The groups’ complication rates were comparable, and there was no significant risk associated with use of the hemostatic agent (P = .764). In each group, there were no complications that would be of particular concern with use of this agent. These complications included wound complications, deep prosthesis infection, and systemic thromboembolic disease (eg, myocardial infarction, stroke, DVT, pulmonary embolus). Nine patients (5 control, 4 experimental) had minor medical complications, and 2 (1 control, 1 experimental) had major medical complications. The control group’s 5 minor medical complications were acute kidney infection treated with antibiotics (1 patient), persistent urinary retention requiring Foley catheter for short period after discharge (1), minor upper gastrointestinal bleed treated medically (1), recalcitrant tachycardia in setting of chronic atrial fibrillation (1), and vasovagal syncope with no identified cardiovascular cause or periprosthetic complication (1); the control patient with the major medical complication died 2 weeks after surgery, after discharge to the inpatient rehabilitation unit. This death was secondary to pneumonia, sepsis, and eventual multisystem organ failure. The experimental group’s 4 minor medical complications were urinary retention requiring catheterization for short period (1 patient), urinary tract infections diagnosed 2 weeks after surgery and treated with antibiotics (2), and new-onset atrial fibrillation treated medically (1); the experimental patient with the major medical complication developed Takotsubo cardiomyopathy, a nonischemic stress-induced weakening of the myocardium requiring medical management. An experimental patient also had reverse TSA shoulder dislocation 12 days after surgery—thought to be caused by inadequate soft-tissue tension and unrelated to hemostatic agent use. The patient was returned to the operating room for polyethylene liner exchange and metallic spacer implantation.
Discussion
Reported rates of transfusion after shoulder arthroplasty have ranged from 7.4% to 43%, when including revision and reverse TSAs.2,3 In the present study, the overall transfusion rate was 23% (includes patients who underwent primary or revision shoulder arthroplasties with anatomical or reverse prostheses). Although the risk for complications is low, serious issues may arise with blood transfusions. Allogeneic blood transfusions can cause fluid overload, allergic reactions, fever, acute immune hemolytic reaction, transfusion-related acute lung injury (TRALI), bloodborne infections, and formation of antibodies complicating any future need for transfusions.7 According to the National Heart, Lung, and Blood Institute, the chances of becoming infected from transfusion are 1 in 2 million for the hepatitis C and human immunodeficiency viruses and 1 in 205,000 for the hepatitis B virus.7 Some studies have also found higher rates of infection after hip or knee arthroplasty in patients who received allogeneic blood transfusions.21,22 In addition, for hospitals, transfusion costs are significant. One study showed that direct and indirect overhead costs amounted to $522 to $1183 per red blood cell unit.23 Given the risks and costs associated with blood transfusions, use of an effective intraoperative blood loss management agent could be beneficial in the setting of shoulder arthroplasty.
The use and efficacy of intraoperative blood management agents remain controversial. Numerous agents for managing perioperative blood loss are commercially available. Previous clinical studies have shown variable results with use of topical hemostatic agents, but not in the setting of shoulder arthroplasty.24 In 1999, Levy and colleagues11 showed that use of fibrin tissue adhesive reduced blood loss and postoperative transfusion rates in patients who underwent TKA. In 2001, Wang and colleagues15 showed that using a fibrin sealant in TKA reduced bloody drainage and maintained higher Hb levels. In 2003, the same group showed that use of fibrin sealant also reduced perioperative blood loss in total hip arthroplasty.12 More recent studies have had contradicting results,13,14 similar to ours. A 2012 prospective study failed to show any significant difference in blood loss after TKA in patients treated with a topical thrombin-based hemostatic agent.13 The authors did find significantly higher Hb values in the treated group on PODs 1 and 2, though the drain outputs and transfusion rates did not differ.
To our knowledge, the present study is the first to evaluate use of a topical hemostatic agent during shoulder arthroplasty. We did not find a significant difference in perioperative blood loss with application of Surgiflo, a topical thrombin-based hemostatic agent. Interestingly, we found that Hb levels both before surgery and on PODs 1 and 2 were significantly lower in the experimental group. However, the difference was about 0.7 g/dL, which would not be clinically significant. The lower Hb levels on PODs 1 and 2 likely resulted from lower preoperative levels.
Other studies have found higher transfusion rates for revision versus primary shoulder arthroplasty.1,2,20 In our series, EBL, autologous blood return, and drain output were higher overall for revision versus primary cases. When we stratified by primary and revision cases, we could not detect a difference in transfusion rates between the experimental and control groups. The lack of significant difference in the revision group could be caused by low statistical power, as the control group had only 13 revision cases. Having more patients in the study may have revealed a larger difference in blood loss with use of the hemostatic agent in revision cases.