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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 15  |  Issue : 2  |  Page : 276-281

Postoperative changes in hemoglobin and packed cell volume values in patients undergoing primary lower limb arthroplasty


1 Department of Orthopaedics, AFMC, Pune, Maharashtra, India
2 Department of Orthopaedics, INHS Kalyani, Visakhapatnam, Andhra Pradesh, India

Date of Submission05-Jun-2020
Date of Decision10-Jun-2020
Date of Acceptance15-Jun-2020
Date of Web Publication21-Dec-2020

Correspondence Address:
Dr. Mohammed Schezan Iqbal
Department of Orthopaedics, INHS Kalyani, Visakhapatnam - 530 005, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_266_20

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  Abstract 


Context: Total knee arthroplasty (TKA) and total hip arthroplasty (THA) are commonly performed procedures for degenerative conditions of knee and hip joints, respectively. Lower limb arthroplasty involves visible and hidden blood losses leading to a routine requirement of blood transfusion. Postoperative rehabilitation and recovery is also dependent on hemoglobin (Hb) and packed cell volumes (PCVs) following surgery. Aims: The aim is to determine changes in Hb and PCV values in patients undergoing primary lower limb arthroplasty in the first 2 weeks' postoperatively. We also aimed to find out any correlation between length of hospitalization following lower limb arthroplasty with preoperative Hb and PCV values. Setting: This study is a cross-sectional, analytical study analyzing the postoperative changes in Hb and PCV in patients undergoing primary lower limb arthroplasty. Subjects and Methods: Forty patients undergoing primary TKA or THA were studied with a compilation of demographic, hematological, and clinical outcomes over a period of 14 days' postoperatively. Statistical Analysis Used: Chi-square test, unpaired t-test, analysis of variance (ANOVA), and Mann–Whitney U-tests. Results: On comparing the data within the groups at multiple intervals using repeated measures ANOVA, significant difference was found in the Hb at various time intervals for THA patients (F = 46.32, P < 0.0001) and for TKA patients (F = 55.26, P < 0.0001). The mean PCV levels of THA and TKA patients were comparable at various time intervals, except postoperative day 1, when the PCV levels were significantly lower in THA group than TKA group (P = 0.0331). Conclusion: There was a definite postoperative decrease in Hb levels, with the highest fall on the 5th day postsurgery, with respect to the preoperative Hb and PCV levels.

Keywords: Blood loss, hemoglobin, packed cell volume, total hip arthroplasty, total knee arthroplasty


How to cite this article:
Dubey R, Iqbal MS, Prasad M, Singh CM, Sarwar G, Kaul R. Postoperative changes in hemoglobin and packed cell volume values in patients undergoing primary lower limb arthroplasty. J Datta Meghe Inst Med Sci Univ 2020;15:276-81

How to cite this URL:
Dubey R, Iqbal MS, Prasad M, Singh CM, Sarwar G, Kaul R. Postoperative changes in hemoglobin and packed cell volume values in patients undergoing primary lower limb arthroplasty. J Datta Meghe Inst Med Sci Univ [serial online] 2020 [cited 2021 Jan 19];15:276-81. Available from: http://www.journaldmims.com/text.asp?2020/15/2/276/304254




  Introduction Top


Many diseases of the hip and knee joint are effectively managed by total knee arthroplasty (TKA) and total hip arthroplasty (THA). However, postoperative blood transfusion in these patients is a major challenge.[1] Studies have historically reported blood losses with THA and TKA.[2],[3] The overall transfusion rate due to this reason has been reported to be 18% in hip procedures and 11% in knee procedures.[4] The expected blood loss in routine, primary TKA has been estimated to be in the range of 800–1800 ml.[5] Postoperative anemia may contribute to poor wound healing, infection, delay in recovery of joint function, and delayed rehabilitation.[4] There is a relative lack of data which shows the pattern of blood loss and its effect in the occurrence of anemia in the postoperative period in patients undergoing THA and TKA. This study was conducted to study the variations of hemoglobin (Hb) and packed cell volume (PCV) levels following primary arthroplasty of the lower limb during the postoperative period and examine the prognostic significance of measuring the Hb and PCV levels at serial time intervals. The primary objective was to determine changes in Hb and PCV values in patients undergoing primary lower limb arthroplasty in the first 2 weeks' postoperatively. Secondary objectives included finding out any correlation between length of hospitalization following lower limb arthroplasty with preoperative Hb and PCV values and any association between drain output with change in postoperative Hb and PCV values.


  Subjects and Methods Top


This study is a single center, cross-sectional analytical study which assesses changes in Hb and PCV values in patients undergoing primary lower limb arthroplasty in the first 2 weeks' postoperatively. The present study was conducted in a tertiary care hospital in the department of orthopedics, over a 2-year from November 2017 to September 2019. Ethical clearance was obtained from the institutional ethics committee prior to start of the study. The inclusion criteria for our study were individuals of either sex >18 years undergoing primary unilateral THA or TKA. Exclusion criteria were patients who had a preoperative Hb of <8 g%, patients who received blood transfusion intraoperatively or postoperatively in the recovery room, patients with comorbidities such as chronic renal disease, inflammatory arthritis or cancer, and patients with a bleeding or clotting disorder.

For sample size calculation, a pilot study was conducted in 10 patients of THA and TKA, following institutional ethics committee approval and presuming α of 0.05 and power of 90%, sample size calculation done using paired t-test and for the purpose of this study, 40 patients were studied.

All eligible subjects (40 subjects) were evaluated preoperatively with history and clinical examination followed by endorsement of their demographic characteristics. A baseline preoperative Hb and PCV count were done for all subjects.

For total knee arthroplasty

A pneumatic tourniquet with 280 mm Hg pressure was applied after exsanguination. A midline incision with a medial parapatellar arthrotomy was done to expose the joint. Tranexamic acid 1 g was given intravenously, 15 min before release of tourniquet. The knee was kept in 15°–30° of flexion for first 24 h postoperatively.

For total hip arthroplasty

Tranexamic acid 1 g was administered intravenously to all patients undergoing THA, 15 min before giving skin incision. A standard, posterolateral approach was done to expose the joint.

Postoperative care and management

Once transferred to the ward, all patients were encouraged to do rehabilitation exercises from day 1 postoperatively. The sutures were removed on 14th postoperative day.

Postoperative anti-coagulation was given as follows:

  1. Injectable low molecular weight heparin 60 mg subcutaneously once daily till 7 days
  2. Oral tablet aspirin 325 mg once daily was prescribed for 3 weeks.


The drain output was measured, and drains were removed after 24 h of operation in both TKA and THA.

Hb and PCV of the study participants were assessed postoperatively at days 1, 3, 5 and 14.

Statistical analysis

Data from the case record forms were entered into a Microsoft Excel Sheet and analyzed using appropriate statistical tests on SPSS version 21 software (SPSS Statistics for Windows, version x.0, SPSS Inc., Chicago, Ill., USA)”.

Ethical Clearance

Ethical approval for this study (AFMC/2019/22) was provided by the Ethical Committee of Armed Force Medical College, on 04/06/2019.


  Results Top


Of all study participants, 24 were male and 16 were female. Mean age of the study population was 56.7 ± 11.9 years in the THR group and 65.3 ± 5.9 years in the TKA group.

In the THA group, the most common diagnosis was avascular necrosis of hips in 7 (43.75%) patients, followed by osteoarthritis in 4 (25%), and fracture of femoral neck in 4 (25%). In the TKA group, bilateral osteoarthritis was present in all patients.

In the THR group, right-sided operation was performed in 10 (61.5%) and left-sided operation was performed in 6 (37.5%) patients. In the TKA group, right- and left-sided operations were performed in 12 (50%) patients each. In the THA group, the most common comorbidity was hypertension, present in 5 (31.25%) patients, while 11 (68.75%) patients had no comorbidity. In the TKA group, the most common comorbidity was hypertension in 15 (62.5%) patients followed by diabetes mellitus in 6 (25%) patients.

In the THA group, 13 (81.25%) patients received combined spinal-epidural anesthesia while 3 (18.75%) received spinal anesthesia. In the TKA group, 18 (75%) patients received combined spinal-epidural anesthesia, 5 (20.83%) received spinal anaesthesia and 1 (4.17%) received general anaesthesia. In the THA group, 10 (62.5%) received uncemented prosthesis, 5 (31.25%) received cemented prosthesis and 1 (6.25%) received hybrid prosthesis. All TKA patients were given cemented implants.

Demographic profile of the study population is depicted in [Table 1].
Table 1: Demographic profile of the study population

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[Table 2] describes the preoperative hematological profile of the study population. The mean preoperative Hb, PCV, and platelet counts of all study participants were similar in both the THA and TKA groups, as assessed using the unpaired t-test.
Table 2: Preoperative haematological assessment of the study population

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For THA and TKA patients, on comparing the data within the group at multiple intervals using repeated measures analysis of variance (ANOVA), it was found that there was significant difference in the Hb at various time intervals (F = 46.32, P < 0.0001) and (F = 55.26, P < 0.0001), respectively. The mean Hb levels of THA and TKA patients were comparable at various time intervals. The mean Hb at different postoperative intervals is depicted in [Figure 1].
Figure 1: Mean haemoglobin at different postoperative intervals. (Repeated measures ANOVA [within group analysis], **P < 0.01 vs. preoperative, &P < 0.05, &&P < 0.01 vs. 1st day postoperative, #P < 0.05 vs. 3rd day postoperative, $$P < 0.01 vs. 5th day postoperative)

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For THA and TKA patients, on comparing the data within the group at multiple intervals using repeated measures ANOVA it was found that there was significant difference in the PCV at various time intervals (F = 53.89, P < 0.0001) and (F = 46.91, P < 0.0001), respectively. The mean PCV levels of THA and TKA patients were comparable at various time intervals, except at day 1 wherein the PCV levels were significantly lower in THA group than TKA group (P = 0.0331). The mean PCV at different postoperative intervals is depicted in [Figure 2].
Figure 2: Mean packed cell volume at different postoperative intervals. (Repeated measures ANOVA [within group analysis], **P < 0.01 vs. preoperative, &P < 0.05, &&P < 0.01 vs. 1st day postoperative, #P < 0.05, ##P < 0.01 vs. 3rd day postoperative, $$P < 0.01 vs. 5th day postoperative)

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The change in Hb from preoperative levels to postoperative intervals was comparable between the THA and TKA groups. The highest mean change in Hb was observed at day 5 in THA and TKA groups, which was 3.44 ± 1.46 g% and 2.91 ± 1.3 g%, respectively and analyzed using Mann–Whitney U-test. This change in Hb is illustrated in [Figure 3].
Figure 3: Mean change in haemoglobin on different postoperative days

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The change in PCV from preoperative levels to postoperative intervals was comparable between the THA and TKA groups. The highest mean change in PCV was observed at day 5 in THA and TKA groups, which was 10.98 ± 4.09% and 9.41 ± 4.58%, respectively and analyzed using Mann–Whitney U-test. This change in PCV is demonstrated in [Figure 4].
Figure 4: Mean change in packed cell volume on different postoperative days

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The mean drain output of THA and TKA patients was 291.3 ± 190.7 ml and 292.9 ± 163.6 ml, respectively. On comparison using Mann–Whitney U-test, it was found that the mean drain output of the two groups was similar (P = 0.9766). The mean drain output for both groups is described in [Table 3].
Table 3: Mean drain output of total hip arthroplasty and total knee arthroplasty patients

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The mean duration of hospital stay of THA and TKA patients was 10.8 ± 3.5 and 11.7 ± 3.3 days, respectively. On comparison using unpaired t-test, it was found that the mean duration of hospital stay of the two groups was similar (P = 0.3905). The mean length of hospitalization for both groups is described in [Table 4].
Table 4: Mean length of hospitalisation of total hip arthroplasty and total knee arthroplasty patients

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In the THA group, the duration of hospital stay had a weak negative correlation with preoperative Hb (r = −0.2768) and a moderate negative correlation with preoperative PCV (r = −0.3229) levels. The drain output had a weak positive correlation with postoperative day 1 Hb (r = 0.297) and PCV (r = 0.275) levels.

In the TKA group, the duration of hospital stay had a weak positive correlation with preoperative Hb (r = 0.203) and a moderate positive correlation with preoperative PCV (r = 0.206) levels. The drain output had a moderate positive correlation with postoperative day 1 Hb (r = 0.304) and PCV (r = 0.327) levels.

The patient outcome variables with correlations are described in [Table 5].
Table 5: Patient outcome variables in total hip arthroplasty and total knee arthroplasty groups

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  Discussion Top


In the present study, we observed a significant reduction in the postoperative Hb and PCV values of the patients undergoing THA and TKA. The values were lowest as observed on the 5th postoperative day. Weak correlations were observed between the duration of hospital stay with preoperative Hb and PCV levels. Similarly, weak correlations were observed between drain output with postoperative Hb and PCV levels.

We followed a restrictive strategy of postoperative blood transfusion. We did not recruit patients with Hb levels <8 g/dl and did not analyze patients who received any blood transfusion before, during, and after the surgery. This allowed us to accurately assess the Hb and PCV changes in the patients, postarthroplasty. However, we did follow the practice of using tranexamic acid during the surgery to reduce the rate of postoperative anemia and transfusion as this was a standard practice in other study settings.[6] The 14-day outcomes in all patients in the current study were good, and all were discharged with an uneventful postoperative period. This demonstrates that the highly restrictive transfusion strategy worked well and was tolerated by all patients in the study. Thus, the comparison of current study findings with other studies should be interpreted in considerations with the above-mentioned participant criteria.

Observing that the mean preoperative Hb levels in THA and TKA patients, were 12.9 ± 1.8 g% and 12.6 ± 1.8 g%, respectively, there were some participants with mild-to-moderate anemia, and it was not feasible to wait for these patients to have this blood parameter corrected prior to operation. We accordingly addressed the change in postoperative in comparison to preoperative levels and consider this as the one of important findings of the study. Although the Hb levels for defining anemia are different for males and females, we assumed the population together for our analysis. The study findings should be interpreted in line with the above-mentioned confounders.

In both the THA and TKA groups, the Hb levels were lowest on 5th day postoperatively, with a mean decrease of 3.44 ± 1.46 g% and 2.91 ± 1.3 g%, respectively. In both the THA and TKA groups, the PCV levels were lowest on 5th day postoperatively, with a mean decrease of 10.98% ± 4.09% and 9.41% ± 4.58%, respectively. The postoperative drops in Hb and PCV have been reported in THA and TKA patients in few earlier studies which involved blood transfusion to the patients at various time intervals in relation to the surgery. Keating et al. studied the postoperative drop in Hb separately in unilateral and bilateral TKA patients, and reported it to be 3.85 g% and 5.42 g%, respectively suggesting that the patients undergoing bilateral TKA had higher drop in Hb compared to the unilateral TKA patients.[7] The Hb drop of 2.91 ± 1.3 g% in TKA patients in the current study is slightly lower than that reported by Keating et al. This difference can be explained by the development of newer techniques over time, such as the routine usage of tranexamic acid. Similarly, Wallis et al. reported Hb levels of 13.6 ± 1.3 g% preoperatively, 10.4 ± 1.3 g%, 10.5 ± 1.5 g%, 12.4 ± 1.3 g%, and 12 ± 1.2 g% on postoperative days 1, 7, 28, and 56, respectively.[8] Significant lower Hb levels on day 56 of surgery indicated that the duration taken for the Hb to revert to preoperative levels is more than 56 days. A similarly decreasing trend of Hb was observed in the present study from postoperative day 1 to day 5. Prasad et al. measured PCV levels in postoperative TKA patients and reported values were 35.9% ± 4.68% preoperatively, followed by 29.95% ± 4.12%, 28.7% ± 3.9%, 29.29% ± 3.34%, and 29.63% ± 3.49% postoperatively on days 1, 2, 7, and 14, respectively.[9] The findings reported by this study were like those in our study for TKA patients. In a systematic review of 13 studies involving THA or TKA patients by Spahn, the mean decrease in Hb levels was observed from preoperative levels of 13.6 ± 0.4 g% to 10.6 ± 0.8 g% postoperatively.[10] In a study in Lagos, the postoperative Hb loss in THA patients was reported to be 2.1 ± 1.1 g%.[11]

In the present study, weak positive correlations between the duration of hospital stay with preoperative Hb and PCV levels in THA and TKA patients has been observed. This contrasts with findings by Halm et al., who found that higher admission Hb levels were associated with shorter length of hospital stay in patients of hip fracture.[12] This difference maybe attributed by the nature of the condition for which surgeries were performed and related comorbidities.

Our study has results similar to Rosencher et al., who found that blood loss in both hip and knee joints is nearly the same during arthroplasty.[13] Our study observed that there was a considerable drop in both parameters namely Hb and PCV, which led to the development of postoperative anemic state in the THA/TKA patients, with the highest drop occurring by the 5th day of surgery. This shows that along with the blood loss which had occurred during the surgery or the immediate blood loss occurring within 24 h of surgery (as observed by the drain output), significant occult blood losses continued till 5th day of surgery. The reasons for this hidden loss can be attributed to internal bleeding. This is further emphasized by the current study finding that the drain output had weak-to-moderate positive correlations with the day 1 postoperative Hb and PCV values.

In the TKA patients, the values reported in our study considered the unilateral arthroplasty. All patients in the study had bilateral knee osteoarthritis. Operating bilaterally in these patients may further increase the blood losses, and the drop in Hb and PCV in such patients might be more than that reported in the current study, as has been reported by Keating et al.[7] It is important to estimate the expected blood loss in patients undergoing THA/TKA prior to the surgery, which will help in planning the hematological correction for these patients. Further, considering the observed values in the current study, it seems necessary to correct the anemia in affected patients preoperatively.

The present study used a highly restrictive strategy of transfusing blood and this raises questions on the impact that low Hb concentrations have on patients who undergo major orthopedic surgeries such as THA or TKA. Although this practice may not affect morbidity or mortality in patients, the effect it has on the functional recovery and quality of life needs to be addressed.[14] The authors agree with the guidelines that a value of Hb below 8 g/dl in THA/TKA patients postoperatively should be accompanied by blood transfusion. Autologous blood transfusion in such patients is an acceptable practice. The clinical outcomes of the patients in the current study were acceptable, and no complications were observed in any of the patients.

The strengths of the present study include its cross-sectional study design in comparison to many earlier studies which were retrospective in nature. Our study has a few limitations namely small sample size, restrictive blood transfusion practice, and a short follow-up.


  Conclusion Top


The study demonstrates that there was significant decrease in Hb and PCV in patients undergoing THA/TKA postoperatively with highest drop on 5th day. There is a definite increase in Hb and PCV levels gradually but does not necessarily reach the preoperative levels.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Oremus K. Tranexamic acid for the reduction of blood loss in total knee arthroplasty. Ann Transl Med 2015;3:S40.  Back to cited text no. 1
    
2.
Smith GH, Tsang J, Molyneux SG, White TO. The hidden blood loss after hip fracture. Injury 2011;42:133-5.  Back to cited text no. 2
    
3.
Pattison E, Protheroe K, Pringle RM, Kennedy AC, Dick WC. Reduction in haemoglobin after knee joint surgery. Ann Rheum Dis 1973;32:582-4.  Back to cited text no. 3
    
4.
Li B, Wen Y, Liu D, Tian L. The effect of knee position on blood loss and range of motion following total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2012;20:594-9.  Back to cited text no. 4
    
5.
Bao N, Zhou L, Cong Y, Guo T, Fan W, Chang Z, et al. Free fatty acids are responsible for the hidden blood loss in total hip and knee arthroplasty. Med Hypotheses 2013;81:104-7.  Back to cited text no. 5
    
6.
Benoni G, Fredin H. Fibrinolytic inhibition with tranexamic acid reduces blood loss and blood transfusion after knee arthroplasty: A prospective, randomised, double-blind study of 86 patients. J Bone Joint Surg Br 1996;78:434-40.  Back to cited text no. 6
    
7.
Keating EM, Meding JB, Faris PM, Ritter MA. Predictors of transfusion risk in elective knee surgery. Clinical orthopaedics and related research, 1998;(357):50-9.  Back to cited text no. 7
    
8.
Wallis JP, Wells AW, Whitehead S, Brewster N. Recovery from post-operative anaemia. Transfus Med 2005;15:413-8.  Back to cited text no. 8
    
9.
Prasad N, Padmanabhan V, Mullaji A. Blood loss in total knee arthroplasty: An analysis of risk factors. Int Orthop 2007;31:39-44.  Back to cited text no. 9
    
10.
Spahn DR. Anemia and patient blood management in hip and knee surgery: A systematic review of the literature. Anesthesiology 2010;113:482-95.  Back to cited text no. 10
    
11.
Ugbeye ME, Lawal WO, Ayodabo OJ, Adadevoh IP, Akpan IJ, Nwose U. An Evaluation of intra-and post-operative blood loss in total hip arthroplasty at the National Orthopaedic Hospital, Lagos. Niger J Surg 2017;23:42-6.  Back to cited text no. 11
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12.
Halm EA, Wang JJ, Boockvar K, Penrod J, Silberzweig SB, Magaziner J, et al. The effect of perioperative anemia on clinical and functional outcomes in patients with hip fracture. J Orthop Trauma 2004;18:369-74.  Back to cited text no. 12
    
13.
Rosencher N, Kerkkamp HE, Macheras G, Munuera LM, Menichella G, Barton DM, et al. Orthopedic surgery transfusion hemoglobin European overview (OSTHEO) study: Blood management in elective knee and hip arthroplasty in Europe. Transfusion 2003;43:459-69.  Back to cited text no. 13
    
14.
Hébert PC, Wells G, Blajchman MA, Marshall J, Martin C, Pagliarello G, et al. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med 1999;340:409-17.  Back to cited text no. 14
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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