Bleeding and Hemostasis Optimization in Primary and Revision Total Knee Arthroplasty: A Structured Expert-Opinion Survey.

BACKGROUND: Disruptive bleeding following total knee arthroplasty (TKA) continues to affect postoperative recovery despite advances in perioperative blood management, with wound drainage and dressing-related findings common clinical concerns. Conventional definitions based on estimated blood loss or hemoglobin decline may not capture bleeding events that alter clinical management. This study sought to establish agreement on disruptive bleeding in TKA and identify clinically relevant factors guiding monitoring, escalation, and hemostatic decision-making.

METHODS: A survey-based study was conducted among 14 fellowship-trained arthroplasty surgeons who had experience in primary and revision TKA. Domains included risk factors, definitions of disruptive bleeding, intraoperative bleeding patterns, postoperative drainage assessment, escalation criteria, and the use of topical hemostatic agents. Responses included Likert-scale ratings, categorical selections, and free-text data. High agreement for items was defined a priori as ≥ 70% agreement.

RESULTS: Respondents supported defining disruptive bleeding as a composite of clinically meaningful outcomes rather than isolated quantitative measures. There was unanimous agreement to include operational indicators (symptomatic hemoglobin decline greater than three g/dL and persistent wound drainage) and downstream events (transfusion, reoperation, embolization, and readmission). Thrombocytopenia and anticoagulant use were important risk factors (n = 14 of 14), followed by coagulopathy and liver disease (n = 12 of 14). Escalation triggers included suspected arterial bleeding (n = 14 of 14), expanding hematoma (n = 13 of 14), hemodynamic instability (n = 13 of 14), neurovascular compromise (n = 13 of 14), and drainage beyond postoperative day five (n = 12 of 14). Routine prophylactic use of topical hemostatic agents was not supported in primary TKA (n = 2 of 14), but was selectively favored in revision cases (n = 7 of 14). Variability remained regarding drainage thresholds and timing of intervention.

CONCLUSIONS: Disruptive bleeding in TKA was viewed as a composite construct defined by events that alter care rather than isolated numeric blood-loss measures. These findings represent an exploratory, hypothesis-generating framework requiring multidisciplinary and data-driven validation.