Case Study: Transfusion-Free Knee Surgery

At the USC Center for Arthritis and Joint Implant Surgery, Edward J. McPherson, M.D., treats patients with advanced degenerative osteoarthritis. In this condition, the cartilage that covers the articular surface of the hip and/or knee bones has deteriorated, resulting in pain and loss of function.

Through joint implant surgery, McPherson, assistant professor of orthopaedic surgery, seeks to ease this pain and restore function to the affected joints.

“While many older people do require total joint replacements as a result of lifelong wear and tear on their cartilage, younger individuals may also need this procedure by mid-life as a result of trauma-induced arthritis,” said McPherson.

Surgeons at USC have made significant advances to the understanding and treatment of arthritis, including designing and refining artificial hip and knee joints that are used around the world.

Amazingly, at USC these advanced joint replacement surgeries can successfully be performed transfusion-free.

Knee replacement surgery means new mobility for 71-year-old patient

M.G. is a 71-year-old female who presented with a chief complaint of bilateral knee pain. Her history dates back to age 7 when she suffered a right knee “dislocation” that was not treated. Throughout her lifetime she had recurrent bilateral kneecap dislocations, again, which were also not treated.

The patient began experiencing severe pain and two years ago was forced to walk with a cane. In August 1998, she became unable to walk because of the weakness and pain in her knee. She had difficulty standing as well. She was interested in surgical intervention for her condition. An exam and X-rays confirmed her diagnosis of severe osteoarthritis of the knees with chronically dislocated kneecaps with dysplasia.

Her overall medical condition was fair. She suffered from intermittent high blood pressure, gastric ulcers, and possible inflammatory arthritis. She was deemed an acceptable candidate for staged bilateral total knee replacements.

The options of blood transfusion, cell saver, hemodilution, and erythropoietin were discussed with her and the bloodless surgery coordinator. The patient is a Jehovah’s Witness who consented to only the use of erythropoietin. She received 40,000 units of erythropoietin for four weeks prior to surgery.

In January 1999, she underwent a right total knee replacement with an extensive lateral release for realignment of her chronically dislocated kneecap. Intraoperatively, an epidural catheter was placed, bypotensive anesthesia was utilized to lower blood pressure, and a tourniquet was placed in order to minimize blood loss. Estimated blood loss was 100 cc’s. Post-operatively blood draws were discontinued for three days. At no time did she experience problems related to decreased blood levels: no lightheartedness, no chest pains. She continued to receive weekly erythropoietin injections.

Because of her excellent progress with her right knee and the fact that her rehabilitation was being slowed by a painful left knee, she underwent a left total knee replacement one month after her right knee was replaced. After a short stay on the acute ward, again, without complications related to blood loss, she returned to aggressive rehabilitation. On February 20th, she was discharged and placed on an outpatient physical therapy program.

On her last office follow-up visit on May 4th, she walked into the office using just a cane.

She reported very little pain in her right knee, and moderate to occasional pain in her left. She had progressed from a house-bound status to walking more than 10 blocks. Her range of motion was increased in both knees from her pre-operative status, and she reported that she was very pleased with her progress.

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