Several studies have demonstrated a correlation between the acetabular cup position and the risk of dislocation, wear and range of motion after total hip arthroplasty. The present study was designed to evaluate the accuracy of the surgeon's estimated position of the cup after freehand placement in total hip replacement. Peroperative estimated abduction and anteversion of 200 acetabular components (placed by three orthopaedic surgeons and nine residents) were compared with measured outcomes (according to Pradhan) on postoperative radiographs. Cups were placed in 49.7° (SD 6.7) of abduction and 16.0° (SD 8.1) of anteversion. Estimation of placement was 46.3° (SD 4.3) of abduction and 14.6° (SD 5.9) of anteversion. Of more interest is the fact that for the orthopaedic surgeons the mean inaccuracy of estimation was 4.1° (SD 3.9) for abduction and 5.2° (SD 4.5) for anteversion and for their residents this was respectively, 6.3° (SD 4.6) and 5.7° (SD 5.0). SigniWcant diVerences were found between orthopaedic surgeons and residents for inaccuracy of estimation for abduction, not for anteversion. Body mass index, sex, (un)cemented Wxation and surgical approach (anterolateral or posterolateral) were not signiWcant factors. Based upon the inaccuracy of estimation, the group's chance on future cup placement within Lewinnek's safe zone (5-25° anteversion and 30-50° abduction) is 82.7 and 85.2% for anteversion and abduction separately. When both parameters are combined, the chance of accurate placement is only 70.5%. The chance of placement of the acetabular component within 5° of an intended position, for both abduction and anteversion is 21.5% this percentage decreases to just 2.9% when the tolerated error is 1°. There is a tendency to underestimate both abduction and anteversion. Orthopaedic surgeons are superior to their residents in estimating abduction of the acetabular component. The results of this study indicate that freehand placement of the acetabular component is not a reliable method.

In this prospective randomized pilot study on APG in total knee arthroplasty, differences in favour of the use of platelet gel were found, but these were subjective evaluations, marginal in effect, or did not reach statistical significance. The use of drains might have decreased the concentration of delivered platelets and may have diminished the effect. However, in this study, a statistically significant clinically important effect in favour of platelet gel application was not found. Further studies with larger numbers of patients, and without the use of drains, are warranted to investigate the possible benefits of autologous platelet gel in total knee arthroplasty.

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Purpose A new intraoperative filtered salvaged blood re-transfusion system has been developed for primary total hip arthroplasty (THA) that filters and re-transfuses the blood that is lost during THA. This system is intended to increase postoperative haemoglobin (Hb) levels, reduce perioperative net blood loss and reduce the need for allogeneic transfusions. It supposedly does not have the disadvantages of intraoperative cell-washing/separating re-transfusion systems, such as extensive procedure, high costs and need for specialised personnel. To re-transfuse as much as blood as possible, postoperatively drained blood was also re-transfused. Methods A randomised, controlled, blinded, single-centre trial was conducted in which 118 THA patients were randomised to an intraoperative autologous blood re-transfusion (ABT) filter system combined with a postoperative ABT filter unit or highvacuum closed-suction drainage. Results On average, 577 ml of blood was re-transfused in the ABT group: 323 ml collected intraoperatively and 254 ml collected postoperatively. Hb level was higher in the ABT vs the high-vacuum drainage group: 11.4 vs. 10.8 g/dl, p =0.02 on day one (primary endpoint) and 11.0 vs. 10.4 g/dl, p = 0.007 on day three. Total blood loss was less in the autotransfusion group: 1472 vs. 1678 ml, p =0.03. Allogeneic transfusions were needed in 3.6 % of patients in the ABT group and 6.5 % in the drainage group, p =0.68. Conclusion The use of a new intraoperative ABT filter system combined with a postoperative ABT unit resulted in higher postoperative Hb levels and less total blood loss compared with a high-vacuum drain following THA.

SUMMARY Autologous retransfusion of filtered drained blood is widely used after total hip (THA) and knee arthroplasty (TKA) in many countries. Despite its wide use, prospective studies on clinical side effects with a substantial number of patients have not been published. In this prospective clinical trial, 1819 consecutive patients in 38 hospitals were retransfused using a low‐suction drainage autologous blood transfusion system, after THA (n = 995) or TKA (n = 824). The occurrence of adverse events during retransfusion of the filtered shed blood was studied. An average of 460 mL of drained blood (THA, 374 mL; TKA, 563 mL) was retransfused within 6 hours postoperatively. The frequency of serious adverse events was 0.1%, which concerned two patients: one had a short asystole during reinfusion that responded quickly to medication; and the other with a history of deep vein thrombosis had pulmonary embolism. By way of non‐serious adverse events, febrile reactions (fever, shivering) were observed in 3.1% of the patients during retransfusion. Clot formation was observed in the drained blood in six (0.3%) patients; therefore, retransfusion was not carried out. These minor adverse events were seen more often after TKA (5.8%) than after THA (1.5%). Nine (0.5%) patients were retransfused with volumes above 1500 mL (average 1657, range 1550–1900), without adverse events. Additional allogenic blood transfusions were required by 18% of the THA and 9% of the TKA patients. In this study, few adverse events were detected during retransfusion. The frequency of serious (0.1%) and minor (3.5%) adverse events was similar to other smaller clinical studies. Based on the low incidence of side effects in this large cohort of orthopedic patients, postoperative cell salvage with such a retransfusion system is considered to be safe.

There is an evident increase in the preoperative use of erythropoietin and the postoperative use of autologous retransfusion of drained blood among Dutch orthopedic departments. There appears to be an increasing awareness and positive attitude among Dutch orthopedic surgeons to implement perioperative blood-saving measures.