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n Feature Article
Factors That Predict Blood Loss After
Bernese Periacetabular Osteotomy
Eduardo N. Novais, MD; Patrick M. Carry, MS; Lauryn A. Kestel, BS; Jason Koerner, BS;
Gee Mei Tan, MD
abstract
Although strategies to reduce bleeding and avoid allogeneic transfusion have
been described, there is controversy about the factors associated with blood
loss after Bernese periacetabular osteotomy. This study was conducted to determine risk factors for postoperative blood loss. After institutional review
board approval was obtained, a retrospective review was conducted of 41
young patients who underwent periacetabular osteotomy for symptomatic
acetabular dysplasia over a 3-year period. Of these patients, two-thirds donated blood before surgery. A Cell Saver Elite autotransfusion system (Haemonetics, Braintree, Massachusetts) was used intraoperatively in all cases.
Hemoglobin and hematocrit were obtained before surgery and during the
hospital stay. The primary outcome variable was the percentage of total
blood volume lost during surgery. Univariate analysis was performed to test
the association between potential predictors of blood volume loss. Candidate variables that were significant at alpha=0.15 were tested with multivariate analysis. The average percentage of blood volume lost during surgery
was 30.3% (95% confidence interval, 25.1%-35.5%). Univariate analysis
showed that operative time, arthrotomy, femoral head-neck osteochondroplasty, labral procedure, male sex, and age were prognostic factors associated with increased blood volume loss. However, operative time (average,
294.6 minutes; range, 204-444 minutes) was the only independent predictor of increased blood loss in the final model. Additional procedures, such
as femoral head-neck osteochondroplasty and labral repair or debridement
performed through an anterior hip arthrotomy at the time of periacetabular
osteotomy, were associated with increased operative time. The findings suggest that all patients undergoing periacetabular osteotomy, including those
having concomitant procedures, may benefit from pre- and intraoperative
strategies to conserve blood and avoid allogeneic transfusion. [Orthopedics.
2016; 39(6):e1147-e1153.]
NOVEMBER/DECEMBER 2016 | Volume 39 • Number 6
B
ernese periacetabular osteotomy
increasingly has been performed
for the treatment of symptomatic
acetabular dysplasia.1,2 Periacetabular
osteotomy is a technically challenging
procedure that is associated with a steep
learning curve and a potentially high rate
of complications, including major blood
loss.3,4 Previous studies estimated blood
loss of 300 to 4500 mL.1,2,5 However,
advances in surgical technique have led
to less blood loss.6-8 A recent study of
complications after periacetabular osteotomy performed by a group of experiThe authors are from the Department of Orthopaedic Surgery (ENN), Boston Children’s
Hospital, Boston, Massachusetts; and the Musculoskeletal Research Center, Department of Orthopaedic Surgery (PMC, LAK) and the Department
of Anesthesiology (GMT), Children’s Hospital
Colorado, and the University of Colorado School
of Medicine (JK), Aurora, Colorado.
The authors have no relevant financial relationships to disclose.
The authors thank Carol Ingraham, RN, and
Amy Edstrom, RN, for assistance with data collection.
Correspondence should be addressed to:
Eduardo N. Novais, MD, Department of Orthopaedic Surgery, Boston Children’s Hospital, 300
Longwood Ave, Hunnewell Bldg, Boston, MA
02215 ([email protected]).
Received: April 25, 2016; Accepted: July 7,
2016.
doi: 10.3928/01477447-20160819-08
e1147
n Feature Article
enced surgeons reported mean estimated
blood loss of 714 mL (range, 100-3900
mL). This wide range of reported blood
loss may be related to the length of the
procedure.9 This is of great importance
because now periacetabular osteotomy
is more commonly performed with concomitant procedures to correct associated intra-articular pathology.10-13
Several strategies, including autologous preoperative blood donation5 and intraoperative use of cell saver systems,9,14
have been reported for the management
of blood loss associated with periacetabular osteotomy. Independent of the method used, the vast majority of patients
require red blood cell transfusion.5,9,14,15
Although allogeneic blood transfusion is
currently accepted as a safe procedure,
with minimal risk of transfusion-transmitted infection, transfusion-associated
morbidity remains a concern.16 Few
studies have described blood conservation methods used during periacetabular
osteotomy. A single study suggested that
tranexamic acid reduced blood loss and
transfusion requirements.15 Further, previous studies showed conflicting results
on potential risk factors for increased
blood loss.9,14 Identification of patients
who are at increased risk for blood loss
during periacetabular osteotomy potentially could allow more specific strategies to conserve blood and avoid allogeneic transfusion.
The goal of the current study was to
investigate patient-specific and operative
factors associated with blood loss during
periacetabular osteotomy.
Materials and Methods
After institutional review board approval was obtained, a retrospective cohort study design was used to identify
factors associated with blood loss during
periacetabular osteotomy. A total of 41
patients underwent periacetabular osteotomy at the study institution between
January 2012 and June 2015. No patient
was excluded from the study; however,
e1148
because of the small number of patients
who underwent bilateral procedures
(n=7), data were collected from the first
procedure only.
The medical records of all subjects
were reviewed retrospectively. Demographic and clinical variables included
sex, age at surgery, body mass index,
affected side, history of surgery, year of
surgery, operative approach (classic approach with release of the rectus femoris tendon vs rectus-sparing approach),
common additional intra-articular operative procedures performed through an
arthrotomy (osteochondroplasty of the
femoral head-neck junction, acetabular
labrum debridement and repair), operative time, estimated blood loss, estimated
total blood volume, and preoperative hemoglobin. Blood volume was estimated
as weight in kilograms*70 for male patients and weight in kilograms*65 for
female patients. Among subjects with
multiple preoperative blood draws, the
hemoglobin level obtained during the
blood draw closest to the date of surgery
was recorded as the preoperative hemoglobin value (range, <1-24 days).
Indications for surgery included a history of activity-related pain for a minimum of 3 months, acetabular dysplasia
defined by a lateral center edge angle of
Wiberg17 of 20° or less and acetabular
roof obliquity of Tönnis18 greater than
10° on anteroposterior pelvic radiograph,
concentric reduction of the joint on functional abduction view, and absence of arthritic changes (Tönnis arthritis grade II
or less). General endotracheal anesthesia
with a total intravenous anesthetic was
used in all cases. No specific hypotensive
anesthesia protocol to reduce blood loss
was used, and tranexamic acid was not
administered.
Periacetabular osteotomy was performed with a classic approach, with
transection of the rectus femoris, as described originally by Ganz et al1 in patients in whom arthrotomy was planned
before surgery. Surgery was performed
with an approach that spared the rectus
femoris in patients with no history of
catching or locking of the hip, more than
20° internal rotation with the hip flexed,
and no signs of acetabular labrum tear on
preoperative magnetic resonance imaging.6 A standard unipolar electrocautery
device, set at 30/30 W, was used during
all periacetabular osteotomy procedures.
All bony cuts were performed through a
single approach from inside the pelvis,
without dissection of the abductor muscles.19 The acetabular fragment was fixed
with 3 or 4 screws measuring 4.5 mm.
After fixation, hip motion was tested.
If less than 90° flexion or less than 20°
internal rotation in flexion was noticed,
arthrotomy was performed to correct for
potential impingement. After arthrotomy,
femoral head-neck osteochondroplasty
was performed with a high-speed burr
when indicated, and the labrum was reattached with suture anchors when a fullthickness labral tear was encountered.
Partial labral debridement was performed
in patients with a hypertrophic labrum
with extensive degenerative changes. The
wound was closed in standard fashion,
and no drains were used after surgery.
Techniques used to minimize intraoperative blood loss included electrocautery of blood vessels and application of
bone wax to fill small bone holes. Similar
techniques were used for all patients in
the study cohort. Patients were allowed
to walk with crutches with touchdown
weight bearing for 6 to 8 weeks, according to radiographic healing.
Preoperative autologous blood donation within 4 weeks of surgery was recommended for all patients However, 13
(32%) patients did not donate blood before surgery for multiple reasons, including out-of-state residence, vasovagal reaction at the time of donation, inability to
achieve good intravenous access, refusal
to donate, and fever. A Cell Saver Elite
autotransfusion system (Haemonetics,
Braintree, Massachusetts) was used for
all patients during surgery. Hemoglobin
Copyright © SLACK Incorporated
n Feature Article
and hematocrit were collected daily during the hospital stay.
All patients with available predonated
blood received an autologous transfusion. Unforeseen transfusion was defined
as transfusion (autologous or allogeneic)
performed intraoperatively after recommendation by the anesthesiologist, based
on hemodynamic status and hemoglobin
or hematocrit level. Data were not collected on specific triggers for postoperative
transfusion, but the indication for allogeneic transfusion was a low hemoglobin
level (≤8 g/dL)20 or the presence of symptoms associated with acute anemia that
compromised rehabilitation with physical
therapy. The number of patients who met
the absolute criteria for blood transfusion
was recorded. Absolute criteria for blood
transfusion included unplanned perioperative allogeneic or autologous blood
transfusion and postoperative blood draw
showing a hemoglobin level of 8 g/dL or
less.20
Primary outcome variables included
the percentage of total blood volume lost
during surgery, which was calculated as
the estimated blood loss divided by the
calculated total circulating blood volume. Estimated blood loss was obtained
from anesthesia records based on the volume calculated by the cell saver system.
Statistical Methods
Descriptive statistics were used to
summarize the demographic and clinical
characteristics of all patients. Multivariate linear regression analysis was used
to identify variables associated with the
percentage of blood volume lost during
surgery. Univariate analysis was used to
test the association between the following candidate predictors and the percentage of blood volume lost during surgery:
operative time, procedures performed
at the time of periacetabular osteotomy,
age, sex, preoperative hemoglobin level,
body mass index, cumulative procedure
count since the start of the study period
(a surrogate variable for surgical learning
curve), and history of previous surgery.
During the model-building step of analysis, a strong correlation was observed between operative time and the procedure
variables osteochondroplasty (Spearman’s rho=0.59, P<.0001), arthrotomy
(Spearman’s rho=0.57, P<.0001), and
labral procedure (Spearman’s rho=0.31,
P=.0465). The authors concluded that
this group of variables was representative of the complexity and invasiveness
of the surgery. Because operative time
was the strongest predictor of percentage of blood volume lost in this grouping of variables, it was the only variable
included in the multivariate model. Candidate variables that were significant at
alpha=0.15 were tested in the multivariate model.
Results
Most (88%) of the patients included
in this study were female. Mean age
at surgery was 19 years (range, 11-36
years). The approach sparing the rectus
femoris was used in 18 (44%) of patients,
whereas 23 (56%) patients underwent the
classic approach, with transection of the
rectus femoris. Of the patients, 39.0%
(95% confidence interval, 24.1%-54.0%)
met the absolute criteria for blood transfusion. Patient demographics and concomitant procedures performed at the
time of periacetabular osteotomy are
shown in Table 1.
The average percentage of blood volume lost during surgery was 30.3% (95%
confidence interval, 25.1%-35.5%).
Operative time, arthrotomy, femoral
head-neck osteochondroplasty, labral
procedure, male sex, and age were prognostic factors associated with increased
percentage of blood volume loss in the
univariate analysis. (Table 2). However,
operative time was the only independent
predictor of increased blood loss in the
final model. After controlling for sex and
age, the percentage of blood volume lost
during surgery increased by 1.1 percentage points for every 10-minute increase
NOVEMBER/DECEMBER 2016 | Volume 39 • Number 6
Table 1
Demographics, Patient
Characteristics, and
Procedures Performed
During Periacetabular
Osteotomy
Variable
Value
Female, No.
36 (87.8%)
Right hip, No.
23 (56.1%)
Previous pelvic osteotomy, No.
1 (2.4%)
Year of surgery, No.
2012
13 (31.7%)
2013
13 (31.7%)
2014
12 (29.3%)
2015
3 (7.3%)
Age, mean (SD), y
19 (6.3)
Body mass index,
mean (SD), kg/m2
22 (3.3)
Preoperative hemoglobin, mean (SD), g/dL
12.8 (2.0)
Approach, No.
Classic approach
23 (56.1%)
Rectus sparing
18 (43.9%)
Arthrotomy, No.
19 (46.3%)
Osteochondroplasty of
femoral head-neck
junction, No.
15 (36.6%)
Labral repair or debridement, No.
4 (9.8%)
Osteoplasty of anterior
inferior iliac spine,
No.
7 (17.1%)
Operative time, mean
(SD), min
294.6 (57.7)
in operative time (95% confidence interval, 0.2%-1.9%; P=.0099). In the
multivariate analysis, age and sex were
not independently predictive of percentage of blood loss during surgery. After
controlling for sex and operative time,
the percentage of blood volume lost during surgery increased by 0.6 percentage
points for every 1-year increase in age
(95 confidence interval, -0.1% to 1.4%;
P=.0837). After controlling for operative
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n Feature Article
Table 2
Variables Related to Percentage of Blood Volume Lost During
Surgery: Univariate Analysis
Variable
Comparison
Estimate
Lower to Upper
P
Demographic/clinical
characteristic
Sexa
Body mass index
a
Age
Male vs female
13.0%
-2.6% to 28.6%
.0996
Per 5-unit increase
-2.4%
-10.5% to 5.8%
.5577
Per 1-y increase
0.9%
0.1% to 1.7%
.0358
Preoperative hemoglobin
Per 1-unit increase
0.2%
-2.6% to 3.7%
.715
Learning curve
Per 5 procedures or
experiences
-0.4%
-2.7% to 1.8%
.7013
Operative timea
Per 10-min increase
1.4%
0.5% to 2.2%
.0017
Labral procedure
Yes vs no
22.7%
6.5% to 38.9%
.0073
Osteochondroplasty
Yes vs no
10.6%
0.2% to 21.0%
.0459
Arthrotomy
Yes vs no
12.1%
2.2% to 21.9%
.0177
Surgical complexity/invasiveness
a
Variables tested in the multivariate model.
Table 3
Operative Time Associated With Different Procedure
Combinations
No.
Mean,
min
Range,
min
2 (5%)
392
385-398
13 (32%)
335
237-444
Periacetabular osteotomy+arthrotomy+labral procedure
2 (5%)
307
299-315
Periacetabular osteotomy+arthrotomy
2 (5%)
279
259-299
Periacetabular osteotomy
4 (10%)
273
229-344
18
260
204-327
Procedure
Classic
Periacetabular osteotomy+arthrotomy+labral
procedure+osteochondroplasty head/neck
Periacetabular osteotomy+arthrotomy+osteochondroplasty head/neck
Rectus-sparing periacetabular osteotomy
time and age, the percentage of blood
volume lost was an average of 9.1%
higher in male subjects compared with
female subjects (95% confidence interval, -5.0% to 23.1%; P=.1991).
Only 2 of 19 (10.5%) patients undergoing arthrotomy had no intra-articular
e1150
procedures. Of the patients, 15 (79%)
were treated for asphericity of the femoral head with osteochondroplasty of
the head-neck junction; 2 (10.5%) were
treated with labral repair, and 2 (10.5%)
were treated with labral debridement.
Average operative time was 294.6 min-
utes (range, 204-444 minutes). Operative
time was increased when periacetabular
osteotomy was performed in conjunction with intra-articular procedures, such
as osteochondroplasty of the femoral
head-neck junction and labral repair or
debridement (Table 3).
Only 1 patient had a transfusion
complication when an intravenous line
failed during autologous blood transfusion and caused infiltration to the right
forearm, with hematoma formation. The
infiltration was managed with thermal
manipulation and application of warm
compresses.
Discussion
Although different blood-conserving
strategies, including the use of predonated
autologous blood, cell saver autotransfusion, and tranexamic acid, have been described to avoid allogeneic transfusion,
there is no universally accepted protocol to
manage blood loss associated with periacetabular osteotomy.5,9,14,15 Periacetabular osteotomy increasingly has been performed
with arthrotomy11,13 or in combination with
hip arthroscopy12,21,22 because of evidence
that femoroacetabular impingement adversely affects the outcome of periacetabular osteotomy 23-25 and because of the high
prevalence of intra-articular pathology.10,11
Findings on predictive factors associated
with blood loss during periacetabular osteotomy are limited and conflicting, and this
study was conducted to determine patient
and procedure risk factors related to blood
loss in a cohort of 41 young patients undergoing periacetabular osteotomy.
Operative time was the strongest independent factor associated with blood
loss during periacetabular osteotomy.
After controlling for sex and age, the
percentage of blood volume lost during surgery increased by 1.1 percentage
points for every 10-minute increase in
operative time (95% confidence interval,
0.2%-1.9%; P=.0099). Similarly, Lee et
al9 found 11% greater loss per hour of
surgery. In contrast, Pulido et al14 did
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not find an association between duration of surgery and blood loss. This discrepancy may be related to differences
in operative time and measurement of
blood loss reported in these 3 studies.
Pulido et al14 reported the lowest mean
operative time of 132 minutes, but the
current study and the study of Lee et
al9 reported an average of 295 minutes
and 255 minutes, respectively (Table 4).
Several factors, such as surgeon experience and operating room staff and surgical team familiarity with periacetabular
osteotomy, may affect operative time.
However, in the current study, the number of procedures performed before the
current surgery, a surrogate for the surgeon’s experience, was not a predictor
of blood loss.
In the current study, the addition of
intra-articular procedures to treat femoral head-neck asphericity and labral
tears was the most important factor associated with increased operative time.
However, Lee et al9 did not find that arthrotomy was an independent risk factor
for increased blood loss. They provided
no details about procedures performed
through the arthrotomy. In the current
study, routine arthrotomy was not performed at the time of periacetabular
osteotomy, and the authors used more
selective criteria for opening the joint.
As a consequence, an intra-articular procedure was performed after arthrotomy
in 89.5% of cases. These findings are
in agreement with a previous study of
151 patients undergoing periacetabular
osteotomy that reported asphericity of
the femoral head-neck junction in 85%
of cases and labral pathology in 21% of
cases at the time of arthrotomy.11 Wingerter et al15 studied the use of tranexamic
acid to reduce blood loss in 100 patients
undergoing periacetabular osteotomy.
Their study included 34 patients who
underwent hip arthroscopy in the same
setting and found no difference in blood
loss in arthroscopically treated vs nonarthroscopically treated patients. De-
spite the increased operative time, it is
possible that intra-articular procedures
performed through an arthroscopic approach before periacetabular osteotomy
do not affect blood loss.
Most bleeding that occurs during
periacetabular osteotomy happens as a
result of pelvic osteotomy. In the current
study, arthrotomy was performed after
periacetabular osteotomy, and additional
bone bleeding may have continued during arthrotomy and the intra-articular
procedure. It is possible that performing
open arthrotomy before osteotomy may
not affect blood loss. However, performing arthrotomy after periacetabular osteotomy allows assessment and correction
of subtle impingement, which may be
limited if arthrotomy is performed first.
Further studies are necessary to identify
patients who will benefit from intraarticular procedures and to establish the
best approach to the joint at the time of
periacetabular osteotomy.
There is controversy as to whether
patient sex affects blood loss associated
with periacetabular osteotomy. Lee et
al9 suggested that male sex was the only
preoperative patient characteristic associated with higher blood loss. In contrast, Pulido et al14 did not find an association between patient sex and the need
for transfusion. In this study, after controlling for age and operative time, sex
was not associated with blood loss. This
observation suggests that sex may not
be directly related to blood loss during
periacetabular osteotomy. Male sex may
be representative of more complex cases
that often require additional procedures
and additional operative time. Previous
studies26,27 suggested that there are sexdependent anatomic and biologic differences in male patients vs female patients
undergoing periacetabular osteotomy
and that these changes make the surgery
more challenging in male patients and
may lead to a higher prevalence of hip
impingement and postoperative complications.
NOVEMBER/DECEMBER 2016 | Volume 39 • Number 6
Limitations
This study had several limitations.
First, autologous blood donation was
recommended for all patients; however,
one-third of the patients could not donate
blood before surgery. Predonated autologous blood was transfused more liberally
than allogeneic blood. The proportion of
patients who received allogeneic transfusion in this study was lower than in previous studies.5,14,15 However, this study
did not investigate factors associated with
increased risk of transfusion because
there were no specific trigger criteria for
transfusion. However, this study identified
factors associated with blood loss during
surgery that are expected to affect the rate
of postoperative transfusion. This limitation is likely inherent to the retrospective
design of the study. Second, it is possible
that total blood loss during surgery was
underestimated because the calculation
was made solely by the cell saver autotransfusion system. However, this method
was used consistently in every patient in
the study cohort, so the risk of misclassification may not be a concern. Third, the
preoperative hemoglobin level may have
been lower in patients who donated blood
before surgery. This could have affected
the rate of postoperative transfusion.14
However, no association was found between preoperative hemoglobin level and
blood loss. Future well-designed prospective studies are needed to clarify the
threshold for the preoperative hemoglobin
level that is associated with greater need
for blood transfusion after periacetabular
osteotomy and to determine the need for
and effect of autologous predonation.
Conclusion
Blood loss during periacetabular osteotomy is directly dependent on the length
of surgery. Strategies to reduce the use of
allogeneic blood, such as autologous preoperative donation, as well as procedures
that minimize blood loss during surgery,
such as the use of hypotensive anesthesia
and tranexamic acid, should be evalu-
e1151
e1152
2015
2012
2013
41
7.2
(11-36)
19
27
(17-47)
50
(TXA)
28
(±9.7)
25.6
(12-49)
30
(13-49)
7.3
4.5
7.9
3.6
(No
TXA)
50
169
2011
2011
141
108
2003
2009
107
1996
(19-28)
(192-444)
295
NA
NA
(±81.6)
255
(77-216)
132
NA
NA
NA
(200-5400)
1244
489
639
(200-3900)
925
(±268)
478
18
(44%)
23
(46%)
11
(22%)
82
(49%)
NA
NA
(±2.0)
12.8
NA
NA
(±3.3)
36.1
(10.1-16.6)
13
(12.9-13.7)
13.25
(1250-4380)
2500a
12.95
(12-13.3)
1905
(13.1-14.3)
13.50
Mean Preop
Hgb (Range
or ±SD),
g/dL
(1089-2661)
a
NA
NA
2100a
(1350-3000)
No. of
Arthrotomies
Mean
Estimated
Intraoperative
BL (Range or
±SD), mL
9.74 (±1.7)
NA
NA
NA
(7-13.2)
9.8
(9.13-10.9)
10.25
(8.3-10.2)
8.85
(10.4-12.4)
11.45
Mean
Postop Hgb
(Range or
±SD), g/dL
28
(68.3%)
Variable
Variable
Majority
(2%)
2/108
100%
0
0
Autologous
Preop
Donation
Abbreviations: BL, blood loss; Hgb, hemoglobin; NA, not applicable; Postop, postoperative; Preop, preoperative.; TXA, tranexamic acid.
a
Median blood loss.
Current
study
Wingerter
et al15
Lee et al9
Pulido et
al14
2005
9.2
24
82
1999
19
(15-24)
8
24
2005
18
6.3
1999
22
Mean Age
(Range or
±SD), y
(19-31)
1996
Atwal et
al5
Ratio,
Female
to Male
1999
Year
Study
No.
of
Hips
Mean
Operative
Time (Range
or ±SD), min
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Cell
Saver
Predictors of Blood Loss Reported in Previous Periacetabular Osteotomy Studies
Table 4
17.1%
24%
48%
NA
21 (20%)
13 (16%)
12 (67%)
18 (82%)
No. of
Allogeneic
Transfusions
Operative
time predicted blood
loss
Use of TXA
reduced
blood loss
and transfusion
Preoperative
hematocrit
predicted
postoperative
hematocrit
Operative
time predicted blood
loss
Operative
time was not
a predictive
factor
Preoperative
Hgb was
predictive of
transfusion
NA
NA
NA
Predictive
Factors
n Feature Article
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n Feature Article
ated in well-designed prospective studies. Patients undergoing periacetabular
osteotomy with expected longer duration
of surgery, including those with planned
associated procedures, may benefit from
these strategies.
9. Lee CB, Kalish LA, Millis MB, Kim YJ.
Predictors of blood loss and haematocrit after periacetabular osteotomy. Hip Int. 2013;
23(suppl 9):S8-S13.
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