Intermediate Hip Arthroplasty in Gabon: Blood Loss and Risk Factor for Transfusion ()
1. Introduction
The intermediate hip prosthesis or hip hemarthroplasty is used for certain fractures of the upper end of the femur. This surgery is often carried out urgently. It concerns an elderly, fragile, polypathological population. The objective of early surgical treatment (48 to 72 hours) is to reduce morbidity and mortality and allow early rehabilitation. The surgery can be performed under general or regional anesthesia. This is the best option when the acetabulum is healthy and the head of the femur is doomed to necrosis. The surgical procedure is less complex than a total prosthesis and allows patients to walk again quickly. The operation is less cumbersome than the installation of a total hip prosthesis and it lasts less time and bleeds less [1] . The main disadvantage of the intermediate hip prosthesis is the reduction in mobility after surgery. Compared to total hip replacement, long-term results are better for total hip replacement, particularly the risk of dislocation [2] [3] . Hip prosthetic surgery has been available in Gabon since 2012, mainly at the Omar Bongo Ondimba army training hospital, at Libreville [4] .
Blood transfusion remains a concern during surgery for intermediate hip replacement, although this technique has a lower risk of bleeding than total hip replacement, and the use of transfusion is often necessary.
The objective of the study was to describe the transfusion practice during anesthesia for hip hemiarthroplasty in Gabon.
2. Material and Method
The study received approval from the ethics committee of the Omar Bongo Ondimba Army Training Hospital, Gabon.
· Study desing
This is a retrospective, descriptive and analytical study. The study was performed in the anesthesia resuscitation department of Omar Bongo Ondimba Army Training Hospital over 11 years, from January 2011 to June 2021.
· Participant
*Inclusion criteria: Patients who underwent intermediate hip prosthesis (IHP) were included.
*Non-inclusion criteria: Patients who underwent DHS (dynamic hip screw), total hip arthroplasty or Clous Gamma were not included.
*Given the retrospective nature of the study, we did not calculate the sample size.
· Study variables
The variables studied were sociodemographic (age, sex, weight, height, BMI, history), comorbidities (arterial hypertension, diabetes, renal failure, HIV, sickle cell disease), ASA score, Biologicals (NFS, urea, creatinine, blood ionogram, coagulation assessment, GsRh, RAI, bilirubin, troponin), operating variables (anesthesia, tranexamic acid, operating time, blood loss), per and post complications operations, per and post-operative blood transfusion.
The variables studied were obtained from medical records (sociodemographic variables, comorbidities), surgical records (postoperative clinical and biological data) and anesthetic records (technical and operative data). All these variables were listed on a survey sheet separated into 3 periods (pre, per and post operative). After discharge from hospital, patients were seen by the surgeon on day 14, day 21 and day 30 as part of the follow-up to obtain late data. All the operated patients carried out an infectious assessment in search of a urinary, dental, sinus infection and antibiotic prophylaxis during the surgery. A cardiological evaluation by electrocardiogram and echocardiography was performed in all patients.
· Bias
There is a risk of recruitment bias. The surgery was performed by two surgeons with different medical experience but they used the same surgical technique.
· Quantitative variables
The quantitative variables were presented according to their means and standard deviations. The qualitative variables were presented according to their respective numbers and percentages.
· Statistical analysis
Data were entered on computer and analyzed using Epi Info 7.2 software, IBM SPSS version 21 and Excel 2016. For data comparison, we used the Chi2 test, the Pearson test and the significance level < 5%. The quantitative descriptive variables were expressed on average with the standard deviation. Qualitative variables were described as percentages. Nonparametric Kruskal Wallis tests for independent samples were used to compare quantitative variables by linear regressions. This made it possible to link together different quantitative variables with determination of the Pearson correlation coefficient. The difference was significant for p values less than 0.05.
3. Results
During the study period, 97 patients benefited from an intermediate hip prosthesis.
· Demography
The surgery concerned elderly patients, mainly males with co-morbidities particuly High blood pressure, with a low ASA score (Table 1).
· Perioperative data
The operating time was relatively high. The mean hemoglobin level was 11.9 ± 1.9 g/dl with a minimum of 5.7 and a maximum of 18.6. Blood losses were around 450 ml. Table 2 summarizes the intraoperative data.
· Transfusion aspects
Transfusion was performed in 37 patients (38.1%). The average number of RBCs transfused was 1.2 ± 0.6 with a maximum of 3 per patient and an average blood loss of 450 ± 453 ml and a maximum of 1900 ml. Tranexamic acid (exacyl®) was used in 11 (11.3%) patients (Table 3).
· Univariate analysis
It shows a significant difference in age, values hemoglobin, hematocrit and
ASA score (Table 4)
· Multivariate analysis
After multivariate analysis with logistic regression, only hemoglobin remained
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Table 4. Analysis of transfused and non-transfused populations.
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Table 5. Risk factors associated with transfusion by logistic regression.
significantly related to transfusion. An increase of one unit in the hemoglobin level reduced the risk of transfusion by a factor of 34%. All other factors were unrelated to transfusion (Table 5).
4. Discussion
The aim of this study was to investigate the factors affecting operative hemoglobin loss and the frequency of transfusions in patients undergoing intermediate hip arthroplasty.
· Epidémiology
Study carried out on a homogeneous population composed of patients having benefited from intermediate hip prosthesis (IHP). IHP is performed for fracture of the femoral neck, a pathology most often affecting elderly male subjects in our study but in other studies, there is a female predominance explained by osteoporosis. In our study and elsewhere the population has a high age around 70 - 80 years old with comorbidities.
· Transfusion
The incidence of transfusion is low in our study population (38.1%), with modest blood loss.
Indeed, the low incidence of transfusion is linked to the surgical technique which is less aggressive and less hemorrhagic than total hip arthroplasty. Aris Luangwaranyoo et al. [5] found a transfusion incidence of 39% in a cohort of 323 hip hemiprosthesis for fracture of the femoral head. Liodakis et al. [6] found an increase in the number of transfusions in the total hip arthroplasty group in a study comparing total hip arthroplasty and hemiarthroplasty, in this study, transfusion concerned 7.04% of patients who received hemiarthroplasty, moreover, postoperative mortality was correlated with transfusion, the study included 4058 patients and 3192 hip hemiarthroplasty. The study of Corentin Pangaud et al. [2] which compared total prostheses and intermediate prosthesis found a transfusion rate of the intermediate prosthesis group at 7.03% on a sample of 64,106 patients.
In our study, the main risk factor for transfusion was the existence of preoperative anemia. Blood loss, obesity, male gender and ASA score were not risk factors for transfusion (Table 5). The study by Aris Luangwaranyoo et al. [5] found as a risk factor for transfusion a female gender (odds ratio (OR) 2.00, p = 0.037), a body mass index lower than 18.5 kg/m2 (OR 2.40, p = 0.028), lower preoperative hemoglobin levels (OR 0.52, p < 0.001) and general anesthesia (OR 2.07, p = 0.028). The weakness of our sample may explain this difference, the study by Luangwaranyo et al. included 323 patients with 232 women while our study included 71 women in a sample of 97 people (Table 1).
Preoperative anemia is common in orthopedic arthroplasty surgery and is prevalent in approximately 25% of patients [7] [8] . Low preoperative Hemoglobin has been identifed as an independent risk factor for postoperative transfusions after hip or knee arthroplasty [9] [10] . This anemia may be associated with high morbidity and mortality and a high incidence of red blood cell transfusions [7] . Our study finds a preoperative hemoglobin level of 11.5 g/dl, despite this anemia was not accompanied by an increase in the incidence of transfusion and blood loss is low in our study (450 ml ± 453). Vipin Sharma et al. [11] , comparing intraoperative bleeding between total and hemiarthroplasty found a reduction in bleeding in favor of the hemiarthroplasty group (200 ml versus 300 ml). Blomfeldt et al. [12] has also found a reduction in bleeding in the hemiarthroplasty group (460 ml (100 to 1100) versus 320 ml (50 to 850) (p < 0.001)), thus the reduction in intraoperative bleeding also explains the low transfusion rate despite preoperative hemoglobin moderate.
Tranexamic acid has been used very little in our practice (11 patients) mainly for reasons of availability. Its impact on intraoperative bleeding was not evaluated in our study. Since a long time Tranexamic acid has been proved to be effective in preventing blood transfusions as well as reducing perioperative blood loss. Meta-analysis of Sadigursky et al. [13] in 7 randomized clinical trials, 948 patients and Rajiv Gandhi et al. [14] , in 33 clinical trials, 403 patients reported a reduced blood loss and lower transfusion rates for patients receiving tranexamic acid, without an increased risk for deep vein thrombosis, pulmonary embolism or other complications in total hip arthroplasty, this effectiveness of tranexamic acid was confirmed by Rapeepat Narkbunnam et al. [15] and Simone Augustinus et al. [16] in two studies on intermediate hip prosthesis in the context of fractures of the femoral head, without an increase in thromboembolic risk. The meta-analysis by Leverett et al. [17] confirms the low thromboembolic risk associated with tranexamic acid during hip hemiarthroplasty.
However, some outcomes indicate that the avoidance of suction drains might be as important as the use of tranexamic acid for the reduction of perioperative blood loss.
Unlike total hip arthroplasty, it is difficult to set up a hemoglobin optimization program with treatment of iron deficiency, erythropoietin during intermediate hip arthroplasty, it would take a lot of time, the priority here is the repair of the fracture of the femoral neck, the use of transfusion helps optimize the hemoglobin level.
5. Study Limitations
1) The present study has several limitations, mainly due to its retrospective design. Secondly, patients have been operated by different surgeons, which might have influenced bleeding. Thirdly, the criteria for insertion of suction drains were systematic, thus, surgeons’ expertise and patient risk factors may have influenced the decision on the use of suction drains.
2) Not taking into account blood loss through the drains. The insertion of drains after knee or hip arthroplasty is still a matter of controversy [18] [19] . The insertion of a suction drain has no proven benefits. Using enhanced recovery protocols in the arthroplasty leads to a changing role for drains, particularly with the use of tranexamic acid. Most literature is from the pre-tranexamic era and there are only few studies on the use of drains in combination with tranexamic acid. In our study, this aspect was not taken into account although in our practice, the installation of drains is very frequent and depends on the surgeons.
6. Conclusion
Preoperative anemia is the main risk factor for transfusion during intermediate hip arthroplasty. A patient blood management type program, although having shown its effectiveness, is difficult to implement in this context given the urgency linked to bone repair. Better use of tranexamic acid associated with minimally invasive surgery could reduce the incidence of transfusion, improve postoperative rehabilitation, save resources, reduce costs and improve patient safety.
Authors’ Contributions
G. Edjo Nkilly: principal investigator, drafting the manuscript.
R. Okoue Ondo: inclusion and follow-up of patients.
A. Matsanga: inclusion and follow-up of patients.
PC Nze Obiang: inclusion and follow-up of patients.
S. Oliveira: inclusion and follow-up of patients.
L. Nguiabanda: surgeon, inclusion and follow-up of patients.
JM Mandji-Lawson: reading and final approval of the manuscript.
Agreement
a) All authors of the manuscript have read and agreed to its content and are accountable for all aspects of the accuracy and integrity of the manuscript;
b) This submitted article is an original work that is not being considered or reviewed by any other publication and has not been published elsewhere in the same or a similar form.