Total shoulders - to drain or not to drain?

Drain Use is Associated with Increased Odds of Blood Transfusion in Total Shoulder ArthroplastyA Population-Based Study

These authors used the nationwide Premier Healthcare claims database to evaluate the trends in frequency of drain usage in shoulder arthroplasty procedures over time, as well as the association between drain usage and blood transfusion usage,  length of stay (LOS), and readmission or early infection within 30 days.

They examined 105,116 cases performed in Northeast, West, and Midwest between 2006-2016 including total, reverse, and partial shoulder arthroplasties, in which drains were used in 20% [20,886] and no drain was used in 80% [84,230]).

They found that the usage of drains decreased over time, from 25% in 2006 to 16% in 2016. After adjusting for relevant covariates, drain use was associated with an increased usage of blood transfusions (OR, 1.49; 95% CI, 1.35–1.65; p < 0.001). This represents an almost 50% increased odds for blood transfusions.

They noted a small increase in LOS (+6%, 95% CI, +4% to +7%; p < 0.001). Drain use was not associated with increased odds for early postoperative infection or 30-day readmission. 

Comment: These authors have demonstrated a highly significant association between drain use in shoulder arthroplasty and the use of transfusion. As they point out, this association does not prove that drain use causes the need for transfusion. So one must consider some possible explanation for the results:

(1) In the absence of closed wound drainage, any postoperative blood loss will provide a hemostatic effect in the form of a tamponade. With the use of a drain, that effect is lost and a conduit for blood loss is introduced.

(2) Patients who are bleeding more at the end of the case are more likely to receive a drain

(3) Surgeons who take less care in establishing hemostasis are more likely to use drains

Bleeding after shoulder arthroplasty is an issue that has not been eliminated by the use of tranexamic acid. Factors that can contribute to postoperative bleeding are many

(1) Shoulder arthroplasty requires resection of osteophytes and soft tissue releases, which can lead to bleeding.

(2) The procedure is often performed in a beach chair position with the patient's blood pressure being kept at low physiologic levels. As a result potential bleeding sources may not be recognized. When the patient returns to the recovery room, he or she is supine and postoperative discomfort may drive the blood pressure up - both of which factors may increase bleeding.

(3) Early implementation of range of motion exercises may prevent effective clot formation.

Our practice is to strive for excellent hemostasis after asking the anesthesiologist to establish normal blood pressure, and using topical thrombin and oxidized regenerated cellulose

as necessary.

We do not use drains. We close the wound with staples, which provides a one-way valve allowing blood to escape if a substantial hematoma is forming. In patients that seem likely to bleed excessively (for example those who have recently been on anticoagulants or anti-inflammatory medications), we hold postoperative motion until the next morning. We reassure patients that some postoperative bleeding and bruising is not uncommon.

Using this protocol we have avoided the need for transfusion in over 99% of our cases and no longer obtain a blood type and screen unless the patient presents with a known bleeding problem or comes to the OR with a very low hematocrit.

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How you can support progress in shoulder surgery

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Shoulder arthroplasty transfusion and complications, egg vs chicken.

Analysis of complication rates following perioperative transfusion in shoulder arthroplasty

These authors sought to examine the postoperative outcomes of patients receiving blood transfusions following TSA and RTSA using the Medicare Standard Analytic Files database between 2005 and 2010. They identified 7,794 patients who received a perioperative blood transfusion following TSA or RTSA, as well as 34,293 age- and gender-matched controls.

Patients who received a perioperative transfusion were sicker, having statistically significantly higher rates of myocardial infarction, pneumonia, systemic inflammatory response syndrome or sepsis, venous thromboembolic events, cerebrovascular accidents, surgical complications, including periprosthetic infection and mechanical complications.

Comment: This study raises at least three possibilities: (1) that patients with complications and co-morbidities are at increased risk for transfusion, (2) patients with transfusion are at increased risk for complications, or (3) both of these interactions are at play. 

What we'd like to know is whether changing our threshold for using transfusions might affect the complication rate. For example, would the complication risk of a patient with a hematocrit of 25 be lower if transfusion was withheld than if blood was transfused? A partial answer to this question might be available if a multivariate analysis was carried out that investigated the relationship of patient age, sex, comorbidities, preoperative hematocrit, surgical procedure, diagnosis, procedure length, and transfusion to surgical and medication complications.

Some related posts are of interest

Blood transfusion in primary total shoulder arthroplasty: incidence, trends, and risk factors in the United States from 2000 to 2009.

These authors used the National Inpatient Sample between 2000 and 2009 to assess the overall blood transfusion rate as well as trends in transfusion patterns over time and the patient and hospital characteristics that independently influenced the likelihood that a given patient undergoes allogeneic blood transfusion. They found that the overall blood transfusion rate (ie, the proportion of patients who received at least 1 transfusion of any kind) was 6.7%. This rate increased over time, from 4.9% in 2000 to 7.1% in 2009 (P < .001).

With respect to the 4 Ps, the risk of allogeneic blood transfusion was increased for patients over 85 years of age, women, non-white patients, patients with other than private insurance, patients with comorbidities and provider hospitals with low case loads and hospitals in the Northeast.

Comment: There are many factors that influence the use of blood transfusion. This study would have been stronger had a multivariate analysis been carried out to determine the most influential factors among those studied. However, other factors could not be identified in such a study, such as the individual surgeon's threshold for transfusion (?based on hematocrit or symptoms?), the time of surgery, the attention to hemostasis, the use of topical thrombin, the time of implementation of motion after surgery, the method of fixation of the components and many more. 

Our approach has been to attempt to minimize the use of blood so that it is saved for those whose life depends on it. We strive for short wound times and excellent hemostasis. We reserve transfusion for those patients with symptoms of anemia, such as orthostatic hypotension that does not respond to fluids, and for those at high risk for complications related to diminished arterial oxygenation.


Medical comorbidities and perioperative allogeneic red blood cell transfusion are risk factors for surgical site infection after shoulder arthroplasty

These authors sought to determine surgical site infection (SSI) risk due to medical comorbidities or blood transfusion after primary or revision shoulder arthroplasty. They collected data on medical comorbidities, surgical indication, perioperative transfusion, and SSI were obtained for 707 patients who underwent primary or revision hemiarthroplasty or total shoulder.

For the purpose of this study, SSI was defined in a rather particular manner:  either (1) treatment of a superficial infection within 30 days of surgery with débridement by the treating surgeon or with antibiotics by either the treating surgeon or an infectious disease specialist or (2) treatment of a suspected or confirmed deep infection by return to the operating room for débridement, component exchange, or explantation of components or treatment with therapeutic or long-term suppressive antibiotics by an infectious disease specialist. Positive cultures on return to the operating room were not a requirement for diagnosis of SSI.

Using this set of definitions, the SSI rate was 1.9% for primary hemiarthroplasties and 1.3% for primary total shoulder arthroplasties.

Revision arthroplasty or prior open reduction and internal fixation had higher SSI risk than primary arthroplasties (incidence risk ratio [IRR], 11.4; 95% confidence interval [CI], 3.84-34.0; P < .001).

Among primary arthroplasties, SSI risk factors included male gender (IRR, 60.0; CI, 4.39-819; P = .002), rheumatoid arthritis (IRR, 8.63; CI, 1.84-40.4; P = .006), and long-term corticosteroid use (IRR, 37.4; CI, 5.79-242; P < .001). 

Perioperative allogeneic red blood cell transfusion significantly increased SSI risk and was dose dependent (IRR, 1.68 per unit packed red blood cell; CI, 1.21-2.35; P = .002).

The culture results are shown below.

Comment: This series of cases points to the complex and uncertain relationship between cultures and clinical findings. Patients without the characteristic signs of infection can have positive cultures. Patients with characteristic signs of infection can have negative cultures.

The culture protocol used for these patients is not explained. Specifically, we do not know which cases were cultured, how many specimens were submitted for culture, what culture media were used, and how long the cultures were observed. It is known that unless 5 deep specimens are cultured on three different media and observed for 3 weeks, there is a substantial risk of overlooking Propionibacterium in the wound.

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The reader may also be interested in these posts:

Healing through joint replacement

Supporting progress in shoulder surgery

Consultation for those who live a distance away from Seattle.

Click here to see the new Shoulder Arthritis Book.

Click here to see the new Rotator Cuff Book

Information about shoulder exercises can be found at this link.

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

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What is an infection anyway?

Medical comorbidities and perioperative allogeneic red blood cell transfusion are risk factors for surgical site infection after shoulder arthroplasty

These authors sought to determine surgical site infection (SSI) risk due to medical comorbidities or blood transfusion after primary or revision shoulder arthroplasty. They collected data on medical comorbidities, surgical indication, perioperative transfusion, and SSI were obtained for 707 patients who underwent primary or revision hemiarthroplasty or total shoulder.

For the purpose of this study, SSI was defined in a rather particular manner:  either (1) treatment of a superficial infection within 30 days of surgery with débridement by the treating surgeon or with antibiotics by either the treating surgeon or an infectious disease specialist or (2) treatment of a suspected or confirmed deep infection by return to the operating room for débridement, component exchange, or explantation of components or treatment with therapeutic or long-term suppressive antibiotics by an infectious disease specialist. Positive cultures on return to the operating room were not a requirement for diagnosis of SSI.

Using this set of definitions, the SSI rate was 1.9% for primary hemiarthroplasties and 1.3% for primary total shoulder arthroplasties.

Revision arthroplasty or prior open reduction and internal fixation had higher SSI risk than primary arthroplasties (incidence risk ratio [IRR], 11.4; 95% confidence interval [CI], 3.84-34.0; P < .001).

Among primary arthroplasties, SSI risk factors included male gender (IRR, 60.0; CI, 4.39-819; P = .002), rheumatoid arthritis (IRR, 8.63; CI, 1.84-40.4; P = .006), and long-term corticosteroid use (IRR, 37.4; CI, 5.79-242; P < .001). 

Perioperative allogeneic red blood cell transfusion significantly increased SSI risk and was dose dependent (IRR, 1.68 per unit packed red blood cell; CI, 1.21-2.35; P = .002).

The culture results are shown below.

Comment: This series of cases points to the complex and uncertain relationship between cultures and clinical findings. Patients without the characteristic signs of infection can have positive cultures. Patients with characteristic signs of infection can have negative cultures.

The culture protocol used for these patients is not explained. Specifically, we do not know which cases were cultured, how many specimens were submitted for culture, what culture media were used, and how long the cultures were observed. It is known that unless 5 deep specimens are cultured on three different media and observed for 3 weeks, there is a substantial risk of overlooking Propionibacterium in the wound.

Here are some related posts:

Low-grade infections in nonarthroplasty shoulder surgery

These authors reviewed 35 patients presenting with suspected low-grade infection in which biopsy specimens taken at revision surgery. Patients presented with symptoms akin to resistant postoperative frozen shoulder (persistent pain and stiffness, unresponsive to usual treatments).

Positive cultures were identified in 21 cases (60.0%), of which 15 were male patients (71%). Of all patients with low-grade infection, half were male patients between 16 and 35 years of age.

Propionibacterium acnes and coagulase-negative staphylococcus were the most common organisms isolated (81.1% [n = 17] and 23.8% [n = 5], respectively).  The mean time from index surgery to diagnosis for P. acnes –positive cases was 1.2 years (60.3 weeks).

Not all patients with clinically suspected low-grade infections presentedwith positive microbiologic cultures, despite use of enhanced culture methods. The authors suggest that the suspect organisms may be nonculturable on routine culture media or that the suspect organism was in an area of the shoulder not sampled. Of 14 negative culture cases, 9 were treated with early empirical antibiotics (64.3%); 7 patients reported symptomatic improvement (77.8%). Of 5 patients treated with late empirical antibiotics, 4 stated improvement.  Again, the majority of the patients with negative cultures reported improvement in their pain, stiffness, and range of movement after early empirical antibiotic treatment (doxycycline and amoxicillin, n = 8 [88.9%]; gentamicin and teicoplanin, n = 1 [11.1%]). More than half of these patients (n = 6 [66.7%]) stated that their pain completely resolved

Comment: This series of cases points to the complex and uncertain relationship between cultures and clinical findings. Patients without the characteristic signs of infection can have positive cultures. Patients with negative cultures can respond to antibiotics.


For more, see the below:

What is a "periprosthetic shoulder infection"? A systematic review of two decades of publications.

These authors point out that while as many as 50% of revision shoulder arthroplasties are culture positive, a consistent, clinically useful definition of a "periprosthetic shoulder infection" is lacking. They conducted a systematic review of the published literature with respect to (1) the definition of a "periprosthetic shoulder infection", (2) the pre-operative evaluation for possible infection, and (3) the harvesting and culturing of specimens at the time of surgical revision.

They found a remarkable lack of consistency in the way different authors defined an 'infection', in the way authors evaluated patients with possible infections before surgery and in the way authors obtained and analyzed specimens obtained for culture harvested at the time of the surgical revision of failed shoulder joint replacements.

This inconsistency makes it very difficult to compare different treatment approaches to failed shoulder joint replacements, recognizing that some of them will have substantial bacteria in the joint, the presence of which may go unrecognized until the culture results are finalized at 2 to 3 weeks after surgery.

Comment: It is critically important not to combine, confuse or commingle data from 

"obvious infections" (i.e. those with swelling, redness, drainage, fever, chills, elevated serum markers of inflammation) where the diagnosis of infection is apparent 

with cases of 

"stealth" presentation (i.e. the unexplained onset of pain and stiffness of the shoulder after a 'honeymoon' of good function in which specimens obtained at revision surgery are strongly positive for organisms such as Propionibacterium).

Here's an example of a stealth presentation:

A 50 year old patient presented desiring a ream and run arthroplasty for severe glenohumeral arthritis

After surgery, the shoulder progressively regained comfort and function. Subsequently, however it started to become stiff and painful without obvious explanation. Eight years after his shoulder arthroplasty, the patient returned to the office with no clinical, laboratory, or radiographic evidence of infection.

A single stage revision was performed (soft tissue releases, prothesis exchange) without any evidence of inflammation, joint fluid, loosening, or osteolysis. Five explant and tissue cultures were sent. The patient was discharge on the yellow protocol  (Augmentin) (see this link)  until the results of the cultures were final.

The culture results were
Humeral head explant: 3+ Propionibacterium
Humeral stem explant: no growth
Collar membrane: 1+ Propionibacterium
Humeral periosteum: 1+ Propionibacterium
Joint capsule: no growth

At this point the red protocol (IV ceftriaxone) (see this link) was started and continued for 6 weeks followed by a 6 month course of Augmentin. The patient has a comfortable shoulder and has regained most of the lost shoulder motion.

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Consultation for those who live a distance away from Seattle.

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Information about shoulder exercises can be found at this link.

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

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Will I need a blood transfusion with my shoulder joint replacement arthroplasty?

Risk factors for blood transfusion after shoulder arthroplasty

The authors identified 1174 shoulder arthroplasties performed on 1081 patients. Of these, 53 (4.5%) required transfusion post-operatively. Patients typically underwent transfusion if they had a level of haemoglobin of < 7.5 g/dl if asymptomatic, < 9.0 g/dl if they had a significant cardiac history or symptoms of dizziness or light headedness.

Predictors of blood transfusion were a lower pre-operative haematocrit (p < 0.001) and shoulder arthroplasty undertaken for post-traumatic arthritis (p < 0.001). ROC analysis identified pre-operative haematocrit of 39.6% as a 90% sensitivity cut-off for transfusion. In total 48 of the 436 (11%) shoulder arthroplasties with a pre-operative haematocrit < 39.6% needed transfusion compared with five of the 738 (0.70%) shoulder arthroplasties with a haematocrit above this level.

Comment: While we agree with these authors' threshold for transfusion, in our practice it is very rare for patients to need a transfusion after shoulder arthroplasty, even though many have preoperative hematocrits in the 32-39% range. Our preoperative blood loss is typically in the 250 cc range.

There has been concern about the increased risk of infection with blood transfusions and shown in this link. Information about the trends in transfusion after shoulder arthroplasty is given in this link.

New strategies for minimizing preoperative blood loss are described in this link.

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Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

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Total shoulder arthroplasty - the role of topical tranexamic acid in reducing blood loss

A randomized, prospective evaluation on the effectiveness of tranexamic acid in reducing blood loss after total shoulder arthroplasty

Tranexamic acid (TXA) is an antifibrinolytic agent that has been shown to significantly reduce blood loss and transfusion requirements after total knee and hip arthroplasty. These authors evaluated the effect of TXA on postoperative blood loss after shoulder arthroplasty in 111 patients (62 women; average age, 67 years) who underwent shoulder arthroplasty. 

Patients discontinued the use of aspirin and nonsteroidal antiinflammatory medications 7 days before surgery. Exclusion criteria for this study were revision surgery, history of cardiac disease, liver disease, renal disease, preoperative hemoglobin level <11.5 g/dL or hematocrit <35%, severe joint deformity, history of joint infection, history of bleeding or metabolic disorder, history of peripheral vascular disease, history of prior deep venous thrombosis (DVT) or pulmonary embolism (PE), any patient unwilling to accept a blood transfusion, and any patient with a documented allergy to TXA.

Patients were prospectively randomized in double-blinded fashion to receive either 100 mL of normal saline or 100 mL of normal saline with 2 g TXA by topical application. Before closure of the deltopectoral interval, each patient in the treatment group had 100 mL of normal saline infused with 2 g of TXA poured into the surgical wound and left in place for 5 minutes. The control group had 100 mL of normal saline poured into the wound and left in place for the same duration. Neither the patient nor the surgeon had knowledge of whether TXA solution or placebo was being administered, and this blinding remained in place until analysis of data at completion of the study. Before closure of the deltopectoral interval, a standard Hemovac drain was placed deep to the deltoid muscle. The estimated blood loss (EBL) for the procedure was determined at this point, and all additional blood loss through the drain was recorded for the purposes of the study.

The average blood loss recorded after surgery was 170 mL in the placebo group and 108 mL in the TXA group (P ..017). The average change in hemoglobin level was 2.6 g/dL in the placebo group and 1.7 g/dL in the TXA group (P < .001). There were no transfusion requirements or postoperative complications noted in either group.

Comment: This is a well-done randomized and carefully controlled trial.  The goal of reducing blood loss in shoulder arthroplasty is not so much to reduce the need for transfusion, but to minimize the local swelling/hematoma that can result from a surgery that involves soft tissue releases, osteotomy, and osteophyte resection. The local accumulation of blood can increase the patient's discomfort and can interfere with early range of motion exercises.

The protocol used here is the  topical application of TXA for 5 minutes near the end of the procedure.  Alternatively, TXA can be administered intravenously with a gram at the beginning and a gram at the end of the case. While there is a theoretical risk of thromboembolic events when intravenous TXA is
given because of its antifibrinolytic properties; a number of lower extremity arthroplasty studies have not demonstrated an increased incidence of these events.

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Consultation for those who live a distance away from Seattle.

Check out the new Shoulder Arthritis Book - click here.

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Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

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Shoulder joint replacement arthroplasty - blood transfusion- the 4 Ps

Blood transfusion in primary total shoulder arthroplasty: incidence, trends, and risk factors in the United States from 2000 to 2009.

These authors used the National Inpatient Sample between 2000 and 2009 to assess the overall blood transfusion rate as well as trends in transfusion patterns over time and the patient and hospital characteristics that independently influenced the likelihood that a given patient undergoes allogeneic blood transfusion. They found that the overall blood transfusion rate (ie, the proportion of patients who received at least 1 transfusion of any kind) was 6.7%. This rate increased over time, from 4.9% in 2000 to 7.1% in 2009 (P < .001).

With respect to the 4 Ps, the risk of allogeneic blood transfusion was increased for patients over 85 years of age, women, non-white patients, patients with other than private insurance, patients with comorbidities and provider hospitals with low case loads and hospitals in the Northeast.

Comment: There are many factors that influence the use of blood transfusion. This study would have been stronger had a multivariate analysis been carried out to determine the most influential factors among those studied. However, other factors could not be identified in such a study, such as the individual surgeon's threshold for transfusion (?based on hematocrit or symptoms?), the time of surgery, the attention to hemostasis, the use of topical thrombin, the time of implementation of motion after surgery, the method of fixation of the components and many more. 

Our approach has been to attempt to minimize the use of blood so that it is saved for those whose life depends on it. We strive for short wound times and excellent hemostasis. We reserve transfusion for those patients with symptoms of anemia, such as orthostatic hypotension that does not respond to fluids, and for those at high risk for complications related to diminished arterial oxygenation.

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Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

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Blood transfusion - the risk of infection - a game changer

Health Care–Associated Infection After Red Blood Cell TransfusionA Systematic Review and Meta-analysis

Confession: We used to insist on a 'good solid hemoglobin' before our patients were discharged because of fear of syncope and increased risk of infection and poor wound healing.

These authors challenged that practice by studying the association between red blood cell transfusion strategies and health care–associated infection.

They performed a meta-analysis of 21 randomized trials comparing restrictive vs liberal transfusion strategies (8735 patients). Most trials define a restrictive transfusion strategy as the administration of red blood cells once hemoglobin falls below either 7 or 8 g/dL, and most trials define a liberal strategy as transfusion once hemoglobin level falls below 10 g/dL.

They found that the pooled risk of all serious infections was 11.8% (95% CI, 7.0%-16.7%) in the restrictive group and 16.9% (95% CI, 8.9%-25.4%) in the liberal group. The risk ratio (RR) for the association between transfusion strategies and serious infection was 0.82 (95% CI, 0.72-0.95) with little heterogeneity.

With stratification by patient type, the RR was 0.70 (95% CI, 0.54-0.91) in patients undergoing orthopedic surgery. There were no significant differences in the incidence of infection by RBC threshold for patients with cardiac disease, the critically ill, those with acute upper gastrointestinal bleeding, or for infants with low birth weight.

They concluded that among hospitalized patients, a restrictive transfusion strategy was associated with a reduced risk of health care–associated infection compared with a liberal transfusion strategy. 

Comment: This article has changed our practice to a restrictive transfusion strategy unless there are overriding reasons to be more liberal.

A very nice discussion of this paper can be found here. In this discussion the point is made that the ideal  threshold for transfusion has yet to be determined.

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Transfusion and revision arthroplasty

The incidence and risk factors for blood transfusion in revision shoulder arthroplasty: our institution’sexperience and review of the literature

The authors reviewed 566 consecutive revision shoulder procedures and found that 11.3% of patients required a transfusion. The transfusion rate was associated with age, operative time (5 hours vs >5 hours). diabetes, low preoperative hemoglobin level, and surgery on humeral component.

A previous study from the same institution found an 8.1% transfusion rate after primary shoulder arthroplasty, with a higher incidence of transfusion among women, patients with a lower preoperative
hemoglobin level and a preoperative diagnosis of sequelae of trauma or rheumatoid arthritis.

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**Check out the new Shoulder Arthritis Book - click here.**

Use the "Search" box to the right to find other topics of interest to you.

You may be interested in some of our most visited web pages including:shoulder arthritis, total shoulder, ream and run, reverse total shoulder, CTA arthroplasty, and rotator cuff surgery as well as the 'ream and run essentials'

See from which cities our patients come.

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