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Does living at high altitude increase the risk of bleeding events after total knee arthroplasty? A retrospective cohort study

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Abstract

Objective

Post-operative bleeding after total knee arthroplasty (TKA) is a frequent cause of post-operative complications. This study compared blood loss and indicators of coagulation and fibrinolysis between TKA patients living at low or high altitudes.

Methods

We retrospectively analyzed 120 patients at our institution who underwent primary TKA from May 2019 to March 2020, and we divided them into those living in areas about 500 m or > 3000 m above sea level. We compared the primary outcome of total blood loss between them. We also compared them in terms of several secondary outcomes: coagulation and fibrinolysis parameters, platelet count, reduction in hemoglobin, hidden blood loss, intra-operative blood loss, transfusion rate, and incidence of thromboembolic events and other complications.

Results

Total blood loss was significantly higher in the high-altitude group than in the low-altitude group (mean, 748.2 mL [95% CI, 658.5–837.9] vs 556.6 mL [95% CI, 496.0–617.1]; p = 0.001). The high-altitude group also showed significantly longer activated partial thromboplastin time, prothrombin time, and thrombin time before surgery and on post-operative day one, as well as increased levels of fibrinogen/fibrin degradation product on post-operative days one and three. Ecchymosis was significantly more frequent in the high-altitude group (41.7 vs 21.7%; relative risk (RR) = 1.923 [95% CI, 1.091–3.389]; p = 0.019). The two groups showed similar transfusion rates, and none of the patients experienced venous thromboembolism, pulmonary embolism, or infection.

Conclusion

High altitude may alter coagulation and fibrinolysis parameters in a way that increases risk of blood loss after TKA. Such patients may benefit from special management to avoid bleeding events.

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References

  1. Van Manen MD, Nace J, Mont MA (2012) Management of primary knee osteoarthritis and indications for total knee arthroplasty for general practitioners. The Journal of the American Osteopathic Association 112:709–715

    Google Scholar 

  2. Kurtz S, Ong K, Lau E, Mowat F, Halpern M (2007) Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. The Journal of bone and joint surgery American 89:780–785. https://doi.org/10.2106/jbjs.F.00222

    Article  Google Scholar 

  3. Laoruengthana A, Rattanaprichavej P, Rasamimongkol S, Galassi M, Weerakul S, Pongpirul K (2019) Intra-articular tranexamic acid mitigates blood loss and morphine use after total knee arthroplasty. A Randomized Controlled Trial. J Arthroplasty 34:877–881. https://doi.org/10.1016/j.arth.2019.01.030

    Article  Google Scholar 

  4. Singla A, Malhotra R, Kumar V, Lekha C, Karthikeyan G, Malik V (2015) A randomized controlled study to compare the total and hidden blood loss in computer-assisted surgery and conventional surgical technique of total knee replacement. Clin Orthop Surg 7:211–216. https://doi.org/10.4055/cios.2015.7.2.211

    Article  Google Scholar 

  5. Shin KH, Choe JH, Jang KM, Han SB (2020) Use of bone wax reduces blood loss and transfusion rates after total knee arthroplasty. Knee 27:1411–1417. https://doi.org/10.1016/j.knee.2020.07.074

    Article  Google Scholar 

  6. Su EP, Su S (2016) Strategies for reducing peri-operative blood loss in total knee arthroplasty. Bone Joint J 98-b(1 Suppl A):98–100. https://doi.org/10.1302/0301-620x.98b.36430

    Article  CAS  Google Scholar 

  7. Levine BR, Haughom B, Strong B, Hellman M, Frank RM (2014) Blood management strategies for total knee arthroplasty. J Am Acad Orthop Surg 22:361–371. https://doi.org/10.5435/jaaos-22-06-361

    Article  Google Scholar 

  8. Luo Y, Zhao X, Releken Y, Yang Z, Pei F, Kang P (2020) Hemostatic and anti-inflammatory effects of carbazochrome sodium sulfonate in patients undergoing total knee arthroplasty: a randomized controlled trial. J Arthroplasty 35:61–68. https://doi.org/10.1016/j.arth.2019.07.045

    Article  Google Scholar 

  9. Quindry J, Dumke C, Slivka D, Ruby B (2016) Impact of extreme exercise at high altitude on oxidative stress in humans. J Physiol 594:5093–5104. https://doi.org/10.1113/jp270651

    Article  CAS  Google Scholar 

  10. Paralikar SJ, Paralikar JH (2010) High-altitude medicine. Indian journal of occupational and environmental medicine 14:6–12. https://doi.org/10.4103/0019-5278.64608

    Article  Google Scholar 

  11. Brent MB (2022) A review of the skeletal effects of exposure to high altitude and potential mechanisms for hypobaric hypoxia-induced bone loss. Bone 154:116258. https://doi.org/10.1016/j.bone.2021.116258

    Article  CAS  Google Scholar 

  12. Liu Y, Zhang JH, Gao XB, Wu XJ, Yu J, Chen JF, Bian SZ, Ding XH, Huang L (2014) Correlation between blood pressure changes and AMS, sleeping quality and exercise upon high-altitude exposure in young Chinese men. Mil Med Res 1:19. https://doi.org/10.1186/2054-9369-1-19

    Article  CAS  Google Scholar 

  13. Zhang R, Yu X, Shen Y, Yang C, Liu F, Ye S, Du X, Ma L, Cao H, Wang Z, Li C (2019) Correlation between RBC changes and coagulation parameters in high altitude population. Hematology (Amsterdam, Netherlands) 24:325–330. https://doi.org/10.1080/16078454.2019.1568658

    Article  CAS  Google Scholar 

  14. Jiang P, Wang Z, Yu X, Qin Y, Shen Y, Yang C, Liu F, Ye S, Du X, Ma L, Cao H, Sun P, Su N, Lin F, Zhang R, Li C (2021) Effects of long-term high-altitude exposure on fibrinolytic system. Hematology (Amsterdam, Netherlands) 26:503–509. https://doi.org/10.1080/16078454.2021.1946265

    Article  CAS  Google Scholar 

  15. Tyagi T, Ahmad S, Gupta N, Sahu A, Ahmad Y, Nair V, Chatterjee T, Bajaj N, Sengupta S, Ganju L, Singh SB, Ashraf MZ (2014) Altered expression of platelet proteins and calpain activity mediate hypoxia-induced prothrombotic phenotype. Blood 123:1250–1260. https://doi.org/10.1182/blood-2013-05-501924

    Article  CAS  Google Scholar 

  16. Damodar D, Vakharia R, Vakharia A, Sheu J, Donnally CJ 3rd, Levy JC, Kaplan L, Munoz J (2018) A higher altitude is an independent risk factor for venous thromboembolisms following total shoulder arthroplasty. J Orthop 15:1017–1021. https://doi.org/10.1016/j.jor.2018.09.003

    Article  Google Scholar 

  17. Kicken CH, Ninivaggi M, Konings J, Moorlag M, Huskens D, Remijn JA, Bloemen S, Lancé MD, De Laat B (2018) Hypobaric hypoxia causes elevated thrombin generation mediated by FVIII that is balanced by decreased platelet activation. Thromb Haemost 118:883–892. https://doi.org/10.1055/s-0038-1641566

    Article  Google Scholar 

  18. von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP (2014) The strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. International journal of surgery (London, England) 12:1495–1499. https://doi.org/10.1016/j.ijsu.2014.07.013

    Article  Google Scholar 

  19. Luo Y, Zhao X, Yang Z, Yeersheng R, Kang P (2021) Effect of carbazochrome sodium sulfonate combined with tranexamic acid on blood loss and inflammatory response in patients undergoing total hip arthroplasty. Bone & joint research 10:354–362. https://doi.org/10.1302/2046-3758.106.Bjr-2020-0357.R2

    Article  Google Scholar 

  20. Gross JB (1983) Estimating allowable blood loss: corrected for dilution. Anesthesiology 58:277–280. https://doi.org/10.1097/00000542-198303000-00016

    Article  CAS  Google Scholar 

  21. Nadler SB, Hidalgo JH, Bloch T (1962) Prediction of blood volume in normal human adults. Surgery 51:224–232

    Google Scholar 

  22. D’Alessandro A, Nemkov T, Sun K, Liu H, Song A, Monte AA, Subudhi AW, Lovering AT, Dvorkin D, Julian CG, Kevil CG, Kolluru GK, Shiva S, Gladwin MT, Xia Y, Hansen KC, Roach RC (2016) AltitudeOmics: red blood cell metabolic adaptation to high altitude hypoxia. J Proteome Res 15:3883–3895. https://doi.org/10.1021/acs.jproteome.6b00733

    Article  CAS  Google Scholar 

  23. Pichler Hefti J, Risch L, Hefti U, Scharrer I, Risch G, Merz TM, Turk A, Bosch MM, Barthelmess D, Schoch O, Maggiorini M, Huber AR (2010) Changes of coagulation parameters during high altitude expedition. Swiss Med Wkly 140:111–117

    Google Scholar 

  24. Vij AG (2009) Effect of prolonged stay at high altitude on platelet aggregation and fibrinogen levels. Platelets 20:421–427. https://doi.org/10.1080/09537100903116516

    Article  CAS  Google Scholar 

  25. Gupta N, Ashraf MZ (2012) Exposure to high altitude: a risk factor for venous thromboembolism? Semin Thromb Hemost 38:156–163. https://doi.org/10.1055/s-0032-1301413

    Article  CAS  Google Scholar 

  26. Damodar D, Donnally CJ 3rd, Sheu JI, Law TY, Roche MW, Hernandez VH (2018) A higher altitude is an independent risk factor for venous thromboembolisms after total hip arthroplasty. J Arthroplasty 33:2627–2630. https://doi.org/10.1016/j.arth.2018.03.045

    Article  Google Scholar 

  27. Wang J, Zhu HL, Shi ZJ, Zhang Y (2018) The application of thromboelastography in understanding and management of ecchymosis after total knee arthroplasty. J Arthroplasty 33:3754–3758. https://doi.org/10.1016/j.arth.2018.08.024

    Article  Google Scholar 

  28. Rocke AS, Paterson GG, Barber MT, Jackson AIR, Main SE, Stannett C, Schnopp MF, MacInnis M, Baillie JK, Horn EH, Moores C, Harrison P, Nimmo AF, Thompson AAR (2018) Thromboelastometry and platelet function during acclimatization to high altitude. Thromb Haemost 118:63–71. https://doi.org/10.1160/th17-02-0138

    Article  Google Scholar 

  29. Wang Z, Liu H, Dou M, Du X, Hu J, Su N, Wang Y, Zhang R, Li C (2017) The quality changes in fresh frozen plasma of the blood donors at high altitude. PLoS ONE 12:e0176390. https://doi.org/10.1371/journal.pone.0176390

    Article  CAS  Google Scholar 

  30. Ong CC, Gopinath SCB, Rebecca LWX, Perumal V, Lakshmipriya T, Saheed MSM (2018) Diagnosing human blood clotting deficiency. Int J Biol Macromol 116:765–773. https://doi.org/10.1016/j.ijbiomac.2018.05.084

    Article  CAS  Google Scholar 

  31. Changjun C, Xin Z, Yue L, Chengcheng Z, Qiuru W, Qianhao L, Pengde K (2021) Tranexamic acid attenuates early post-operative systemic inflammatory response and nutritional loss and avoids reduction of fibrinogen in total hip arthroplasty within an enhanced recovery after surgery pathway. Int Orthop 45:2811–2818. https://doi.org/10.1007/s00264-021-05182-3

    Article  Google Scholar 

  32. Carling MS, Zarhoud J, Jeppsson A, Eriksson BI, Brisby H (2016) Preoperative plasma fibrinogen concentration, factor XIII activity, perioperative bleeding, and transfusions in elective orthopaedic surgery: a prospective observational study. Thromb Res 139:142–147. https://doi.org/10.1016/j.thromres.2016.01.001

    Article  CAS  Google Scholar 

  33. Weitz JI, Fredenburgh JC, Eikelboom JW (2017) A test in context: D-dimer. J Am Coll Cardiol 70:2411–2420. https://doi.org/10.1016/j.jacc.2017.09.024

    Article  CAS  Google Scholar 

  34. Xiao L, Zheng X, Jiang H, Huang W, Qiu F, Li X (2021) Risk factors for ecchymosis in patients receiving rivaroxaban for thromboprophylaxis after total knee arthroplasty: a retrospective cohort study. J Clin Pharm Ther 46:1281–1287. https://doi.org/10.1111/jcpt.13420

    Article  CAS  Google Scholar 

  35. Ahmed I, Chawla A, Underwood M, Price AJ, Metcalfe A, Hutchinson CE, Warwick J, Seers K, Parsons H, Wall PDH (2021) Time to reconsider the routine use of tourniquets in total knee arthroplasty surgery. Bone Joint J 103-b(5):830–839. https://doi.org/10.1302/0301-620x.103b.Bjj-2020-1926.R1

    Article  Google Scholar 

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Acknowledgements

We want to express our sincere appreciation for all the patients that joined this study.

Funding

This work was supported by the 1.3.5 project for disciplines of excellence, West China Hospital, Sichuan University (No. ZYJC18040).

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Author notes

  1. Cheng-cheng Zhao and Li-yile Chen contributed equally to this work and should be regarded as first co-authors.

Authors and Affiliations

  1. Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, No. 37 Guoxue Road, Chengdu, People’s Republic of China

    Cheng-cheng Zhao, Li-yile Chen, Chang-jun Chen, Qiu-ru Wang, Qian-hao Li & Peng-de Kang

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  1. Cheng-cheng Zhao
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Contributions

All authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by Cheng-cheng Zhao, Li-yile Chen, Chang-jun Chen, Qiu-ru Wang, and Qian-hao Li. The first draft of the manuscript was written by Cheng-cheng Zhao and Li-yile Chen, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Peng-de Kang.

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Ethics approval

The trial was registered in the Chinese Clinical Trial Registry (ChiCTR2200060414), and ethically approved by Biomedical Ethics Committee of West China Hospital.

Competing interests

The authors declare no competing interests.

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Zhao, Cc., Chen, Ly., Chen, Cj. et al. Does living at high altitude increase the risk of bleeding events after total knee arthroplasty? A retrospective cohort study. International Orthopaedics (SICOT) 47, 67–74 (2023). https://doi.org/10.1007/s00264-022-05614-8

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