Archives of Orthopaedic and Trauma Surgery

, Volume 131, Issue 5, pp 663–667 | Cite as

Maximum surgical blood ordering schedules for revision lower limb arthroplasty

  • Devendra Mahadevan
  • Christopher Challand
  • Andrew Clarke
  • Jonathan Keenan
Orthopaedic Surgery



Effective utilisation of blood products is fundamental. The introduction of maximum surgical blood ordering schedules (MSBOS) for operations has been shown to improve transfusion services. A retrospective analysis was undertaken to establish an evidence-based MSBOS for revision total hip replacement (THR) and total knee revision (TKR). The impact of this schedule on blood conservation was analysed.


A retrospective analysis was undertaken on 397 patients who underwent revision THR and TKR over a 4-year period. The cross-match-to-transfusion ratio (CTR) and transfusion index (TI) were calculated. A MSBOS protocol was created based on the TIs and its’ impact on transfusion services was assessed prospectively on 125 patients by comparing CTRs.


In revision THR, TI was 1.19 for elective cases, 1.55 for emergency cases and 2.35 for infected cases. There was no difference in TI for revisions of cemented and uncemented components. Single component THR revision required less transfusion. In revision TKR, TI was 0.31 for elective cases, 2.0 for emergency cases and 1.23 for cases with infection. The introduction of the MSBOS protocol had resulted in a considerable improvement in blood ordering. Reductions in the CTR were seen for all types of revision surgery, but most evident in elective revision THR (3.24–2.18) and elective revision TKR (7.95–1.2).


Analysis confirmed that excessive cross-matching occurred for revision lower limb arthroplasty. The introduction of our MSBOS protocol promoted blood conservation and compliance with established national guidelines.


Revision arthroplasty Hip Knee Transfusion MSBOS 


  1. 1.
    Sharma S, Cooper H, Ivory JP (2002) An audit on the blood transfusion requirements for revision hip arthroplasty. Ann R Coll Surg Engl 84(4):269–272PubMedCrossRefGoogle Scholar
  2. 2.
    Bridgens JP, Evans CR, Dobson PMS, Hamer AJ (2007) Intraoperative red blood-cell salvage in revision hip surgery: a case-matched study. J Bone Joint Surg Am 89(2):270–275PubMedCrossRefGoogle Scholar
  3. 3.
    Nicholis MD (1993) How safe is blood? Anaesth Intensive Care 21:13–14Google Scholar
  4. 4.
    Bird SM (2004) Recipients of blood or blood products ‘at vCJD risk’. BMJ 328(7432):118–119PubMedCrossRefGoogle Scholar
  5. 5.
    National Blood Service (2004) UK blood services defer transfused blood donors [news release]. National Blood Service, Mar 16Google Scholar
  6. 6.
    Clarke A, O’Malley M, Hegarty JF, Freeman BJC (2006) Blood audit evidence-based cross-match requesting for lumbar spine surgery. Spine 31(12):E373–E375PubMedCrossRefGoogle Scholar
  7. 7.
    Rogers BA, Johnstone DJ (2006) Audit on the efficient use of cross-matched blood in elective total hip and total knee replacement. Ann R Coll Surg Engl 88(2):199–201PubMedCrossRefGoogle Scholar
  8. 8.
    Hamer AJ, Dobson PMS, Earnshaw PH, Knowles S, Newman JH (2005) Blood conservation in elective orthopaedic surgery. Br Orthop Assoc, LondonGoogle Scholar
  9. 9.
    Voak D, Napier JAF, Boulton FE, Cann R, Finney RD, Fraser ID, Wagstaff W, Waters AH, Wood JK (1990) British Committee for Standards in haematology blood transfusion task force guidelines for implementation of a maximum surgical blood order schedule. Clin Lab Haematol 12:321–327CrossRefGoogle Scholar
  10. 10.
    Richardson NGB, Bradley WN, Donaldson DR, O’Shaughnessy DF (1998) Maximum surgical blood ordering schedule in a district general hospital saves money and resources. Ann R Coll Surg Engl 80(4):262–265PubMedGoogle Scholar
  11. 11.
    Wilson WJ (1989) Intraoperative autologous transfusion in revision total hip arthroplasty. J Bone Joint Surg Am 71:8–14PubMedGoogle Scholar
  12. 12.
    Zarin J, Grosvenor D, Schurman D, Goodman S (2003) Efficacy of intraoperative blood collection and reinfusion in revision total hip arthroplasty. J Bone Joint Surg Am 85:2147–2151PubMedGoogle Scholar
  13. 13.
    Semkiw LB, Schurman DJ, Goodman SB, Woolson ST (1989) Postoperative blood salvage using cell saver after total joint arthroplasty. J Bone Joint Surg Am 71:823–827PubMedGoogle Scholar
  14. 14.
    Gehrke T (2005) Revision is not difficult!. In: Breusch SJ, Malchau H (eds) The well-cemented total hip arthroplasty: theory and practice. Springer, Berlin, pp 348–358CrossRefGoogle Scholar
  15. 15.
    Lemaire R (2008) Strategies for blood management in orthopaedic and trauma surgery. J Bone Joint Surg Br 90(B9):1128–1136PubMedGoogle Scholar
  16. 16.
    Pola E, Papaleo P, Santoliquido A, Gasparini G, Aulisa L, De Santis E (2004) Clinical factors associated with an increased risk of perioperative blood transfusion in non-anemic patients undergoing total hip arthroplasty. J Bone Joint Surg Am 86(A1):57–61PubMedGoogle Scholar
  17. 17.
    Guay J (2006) Postoperative pain significantly influences postoperative blood loss in patients undergoing total knee replacement. Pain Med 7(6):476–482PubMedCrossRefGoogle Scholar
  18. 18.
    The Sanguis Study Group (1994) Use of blood products for elective surgery in 43 European hospitals. Transfus Med 4:251–268Google Scholar
  19. 19.
    Bierbaum BE, Callaghan JJ, Galante JO, Rubash HE, Tooms RE, Welch RB (1999) An analysis of blood management in patients having a total hip or knee arthroplasty. J Bone Joint Surg Am 81:2–10PubMedGoogle Scholar
  20. 20.
    Churchill WH, McGurk S, Chapman RH, Wallace EL, Bertholf MF, Goodnough LT et al (1998) The Collaborative Hospital Transfusion Study: variations in use of autologous blood account for hospital differences in red cell use during primary hip and knee surgery. Transfusion 38:530–539PubMedCrossRefGoogle Scholar
  21. 21.
    Hatzidakis AM, Mendlick RM, McKillip T, Reddy RL, Garvin KL (2000) Preoperative autologous donation for total joint arthroplasty. An analysis of risk factors for allogeneic transfusion. J Bone Joint Surg Am 82:89–100PubMedGoogle Scholar
  22. 22.
    Borghi B, Fanelli G, Celleno D (1999) Autotransfusion with predeposit-haemodilution and perioperative blood salvage: 20 years of experience Rizzoli Study Group on Orthopaedic Anesthesia. Int J Artif Organs 22:230–234PubMedGoogle Scholar
  23. 23.
    Carson JL, Terrin ML, Magaziner J, Chaitman BR, Apple FS, Heck DA, Sanders D (2006) Transfusion trigger trial for functional outcomes in cardiovascular patients undergoing surgical hip fracture repair. Transfusion 46:2192–2206PubMedCrossRefGoogle Scholar
  24. 24.
    Smith TO, Hing CB (2010) Is a tourniquet beneficial in total knee replacement surgery? a meta-analysis and systematic review. Knee 17(2):141–147PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag 2010

Authors and Affiliations

  • Devendra Mahadevan
    • 1
  • Christopher Challand
    • 2
  • Andrew Clarke
    • 2
  • Jonathan Keenan
    • 2
  1. 1.University Hospitals of Leicester, Leicester Royal InfirmaryLeicesterUK
  2. 2.Plymouth Hospitals NHS TrustDerriford HospitalPlymouthUK

Personalised recommendations