Effectiveness of Multi-Modal Blood Management in Bernese Periacetabular Osteotomy and Periacetabular Osteotomy with Proximal Femoral Osteotomy

Abstract

Objective: Bernese periacetabular osteotomy (PAO), an effective treatment for patients with developmental dysplasia of the hip (DDH), is characterized by wide exposure, cancellous bone surgery, and difficult techniques. In addition, the hip joint is deep and of rich muscles and neurovascular supply, which significantly increases bleeding. For patients who had combined proximal femoral osteotomy (PFO), the blood loss may be tremendous. The blood management for PAO is still challenging. We aimed to evaluate the effectiveness of multi-modal blood management for PAO and PAO combined with PFO. Patients and Methods: We retrospectively evaluated patients who had PAO with or without combined procedures from June 2010 to December 2018 in our department. The multi-modal blood management protocol included three parts: (i) pre-operation – autologous component blood donation and iron supplement/erythropoietin; (ii) during operation – controlled hypotension anesthesia, intraoperative auto-blood transfusion, tranexamic acid (20 mg/kg, IV / 0.5 g local), and standardized surgical procedure to shorten surgical time; and (iii) post-operation – no drainage used, selective allo-blood transfusion, and ice packing technique. As the lacking of the above standard blood management protocol during PAO or PAO + PFO initially, we divided all the patients into three groups: Group A (PAO) – before protocol started, 74 hips; Group B (PAO) – after protocol finalized, 178 hips; Group C (PAO + PFO) – after protocol finalized, 55 hips. The intraoperative blood loss, surgical time, allo-transfusion rate, pre- and postoperative hemoglobin were compared among groups. Results: Both the general characteristics and preoperative hemoglobin were comparable among the three groups (P < 0.001). The intraoperative blood loss was 797.1 ± 312.2, 381.7 ± 144.0 and 544.1 ± 249.1 mL, respectively. The surgical time was 109.6 ± 18.5, 80.2 ± 20.0 and 154.3 ± 44.7 min, respectively. The allo-transfusion rate was 86.5%, 0%, and 2%, respectively. The mean decreased value of hemoglobin on the first postoperative day of group B and group C was greater than that of group A, which was associated with the higher allo-transfusion rate of group A. However, on the third postoperative day, the mean decreased value of hemoglobin of group B was less than that of group A and group C. Conclusion: Perioperative multi-modal blood management for PAO or PAO + PFO can significantly decrease intraoperative blood loss, reduce allo-transfusion rate from over 80% to 0%, and ensure the rapid recovery of postoperative hemoglobin level.