Active ankylosing spondylitis increases blood loss during total hip arthroplasty for a stiff hip joint

Abstract

Background: Total hip arthroplasty (THA) has been highlighted as the best treatment option for ankylosing spondylitis (AS) patients with advanced hip involvement. The huge blood loss associated with THA is a common concern of postoperative complications. Disease activity is a specific reflection of systematic inflammation of AS. The purpose of this study was to determine the effect of disease activity on blood loss during THA in patients with AS. Methods: Forty-nine patients with AS who underwent unilateral THAs were retrospectively studied. Ankylosing Spondylitis Disease Activity Score (ASDAS) was employed to evaluate the disease activity. Orthopedic Surgery Transfusion Hemoglobin European Overview (OSTHEO) formula was used to assess the surgical blood loss. The patients were divided into active group (ASDAS≥1.3; n = 32) and stable groups (ASDAS< 1.3; n = 17) based on the ASDAS. Peri-operative laboratory values, plain radiographs, intra-operative data, transfusion volume, and use of hemostatic agents were recorded and statistically analyzed. Results: The ASDAS, pre-operative C-reactive protein level, erythrocyte sedimentation rate, and fibrinogen concentration in the active group were higher than the stable group (all P < 0.05); however, the pre-operative hemoglobin concentration and albumin level were higher in the stable group (both P < 0.05). The total blood loss during THA in stable patients was 1415.31 mL and 2035.04 mL in active patients (P = 0.006). The difference between the two groups was shown to be consistent after excluding the gender difference (P = 0.030). A high transfusion rate existed in both groups (stable group, 76.47% with an average of 1.53 units; active group, 84.37% with an average of 2.31 units), but there was no significant difference between the two groups (both P > 0.05). Compensated blood loss, corresponding to transfusion, was noted significantly more in the active group compared to the stable group (P = 0.027). There was no significant difference with regard to functional recovery (P > 0.05). Conclusion: Active AS patients are at high risk for increased blood loss during THA compared to stable patients. The underlying mechanism includes disorders of the coagulation and fibrinolytic systems, poor nutrition status, osteoporosis, imbalance of oxidative-antioxidative status and local inflammatory reaction. It is strongly recommended to perform THA in AS patients with stable disease.

Factors associated with blood loss in ankylosing spondylitis patients with hip involvement undergoing primary total hip arthroplasty: a cross-sectional retrospective study of 243 patients

“…However, autologous transfusion only is insufficient, and allogenic blood transfusion is also needed. The total allogenic transfusion rate in this study is higher than reported in other studies [ 13 , 17 , 18 ], which is mainly due to the higher proportion of patients undergoing bilateral THA compared with unilateral THA (approximately 2/3). If the allogenic transfusion rate in only patients who underwent unilateral THA is compared between this study and the studies mentioned, our results are comparable.…”

“…ESR and CRP are biomarkers of inflammatory diseases that are commonly examined and can reflect the disease activity to some extent. Similar to Hu et al [ 17 ], we determined that an elevated ESR level is a risk factor for blood loss in AS patients with end-stage hip disease undergoing THA. The frequency of elevated ESR level was higher in group II and did not gradually increase with the grade of blood loss, which could be interpreted as follows: patients in that group were mainly at the transition period from mid- to end-stage AS.…”

“…The blood loss calculated in our study included that of all the bleeding events: intraoperative blood loss, postoperative drainage, and “hidden” blood loss [ 25 ]. As mentioned, bony ankylosis at the hip [ 13 ] and a higher disease activity [ 17 ] increase bleeding during THA in AS patients. Owing to the characteristic differences between AS and other hip diseases requiring THA, we hypothesized that disease activity, the severity of hip disease, and the administration of perioperative medication might be associated with perioperative bleeding in AS patients.…”

“…Conventionally, the perioperative use of hemostatic [ 14 , 15 ] and anticoagulant drugs [ 16 ] is also taken into account. Several studies have shown that bony ankylosis in the hip [ 13 ] and a higher disease activity [ 17 ] can cause an increase in bleeding during THA in AS patients, while a lower body mass index (BMI) is responsible for greater hidden blood loss postoperatively and a higher transfusion rate [ 18 ]. However, the comprehensive effects and interrelationships among these characteristic factors related to blood loss during THA in AS patients have not been reported, and whether any other factors may exist remains unclear.…”

Incidence and risk factors associated with human albumin administration following total joint arthroplasty: a multicenter retrospective study

“…In the current study, we found that patients with inflammatory arthritis such as RA and AS tended to receive HA administration after TKA. Previous studies reported that active RA or AS patients were characterized by anemia and hypoalbuminemia [ 29 , 30 ]. This may be associated with inflammation mediated by tumor necrosis factor-α and interleukin-6, which decreased the expression of the albumin gene at the transcriptional level in the liver [ 31 ].…”