TOTAL HIP REPLACEMENT

Transcription

1 TOTAL HIP REPLACEMENT INFORMATION BOOKLET FOR PATIENTS St Vincent s Clinic, Department of Orthopaedic Surgery 438 Victoria Street, Darlinghurst NSW 2010 Sydney Australia Tel / Fax [email protected] Michael J. Neil Pty Ltd ABN Provider No J PO Box 627, Coogee NSW 2034

2 INTRODUCTION TOTAL HIP REPLACEMENT INFORMATION BOOKLET FOR PATIENTS Dr. MICHAEL J. NEIL MB.,BS.,FRCSEd(Orth.).,FRACS.,FAOrthA. ORTHOPAEDIC SURGEON A painful stiff hip can keep you from doing simple things in life, even walking without pain. Total hip replacement is one of the great surgical advances of this century. In this operation, your arthritic painful hip is replaced with an artificial device or prosthesis. Total hip replacement is a safe, effective and reliable operation that can relieve your hip pain and return you to most of the activities that you enjoy. WHAT IS ARTHRITIS? The bone ends in a joint, such as the hip or knee, are covered with a smooth glistening material called cartilage. This material cushions the underlying bone from excessive force or pressure and allows the joint to move easily without pain. In Osteoarthritis (OA), the cartilage becomes worn and no longer allows smooth movement of the joint. The bone surfaces may begin to rub together in more advanced disease causing severe pain, swelling and stiffness in the affected joint, particularly if the joint bears weight. The hip joint may also be damaged by Rheumatoid Arthritis, where the lining of the joint produces destructive enzymes that eat away at cartilage, bone and tendons. Trauma such as a fracture through the hip or a dislocation can cause permanent damage to the cartilage producing arthritis. Avascular Necrosis (AVN) is when the blood supply to the ball of the hip joint is lost, for one of many reasons, and can result in death of the bone with collapse of the hip joint causing severe pain and limp. Total hip replacement can relieve pain and improve function in all these conditions. YOUR HIP PROSTHESIS Your hip is a ball-and-socket joint where the thigh bone articulates with the pelvic bone. Your hip prosthesis has the same basic parts as your own hip joint. A ball, either metal or ceramic, is used to replace the worn ball of the thigh bone, with a stem inserted into the tube of the bone to anchor the prosthesis to your femur. A socket, either cemented plastic or press-fit titanium with a ceramic or plastic liner, is implanted into your worn socket in the pelvic bone. Like a healthy hip, your prosthesis has smooth gliding surfaces that allow the joint to move easily without pain. The bearing surfaces are either metal on plastic, ceramic on plastic, or ceramic on ceramic. Each has advantages and disadvantages. Cementless prostheses have been developed which allow the bone to directly bond to the implant. However, cemented prostheses have the longest track record in clinical use and are still commonly used. The main factors in deciding whether you will have a cemented or non-cemented implant are age, activity and bone quality.

3 BASIC FACTS ABOUT THE OPERATION Total hip replacement is a major operation. It involves admission to hospital, anaesthesia, rehabilitation and well defined risks. The operation takes about 90 minutes for me to perform. It is an operation I do about 150 times per year. This represents a busy surgical practice specialising in hip and knee replacement. Anaesthesia used is often a spinal block with sedation/general anaesthesia. You will not be aware during the operation. You can be completely asleep if you wish. Your anaesthetist will discuss this with you the night before surgery. Your operation will be carried out in an Orthopaedic operating theatre at St. Vincent s Private Hospital. Strict aseptic conditions will apply, including the use of full exhaust space suits. Your arthritic hip is dislocated surgically and the ball of the femur removed. Drills and reamers are used to prepare the bone surfaces for accurate implantation of your new hip. Special care is taken to ensure the hip is stable and the length of the leg is the same as the other side if possible. The wound is sutured close with a dissolving material so no stitches are seen or need to be removed. After the operation, you will be transferred to the recovery ward for observation for a period of hours. A check X-ray of your new hip will be taken and shown to me before you return to the hospital ward. You will have a drip with fluids and antibiotics running into the vein, an indwelling urinary catheter draining the bladder of urine and a drain in the hip wound draining blood from the operation site. Pain medicine will be given by the drip using self-administered system (PCA) or intra-muscular injection. A triangular pillow is kept between your legs whilst in bed to prevent dislocation of the hip. Calf compressors are applied to decrease clots forming in the legs. Heel Protectors are used to avoid pressure ulcers. You can start eating and drinking as soon as you feel like it. Within 48 hours after surgery, all the tubes will be removed and you will start to bear weight on your new hip with the physiotherapist, who will work with you until discharge or transfer to a rehabilitation unit. You will be encourage to be full weight-bearing on the hip and to progress to a walking stick as soon as possible. Most patients stay in hospital between 7-10 days and go directly home by car or ambulance. You should use a walking stick until the first post-operative visit at 8 weeks from surgery. You will be given strict instructions on dos and donts by your physiotherapist on discharge. Hydrotherapy, either as an outpatient or inpatient in a rehabilitation hospital is beneficial to your recovery, and is very much encouraged.

4 THE BENEFITS OF TOTAL HIP REPLACEMENT The main benefits are relief of pain and improved mobility which are often quite dramatic. Most patients will have some soreness in the replaced joint which may last for several weeks. The discomfort occurs because muscles surrounding the joint are weak and contracted from inactivity and need to get working again! Muscle power, lost because the painful arthritic joint was not used, usually returns with exercise when the pain is relieved by surgery. This exercise requires your effort for the best result. Motion of the hip will generally improve, depending how stiff the hip was before the operation. This improvement may continue for 1 year or longer after surgery with continued exercise. However, an extremely stiff hip will continue to be stiff for some time after the operation and will not regain normal motion. THE RISKS AND POSSIBLE COMPLICATIONS OF HIP REPLACEMENT As with all major surgery, there are certain risks and complications that can occur and which you need to understand and accept before I will carry out your surgery. Naturally there is a possibility of a major complication, and complications can be life-threatening. Although, theoretically anything can happen to anyone undergoing major surgery, the following complications are the most usual ones seen in clinical practice. 1. Deep vein thrombosis (DVT) and Pulmonary embolus (PE) Post-operative DVT is one of the most common complications following hip and knee replacement surgery and a deep venous thrombosis can be detected in approximately 50% of patients, with full surveillance techniques of duplex ultrasound scanning. The most serious complication however, from a deep venous thrombosis, is a secondary pulmonary embolus (a blood clot traveling to the lung). Currently, with our prophylaxis regime, the incidence of pulmonary embolus is less than 0.5%. Major pulmonary embolus can be fatal and can occur suddenly. Over the last 8 years, with our treatment regime, we have had no fatal emboli. The risk of a deep venous thrombosis in hip replacement is much less than knee replacement, of the order of 5-10%, but the DVTs are often more serious about the hip. Drug treatment of this complication most commonly relies on subcutaneous Heparin or oral Warfarin. Non-drug preventative measures include early ambulation, compression stockings, calf compression devices, spinal anaesthesia and continuous passive motion devices. Low molecular weight Heparin was developed after clinical studies showed this drug was effecting in preventing thrombosis. This drug is commenced post operatively, once bleeding is stable and given by skin injection daily. There is a small risk of bleeding at the operation site. Warfarin is the main oral anticoagulant ( blood thinner ) used after major DVT or PE. Treatment is continued for about 3 months and requires regular blood tests to monitor the dosage level. Warfarin can have major interactions with other drugs including alcohol. Professor Neil s protocol for prevention of DVT/PE Pre-operative: Post-operative: Stop smoking and lose weight Consultation with vascular physician if significant risk factors Compressive stockings/calf compressors night before surgery Low molecular weight Heparin 7-10 days then low dose aspirin Duplex Doppler scan leg veins at day 5 (all joint replacements) Compressive stockings 2 months Calf compressors 7 days or until ambulant Early ambulation hours post op With this protocol, which has been developed in conjunction with the Vascular Medicine Department at St Vincent s Clinic, headed by Dr. Michael McGrath, the incidence of DVT in my patients is 18%, and the incidence of PE is 0.5%. We have had no fatal Pulmonary embolus. This incidence is one of the lowest in any institution in the world. Our protocol continues to be studied and modified to improve these results.

5 2. Infection The overall reported incidence of infection in joint replacements is approximately 1%. Over the past 3 years at St Vincent s Private Hospital, the incidence of in-house hospital infection for total joint replacements has been 0%. Infection may occur early, within 4 weeks or late, after 4 weeks. Early infection is treated with antibiotics and possible re-operation to clean out the hip and try and save the prosthesis from removal. Later infection generally requires re-operation with removal of the prosthesis and possibly a second stage operation to re implant a new hip when it is safe. Occasionally, another hip cannot be implanted (Girdlestone Excision Arthroplasty), and you are left without a hip joint, producing permanent limp, shortening of the leg and difficulty walking. Spread of infection from another part of the body to a hip replacement can occur years after operation. To prevent such infection, persons with a joint replacement should be given antibiotics with extensive dental surgery, urinary tract infection or any invasive procedures that may produce bacteria in the bloodstream. I recommend Keflex 1mg 2 hours before and after the procedure. If you develop infection anywhere, it must be treated promptly with antibiotics. Preventative measures to minimise infection which will be used, include intravenous antibiotics given immediately prior to the operation and continued until the drip is removed, urinalysis to detect symptomatic urine infection, operation performed under strict aseptic conditions in maximal air exchange operating theatres, with full occlusive exhaust operating suits, occlusive wound dressings until first shower, intra-operative pulsatile lavage and immediate preoperative antiseptic scrub of operative area prior to routine skin antiseptic preparation. 3. Leg length discrepancy Most total hip replacement are unconstrained. This means that the ball is not locked into the socket, and the hip can theoretically dislocate with extreme movement. Stability is produced, in part, by soft tissue tension in the muscles and ligaments around the hip. Sometimes it is necessary to lengthen the leg, which tightens the soft tissues, to improve the stability of the hip. About 16% of patients feel longer after hip replacement, whereas only 3% are truly longer. This is called functional leg length discrepancy and is due to tightening of the muscles around the new hip. This feeling of lengthening of the leg can take 6 months to improve and requires stretching exercises of the hip and pelvis. Leg length difference is usually less than 5mm in the vast majority of cases, but can be up to 2.5cm in unusual circumstances. Any difference over 10mm usually requires a shoe raise. Preventative measures taken with your surgery to minimise this complication: a. Accurate physical examination with blocks b. Preoperative template of pelvic X-ray to determine real and apparent leg length c. Preoperative template of hip prosthesis to closely match anatomy and offset d. Intra-operative external jig used to assess length and offset of the hip 4. Dislocation Report risk of dislocation is approximately 3% in large series, usually within the first 12 months after surgery. The incidence of dislocation is related to patient factors, surgical technique and surgical experience. My current risk of dislocation is.5%. The risk is minimised by strict adherence to the physiotherapist s post-operative instructions, particularly with movement of the leg upwards and inwards. If the hip dislocates, it can usually be put back into place by manipulation under anaesthesia. If it keeps popping out afterwards easily, then re operation will be necessary.

6 5. Loosening and wear of the prosthesis All artificial hips wear out sooner or later. How quickly this occurs and whether it will worry you depends on age, life expectancy, weight, activity and use. Polyethylene wears at a rate of about 0.5mm per annum. We aim to have a minimum thickness of 10mm of polyethylene, to allow for 20 years of wear. Survivorship studies suggest 90% continued excellent function in cemented metal-on-plastic total hips at 20 years! We hope that ceramic / ceramic hips will perform even better with the elimination of plastic and cement as a possible means of later failure. In laboratory studies, modern ceramic bearings appear to function very well, with minimal wear, for the equivalent of 30 yeas normal use. This does not necessarily mean ceramic implants will last this distance, however there is a lot of mechanical evidence to suggest that ceramics will survive well long term, with minimal wear. The clinical survivorship studies of ceramic on ceramic articulations in cemented hips, used in France for many years, recently suggest 98% continued excellent function at 15 years! As wear or loosening of an implant can occur silently before the onset of symptoms, you will be followed up for life after your hip replacement. Routine reviews are at 2 months, 1 year, 6 yearly afterwards. If the hip loosens or wears, you may need to undergo a revision operation to re implant part or all of a new prosthesis. This surgery is more difficult with a higher risk of complication. 20% of my current surgical practice is revision operation of patients referred with loose implants. This work requires extensive inventory and expertise, and access to a bone bank to provide bone graft material. St Vincent s Private Hospital has a fully operational bone bank which has achieved the highest standard of quality rating, being full TGA (Therapeutic Goods Administration) approval. This rating has been given to only a handful of units in Australia. If you are a suitable donor, I may ask your permission to bank your bone taken at hip replacement for future transplantation in another patient. There is no cost or risk to you in donating bone, but several screening tests are required. 6. Blood transfusion Joint replacement surgery involves blood loss, which may require a blood transfusion. The average volumetric blood loss, for a routine operation, is approximately 5-600mls. Whether or not a blood transfusion is required depends on the patient s preoperative haemoglobin and general medical state. On average, if the preoperative haemoglobin is 13 or above, for a normal body mass index, for a routine operation, then blood transfusion may not be required. If transfusion is required, it is usually no more than 1 to 2 units of blood. We have ceased collecting autologous blood preoperatively, as this appeared to be an expensive and cumbersome exercise, and did not decrease the need for banked blood. What we have found is that the patients who have given blood preoperatively usually present for surgery more anaemic, require their banked blood to be re exchanged and still may require a blood transfusion. Banked homologous blood from Red Cross donors is stringently screened and tested to ensure that it is safe and free from infectious agents such as HIV and Hepatitis. Nevertheless, there is no guarantee that blood from homologous donors is safe, or will not cause a blood reaction. The risk is extremely low (about 1 in 60,000).

7 PREPARATION FOR SURGERY Preparing mentally and physically is an important step toward a successful result. I strongly recommend the following: 1. Prehab this means being involved in a diligent exercise and hydrotherapy program, 6 weeks before your anticipated surgery, if possible. This would involve aqua aerobics, cycling, rowing and exercise in a pool. 2. Stop smoking 3. Weight loss: low fat diet high in vitamins A, C and Zinc. 4. Stop these following medications 2 weeks prior to surgery Non Steroidal Anti Inflammatories eg, Voltaren, Brufen, Mobic ASPIRIN Plavix, Clopidogrel HRT (Hormone Replacement Therapy) eg, Provera, Oestrogen patches. You will be given a list of other medications that need to be stopped, including alternative and herbal preparations. 5. Continue all other prescription medications 6. Regular stretching and strengthening exercises (swimming, walking, bike) 7. Attend to any infective sites (eg, prostate, urine, skin, teeth, nails and feet) ACTIVITY AFTER SURGERY Following your hip replacement, you will be encouraged to use your leg, walking and swimming. Most sports such as golf, doubles tennis, bowls and swimming are permitted and beneficial. Even skiing (blue runs, groomed slopes) and horse riding do not harm, but are associated with an intrinsic risk with falling. High impact sports such as jogging, however, may stress the prosthesis excessively and should be avoided. INSTRUCTIONS ON DISCHARGE FROM HOSPITAL Wound - Wash normally. Avoid excessive sunlight exposure, as this may burn the scar. Topical lotions such as Vitamin E or Sorbolene are useful to soften surrounding skin. Compression stockings should be worn until the first post op visit. It is usually not necessary to wear them at night, but more when you are upright. The stockings can be washed. Crutches or walking stick should be used at all times out of doors until first post op visit. Low dose aspirin (half aspirin per day) should be taken for 1 year after surgery to improve circulation, prevent late clots and help reduce swelling. This can be continued for life! Sleep on back for 1 month if possible. Otherwise sleep on unoperated side with pillow between legs. After 1 month, sleep on side with pillow between legs for 1 month. Drive after 6 weeks. Work when you are able to travel and sit comfortably. If you have a standing job, you will need 2 months off. Exercise regularly each day for 2 months. This may be formal hydrotherapy or regular swimming, walking or an exercise bike. Avoid low chairs and crossing your legs for 1 year, and preferably for life! Sexual intercourse can recommence once you are at home. It is recommended that you take a passive role, laying on your back only, for 2 months. Follow up appointment should be made by contacting my office directly / to see me at 2 months from operation. X-rays will be taken at each visit.

8 It is important that you contact my office directly after discharge if you have any concerns whatsoever about your operation and progress. I will always be available, even if not immediately, to answer any queries. My office contact is: Associate Professor Michael Neil Department of Orthopaedic Surgery St. Vincent s Clinic Level Victoria St Darlinghurst NSW 2010 Telephone: (02) / (02) Fax: (02) SUCCESS RATE Following these protocols, the current success rate, measured by patient satisfaction rate, is approximately 95% for primary hip replacement surgery. This means that 95% of patients are very happy with their operation, have no regrets in having proceeded with surgery and would have the operation performed again, if required. THIS PROTOCOL IS NOT TO BE RELEASED TO, OR REPRODUCED BY A THIRD PARY WITHOUT MY SPECIFIC PERMISSION

9 Arthroplasty Society of Australia Guidelines for Thromboembolic Prophylaxis after Total Joint Replacement Weighing Efficacy Against Risk A major focus of the Arthroplasty Society of Australia is to ensure that joint replacement surgery is made as safe as possible, particularly by putting in place measures to decrease the incidence of thromboembolic disease. After consideration of the current literature, this statement is a consensus opinion from this group of specialist joint replacement surgeons. When considering the varying effectiveness of the methods of prevention, the risks of thromboembolic disease that we wish to prevent need to be weighed against the risks of complications caused by preventative measures. Several effective measures to prevent thromboembolic disease have low complication rates. These include the institution of early mobilisation regimes, spinal anaesthetic, graduated compression stockings, foot pumps and sequential pneumatic compression boots. Use of one or more of these measures is strongly suggested. For some patients who have a higher risk of thromboembolic disease, additional measures by a pharmacological method may also be indicated. Pharmacological or chemical methods include the use of aspirin, Warfarin, heparin, low molecular weight heparins (i.e. Clexane, Fragmin, etc.), fondoparinux and the melagatran group. While chemical prophylaxis has been shown to reduce rates of deep venous thrombosis, it may not alter the more important incidence of pulmonary embolism or sudden death from embolic disease following surgery. All of these pharmacological methods have, however, significantly higher complication rates, which include limb swelling, haematoma, bleeding from the surgical site, wound breakdown, joint stiffness, increased infection rates, remote bleeding episodes, stroke and even death. The use of these additional means need to be carefully considered and thoroughly discussed with the patient in this context. Position Statement on Driving after Total Hip and Knee Replacement Surgery After consideration of the relevant literature, the Arthroplasty Society of Australia recommends that for a minimum period of six weeks following hip or knee replacement surgery that patients abstain from driving a motor vehicle. This is inclusive of manual and automatic cars, and independent of right or left side surgery. After this six week period, each individual s choice to resume driving should only be made when he or she feels confident to be able to control the vehicle safely.

10 Position Statement for Recommendations for Patients with Hip or Knee Joint Replacement who Require Dental Treatment Dental problem in the first 3 months following hip or knee joint replacement surgery Infection with abscess formation: Urgent and aggressive treatment of the abscess. Remove the cause (exondontic or endodontic) under antibiotic prophylaxis. Pain: Provide emergency dental treatment for pain. Antibiotics are indicated if a high or medium risk dental procedure performed. Non-infective dental problem without pain: Defer non-emergency dental treatment until 3 to 6 months after prosthesis replacement. Dental treatment after 3 months in a patient with a normally functioning artificial joint Routine dental treatment including extraction. No antibiotic prophylaxis required. Dental treatment for patients with significant risk factors for prosthetic joint infection Immunocompromised patients include: those with insulin-dependent diabetes those taking immunosuppressive treatment for organ transplants or malignancy those taking systemic rheumatoid arthritis those taking systemic steroids (e.g., patients with severe asthma, dermatological problems) Consultation with the patient s treating physician is recommended. Failing, particularly chronically inflamed, artificial joints: Consultation with the patient s treating orthopaedic surgeon is recommended. Defer non-essential dental treatment until orthopaedic problem has resolved. Previous history of infected artificial joints: Routine non-surgical dental treatment no prophylaxis indicated. Recommended antibiotic regimens where indicated 1. Dental clinic LA extractions or deep curettage Amoxycillin 2-3g orally 1 hour prior to procedure 2. Theatre procedures Amoxycillin 1g I/V at induction Followed by 500mg Amoxicillin I/V or orally 6 hours later. 3. Penicillin hypersensitivity, long term penicillin, recent penicillin/other B-lactam. Clindamycin 600mg 1 hour prior to procedure or Vancomycin 1g I/V 1 hour to finish 2 hours or Lincomycin 600mg just prior to the procedure 4. High risk case (i.e., Gross oral sepsis/severely immunocompromised/previous joint infection.) Gentamicin 2mg/kg I/V just before procedure (can be administered 3mg/kg provided there is no concomitant renal disease) PLUS Amoxycillin 1g I/V just before procedure followed by 500mg I/V or orally 6 hours later. If hypersensitive to penicillin replace Amoxicillin with Vancomycin 1mg I/V over 1 hour to finish just before procedure. Ref: Scott JF et al, Patients with artificial joints: do they need antibiotic cover for dental treatment? Aust Dent J 2005:50 Suppl 2S45-S53

11 Autologous Blood Donation Broadcast Monday 23 rd September 2002 With Norman Swan (ABC Science Health Matters All in the Mind, The Buzz Earthbeat, In Conversation, Ockhams Razor Science Show, The Lab Catalyst Quantum SUMMARY: People who are worried about receiving other people s blood when they need a blood transfusion during surgery often donate their own blood (autologous blood donation) before having surgery. TRANSCRIPT: Still to come, a spot of scatology, giving new meaning to turning the other cheek. Before that though, while we re talking about fainting at the sight of blood, the whole business of blood transfusion in the era of AIDS, Hepatitis C and Mad Cow Disease has become much more fraught. This in turn has driven a trend for people undergoing certain kinds of planned surgery, like a hip replacement, to donate two or three units of their own blood ahead of time. This means that if they need a transfusion, it can be autologous, from themselves. But findings from a Victorian study of the patterns of autologous blood donation has found that the process is not necessarily worth the money and effort. In fact you may need a transfusion simply because you ve donated so much blood! Dr Helen Savoia is a Consultant Haematologist at the Women s and Children s Hospitals, and this work was done when she was a transfusion consultant with the Red Cross in Melbourne. Helen Savoia: We asked the questions: what patients were presenting to have autologous blood collected, how many units were their doctors requesting, how many were actually collected and if the numbers weren t the same, why not? And how many of those units were actually transfused? And overall, we found that about 2,800 units were requested and just over 2,000 of those were actually collected. The main reason that patients didn t have the number of units collected that their surgeon wanted was there simply wasn t enough time to collect the number of units, and the second most common reason was that some patients would become too anaemic to have blood taken from them during the process of blood collection. Norman Swan: And how much of that was actually used? Helen Savoia: Nearly three-quarters of the units were actually transfused, and 27% were wasted or discarded. Norman Swan: Now you also compared that to the use of blood in operations in general, and I think you found that if you gave your own blood you were more likely to get it back again. Helen Savoia: That s right, yes. For most surgical procedures, people who donated their own blood had higher transfusion rates, and this was up to five times higher. Norman Swan: Were you able to tell whether or not those transfusions breached guidelines? I mean there are now guidelines as to when a blood transfusion is in fact warranted, does that mean that the surgeon thought, Well you ve got it, you re a little bit anaemic, I ll whack it in anyway, what s the risk?. Helen Savoia: That s a possibility. We were not able to assess that in this study. It has been suggested that that is one possible cause for transfusion rates being higher in this population, the attitude that, Well, you ve gone to all this trouble, we probably should use it. But also the actual process of donating autologous blood makes you anaemic and makes you more likely to need a transfusion during your surgery. Norman Swan: Ah, so the very process itself may say, Well we ve taken it out, we ll put it back, having depleted you?. Helen Savoia: That s right, yes. It s quite interesting. A study just published from some researchers in the United States has confirmed our findings. This was a small study in total hip replacement and

12 they compared 42 patients who donated 2 units of autologous blood each, and 54 patients who did not donate their own blood. And they were very strict about transfusion guidelines, so that all the patients in the group were transfused at the same transfusion trigger, same level of haemoglobin and 69% of patients in the autologous group received a transfusion and none of the non-donors received a transfusion. So these authors concluded that in hip replacement surgery, for non-anaemic patients, that autologous donation had no benefit at all, and increased the costs associated with surgery. Norman Swain: And that is your conclusion? Helen Savoia: Our study shows that autologous transfusion in 2002 has a significantly less role than it s believed to have had in the past. There may still be particular surgical procedures or particular patients where it may be applicable, but I think that what we really need to do to answer many of these transfusion questions is to do some well-designed studies. Norman Swan: And the cost involved, both personally and financially? Helen Savoia: In the Australian setting it s very difficult to actually attribute cots, but certainly costs involved would be for the patient, the time it takes. Each unit of blood would need an hour or two of patient time to actually make the blood donation and then there is a cost to the testing, since all blood does need to be tested for the various viral markers. Autologous collections are done both in public hospital settings, private pathology settings, and through Red Cross, and so there are various charges at different levels. I guess one of the things that are not been discussed is what s the actual risk of donating blood. Is there an adverse event rates with the actual process? Although adverse events associated with normal blood donation are very low, the majority of patients undergoing autologous donation are often more elderly and with more medical problems. Norman Swan: And giving more than one unit, which you don t do when you re donating autologously. Has any research been done into the effects on the person? I ve seen a few people who ve given their own blood for, say hip operations, and they look dreadful just before they go into theatre, I mean they look pale and weak, they look really sapped. Helen Savoia: Yes, the study I mentioned from the United States certainly said that the group of autologous donors had a significantly lower haemoglobin both on hospital admission and in the recovery room, compared with the non-donor group. Norman Swan: So here s the $64 question: If you re going in for a hip operation, you ve worked as a blood transfusion specialist, you know the risks: would you donate your own blood beforehand? Helen Savoia: The most important thing is that I would go to an experienced and meticulous surgeon and I think that currently anaesthetic and surgical techniques are probably more important in elective surgery and in actually minimising blood loss, and I probably wouldn t. Norman Swan: So is that a no? Helen Savoia: Yes. Norman Swan: And finally, did it prevent people getting a homologous blood transfusion, in other words did it realistically prevent people having somebody else s blood? Helen Savoia: Yes, I think it did. 90% of patients avoided having someone else s blood. What the real question is though is if they had not donated autologous blood, what would have happened. And since our study wasn t randomized, that s very difficult to know. But certainly the US study in total hip replacement suggests that figure may be quite low. Norman Swan: And by the way there have been studies in cardiac bypass surgery and hysterectomy which show that blood loss during those operations is so low these days that autologous blood donation is now worth doing. Dr Helen Savoia is a haematologist at the Women s and Children s Health, Royal Children s Hospital, Flemington Road, Parkville VIC [email protected] Savoia H.F. et al. Utilization of Preoperative Autologous Blood Donation In Elective Surgery. ANZ Journal of Surgery 2002; 72: