The use of regional anesthesia in orthopedic surgery has shown measurable reduction in blood loss compared with general anesthesia (Flordal and Neander 1991; Sculco and Ranawat 1975; Sharrock et al. 1993). This has been linked to the potential influences of the anesthetic drugs on the postoperative platelet function. The addition of a hypotensive regimen to the epidural anesthesia (HEA) has led to further decrease in blood loss, simultaneously improving a bloodless field at the bony surfaces for better implant fixation and leading to shorter surgical time (Sharrock et al. 1993; Davis et al. 1974; An et al. 1991; Mallory 1973; Nelson and Bowen 1986). Hypotensive epidural anesthesia is one of the techniques used to reduce perioperative blood loss by achieving an epidural block at least as far as the T2 level and to establish a sufficiently extensive and dense block of the cardio-acceleratory fibers of the thoracic sympathetic chain (Moonen et al. 2006). Patients tolerate the use of HEA well without additional morbidity and with a decreased rate of postoperative deep venous thrombosis. An added benefit has been the improved analgesia produced by using a patient-controlled system of postoperative pain medication through the indwelling epidural catheter, avoiding bleeding by pain-induced hypertension.

In a prospective, randomized clinical study, Eroglu et al. (2005) compared hypotensive epidural anesthesia (HEA) with bupivacaine and hypotensive total intravenous anesthesia (HTIVA) with propofol and remifentanil on blood loss on 40 patients (ASA scores I–III) undergoing primary hip arthroplasty. The study resulted in less intraoperative blood loss and a minor percentage of patients receiving blood and total packed red blood cells transfusions as well as a lower intraoperative mean central venous pressure in patients receiving HEA.

A comparison between HEA and spinal anesthesia (SPA) by Niemi et al. (2000) on patients undergoing primary total hip arthroplasty documented a minor blood loss and a reduced number of transfused units of packed cells (UPC) in the HEA group, in which coagulation system was considered to be better preserved than in SPA group.

Sometimes it can be necessary to titrate epinephrine intravenously to keep the blood pressure at an acceptable level for tissue oxygenation. Epinephrine-augmented hypotensive epidural anesthesia is effective in avoiding the use of tourniquet in TKA without negative effects on perioperative hemoglobin values, as documented by Kiss et al. (2005).

Anesthesia and surgery itself may cause perioperative hypothermia. Mild perioperative hypothermia increases the incidence of myocardial morbidity, reduces the resistance to surgical wound infection, causes coagulopathy resulting from platelet inhibition, and prolongs both postanesthetic recovery and hospitalization. Postoperative blood loss has been shown to be significantly greater in hypothermic patients (Schmied et al. 1995). It is therefore recommended that patients be kept normothermic during orthopedic surgery using warmed fluids, heated blankets, and a warm airflow with inflatable devices on the body of the patient. New technologies like a double-heated blanket (HotDog^® Augustine Temperature Management, Eden Prairie, MN, USA, or EasyWarm^® Mölnlycke Health Care AB, Göteborg, Sweden) can keep patients normothermic without needing a general raise of the room temperature or forced airflows in the room which may disrupt the laminar airflow (Fig. 2.2).

Preoperative acute normovolemic hemodilution (ANH) can be considered appropriate for patients with high Hb levels undergoing potentially high bleeding surgery, like complicated revisions. The predonation of 20 % of their total blood volume will make a few UPC available for after the procedure, and because the hemoglobin concentration of the blood is lower, it will lead to less valuable blood loss. This technique is especially indicated for patients with high-viscosity diseases that present increased risks of DVT after surgery (Juelsgaard et al. 2002).

To reduce tourniquet and surgery-induced fibrinolysis and blood loss, drugs with antifibrinolytic properties such as tranexamic acid (TXA) can be used. TXA has been shown to inhibit fibrinolysis by competitively blocking the lysine-binding sites of plasminogen (Fig. 2.3). Tranexamic acid has been diffusely tested in orthopedic surgery and particularly after TKA (Dunn and Goa 1999; Engel et al. 2001; Eubanks 2010). In a review study, Wind et al. (2013) observed a statistically significant decrease in blood transfusion in patients receiving TXA via IV infusion (p = 0.001) and in topical application of TXA (p = 0.019) compared to the control group. While both systematic and topical TXA reduced blood loss after TKA, the effect of either treatment is influenced by doses and timing of administration. Tanaka et al. (2001) compared two different single-dose regimens and a split-dose regimen (before and during surgery), finding the latter to be the more efficacious even though the total amount of TXA used was the same. Maniar et al. (2012) found a single-dose regimen to be least efficacious, while administering TXA before and during surgery was more efficacious than during and after surgery. As for topical TXA administration, Wong et al. (2010) found that only a high concentration reduces transfusion rate whereas low concentration does not. After TKA, a second phase of fibrinolysis can be observed after 6 h (Fedi et al. 1999; Aglietti et al. 2000). It can therefore be important to use a second dose of TXA before this new fibrinolytic episode starts (Maniar et al. 2012; Blanié et al. 2013). Regardless of the dose, timing, and route of administration, several studies reported no increase in the incidence of deep vein thrombosis (DVT) or pulmonary embolism (PE) (Wind et al. 2013; Kim et al. 2014).

Hip and knee flexion during surgery is an efficacious temporary method to reduce bleeding as it decreases venous bleeding due to the elevated limb position, and it increases the intra-articular pressure due to the knee flexion (Fig. 2.8).

In a study by Li et al., 110 patients undergoing TKA were randomized in 2 groups. Both groups had a 30° hip flexion for the first 72 h after surgery, but patients in the experimental group maintained also a 30° knee flexion and the control group maintained knee extension. The results showed that blood loss, swelling, and hematoma were significantly lower in the experimental group. Active ROM after 3 and 7 days and the number of patients who managed straight leg raises after 1 and 3 days were significantly higher in the experimental group. The authors concluded that postoperative knee flexion was associated with a lower blood loss and a better functional recovery without the risk of residual flexion contracture (Li et al. 2012).

Ong and Taylor found that knee flexion and knee elevation in extension reduced hemoglobin loss by 25 %. Compromise to tissue oxygenation has been reported with prolonged knee flexion. The author recommended elevation of the leg at 35° from the hip with the knee extended (Ong and Taylor 2003).

In a randomized controlled trial (RCT) of 420 TKAs, patients were randomized to one of three postoperative knee positions: flexion for 3 or 6 h postoperatively or knee extension. Positioning of the knee in flexion for 6 h immediately after surgery significantly reduced blood loss (p = 0.002). These authors reported an incidence of 4.7 % of lower limb sensory neuropathy at their 3-month review when flexion was prolonged more than 6 h (Napier et al. 2014).

The modified Robert Jones dressing (MRJD) is a splint bandage consisting of many layers of soft material wrapped around a joint or extremity covered by an elastic layer with more tension distally than proximally in an effort to promote venous drainage (Fig. 2.9). This dressing was proposed to limit edema of the extremity, effusions, and hemarthrosis. However, a recent randomized controlled trial (RCT) comparing MRJD and a conventional wound dressing did not show any differences in total mean drainage, hematocrit, and transfusion rates between the two groups (Pinsornsak and Chumchuen 2013). The limits of this study were first that the hidden blood loss was not evaluated, the pressure under the bandage in each patient with the MRJB dressing was not measured, so the pressures underneath might have been different with each application. A previous study comparing the advantage of the MRJD with the elastic support bandage (Hughes et al. 1995) found no differences in pain (VAS), ROM, and analgesic need from the initial period to 3 weeks postoperative. However, the authors reported an elastic support bandage made the patients feel more comfortable than the MRJD during the first week in the early post injury period.