Using endoprostheses with minimal bleeding – this is the goal that orthopedics at the University Hospital Leipzig (UKL) has set itself very successfully. After various changes in the processes during and after the operation, the surgeons around Prof. Andreas Roth can not only avoid the sometimes high blood loss when inserting a knee or hip prosthesis and subsequent problems such as infections, but also help the patient get back on his feet faster .
Four years full of changes lie behind Prof. Andreas Roth and his team. That's how long it took for the first adaptation of the processes in the operating room of the orthopedic surgeons in the Leipzig University Hospital to become the endoprosthetics that are almost blood-loss-free today. Years in which many disciplines worked together and innovations were gradually introduced. The result: "Nowadays, we hardly ever need transfusions to make up for the blood lost during a hip or knee prosthesis operation," says Prof. Roth, head of the endoprosthetics/orthopaedics department. His specialty was and still is considered to be rather "bloody" surgery, which, unlike others, is not minimally invasive, one or the other vessel is affected and some blood supplies are required. "Endoprosthetic surgeries were often associated with significant blood loss and meant that up to 46 percent of patients required a blood transfusion during or after the operation," explains the experienced orthopaedist.
For the patient, this means a longer recovery time after the procedure, because the circulatory system also has to get back on its feet first. "In addition, the loss of fluid often continued over the following days using the usual drainage to check whether it might still be bleeding," Roth describes. He is convinced that modern surgery should look for other solutions here. And he found what he was looking for: on the one hand, with procedures for subtle haemostasis during the operation, which are used by the plastic surgeons at the UKL. "The vessels are closed directly during the procedure using special methods," explains Roth. As a result, the operation lasts up to 15 minutes longer, but "afterwards there are far fewer bruises, swellings or infections in the operation area". Roth learned from his colleagues and changed his technique with the patients where possible. Other surgeons followed, so that today the vast majority of endoprostheses at the UKL are used with minimal blood loss. The result: a blood transfusion is only required for a minimum of three percent of endoprosthetic operations!
Blood value and coagulation control
In order to make this possible, however, many other factors had to be changed before, during and after the operation, such as checking blood values, coagulation, adjustments to the anesthetic and pain treatment. For example, tranexamic acid (TXA) is used during the operation, a special agent that temporarily increases the tendency to coagulate and thus prevents bleeding. "The individual risk of the patient is carefully weighed and, among other things, a decision is made as to whether we use the agent systemically or only locally directly on the joint to be operated on," explains private lecturer Dr. Christian Pfepper. The coagulation specialist supported the orthopedists in their project and checked the conditions under which the drug-based hemostasis, which is not explicitly approved for this purpose, can be used. "We then found that in this way we could both ensure a high level of patient safety and effectively prevent bleeding." The risk assessment in advance is the responsibility of the anesthesiologists, who also assess which anesthesia can be used - general anesthesia or only partial anesthesia of the person to be operated on leg The concept also includes controlling the after-effects of the anesthetic in such a way that the patients can get up quickly and start moving. "All of this has advantages and disadvantages," says anesthetist Prof. Robert Werdehausen, "that's why we weigh up exactly what is best for the individual." Because the package of measures is definitely effective.
Transfusion frequency of only three percent
So effective that blood preparations are currently only prepared and made available for certain risk patients before the operation as a precautionary measure - instead of for everyone, as was the case before. With up to 400 operations a year, that makes a big difference. "We were able to adjust the internal guidelines because with our procedure we have reduced the transfusion frequency in endoprosthetic operations to three percent," explains orthopedist Dr. Christina Pepe.
She has accompanied the process from the beginning and is trying to push it further: Even before the operation, it can be ensured that transfusions become superfluous. "The hemoglobin value HB gives us important information for this." In the case of anemia, i.e. anemia, the risk of transfusions increases despite all measures, evaluations have shown. So the UKL orthopaedists already check the blood values and the HB value in the consultation hours before the operation. "If this is too low, we ask the general practitioners to treat the patient's associated anemia before the operation," explains Pempe. If that works, this building block also contributes to creating the perfect conditions for the success of the complex implantation of the artificial joints.
"We are now increasingly using the new procedure for more complicated operations to change an endoprosthesis," says Dr. Christina Pempe further. Because the processes have worked well – including those after the operation. Because another innovation is the omission of drainage, i.e. the drainage of liquid from the tissue via a catheter. "Since we close the vessels, we no longer need this tube under the skin," says Prof. Andreas Roth. So far, this should prevent swelling, but also ensure that possible postoperative bleeding is controlled. This is no longer needed; the hemostasis during the operation takes care of that. At the same time, inflammation can be completely avoided. "In this way, we also prevent prostheses from loosening again," says the orthopaedist.
The changes during the operation also change the routines on the ward: Drainage checks and changes are no longer necessary, but the patients receive special cooling in aftercare, get up much faster to get moving again, and leave earlier Hospital.
"It wasn't always an easy learning process full of changes," Roth looks back, "which was probably only possible in a clinic like ours, where so many experts come together." His patients benefited. "When I visit them after the operation, I am always surprised myself at how well they are doing and how quickly they are mobile again."
Source: Press release University Hospital Leipzig from 01.08.2023