Total hip replacement (THR) is a widely performed surgical procedure for treating neck of femur fractures, especially in the elderly. This surgery aims to alleviate pain, improve mobility, and restore the functional capacity of patients. THR can be categorized into three types based on the fixation method used: cemented, uncemented, and hybrid. Each type has its own set of advantages, challenges, and clinical outcomes. Among the critical considerations during THR is intraoperative blood loss, which can significantly influence postoperative recovery, complication rates, and overall patient outcomes. Neck of femur fractures are prevalent among the elderly, often resulting from low-energy trauma such as falls. These fractures are associated with high morbidity and mortality rates, necessitating effective surgical intervention. Total hip replacement, compared to other surgical options like internal fixation, offers superior functional outcomes and reduced pain, making it a preferred treatment modality. However, the choice between cemented, uncemented, and hybrid THR remains a subject of debate among orthopedic surgeons. Cemented THR involves the use of bone cement to fix the prosthetic components to the bone, providing immediate stability and facilitating early weight-bearing. Uncemented THR relies on biological fixation, where the prosthesis is designed to allow bone ingrowth over time, potentially offering long-term stability without the issues related to cement. Hybrid THR combines both techniques, with a cemented femoral component and an uncemented acetabular component, aiming to harness the benefits of both approaches. Intraoperative blood loss during THR is a significant concern as it can impact patient recovery and hospital resources. Excessive blood loss may necessitate blood transfusions, which carry risks such as transfusion reactions, infections, and increased hospital stay. Managing intraoperative blood loss effectively can reduce the incidence of postoperative anemia, which is associated with delayed rehabilitation and increased morbidity [1-3]. The primary objective of this study is to conduct a comparative analysis of intraoperative blood loss among cemented, uncemented, and hybrid THR in patients with neck of femur fractures. By evaluating the extent of blood loss associated with each technique, this study aims to provide insights that can inform surgical decision-making, optimize patient outcomes, and improve perioperative management strategies.

This study was carried out on 60 patients who had undergone surgery for total hip replacement for neck of femur fractures at the Department of Orthopaedics, Darbhanga Medical College and Hospital, Darbhanga, Bihar (India).

The study included a cohort of sixty patients with ASA status I and II, aged between 60 and 85 years, weighing between 40 and 70 kg, and with heights ranging from 150 to 185 cm. These patients had a hemoglobin level above 10gm%, normal prothrombin time or activated partial thromboplastin time, and were scheduled to undergo hip surgeries without the use of a tourniquet. The surgeries were performed under a subarachnoid block. Patients who met any of the following criteria were excluded from the research: ASA status III or higher, age less than 20 years or greater than 60 years, weight less than 40kg or greater than 70kg, height less than 150cm or greater than 185cm, patients with haemoglobin level less than 10gm%, pre-operative hepatic or renal dysfunction, serious cardiac or respiratory disease, patients on thrombolytic agents, abnormal prothrombin time or activated partial thromboplastin time, and patients with a history of thromboembolic disease.

Before the procedure, all patients underwent a pre-anesthetic examination. A comprehensive and systematic examination was conducted following the acquisition of a detailed medical history. Before the procedure, standard tests, particularly for hemoglobin and hematocrit levels, were conducted. An oral tablet was administered as a premedication to the patients. Before the surgical procedure, administer a dosage of 0.25 mg of alprazolam and 20 mg of Omeprazole tablets. Patients underwent a period of fasting, known as NBM (Nil by Mouth), for 8 hours before surgery. Upon the patient's arrival in the operating room, a large-diameter cannula was securely placed and ringer lactate solution was initiated at a rate of 10 milliliters per kilogram. Before the surgery, the patient was connected to Noninvasive Blood Pressure (NIBP), pulse oximeter, and Electrocardiogram (ECG) monitors. Baseline data including Heart Rate (HR), Systolic Blood Pressure (SBP), Diastolic Blood Pressure (DBP), Respiratory Rate (RR), and Oxygen Saturation (SpO2) were collected. Shortly prior to anaesthetic induction, hemodynamic measures including heart rate (HR), systolic blood pressure (SBP), diastolic blood pressure (DBP), peripheral oxygen saturation (SpO2), and respiratory rate (RR) were documented. The patients were anaesthetized using a subarachnoid block with 3ml of 0.5% hyperbaric Bupivacaine. Cardiorespiratory parameters, including heart rate (HR), diastolic blood pressure (DBP), systolic blood pressure (SBP), respiratory rate (RR), and oxygen saturation (SpO2), were closely monitored to detect any side effects of spinal anaesthesia, such as hypotension, bradycardia, and decrease in oxygen levels. These parameters were recorded at 5-minute intervals during the first 30 minutes and at 10-minute intervals thereafter until the completion of the surgery. The study examined the efficacy of cemented, uncemented, and hybrid total hip replacement procedures for treating neck of femur fractures. During the surgical procedure, the amount of blood lost was assessed at 10-minute intervals by measuring the weight change of surgical swabs on a digital weighing scale and the volume in the suction reservoir. This measurement was considered as the intra-operative blood loss. Prior to its shipment for sterilisation, the mean weight of a desiccated gauze and mop was documented. This was true for every single mop and piece of gauze. Blood loss was quantified by calculating the difference between the weight of the saturated mop and gauze and the weight of the dry mop and gauze. According to [4], a 1gm rise in the weight of wet gauze and mop is considered to be equal to a 1 millilitre blood loss. The estimation of blood loss in suction drains was determined by subtracting the volume of normal saline used for cleaning the surgical site from the total output collected in the suction device [5]. In cases where the amount of blood lost during surgery was more than 40% of the total blood volume in circulation, blood transfusion was initiated during the surgery. Crystalloids (specifically lactated ringers) were administered in a 3:1 ratio to replenish the blood volume lost during the surgery [6]. Post-procedure, a vacuum drain was implanted at the surgical site over the subsequent 24 hours. The volume of blood in the suction drain was used to monitor post-operative blood loss for up to 24 hours after surgery. After the surgical procedure, patients were relocated to the post-operative care unit. The contents of the drain were quantified and recorded in the recovery room and post-operative ward for 24 hours following the procedure. The total amount of blood lost was determined by combining the blood loss that occurred during the surgery with the blood loss that occurred after the surgery. On the 24th hour after the surgery, regular noninvasive monitoring was conducted. A blood specimen was collected from the patient 24 hours following the surgical procedure to evaluate the post-operative levels of hemoglobin and hematocrit. A decrease in hemoglobin greater than 25% of the level before the operation was considered a signal to administer a blood transfusion. The number of patients who received blood transfusions and the quantity of blood units transfused during the post-operative period, which lasted for 24 hours after the surgery, were documented. The patient's post-operative pain was managed by administering an analgesic, namely a slow intravenous drip of tramadol 100mg, in response to the patient's request. This was done to prevent any increase in heart rate and blood pressure caused by discomfort since such increases could have negatively affected postoperative blood loss.

Statistical Analysis: The collected data was organized into a table using Microsoft Excel 2019. Subsequently, the data was transferred to GraphPad version 8.4.3 for further statistical analysis. Descriptive statistics were employed to calculate and display frequencies and percentages. A p-value of less than 0.05 was taken as a measure of significance.

The study included 60 patients, ranging from 60 to 85 years. The sample consisted of 32 (53.33%) males and 28 (46.67%) females. Patients were divided into three groups based on the use of cement for implant fixation. The first group consisted of 20 patients who had both the acetabular and femoral components cemented. The second group, the hybrid group, included 20 patients who had an uncemented acetabular component and a cemented femoral component. The third group comprised 20 patients who had both the acetabular and femoral components uncemented. The study evaluated intraoperative blood loss in three groups of patients undergoing total hip replacement for neck of femur fractures. The cemented group, showed a blood loss ranging from 241.50 mL to 2543.2 mL, with a mean of 1105.57 mL and a standard deviation of 643.35 mL. The hybrid group, had a blood loss range of 246.35 mL to 2172.37 mL, with a mean of 1062.50 mL and a standard deviation of 520.11 mL. The uncemented group, exhibited a blood loss range from 50.67 mL to 1956.55 mL, with a mean of 965.30 mL and a standard deviation of 523.02 mL. Statistical analysis revealed no significant difference in blood loss among the three groups, with a P value of 0.725. These findings suggest that the type of fixation method used: cemented, hybrid, or uncemented; does not significantly impact intraoperative blood loss in total hip replacement surgeries for the neck of femur fractures [Table 1].

Table 1: Showing the comparison of perioperative blood loss in the three groups of the study population

[* Statistically Not Significant]

It is projected that the global incidence of hip fractures will increase rapidly and reach 2.5 million by 2050 [7]. In accordance with the NICE guidelines, there has been a growing inclination to carry out total hip replacement (THR) surgeries in suitable patients with fractures of the neck of femur (NOF). Based on the latest data from the UK National Joint Registry, the most prevalent method of fixing total hip replacement for fractures of the neck of the femur (NOF) was hybrid fixation, with cemented fixation being a close second. Uncemented fixation is the least frequent, accounting for only one out of every seven total hip replacements for neck of femur fractures [8]. Hemorrhage is the leading cause of death in operating rooms worldwide [9]. The amount of blood loss determines the morbidity, mortality, duration of surgery, duration of hospital stay, the need to re-explore, and most importantly the need for blood transfusion. The current research evaluated perioperative blood loss. Substantial blood loss before surgery can lead to a serious drop in blood pressure, as well as a severe lack of oxygen in the blood, which can cause either a heart attack or long-lasting damage to the central nervous system. Elderly patients with medical conditions are particularly susceptible to problems due to considerable blood loss during total hip replacement (THR) procedures [10]. The use of cemented or cementless implants for total hip replacement (THR) in patients with a fractured neck of femur (NOF) remains a topic of ongoing debate. Literature exhibits ambiguity. A recent study analyzed the latest yearly data from five international joint arthroplasty registries, each with a follow-up period of over five years. The study showed that there is no substantial distinction between the two fixation methods [11]. A separate study investigated the economic advantages of patients aged 70 and above who underwent cemented and uncemented total hip replacement (THR) for neck of femur (NOF) fractures and concluded that there was no discernible distinction [12]. Excessive blood loss might result in the need for a blood transfusion, which carries its own set of risks, such as transfusion-related lung injury, immunomodulation, and transmission of pathogens. Research has also shown that blood transfusion raises the likelihood of both early and late illness and death [10]. Patients who have additional allogeneic blood transfusions during initial total hip replacement (THR) surgery experience a longer duration of hospitalization, which ultimately leads to higher treatment costs [13]. This study examined the amount of blood loss in total hip replacement (THR) surgeries for neck of femur (NOF) fractures. Prior research has established that there is no discernible disparity in perioperative blood loss between cemented and uncemented primary total hip replacement (THR) procedures for osteoarthritis. This study provides additional evidence and demonstrates that there is no significant variation in blood loss among patients with NOF who have cemented hybrid, or uncemented total hip replacement (THR). We anticipate that this will stimulate clinicians to conduct randomized control studies to delve deeper into the topic of blood loss in total hip replacement for neck of femur fractures. Intraoperative blood loss is a critical factor in determining the overall success and recovery of patients undergoing THR. Excessive blood loss can lead to increased transfusion requirements, longer hospital stays, and higher rates of complications such as infections and delayed wound healing. Our study's results suggest that the choice between cemented, hybrid and uncemented THR does not significantly influence the amount of intraoperative blood loss. This finding is important as it indicates that surgeons can select the fixation method based on other clinical factors, such as patient bone quality, surgeon expertise, and long-term prosthesis stability, without being overly concerned about differences in blood loss.

This study does not show any difference in blood loss between cemented and uncemented total hip replacement (THR) for neck of femur (NOF) fractures. Given the shorter operating time and absence of cementation-related complications, uncemented THR may be a viable option for patients with NOF. The decision to perform cemented, hybrid, or uncemented THR in NOF should involve shared decision-making between the patient and the treating physician. This decision should consider various factors, including bone quality, implant longevity, patient life expectancy, and risks associated with cementation. Generally, cemented implants perform better in elderly patients, while uncemented THR tends to last longer in younger patients. It is important to note that the uncemented femoral component carries a higher risk of periprosthetic fracture. This study suggests that blood loss during THR for NOF should not be a deciding factor in choosing between cemented or uncemented THR for patients with NOF.

1. Smilowitz NR, Oberweis BS, Nukala S, Rosenberg A, Zhao S, Xu J et al. Association between anemia, bleeding, and transfusion with long-term mortality following noncardiac surgery. Am J Med. 2016;129:315-323.
2. Christensen MC, Dziewior F, Kempel A, Von Heymann C. Increased chest tube drainage is independently associated with adverse outcome after cardiac surgery. J Cardiothorac Vasc Anesth. 2012;26:46-51.
3. Piekarski F, Wunderer F, Raimann FJ, Neef V, Peuckert M, Brenner T, et al. Erfassung von intra-operativen Blutverlusten Ergebnisseeiner multizentrischen und-Überblickaktueller Methodenzur Quantifizierung von Blutverlusten. Anä sthIntensivmed. 2020;61:110-6.
4. Chen JY, Lo NN, Tay DK, Chin PL, Chia SL, Yeo SJ. Intra- articular administration of tranexamic acid in total hip arthroplasty. J Orthop Surg Res. 2015;23:213-217.
5. Mehr Aein MS. Does a single bolus dose of tranexamic acid reduce blood loss and transfusion requirements during hip fracture surgery? A prospective randomezed double blind research in 67 patients. Acta Medica Iranica. 2007;45:437-442.
6. Vijay BS, Bedi V, Mitra S, Das B. Role of tranexamic acid in reducing post-operative blood-loss and transfusion requirement in patients undergoing hip and femoral surgeries. Saudi J Anaesth. 2013;7:29-32.
7. Cheung CL, Ang SB, Chadha M, et al.: An updated hip fracture projection in Asia: the Asian Federation of Osteoporosis Societies study. Osteoporos Sarcopenia. 2018;4:16-21.
8. National Joint Registry. Indications for primary hip procedures based on age groups. (2022). Accessed: February 20, 2022: https://reports.njrcentre.org.uk/hips-primary-procedures-patient-characteristics/H07v1NJR.
9. Irita K: Risk and crisis management in intraoperative hemorrhage: human factors in hemorrhagic critical events. Korean J Anesthesiol. 2011;60:151-60.
10. Carling MS, Jeppsson A, Eriksson BI, Brisby H: Transfusions and blood loss in total hip and knee arthroplasty: a prospective observational study. J Orthop Surg Res. 2015;10:48.
11. Zhang CF, Yan CH, Zhang WM: Cemented or cementless fixation for primary hip arthroplasty - evidence from the International Joint Replacement Registries. Ann Joint. 2017;2:57.
12. Marinelli M, Soccetti A, Panfoli N, de Palma L: Cost-effectiveness of cemented versus cementless total hip arthroplasty. A Markov decision analysis based on implant cost. J Orthop Traumatol. 2008;9:23-8.
13. Bou Monsef J, Boettner F: Blood management may have an impact on length of stay after total hip arthroplasty. HSS J. 2014;10:124-30.