Arthroplasty with minimal blood loss

Four years of change lie behind Prof Andreas Roth and his team. That's how long it took for the first adaptation of the drains in the operating theatre of the Orthopaedics Department at Leipzig University Hospital to become the almost blood loss-free arthroplasty that it is today. Years in which many specialities worked together and innovations were gradually introduced. The result: „Today, we hardly need any transfusions to compensate for blood loss during a hip or knee prosthesis operation“, describes Prof Roth, Head of the Endoprosthetics/ Orthopaedics Department. His speciality was and still is regarded as a rather „bloody“ surgery, which, unlike others, is not minimally invasive, involves one or two vessels and requires a lot of blood.

Endoprosthetic operations were often associated with considerable blood loss and resulted in up to 46 per cent of patients requiring a blood transfusion during or after the operation,

explains the experienced orthopaedic surgeon.

For patients, this means a longer recovery time after the procedure, as the circulation also has to get back on its feet first. In addition, the loss of fluid often continues in the following days after the usual drainage to check whether there is still bleeding," explains Roth. He is convinced that modern surgery should look for other solutions here. And he was successful: Firstly, in procedures for subtle haemostasis during the operation, which are used by the plastic surgeons at the UKL. „Here, the vessels are closed directly during the procedure using special methods“, explains Roth. This means that the operation takes up to 15 minutes longer, but there is much less postoperative haematoma, swelling or infection in the surgical area. Roth learnt from his colleagues and adapted his technique for patients where possible. Other surgeons followed suit, so that today the vast majority of endoprostheses at the UKL are inserted with minimal blood loss. The result: a blood transfusion is now only required for a minimal three per cent of arthroplasty operations!

Blood value and coagulation monitoring

In order to make this possible, however, many other factors had to be changed before, during and after the operation, such as the monitoring of blood values, coagulation, adjustments to the anaesthetic and even pain management. For example, tranexamic acid (TXA), a special agent that briefly increases the tendency to clot and thus prevents bleeding, is used during the operation. „The individual risk of the patient is carefully weighed up and a decision is made as to whether we use the agent systemically or only locally directly on the joint to be operated on“, explains Dr Christian Pfrepper. The coagulation specialist supported the orthopaedists in their project and examined the conditions under which the drug, which is not explicitly authorised for this purpose, can be used for haemostasis. „We then established that we can both ensure a high level of patient safety and effectively prevent bleeding in this way.“ The risk assessment is carried out in advance by the anaesthetists, who also assess which anaesthesia can be used – general anaesthesia or only partial anaesthesia of the leg to be operated on. The concept also includes controlling the after-effects of the anaesthetic so that patients can get up quickly and get moving.

This all has advantages and disadvantages,

says anaesthetist Prof Robert Werdehausen,

which is why we weigh up exactly what is best for each individual patient,

because the anaesthetic package is effective in any case.

Transfusion frequency of just three per cent

So effective that blood samples are now only prepared and made available as a precautionary measure for certain high-risk patients before the operation instead of for everyone, as was previously the case. With up to 400 operations a year, this makes a big difference.
We were able to adapt the internal guidelines for this because our procedure has reduced the transfusion rate for endoprosthetic operations to three per cent,
explains orthopaedic surgeon Dr Christina Pempe.
She has been involved in the process from the very beginning and is trying to drive it forward: Even before the operation, transfusions can be made unnecessary. The haemoglobin value HB gives us important indications of this.“ Analyses have shown that the risk of transfusions increases with anaemia, i.e. anaemia, despite all measures taken. The UKL orthopaedists therefore check the blood values and HB level during the consultation before the operation. If this is too low, we ask the GPs to treat the patient's associated anaemia before the operation," explains Pempe. If this works, this component also contributes to creating perfect conditions for the success of the complex implantation of artificial joints.

„We are now also increasingly using the new procedure for the more complicated operations to replace an endoprosthesis,

continues Dr Christina Pempe. This is because the procedures have become well-rehearsed - even after the operation. Another innovation is the elimination of drains, i.e. the drainage of fluid from the tissue via a catheter. Since we close the vessels, we no longer need this tube under the skin," explains Prof Andreas Roth. This was previously intended to prevent swelling, but also to ensure control of possible post-operative bleeding. This is no longer needed, as the haemostasis during the operation takes care of this. At the same time, inflammation can be completely avoided. „This also prevents prostheses from loosening again“, says the orthopaedic surgeon.

The changes during the operation also change the routines on the ward: drainage checks and changes are no longer necessary, but patients receive special care during aftercare, get up much more quickly to get moving again and leave the hospital earlier.
„That was not always an easy joint learning process full of changes,
says Roth, looking back, „ His patients have benefited.

When I visit them after the operation, I am always surprised myself at how well they are doing and how quickly they are able to move again.

Article from the "innovations report" from 02/08/2023