Blood Conservation During Joint Replacement Surgery

By
Brett Greenky, MD
Kimberley Murray, RN

Everyone undergoing joint replacement surgery is concerned with preventing the need for blood transfusion.  There are compelling reasons to minimize the need for blood transfusions which include:

·        Increased postoperative infection rates

·        Possible disease transmission

o   Anxiety about the risk of transfusion related problems include the unlikely possibility of disease infection, however, the risk of HIV or Hepatitis B or C transmission is quite remote

·        Allergic reactions

·        Potential for administration errors

·        Lung injuries

·        Increased postoperative length of stay in the hospital

·        High cost

o   Approximately $200 for the blood unit itself but with processing and handling the overall cost is upwards of $1000 per unit.

Let’s examine the HISTORICAL facts:

1.      No single transmission of HIV (the AIDS virus) has been reported in a joint replacement surgery associated with a transfusion in the past 15 years according to the Centers for Disease Control (CDC).  This is because of the now routine and sophisticated testing of donated units over the last 15 years.

2.      There is no test for Hepatitis C presence in donated blood. Although the transmission risk is remote, a very small risk persists.  Donators of blood units are questioned about the risk factors for the presence of Hepatitis C and are subsequently excluded from donation.

3.      The risk of a transfusion related problem resulting from receiving a transfusion from a family member is the same as it is for receiving a blood transfusion from the general public.  Family designated donation for upcoming surgery is NOT safer than getting blood from the general American Red Cross blood bank.  As a result of this fact, nearly all large joint replacement programs have discontinued designated donor programs.

4.      Donating your own blood to be available for later surgery (Autologous Blood Donation) has NOT been successful in reducing the need for blood transfusion from the bank.  Additionally, autologous transfusion is not without health risks:

·        Lowering your blood count near the time of your surgery

·        Decreased effectiveness related to cold storage and processing

·        Potential clerical/handling errors

As a result, nearly all large joint replacement programs have discontinued autologous donation programs.

What is the present “State of the Art” nationally for Joint Replacement Programs?

1.      A national transfusion rate of approximately 25% is noted for joint replacement surgery.  The rate of transfusion is a slightly higher for total hip replacement than for total knee replacement.

2.      Patients that require blood transfusions have slightly longer hospital stays than patients that do not need a transfusion.

3.      Blood products are a precious resource in which the demand exceeds the available supply.  Transfusions are costly to the health care system when used for elective surgery and also deplete our supply of banked blood for emergency situations.

The St. Joseph’s Hospital Health Center Joint Replacement Program has successfully and dramatically reduced the need for transfusion far beyond the average hospital.  We have done this with a multifaceted approach.  Our goal is to even further reduce the need for transfusion.  We were recently awarded the 2011 Red Cross Home Town Hero Award for a 400% reduction in the use of blood products for patients in our joint replacement program!   The transfusion rate at St. Joseph’s for our total joint replacement patients is below 8% which equates to less than 0.2 units of packed red blood cells transfused per patient.

How this was achieved:

(Preoperative, Intraoperative, and Postoperative Measures)

1.      Development of a formal Blood Management Program in 2005 which includes a dedicated blood conservation nurse.

2.      Preoperative screening for all elective joint replacement patients includes testing of Iron reserves and reticulocyte counts (young red blood cells).  Patients who are anemic or low in Iron stores receive supplements PRIOR to the surgery to boost them.

3.      Appropriate anemic patients receive Erythropoietin, a natural hormone that boosts red blood cell counts prior to surgery.

4.      Preoperative nutritional counseling and guidance to build iron stores

5.      Blood salvage machines collect, wash, and re-transfuse the patients’ red blood cells both during and after surgery, minimizing the amount of lost cells. 

6.      Use of an intraoperative tourniquet during knee replacement surgery.

7.      Spinal anesthesia administration

8.      Maintenance of normothermia (body temperature regulated within a controlled range)

9.      Our newest strategy involves the use of Tranexamic Acid, a medicine which helps reduce operative bleeding, during the operation

10.  Elimination of “routine” blood transfusions and instead transfusing patients when their symptoms/condition necessitate it

  

Our goal is to totally eliminate the need for transfusions for elective joint replacement surgery while continuing to provide safe and optimal surgical outcomes for our patients.

Coming next week........Minimizing Blood Transfusion Needs Associated with Total Joint Replacement

Multimodal Pain Management During Joint Replacement Surgery

By
Seth Greenky, MD
Kimberley Murray, RN

We recognize that pain is a major concern for a patient about to undergo hip or knee replacement surgery.  Educating yourself about pain and effective ways to manage it before experiencing surgical pain can reduce your fear and assist you to manage your expectations and ultimately, your post-operative pain. 

Orthopedic surgeons are continuously challenged to find a pain relief regime that reduces the amount of pain that a patient experiences while minimizing the side effects of narcotics and other analgesics.  Inadequate pain control potentially delays physical therapy progress, hospital discharge, and the overall surgical recovery time.  More and more research is emerging that supports the use of a Multimodal Pain Management Strategy as the most effective mechanism to control pain , promote mobility, and improve functional outcomes after hip and knee replacement.

What is it?

Multimodal analgesia or balanced analgesia is the use of more than one method of managing or controlling pain.  It involves administering multiple drug and treatment modalities utilizing more than a single route of administration across the entire surgical course or perioperative continuum including:

·         Preoperative period (before surgery)

·         Intra-operative (during surgery)

·         Post-operative (after surgery)

Post-operative pain is the result of a complex series of events and reactions within the body as the result of the trauma or assault caused by the surgical procedure.  The response to pain is triggered by reactions occurring locally at the site of the surgery as well as centrally in the brain.  Using a combination of methods and drugs to control pain at the surgical site as well as centrally in the nervous system achieves the optimal pain control results.

Preoperative Phase of Care

Measures begin prior to the surgical incision.  They reduce the need for opioid drugs after surgery and usually include a combination of one or more of the following drugs:

·         NSAIDs

o   Nonsteroidal anti-inflammatory drugs that have analgesic, fever-reducing, and inflammation reducing properties

·         Cox-2 Inhibitors

o   A newer type of nonsteroidal anti-inflammatory drug that directly targets an enzyme responsible for inflammation and pain

·         Anti-neuropathics

o   A type of drug that is often used to treat seizures and neuropathic pain syndromes.  Studies have found that these drugs can help reduce the pain signals that are sent to the brain and result in reduced post-operative pain and use of morphine

Intraoperative Phase of Care

Measures are implemented during the surgical procedure.  They may include a combination of one or more of the following:

·         Spinal Analgesia/Spine Block (Regional Anesthesia)

o   Uses local anesthetics to blockade the central sensory and motor receptors for the time during the surgery as well as into the post-operative recovery phase of care

o   Also assists in reducing surgical blood loss and may diminish the incidence of post-operative nausea and vomiting as well

·         Peripheral Nerve Blocks

o   The injection of a local anesthetic onto or near nerves for the temporary control of pain

o   Performed either with a single injection or a continuous infusion through a catheter

·         Intraoperative Injections

o   Use of “cocktails” comprised of morphine, an anti-inflammatory, and a local anesthetic to block the inflammatory and pain pathways

Post-operative Phase of Care

Measures are implemented during the recovery period.  They may include a combination of one or more of the following:

·         Intravenous Patient Controlled Analgesia (PCA)

o   Utilizes infusion pumps to deliver patient initiated  small doses of opioids (morphine, hydromorphone, fentanyl)

o   Patients must be willing and able to actually participate in their care

·         Continuous Non-narcotic, Surgical Site Pain Relief Pump

o   A device that continuously pumps a local anesthetic through a catheter to the surgical site and surrounding area for 1-2 days after the surgery

·         Acetaminophen

o   Results in reduced opioid requirements

There is no single approach to multimodal pain management that has emerged as the best practice method.  There are myriad variations to the approaches used by joint replacement surgeons and anesthesia providers but the elements are similar and they all focus on

·         Getting ahead of pain (preventing it before it begins)

·         Reducing the use of narcotics

·         Reducing nausea and vomiting

·         Diminishing post-operative sleepiness

·         Promotion of early mobility (which also minimizes the risk of deep venous thrombosis—DVT)

·         Contributing to the overall improved surgical outcomes and early discharge from the hospital

If joint replacement surgery is in your near future, be inquisitive and ask your surgeon about his or her adoption of this approach to managing post-operative pain.  Take charge of your health and be your own best patient advocate.

References:

Gandhi, K. & Viscusi, E., Multimodal Pain Management Techniques in Hip and Knee Arthroplasty. The Journal of New York School of Regional Anesthesia, July, 2009.

Harlocker, T., Kopp, S., Pagnano, M.,  & Hebl, J., Analgesia for Total Hip and Knee Arthroplasty:  A Multimodal Pathway Featuring Peripheral Nerve Block.   Journal of the American Academy of Orthopedic Surgeons, March, 2006.

Joshi, GP., Ogunnaike, BO., Consequences of Inadequate Postoperative Pain Relief and Chronic Persistent Postoperative Pain.  Anesthesiology Clinics of North America, 2005.

Poruczni, M., Two Views on Multimodal Pain management. American Academy of Orthopedic Surgeons Now, July, 2010.

Coming Sunday...........

Multimodal Pain Management For Patients Undergoing Total Joint Replacement:  Easing the Discomfort of Surgery

What factors affect the result of my knee or hip replacement success?

Dr. Brett Greenky

            Experience,Experience, Experience

           

Increasingly patients are accessing health care services to increase mobility, functionality, and pain-free lifestyle choices through joint replacement services.  This year more than 560,000 knee replacements and over 400,000 hip replacements will be performed in the United States alone.  As our population ages, becomes more active and in some cases heavier, the need for joint replacement surgery is expected to increase over 300% in the next decade! Where should you go to get fixed? Data is available to help you make an informed decision.

Consider these facts:

            10 years ago, 60% of knee replacements were performed by surgeons who did less than 30 cases per year and in institutions that performed less than 100 cases per year. 

            Currently there is a strong trend towards specialization in the delivery of hip and knee replacement services. Select hospitals that perform more than a 1000 cases per year are emerging.  These institutions and the surgeons who work there have dramatically better results and lower complication rates when compared to the nonspecialized hospitals and surgeons.

            Studies over and over have shown lower pneumonia, urinary tract infection, deep infection, heart attacks, and blood clot rates after joint replacement surgery performed in these institutions. They all show the same thing: experience breeds excellence. The more experience, the bigger the gap in performance over the low volume centers. 

See for yourself:

1.    Journal of Bone and Joint Surgery (JBJS) 2004.  95-99% confidence levels are exhibited; high volumes equal lower risks and better results.

2.    JBJS 2004.  At the Brigham Hospital in Boston, surgeons doing less than 25 cases per year did 11% of the knee replacements but had problems at a rate twice as high as surgeons who do more than 100 cases per year.

3.    JBJS 2004.  81,000 Medicare patients were reviewed and results were superior in cases performed by surgeons with volumes above 50/ year compared with those done by surgeons with less than 12/ year.

4.    JBJS 2006.  High volume surgeons superior results seem to benefit all patients, but especially those with co-morbidities (that means lots of other medical issues that could complicate an otherwise routine procedure).

5.    JBJS 2010.  High volume surgeons and institutions provided care with lower rates of readmission, shorter lengths of stay in the hospital, more common discharge to home versus a rehab center, and lower risks of bleeding, infection, blood clots and pneumonia.

6.    The Proceedings of the Knee Society 2010.     High surgical volumes increase the likelihood of positive patient outcomes.

            Higher volumes equal superior results---Period. 

            It is becoming clearer that super high volumes are even better than high volumes.  Major joint replacement centers are emerging in many of America's major cities.  Hospitals that perform more than 1000 joint replacements per year are now available.  These centers have established treatment protocols which streamline care and give reliable and reproducible results.  There is little doubt that these centers and the corresponding surgeon staff will have the most experience in providing surgery services and exceptional patient outcomes.

          We are fortunate in our community to have one of these centers:  St Joseph's Hospital Health Center. St. Joe’s performed nearly 1400 joint replacement surgeries in 2010, the most of any hospital in Central New York. Indeed, data from 2004-2005 suggests 46% of ALL of Central New York joint replacement operations are performed at St Joe's! The team at SJH, headed by Drs. Seth and Brett Greenky is proud of our elite program and is dedicated to not only maintain an outstanding level of care, but to seek continuous improvement.

                        Brett Greenky

Coming January 16th

Watch for our upcoming post on Sunday..........

Total Joint Replacement Volume--How do surgeon and program volumes correlate with patient outcomes?

Boning Up On Osteoporosis



Dr. Seth Greenky



Necessary evils of all surgical subspecialties are important medical conditions that don't require surgery but require other intervention.  One such condition is osteoporosis, a problem responsible for contributing to more than 1.5 million fractures each year.  Orthopedists are in the front line in this battle so we unfortunately must deal with it.

A broken bone may be more than meets the eye.  It might be an early warning sign that you have osteoporosis.  Although osteoporosis is a fairly commonly used medical term in 2009, most people aren’t really aware of the far-reaching impact of this major health problem and the risk that it poses.

Osteoporosis (also call porous bone) is a condition that causes a loss of bone mineral density (BMD) resulting in the body’s bone becoming sponge-like and porous (filled with holes).  It gradually weakens the bones and makes them vulnerable to injury over time.  Persons with low bone density have a higher risk for an initial fracture and then a later re-fracture of the bones that are impacted by this disease.

Osteoporosis is a silent disease and people are often completely unaware that they are inflicted with this condition until experiencing a fall that normally would have had minor impact, results in a fractured wrist, hip, or compression fracture of the spine.

A Compelling Argument for Action

Consider the impact to society.  Osteoporosis contributes to more than 1.5 million fractures each year, including:

·         300,000 hip fractures

·         700,000 spine (vertebral) fractures

·         250,000 wrist fractures

·         300,000 fractures at other areas of the body

Often, the fracture dramatically impacts a person’s well-being and ability to live and function independently:

·         The risk of a serious repeat fracture can more than double after experiencing the first fracture

·         One out of four people who experience an osteoporotic hip fracture will need long-term nursing home care

·         More than half the people experiencing osteoporotic hip fractures will be unable to walk without the use of an assistive device

·         People experiencing an osteoporotic hip fracture have a 24% increased risk of dying within one year following the fracture

Hip fractures heal slowly, cause significant physical pain, and result in long-lasting disability.  Their impact is far reaching and extends to others beyond the person experiencing the fracture.  A broken bone does not always mean an individual has osteoporosis.  It does mean, however, that bone density testing should be considered to determine if it is a possible contributing cause.  Discuss this with your doctor.

According to the National Osteoporosis Foundation, more than 10 million Americans have osteoporosis and over 30 million have a bone density mass low enough that they are at risk for the disease.

The Many Faces of Osteoporosis

It may surprise you who should be concerned about developing osteoporosis.  Although aging Caucasian women are well-recognized to be affected by the disease, more than 2 million American men have osteoporosis as well.  The loss of bone knows no age boundaries and can also begin as young as the mid twenties.

Factors that put you at risk for developing osteoporosis include:

·         Aging

·         Caucasian race

·         Family history of osteoporosis

·         Small bone structure or being thinner than normal

·         Lack of weight-bearing exercise

·         Smoking cigarettes

·         Excessive alcohol intake

·         Reduced levels of estrogen after menopause

·         Long term use of certain drugs such as steroids

·         Low dietary intake of calcium or the reduced ability to absorb calcium and vitamin D

Diagnosis

Osteoporosis is usually diagnosed by your doctor by conducting a complete medical history and physical, x-rays, laboratory tests, and bone density testing.  Bone density testing is an x-ray technique that compares your own bone density to the peak bone density of a person usually in the mid twenties of your same sex and ethnicity.

Prevention

Osteoporosis is preventable and treatable.  Preventative measures should actually begin in childhood. Eating a well-balanced, calcium-rich diet and regular physical exercise are critical to ensuring healthy bones.  Bone mass reaches its peak in the mid twenties and then levels off.  After people reach their mid thirties, bone mass begins to decline.  Adopting a life-long diet rich in calcium and vitamin D (milk, cheese, yogurt, soy, almonds, leafy green vegetables), engaging in regular weight-bearing exercise such as walking, hiking, jogging, and tennis, and avoiding habits that lead to calcium loss such as excessive alcohol consumption and cigarette smoking, can reduce bone density loss. Vitamin D in sufficient quantities supports the effective absorption of calcium.  Calcium supplements may also be an effective way to ensure an adequate daily intake of this important nutrient.  Ask your doctor for the calcium supplement that is right for you.

Treatment

It is impossible to replace bone that has been lost so treatment focuses on reducing the further loss of bone and preventing injuries.  Although there is no cure for osteoporosis, there are many medications that are effective in slowing the loss of bone and increasing bone density.  Discuss medication options with your doctor if you have a family history of osteoporosis or have been diagnosed with it by bone density testing.

Conclusion

Osteoporosis is a major health problem affecting millions of Americans.  Your doctor and you can effectively develop and implement a combination of measures to prevent the further loss of bone, establish effective exercise and nutritional therapies, explore medication treatment options, and adopt practices to minimize your risk of injury.  Be sure to discuss these options with your doctor at your next visit.

References:

American Academy of Orthopedic Surgeons

Centers for Disease Control and Prevention

National Osteoporosis Foundation

Welcome to Our Blog

About us:



We are orthopedic surgeons specializing in joint replacement surgery who practice together at Syracuse Orthopedic Specialists in Syracuse, NY and are affiliated with St. Joseph’s Hospital Health Center.  Even after 20+ years of practice, we still find the ever-advancing field of joint replacement fascinating.  We created this blog to open a small window of our world to others.





Dr. Brett Greenky



Dr. Seth Greenky





 

Rather than pontificate our credentials and backgrounds, we know of no better way to introduce ourselves to you than through the eyes of our mother.  Read on……………………

Help your brother’s boat across, and your own will reach the shore.

    --Hindu Proverb

This seems to be the mantra of the strikingly similar, yet dramatically different Greenky brothers.  As Dr. Seth Greenky, the more affable of the two, lingers behind to offer a reassuring word to a concerned patient or family member or to greet a hospital employee, Dr. Brett Greenky, precisely punctual and highly efficient, has finished rounding on his patients, checked in with his office, and moved on to arrive at his next destination well ahead of the scheduled time.  They jokingly identify and accentuate the other’s differences to all who know them and are highly competitive; however, brotherly instinct and protective action dramatically kick in if anyone else offers similar commentary.  It seems to be an activity reserved for exclusive exchange between the two of them.  They are remarkably passionate and completely unified about their profession, their specialty, and the care that they provide to their patients.  They seem to complement each other exceptionally well and strive to assist the other reach the next level of success.

Seth and Brett Greenky exude success and accomplishment.  There is an incomparable energy that surrounds them and radiates to those who work closely with them.  Merely fourteen months apart, the brothers grew up side by side and appear to have lives that paralleled each other in more ways than not.     They come from the same family, attended the same elementary and high schools, excelled at the same sport (wrestling) which earned them scholarships at Northwestern University, and attended medical school at SUNY Health Science Center.  After a brief divergent pathway as they each participated in fellowships at different locations, Seth at the Cleveland Clinic and Brett at New England Baptist, they reunited to partner together to pursue their chosen specialty, total joint replacement, at St. Joseph’s Hospital Health Center.

Is their parallel track and close relationship today a mere coincidence, or the result of a carefully crafted plan by their mother?  Their mother, Patricia Greenky, seems to unequivocally know the answer to this question.


Most decisions in life depend on custom, rules, and willy nilly choices, as in eenie meenie…and then there is the GUT. When Brett Bryan made his outstanding debut 14 months after his brother Seth Samuel, it took only the first 2 ½ months to understand that the mutual curiosity between the boys was motivated by awe, respect, poking exploration and a unique dialogue consisting of grunts, giggles and squeals.   Although constant supervision was critical it became crystal clear to the Mother that a fraternal bond was in the making.  The rolling giggling crawling gymnastic foray developed into an infant brotherhood.  Little did Mother ever imagine that those rumble tumble kiddies would later on become high school and then college wrestling champions.

While maintaining their rolling wrestling bond they also developed other specific interests.  Seth concentrated on the discovery of the wheel, a fascinating invention which facilitated pulling a wagon, then allowing mastering the tricycle and finally, before he was five, riding off into the setting sun on a junior size two wheeler!  Oh!  If those Ford Brothers could have seen him charge on down the road…

But where was Brett during these sidewalk forays?  Why, Brett was upstairs, now mesmerized with a challenging game of small painted wooden shapes --- squares, triangles, circles and oblongs, each having a  small hole in its center.  With a dozen or more squat nails and child size hammer, a cork board allowed the developing architect to

build a castle or mansion on the corkboard site.  Brett needed no assistance.  He politely

but firmly rejected partners.  There were certain areas of life which required sublime privacy for personal fulfillment.  During these same months, Brett also took exquisite time to crawl into the crib of his new sibling, a little sister just over 2 years his junior.  With saintly patience he taught Sharmon to talk, one syllable at a time.  Mom-mee,  Dad-dee, Em-mah, so that by the time little Sharmon was 9  months old she had a magnificent vocabulary of 2-3 dozen words.

Soon, home games, rolling around in the summer grass, autumn leaves and Buffalo winter snows, gave way to the exiting prospect of Kindergarten!  It was time to GO TO  SCHOOL!

Seth entered Kindergarten in September 1961 at  The Lindberg School in Kenmore, N.Y.  when he was exactly 5 years old.  His birthday is September 15. 1956.

One year later, when Brett was 4 years and 10 months old, Mother was advised that Brett’s entrance into Kindergarten, and essentially his entrance into his academic career, should begin the NEXT year because his birth date of November 17, 1957 officially took him out of the specified cut-off date for entrance into Kindergarten that particular year.  That regulation would  separate the brothers by two class years instead of one.

The Greenky Mother’s GUT spoke loud and clear.  The boys had a fast and enduring bond.  The Big Brother was clearly a care giver and a creative partner in all endeavors in life such as 1. Wrestling and Rolling About, and, 2.  Conniving Non Official Events e.g. SNEAK NIGHT and 3. When And How To Schedule Other Social Engagements…   

Mother went directly to the school.  She spoke to the Principal, a man she had known earlier from her own High School Days.  There could be no doubt but that Brett was physically able and cognitively competent to enter Kindergarten at the age of 4 years and 10 months and succeed admirably.

Another teacher was brought into the discussion.  The rules at that particular time were not irrevocable.  Mother was required to bring Brett to school for an informal meeting with Mr. Principal and Miss Kindergarten Teacher.  Mother was advised that the ultimate responsibility for Brett’s satisfactory Kindergarten experience was on her shoulders.

Mother agreed.  And the deed was sealed.

Mother’s GUT absolutely positively emphatically inescapably KNEW that the boys must be separated academically by one year and one year only.  That would be the only way that their phenomenal relationship would remain intact.  The crisis was avoided. 

GUT won the day.