**5.6 Aspiration pressure**

Aspiration pressure is one of many variables when using drains. Cheung et al. state that low suction drains do not increase the number of complications (Cheung & Chiu, 2006). Along the same lines, Benoni et al (Benoni & Fredin, 1997) show that a high aspiration pressure increases drained quantity after knee arthroplasty in a significant way with respect to lowpressure aspiration drainages. The average drained amount in 24 hours is 570 mL in highpressure aspiration drains and 480 mL in low-pressure ones (p=0,03). At 48 hours, drained quantity had raised to 785 mL and 585 mL (p=0,002) respectively.

Another study regarding aspiration pressure is that from Kirschner et al. (Kirschner et al., 1989) where it is observed that the higher suction pressure increases the risk of secondary hematomas. Martin et al. (Martin et al., 2004), in their study with three groups (no drainages, suction drainages and a third group with non-suction drains), find that the group using non-suction drainages is that with fewer complications and less transfusion requirements.

When studying another variable such as time of aspiration (continuous or discontinuous), and according to Berman et al. (Berman et al., 1990), using continuous aspiration increases drained amount, however it also decreases complications from the surgical wound and transudation through surgical injury. Another study evaluating results from a discontinuous opening of the drain is that from Brueggemann, who shows that clamping the drainages during 55 minutes every hour for the first 6 postoperative hours decreases transfusion needs, without increasing the risk of hematomas or complications from the surgical wound (Brueggemann et al., 1999). Prasad et al. in their study show that an intermittent clamping of drains decreases bleeding, rather than clamping the drainage only initially for 2 hours (Prasad et al., 2005).

Seyfert et al. (Seyfert et al., 2002) compare a group with unicompartmental knee prosthesis with suction drainage and another one with no drainage. The study analyzes bleeding at 12, 24, 36 and 48 hours. Average bleeding in the suction-drainage group was

Several studies compare the different blood retrievals, finding out that whereas some are easier to use, others have a better suction and that side effects do not present statistically

Another point of view to look at is that from Mauerhan et al. (Mauerhan et al., 1993) and other authors (Mac et al., 1993; Reize et al., 2006), who find that the use of a recovered blood is not necessary in hip and knee arthroplasty. Faraj et al. show in their study that cost/profit ratio is not profitable when using a blood retrieval (Evans et al., 1993; Faraj & Raghuvanshi,

The study by Labek et al. (Labek & Bohler, 1998) links the number of drainages with prosthetic hip bleeding. Their article studies the relationship between number of drainages, its positioning (deep and/or superficial) and its relationship with transfusions needed, wound's exudation, subcutaneous hematoma and thigh edema. Given the possibility of placing three drainages, two drainages, (subcutaneously and subfascial) or one drainage (subcutaneously or subfascial), the conclusion was that using two drainages alone is better rather than 3 drainages or no drainage as there are no more complications with respect to

Aspiration pressure is one of many variables when using drains. Cheung et al. state that low suction drains do not increase the number of complications (Cheung & Chiu, 2006). Along the same lines, Benoni et al (Benoni & Fredin, 1997) show that a high aspiration pressure increases drained quantity after knee arthroplasty in a significant way with respect to lowpressure aspiration drainages. The average drained amount in 24 hours is 570 mL in highpressure aspiration drains and 480 mL in low-pressure ones (p=0,03). At 48 hours, drained

Another study regarding aspiration pressure is that from Kirschner et al. (Kirschner et al., 1989) where it is observed that the higher suction pressure increases the risk of secondary hematomas. Martin et al. (Martin et al., 2004), in their study with three groups (no drainages, suction drainages and a third group with non-suction drains), find that the group using non-suction drainages is that with fewer complications and less transfusion

When studying another variable such as time of aspiration (continuous or discontinuous), and according to Berman et al. (Berman et al., 1990), using continuous aspiration increases drained amount, however it also decreases complications from the surgical wound and transudation through surgical injury. Another study evaluating results from a discontinuous opening of the drain is that from Brueggemann, who shows that clamping the drainages during 55 minutes every hour for the first 6 postoperative hours decreases transfusion needs, without increasing the risk of hematomas or complications from the surgical wound (Brueggemann et al., 1999). Prasad et al. in their study show that an intermittent clamping of drains decreases bleeding, rather than clamping the drainage only

Seyfert et al. (Seyfert et al., 2002) compare a group with unicompartmental knee prosthesis with suction drainage and another one with no drainage. The study analyzes bleeding at 12, 24, 36 and 48 hours. Average bleeding in the suction-drainage group was

surgical injury and a 47% reduction of blood units was achieved.

quantity had raised to 785 mL and 585 mL (p=0,002) respectively.

significant differences (Trammell et al., 1991).

2006; Jackson et al., 2000).

**5.5 Number of drainages** 

**5.6 Aspiration pressure** 

requirements.

initially for 2 hours (Prasad et al., 2005).

528 mL, whereas in the non-suction 436 mL. However, difference between both averages was not statistically significant.

### **5.7 Start/opening-up/end of drainage**

If the opening-up of drainage is delayed, the obtained amount through drainage diminishes in a statistically significant manner (Roy et al., 2006; Tsumara et al., 2006). Along the same lines, another study states that delaying the opening-up of drainages 4 hours; drainage decreases in a statistically significant way (Shen et al., 2005).

On the other hand, some authors conclude that clamping drains during first 2 postoperative hours does not influence within drained quantity, nor transfusion number, or mobility, or surgical wound complications (Kiely et al., 2001). Study by Leemann et al. affirms that after 6 hours drainage can be removed as 78% of bleeding has been already drained (Leeman et al., 2006).

Senthil et al. (Senthil et al., 2005) state in their study that 84% of total drain was collected during first 12 hours, and 94% during first 24 hours. The study's conclusion is that articular drainages can be safely removed after first 12 postoperative hours.

The Spanish group headed by Zamora-Navas (Zamora-Navas et al., 1999) study bleeding features in three groups in which drainage is maintained 12, 24 and 48 hours. They observed that the group maintaining drainage for 24 hours had already drained 87% of the total amount at 12 hours time. In the last group (with drainage 48 hours), bleeding at 12 hours corresponded to 91% of the total amount, and bleeding at 24 hours was 97% of the total amount collected after 48 hours.

Regarding when to remove drainage, in the study by Benoni et al. (Benoni & Fredin, 1997) we can observe how the drained amount between 24 and 48 hours is only 215 mL in the high-pressure aspiration drainages, and 105 mL in those with low-pressure aspiration. In conclusion, we can see that aspiration pressure is not more than a variable, as previously seen, and that drained volume between 24 and 48 hours is not as far as important as the bleeding that occurs during first 24 hours.

In the study by Slagis et al., the conclusion of greater volume collected during first operative hours repeats (Slagis et al., 1991). The average collected volume was 493 mL, great part of it being collected during first 4 hours.

Another study showing that prosthetic bleeding is produced during first postsurgical hours is that from Willemen et al. (Willemen et al., 1991), in which they keep drains 48 hours and they observe that 85% of total volume was drained after 24 hours. Between 24 and 48 hours the drain was of only 50 mL.

In our own study (Ares-Rodriguez et al., 2008), we observed that mean of the survival curve for postoperative bleeding time was 16 hours for total knee arthroplasty, and we therefore concluded that drainage in total knee arthroplasty can be safely removed after 18 postoperative hours, with a safety margin.

### **5.8 Tourniquet**

A first study shows that releasing the tourniquet intraoperative (before wound closure) and a correct hemostasis does not reduce total amount of blood lost in total knee arthroplasty (Hersekli et al., 2004). Barwell et al. (Barwell et al., 1997) present in their study that using tourniquet has some side effects and that these can be minimized if removal of tourniquet is done prematurely, together with a thoroughly hemostasis prior to surgical wound closing.

Blood Transfusion in Knee Arthroplasty 123

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### **5.9 Surgical technique**

Regarding which surgical technique would most reduce postoperative bleeding, several maneuvers have been discussed; such as navigation, sealing the intramedullary femoral canal during femoral preparation in total knee arthroplasty, different prosthetic models and using minimally invasive techniques.

The use of the navigator reduces bleeding through drainage in a statistically significant way, according to the studies by Kalairajah (Kalairajah et al., 2005) and Hinarejos (Hinarejos et al., 2009). On the other hand, groups such as Chang's (Chang CW et al., 2010) or Turajane's (Turajane T et al., 2009) do not find statistically significant differences between minimally invasive surgery with navigation and conventional surgery.

Sealing the intramedullary femoral canal in non-navigated surgery and with intramedullary femoral guide decreases both the fall in hemoglobin and transfusion requirements in a statistically significant way ( Ko et al., 2003; Raut et al., 1993). Another study showed a decrease in bleeding through drainages with this technique (Kumar et al., 2000).

Porteous et al. (Garcia-Erce et al., 2002; Porteous and Bartlett, 2003) analyze postoperative drainage in three implant types; cemented, hybrid and uncemented total knee replacement. The statistically significant conclusion is that cemented prosthesis has a lesser bleeding with regard to other two groups during 8 first hours, but this difference decreases after 24-48 hours. Another study states that constrained arthroplasty increases blood loss (Berman et al., 1988).

### **6. References**


Lotke finds in his study that releasing tourniquet, together with coagulation and immediate start of continuous passive motion (CPM) therapy, increases arthroplasty

Regarding which surgical technique would most reduce postoperative bleeding, several maneuvers have been discussed; such as navigation, sealing the intramedullary femoral canal during femoral preparation in total knee arthroplasty, different prosthetic models and

The use of the navigator reduces bleeding through drainage in a statistically significant way, according to the studies by Kalairajah (Kalairajah et al., 2005) and Hinarejos (Hinarejos et al., 2009). On the other hand, groups such as Chang's (Chang CW et al., 2010) or Turajane's (Turajane T et al., 2009) do not find statistically significant differences between minimally

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Porteous et al. (Garcia-Erce et al., 2002; Porteous and Bartlett, 2003) analyze postoperative drainage in three implant types; cemented, hybrid and uncemented total knee replacement. The statistically significant conclusion is that cemented prosthesis has a lesser bleeding with regard to other two groups during 8 first hours, but this difference decreases after 24-48 hours. Another study states that constrained arthroplasty increases blood loss (Berman et al., 1988).

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**Acoustic Emission Studies in Hip Arthroplasty –**

**Peak Stress Impact** *In Vitro* **Cemented Prosthesis** 

*CIETI - Centre of Innovation in Engineering and Industrial Technology,* 

N. Gueiral and E. Nogueira

*Portugal* 

**8**

*ISEP - School of Engineering, Polytechnic of Porto* 

Sir John Charnley revolutionized the field of joint arthroplasty in the 1960s with the development of the total hip replacement. He replaced the diseased hip joint with a steel femoral component and a plastic acetabular socket cup combination, both fixed into the bone using a self-curing acrylic cement, polymethylmethacrylate (PMMA) (Browne et al, 2005).

The placement of the metal implant in the channel open in the femoral bone without using cement or by mechanical attack, called a non cemented arthroplasty, came into use in an effort

A study about prostheses reviews, between 1979 and 2005, show that's were higher in non-cemented prosthesis, leading to studies on new forms of interface bone/metal. The

By Ramos (Ramos et al, 2005), cemented arthroplasty is one of the most successful surgical techniques in orthopaedics. However, the cemented prosthesis has a tendency to fray during the time of their life due to stress and fatigue of the cement material leading to it cracking. The growing importance of different Total Hip Arthroplasty (THA) studies is due to increased life expectancy of the population and its social and clinical relevance. Interdisciplinary THA studies such as: biomechanics (Bergmann et al, 2001; Fonseca et al, 2010; Nabais, 2006; Ramos et al, 2005; Stolk et al, 2006; Teixeira et al, 2008; Vieira, 2004); finite element analysis (Bachtar et al, 2006; Nizam Ahmad et al, 2006; Ridzwan et al, 2006) and acoustic emission monitoring (Browne et al, 2005; Cristofolini et al, 2003; Davies et al, 1996; Franke et al, 2004; Gueiral, 2008;

Research has been done to improve the performance of artificial implants, addressing factors such as geometry, materials, cements, and other surgical techniques that directly or indirectly,

Although the lifetime of a THA is between 10 and 15 years, there are factors that lead to loss of prosthesis such as the separation of the femoral prosthesis due to the splitting of connection between the implant/cement and cement/bone. The human body responds through its immune system causing inflammation and pain in osseous structure, which in most cases

That way, he has restored some of the most problematic joints in the human body.

orthopaedical systems allowing the evaluation of its integrity.

growth of cemented arthroplasties has been observed since 2005.

Qi et al, 2005; Qi, 2000; Rowland et al, 2004) have been published.

leads to the replacement of the prosthesis.

might influence the performance and success of cemented arthroplasty.

to solve the problem.

**1. Introduction** 

