Is total hip arthroplasty a successful and safe procedure in Jehovah’s Witnesses? Mean five-year results Steven F. Harwin, Robert Pivec, Qais Naziri, Kimona Issa, Michael A. Mont Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland - USA
Total hip arthroplasty (THA) can be challenging in Jehovah’s Witnesses because of the potential for blood loss. Because these patients will not accept blood transfusions, multiple strategies to prevent blood loss have been developed. The purpose of this study was to report implant survivorship, clinical outcomes, radiographic outcomes, morbidity, and mortality of Jehovah’s Witnesses undergoing primary THA. Databases from two institutions were reviewed to identify 53 patients (55 hips) who were Jehovah’s Witnesses and had a primary total hip arthroplasty. There were 27 women and 26 men who had a mean age of 63 years (range 35-94 years), and a mean follow-up of 63 months (range 24-120 months). All Jehovah’s Witnesses had a comprehensive perioperative blood management strategy employed by a coordinated medical and surgical team. Mean post-operative Harris Hip Scores were 86 points, and implant survivorship was 97%. There were two aseptic revisions for osteolysis and component loosening. There were no mortalities, and three minor surgical and two minor medical complications occurred during the study. Excellent clinical outcomes were found for Jehovah’s Witness undergoing total hip arthroplasty using a comprehensive blood management protocol. We believe that the use of a specialised blood management protocol involving a team approach to preoperative evaluation, appropriate anaesthesia, and surgical and postoperative management was responsible for minimising complications. Total hip arthroplasty is safe and efficacious in this patient group if proper preoperative safeguards are utilised. Keywords: Total hip arthroplasty, Blood management, Jehovah's Witness, Anaemia, Bleeding, Blood loss Accepted: August 22, 2013
INTRODUCTION Total hip arthroplasty (THA) has been an effective procedure leading to long-term pain relief and improved function in patients who have degenerative joint disease (1-3). Reported morbidity and mortality rates have been low (4); however, major bleeding complications and perioperative anaemia may require autologous blood transfusion (5-9). The incidence of preoperative anaemia alone has been reported to be as high as 44% (range 24-44%) of THAs in
a systematic review of the literature by Spahn et al (10). Additionally, preoperative anaemia and low body mass index (BMI) have both been identified as independent predictors for blood transfusion, and blood loss during total hip arthroplasty may average between 750 and 1,000 mL (11, 12). Anaemia negatively impacts length of stay, patient function during rehabilitation, and patient mortality (10, 13). Transfusions carry well known risks, including infection and fatal anaphylaxis, which are important factors to consider given that patients who are transfused receive, on
average, two units of blood, and that the transfusion rate has been reported to be as high as 45% (7, 14-16). Jehovah’s Witnesses are well known to the medical community for their opposition to receiving blood transfusions. Since these patients do not have this treatment option available for them, there has been interest in using “bloodless surgery” for elective and non-elective procedures (17). Methods that have been described in the literature include pre-treatment with erythropoietin (18), preoperative haemodilution with intraoperative blood salvage (16), surgical techniques such as gentle soft tissue handling and meticulous haemostasis (7), bipolar sealers (19, 20), intravascular occlusion (21), haemostatic agents (22), and early removal of drains (8, 23). However, the preponderance of the literature investigating clinical outcomes of THA in Jehovah’s Witnesses was published over two decades ago, and the few studies that enrolled large numbers of patients focused on the perioperative period rather than long-term follow-up (9, 18, 21, 24-28). To the best of our knowledge, there is no study of this patient population that has investigated implant survivorship, mid-term clinical outcomes, and mortality following primary THA in the setting of a comprehensive blood management strategy. Because of the paucity of recent data regarding Jehovah’s Witnesses who have had THAs, we studied a group of patients to determine: 1) implant survivorship; 2) mid-term clinical outcomes; 3) complications; and 4) radiographic outcomes of patients who self-identified as Jehovah’s Witnesses. These results were compared to a matched nonJehovah’s Witness group.
TABLE I - DEMOGRAPHIC AND OUTCOME DATA Jehovah’s Witness
Number of Patients
Number of Hips
63 (range 35-94)
62 (range 35-92)
p = 0.41
Body mass index (kg/m2)
32 (range 24-52)
32 (range 21-52)
p = 0.52
Mean follow-up (months)
63 (range 24-120)
60 (range 24-113)
p = 0.19
p = 0.53
p = 0.69
p = 0.98
p = 0.55
p = 0.05
p = 0.85
p = 0.85
p = 0.75
METHODS Fifty-three patients (55 THAs) were performed by two highvolume fellowship-trained surgeons between 1998 and 2009 in patients who identified themselves as Jehovah’s Witnesses. There were 26 men and 27 women who had a mean age of 63 years (range 35-94 years); the mean follow-up was 63 months (range 24-120 months). No patients were lost to follow-up. Institutional review board approval was obtained for this study at both institutions. Patients were included in the study group if they identified themselves as a Jehovah’s Witness. Exclusion criteria included patients who did not identify themselves as Jehovah’s Witnesses, patients who consented to receive a blood transfusion during their hospitalisation, and patients younger than 18 years. 70
All patients were matched by age (within three years), gender, body-mass index (BMI) (within 5 kg/m2), length of follow-up (within 12 months), surgeon, and procedure (unilateral versus bilateral) to a group of patients who underwent primary THA and who did not self-identify as Jehovah’s Witnesses. In the matching group, there were 26 men and 27 women who had a mean age of 62 years (range 35-92 years), a mean BMI of 32 kg/m2 (range 21-52), and a mean follow-up time of 60 months (range 24-113 months) (Tab. I). No patients in the matched group were lost to follow-up. Jehovah’s Witnesses were treated with a comprehensive perioperative blood management protocol, which was based on their preoperative haemoglobin level (Fig. 1). However, non-Jehovah’s Witnesses in the matching group
Fig. 1 - Perioperative blood management strategies used for Jehovah’s Witness patients. Dosages utilised: EPO (600 u/kg IV per week for 21 days) and iron (25-100 mg IV daily) which is calculated as [dose = 0.0442 * (desired Hb – observed Hb) * LBW + (0.26 * LBW)] where LBW is lean body weight. All patients also receive folate (1000 mg PO daily) and iron supplementation (325 mg PO daily). * Pre-donation is not accepted by Jehovah’s Witnesses. PO = per os; IV = intravenous; DVT = deep venous thrombosis; LBW = lean body weight; EPO = erythropoietin; ANH = acute normovolemic haemodilution; EBL = estimated blood loss.
were managed using this protocol since all these patients agreed to blood transfusions, if necessary. Preoperatively, all patients were evaluated medically, and if necessary, Jehovah’s Witnesses were optimised with erythropoietin, iron, and folate if their initial Hb was 12 g/dL or less (described below). Evaluation consisted of standard history and physical examination as well as assessment of estimate intraoperative blood loss, with patients stratified as either high-risk or low-risk. Factors which placed patients in the high-risk category include poorly controlled systemic disease (e.g. insulin-dependent diabetes, symptomatic congestive heart failure, angina, chronic renal failure) or higher expected intraoperative blood loss (e.g. morbid obesity; BMI>40 kg/m2). There were a total of five Jehovah’s
Witness patients (9%) who were in the high-risk category, and only one patient required EPO due to a preoperative haemoglobin of 11.1 g/dL. Preoperatively, patients were evaluated medically, and if necessary, optimised with erythropoietin (600 units/ kg/week intravenously for 21 days prior to surgery), iron (325 mg orally daily; if iron deficiency anaemia was present, then 325 mg orally three times a day or 25-100 mg IV daily if Hb11 g/dL
Bourantas et al. (2000) (37)
54 (46-58 years)
Preoperative erythropoietin (10,000 IU 3 times a week for 3 weeks)
Panousis et al. (2003) (24)
Preoperative erythropoietin (600 IU/kg onceweekly for 4 weeks), hypotensive anaesthesia
Mangar et al. (2011) (21)
Occlusion of left external iliac artery with arterial balloon; 20 mL blood loss
63 (35-94 years)
Preoperative erythropoietin, iron, and folate. Hypotensive anaesthesia and Cell Saver.
*NR - not reported. † Includes two patients undergoing revision total hip arthroplasty; mortality occurred during primary total hip arthroplasty.
Wingard reported a successful conversion to a total hip arthroplasty from a Girdlestone arthroplasty in a 78-yearold healthy woman utilising hypotensive anaesthesia and treatment with iron supplementation. At two months follow-up, the authors reported that the patient had no complaints and was ambulating with a cane (28). Panousis et al reported the case of a 55-year-old Jehovah’s Witnesses with rheumatoid arthritis who underwent staged bilateral total hip and knee arthroplasty. The authors reported satisfactory clinical results at one-year follow-up, but did not provide any objective outcome measures (24). Similar results have also been observed in case reports by Rab et al, Cunningham, Bouranatas et al, and Mangar et al (21, 26, 27, 37). Numerous other surgical specialties have reported similarly successful outcomes in Jehovah’s Witnesses following major tumour (38), obstetric and gynecologic (39, 40) cardiac (41, 42) abdominal (43, 44), vascular (45, 46) and transplant surgeries (47). The growing consensus demonstrates favorable results and low mortality following “transfusion-free” surgeries as long as proper pre- and intraoperative strategies are employed to minimise complications. Elective primary THA can be safely performed in Jehovah’s Witnesses who have declined to receive blood transfusions. The care of these patients can be challenging, and requires a multi-disciplinary, team-based approach. Proper
preoperative planning should be done to optimise the patient medically. Physicians should have a clearly defined protocol for pre-, intra-, and postoperative management in place. In at-risk patients who have multiple medical comorbidities, the potential complications, including prolonged hospitalisation and death, must be clearly explained to the patient prior to surgery. Physicians should council patients who are Jehovah’s Witnesses that, although THA is an effective procedure to help restore function, there remain marked risks to be considered. However, patients should also be made aware that several blood management options exist that are not in conflict with their beliefs, and that though careful planning, the majority of patients have excellent functional outcomes with little, if any, increased chance for perioperative morbidity or mortality. Financial Support: None. Conflict of Interest: None. Address for correspondence: Michael A. Mont, MD Rubin Institute for Advanced Orthopedics Center for Joint Preservation and Replacement Sinai Hospital of Baltimore 2401 West Belvedere Avenue Baltimore, Maryland 21215, USA [email protected]
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