Blood transfusion and venous thromboembolism trends and risk factors in primary and aseptic revision total hip and knee arthroplasties: A nationwide investigation of 736,061 cases - 26/06/21

Doi : 10.1016/j.otsr.2021.102987

Elke Jeschke ^a,⁎ , Mustafa Citak ^b, Andreas M. Halder ^c, Karl-Dieter Heller ^d, Fritz U. Niethard ^e, Peter Schräder ^f, Josef Zacher ^f, Hanna Leicht ^g, Jürgen Malzahn ^h, Christian Günster ^a, Thorsten Gehrke ^b
^a Research Institute of the Local Health Care Funds, Rosenthaler Straße 31, 10178 Berlin, Germany
^b Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Holstenstraße 2, 22767 Hamburg, Germany
^c Department of Orthopaedic Surgery, Sana Kliniken Sommerfeld, Waldhausstraße 44, 16766 Sommerfeld/Kremmen, Germany
^d Department of Orthopaedic Surgery, Herzogin Elisabeth Hospital, Leipziger Straße 24, 38124 Braunschweig, Germany
^e German Society of Orthopedics and Orthopedic Surgery, Straße des 17. Juni 106-108, 10623 Berlin, Germany
^f Department of Orthopaedic Surgery, Kreisklinik Jugenheim, Hauptstraße 30, 64342 Seeheim-Jugenheim, Germany
^g Helios Kliniken GmbH, Friedrichstrasse 136, 10117 Berlin, Germany
^h Federal Association of the Local Health Care Funds, Rosenthaler Straße 31, 10178 Berlin, Germany

^⁎Corresponding author.

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Abstract

Background

Over the last years, new transfusion guidelines and pharmaceuticals have been introduced in primary and revision total hip and knee arthroplasty (P-THA, P-TKA, R-THA, R-TKA). In the US, a substantial decrease in transfusions has been observed in recent years. Little data exists on the subject in Europe. In this context we aimed to analyze: (1) Is there also a significant decrease in blood transfusion for these procedures in Germany? (2) Which patient and hospital related factors are associated with the risk of blood transfusion? (3) Is there a trend in complications, especially venous thromboembolism and stroke events that can be linked to tranexamic acid use?

Hypothesis

There is a significant trend in decreasing blood transfusions in hip and knee arthroplasty.

Methods

Using nationwide healthcare insurance data for inpatient hospital treatment, 736,061 cases treated between January 2011 and December 2017 were included (318,997 P-THAs, 43,780 R-THAs, 338,641 P-TKAs, 34,643 R-TKAs). Multivariable logistic regression was used to model the odds of transfusion as a function of the year of surgery. Adjusted odds ratios (OR) and 95% confidence intervals (CI) were calculated.

Results

In each cohort the odds of transfusion decreased over time (2017 vs. 2011 (reference): P-THA: OR 0.42 (95%CI: 0.39–0.45), P-TKA: OR 0.41 (95%CI: 0.37–0.46), R-THA: OR 0.52 (95%CI: 0.47–0.58), R-TKA: OR 0.53 (95%CI: 0.46–0.61). Patient-related risk factors for blood transfusion included older age, female gender, lower Body Mass Index, comorbidities such as renal failure, cardiac arrhythmia, congestive heart failure, valvular disease, coagulopathy, depression, and antithrombotic medication prior to surgery. Venous thromboembolism or stroke events did not increase over the study period.

Discussion

The incidence of blood transfusions in primary and revision TKA and THA decreased over the study period. This may be due to new transfusion guidelines and the introduction of novel pharmaceuticals such as tranexamic acid. A further improved patient blood management and a focus on vulnerable patient groups might lead to a further future reduction of transfusions, especially in R-THA.