Aims. The aim of this study was to examine whether tourniquet use can improve perioperative blood loss, early function recovery, and pain after primary total knee arthroplasty (TKA) in the setting of multiple-dose intravenous tranexamic acid. Methods. This was a prospective, randomized clinical trial including 180 patients undergoing TKA with multiple doses of intravenous tranexamic acid. One group was treated with a tourniquet during the entire procedure, the second group received a tourniquet during cementing, and the third group did not receive a tourniquet. All patients received the same protocol of intravenous tranexamic acid (20 mg/kg) before skin incision, and three and six hours later (10 mg/kg). The primary outcome measure was perioperative blood loss. Secondary outcome measures were creatine kinase (CK), CRP, interleukin-6 (IL-6), visual analogue scale (VAS) pain score, limb swelling ratio, quadriceps strength, straight leg raising, range of motion (ROM), American Knee Society Score (KSS), and adverse events. Results. The mean total blood loss was lowest in the no-tourniquet group at 867.32 ml (SD 201.11), increased in the limited-tourniquet group at 1024.35 ml (SD 176.35), and was highest in the tourniquet group at 1,213.00 ml (SD 211.48). The hidden blood loss was lowest in the no-tourniquet group (both p < 0.001). There was less mean intraoperative blood loss in the tourniquet group (77.48 ml (SD 24.82)) than in the limited-tourniquet group (137.04 ml (SD 26.96)) and the no-tourniquet group (212.99 ml (SD 56.35); both p < 0.001). Patients in the tourniquet group showed significantly higher levels of muscle damage and inflammation biomarkers such as CK, CRP, and IL-6 than the other two groups (p < 0.05). Outcomes for VAS pain scores, limb swelling ratio, quadriceps strength, straight leg raising, ROM, and KSS were significantly better in the no-tourniquet group at three weeks postoperatively (p < 0.05), but there were no significant differences at three months. No significant differences were observed among the three groups with respect to transfusion rate, thrombotic events, or the length of hospital stay. Conclusion. Patients who underwent TKA with multiple doses of intravenous tranexamic acid but without a tourniquet presented lower total blood loss and hidden blood loss, and they showed less postoperative inflammation reaction, less muscle damage, lower VAS pain score, and better early knee function. Our results argue for not using a tourniquet during TKA. Cite this article: Bone Joint Res 2020;9(6):322–332

Background and goal of study: Although a great percentage of the total postoperative bleeding corresponds to a hidden blood loss in the tissues and joint, visible blood from the drainage is considered the gold standard for monitoring blood loss after a knee arthroplasty. Only one study was not able to find a consistent relationship between the total blood loss and postoperative drained blood. The aim of our study was to assess the usefulness of a postoperative drainage as a monitor of bleeding following a knee arthroplasty. Material and methods: Fifty patients undergoing unilateral arthroplasty from March to November 2004, were prospectively followed until the fourth postoperative day. Drained red blood cells(RBC) loss was assessed by multiplying the drained blood volume by an haematocrit (Hct) of 30% from a pilot study. Total RBC loss and hidden RBC loss from each patient were calculated. Regression analysis was performed to assess the relationship between the total RBC loss and drained RBC loss. Results and discussions: The average age of the fifty ASA 2 patients was 72 +− 7 years. Nearly all the procedures were performed under intradural anaesthesia. Cemented technique and tourniquet were used in all cases. The mean total RBC loss was 615 +−197ml. The mean drained RBC loss was 206+− 113ml, and mean hidden RBC loss was 414 +−194ml. Thus the hidden loss was 67% of the total blood loss. Regression analysis shown a poor correlation coefficient between the total RBC loss and drained RBC loss (r= 0.31, p< 0.03)

Aims. A variety of surgical methods and strategies have been demonstrated for Andersson lesion (AL) therapy. In 2011, we proposed and identified the feasibility of stabilizing the spine without curettaging the vertebral or discovertebral lesion to cure non-kyphotic AL. Additionally, due to the excellent reunion ability of ankylosing spondylitis, we further came up with minimally invasive spinal surgery (MIS) to avoid the need for both bone graft and lesion curettage in AL surgery. However, there is a paucity of research into the comparison between open spinal fusion (OSF) and early MIS in the treatment of AL. The purpose of this study was to investigate and compare the clinical outcomes and radiological evaluation of our early MIS approach and OSF for AL. Methods. A total of 39 patients diagnosed with AL who underwent surgery from January 2004 to December 2022 were retrospectively screened for eligibility. Patients with AL were divided into an MIS group and an OSF group. The primary outcomes were union of the lesion on radiograph and CT, as well as the visual analogue scale (VAS) and Oswestry Disability Index (ODI) scores immediately after surgery, and at the follow-up (mean 29 months (standard error (SE) 9)). The secondary outcomes were total blood loss during surgery, operating time, and improvement in the radiological parameters: global and local kyphosis, sagittal vertical axis, sagittal alignment, and chin-brow vertical angle immediately after surgery and at the follow-up. Results. Data for 30 patients with AL were evaluated: 14 in the MIS group and 16 in the OSF group. All patients were followed up after surgery; no nonunion complications or instrumentation failures were observed in either group. No significant differences in the VAS and ODI scores were identified between the two groups. Mean ODI improved from 51 (SE 5) to 17 (SE 5) in the MIS group and from 52 (SE 6) to 19 (SE 5) in the OSF group at the follow-up. There were significant improvements in total blood loss (p = 0.025) and operating time (p < 0.001) between the groups. There was also no significant difference in local kyphosis six months postoperatively (p = 0.119). Conclusion. Early MIS is an effective treatment for AL. MIS provides comparable clinical outcomes to those treated with OSF, with less total blood loss and shorter operating time. Our results support and identify the feasibility of solid immobilization achieved by posterior instrumentation without bone graft via MIS for the treatment of AL. Cite this article: Bone Jt Open 2024;5(10):886–893

This study aims to investigate that a single dose of tranexamic acid (TXA) will reduce blood loss and transfusion rates in elderly patients, undergoing intertrochanteric (IT) or femoral neck fractures surgery. Consecutive elderly patients receiving hip fracture surgery for stable or unstable IT fracture, treated with short intramedullary nail (IMN) insertion as well as cemented hemiarthroplasty for acute femoral neck (subcapital) hip fracture, were screened for inclusion in this single-centre randomized trial. Patients were randomly allocated to a study group by sealed envelope. One TXA dose of 15 mg/kg i.v. diluted in 100 ml N/S or one placebo dose i.v. in 100 ml N/S were administered 5 mins before the skin cut. Haemoglobin (Hb) concentration was measured at admission time and prior to surgery. Post-operatively it was measured on a daily basis until day 4, giving a total of four Hb measurements (days 1 to 4). The transfusion trigger point was determined in accordance with the French guidelines for erythrocyte blood transfusion. The transfusion trigger was 10 g/dl for patients at risk, while in all other cases, it was 9 g/dl. Information regarding the transfusions number was assessed directly by the hospital blood bank database. Blood loss was calculated by the Hb dilution method. Nadler's formula was used to calculate patients' blood volume. For calculation of total blood loss (TBL) expressed to total Hb loss and total Volume loss, the number of transfusions (55 grams of Hb per transfusion), the Hb concentration on preoperatively (Hgbi) and the Hb concentration on the last measure (Hgbe) were used. (Hb balance method). The primary efficacy outcome was the number of transfusions of allogeneic RBC from surgery up to day 4. The secondary ones were the total blood loss from surgery to day 4 as it was calculated by Hb-balance method. After randomization, 35 patients with femoral neck fracture and 30 patients with IT fracture received TXA prior to surgery. Respectively, 30 patients with femoral neck fracture and 55 with IT fracture didn't receive TXA. The groups did not differ significantly in their basic demographics (age, gender, BMI, injury mechanism, ASA score, co-morbidities). Results showed that patients undergoing hemiarthroplasty after receiving TXA, were transfused with less allogeneic RBC and had less total blood loss than patients that didn't receive TXA, but without statistical significance. While patients treated with IMN in the TXA group received a significantly lower number of RBC units than the control group (1.28 ± 1.049 vs 2.075 ± 1.685), (P = 0.0396), had a significantly lower loss of Hb (98.59 ± 55.24 vs 161.6 ± 141.7), (P = 0.0195) and a lower total blood volume loss (951.3 ± 598.9 ml vs 1513 ± 1247 ml), (P = 0.023). This trial confirmed TXA administration efficacy in reducing blood loss and transfusion rate in elderly patients undergoing hip fracture surgery. A TXA single dose may be a safer option, taking into account these patients' physiological status and co-morbidities

Introduction and Objective. Tranexamic acid (TXA) is used across surgical specialties to reduce perioperative bleeding. It has been shown to be effective in trauma, spinal surgery, and lower limb arthroplasty. The aim of this study is to investigate the clinical effectiveness of TXA in all types of shoulder surgery on bleeding and non-bleeding related outcomes. Materials and Methods. This study was registered prospectively on the PROSPERO database (ref: CRD42020185482). A systematic review and meta-analysis of randomised controlled trials (RCTs) investigating intra-operative use of TXA versus placebo in any type of surgery to the shoulder girdle. Electronic databases searched included MEDLINE, EMBASE, PsychINFO, and the Cochrane Library. Risk of bias within studies was assessed using the Cochrane risk of bias v2.0 tool and Jadad score. Certainty of findings were reported using the GRADE approach. The primary outcome was total blood loss. Secondary outcomes included patient reported outcome measures, adverse events, and rate of blood transfusion. Results. Eight RCTs were included in the systematic review and data from 7 of these studies pooled in the meta-analysis. A total of 708 patients were randomized across the studies (406 received TXA, 302 received placebo). Studies included patients undergoing anatomic or reverse total shoulder arthroplasty, open Latarjet surgery, and arthroscopic rotator cuff repair. Pooled analysis demonstrated significant reduction in perioperative bleeding with TXA compared to controls; estimated total blood loss (mean difference [MD], −209.66; 95% CI −389.11 to −30.21; p=0.02), and post-operative blood loss (via drain output) (MD, −84.8ml; 95% CI, −140.04 to −29.56; p=0.003). A mean difference in Visual Analogue Scale (VAS) of 2.93 was noted in favour of TXA (95% CI 0.2 to 5.66; p=0.04). Conclusions. Whilst noting some risk of bias within the studies, TXA was effective in reducing blood loss and pain in shoulder surgery. There may be a benefit of TXA use in both open and arthroscopic shoulder procedures. Larger, low risk of bias, RCTs for specific surgical shoulder procedures are required

Aims. The purpose of this study was to examine the efficacy and safety of carbazochrome sodium sulfonate (CSS) combined with tranexamic acid (TXA) on blood loss and inflammatory responses after primary total hip arthroplasty (THA), and to investigate the influence of different administration methods of CSS on perioperative blood loss during THA. Methods. This study is a randomized controlled trial involving 200 patients undergoing primary unilateral THA. A total of 200 patients treated with intravenous TXA were randomly assigned to group A (combined intravenous and topical CSS), group B (topical CSS), group C (intravenous CSS), or group D (placebo). Results. Mean total blood loss (TBL) in groups A (605.0 ml (SD 235.9)), B (790.9 ml (SD 280.7)), and C (844.8 ml (SD 248.1)) were lower than in group D (1,064.9 ml (SD 318.3), p < 0.001). We also found that compared with group D, biomarker level of inflammation, transfusion rate, pain score, and hip range of motion at discharge in groups A, B, and C were significantly improved. There were no differences among the four groups in terms of intraoperative blood loss (IBL), intramuscular venous thrombosis (IMVT), and length of hospital stay (LOS). Conclusion. The combined application of CSS and TXA is more effective than TXA alone in reducing perioperative blood loss and transfusion rates, inflammatory response, and postoperative hip pain, results in better early hip flexion following THA, and did not increase the associated venous thromboembolism (VTE) events. Intravenous combined with topical injection of CSS was superior to intravenous or topical injection of CSS alone in reducing perioperative blood loss. Cite this article: Bone Joint Res 2021;10(6):354–362

The purpose of this prospective randomized study was to compare the visible, hidden, total blood loss and postoperative haemodynamic change of subcutaneous and intra-articular indwelling closed suction drainage method after total knee arthroplasty (TKA). Patients with primary osteoarthritis, who underwent unilateral TKA were enrolled; Group A with subcutaneous (n=78) and group B with intra-articular (n=79) indwelling closed suction drainage method. Total blood loss, visible blood loss, internal blood loss, postop (day 1), 5. th. , 10. th. day hemoglobin, hematocrit levels were compared. Allogenic blood transfusion rate and complications related to soft tissue hematoma formation were additionally compared. Subcutaneous indwelling closed suction drainage method reduced both the visible blood loss and total blood loss (hemovac drainage + internal blood loss) thus decreasing the rate of allogenic transfusion. Although the minor complications such as the incidence of bullae formation and the ecchymosis were higher in the subcutaneous indwelling group, the functional outcome at postoperative 2 year did not demonstrate difference from intra-articular drainage group

In Total Knee Arthroplasty (TKA) and Total Hip Arthroplasty (THA) the total blood loss is composed of ‘visible’ blood loss from the surgical field and wound drainage, and blood loss into the tissues which is ‘hidden’. Blood management should be aimed at addressing the total blood loss. 56 TKAs and 46 THAs were prospectively studied. TKAs were performed with tourniquet. After tourniquet release, all drained blood was salvaged and significant volumes reinfused. No reinfusion was used for THAs. The true total blood loss was calculated in the following way:. Patient Blood Volume (PBV) is: [1]. PBV = k1 x height3 + k2 x weight + k3. Therefore patient total Red Blood Cell volume (RBCv) is:. RBCv = PBV x Hct. (where Hct is Haematocrit). Total RBCv loss = PBV x (Hct preop – Hct postop) + ml RBC transfused. The result is reconverted to Whole Blood volume. Hidden Loss = Total Loss – Visible Loss. In TKA, the mean total true blood loss was 1474ml. The mean hidden loss was 735ml. Therefore hidden loss is 50% of the total loss and the total true loss following TKA is twice the visible volume. In THA, the mean total true blood loss was 1629ml. The mean hidden loss was 343ml. Thus hidden loss in THA is much smaller. (21%) Total loss is 1.3 times the visible loss. In the TKA group, comparing patients with large losses receiving reinfusion and those with small losses not receiving reinfusion, the proportion of total true loss which was hidden was the same, at 50%. Patients with Body Mass Index (BMI) > 30 were compared with those with a BMI < 30 and no correlation was found between BMI and Hidden Loss. Joint Replacement Surgery involves a ‘hidden’ blood loss which is not revealed and cannot be measured or reinfused in practice, but which should be taken into account when planning blood loss management. In TKA it is substantial. In THA it is much smaller and probably not of as much clinical concern. Hidden loss is no greater in the Obese patient

Bleeding is an inevitable consequence of most surgical interventions. Total blood loss resulting from an operation can be calculated from the observed drop in haemoglobin and haematocrit levels, taking into account the amounts of blood transfused. Total blood loss is partly accounted for by the measurable external blood loss, during operation and in the drains, but there is also occult blood loss in the tissues, which is often as much as or even greater than the measurable external blood loss; occult blood loss is often underestimated; it has been found to represent on average 30% of the total blood loss after THR, and 45 to 60% after TKR. Blood loss may be important enough to require compensatory measures. Transfusion of homologous blood has been for a long time the method of choice, but its use has been restricted for a number of reasons, among which the fear of viral transmission, although it has decreased dramatically over the past few years. There are several possible ways to reduce the requirement for allogenic blood transfusion in surgery. They can be distributed under the following headings:. Reduce perioperative blood loss. Increase the preoperative erythrocyte volume. Lower the transfusion trigger. Use autologous blood. Use blood substitutes. These topics will be covered by the participants to this symposium, each of whom has been involved in major clinical studies and is a recognised expert on one or several aspects of this blood management strategy. As we will see, transfusion of homologous blood can be avoided in a high proportion of cases through judicious use of the various possibilities available. Before any given operation, the first step must be to evaluate the anticipated total blood loss, and to figure out whether this is higher or lower than the allowable blood loss for that specific patient. The allowable blood loss will depend on the preoperative blood volume and haematocrit of that patient, and also on the haematocrit that is to be preserved postoperatively, taking into account specific features of that patient, such as coronary heart disease. If the anticipated blood loss is greater than the allowable blood loss, some form of action is necessary in order to reverse the balance. This can be achieved by reducing blood loss and/or by improving the preoperative haematocrit of the patient, together with either autologous blood predonations – if the patient’s condition permits - and/or re-infusion of recuperated shed blood. Blood substitutes have not yet reached a stage of clinical applications. The management of blood loss must be given appropriate consideration in all surgical procedures; it requires a customised approach, from the preoperative consultation until the postoperative period

Purpose. We compared visible blood loss and calculated blood loss after bipolar hemiarthroplasty in femoral neck fracture, and evaluated correlation between blood loss and its risk factors. Materials and Methods: A total of 356 patients who underwent bipolar hemiarthroplasty in femoral neck fracture between 2004 and 2010 were enrolled in this study. The total blood loss was calculated using the formula reported by Mercuiali and Brecher. We analyzed several factors, including gender, age, body mass index (BMI), anesthesia method, cardiovascular and cerebrovascular disease, preoperative anemia, American Society of Anesthesiologists (ASA) score, use of cement, and use of antithrombotic agents. Results: Total calculated blood loss (1,408±72 ml) differed significantly from visible blood loss(980±102 ml). In addition, calculated blood loss differed between risk factors (1,526±369 ml in cardiovascular disease, 1,588±279 ml in general anesthesia, 1,645±920 ml in obesity, and 1,605±439 ml in use of antithrombotic agents). Conclusion: Total calculated blood loss was much greater than visible blood loss. Patients with risk factors such as cardiovascular disease, obesity, use of antithrombotic agents, and general anesthesia should be treated with care in order to reduce blood loss

Introduction: Blood loss is a major concern following total knee arthroplasty (TKA) frequently resulting in blood transfusions postoperatively. Various strategies exist to reduce blood loss and allogenic transfusion requirements. This study investigates the effect of immediate postoperative flexion on blood loss and transfusion requirements following TKA. Methods: 180 consented patients undergoing primary TKA by a single surgeon were enrolled into a prospective randomised controlled study. 90 patients were randomised to have the operated knee nursed in extension postoperatively, and 90 patients to have the knee nursed in flexion for six hours postoperatively. Both groups followed a strict transfusion protocol. Data collected included calculated pre- and postoperative haemoglobin and haematocrit which was used to calculate total blood loss. Units transfused and postoperative complication rates were also recorded. Results: There was no significant difference in demographics or factors predisposing to bleeding between the groups. The mean total blood loss was 1841mls for those in the extension group compared with 1587mls in the flexion group (p=0.02). The mean number of units transfused in the extension group was 0.78 units/patient compared with 0.36 units/patient in the flexion group (p=0.004). There was no significant difference in pain scores between the groups (p= 0.62). Conclusion: This study shows that the use of immediate postoperative flexion significantly reduces calculated total blood loss and transfusion rates following TKA

Aim: We studied the effect of filling the femoral entrance hole in relation to the total blood loss during and after the procedure of Total knee arthroplasty in 72 patients performed between 1997 and 1999 performed in our unit. Materials and methods: This was a retrospective review and the patients were be broadly classified into three groups, the first (Group A) who had the entrance holes left unblocked (n= 21), the second (Group B) had the holes filled with bone cement (n= 21) and the third (Group C) with the holes filled with bone (n= 26). Results: The average Blood loss for group A was 1019, group B was 11077 and group C was 1162. The Average Blood transfusion for group A was 0.70 units, group B was 0.40 units and group C was 0.30 units. Conclusions: We found no significant difference in the Total Blood loss between the three groups and conclude that filling the entrance holes does not effectively reduce the Total Blood Loss in Total Knee arthroplasty and that there is no advantage to be gained in respect of the total transfusion needed for these patients

Objective. The optimal dosage and timing of tranexamic acid in total hip arthroplasty (THA) still is undetermined. Previous studies showed the hyper-fibrinolysis would last for 18 hours after surgery. The study aimed to examine the efficacy and safety of multiple bolus of intravenous TXA on hidden blood loss and inflammation response following primary THA. Methods. 150 patients were randomly divided into three groups to receive single bolus of 20 mg/kg IV-TXA before skin incision (Group A), or another bolus of 1 g IV-TXA 3 hours later (Group B), or another two boluses of 1g IV-TXA 3 hours and 6 hours later (Group C). All patients received a standard perioperative enhanced recovery protocol. The primary outcomes was hidden blood loss. Other outcome measurements such as hemoglobin level, total blood loss, transfusion rate, inflammation markers (CRP, IL-6), VAS pain score, length of hospital stay (LOH) and venous thromboembolism (VTE) were also compared. Results. The hidden blood loss in group C was 402.13 ± 225.97 ml, which was less than that in group A (679.28±277.16 ml, p< 0.001) and group B (560.62±295.22 ml, p= 0.010). However, such difference was not detected between group A and B (p= 0.072). The mean value of total blood loss in group A, B and C were 1090.78±251.41, 979.42±247.89, 768.71±180.19 ml, respectively, with a significant intergroup difference (p <0.001). The Hb drop on postoperative day (POD) 3 in group A, B and C was 30.82±6.31, 27.16±6.83, 21.98±3.72 g/L, and the difference between groups was significant (p <0.001). Only one patients received red blood cell transfusion. The mean level of CRP in group C was lower than that in group A and B on POD 2 (p= 0.000, p= 0.034), POD 3 (p= 0.000, p= 0.014). The serum level of IL-6 in group C was lower than group A on POD 1, POD 2 and POD 3 (p=0.017, p=0.023, p= 0.005; respectively). The patients in group C had slightly less postoperative pain. The LOH in group C was shorter than those in group A (p= 0.023). No episodes of VTE or other adverse events occurred in any patient. Conclusion. Multiple boluses of IV-TXA can effectively reduce hidden blood loss following primary THA. What is the most important is that, by adding another boluses of IV-TXA, patients can gain a smaller decline of Hb, less postoperative inflammation response, less pain and shorter length of hospital stay

Aims: High evacuation pressure is known to increase drained blood loss following uncemented total knee replacements (TKRs). However, the effect of different evacuation pressures on drained loss or total blood loss in cemented TKRñs is unknown. We set out to investigate this effect. Methods: One hundred patients undergoing cemented TKRñs were randomised to receive high or low-pressure suction drains after surgery. The following were observed:-. The volume of blood evacuated from the knee joint,. The calculated total blood loss,. Time to discharge, range of movement and incidence of wound problems. Results: Greater drainage volumes were seen with the higher evacuation pressures. However, total blood loss from the circulating volume was not statistically different between the two groups. No difference was seen in morbidity or clinical outcome. Drained volumes were substantially less than published values for uncemented TKRs. Conclusions: For a given drop in total blood volume, the high-pressure drains were more efþcient in evacuating haemarthrosis. However, the lower pressures drains demonstrated no increase in morbidity or worsened clinical outcome. The relevance of these þndings in the context of autologous salvage drainage systems, which operate at similar low-pressures to avoid haemolysis, is presented

Objective. The efficacy and safety of tranexamic acid (TXA) on reducing blood loss and transfusion has been confirmed in primary total hip arthroplasty (THA). The main methods of administration includes intravenous, topical alone or combined use, and the most appropriated methods remains undecided. This study was aimed to compare the efficacy and safety of different methods of TXA following primary THA. Methods. We prospectively collected patients' data through National Health Database from January 2013 to December 2016. The patients were divided into control group, intravenous group, topical group and combined group according to the different methods of TXA. The primary outcome was the incidence of transfusion and venous thromboembolism. Secondary outcomes were total blood loss, hemoglobin level on postoperative day 3 and decrease in hemoglobin, incidence of wound complications and other adverse events. Results. A total of 7537 primary THA procedures were collected, 4102 with TXA, 3435 without TXA. 2847 (37.8%) patients received intravenous TXA alone, 235 (3.1%) patients received topical TXA alone and 1020 (13.5%) patients received combined use. The transfusion rate decreased from 33.07% to 12.7% with the use of TXA (p< 0.001). The transfusion rate was 30.21% in topical group, 10.68% in intravenous group, and 14.31% in combined group, with a significant difference between treatment groups (p< 0.01 for all). The hemoglobin on postoperative day 3 in control group was 91.24±17.09 g/L, which was significantly lower than that in topical group (101.38±16.71 g/L), intravenous group (102.79±32.37 g/L) and combined group (104.34±16.67 g/L, p<0.05 for all). The hemoglobin drop on POD 3 in control group was 38.07±18.10 g/L, which was significantly higher than that in topical group (30.02±17.11 g/L), intravenous group (29.35±16.05 g/L) and combined group (29.22±16.37 g/L, p<0.05 for all). The total blood loss in control group was (1377.74 ± 851.97 ml), which was significantly higher than that in topical group (1123.15±628.59 ml), intravenous group (971.08±671.39 ml) and combined group (946.4±724.82 ml, p<0.05 for all). A total of 14 DVT (0.41%) in control group, 4 patients (0.1%) in TXA group occurred DVT, and the difference was significant (0.10%, p= 0.006). Cardiac infarction occurred in 3 patients (0.04%), stroke occurred in 2 patients (0.03%), and 3 patients (0.04%) developed wound infection. No episode of PE or death occurred. Conclusion. TXA was effective and safe to decrease blood loss and transfusion following primary THA no matter of intravenous, topical use alone or combined use. In order to achieve better hemostatic effect, intravenous or combined application was recommended if no contradictions were found

Purpose. This meta-analysis was designed to compare the effectiveness and safety of intravenous (IV) versus topical administration of tranexamic acid (TXA) in patients undergoing primary total knee arthroplasty (TKA) by evaluating the need for allogenic blood transfusion, incidence of postoperative complications, volume of postoperative blood loss, and change in hemoglobin levels. Materials and Methods. Studies were included in this meta-analysis if they assessed the allogenic blood transfusion rate, postoperative complications including pulmonary thromboembolism (PTE) or deep vein thrombosis (DVT), volume of postoperative blood loss via drainage, estimated blood loss, total blood loss, and change in hemoglobin before and after surgery in primary TKA with TXA administered through both the intravenous (IV) and topical routes.[Fig. 1]. Results. Ten studies were included in this meta-analysis.[Fig. 2] The proportion of patients requiring allogenic blood transfusion (OR 1.34, 95% CI: 0.63 to 2.81; P=0.45) [Fig. 3] and the proportion of patients who developed postoperative complications including PTE or DVT (OR 0.85, 95% CI: 0.41 to 1.77; P=0.66) did not significantly differ between the two groups. There was 52.3 mL less blood loss via drainage (95% CI: −50.74 to 185.66 ml; P=0.44),[Fig. 4] 21.5 mL greater estimated blood loss (95% CI: −98.05 to 55.12 ml; P=0.32), and 51.4 mL greater total blood loss (95% CI: −208.16 to 105.31 ml; P=0.52) [Fig. 5]in the topical TXA group as compared to the IV TXA group. The two groups were also similar in terms of the change in hemoglobin levels (0.02 g/dl, 95% CI: −0.36 to 0.39 g/dl; P=0.94). Conclusion. In primary TKA, there are no significant differences in the transfusion requirement, postoperative complications, blood loss, and change in hemoglobin levels between the intravenous and topical administration of TXA. For figures/tables, please contact authors directly.

Introduction. The use of tranexamic acid (TXA) in primary total hip arthroplasty (THA) is supported by many studies that confirm its efficacy for decreasing blood loss, but the comparison between topical intra-articular (IA) and intra-venous (IV) is unclear, especially combined with chemical prophylaxis. The purpose of this study is to verify non-inferior efficacy of topical IA TXA compared with IV TXA in primary THA. Methods & Methods. A single center, randomized, controlled clinical trial was performed to compare topical IA TXA (2 g of TXA in 100 cc of normal saline) with two IV doses of TXA (1 g dose before surgery and another 1 g dose 3 hours later) on blood loss. The primary outcome was total blood loss as calculated from the difference between the preoperative hemoglobin (Hb) and the lowest postoperative Hb. The secondary outcome included drained blood loss, transfusion volume, and thromboembolic events. The sample size of 112 patients was calculated to give a statistical power of 99% for demonstrating inferiority. Fifty-six patients each was assigned to receive topical IA TXA (IA group) and IV TXA (IV group). There were no significant differences in demographics and preoperative laboratory values between the two groups. Non-inferiority was estimated by comparing the confidence interval with a delta of 10%. All subjects took oral direct factor Xa inhibitor to prevent venous thromboembolism included during 2 weeks after surgery. Results. The total blood loss was 875.0 mL (range, 199.7 – 2149.2 mL) in topical IA group and 1070.2 mL (range, 389.5 – 2738.8 mL) and thus, non-inferiority was demonstrated for the primary efficacy end point (p<0.001). Drained blood loss also show a significant difference (370.1 ± 77.4 versus 539.9 ± 180 mL, p=0.037). The number of patients given transfusion was 9 (16.1%) and 19 (33.9%) in IV group (p=0.029) and the number of transfusion units was 0.2 (range, 0 – 2) in topical IA group and 0.5 (range 0 – 3) in IV group (p=0.027). No significant difference was seen in thromboembolic events between groups. Conclusions. Topical IA administration of TXA demonstrated non-inferiority compared with IV TXA. Our findings support the topical IA use of TXA in primary THA

Purpose. The purposes of this study are as follows; 1) to compare postoperative blood loss between general anesthesia(GA) and spinal anesthesia(SA) and 2) to analyze the affecting factors of postoperative blood loss through the subgroup analysis. METHODS. A retrospective analysis was made on the clinical data of 122 patients with osteoarthritis undergoing primary TKA between January 2012 and December 2013. According to different anesthetic method, the patients were divided into the General Anesthesia group (73 cases) and the Spinal Anesthesia group (49 cases). Each group was divided subgroup as age, BMI, Preoperative blood pressure, Surgery time, Torniquet time, INR. The total blood loss, Post Operation 1 day blood loss, hidden blood loss, and the percentage of hidden blood loss were compared between 2 groups. For the analysis of postoperative blood loss, each group was compared postoperative blood loss using hemovac drainage per day and total blood loss. In preoperative blood pressure, Higher than 140 mmHg in systolic blood pressure and higher than 90 mmHg in diastolic blood pressure were employed as a cut-off value to group the well-controlled hypertension group(n=42) and uncontrolled hypertension group(n=29). RESULTS. One day after the surgery blood loss(p=0.322) and total blood loss(p=0.560) showed no significant differences between two group. But in the uncontrolled hypertension group showed a large amount of bleeding one day after the surgery(p=0.003) and total blood loss(p=0.004) in the spinal anesthesia. CONCLUSION. It seems that, general anesthesia is effective method to reduce postoperative blood loss. Preoperative blood pressure control is one of the important affecting factor of postoperative blood loss

Introduction: In the last few years minimally invasive surgery in hip replacement is becoming more popular among orthopaedic surgeons because of less morbidity and faster rehabilitation. However several complications have been reported expecially in the so called “learning curve” (first twenty cases). The purpose of this study is to evaluate the learning curve of three different minimally invasive approaches. Methods and Materials: In this study three different surgical approaches of THA were evaluated: lateral mini incision (GroupA), minimally invasive anterior approach (GroupB) and minimally invasive antero lateral approach (GroupC). The first twenty cases of each surgical approach were selected and compared with a control group (GroupD) of 149 total hip replacement operated using a lateral standard approach (> 12 cm) in the same period by the same experienced surgeon. In all cases a specialized dedicated surgical instrumentation was used. Inclusion criteria to enter the study group (A-B-C Groups) were:BMI< 30, diagnosis of primary osteoarthritis, age< 75 years. Following parameters were evaluated: intra and post operative complications, total blood loss, time of surgery, component placement, length of hospital stay and functional outcomes (HHS, WOMAC) at six weeks. Results: No dislocations, infections and early aseptic loosening were detected in groups A, B and C. No significant differences were detected regarding the length of hospital stay in all groups. In group B the time of surgery was significantly higher than in group D. The total blood loss of group A, B and C was statistically lower than group D. Clinical outcomes at six weeks in groups B and C were significantly better that in group A and D. The following complications were detected:. Group A: two sciatic nerve palsy (one transient and one permanent), one greater trochanter fracture, one femoral stem malposition. Group B: one greater trochanter fracture, one proximal femoral fracture, one rupture of tensor fasciae latae, two haematomas. Group C: no complications were detected. In control group D (149 patients) the following complications were observed: one proximal femoral fracture, one case of cup malposition and one infection. Conclusions: The main advantages of all MIS approaches seem to be the reduced total blood loss, even in the learning curve. However during learning curve the minimally invasive approaches seem to have a higher rate of complications than the standard procedures even in selected patients. In muscle sparing approaches (anterior and antero lateral) the early functional outcomes are better than other approaches (standard and mini incision). Among the evaluated minimally invasive procedures, the antero lateral approach seems to be safer and less demanding than others

Purpose. To evaluate the effectiveness of post-operative pain management using the intra-operative peri-articular injection(PAI) and/or electromyography (EMG)-guided preoperative femoral nerve block (FNB) in total knee arthroplasty(TKA). Materials and Methods. From March 2013 to February 2014, 90 knees which underwent primary TKA by one surgeon were included in our study. The patients were classified into three groups; a single injection FNB with an EMG guide (Group I, 30 knees), intra-operative PAI (Group II, 30 knees) and both FNB and PAI (Group III, 30 knees). Pain at rest and moving was evaluated by Visual Analogue Scale (VAS) at postoperative 0, 4, 8, 24 and 48 hours. Postoperative range of motion, time to walking, total blood loss, amount of opioid consumption and complications were compared in each group. Results. VAS immediately after surgery was 67.9 in group I, 54.6 in group II and 54.7 in group III. VAS was significantly higher in group I than group II and III (p=0.005), but was not significantly different between group II and III (p>0.05). VAS at postoperative 4 and 8hr showed similar results. VAS at postoperative 24 hr was 49.6 in group I, 56.4 in group II and 46.7 in group III, which was significantly higher in group II than group I and III (p=0.043). After postoperative 48hr, there were no differences in group I, II and III. The total amount of opioid consumption in group III was smaller than that in group I and II (p=0.017). There were no differences in postoperative range of motion, time to walking and total blood loss. There was one case with temporary peroneal nerve palsy in group II and no infection in all cases. Conclusion. PAI was more effective than FNB for early (0∼8hr) postoperative period after TKA. However, PAI showed rebound pain at 24hr after TKA. PAI in combination with FNB could enhance the effect of postoperative pain management from immediate postoperative period to 24hr