Paradigm Shift: Patient Optimization Before Elective Arthroplasty

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“We’ve had a change in mindset,” says Harpal Khanuja, chief of adult reconstruction, hip and knee replacement in the Johns Hopkins Department of Orthopaedic Surgery. Having published a recent review* of perioperative iron supplementation for elective total joint arthroplasty (TJA), Khanuja is helping to lead the collective conversation about minimizing postoperative anemia and optimizing patient hemoglobin levels before surgery.

While the avoidance of blood transfusions to improve patient outcomes after TJA was the initial goal for blood management, Khanuja explains, “It’s not just about avoiding transfusions anymore. Now we know we have to minimize anemia too. Even patients who avoided transfusions, when their hemoglobin after surgery dropped to less than 8 g/dL [grams per decilitre], they experienced more complications.”

Anemia is associated with several poor outcomes, including longer hospital stays, increased need for transfusions, and higher risk of surgical site and periprosthetic joint infections. The goal of preoperative patient optimization, which can also include weight loss, diabetes control, and cessation of tobacco and narcotic use, is to avoid such complications. Khanuja recently explored two critical research questions: Can perioperative iron supplementation improve a patient’s hemoglobin level after TJA? And if so, can it reduce adverse events and improve quality of life?

Transfusion avoidance and postoperative anemia are directly related. In recent years, the rate of transfusions after TJA decreased from approximately 20% to less than 1%. In addition to meticulous surgical technique, the use of tranexamic acid and other blood conservation strategies, a major contributor to the decrease in transfusions is tolerating a lower intraoperative hemoglobin level. Previously, common practice was to administer transfusions to keep hemoglobin concentration no lower than 10 g/dL. “Now we let patients go down to 7 g/dL, which is the equivalent of about two units of blood,” says Khanuja. An unintended effect of this practice, however, is that more patients experience postoperative anemia.

Khanuja says he and his team found in their review that “it wasn’t compelling at all to be giving patients oral iron. In patients who are very anemic, with hemoglobin less than 10 g/dL, it does help to give intravenous iron, but in elective cases, we should really be treating anemia before the patient comes to surgery.”

They found evidence supporting intravenous iron supplementation during and after surgery to reduce the rate of anemia at 30 days postoperatively, and some data suggesting that intravenous iron was associated with improved quality of life.

Today, Khanuja advocates for collaboration among primary care physicians and orthopaedists to ensure that patients’ hemoglobin levels are as high as possible before elective TJA. “We want to figure out how to make it easy for orthopaedists to do this, possibly using an algorithm,” he says. “For patients who are on the low end of normal [hemoglobin], they will be cleared by primary care for surgery. But that low level does have implications for outcomes. We need to identify and treat the underlying reason for their anemia. This is a bit of a paradigm shift.”

Khanuja’s multidisciplinary approach to preoperative optimization for elective TJA “really comes down to population health,” he says. Khanuja and his team continue to work to obtain the best possible outcomes for their patients with TJA and to research ways for orthopaedists around the globe to do the same.


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*Chaudhry Y et al. Intraoperative and Postoperative Iron Supplementation in Elective Total Joint Arthroplasty: a Systematic Review. J Am Acad Orthop Surg. 2021 Feb 15. doi:10.5435/JAAOS-D-20-01171. Online ahead of print.