Use of a fibrin sealant within a blood-saving protocol in patients undergoing revision hip arthroplasty: effects on post-operative blood transfusion and healthcare-related cost analysis

  • Marco Scardino
  • Federica Martorelli
  • Tiziana D’Amato
  • Giorgia Fenocchio
  • Vincenzo Simili
  • Guido Grappiolo
  • Berardo Di MatteoEmail author
  • Elizaveta Kon
  • Michele Lagioia
Original Paper



Blood transfusion and blood management are important aspects in orthopaedic surgery. Strategies include intra-operative and post-operative blood salvage and even the use of fibrin sealant in selected case. Objectives of the study were (1) to compare the total number of transfusions and the length of hospital stay in patients undergoing complete revision hip arthroplasty (RHA) with and without the use of a fibrin sealant (EVICEL®) and (2) to evaluate the possible role in cost savings of EVICEL® in association with the blood-saving protocol.


Retrospective observational study evaluating patients undergoing complete RHA (stem + cup) with a blood-saving protocol with (n = 50) and without EVICEL® (n = 60). The outcome measures were: number of patients transfused (allogeneic red blood cells—RBC—and plasma), amount of blood/plasma transfusions, quantity of re-infused recycled blood, and length of hospital stay. An economic model was developed to assess the differences in costs between the two groups.


EVICEL® reduced the number of transfused red blood cells and plasma (p < 0.001), and the hospital stay (p = 0.01) compared to control group. EVICEL® can induce a reduction in resource consumption with an average cost-savings of €1.676 per patient.


EVICEL® may be effective in reducing red blood cells and plasma transfusion as well as hospital stay. The inclusion of EVICEL® in a blood-saving protocol seems to produce clinical efficacy and cost savings.


Total hip arthroplasty Revision Blood management Transfusion Fibrin sealant Evicel 



America Society of Anesthesiologists


Body mass index


Good clinical practice




Hepatitis C virus


Pound per square inch


Revision hip arthroplasty


Total knee replacement


Red blood cells


Range of motion


Compliance with ethical standards

The study protocol was notified to Humanitas Research Hospital (ICH) Ethical Committee. During the study, the data were collected in complete anonymity and handled according to the local law on privacy. The ICH blood management protocol is compliant with the Declaration of Helsinki, to standards EN ISO 14155:1, EN ISO 14155:2 and Good Clinical Practices (GCP). Moreover, all personnel involved in the study agreed to act in accordance with the principles contained in these GCPs.

Disclosure statement

All the authors of the present manuscript have nothing to disclose.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.


  1. 1.
    Bierbaum BE, Callaghan JJ, Galante O, Rubash HE, Tooms RE, Welch RB (1999) An analysis of blood management in patients having a total hip or knee arthroplasty. J Bone Joint Surg Am 81:2–10CrossRefGoogle Scholar
  2. 2.
    Bong MR, Patel V, Chang E, Issack PS, Hebert R, Di Cesare PE (2004) Risks associated with blood trasfusion after total knee arthroplasty. J Arthroplast 19:281–287. CrossRefGoogle Scholar
  3. 3.
    Sehat K, Evans R, Newman J (2000) How much blood is really lost in total knee arthroplastic? Correct blood loss management should take hidden loss into account. Knee 7:151–155. CrossRefGoogle Scholar
  4. 4.
    Spahn DR (2010) Anemia and patient blood management in hip and knee surgery: a systematic review of the literature. Anesthesiology 113:482–495. CrossRefGoogle Scholar
  5. 5.
    Husted H, Holm G, Jacobsen S (2008) Predictor of length of stay and patient satisfaction after hip and knee replacement surgery: fast-track experience in 712 patients. Acta Orthop 79:168–173. CrossRefGoogle Scholar
  6. 6.
    Lemaire R (2008) Strategies for blood management in orthopaedic and trauma surgery. J Bone Joint Surg (Br) 90:1128–1136. CrossRefGoogle Scholar
  7. 7.
    Musallam KM, Tamim HM, Richards T, Spahn DR, Rosendaal FR, Habbal A, Khreiss M, Dahdaleh FS, Khavandi K, Sfeir PM, Soweid A, Hoballah JJ, Taher AT, Jamali FR (2011) Preoperative anaemia and postoperative outcomes in non-cardiac surgery: a retrospective cohort study. Lancet 378:1369–1407. CrossRefGoogle Scholar
  8. 8.
    Borghi B, Casati A (2000) Incidence and risk factors for allogenic blood transfusion during major joint replacement using an integrated autotransfusion regimen. The Rizzoli Study Group on Orthopaedic Anaesthesia. Eur J Anaesthesiol 17:411–417. CrossRefGoogle Scholar
  9. 9.
    Villatte G, Engels E, Erivan R, Mulliez A, Caumon N, Boisgard S, Descamps S (2016) Effect of local anaesthetic wound infiltration on acute pain and bleeding after primary total hip arthroplasty: the EDIPO randomised controlled study. Int Orthop 40(11):2255–2260. CrossRefGoogle Scholar
  10. 10.
    Reina N, Fennema P, Hourlier H (2017) The impact of mild peri-operative hypothermia on the effectiveness of tranexamic acid in total hip arthroplasty. Int Orthop 41(1):55–60. CrossRefGoogle Scholar
  11. 11.
    Sucher MG, Giordani M, Figoni A, Nedopil AJ (2016) Peri-operative blood-loss after total hip arthroplasty can be significantly reduced with topical application of epsilon-aminocaproic acid. Int Orthop 40(10):2019–2023. CrossRefGoogle Scholar
  12. 12.
    Green AL, Arnaud A, Batiller J, Eljamel S, Gauld J, Jones P, Martin D, Mehdorn M, Ohman J, Weyns F (2014) A multicentre, prospective, randomized, controlled study to evaluate the use of a fibrin sealant as an adjunct to sutured dural repair. Br J Neurosurg 12:1–7. Google Scholar
  13. 13.
    Bou Monsef J, Buckup J, Waldstein W, Cornell C, Boettner F (2014) Fibrin sealants or cell saver eliminate the need for autologous blood donation in anemic patients undergoing primary total knee arthroplasty. Arch Orthop Trauma Surg 134:53–58. CrossRefGoogle Scholar
  14. 14.
    Padgett D, Lewallen D, Penenberg B, Hanssen A, Garvin K, Mahoney O, Kinsey T (2009) Surgical technique for revision Total hip replacement. J Bone Joint Surg Am 91(Suppl 5):23–28. CrossRefGoogle Scholar
  15. 15.
    Greenky M, Shaner J, Rasouli MR, Han SB, Parvizi J, Hozack WJ (2014) Intraoperative blood salvage in revision total hip arthroplasty: who benefits most? J Arthroplast 29(6):1298–1300. CrossRefGoogle Scholar
  16. 16.
    Geerts WH, Bergqvist D, Pineo GF, Heit JA, Samama CM, Lassen MR, Colwell CW, American College of Chest Physicians (2008) Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th edition). Chest 133(Suppl 6):381S–453S. CrossRefGoogle Scholar
  17. 17.
    Nicolaides AN, Fareed J, Kakkar AK, Breddin HK, Goldhaber SZ, Hull R, Kakkar VV, Michiels JJ, Myers K, Samama M, Sasahara A, Kalodiki E (2006) Prevention and treatment of venous thromboembolism. International consensus statement (guidelines according to scientific evidence). Int Angiol 25:101–161. Google Scholar
  18. 18.
    Levy O, Martinowitz U, Oran A, Tauber C, Horoszowski H (1999) The use of fibrin tissue adhesive to reduce blood loss and the need for blood transfusion after total knee arthroplasty. J Bone Joint Surg 81:1580–1588CrossRefGoogle Scholar
  19. 19.
    Wang GJ, Hungerford DS, Savory CG, Rosenberg AG, Mont MA, Burks SG et al (2001) Use of fibrin sealant to reduce bloody drainage and hemoglobin loss after total knee arthroplasty: a brief note on a randomized prospective trial. J Bone Joint Surg Am 83:1503–1505CrossRefGoogle Scholar
  20. 20.
    Wang GJ, Goldthwaite CA Jr, Burks S, Crawford R, Spotnitz WD, Orthopaedic Investigators Group (2003) Fibrin sealant reduces perioperative blood loss in total hip replacement. J Long Term Eff Med Implants 13:399–411. CrossRefGoogle Scholar
  21. 21.
    Crawford RW, Giangrande P, Murray D (1999) Fibrin sealant reduces blood loss in total hip arthroplasty. Hip Int 9:127–132. CrossRefGoogle Scholar
  22. 22.
    Kluba T, Fiedler K, Kunze B, Ipach I, Suckel A (2012) Fibrin sealants in orthopaedic surgery: practical experiences derived from use of QUIXIL® in total knee arthroplasty. Arch Orthop Trauma Surg 132:1147–1152. CrossRefGoogle Scholar
  23. 23.
    Everts PAM, Devilee RJ, Oosterbos CJ, Mahoney CB, Schattenkerk ME, Knape JT et al (2007) Autologous platelet gel and fibrin sealant enhance the efficacy of total knee arthroplasty: improved ROM, decreased length of stay and a reduced incidence of arthrofibrosis. Knee Surg Sports Traumatol Arthrosc 15:888–894. CrossRefGoogle Scholar
  24. 24.
    Randelli F, D'Anchise R, Ragone V, Serrao L, Cabitza P, Randelli P (2014) Is the newest fibrin sealant an effective strategy to reduce blood loss after total knee arthroplasty? A randomized controlled study. J Arthroplast 29:1516–1520. CrossRefGoogle Scholar
  25. 25.
    Skovgaard C, Holm B, Troelsen A, Lunn TH, Gaarn-Larsen L, Kehlet H, Husted H (2013) No effect of fibrin sealant on drain output or functional recovery following simultaneous bilateral total knee arthroplasty: a randomized, double-blind, placebo-controlled study. Acta Orthop 84:153–158. CrossRefGoogle Scholar
  26. 26.
    Kim TK, Chang CB, Kang YG, Seo ES, Lee JH, Yun JH, Lee SH (2014) Clinical value of tranexamic acid in unilateral and simultaneous bilateral TKAs under a contemporary blood-saving protocol: a randomized controlled trial. Knee Surg Sports Traumatol Arthrosc 222:1870–1878. CrossRefGoogle Scholar
  27. 27.
    Colombo GL, Caruggi M, Ottolini C, Di Matteo S, Valentino MC, Bruno GM (2015) Economic evaluation of fibrin sealant patch: a proposal to assess the economic value in hemostasis and as a surgical sealant. Value Health 18:A533. CrossRefGoogle Scholar
  28. 28.
    Lim S, Ferko N, Tibensky B, Danker WI, Jamous N, Batiller J, Kocharian R (2015) Economic analysis of Evicel® compared with standard of care for Dural closure in elective cranial surgery: a United Kingdom hospital perspective. Value Health 18:A369. CrossRefGoogle Scholar

Copyright information

© SICOT aisbl 2019

Authors and Affiliations

  • Marco Scardino
    • 1
  • Federica Martorelli
    • 1
  • Tiziana D’Amato
    • 1
  • Giorgia Fenocchio
    • 1
  • Vincenzo Simili
    • 1
  • Guido Grappiolo
    • 2
  • Berardo Di Matteo
    • 3
    • 4
    Email author
  • Elizaveta Kon
    • 3
    • 4
  • Michele Lagioia
    • 4
  1. 1.Anesthesiology Hip and Knee Replacement UnitHumanitas Clinical and Research CenterMilanItaly
  2. 2.Hip Diseases and Joint Replacement Surgery UnitHumanitas Clinical and Research CenterMilanItaly
  3. 3.Department of Biomedical SciencesHumanitas UniversityMilanItaly
  4. 4.Humanitas Clinical and Research CenterMilanItaly

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