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Trauma: N. B. Foss and H. Kehlet Hidden blood loss after surgery for hip fracture J Bone Joint Surg Br 2006; 88-B: 1053-1059 [Abstract] [Full text] [PDF]

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Blood loss associated with hip fracture fixation

Aiman S Khunda, Maya Rookmoneea, A C Hui   (29 October 2009)

Hidden blood loss after surgery for hip fracture

Lalit Sharma, Vijay Kumar, Rajesh Malhotra   (20 October 2006)

Blood loss associated with hip fracture fixation 29 October 2009
Aiman S Khunda, Surgical Trainee The James Cook University Hospital, Middlesbrough, United Kingdom, Maya Rookmoneea, A C Hui Send letter to journal: Re: Blood loss associated with hip fracture fixation aiman.khunda{at}doctors.org.uk Aiman S Khunda, et al.	Sir, We read this paper with great interest and we were stimulated by its findings to carry out a project in our department. We compared haemoglobin level drop in patients undergoing classic hip screw (CHS) with those having intramedullary hip screw (IMHS) fixation for extracapsular proximal femoral fractures. We also examined the effect of the seniority of the surgeon on haemoglobin drop in those patients. We reviewed 159 CHS and 146 IMHS successive procedures. Of those, 137 CHS and 123 IMHS procedures were included as they fulfilled the blood testing and transfusion criteria. Patients undergoing a CHS procedure were found to drop their haemoglobin level by 2.32 g/dl, while those having an IMHS drop their haemoglobin level by 2.96 g/dl. The 0.6 g/dl difference was found to be statistically significant with a 95% CI (0.27 – 1.01) g/dl, p=0.001. A one-way ANOVA test showed that when the surgeons are divided into consultants, registrars and senior house officers, the degree of variation in haemoglobin drop is statistically not significant. This was true for both procedures. Our results support the paper’s findings that patients undergoing IMHS fixation of their hip fractures drop their haemoglobin more than those undergoing a CHS procedure. We, therefore, recommend the use of CHS for stable fractures and reserve the IMHS for unstable ones due to the perceived increase of blood loss with IMHS procedures. A.S. Khunda, Surgical Trainee, M. Rookmoneea, A.C. Hui, The James Cook University Hospital, Middlesbrough, UK.
Hidden blood loss after surgery for hip fracture 20 October 2006
Lalit Sharma, Orthopaedic surgeon Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India, Vijay Kumar, Rajesh Malhotra Send letter to journal: Re: Hidden blood loss after surgery for hip fracture drlalit76{at}hotmail.com Lalit Sharma, et al.	Sir, We read this article with interest and we congratulate the authors on their excellent work. In the study, the level of haemoglobin at the time of admission was corrected by a factor of 0.9 in all patients, assuming dehydration of 10% in all patients. Although dehydration is common, it is not a universal finding in all patients and is influenced most frequently by the interval between the time of injury and admission to hospital. A patient admitted two to three hours after trauma would not be dehydrated to the same degree as one with a two-day-old trauma. We would like to know what the usual delay was in admission in the authors' practice, and also how a figure of 10% dehydration was calculated or assumed? The study has not excluded the patients with medical diseases such as renal insufficiency, unstable angina, and severe coronary artery disease, etc. These diseases are common in the study age group and can influence the intravascular volume of the patient. Similarly, the study does not comment on patients with acute post-operative infection, which can also significantly affect fluid and electrolyte homeostasis. This study has used haemoglobin balance to measure hidden blood loss, but this does not take into account the hemolysis and simultaneous erythropoiesis. The rate of hemolysis can vary in these patients and can be particularly high as allogenic RBC are transfused to most patients. Thus, hemolysis can significantly affect the haemoglobin values, rendering this method vulnerable to error. Although we agree with the authors that in most patients following hip surgery, actual loss of blood is more than the apparent loss, we do feel that the method of haemoglobin balance to assess hidden blood loss is not very accurate, particularly in the elderly where compounding diseases influencing intravascular volume are common, and when allogenic RBCs are transfused. L. Sharma, Orthopaedic Surgeon, V. Kumar, R. Malhotra, Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India.