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Transfusion after Intramedullary Nailing of Hip Fractures

Guy S P, Sehjal R, Ulhaq MI and Shaw D L

Introduction: Patients with unstable multi-fragmentary trochanteric fractures in comparison to those with simple intra-capsular and inter-trochanteric fractures have a larger amount of fractured metaphyseal bone from which bleeding can occur at the time of injury. A detailed analysis was performed comparing haemoglobin (Hb) in the pre and postoperative periods between patients requiring transfusion and those not. This was to determine if pre-operative blood loss caused a greater magnitude of fall in Hb concentration compared to post-operative blood loss, demonstrating if bleeding from the fracture as opposed to the surgery that patients had undergone was associated with the need for transfusion.

Methods: Retrospective review of patients undergoing third generation Gamma Nail (Stryker Trauma, Switzerland) fixation for unstable peritrochanteric fractures. Fracture type was classified according to the MÜller AO/ OTA classification. Patients were excluded if they had prophylactic nailing for metastatic disease; had sustained a diaphyseal fracture; or if they had been on warfarin, had any previous documented anaemia or acute gastrointestinal haemorrhage. The pre and post-operative Hb was recorded, timing and volume of transfusion. The Hb levels were analysed using a repeated measures regression model. The mean arterial blood pressure (MAP), level of fitness prior to surgery according to the American Society Anaesthesiologists (ASA) grading and fracture type was defined for each patient.

Results: There were 51 patients with a mean age of 78 years after exclusions. 23 patients received a transfusion and 28 did not. The mean pre-operative Hb in the non-transfused group was 118.4 g/L, higher than the Hb in the transfused group, 95.9 g/L (p < 0.00). In comparison, in the 48 hour period after their operation, the mean Hb concentrations were comparable in both groups (p=0.358).

Conclusions: There was a significant difference in the starting Hb level between groups: in the group requiring transfusion patients were anaemic before surgery. The association of pre-operative anaemia with an unstable multifragmentary trochanteric fracture should alert clinicians that these patients are likely to require blood replacement.