Department of Orthopedics, Orthopedic Research Institute, West China Hospital, Sichuan University, Chengdu, China.
Orthop Surg. 2022 Jan;14(1):18-26. doi: 10.1111/os.13176. Epub 2021 Nov 25.
To verify whether an elevated preoperative international normalized ratio (INR) increases transfusion and complications independently in primary total hip arthroplasty (THA) with the management of an enhanced recovery after surgery (EARS) protocol.
We retrospectively reviewed the database of adults who underwent primary THA between 2014 and 2018 by the same surgeon. A total of 552 patients were assigned into three groups by preoperative INR class: INR ≤ 0.9, 0.9 < INR < 1.0, and INR ≥ 1.0. We regarded transfusion within 90 days during the same hospitalization as the primary outcome. We also included perioperative blood loss, maximum Hb drop, postoperative anaemia requiring medicine, and length of hospital stay (LOS) during the same hospitalization in the study. Complications and reoperation at 90 days and mortality at 90 days and 12 months were also included in the study. Univariable analyses were utilized to compare baselines and outcomes among the three groups. Multivariate logistic regressions were used to adjust for differences at baseline among the groups.
All patients had an INR < 1.5 preoperatively and were managed with the ERAS protocol. Among them, 93 (16.8%) patients had INR ≤ 0.9, 268 (48.6%) patients had 0.9 < INR < 1.0, and 191 (34.6%) patients had INR ≥ 1.0. In the univariable analyses, as the INR increased, the transfusion rates increased from 1.08% for INR ≤ 0.9, to 1.12% for 0.9 < INR < 1.0 and to 5.76% for INR ≥ 1.0 (P < 0.05). The overall complication rate increased from 10.8% for INR ≤ 0.9, to 16.4% for 0.9 < INR < 1.0, and to 22.5% for INR ≥ 1.0 (P < 0.05). The length of stay (LOS) in the INR ≥ 1.0 group was 5.7 ± 2.2 days, which was significantly longer than that in the INR ≤ 0.9 group (4.7 ± 1.6 days, P = 0.000) and 0.9 < INR < 1.0 group (5.1 ± 2.0 days, P = 0.007). No statistical significance was detected among the groups regarding blood loss, maximum Hb drop, or the incidence of postoperative anaemia that required medicine. There was no significant difference in reoperation or mortality among the groups. When controlling for demographic and comorbidity characteristics, there was no statistically significant difference in the odds of transfusion during the same hospitalization or overall complications at 90 days among the groups (P > 0.05).
Elevated preoperative INR cannot increase transfusion or complication rates independently in primary THA with the management of the ERAS protocol. With the improvement in the ERAS protocol and the use of tranexamic acid (TXA), an INR < 1.5 is still a conventional safe threshold for THA surgery.
验证在接受增强术后康复（EARS）方案管理的初次全髋关节置换术（THA）中，术前国际标准化比值（INR）升高是否会独立增加输血和并发症。
我们回顾性分析了同一位外科医生在 2014 年至 2018 年间进行的初次 THA 的数据库。根据术前 INR 类别将 552 例患者分为三组：INR ≤0.9、0.9＜INR＜1.0 和 INR ≥1.0。我们将 90 天内同一住院期间的输血视为主要结局。我们还将围手术期失血量、最大 Hb 下降量、术后需要药物治疗的贫血以及同一住院期间的住院时间（LOS）纳入研究。90 天和 12 个月时的并发症和再次手术以及 90 天和 12 个月时的死亡率也包括在研究中。采用单变量分析比较三组间的基线和结局。采用多元逻辑回归调整组间基线差异。
所有患者术前 INR 均＜1.5，并采用 EARS 方案进行管理。其中，93（16.8%）例患者 INR≤0.9，268（48.6%）例患者 0.9＜INR＜1.0，191（34.6%）例患者 INR≥1.0。在单变量分析中，随着 INR 的升高，输血率从 INR≤0.9 的 1.08%增加到 0.9＜INR＜1.0 的 1.12%和 INR≥1.0 的 5.76%（P＜0.05）。总体并发症发生率从 INR≤0.9 的 10.8%增加到 0.9＜INR＜1.0 的 16.4%和 INR≥1.0 的 22.5%（P＜0.05）。INR≥1.0 组的 LOS 为 5.7±2.2 天，明显长于 INR≤0.9 组（4.7±1.6 天，P=0.000）和 0.9＜INR＜1.0 组（5.1±2.0 天，P=0.007）。三组间失血量、最大 Hb 下降量或需要药物治疗的术后贫血发生率无统计学差异。三组间再手术或死亡率无统计学差异。在控制人口统计学和合并症特征后，三组间同一住院期间输血的可能性或 90 天内总体并发症的可能性无统计学差异（P＞0.05）。
在接受 EARS 方案管理的初次 THA 中，术前升高的 INR 并不能独立增加输血或并发症的发生率。随着 EARS 方案的改进和氨甲环酸（TXA）的使用，INR＜1.5 仍然是 THA 手术的常规安全阈值。
