O R I G I N A LJ Orthopaed Traumatol (2005) 6:163–166DOI 10.1007/s10195-005-0102-9

T. NakaiK. TemporinR. MuraoM. Kakiuchi

Intraosseous pressure correlates withpostoperative blood loss following cementlesstotal hip arthroplasty

Received: 1 February 2005Accepted: 1 July 2005

T. Nakai (�) • K. Temporin • R. MuraoM. KakiuchiDepartment of Orthopaedic SurgeryOsaka Police Hospital10-31 Kitayama-cho, Tennoji-ku,Osaka 543-0035, JapanE-mail: tsuyoshi244nakai@yahoo.co.jp

Abstract The relationship betweenperioperative blood loss andintraosseous pressure of the iliumduring cementless total hip arthro-plasty has not previously been clar-ified. The aim of the present studywas to evaluate whether blood lossin cementless total hip arthroplastycorrelates with intraosseous pres-sure of the ilium or systemic arteri-al pressure. The subjects were 26patients (5 men and 21 women)undergoing primary cementlesstotal hip arthroplasty. Intraoperativeand postoperative blood loss,intraosseous pressure of the ilium,and systemic arterial pressure weremeasured prospectively. Mean ageof the subjects was 68.3 years.Intraoperative blood loss correlated

significantly with mean arterialpressure (r=0.522, p=0.0079), butnot with intraosseous pressure, age,or body weight. Postoperativeblood loss correlated significantlywith intraosseous pressure(r=0.399, p=0.0427), but not withmean arterial pressure, age, or bodyweight. Intraosseous pressure didnot correlate with mean arterialpressure. These results suggest thatintraosseous pressure of the ilium isa predictor of postoperative bleed-ing in primary cementless total hiparthroplasty.

Key words Blood loss •

Intraosseous pressure • Total hiparthroplasty

Introduction

Total hip arthroplasty (THA) always involves substantialblood loss, irrespective of operative technique. Because themain source of bleeding during THA has generally beenthought to be veins and arteries, hypotensive anesthesia hasbeen used to reduce intraoperative blood loss during THA[1, 2]. Studies have demonstrated a two- to four-fold reduc-tion in intraoperative blood loss when mean arterial pres-sure is reduced to 50 mmHg during surgery [2–4].However, the source of bleeding during THA may includebone, in addition to veins and arteries. We previouslyreported a positive relationship between vertebral intraos-seous pressure and blood loss during posterior spinal sur-

gery [5]. However, to our knowledge, there have been noreports of correlation between intraosseous pressure and in-traoperative or postoperative blood loss in cementless THA.The purpose of the present study was to examine whetherblood loss in cementless THA correlated with intraosseouspressure of the ilium or systemic arterial pressure.

Materials and methods

The subjects were 26 patients (5 men and 21 women) undergo-ing primary cementless THA. The institutional ethics committeeof our hospital approved the study, and all patients gave infor-med consent.

All patients were operated on because of secondaryosteoarthritis of the hip, and none had a history of previous hipsurgery. None of the patients had a history of cardiovascular,pulmonary or chronic liver disease, all of which can causevenous hypertension. Patients with bleeding disorders were alsoexcluded.

Administration of anti-inflammatory drugs was suspended atleast 1 week before surgery. All operations were performedunder normotensive general anesthesia with epidural anesthesia,and by the same surgeon (TN). None of the patients were treat-ed with heparin or warfarin for prevention of thrombosis.Surgery was performed via a posterolateral approach withouttrochanteric osteotomy. We used a Trilogy hemisphericalporous-coated (HA/TCP) titanium acetabular component and aVersys Fiber Metal Mid taper stem (Zimmer, Warsaw, Indiana,USA). No bone reconstruction was necessary. A metal cannula(diameter, 2.0 mm) was inserted into the iliac crest 3 cm poste-rior to the anterior superior iliac spine, at a depth of 2 cm intothe bone. The cannula, which was spontaneously filled withblood from the bone marrow, was flushed with a heparin solu-tion. Intraosseous pressure of the ilium was measured immedi-ately before surgical incision, after allowing 10 minutes for equi-libration. Systemic arterial pressure was measured continuouslyduring the operation through a catheter inserted into the radialartery. A transducer (Transpac; Abbott Critical Care Systems,North Chicago, Illinois, USA) and a monitoring system withamplifier (Life Scope 9; Nihon Koden, Tokyo, Japan) was usedto record intraosseous and arterial pressure.

After surgery, a suction drainage device was inserted into thejoint (Sumitomo, Osaka, Japan). Operative blood loss was esti-mated by weighing all the swabs and the contents in the suctionapparatus, compensating for irrigation. The drainage device wasremoved 24 hours after surgery, and postoperative blood losswas considered equal to the volume collected up to that time.The surgeon was not informed of the measured values until theskin was closed.

The values of demographic variables are expressed as themean (±SD). Statistical analysis was performed using theStatview-J 5.0 statistical package (SAS Institute, Cary, NorthCarolina, USA) for correlation analysis. A value of p<0.05 wasconsidered to indicate significance.

Results

The study enrolled 26 patients undergoing THA (Table 1).The mean duration of surgery was 80.1 minutes. Averageintraoperative and postoperative blood loss was 382.5grams and 561.5 grams, respectively. Mean intraosseouspressure of the ilium immediately before surgical incisionwas 22.0 mmHg. Mean arterial pressure was 81.9 mmHgimmediately before surgical incision, 79.4 mmHg halfwaythrough the operation, and 82.1 mmHg at the time of skinclosure.

Intraoperative blood loss correlated with mean arterialpressure immediately before surgical incision (Fig. 1), but

not with mean intraosseous pressure of the ilium, age orbody weight (Table 2). Postoperative blood loss correlat-ed with mean intraosseous pressure of the ilium (Fig. 2),but not with mean arterial pressure, age or body weight.Intraosseous pressure of the ilium did not correlate withmean arterial pressure.

There were no complications associated with monitor-ing of intraosseous pressure. All procedures were consid-ered technically satisfactory, and without complicationssuch as early infection or dislocation. All patients weretransfused with preoperatively drawn autologous blood.No allogenic blood transfusion was performed.

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Table 1 Clinical characteristics of 26 patients who underwent totalhip arthroplasty. Values are mean (SD)

Age, years 68.3 (10.1)

Weight, kg 57.3 (9.2)

Intraosseous pressure, mmHg 22.0 (10.9)

Mean arterial pressure, mmHgImmediatly before surgical incision 81.9 (16.0)Halfway through operation 79.4 (13.7)At skin closure 82.2 (12.5)

Blood loss, gIntraoperative 383 (226)Postoperative 562 (250)

Fig. 1 Correlation between intraoperative blood loss and meanarterial pressure immediately before surgical incision (r=0.522,p=0.0079)

Mean arterial pressure, mmHg

1200

1000

800

600

400

200

0

-200

60 70 80 90 100 110 120 130

Blo

od lo

ss,g

Discussion

The viral and immunological risks associated with homol-ogous blood transfusion have been greatly reduced. Also,many techniques have been developed to minimize use ofhomologous blood transfusion, including strategiesinvolving hemodilution, erythropoietin, blood salvage andautologous transfusion. The ability to predict periopera-tive blood loss during THA can increase the effectivenessof these techniques.

In the present study, intraoperative blood loss correlat-ed with mean arterial blood pressure immediately beforesurgical incision, indicating that high blood pressure

increases blood loss via veins and arteries. We previouslyreported that vertebral intraosseous pressure correlatedwith intraoperative blood loss in cervical laminoplasty[5]. In the present study, we found no relationshipbetween intraosseous pressure and intraoperative bloodloss in cementless THA. We speculated that the mainsource of bleeding during cervical laminoplasty could bethe surface of bone [5]. However, the main source ofbleeding during cementless THA must include not onlythe bone but also veins and arteries. It has been reportedthat intraosseous pressure and nutrient venous pressureare nearly identical in the canine tibia [6]. Such a closerelationship between the intraosseous and peripheralvenous systems validates the use of intraosseous pressureto determine changes in pressure in adjacent veins, andconfirms the risk of bleeding from both bone and veins.

In the present study, a positive correlation wasobserved between postoperative blood loss andintraosseous pressure of the ilium immediately before sur-gical incision. We speculate that the main source of post-operative blood loss after cementless THA could be theintramedullary circulation of the femoral canal and theacetabular bony bed. We did not measure blood pressurein the femoral bone, for several reasons. Termansen et al.[7] measured intraosseous pressure of femoral head andgreater trochanter in a study of primary osteoarthritis ofthe hip, and found that intraosseous pressure in thefemoral head varied appreciably. Also, pressures in thegreater trochanter were significantly lower than those ofthe femoral head. Furthermore, operated limbs are notsuitable for blood pressure measurement in clinical stud-ies of the relationship between intraosseous pressure andblood loss, because it is often necessary to change theposition of the operative field. We did not measure pres-sure in the femoral vein, due to the risk of causing throm-bosis. All patients in this study had a normal cardiac con-dition, i.e. pressure in the central veins was low and

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Table 2 Correlation of blood loss during total hip arthroplasty with clinical parameters

Intraoperative blood loss Postoperative blood loss

r p r p

Intraosseous pressure -0.042 0.84 0.399 0.0427

Mean arterial pressureImmediately before surgical incision 0.522 0.0079 021 0.32Halfway through operation 0.3 0.14 0.011 0.96At skin closure -0.037 0.86 -0.26 0.20

Age -0.3 0.14 0.2 0.34

Weight 0.17 0.41 -0.0076 0.71

Fig. 2 Correlation between postoperative blood loss andintraosseous pressure immediately before surgical incision(r=0.399, p=0.043)

Intraosseous pressure, mmHg

1200

1000

800

600

400

200

00 5 10 15 20 25 30 35 40 45

Blo

od lo

ss,g

remained within narrow limits. In cemented THA, thefemoral canal (and possibly the acetabular bony bed) isclosed off by cement, and pressurization of cement canreduce blood loss from intramedullary circulation.Intraoperative bleeding is more controllable than postop-erative bleeding, and can be controlled using techniquessuch as electrical cautery and hypotensive anesthesia.Thus, postoperative bleeding may be higher in cementlessTHA than in cemented THA, due to spontaneous bleedingfrom intramedullary circulation.

The present results suggest that susceptibility to post-operative bleeding in primary cementless THA under nor-motensive anesthesia is affected by intraosseous pressureof the ilium, and not by systemic arterial pressure.Yamasaki et al. [8] reported that administration of tranex-

amic acid immediately before cementless THA reducedpostoperative blood loss within 12 hours after surgery andtotal bleeding. However, there is evidence suggesting thattranexamic acid promotes a hypercoagulable state, andseveral cases of thrombosis occurring after administrationof tranexamic acid have been reported [9]. We previouslyreported that intraosseous pressure in male New Zealandwhite rabbits can be decreased by repeated infusion ofprostaglandin E1, independent of mean arterial pressure[10]. This suggests that preoperative infusion ofprostaglandin E1 can reduce postoperative blood loss incementless THA.

Acknowledgment This investigation was performed at OsakaPolice Hospital.

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3. Barbier-Bohm G, Desmonts JM, Cou-derc E, Moulin D, Prokocimer P, Oli-vier H (1980) Comparative effects ofinduced hypotension and normo-volaemic haemodilution on blood lossin total hip arthroplasty. Br J Anaesth52:1039–1042

4. Vazeery AK, Lunde O (1979) Control-led hypotension in hip joint surgery: anassessment of surgical haemorrhageduring sodium nitroprusside infusion.Acta Orthop Scand 50:433–441

5. Kakiuchi M (2002) Intraoperativeblood loss during cervical laminoplastycorrelates with the vertebral intraos-seous pressure. J Bone Joint Surg Br84:518–520

6. Wilkes CH, Visscher MB (1975) Somephysiological aspects of bone marrowpressure. J Bone Joint Surg Am57:49–57

7. Termansen NB, Teglbjaeg PS, SorensenKH (1981) Primary osteoarthritis of thehip: interrelationship between intraos-seous pressure, X-ray changes, clinicalseverity and bone density. Acta OrthopScand 52:215–222

8. Yamasaki S, Masuhara K, Fuji T (2004)Tranexamic acid reduces blood lossafter cementless total hip arthroplasty:prospective randomized study in 40cases. Int Orthop 28(2):69–73

9. Reid RW, Zimmerman AA, Laussen PC,Mayer JE, Gorlin JB, Burrows FA (1997)The efficacy of tranexamic acid versusplacebo in decreasing blood loss in pedi-atric patients undergoing repeat cardiacsurgery. Anesth Analg 84:990–996

10. Kakiuchi M (2004) Prostaglandin E1induces intraosseous hypotension underconditions of normal arterial pressure.Prostaglandins Leukot Essent FattyAcids 71(2):75–78

References