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Knee: A. Amin, A. Watson, J. Mangwani, D. Nawabi, R. Ahluwalia, and M. Loeffler A prospective randomised controlled trial of autologous retransfusion in total knee replacement J Bone Joint Surg Br 2008; 90-B: 451-454 [Abstract] [Full text] [PDF]

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Authors' reply:

Amit AMIN, On behalf of all co-authors   (23 May 2008)

Autologous transfusion does reduce allogenic blood transfusion in total knee replacement

Santoshkumar Hakkalamani, Carroll FA   (8 May 2008)

Authors' reply: 23 May 2008
Amit AMIN, SpR Orthopaedics Colchester General Hospital, On behalf of all co-authors Send letter to journal: Re: Authors' reply: amitamin{at}doctors.org.uk Amit AMIN, et al.	Sir, We thank Mr Hakkalamani and Mr Carroll for their interest in our paper. Firstly, regarding the eight patients who did not receive their autologous transfusion, those with less than 100ml of drainage (five patients) are unlikely to require a homologous blood transfusion. Unfortunately, technical difficulties do occur and include human error, although only three of 92 patients in our series did not receive back their autologous blood. Looking back at our results, we confirm that none of the eight patients required a subsequent blood transfusion. We agree that this should have been made clear. However, this did not affect the transfusion rate between groups, and therefore the conclusions of the study. We disagree that these patients should have been excluded or 'treated as controls'. Such a small control group would have added little useful information. Additionally, the 'intention to treat principle' in our opinion was correctly applied and allows the results of the study to be viewed in the 'real world'. There were no wound complications in the group which had less than 100ml drainage. We accept Mr Hakkalamani's suggestion that using no drain may 'slightly' increase the wound complication rate, but would add that the presence of a drain may increase the local infection rate. Hence we recommended in our conclusions that a prospective randomised trial with three arms, no drain, vacuum drain and autologous drain, would be the ideal. We are not the first group to question the efficacy of autologous drains. Whilst the results in Mr Hakkalamani's unit may be favourable, these findings are not universal and we feel our prospective randomised trial strongly supports this view. It may be more sensible to try and modify transfusion policies in an attempt to reduce post-operative homologous blood transfusion. A. Amin, SpR Orthopaedics, A. Watson, J. Mangwani, D. Nawabi, R. Ahluwalia, M. Loeffler, Colchester General Hospital, Colchester, Essex, UK.
Autologous transfusion does reduce allogenic blood transfusion in total knee replacement 8 May 2008
Santoshkumar Hakkalamani, Specialist Registrar Trauma and Orthopaedics Wirral University Teaching Hospitals NHS Trust UK, Carroll FA Send letter to journal: Re: Autologous transfusion does reduce allogenic blood transfusion in total knee replacement hakkal{at}rediffmail.com Santoshkumar Hakkalamani, et al.	Sir, This paper drew our attention and interest as we use retransfusion drains in all our primary total knee replacements. We also use similar transfusion criteria and agree with the authors' suggestions. Following such criteria will reduce the need for allogenic blood transfusion. We have two questions: In the study group (retransfusion group 92 patients) eight patients did not receive the autologous blood (five patients due to low drainage <100ml and three patients due to technical difficulty). The authors included them with the intention to treat principle. In our view these patients should have been treated as controls or should have been excluded from the study because all the drained blood was discarded. Furthermore, the authors did not clarify whether these eight patients received an allogenic blood transfusion or not. If all these patients or half of them had received the allogenic blood transfusion, there would be a reduction of 50% or more in blood transfusion in the study group. The second point is that in the complications the authors mentioned the overall wound problems in each group. We would like to know whether the patients who had less drainage (<100 ml) had any wound problems. The patients with no drain after TKR have more wound problems when compaired with the drained groups.1 S. Hakkalamani, Specialist Registrar Trauma and Orthopaedics, F.A. Carroll, Wirral University Teaching Hospitals NHS Trust, Wirral, Merseyside, UK. 1. Parker MJ, Roberts CP, Hay D. Closed suction drainage for hip and knee arthroplasty. A meta-analysis. J Bone Joint Surg [Am] 2004;86-A:1146-52.