| Abstract|| |
BACKGROUND: Significant blood loss and requirement of allogenic blood transfusion during or after total knee replacement (TKR) have been reported. Incidence of blood transfusion in TKR is highly variable and depends on several factors. We investigated the blood utilization in patients undergoing TKR in our hospital and depicted the important risk factors that determine the need of allogenic blood transfusion in primary unilateral TKR.
MATERIALS AND METHODS: The study included 1241 consecutive patients undergoing primary unilateral total knee arthroplasty. All the surgeries were performed by a single surgical team of orthopedists following standard procedure. Patient and disease details were obtained from patient file and hospital information system. Compatibility test was performed in blood bank before blood reservation following mandatory guidelines. Details of test, blood issue, and blood transfusion were documented in the blood bank.
RESULTS: Of 1241 enrolled patients, 1069 (86.2%) were female. The median age of patients was 66 years with mean preoperative hemoglobin of 9.9 g/dL. Allogenic blood transfused was needed in 223 (17.9%) patients. Diabetes mellitus, hypertension, thyroid disorders, and chronic heart diseases were the major comorbid conditions. Risk factors such as gender, American Society of Anesthesiologists score, preoperative hemoglobin, and intraoperative and postoperative blood losses were significantly associated with blood transfusion.
CONCLUSION: The risk factors determining blood transfusion in TKR vary between studies, however, all centers should establish standard operating procedures describing the surgical procedure and transfusion support in TKR. In addition, each center may develop specific blood management strategy to rationalize blood transfusion in TKR and overall successful care in TKR.
Keywords: Allogenic blood transfusion, osteoarthritis, preoperative hemoglobin, total knee arthroplasty, total knee replacement
|How to cite this article:|
Das SS, Kamilya R, Biswas RN, Ghosh S. An insight into the utilization of allogenic blood transfusion and factors affecting blood transfusion in total knee replacement surgery in a tertiary care hospital in Eastern India. Asian J Transfus Sci 2021;15:133-9
|How to cite this URL:|
Das SS, Kamilya R, Biswas RN, Ghosh S. An insight into the utilization of allogenic blood transfusion and factors affecting blood transfusion in total knee replacement surgery in a tertiary care hospital in Eastern India. Asian J Transfus Sci [serial online] 2021 [cited 2021 Dec 6];15:133-9. Available from: https://www.ajts.org/text.asp?2021/15/2/133/329646
| Introduction|| |
Significant blood loss and subsequent requirement of allogenic blood transfusion during or after total knee replacement (TKR) surgeries have been reported by previous authors.,,, TKR is performed to treat various joint pathologies, the common being osteoarthritis, rheumatoid or inflammatory arthritis, osteonecrosis, and posttraumatic degenerative joint diseases., In addition to the inherent side effect of blood transfusion such as alloimmunization, transfusion-transmitted infections, hemolytic transfusion reactions, and allergic reactions, it also increases the risk of surgical site infection due to transfusion-related immunomodulation, prolonged hospital length of stay (LOS), and even mortality.,, To prevent the risk of blood transfusion, various workers have developed perioperative blood management algorithm for rational utilization of blood and blood components in total knee arthroplasty (TKA)., The reported incidence of blood transfusion varies from 3.5% to 18.5%. Bierbaum et al. reported a transfusion rate as high as 39% following TKA, with an increased risk of fluid overload, infection rate, and duration of hospitalization in patients who received allogenic blood. Factors determining the need of blood transfusion have been discussed elaborately in the past. Some of these important factors included patient age, American Society of Anesthesiologists (ASA) grade, preoperative hemoglobin (Hb), associated medical comorbidities, and postoperative drainage volume.,,,,,, Pierson et al. in 2004 calculated the Hb loss in routine primary TKA and found it to be 3.8 g/dL.
Most Maximum Surgical Blood Ordering Schedule dictates reservation of blood, particularly packed red blood cell (PRBC) units before TKR. Ours being a tertiary care hospital with specialty knee and hip clinics, the number of patients referred for TKR is significantly high. As per our hospital protocol for every patient planned for TKR, a routine blood sample should be sent for reservation of two units of compatible PRBC in the blood bank. In this study, we aimed to investigate the blood utilization in patients undergoing TKR in our hospital and discuss the important risk factors determining the need of allogenic blood transfusion in primary unilateral TKR.
| Materials and Methods|| |
The retrospective study included 1241 consecutive patients from January 2017 to February 2020 undergoing primary unilateral TKA. The study was conducted in the hospital blood center after obtaining ethical approval from the Institute Ethics Committee. All the surgeries were performed by a single surgical team of orthopedists following standard procedure. Patients with coagulopathies, hematological diseases, and trauma were excluded from the study. All surgeries were performed by using the medial parapatellar arthrotomy approach with application of pneumatic tourniquet before skin incision and released after cementing the prosthesis. Autologous blood and medications such as tranexamic acid and other hemostatic agents were not used in the patients. Postoperatively, a closed drainage system was used in all patients and kept for an average of 2–3 days.
Patient and disease details such as demographic profile, LOS, and clinical and surgical profiles including postoperative complications were obtained from patient file and hospital information system. Blood samples for blood grouping and crossmatching were sent to blood bank for mandatory compatibility test and blood reservation before surgery. Compatibility test was performed using automated column agglutination technology (Ortho Clinical Diagnostics, Raritan, New Jersey 08869, USA). Details of test, blood issue, and blood transfusion were documented in the blood bank. All transfusions were subjected to hemovigilance, and any adverse events observed during or after blood transfusion were investigated and documented.
Statistical analysis was done using the SPSS statistical package (version 13, IBM, 2015, Armonk, New York, USA). All results were calculated as mean ± standard deviation, and P < 0.05 was considered statistically significant. Demographic, clinical, and surgical variables were compared between transfused and nontransfused groups. Qualitative variables and quantitative variables were analyzed using the Chi-square test and t-test, respectively. Risk factors with P < 0.05 were statistically analyzed through multivariate logistic regression to identify the independent risk factor for blood transfusion. All results were reported in terms of odds ratio and corresponding 95% lower control limit and 95% upper control limit.
| Results|| |
The study included 1241 patients, of which 172 (13.8%) were male and 1069 (86.2%) were female. The median age of patients was 66 years with a mean body mass index (BMI) of 31.6 kg/m2. The mean preoperative Hb and platelet values in the enrolled patients were 9.9 g/dL and 186 × 103/μL, respectively. While the mean operation time was 116.4 min;the intraoperative blood loss was 236.5 mL; the intraoperative blood loss was 236.5 mL. The mean LOS was observed to be 6.2 days [Table 1].
|Table 1: Demographic, clinical, and surgical characteristics of patients undergoing total knee replacement (n=1241)|
Click here to view
Allogenic blood transfused was needed in 223 (17.9%) patients, and among them, 83 (37.2%) patients received transfusion during surgery. [Table 2] describes the risk factors affecting blood transfusion in TKR. A total of 759 (61.2%) patients were more than 60 years. Diabetes mellitus, hypertension, thyroid disorders, and chronic heart diseases were the major comorbid conditions observed in 1031 (83.1%) patients where the primary indication of TKR was osteoarthritis (93.3%); majority of patients belonged to ASA score 2 (65.4%). The operation time was <120 min in 1015 (81.8%) patients with intraoperative blood loss below 250 mL in 791 (63.7%) patients. Most of the TKR patients received spinal anesthesia (99.1%). Risk factors such as gender (P = 0.0308), ASA score (P = 0.0462), preoperative Hb values (P = 0.0074), intraoperative blood loss (P = 0.0296), and postoperative blood loss (P = 0.0036) were significantly associated with blood transfusion. [Table 3] depicts the multivariate logistic regression analysis to identify independent significant risk factors for blood transfusion in TKR. Gender (P = 0.0317), preoperative Hb level (P = 0.0001), increased volume of intraoperative blood loss (P = 0.0301), and increased volume of postoperative blood loss (P = 0.0038) were independent risk factors for allogenic blood transfusion. On analyzing the predictors of intraoperative and postoperative blood transfusion, gender (P = 0.0003), preoperative Hb (P < 0.001), and intraoperative blood loss (P = 0.0061) were independent predictors of intraoperative blood transfusion. Factors such as preoperative Hb (P = 0.032) and postoperative blood loss (P = 0.0245) were independent predictors of postoperative blood transfusion [Table 1].
|Table 2: Risk factors affecting blood transfusion in total knee replacement|
Click here to view
|Table 3: Multivariate logistic regression analysis to identify independent significant risk factors for blood transfusion in total knee replacement|
Click here to view
| Discussion and Conclusion|| |
The past two decades have observed a significant increase in the number of patients undergoing TKR. Due to various underlying risk factors, blood transfusion is often needed in TKR which at times makes the overall treatment more complicated adding more burden to the blood bank inventory.,, The present study witnessed an increased number of elderly females undergoing TKR. The median age was 66 years, with female patients as high as 86.2%. This is due to the fact that the most common indication of TKR is osteoarthritis which commonly affects the elderly population. Women are more affected and burdened by osteoarthritis of the knee than men, and the causes mainly include anatomic differences, previous trauma, genetic causes, and hormonal issues.,,,,,, While Song et al. observed that 82.1% of their Chinese patients were females with a mean age of 67.4 years; Al-Turki et al. in their Saudi patients reported 77.1% females with a mean age of 64.59 years; Al-Turki et al. in their Saudi patients reported 77.1% of females with a mean age of 64.59 years., The mean weight and BMI of our enrolled patients were 67 kg and 31.6 kg/m2, respectively. The prevalence of obesity has been growing alarmingly in the world and is now a key factor for knee osteoarthritis., Felson et al. reported that obese individuals have a 1.5–2 times risk of developing knee osteoarthritis compared to their leaner counterparts. Fowler-Brown et al. also found that a 5 kg/m2 increase in BMI was associated with a 32% increase in the probability of osteoarthritis. Similarly, Larson et al. and Al-Turki et al. observed high BMI in their TKR patient populations.,
The 2009 Nationwide Inpatient Sample (NIS) data of the USA revealed that most patients who underwent TKR were elderly women and the most common comorbid conditions included hypertension (67.8%), diabetes (20.0%), and obesity (19.8%), chronic renal disease at 14.7%, and depression at 11.8%. In addition, the data mentioned that over 85% of patients had at least one comorbidity and these increasing numbers of medical comorbidities were associated with incremental increase in LOS and use of hospital resources. Similarly, other authors also observed an association between comorbidities and higher LOS. The major comorbidities we observed were obesity (72.4%), hypertension (57.3%), diabetes (26.7%), thyroid disorders (20.4%), and chronic heart diseases (7.7%). Single or multiple comorbidities were observed in over 83% of patients. Although the average LOS was estimated to be 5.3 days, patients with 3 or more comorbidities had a mean LOS of 6.7 days.,
As high as 94.3% of our patients belonged to ASA classification 2 and 3, and this explained that most of them had mild-to-severe systemic diseases. Associations between ASA scores and specific surgical complications and outcomes have been reported in the literature., Previous workers reported a significant correlation of ASA scores with operating times, hospital LOS, postoperative infection rates, overall morbidity, and mortality rates.,, Al-Turki et al. found similar data like ours and they reported 63.4% and 31.6% of patients under ASA categories 2 and 3, respectively.
In the current study, the mean preoperative Hb was 9.9 g/dL which was lower than values described by Song et al. in their Chinese patients or Al-Turki et al. and Larson et al. in their Saudi and American patients, respectively.,, These variations may be attributed to average low Hb in our Indian patients, particularly the elderly female population which was also observed by previous Indian authors., We also observed that 74.3% of our TKR patients were admitted with Hb ≤10 g/dL. Since the allogenic blood transfusion trigger was a Hb level <9 g/dL as per the institutional protocol, therefore 57 (6.9%) of these patients received blood transfusion before or during operation.
The present investigation reviewed in detail the surgical factors that determine the outcome of TKR surgeries. Data relating to average operation time and intraoperative and postoperative blood losses could be compared with those reported by others.,, Several studies have reported the range of blood loss between 1000 and 1790 mL in TKR surgery., According to published literature, total blood loss could be visible or hidden. Approximately 50% of blood loss occurs during the postoperative period and the hidden blood loss was estimated to be 38% by Li et al. Likewise, we observed that in 34.6% of patients, the postoperative blood loss was >500 mL. Multiple previous studies have shown that spinal anesthesia reduces the incidence of postoperative complications, morbidities, and mortalities.,, We also found that more than 99% of patients received spinal anesthesia during surgery. General anesthesia was opted for those patients who had problems with coagulation, spine, or cardiac functions.
The incidence of blood transfusion in the present study was estimated to be 17.9%, and majority of transfused patients (62.8%) received blood postoperatively. The need for blood transfusion in TKR depends on multiple factors. While Al-turki et al. reported 163 (35.3%) patients receiving blood transfusion; Song et al. and Larson et al., respectively, observed a 19.4% and 45.7% incidence of blood transfusion in their patients.,, Cardozo et al. observed a low incidence rate of 10.9% and concluded that patients with fall in Hb >20% or Hb value <9 g/dL after surgery may need blood transfusion, particularly when accompanied by major symptoms of tissue hypoperfusion. In this context, Liu et al. described in detail the blood management strategies in TKR and advised restrictive blood transfusion in these patients by adhering to evidence-based transfusion guidelines and utilization of appropriate transfusion triggers. They recommended transfusion in patients with Hb <7 g/dL and Hb <8 g/dL in setting of cardiac diseases or specific patient situation where additional oxygen-carrying capacity is needed. We observed that factors relating to patient and surgery such as gender, ASA score, preoperative Hb, and both intraoperative and postoperative blood losses were significantly associated with blood transfusion (P < 0.05). Previous studies showed that gender and old age have been associated with blood transfusion., Song et al. reported variables such as gender, preoperative Hb, and intraoperative blood loss as significant determinants of blood transfusion which is consistent with our findings. It has also been observed that patients with a preoperative Hb level <13 g/dL are at a fourfold higher risk of having transfusion and bleeding and clotting disorders are independent risk factors for blood transfusion., Low preoperative Hb, high amount blood loss, bilateral surgery, high ASA score, and general anesthesia techniques were significantly associated with blood transfusion as per Al-Turki et al. It was reported that ASA scores are correlated with total blood loss during surgery and are significant variables associated with blood transfusion. We investigated that gender, preoperative Hb, and increased volume of intraoperative and postoperative blood losses were independent risk factors for allogenic blood transfusion. Song et al. reported preoperative Hb levels and intraoperative blood loss as the independent risk factors for blood transfusion. Previous authors also documented weight, age >75 years, male gender, hypertension, and BMI as risk factors of blood transfusion., We analyzed the predictors of intraoperative and postoperative blood transfusion and found gender, preoperative Hb, and intraoperative blood loss as independent predictors of intraoperative blood transfusion and factors such as preoperative Hb and postoperative blood loss as independent predictors of postoperative blood transfusion. Likewise, Song et al. reported prolonged APTT, low preoperative Hb, and increased blood loss as independent predictors for intraoperative transfusion and female gender and postoperative low Hb as independent predictors of postoperative blood transfusion.
Although the risk factors determining blood transfusion in TKR vary from study to study, gender, preoperative low Hb level, and blood loss during or after surgery are common ones in the literature. More prospective, multicentric, and large studies are needed to accurately assess the risk factors determining allogenic blood transfusion in TKR. Moreover, all centers should establish standard operating procedures describing the surgical procedure and transfusion support in TKR. Each center may develop specific blood management strategy which at recent times is considered as a critical component of successful care in TKR.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Hart A, Khalil JA, Carli A, Huk O, Zukor D, Antoniou J. Blood transfusion in primary total hip and knee arthroplasty. Incidence, risk factors, and thirty-day complication rates. J Bone Joint Surg Am 2014;96:1945-51.
Nichols CI, Vose JG. Comparative risk of transfusion and incremental total hospitalization cost for primary unilateral, bilateral, and revision total knee arthroplasty procedures. J Arthroplasty 2016;31:583-9.e1.
Kim JL, Park JH, Han SB, Cho IY, Jang KM. Allogeneic blood transfusion is a significant risk factor for surgical-site infection following total hip and knee arthroplasty: A meta-analysis. J Arthroplasty 2017;32:320-5.
Menendez ME, Lu N, Huybrechts KF, Ring D, Barnes CL, Ladha K, et al.
Variation in use of blood transfusion in primary total hip and knee arthroplasties. J Arthroplasty 2016;31:2757-63.e2.
Pierson JL, Hannon TJ, Earles DR. A blood-conservation algorithm to reduce blood transfusions after total hip and knee arthroplasty. J Bone Joint Surg Am 2004;86:1512-8.
Bierbaum BE, Callaghan JJ, Galante JO, Rubash HE, Tooms RE, Welch RB. An analysis of blood management in patients having a total hip or knee arthroplasty. J Bone Joint Surg Am 1999;81:2-10.
Tang JH, Lyu Y, Cheng LM, Li YC, Gou DM. Risk factors for the postoperative transfusion of allogeneic blood in orthopedics patients with intraoperative blood salvage: A retrospective cohort study. Medicine (Baltimore) 2016;95:e2866.
Boutsiadis A, Reynolds RJ, Saffarini M, Panisset JC. Factors that influence blood loss and need for transfusion following total knee arthroplasty. Ann Transl Med 2017;5:418.
Slover J, Lavery JA, Schwarzkopf R, Iorio R, Bosco J, Gold HT. Incidence and risk factors for blood transfusion in total joint arthroplasty: Analysis of a statewide database. J Arthroplasty 2017;32:2684-7.e1.
Helder CW, Schwartz BE, Redondo M, Piponov HI, Gonzalez MH. Blood transfusion after primary total hip arthroplasty: National trends and perioperative outcomes. J Surg Orthop Adv 2017;26:216-22.
Al-Turki AA, Al-Araifi AK, Badakhan BA, Al-Nazzawi MT, Alghnam S, Al-Turki AS. Predictors of blood transfusion following total knee replacement at a tertiary care center in central Saudi Arabia. Saudi Med J 2017;38:598-603.
Song K, Pan P, Yao Y, Jiang T, Jiang Q. The incidence and risk factors for allogenic blood transfusion in total knee and hip arthroplasty. J Orthop Surg Res 2019;14:273.
Borkhoff CM, Hawker GA, Kreder HJ, Glazier RH, Mahomed NN, Wright JG. The effect of patient's sex on physician's recommendations for total knee arthroplasty. CMAJ 2008;178:681-7.
Blagojevic M, Jinks C, Jeffery A, Jordan KP. Risk factors for onset of osteoarthritis of the knee in elderly adults: A systematic review and meta-analysis. Osteoarthr Cartil 2010;18:24-33.
Felson DT, Naimark A, Anderson J, Kazis L, Castelli W, Meenan RF. The prevalence of knee osteoarthritis in the elderly. The Framingham osteoarthritis study. Arthritis Rheum 1987;30:914-8.
Felson DT, Zhang Y, Hannan MT, Naimark A, Weissman BN, Aliabadi P, et al.
The incidence and natural history of knee osteoarthritis in the elderly. The Framingham osteoarthritis study. Arthritis Rheum 1995;38:1500-5.
O'Connor MI. Osteoarthritis of the hip and knee: Sex and gender differences. Orthop Clin North Am 2006;37:559-68.
Hanna FS, Teichtahl AJ, Wluka AE, Wang Y, Urquhart DM, English DR, et al.
Women have increased rates of cartilage loss and progression of cartilage defects at the knee than men: A gender study of adults without clinical knee osteoarthritis. Menopause 2009;16:666-70.
Conley S, Rosenberg A, Crowninshield R. The female knee: Anatomic variations. J Am Acad Orthop Surg 2007;15 Suppl 1:S31-6.
Yoon KH, Lee JH, Kim JW, Cho JH, Choi YH, Ko SH, et al.
Epidemic obesity and type 2 diabetes in Asia. Lancet 2006;368:1681-8.
Lohmander LS, Gerhardsson de Verdier M, Rollof J, Nilsson PM, Engström G. Incidence of severe knee and hip osteoarthritis in relation to different measures of body mass: A population-based prospective cohort study. Ann Rheum Dis 2009;68:490-6.
Felson DT, Anderson JJ, Naimark A, Walker AM, Meenan RF. Obesity and knee osteoarthritis. The Framingham study. Ann Intern Med 1988;109:18-24.
Fowler-Brown A, Kim DH, Shi L, Marcantonio E, Wee CC, Shmerling RH, et al.
The mediating effect of leptin on the relationship between body weight and knee osteoarthritis in older adults. Arthritis Rheumatol 2015;67:169-75.
Larson A, Hoitsma S, Metzger J, Oehlke K, Bebensee S. Impact of tranexamic acid on blood loss and need for blood transfusions in total knee and total hip arthroplasty. Fed Pract 2017;34:14-9.
Pugely AJ, Martin CT, Gao Y, Mendoza-Lattes S, Callaghan JJ. Differences in short-term complications between spinal and general anesthesia for primary total knee arthroplasty. J Bone Joint Surg Am 2013;95:193-9.
Monsef JB, Della Valle AG, Mayman DJ, Marx RG, Ranawat AS, Boettner F. The impact of blood management on length of stay after primary total knee arthroplasty. Open Orthop J 2014;8:108-13.
Dripps RD. New classification of physical status. Anesthesiol 1963;24:111.
Tang R, Chen HH, Wang YL, Changchien CR, Chen JS, Hsu KC, et al.
Risk factors for surgical site infection after elective resection of the colon and rectum: A single-center prospective study of 2,809 consecutive patients. Ann Surg 2001;234:181-9.
Sauvanet A, Mariette C, Thomas P, Lozac'h P, Segol P, Tiret E, et al.
Mortality and morbidity after resection for adenocarcinoma of the gastroesophageal junction: Predictive factors. J Am Coll Surg 2005;201:253-62.
Carey MS, Victory R, Stitt L, Tsang N. Factors that influence length of stay for in-patient gynaecology surgery: Is the Case Mix Group (CMG) or type of procedure more important? J Obstet Gynaecol Can 2006;28:149-55.
Grosflam JM, Wright EA, Cleary PD, Katz JN. Predictors of blood loss during total hip replacement surgery. Arthritis Care Res 1995;8:167-73.
Subramanian A, Sagar S, Kumar S, Agrawal D, Albert V, Misra MC. Maximum surgical blood ordering schedule in a tertiary trauma center in northern India: A proposal. J Emerg Trauma Shock 2012;5:321-7.
] [Full text]
Subramanian A, Rangarajan K, Kumar S, Sharma V, Farooque K, Misra MC. Reviewing the blood ordering schedule for elective orthopedic surgeries at a level one trauma care center. J Emerg Trauma Shock 2010;3:225-30.
] [Full text]
Konig G, Hamlin BR, Waters JH. Topical tranexamic acid reduces blood lossand transfusion rates in total hip and total kee arthroplasty. J Arthroplasty 2013;28:1473-6.
Tetro AM, Rudan JF. The effect of pneumatic tourniquet on blood loss in total knee arthroplasty. Can J Surg 2001;44:33-8.
Li B, Wen Y, Wu H, Qian Q, Lin X, Zhao H. The effect of tourniquet use on hidden blood loss in total knee arthroplasty. Int Orthop 2009;33:1263-8.
Rodgers A, Walker N, Schug S, McKee A, Kehlet H, van Zundert A, et al.
Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: Results from overview of randomised trials. BMJ 2000;321:1493.
Turnbull ZA, Sastow D, Giambrone GP, Tedore T. Anesthesia for the patient undergoing total knee replacement: Current status and future prospects. Local Reg Anesth 2017;10:1-7.
Macfarlane AJ, Prasad GA, Chan VW, Brull R. Does regional anesthesia improve outcome after total knee arthroplasty? Clin Orthop Relat Res 2009;467:2379-402.
Cardozo RT, de Souza Junior EF, Alves WC, Filho FB. Total knee arthroplasty: Indication of blood transfusion according to hematimetric variation and clinical symptoms of hypoperfusion. Rev Bras Ortop 2014;49:507-12.
Liu D, Dan M, Martos SM, Beller E. Blood management strategies in total knee arthroplasty. Knee Surg Relat Res 2016;28:179-87.
To J, Sinha R, Kim SW, Robinson K, Kearney B, Howie D, et al.
Predicting perioperative transfusion in elective hip and knee arthroplasty: A validated predictive model. Anesthesiology 2017;127:317-25.
Sizer SC, Cherian JJ, Elmallah RD, Pierce TP, Beaver WB, Mont MA. Predicting blood loss in total knee and hip arthroplasty. Orthop Clin North Am 2015;46:445-59.
Salido JA, Marín LA, Gómez LA, Zorrilla P, Martínez C. Preoperative hemoglobin levels and the need for transfusion after prosthetic hip and knee surgery: Analysis of predictive factors. J Bone Joint Surg Am 2002;84:216-20.
Everhart JS, Sojka JH, Mayerson JL, Glassman AH, Scharschmidt TJ. Perioperative allogeneic red blood-cell transfusion associated with surgical site infection after total hip and knee arthroplasty. J Bone Joint Surg Am 2018;100:288-94.
Noticewala MS, Nyce JD, Wang W, Geller JA, Macaulay W. Predicting need for allogeneic transfusion after total knee arthroplasty. J Arthroplasty 2012;27:961-7.
Bong MR, Patel V, Chang E, Issack PS, Hebert R, Di Cesare PE. Risks associated with blood transfusion after total knee arthroplasty. J Arthroplasty 2004;19:281-7.
Dr. Sudipta Sekhar Das
Department of Transfusion Medicine, Apollo Gleneagles Hospitals, Kolkata - 700 054, West Bengal
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3]