for Group 2, 244.1 ± 223.4 mL for Group 3, and 563.5 ± 269.7 mL for Group 4. In comparison with the control group, Group 3 had significantly lower total blood loss (p < 0.001), but it was not significantly lower in Groups 1 and 2. The overall rate of patients who had a blood transfusion was 21.1% (thirty-five of 166 patients analyzed per protocol). Two patients required transfusion in Group 3 compared with twelve patients in Group 4 (p = 0.015). No significant difference was observed between the two fibrin glue groups and the control group with regard to the need for transfusion. There was no difference between groups with regard to the percentage of adverse events.

CONCLUSIONS

Neither type of fibrin glue was more effective than routine hemostasis in reducing postoperative bleeding and transfusion requirements, and we no longer use them. However, this trial supports findings from previous studies showing that intravenous tranexamic acid can decrease postoperative blood loss.

Blood loss reduction in cementless total hip replacement with fibrin spray or bipolar sealer: a randomised controlled trial on ninety five patients

Purpose

Several studies have investigated effectiveness of fibrin spray or bipolar sealer to control peri-operative bleeding and reduce the need for blood transfusion, but a direct comparison between the two methods has not been previously performed. We conducted a prospective randomised trial, with standard electrocautery as a control group.

Methods

In our investigation, 95 patients were randomised to one of three parallel groups receiving (1) 10 mL of topical fibrin spray before closure, (2) haemostasis with radiofrequency energy using a bipolar sealer, and (3) standard electrocautery. All patients and staff apart from the surgeons were blinded until data analysis was complete. Peri-operative blood loss has been calculated using a formula described by Ward and Gross (considering estimated patient blood volume, pre- and post-operative haemoglobin and haematocrit levels), with mention of eventual blood re-infusion or transfusion, at given intervals from surgery (6, 24, 48, 72 hours).

Results

Mean blood loss was lower for both methods investigated, compared to the control group at every time interval considered, although differences were stronger for fibrin spray [Quixil]. Mean blood saving at the given intervals from surgery (6–24–48–72 hours) was respectively 96 ml, 129 ml, 296 ml, and 121 ml for bipolar sealer [Aquamantys] and 235 ml, 368 ml, 642 ml, and 490 ml for fibrin spray. These results are statistically significant (p = 0.05) for fibrin spray at every interval compared to control values, while a significance is detectable for bipolar sealer only at 48 hours after surgery.

Conclusions

The fibrin spray group had the best performance in terms of blood loss, significantly reduced in comparison with the control group and bipolar sealer group. Blood loss reduction for the bipolar sealer was remarkable only at 48 hours, compared with the control group. Blood loss reduction for fibrin spray was significant at every time interval considered. Differences between the two treatments investigated and the control group narrowed slightly at 72 hours, as an expression of spontaneous homeostasis. Notable is the fact that blood volume saved with fibrin spray at 24 and 48 hours is comparable to the volume of at least one blood unit. A cost-effectiveness analysis should be considered in term of expense, biological risks (related to blood transfusion or human-derived products use) and bleeding-related complications.

Effectiveness of Fibrin Sealant after Cementless Total HIP Replacement: A Double-Blind Randomized Controlled Trial

Fibrinogen-based sealants have been used to improve hemostasis after total hip replacement (THR) with conflicting results. We therefore conducted a double-blind randomized controlled trial to determine whether the commercially available fibrin sealant Quixil is effective in reducing the volume of red blood cell transfusions, postoperative blood loss and postoperative hemoglobin drop. Patients with coxarthrosis scheduled for primary cementless THR, were enrolled in a single hospital setting and randomized to either a fibrin sealant group (n=35) or a negative control group (n=35). The surgeon was blind to group allocation until the moment of fibrin application, while the cardiologist determining the need for transfusions remained blind throughout the intervention. In the fibrin sealant group, less blood was lost in the first 48 hours (median, 125 vs 200 ml), fewer patients required allogeneic blood transfusion (1 vs 6 in the control group), and fewer total units of allogeneic blood were transfused (2 vs 12). These differences, however, were not significant partly due to confounding from the use of autologous transfusion of predeposited blood (according to a more liberal regime) and intraoperative autologous blood reinfusion in some patients of both groups. Excluding these last individuals from analysis, no remaining patient of the fibrin sealant group had an allogeneic blood transfusion that, instead, was carried out on 5 patients (23.8%) of the control group (p=0.048). Overall postoperative hemoglobin drop from baseline was significantly less in the fibrin-treated group on day 7 (mean, 3.5 vs 4.5 g/dl; p=0.02). No adverse events were associated with fibrin treatment. These results strengthen the evidence in support of the safety and efficacy of the use of fibrin sealant in improving hemostasis after THR. Clinical trial registration: EudraCT 2008-002024-28.

Bipolar sealing in revision total hip arthroplasty for infection: efficacy and cost analysis

Saline-coupled bipolar sealing has shown mixed results in primary arthroplasty. However, this technology has not been studied in infected revision total hip arthroplasty (THA), where morbidity is higher and conventional methods of blood management, such as cell salvage, often cannot be used. This case-matched study of 76 consecutive revision THA for infection included an experimental bipolar sealing group and a control group of conventional electrocautery. Groups were matched for gender, body mass index, American Society of Anesthesiologists classification, and surgery type. Total blood loss, intraoperative blood loss, and perioperative hemoglobin drop were significantly less in the experimental group. In addition, operative time was significantly shorter in the experimental group, which translated into gross savings approximately equal to the cost of the device. The decreases in total blood loss and perioperative hemoglobin decline, along with financial savings, may support the use of bipolar sealing in infected revision THA.

Fibrin sealants in orthopaedic surgery: practical experiences derived from use of QUIXIL® in total knee arthroplasty

BACKGROUND

Total knee arthroplasty is associated with a significant postoperative blood loss even without any form of perioperative anticoagulation.

METHODS

The potential role of QUIXIL(®), a fibrin sealant used in orthopaedic surgery to control blood loss and avoid blood transfusions in patients undergoing total knee arthroplasty was evaluated in a prospective randomized trial with twenty-four patients diagnosed with primary osteoarthritis of the knee.

RESULTS

Results showed that application of 2 ml QUIXIL(®) adds costs to treatment without reducing the number of transfused red blood cell counts and postoperative haemoglobin loss. However, significant lower levels of postoperative fluid loss (P = 0.026) was detected in QUIXIL(®) treated patients.

CONCLUSION

Regarding cost effectiveness and benefit no indication for the use of 2 ml QUIXIL(®) fibrin sealant in standard knee arthroplasty could be proofed statistically.

Reduction of blood loss in primary hip arthroplasty with tranexamic acid or fibrin spray

BACKGROUND AND PURPOSE

Previous studies have shown that either fibrin spray or tranexamic acid can reduce blood loss at total hip replacement, but the 2 treatments have not been directly compared. We therefore conducted a randomized, controlled trial.

PATIENTS AND METHODS

In this randomized controlled trial we compared the effect of tranexamic acid and fibrin spray on blood loss in cemented total hip arthroplasty. 66 patients were randomized to 1 of 3 parallel groups receiving (1) a 10 mg/kg bolus of tranexamic acid prior to surgery, (2) 10 mL of fibrin spray during surgery, or (3) neither. All participants except the surgeon were blinded as to treatment group until data analysis was complete. Blood loss was calculated from preoperative and postoperative hematocrit.

RESULTS

Neither active treatment was found to be superior to the other in terms of overall blood loss. Losses were lower than those in the control group, when using either tranexamic acid (22% lower, p = 0.02) or fibrin spray (32% lower, p = 0.02).

INTERPRETATION

We found that the use of tranexamic acid at induction, or topical fibrin spray intraoperatively, reduced blood loss compared to the control group. Blood loss was similar in the fibrin spray group and in the tranexamic acid group. ClinicalTrials.gov identifier: NCT00378872. EudraCT identifier: 2006-001299-19. Regional Ethics Committee approval: 06/S0703/55, granted June 6, 2006.

The effect of postoperative pain on postoperative blood loss after sequential bilateral total knee arthroplasty

Background

Bilateral total knee arthroplasty is generally accompanied by a significant amount of blood loss. We investigated the relationship between the intensity of pain and the amount of blood loss in the early postoperative period after bilateral total knee arthroplasty.

Methods

A prospective study was conducted on 91 patients who underwent elective sequential bilateral total knee arthroplasty for osteoarthritis. All patients received combined spinal and epidural anesthesia. Patients were divided into three groups based on their scores on the verbal numerical rating scale (VNRS) for pain at 6 hours postoperatively. The VNRS was classified as follows; mild pain (n = 34, VNRS score 0-4), moderate pain (n = 24, VNRS score 5-6), and severe pain (n = 33, VNRS score 7-10). We compared the mean arterial pressures and the amount of blood loss during the first 24 postoperative hours in the three groups. Factors influencing postoperative blood loss were analyzed.

Results

Postoperative mean arterial pressures and blood loss were not different among the groups. Of the factors examined, the amount of postoperative blood loss was only dependent on the amount of intraoperative blood loss (P = 0.001).

Conclusions

Early postoperative pain has no effect on postoperative blood pressure and the amount of blood loss after bilateral total knee arthroplasty. For postoperative blood loss, intraoperative blood loss is the main determinant.

Gel-type autologous chondrocyte (Chondron) implantation for treatment of articular cartilage defects of the knee

BACKGROUND

Gel-type autologous chondrocyte (Chondron) implantations have been used for several years without using periosteum or membrane. This study involves evaluations of the clinical results of Chondron at many clinical centers at various time points during the postoperative patient follow-up.

METHODS

Data from 98 patients with articular cartilage injury of the knee joint and who underwent Chondron implantation at ten Korean hospitals between January 2005 and November 2008, were included and were divided into two groups based on the patient follow-up period, i.e. 13~24-month follow-up and greater than 25-month follow-up. The telephone Knee Society Score obtained during telephone interviews with patients, was used as the evaluation tool.

RESULTS

On the tKSS-A (telephone Knee Society Score-A), the score improved from 43.52 +/- 20.20 to 89.71 +/- 13.69 (P < 0.05), and on the tKSS-B (telephone Knee Society Score-B), the score improved from 50.66 +/- 20.05 to 89.38 +/- 15.76 (P < 0.05). The total improvement was from 94.18 +/- 31.43 to 179.10 +/- 24.69 (P < 0.05).

CONCLUSION

Gel-type autologous chondrocyte implantation for chondral knee defects appears to be a safe and effective method for both decreasing pain and improving knee function.

The role of fibrin sealants in orthopaedic surgery

Blood conservation, specifically the avoidance of allogeneic blood transfusion, is becoming an important aspect of preoperative planning and intraoperative decision making in orthopaedic surgery. Knee and hip arthroplasty, as well as certain spine procedures, place patients at risk of significant blood loss. Fibrin sealants are topically applied hemostatic agents that reduce the time required to achieve hemostasis as well as the volume of blood loss. Fibrin sealants may provide additional benefits beyond hemostasis, such as improvements in wound healing and postoperative range of motion as well as lower rates of wound infections.

Autologous chondrocyte implantation for rheumatoid arthritis of the knee: a case report

Introduction

Although pharmacologic treatment remains the mainstay for treating rheumatoid arthritis, there is an increasing need for a method that biologically regenerates arthritic knee lesions as patient longevity continually increases.

Case presentation

We treated rheumatoid arthritis of the right knee in a 35-year-old female Korean patient using autologous chondrocyte implantation. Twelve months after surgery, the patient could walk without pain.

Conclusion

Autologous chondrocyte implantation appears to be effective for treating rheumatoid arthritis of the knee.

Fibrin sealant use for minimising peri-operative allogeneic blood transfusion

BACKGROUND

Fibrin sealants have gained increasing popularity as interventions to improve peri-operative (intra/post-operative) haemostasis and diminish the need for allogeneic red cell transfusion (blood from an unrelated donor).

OBJECTIVES

To examine the efficacy of fibrin sealants in reducing peri-operative blood loss and allogeneic red blood cell (RBC) transfusion.

SEARCH STRATEGY

Studies were identified by: searches of MEDLINE, EMBASE, Current Contents, the Cochrane Library (July 2002), manufacturer web sites (to July 2002), and bibliographies of published articles.

SELECTION CRITERIA

Controlled trials in which adult patients, scheduled for elective surgery, were randomised to fibrin sealant treatment or to a control group who did not receive fibrin sealant treatment. Trials were eligible if they reported data on the number of patients exposed to allogeneic red cell transfusion, the volume of blood transfused, or blood loss (assessed objectively).

DATA COLLECTION AND ANALYSIS

Primary outcomes measured were: the number of patients exposed to allogeneic red cells, the amount of blood transfused, and blood loss. Other outcomes measured were: re-operation due to bleeding, infection, mortality, and length of hospital stay. Treatment effects were pooled using a random effects model.

MAIN RESULTS

Seven trials, including a total of 388 patients, reported data on peri-operative exposure to allogeneic RBC transfusion. Fibrin sealant treatment, on average, reduced the rate of exposure to allogeneic red cell transfusion by a relative 54% (relative risk [RR] = 0.46: 95%CI = 0.32 to 0.68). Eight trials, including a total of 442 patients, provided data for post-operative blood loss. Fibrin sealant treatment reduced blood loss on average by around 134 per patient (95%CI = 51 to 217 ). However the trials reviewed were small and of poor methodological quality (91% unblinded).

REVIEWER'S CONCLUSIONS

Overall the results suggest that fibrin sealants are efficacious in reducing both post-operative blood loss and peri-operative exposure to allogeneic RBC transfusion. However, due to the lack of blinding, transfusion practices may have been influenced by knowledge of the patient's treatment status. This raises concerns about the use of blood transfusion practice as an outcome variable in trials of fibrin sealant. In the case of blood loss, the results must be interpreted with caution, in view of the statistically significant heterogeneity in treatment effect observed. Large, methodologically rigorous, randomised controlled trials of fibrin sealants are needed.