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The efficacy of autologous blood transfusion in primary Total Hip Arthroplasty

A R Guha, S Mukhopadhyay, A McMurtrie, R Kulshreshtha, S L Karlakki

1Department of Orthopaedics, Wrexham Maelor Hospital
2Department of Orthopaedics, Robert Jones and Agnes Hunt Orthopaedic Hospital, U.K.
3University Hospital of Wales, Cardiff,U.K.

Address for Correspondence:
Department of orthopaedics,
University Hospital of Wales
Cardiff, CF14 4XW

++44 7828652404


The use of Autologous blood transfusion (ABT) has been recommended in primary total knee arthroplasty and also in revision hip arthroplasty. Currently, however, no guidelines exist regarding its use in primary total hip arthroplasty (THA).

The purpose of this study was to assess whether the use of ABT in primary THA reduced the overall rate of allogeneic transfusion.

We prospectively reviewed 80 patients who underwent primary THA with ABT between June 2005 and January 2007 (study group). 33 patients who underwent primary THA without ABT during the same period were used as controls. All patients were operated on by the senior author (SLK). We compared the pre-op and post-op haemoglobin and PCV, intra and post operative blood loss, volume of blood re-transfused using the ABT system and volume of allogeneic blood transfused in both groups.

A significantly higher number of patients received allogeneic blood transfusion in the control Group (45.5%) compared to patients in the study group (27.5 %) p<0.03. The mean volume of allogeneic blood transfused per person in the study group was 0.65 units (195mls) compared to 0.82 units (245mls) in the control group.

Of the 80 patients in the study group, 34 had autologous blood transfused. The mean volume transfused in these 34 patients was 309.26 mls which equated to a mean of 131.44 mls of autologous blood transfused per person in the study group. There was no significant difference in the mean drop in Hb or PCV, immediately post op or at discharge between the two groups.

Our study suggests that the use of autologous blood transfusion reduces the requirement of allogeneic blood transfusion in primary THA.

J.Orthopaedics 2009;6(3)e12


Primary hip replacement; autologous blood transfusion


Salvage of blood following surgery and reinfusion has been shown to reduce the need for allogeneic blood transfusion in several studies.( 1,2,3  ) There are many recognised complications following allogeneic blood transfusion including disease transmission, transfusion reactions and immunomodulation.(1,2) Reduction in infections after orthopaedic procedures has been associated with the avoidance of allogeneic transfusion.(4) Although the implementation of blood screening measures have greatly reduced the risk of transmission of blood borne infection, this still remains a major concern. Current options for blood management in Orthopaedic procedures include good anaesthetic and operative technique, preoperative autologous blood donation, intraoperative and postoperative blood salvage, acute normovolemic haemodilution, unit by unit allogeneic blood transfusion and pharmacologic interventions eg Epoetin alfa, Tranexamic acid and Aprotinin.(1,3) Nonetheless, recent studies have reported an allogeneic blood transfusion rate of 39% -57% following joint replacement surgery.(6,7) Autologous drains are increasingly used in total knee arthroplasty (TKA) and guidelines issued by the British Orthopaedic Association recommend their use.(5) Currently, however, no guidelines exist in the UK regarding the use of autologous drains in primary Total Hip Arthroplasty (THA).

We have been using autologous drains in all patients undergoing primary THA since January 2006. The aim of this study was to evaluate the efficacy of autologous drains in primary THAs. We assessed whether a reasonable volume of blood was collected for re-infusion in a sufficient number of patients and whether this resulted in an overall reduction in allogeneic transfusion requirements.

Materials and Methods:

All primary THAs carried out for Osteoarthritis of the hip by the senior author between June 2005 and January 2007 were included in the study. 13 patients in whom a complete data set was not available were excluded. Data for the study group was collected prospectively and comparison made with a control group. All patients in the control group underwent THA without the use of ABT. All procedures were carried out under general anaesthetic by the senior author or under his direct supervision. The posterior approach was used in all cases with the patient in the lateral position. The same standard peri-operative regimen was used throughout. All patients received aspirin 150mg post operatively for six weeks as thrombo-embolic prophylaxis (unless there was a specific contraindication to aspirin). IRB/Ethics Committee approval was not required for this study.

Between June 2005 and January 2006, 33 patients received a standard deep drain. These patients formed the Control group. The standard drainage system used was the Bellovac low-vacuum drain (Astra Tech, Gloucester), referred to as ‘normal drains’ throughout the rest of this paper. Since January 2006, 80 consecutive patients had a single autologous drain lying deep to the fascia lata. These patients formed the Study group. The autologous drainage system used was the Bellovac A.B.T (Astra Tech). These are referred to as ‘autologous drains’ throughout the rest of this paper. Blood drained in the first 6 hours was re-infused. After six hours the drain continued to function as a ‘normal drain’. All drains were removed within 24 hours following surgery.

The criteria for allogeneic blood transfusion was determined according to the protocol established by the hospital transfusion committee and it remained constant throughout the study. Only symptomatic patients with haemoglobin less than 8.0 g/dl received allogeneic blood transfusion. The decision to transfuse was made in conjunction with the senior author (SLK).

The patients’ case notes, and electronic patient records were reviewed. The volume of blood drained, volume of autologous blood re-infused, volume of allogeneic blood transfused, pre and post operative haemoglobin, packed cell volume (PCV), length of hospital stay, age, sex, and ASA grade was reviewed in all patients in both groups.

Statistical analysis was carried out using the SPSS version 11 statistical package (SPSS, Chicago, IL, USA).  Independent samples t test was used to assess the difference between the preoperative and postoperative haemoglobin and PCV. The z-test was used to compare the volume of allogeneic blood transfused and the chi-squared test to compare the transfusion rates between each group.

Results :

A total of 113 patients were reviewed. 80 patients in the study group had an autologous drain while 33 patients in the control group had the ‘normal drain’. All patients had osteoarthritis of the hip. The patient characteristics in both groups were    matched (Table 1).


Study group

Control group


80 (33M,47F)

33 (8M, 25F)

Mean age

68.8 (45 – 87)

66.4 (51 – 81)

Mean ASA

1.95 (1 – 3)


1.88 (1 – 3)

Pre-operative Haemoglobin

13.5 (8.0–15.8)

13.5 (9.9–15.6)

Table 1: Patient characteristics of the two groups

There was no significant difference when comparing the pre-op haemoglobin and the haemoglobin on discharge in both groups. There was no significant difference in the immediate postoperative PCV in either group, thus peri-operative haemodilution was comparable in both groups. Length of stay was similar in both groups as well.

There was no significant difference in the mean volume of blood drained in both groups (205ml in the study group, 209 ml in the control group). The mean volume of allogeneic blood transfused per person in the study group was 195ml compared to 245ml in the control group (Table 2).


Study group

(n = 80)


Control group

(n = 33)

Mean vol. drained (mls) [range]


205 (10-1200)

209 (60 – 1050)

Mean allogeneic transfusion

(mls per patient) [range]

195 (0 – 1500)

245 (0 – 1200)

Table 2: Drainage and transfusion in the two groups

This difference of 50 mls per person was however, not statistically significant (Graph-1).

Graph 1: Curve fit model (regression analysis) shows no significant difference

26.3% (21/80) of patients in the autologous drain group required allogeneic blood transfusion while 45.5% (15/33) of those in the normal drain group required allogeneic blood transfusion. This was statistically significant (p<0.03) {z-test of proportions}.

The mean volume of drainage in the THAs with uncemented implants was significantly higher than in the THAs using cemented implants.(p<0.03)(Table 3)



Study Group


Control Group

Number of patients

Mean Volume Drained (mls)

Number of patients

Mean Volume Drained (mls)

Cemented Implants



Range (0 - 500)




Range (0 – 460)

Uncemented Implants




Range (0 – 1200)




Range (0 – 1050)





Range ( 0 – 540)



Range (0 – 820)

p value





Table 3: Drainage in Cemented vs. Uncemented implants

In the autologous drain group, 34/80 (42.5%) had some autologous blood reinfused. The mean volume of autologous blood reinfused in this group was 309ml per person (range 100-1100ml). 46 patients in the study group did not have any autologous blood reinfused. In 43 cases this was due to an insufficient volume (<100ml) of blood drained within the stipulated time of six hours. In the remaining 3 cases the documentation was incomplete and consequently the autologous blood collected had to be discarded. The volume of blood re-infused using the autologous drainage system is shown in Figure 1.

Figure 1:Volume of blood re-infused (ABT) in study group

The allogeneic blood transfusion requirements in each group are shown in Figures 2a and 2b.

Figure 2a:Volume of allogeneic blood transfused in Study group

Figure 2b:Volume of Allogeneic blood transfused in Control group


Arthroplasty surgery is associated with significant blood loss and allogeneic blood transfusion is required in many cases. Despite numerous advances in operative technique and peri-operative pharmacological interventions, blood loss in primary hip and knee arthroplasty may be considerable. In the UK, 10% of allogeneic blood is used by orthopaedic patients and 40% of this by patients undergoing hip and knee arthroplasty.(11) The ultimate goal of blood management by Orthopaedic surgeons is to eliminate the need for allogeneic blood transfusion.(13) Postoperative blood salvage using autologous re-infusion drains have been shown to reduce allogeneic transfusion requirements in total knee arthroplasty by 86% (9) with obvious economic and clinical benefits. Allogeneic blood transfusion has been reported to be associated with a five fold increase in inpatient infection rates (12) and increase in the length of hospital stay (9). In TKA the mean total blood loss ranges from 520-1600ml almost all of which occurs postoperatively, following release of the tourniquet. In comparison the mean total blood loss in THA has been reported to be between 550-2200ml, approximately half of which is lost post-operatively.

Slagis et al have reported that postoperative blood salvage was not economically justified in THAs. (2) However, they used a washed cell salvage system which resulted in significant costs. Keating et al have reported that blood salvage was not cost effective in THA because not enough blood was collected post operatively. (11) Our study has shown that a mean volume of blood of 309ml was collected for re-infusion in almost half of our patients. This has resulted in a significant reduction in the incidence of allogeneic blood transfusion. Some authors have reported side effects including hypotension, hyperthermia and febrile reactions to the transfusion of unwashed, filtered salvaged blood.(15) In our study we did not encounter any adverse reactions to the autologous blood transfusion.

Sturdee et al have recently reviewed their use of autologous drains in primary THAs and concluded that they should be used. (11) Our results would support their findings.

In the recent past un-cemented implants have been increasingly used for primary THA in the UK and this popular trend is reflected in our study. We have shown a significant increase in the volume of blood drained in un-cemented THAs as compared to cemented THAs and this would further justify the usage of ABT drains in patients undergoing primary THA using un-cemented implants.

The routine use of surgical drains in total hip arthroplasty (THA) remains controversial (4) Ritter et al reported no difference in transfusion rate or haemoglobin decrease between patients with or without drains in THA.(15) Nonetheless, in the UK, drains are widely used following primary THA. We recommend that if a drain is to be used, then an autologous drainage system should be considered in preference to a ‘normal’ drain, especially if un-cemented implants are being implanted.


We are grateful to Mr J. Turner, Statistician, Cardiff University, for his help with statistical analyses.


  1. Majkowski RS, Currie IC, Newman JH. Postoperative collection and reinfusion of autologous blood in total knee arthroplasty. Ann R Coll Surg Engl 1991; 73:381-4.

  2. Slagis SV, Benjamin JB, Volz RG, Giordano GF. Postoperative blood salvage in total hip and knee arthroplasty: A randomised controlled trial. J Bone Joint Surg(Br) 1991;73:591-4.

  3. Dalen T, Skak S, Thorsen K, Fredin H. The efficacy and safety of blood reinfusion in avoiding homologous transfusion after Total Knee Arthroplasty. American Journal of Knee Surgery 1996;9(3):117-120.

  4. Faris PM, Ritter MA, Keating EM, Valeri CR. Unwashed filtered shed blood collected after hip and knee arthroplasties. J. Bone Joint Surg (A) 1991; 73-A: 1169-78.

  5. Walmsley PJ, Kelly MB, Hill RN, Brenkel I. A prospective, randomised,       controlled trial of the use of drains in total hip arthroplasty. J Bone Joint Surg (Br) 2005; 87-B(10): 1397-1401.

  6. Blood Conservation in elective orthopaedic surgery: British Orthopaedic Association, April 2005.

  7. Bierbaum BE, Callaghan JJ, Galante JO. An analysis of blood management inpatients having a total hip or knee arthroplasty. J Bone Joint Surg (Am) 1999;81-A:2-10.

  8. Hatzidakis AM, Mendlick RM, McKillip T. Preoperative autologous donationfor total joint arthroplasty. J Bone Joint Surg (Am) 2000; 82-A:89-100.

  9. Newman JH, Bowers M, Murphy J. The Clinical advantages of Autologous Transfusion A randomised controlled study after knee replacement. J Bone  Joint Surg (Br)1997; 79-B(4): 630-32.

  10. Keating EM, Ritter MA. Transfusion options in total joint arthroplasty. J Arthroplasty 2002; 17: 125-8.

  11. Sturdee SW, Beard DJ, Nandhara G, Sonanis SV. Decreasing the blood transfusion rate in elective hip replacement surgery using an autologous drainage system. Ann R Coll Surg Engl 2007;89:136-139

  12. Triulzi DJ, Vanek K, Ryan DH, Blumberg N. A Clinical and immunologic study of blood transfusion and postoperative bacterial infection in spinal surgery. Transfusion 1992; 32(6): 517-524

  13. Keating EM. Current options and approaches for blood management in orthopaedic surgery. An instructional course lecture. J Bone Joint Surg 1998; 80-A (5): 750-762.

  14. Ritter MA, Keating EM, Faris PM. Closed wound drainage in total hip or knee replacement. A prospective randomised study. J Bone Joint Surg Am 1994; 76:35-8

  15. Blevins FT, Shaw B, Valeri CR, Kasser J, Hall J. Reinfusion of shed blood after orthopaedic procedures in children and adolescents J Bone Joint Surg(Am) 1993; 75: 363-71.alysis) shows no significant difference.

This is a peer reviewed paper 

Please cite as: S.Mukhopadhyay: The efficacy of autologous blood transfusion in primary Total Hip Arthroplasty

J.Orthopaedics 2009;6(3)e12





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