BackgroundOur goal was to determine whether postoperative delirium is associated with inpatient complication rates after primary elective total hip arthroplasty (THA).MethodsUsing the National Inpatient Sample, we analyzed records of patients who underwent primary elective THA from 2000 through 2009 to identify patients with delirium (n = 13,551) and without delirium (n = 1,992,971) and to assess major perioperative complications (acute renal failure, death, myocardial infarction, pneumonia, pulmonary embolism, and stroke) and minor perioperative complications (deep vein thrombosis, dislocation, general procedural complication, hematoma, seroma, and wound infection). Patient age, sex, length of hospital stay, and number of comorbidities were assessed. We used multivariate logistic regression to determine the association of delirium with complication rates (significance, p < 0.01).ResultsPatients with delirium were older (mean, 75 ± 0.2 vs. 65 ± 0.1 years), were more likely to be male (56% vs. 52%), had longer hospital stays (mean, 5.7 ± 0.07 vs. 3.8 ± 0.02 days), and had more comorbidities (mean, 2.8 ± 0.03 vs. 1.4 ± 0.01) (all p < 0.001) versus patients without delirium. Patients with delirium were more likely to have major (11% vs. 3%) and minor (17% vs. 7%) perioperative complications versus patients without delirium (both p < 0.001). When controlling for age, sex, and number of comorbidities, delirium was independently associated with major and minor complications (odds ratio, 2.0; 95% confidence interval, 1.7 to 2.3).ConclusionsDelirium is an independent risk factor for major and minor perioperative complications after primary elective THA.

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Osteonecrosis is one of the most devastating musculoskeletal manifestations of sickle cell disease and most commonly affects the femoral head. Although the exact pathophysiology of this condition in patients with sickle cell disease is unknown, it is suggested that red cell sickling and repetitive vaso-occlusion may be associated with tissue hypoxia, inflammation, and subsequent bone necrosis and collapse. If left untreated, osteonecrosis can be extremely debilitating and may lead to severe pain, loss of function, and degenerative joint changes. Although several conservative management approaches exist, total joint arthroplasty remains the most effective treatment intervention. A multidisciplinary approach among the primary care physician, hematologist, and orthopedic surgeon is essential in optimizing patient management.

It is estimated that ∼24 million units of blood products are administered annually in the United States, with ∼10% of all packed red blood cell transfusions used in orthopedic surgery. Protocols and guidelines for the administration of blood vary widely among orthopedic practices and hospitals. Although transfusions can be lifesaving, their use carries substantial risks, from minor to life-threatening complications. Therefore, transfusions should be considered a last option when dealing with postoperative anemia. Blood conservation and taking steps to avoid postoperative anemia should be goals in orthopedic surgery. Creating a standardized approach to blood management is important to enhance outcomes and decrease transfusions and their attendant risks. This includes correcting preoperative anemia when possible and using techniques to minimize perioperative blood loss. Restrictive transfusion triggers have been shown to decrease the number of transfusions without compromising outcomes. Use of antifibrinolytic agents such as tranexamic acid has also decreased the need for transfusions. This article reviews current transfusion practices, including indications and contraindications, perioperative blood management techniques, transfusion complications, and safe transfusion thresholds for patients undergoing orthopedic surgery.