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Blood management in total knee arthroplasty: state-of-the-art review
  1. Antony Palmer1,
  2. Antonia Chen2,
  3. Tomoyuki Matsumoto3,
  4. Mike Murphy4,5,
  5. Andrew Price1
  1. 1 Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, University of Oxford, Oxford, UK
  2. 2 Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
  3. 3 Department of Orthopaedic Surgery, Kobe University, Kobe, Japan
  4. 4 NHS Blood and Transplant, Oxford, UK
  5. 5 Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
  1. Correspondence to Mr Antony Palmer, Nuffield Department of Orthopaedics, Rheumatology, and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford OX3 7LD, UK; antony.palmer{at}


Total blood loss from primary total knee arthroplasty may exceed 2 L with greater blood loss during revision procedures. Blood loss and allogeneic transfusion are strongly associated with adverse outcomes from surgery including postoperative mortality, thromboembolic events and infection. Strategies to reduce blood loss and transfusion rates improve patient outcomes and reduce healthcare costs. Interventions are employed preoperatively, intraoperatively and postoperatively. The strongest predictor for allogeneic blood transfusion is preoperative anaemia. Over 35% of patients are anaemic when scheduled for primary and revision knee arthroplasty, defined as haemoglobin <130 g/L for men and women, and the majority of cases are secondary to iron deficiency. Early identification and treatment of anaemia can reduce postoperative transfusions and complications. Anticoagulation must be carefully managed perioperatively to balance the risk of thromboembolic event versus the risk of haemorrhage. Intraoperatively, tranexamic acid reduces blood loss and is recommended for all knee arthroplasty surgery; however, the optimal route, dose or timing of administration remains uncertain. Cell salvage is a valuable adjunct to surgery with significant expected blood loss, such as revision knee arthroplasty. Autologous blood donation is not recommended in routine care, sealants may be beneficial in select cases but further evidence of benefit is required, and the use of a tourniquet remains at the discretion of the surgeon. Postoperatively, restrictive transfusion protocols should be followed with a transfusion threshold haemoglobin of 70 g/L, except in the presence of acute coronary syndrome. Recent studies report no allogeneic transfusions after primary knee arthroplasty surgery after employing blood conservation strategies. The current challenge is to select and integrate different blood conserving interventions to deliver an optimal patient pathway with a multidisciplinary approach.

  • knee
  • arthroplasty
  • total joint replacement
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  • Contributors AJRP drafted the initial manuscript. All authors performed critical revision and approved the final manuscript.

  • Funding Outside of the submitted work, AFC received grant funding from the Orthopaedic Research and Education Foundation; consultancy fees from Heraeus, Zimmer, 3M, Convatec, Irrisept, Haylard, Pfizer, DJO, ACI, bOne and Stryker; royalties from SLACK Publishing; and holds equity in Joint Purification Systems, Sonoran Biosciences, Graftworx, and sits on the advisory board for Recro. AJP receives grant funding from Arthritis Research UK and the National Institute for Health Research, and personal fees from Zimmer Biomet, DePuy, and Smith and Nephew.

  • Competing interests None declared.

  • Patient consent Not required.

  • Provenance and peer review Commissioned; externally peer reviewed.

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