Clinical orthopaedics and related research
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Clin. Orthop. Relat. Res. · Dec 2005
Blood salvage and allogenic transfusion needs in revision hip arthroplasty.
Blood transfusions frequently are required after revision total hip arthroplasty, and although autologous and allogenic transfusions are effective in replacing blood loss, they are not without risks. To reduce the dependency on these types of transfusions, intraoperative blood collection and return by autotransfusion replacement systems are being used as an alternative or conjunctive therapy. We retrospectively reviewed 147 hip revision surgeries to determine if autotransfusion replacement systems return from the Cell Saver or the OrthoPat decreased the need for allogenic blood. We also questioned if components revised and preoperative hematocrit were risk factors for allogenic transfusion. The two blood salvage systems were compared for blood loss, autotransfusion replacement systems collection and return, allogenic use, and the implants replaced. Both systems were found to replace at least 42% of blood lost during surgery, averaging a return of 370 mL. Allogenic blood transfused was reduced by 31% with the use of an autotransfusion replacement systems machine. Risk factors found to be associated with the need for allogenic transfusions are femoral component revision or femoral and acetabular revision, preoperative hematocrit less than 45%, and autotransfusion replacement systems return greater than 300 mL. ⋯ Therapeutic study, Level IV (case series). See the Guidelines for Authors for a complete description of levels of evidence.
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Historically, general anesthesia has been the "gold standard" for surgeons and patients when major hip surgery is being done. The recent introductions of improved techniques and catheters for continuous peripheral nerve blocks have made regional anesthesia more attractive to patients and surgeons. We focus on current trends and future directions in perioperative pain management for major orthopaedic procedures done on the hip. The use of epidural or spinal anesthesia during major hip surgery has been linked to a reduced risk of perioperative complications like deep venous thrombosis, less deterioration of cerebral and pulmonary functions in patients who are at high risk for complications, and overall reduced blood loss. In addition, continuous peripheral nerve blocks showed effective and safe postoperative pain control, allowing for lower opioids consumption, improved and earlier rehabilitation, and high patient satisfaction. Accurate patient selection and patient education are fundamental for the success of any regional anesthesia technique. Modern regional anesthesia for major hip surgery includes the use of a single shot and continuous epidural injections, single-shot and continuous spinal injection, continuous lumbar plexus blockade, and continuous peripheral blockade of the femoral and sciatic nerves. Continuous peripheral nerve blocks represent an adjunctive, effective, and safe technique for postoperative pain control after total hip arthroplasty. Future directions in postoperative pain control include the creation of a comprehensive system that supervises the use of continuous peripheral nerve blocks outside the acute inpatient setting for few days following the surgical procedure. ⋯ Therapeutic study, Level V (expert opinion). See the Guidelines for Authors for a complete description of levels of evidence.
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Clin. Orthop. Relat. Res. · Dec 2005
Single-incision anterior approach for total hip arthroplasty on an orthopaedic table.
Dislocation remains the leading early complication of total hip arthroplasty; surgical approach and implant positioning have been recognized as factors influencing total hip arthroplasty stability. We describe a total hip arthroplasty technique done through a single, tissue sparing anterior approach that allows implantation of the femoral and acetabular components without detaching or sectioning any of the muscles and tendons around the hip joint. A series of 437 consecutive, unselected patients who had 494 primary total hip arthroplasty surgeries done through an anterior approach on an orthopaedic table from September 1996 to September 2004 was reviewed. There were 54 hybrid and 442 uncemented hips in the 437 patients (57 bilateral). The average patient age was 64 years. Radiographic analysis showed an average abduction angle of 42 degrees , with 96% in the range of 35 degrees to 50 degrees abduction. The average cup anteversion was 19 degrees with 93% within the target range of 10 degrees to 25 degrees . Postoperative leg length discrepancy averaged 3 +/- 2 mm (range, 0-26 mm). Three patients sustained dislocations for an overall dislocation rate of 0.61%, and no patients required revision surgery for recurrent dislocation. There were 17 operative complications, including one deep infection, three wound infections, one transient femoral nerve palsy, three greater trochanter fracture, two femoral shaft fractures four calcar fractures, and three ankle fractures. Operative time averaged 75 minutes (range 40-150 minutes), and the average blood loss was 350 mL (range, 100-1300 mL). The mean hospital stay was 3 days (range, 1-17 days). The anterior approach on the orthopaedic table is a minimally invasive technique applicable to all primary hip patients. This technique allows accurate and reproducible component positioning and leg-length restoration and does not increase the rate of hip dislocation. ⋯ Therapeutic study, Level IV-1 (case series). See the Guidelines for Authors for a complete description of levels of evidence.