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Outcomes of Total Joint Arthroplasty in Jehovah Witnesses

Josephine

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Outcomes of Total Joint Arthroplasty in Jehovah Witnesses SCIENTIFIC EXHIBIT NO. SE14
Aaron Johnson, MD, Baltimore, MD
Qais Naziri, MD, Baltimore, MD
Michael Mont, MD, Baltimore, MD
Steven Harwin, MD, New York, NY


INTRODUCTION: Total joint arthroplasty (TJA) can be quite challenging in Jehovah’s Witness patients because of the potential for marked blood loss. Because patients can not accept allogeneic or autologous blood transfusions, multiple strategies to prevent blood loss can be used in these patients, which include special methods of preoperative screening and treatment, anesthesia protocols, special surgical techniques, and various types of devices and in most cases, blood recovery re-infusion systems. In this two-center study we report on our experiences with the use of a special blood management protocol for these patients. The purpose of this scientific exhibit was to present the details of this protocol, and to review the complications as well as clinical and radiographic outcomes of Jehovah’s Witness patients who underwent a primary TJA.

METHODS: All patients underwent a specific blood management strategy, which included preoperative, perioperative, and postoperative measures. A coordinated team including internists, hematologists, intensivists, and anesthesiologists evaluated the patient preoperatively to optimize the patient’s condition, and if necessary, to administer hemoglobin enhancing drugs such as epoetin, folate, and iron according to an established algorithm. Expected blood loss for each type of procedure was estimated. Intraoperative measures included hypotensive anesthesia, meticulous hemostasis using mechanical devices and topical agents, rapid surgery, cell saver, and avoidance of drains if possible. Antifibrinolytic agents were administered as needed. Postoperative measures included microvenipunctures, iron supplements, and epoetin. Pharmacological DVT prophylaxis was avoided if possible. Additionally, databases from two institutions were reviewed to identify 186 patients (206 joints) who were Jehovah’s Witnesses. Evaluated patients included only those operated on by one of two high-volume surgeons between 1998 and 2009, with a minimum follow-up of two years. There were 110 women and 76 men who had a mean age of 62 years (range, 26 to 85 years), a mean body mass index of 32.5 kg/m2 (range, 15 to 53 kg/m2), and a mean follow-up of 62 months (range, 24 to 120 months). The diagnoses were 146 patients who had osteoarthritis, 19 who had rheumatoid arthritis, and 31 who had osteonecrosis. Subsequent procedures and complications were reviewed.

RESULTS: For the total hip arthroplasties, the mean Harris Hip score (HHS) improved from 52 points (range, 22 to 78 points) to 93 points (range, 58 to 100 points) with an overall 96% survivorship at last follow-up. The mean Knee Society knee and function scores improved from 59 points (range, 20 to 75 points) and 48 points (range, 5 to 70 points) points, respectively, to 90 points (range, 61 to 100 points) and 83 points (range, 45 to 100 points) points with an overall 98% survivorship at last follow-up. There were three hip re-operations: two because of loose acetabular cups and one because of a loose stem (All revision patients were doing well clinically (HSS > 80 points) at last follow-up. Other complications included one superficial wound infection treated with antibiotics, one case of skin necrosis that responded to local wound care and antibiotics, and one greater trochanter fracture (treated non-operatively). For the knees, Three patients underwent a re-operation; one for flexion instability at two years, one for tibial loosening at 7 years, and one for late instability at 8 years. All revision patients were

DISCUSSION: Using the protocol described in this scientific exhibit, excellent clinical and radiographic outcomes were found for Jehovah’s Witness patients who had undergone TJA. Patients had an overall survivorship of 97% at mean approximately 5 year follow-up with excellent clinical and radiographic results. We believe that the use of this special blood management protocol involving a team approach to preoperative evaluation, appropriate anesthesia, and surgical and post-operative management was responsible for minimizing complications.
 

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