Skip to main content
SpringerLink
Log in

Patient Preparation for Total Knee Arthroplasty: Reducing Blood Loss, Thromboprophylaxis and Reducing Infection Risk

  • Chapter
Total Knee Arthroplasty

Abstract

The patient’s journey begins with the initial consultation and decision to undertake total knee arthroplasty (TKA) and is an important opportunity to begin optimisation of every facet of their condition.

Perioperative risks can be mitigated through careful preoperative assessment and planning. Every step in this process is key, and time and effort should be invested to ensure the patient is optimised from all perspectives and any adverse conditions remedied. In addition, a number of features of TKA are particularly important including thromboprophylaxis, reducing blood loss and reducing the risk of infection. Strategies employed to do this have been reviewed although the implementation and use vary depending on the institution. Healthcare professionals should play an active role in reducing potential complications after TKA. This can have a powerful effect on clinical outcomes and also reduce the economic burden on stretched healthcare systems.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Log in via an institution
Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 84.99
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 109.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info
Hardcover Book
USD 159.99
Price excludes VAT (USA)
  • Durable hardcover edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

References

  1. Ayalon O, Liu S, Flics S, Cahill J, Juliano K, Cornell CN (2011) A multimodal clinical pathway can reduce length of stay after total knee arthroplasty. HSS J 7:9–15

    Article  PubMed Central  PubMed  Google Scholar 

  2. McDonald DA, Siegmeth R, Deakin AH, Kinninmonth AW, Scott NB (2012) An enhanced recovery programme for primary total knee arthroplasty in the United Kingdom–follow up at one year. Knee 19:525–529

    Article  CAS  PubMed  Google Scholar 

  3. den Hertog A, Gliesche K, Timm J, Muhlbauer B, Zebrowski S (2012) Pathway-controlled fast-track rehabilitation after total knee arthroplasty: a randomized prospective clinical study evaluating the recovery pattern, drug consumption, and length of stay. Arch Orthop Trauma Surg 132:1153–1163

    Article  Google Scholar 

  4. Dowsey MM, Kilgour ML, Santamaria NM, Choong PF (1999) Clinical pathways in hip and knee arthroplasty: a prospective randomised controlled study. Med J Aust 170:59–62

    CAS  PubMed  Google Scholar 

  5. Larsen K, Hvass KE, Hansen TB, Thomsen PB, Soballe K (2008) Effectiveness of accelerated perioperative care and rehabilitation intervention compared to current intervention after hip and knee arthroplasty. A before-after trial of 247 patients with a 3-month follow-up. BMC Musculoskelet Disord 9:59

    Article  PubMed Central  PubMed  Google Scholar 

  6. Malviya A, Martin K, Harper I, Muller SD, Emmerson KP, Partington PF, Reed MR (2011) Enhanced recovery program for hip and knee replacement reduces death rate. Acta Orthop 82:577–581

    Article  PubMed Central  PubMed  Google Scholar 

  7. Yoon RS, Nellans KW, Geller JA, Kim AD, Jacobs MR, Macaulay W (2010) Patient education before hip or knee arthroplasty lowers length of stay. J Arthroplasty 25:547–551

    Article  PubMed  Google Scholar 

  8. Ditmyer MM, Topp R, Pifer M (2002) Prehabilitation in preparation for orthopaedic surgery. Orthop Nurs 21:43–51

    Article  PubMed  Google Scholar 

  9. Hoogeboom TJ, Oosting E, Vriezekolk JE, Veenhof C, Siemonsma PC, de Bie RA, van den Ende CH, van Meeteren NL (2012) Therapeutic validity and effectiveness of preoperative exercise on functional recovery after joint replacement: a systematic review and meta-analysis. PLoS One 7:e38031

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  10. Gherini S, Vaughn BK, Lombardi AV Jr, Mallory TH (1993) Delayed wound healing and nutritional deficiencies after total hip arthroplasty. Clin Orthop Relat Res 293:188–195

    PubMed  Google Scholar 

  11. Stratton RJ, Hackston A, Longmore D, Dixon R, Price S, Stroud M, King C, Elia M (2004) Malnutrition in hospital outpatients and inpatients: prevalence, concurrent validity and ease of use of the ’malnutrition universal screening tool’ (’MUST’) for adults. Br J Nutr 92:799–808

    Article  CAS  PubMed  Google Scholar 

  12. Font-Vizcarra L, Lozano L, Rios J, Forga MT, Soriano A (2011) Preoperative nutritional status and post-operative infection in total knee replacements: a prospective study of 213 patients. Int J Artif Organs 34:876–881

    Article  CAS  PubMed  Google Scholar 

  13. Berend KR, Lombardi AV Jr, Mallory TH (2004) Rapid recovery protocol for perioperative care of total hip and total knee arthroplasty patients. Surg Technol Int 13:239–247

    PubMed  Google Scholar 

  14. Nicholson JA, Dowrick AS, Liew SM (2012) Nutritional status and short-term outcome of hip arthroplasty. J Orthop Surg (Hong Kong) 20:331–335

    Google Scholar 

  15. Spahn DR (2010) Anemia and patient blood management in hip and knee surgery: a systematic review of the literature. Anesthesiology 113:482–495

    Article  PubMed  Google Scholar 

  16. Kotze A, Carter LA, Scally AJ (2012) Effect of a patient blood management programme on preoperative anemia, transfusion rate, and outcome after primary hip or knee arthroplasty: a quality improvement cycle. Br J Anaesth 108:943–952

    Google Scholar 

  17. Greenky M, Gandhi K, Pulido L, Restrepo C, Parvizi J (2012) Preoperative anemia in total joint arthroplasty: is it associated with periprosthetic joint infection? Clin Orthop Relat Res 470:2695–2701

    Article  PubMed Central  PubMed  Google Scholar 

  18. Cuenca J, Garcia-Erce JA, Munoz M, Izuel M, Martinez AA, Herrera A (2004) Patients with pertrochanteric hip fracture may benefit from preoperative intravenous iron therapy: a pilot study. Transfusion 44:1447–1452

    Article  CAS  PubMed  Google Scholar 

  19. Cuenca J, Garcia-Erce JA, Martinez F, Cardona R, Perez-Serrano L, Munoz M (2007) Preoperative haematinics and transfusion protocol reduce the need for transfusion after total knee replacement. Int J Surg 5:89–94

    Article  PubMed  Google Scholar 

  20. Douketis JD, Spyropoulos AC, Spencer FA, Mayr M, Jaffer AK, Eckman MH, Dunn AS, Kunz R et al (2012) American College of Chest Physicians. Perioperative management of antithrombotic therapy: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 141(Suppl 2):e326S–e350S

    CAS  PubMed Central  PubMed  Google Scholar 

  21. Hinarejos P, Corrales M, Matamalas A, Bisbe E, Cáceres E (2009) Computer-assisted surgery can reduce blood loss after total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 17:356–360

    Article  PubMed  Google Scholar 

  22. Richman JM, Rowlingson AJ, Maine DN, Courpas GE, Weller JF, Wu CL (2006) Does neuraxial anesthesia reduce intraoperative blood loss? A meta-analysis. J Clin Anesth 18:427–435

    Article  PubMed  Google Scholar 

  23. Macfarlane AJ, Prasad GA, Chan VW, Brull R (2009) Does regional anesthesia improve outcome after total knee arthroplasty? Clin Orthop Relat Res 467:2379–2402

    Article  PubMed Central  PubMed  Google Scholar 

  24. Rajagopalan S, Mascha E, Na J, Sessler DI (2008) The effects of mild perioperative hypothermia on blood loss and transfusion requirement. Anesthesiology 108:71–77

    Article  PubMed  Google Scholar 

  25. Paul JE, Ling E, Lalonde C, Thabane L (2007) Deliberate hypotension in orthopedic surgery reduces blood loss and transfusion requirements: a meta-analysis of randomized controlled trials. Can J Anesth 54:799–810

    Article  PubMed  Google Scholar 

  26. Cid J, Lozano M (2005) Tranexamic acid reduces allogeneic red cell transfusions in patients undergoing total knee arthroplasty: results of a meta-analysis of randomized controlled trials. Transfusion 45:1302–1307

    Article  CAS  PubMed  Google Scholar 

  27. Ishida K, Tsumura N, Kitagwa A, Hamamura S, Fukuda K, Dogaki Y et al (2011) Intra-articular injection of tranexamic acid reduces not only blood loss but also knee joint swelling after total knee arthroplasty. Int Orthop 35:1639–1645

    Article  PubMed Central  PubMed  Google Scholar 

  28. Gillette BP, DeSimone LJ, Trousdale RT, Pagnano MW, Sierra RJ (2013) Low risk of thromboembolic complications with tranexamic acid after primary total hip and knee arthroplasty. Clin Orthop Relat Res 471:150–154

    Article  PubMed Central  PubMed  Google Scholar 

  29. Carless PA, Henry DA, Anthony DM (2003) Fibrin sealant use for minimizing perioperative allogeneic blood transfusion. Cochrane Database Syst Rev (2):CD004171

    Google Scholar 

  30. Patel S, Rodriguez-Merchan EC, Haddad FS (2010) The use of fibrin glue in surgery of the knee. J Bone Joint Surg Br 92:1325–1331

    Article  CAS  PubMed  Google Scholar 

  31. Carless PA, Henry DA, Moxey AJ, O’Connell D, Brown T, Fergusson DA (2010) Cell salvage for minimising perioperative allogeneic blood transfusion. Cochrane Database Syst Rev (4):CD001888

    Google Scholar 

  32. Parker MJ, Livingstone V, Clifton R, McKee A (2007) Closed suction surgical wound drainage after orthopaedic surgery. Cochrane Database Syst Rev (3):CD001825

    Google Scholar 

  33. Tai TW, Yang CY, Jou IM, Lai KA, Chen CH (2010) Temporary drainage clamping after total knee arthroplasty: a meta-analysis of randomized controlled trials. J Arthroplasty 25:1240–1245

    Article  PubMed  Google Scholar 

  34. Anderson LA, Engel GM, Bruckner JD, Stoddard GJ, Peters CL (2009) Reduced blood loss after total knee arthroplasty with local injection of bupivacaine and epinephrine. J Knee Surg 22:130–136

    Article  PubMed  Google Scholar 

  35. Muñoz M, Slappendel R (2012) Unwashed blood: is widespread use justified? A review of current knowledge. TATM 2012; http://dx.doi.org/10.1111/j.1778-428X.2012.01162.x

  36. Carless P, Moxey A, O’Connell D, Henry D (2004) Autologous transfusion techniques: a systematic review of their efficacy. Transfus Med 14:123–144

    Article  CAS  PubMed  Google Scholar 

  37. Alvarez JC, Santiveri FX, Ramos I, Vela E, Puig L, Escolano F (2008) Tranexamic acid reduces blood transfusion in total knee arthroplasty even when a blood conservation program is applied. Transfusion 48:519–525

    Article  PubMed  Google Scholar 

  38. Warwick DJ, Whitehouse S (1997) Symptomatic venous thromboembolism after total knee replacement. J Bone Joint Surg 79:780–786

    Article  CAS  Google Scholar 

  39. Stulberg BN, Insall JN, Williams GW, Ghelman B (1984) Deep-vein thrombosis following total knee replacement: an analysis of six hundred and thirty-eight arthroplasties. J Bone Joint Surg Am 66:194–201

    CAS  PubMed  Google Scholar 

  40. National Institute for Health and Care Excellence (2015) Venous Thromboembolism. http://pathways.nice.org.uk/pathways/venous-thromboembolism. Accessed 1 Jan 2015

  41. Venous thromboembolism: reducing the risk. Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in patients admitted to hospital. Issued: January 2010. NICE clinical guideline 92 www.nice.org.uk/cg92

  42. (Clots in Legs Or sTockings after Stroke) Trial Collaboration (2010) Thigh-length versus below knee stockings for deep venous thrombosis prophylaxis after stroke: a randomized trial. Ann Intern Med 153:553–562

    Article  Google Scholar 

  43. Chin PL, Amin MS, Yang KY, Yeo SJ, Lo NN (2009) Thromboembolic prophylaxis for total knee arthroplasty in Asian patients: a randomised controlled trial. J Orthop Surg (Hong Kong) 17:1–5

    Article  CAS  Google Scholar 

  44. Edwards JZ, Pulido PA, Ezzet KA, Copp SN, Walker RH, Colwell CW Jr (2008) Portable compression device and low-molecular-weight heparin compared with low-molecular-weight heparin for thromboprophylaxis after total joint arthroplasty. J Arthroplasty 23:1122–1127

    Article  PubMed  Google Scholar 

  45. Turpie AG, Bauer KA, Eriksson BI, Lassen MR (2002) Fondaparinux vs. enoxaparin for the prevention of venous thromboembolism in major orthopedic surgery: a meta-analysis of 4 randomized double-blind studies. Arch Intern Med 162:1833–1840

    Article  CAS  PubMed  Google Scholar 

  46. Yoshida Rde A, Yoshida WB, Maffei FH, El Dib R, Nunes R, Rollo HA (2013) Systematic review of randomized controlled trials of new anticoagulants for venous thromboembolism prophylaxis in major orthopaedic surgeries, compared with enoxaparin. Ann Vasc Surg 27:355–369

    Article  PubMed  Google Scholar 

  47. Zmistowski B, Karam JA, Durinka JB, Casper DS, Parvizi J (2013) Periprosthetic joint infection increases the risk of one-year mortality. J Bone Joint Surg 95:2177–2184

    Article  PubMed  Google Scholar 

  48. England SP, Stern SH, Insall JN, Windsor RE (1990) Total knee arthroplasty in patients with diabetes mellitus. Clin Orthop Rel Res 260:130–134

    Google Scholar 

  49. Petty W, Bryan RS, Coventry MB, Peterson LF (1975) Infection after total knee arthroplasty. Orthop Clin North Am 6:1005–1014

    CAS  PubMed  Google Scholar 

  50. Papavasiliou AV, Isaac DL, Marimuthu R, Skyrme A, Armitage A (2006) Infection in knee replacements after previous injection of intra-articular steroid. J Bone Joint Surg Br 88:321–323

    Article  CAS  PubMed  Google Scholar 

  51. Wilson MG, Kelley K, Thornhill TS (1990) Infection as a complication of total knee-replacement arthroplasty. Risk factors and treatment in sixty-seven cases. J Bone Joint Surg Am 72:878–883

    CAS  PubMed  Google Scholar 

  52. Rao N, Cannella BA, Crossett LS, Yates AJ Jr, McGough RL 3rd, Hamilton CW (2011) Prospective screening/decolonisation for Staphylococcus aureus to prevent orthopaedic surgical site infection: prospective cohort study with 2-year follow-up. J Arthroplasty 26:1501–1507

    Article  PubMed  Google Scholar 

  53. Courville XF, Tomek IM, Kirkland KB, Birhle M, Kantor SR, Finlayson SR (2012) Cost-effectiveness of preoperative nasal mupirocin treatment in preventing surgical site infection in patients undergoing total hip and knee arthroplasty: a cost-effectiveness analysis. Infect Control Hosp Epidemiol 33:152–159

    Article  PubMed  Google Scholar 

  54. Fletcher N, Sofianos D, Berkes MB, Obremskey WT (2007) Prevention of perioperative infection. J Bone Joint Surg Am 89:1605–1618

    Article  PubMed  Google Scholar 

  55. Owers KL, James E, Bannister GC (2004) Source of bacterial shedding in laminar flow theatres. J Hosp Infect 58:230–232

    Article  CAS  PubMed  Google Scholar 

  56. Hubble MJ, Weale AE, Perez JV, Bowker KE, MacGowan AP, Bannister GC (1996) Clothing in laminar-flow operating theatres. J Hosp Infect 32:1–7

    Article  CAS  PubMed  Google Scholar 

  57. Lidwell OM, Lowbury EJ, Whyte W, Blowers R, Stanley SJ, Lowe D (1982) Effect of ultraclean air in operating rooms on deep sepsis in the joint after total hip or knee replacement: a randomised study. Br Med J (Clin Res Ed) 285:10–14

    Article  CAS  Google Scholar 

  58. British Orthopaedic Association (1999) Recommendations on sterile procedures in operating theatres. http://www.boa.ac.uk/site/showpublications.aspx?ID=59. Accessed 28 Dec 2014

  59. Charnley J (1972) Postoperative infection after total hip replacement with special reference to air contamination in the operating room. Clin Orthop Relat Res 87:167–187

    Article  CAS  PubMed  Google Scholar 

  60. Bratzler DW, Dellinger EP, Olsen KM, Perl TM, Auwaerter PG, Bolon MK, Fish DN, Napolitano LM, Sawyer RG, Slain D, Steinberg JP, Weinstein RA, American Society of Health-System Pharmacists (ASHP); Infectious Diseases Society of America (IDSA); Surgical Infection Society (SIS); Society for Healthcare Epidemiology of America (SHEA) (2013) Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm 70:195–283

    Article  CAS  PubMed  Google Scholar 

  61. Hawn MT, Richman JS, Vick CC, Deierhoi RJ, Graham LA, Henderson WG, Itani KM (2013) Timing of surgical antibiotic prophylaxis and the risk of surgical site infection. JAMA Surg 148:649–657

    Article  PubMed  Google Scholar 

  62. Wang J, Zhu C, Cheng T, Peng X, Zhang W, Qin H, Zhang X (2013) A systematic review and meta-analysis of antibiotic-impregnated bone cement use in primary total hip or knee arthroplasty. PLoS One 8:e82745

    Article  PubMed Central  PubMed  Google Scholar 

  63. Hinarejos P, Guirro P, Leal J, Montserrat F, Pelfort X, Sorli ML, Horcajada JP, Puig L (2013) The use of erythromycin and colistin-loaded cement in total knee arthroplasty does not reduce the incidence of infection: a prospective randomized study in 3000 knees. J Bone Joint Surg Am 95:769–774

    Article  PubMed  Google Scholar 

  64. Bohm E, Zhu N, Gu J, de Guia N, Linton C, Anderson T, Paton D, Dunbar M (2014) Does adding antibiotics to cement reduce the need for early revision in total knee arthroplasty? Clin Orthop Relat Res 472:​162–168

    Article  PubMed Central  PubMed  Google Scholar 

  65. Namba RS, Inacio MCS, Paxton EW (2013) Risk factors associated with deep surgical site infections after primary total knee arthroplasty: an analysis of 56,216 knees. J Bone Joint Surg Am 95:775–782

    Article  PubMed  Google Scholar 

  66. Garcia S, Lozano ML, Gatell JM, Soriano E, Ramon R, Sanmiguel JG (1991) Prophylaxis against infection. Single-dose cefonicid compared with multiple-dose cefamandole. Bone Joint Surg Am 73:1044–1048

    CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Orthopaedics, University College London Hospitals, 235 Euston Road, London, NW1 2BU, UK

    Luthfur Rahman & Sam Oussedik

Authors
  1. Luthfur Rahman
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Sam Oussedik
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Sam Oussedik .

Editor information

Editors and Affiliations

  1. "La Paz" University Hospital-IdiPaz, Madrid, Spain

    E. Carlos Rodríguez-Merchán

  2. University College London Hospitals, London, United Kingdom

    Sam Oussedik

Rights and permissions

Reprints and permissions

Copyright information

© 2015 Springer International Publishing Switzerland

About this chapter

Cite this chapter

Rahman, L., Oussedik, S. (2015). Patient Preparation for Total Knee Arthroplasty: Reducing Blood Loss, Thromboprophylaxis and Reducing Infection Risk. In: Rodríguez-Merchán, E., Oussedik, S. (eds) Total Knee Arthroplasty. Springer, Cham. https://doi.org/10.1007/978-3-319-17554-6_5

Download citation

  • DOI: https://doi.org/10.1007/978-3-319-17554-6_5

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-319-17553-9

  • Online ISBN: 978-3-319-17554-6

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics

Search

Navigation