Aims

Closed suction subfascial drainage is widely used after instrumented posterior spinal fusion in patients with a spinal deformity. The aim of this study was to determine the effect of this wound drainage on the outcomes in patients with adolescent idiopathic scoliosis (AIS). This was a further analysis of a randomized, multicentre clinical trial reporting on patients after posterior spinal fusion using segmental pedicle screw instrumentation. In this study the incidence of deep surgical site infection (SSI) and chronic postoperative pain at two years’ follow-up are reported.

The February 2023 Foot & Ankle Roundup³⁶⁰ looks at: Joint inflammatory response in ankle and pilon fractures; Tibiotalocalcaneal fusion with a custom cage; Topical application of tranexamic acid can reduce blood loss in calcaneal fractures; Risk factors for failure of total ankle arthroplasty; Pain catastrophizing: the same as pain forecasting?.

Aims

The aim of this study was to determine the prevalence and impact of tourniquet use in patients undergoing limb salvage surgery with endoprosthetic reconstruction for a tumour around the knee.

Aims. The aim of this study was to evaluate whether, after correction of an adolescent idiopathic scoliosis (AIS), leaving out the subfascial drain gives results that are no worse than using a drain in terms of total blood loss, drop in haemoglobin level, and opioid consumption. Methods. Adolescents (aged between 10 and 21 years) with an idiopathic scoliosis (major curve ≥ 45°) were eligible for inclusion in this randomized controlled noninferiority trial (n = 125). A total of 90 adolescents who had undergone segmental pedicle screw instrumentation were randomized into no-drain or drain groups at the time of wound closure using the sealed envelope technique (1:1). The primary outcome was a drop in the haemoglobin level during first three postoperative days. Secondary outcomes were 48-hour postoperative oxycodone consumption and surgical complications. Results. All 90 patients were included in the primary outcome analysis (no drain = 43; drain = 47). The mean total postoperative blood loss (intraoperative and drain output) was significantly higher in the group with a subfascial drain than in the no-drain group (1,008 ml (SD 520) vs 631 ml (SD 518); p < 0.001). The drop in haemoglobin level did not differ between the study groups over the postoperative timepoints (p = 0.290). The 48-hour opioid consumption was significantly higher in the no-drain group (2.0 mg/kg (SD 0.9) vs 1.4 (SD 0.6); p = 0.005). Two patients in the no-drain and one patient in the drain group developed a surgical site infection. Conclusion. Leaving the subfascial drain out after pedicle screw instrumentation for AIS is not associated with higher postoperative haemoglobin levels. Patients treated without a subfascial drain needed 30% more opioids during the first 48 hours than those who had a drain. Cite this article: Bone Joint J 2022;104-B(9):1067–1072

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.

Aims

Many surgeons choose to perform total knee arthroplasty (TKA) surgery with the aid of a tourniquet. A tourniquet is a device that fits around the leg and restricts blood flow to the limb. There is a need to understand whether tourniquets are safe, and if they benefit, or harm, patients. The aim of this study was to determine the benefits and harms of tourniquet use in TKA surgery.

Aims

Optimal exposure through the direct anterior approach (DAA) for total hip arthroplasty (THA) conducted on a regular operating theatre table is achieved with a standardized capsular releasing sequence in which the anterior capsule can be preserved or resected. We hypothesized that clinical outcomes and implant positioning would not be different in case a capsular sparing (CS) technique would be compared to capsular resection (CR).

Aims. Tranexamic acid (TXA) has been shown to reduce blood loss and transfusion requirements in patients undergoing orthopaedic surgery. There remains a lack of prospective evidence for the use of TXA in patients undergoing periacetabular osteotomy (PAO). The purpose of this study was to determine if intravenous (IV) TXA is effective in reducing calculated blood loss and transfusions after PAO. Methods. This was a single-centre prospective double-blind placebo-controlled randomized trial of 81 patients aged 12 to 45 years undergoing elective PAO by a single surgeon. The intervention group (n = 40) received two doses of IV TXA of a maximum 1 g in each dose; the control group (n = 41) received two doses of 50 ml 0.9% saline IV. The primary outcome was perioperative calculated blood loss. Secondary outcomes included allogenic transfusions and six-week postoperative complications. Results. There were no differences in demographics or intraoperative variables between study groups. The TXA group demonstrated lower mean calculated blood loss (1,265 ml, (SD 321) vs 1,515 ml, (SD 394); p = 0.002) and lower frequency of allogenic transfusion (10%/n = 4 vs 37%/n = 15; p = 0.008). Regression analyses associated TXA use with significant reductions in calculated blood loss (p < 0.001) and transfusion (p = 0.007) after adjusting for age, sex, body mass index, preoperative haemoglobin, cell-saver volume, intraoperative mean arterial blood pressure, and operating time. No patients suffered venous thromboembolic complications. Conclusion. In this trial, IV TXA decreased postoperative calculated blood loss by 293 ml and reduced the frequency of allogenic transfusions by 73% (37% vs 10%) following PAO. TXA may be safe and effective for reducing blood loss in patients undergoing PAO. Cite this article: Bone Joint J 2020;102-B(9):1151–1157

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.

Objectives

Tranexamic acid (TXA) is an anti-fibrinolytic medication commonly used to reduce perioperative bleeding. Increasingly, topical administration as an intra-articular injection or perioperative wash is being administered during surgery. Adult soft tissues have a poor regenerative capacity and therefore damage to these tissues can be harmful to the patient. This study investigated the effects of TXA on human periarticular tissues and primary cell cultures using clinically relevant concentrations.

Aims

The aim of this study was to identify the most effective regimen of multiple doses of oral tranexamic acid (TXA) in achieving maximum reduction of blood loss in total knee arthroplasty (TKA).

Background. It is unclear whether the approach of hemiarthroplasty influence the outcomes in elderly patients with displaced femoral neck fractures. We conducted a randomized controlled trial to compare the direct lateral approach (DL approach) and posterolateral approach (PL approach) for hemiarthroplasty. Methods. This study included patients presenting to our hospital with displaced femoral neck fractures (Garden stage 3 or 4) from August 2010 to August 2011. 59 patients agreed the prospective study. They were randomized between the hemiarthroplasty using DL approach or PL approach. We evaluated and compared the operative time, perioperative blood loss, peri- and post-operative complications, and 5-year survival rates. Results. Thirty-two patients underwent the hemiarthroplasty using DL approach and 27 patients underwent hemiarthroplasty using PL approach. The mean operative time was 91 min in DL group and 77 min in PL group. A significant difference was observed for the mean operative times(p<0.005). The bleeding during surgery was 194 g in DL group and 180 g in PL group. The postoperative blood loss was 268 g in DL group and 264 g in PL group, no significant difference was observed postoperatively. Perioperative and postoperative complications were observed in 8 patients of DL group and 5 patients of the PL group. In DL group, perioperative complications included fracture in 1 patient, whereas postoperative complications included deep vein thrombosis in 7 patients. In PL group, postoperative complications included deep vein thrombosis in 3 patients, deep infection in 1 patient and subluxation of the outerhead in 1 patient. Two patients of DL group and 3patients of PL group suffered second hip fractures within the follow-up period, and 1 patient of PL group suffered periprosthetic fracture and treated conservatively. We identified 28 patients as dead in the follow-up period. The 5-year survival rate of DL group was 51.3% and that of PL group was 44.2%; there were not significantly different between the groups (log-rank test, p = 0.324). Conclusion. The mean operative time was significantly longer in DL groups, but peri- and post-operative complications and the surbival rate were not significantly different between the two groups. Surgical approach might not affect the outcomes of hemiarthroplasty in patients with femoral neck fractures

Objectives. Tranexamic acid (TXA), an inhibitor of fibrinolysis blocking the lysine-binding site of plasminogen to fibrin, has been reported to reduce intraoperative and postoperative blood loss in patients undergoing primary total hip arthroplasty (PTHA) both with and without cement. Both intravenous (IV) and topical (TOP) administration of TXA can effectively reduce blood loss in THA without increasing risk of deep venous thrombosis (DVT). However, there have been few reports investigating the combination of intravenous and topical administration of TXA in bilateral cementless PTHA. We investigated the effects of combined intravenous and topical administration of TXA on postoperative blood loss, drainage volume, and perioperative complications in patients with bilateral simultaneous cementless PTHA for hip osteoarthritis. Patients and methods. We retrospectively reviewed the demographic and clinical data of 41 patients who underwent bilateral simultaneous cementless PTHA for hip osteoarthritis from May 2015 to January 2017, of which there were 29 male (70.7%) and 12 female (29.3%) patients. Patients in IV group (n= 11) received only TXA (15 mg/kg) 10 min prior to the incision of each side; and patients in IV + TOP group (n=13) received i.v. TXA (15 mg/kg) combined with topical adiministration (1.0 g) of TXA during the each THA procedure; patients in control group (n=17) received the same dosage of normal saline both i.v. and topically. Outcome measures were total blood loss, hemoglobin, hematocrit value (HCT) changes preoperatively, and on the 1st, 3rd postoperative day, the amount of drainage, and perioperative complications. Results. On the 1st, 3rd postoperative day, patients in group IV and group IV + TOP had significantly higher haematological parameters (haemoglobin, hematocrit value (HCT)) than patients in control group (P < 0.05 (group IV vs control group), P < 0.01 (group IV + TOP vs control group), respectively), while no significant differences found between patients in group IV and group IV + TOP (P > 0.05). The postoperative drainage volume of patients in group IV and group IV + TOP were significantly less than those in control group (P < 0.01, P < 0.01, respectively), while no significant differences found between those in group IV and group IV + TOP (P > 0.05). No significant differences were found in the perioperative complications (DVT or PE) among all three groups. Conclusion. The combined administration of intravenous and topical TXA resulted in a significantly reduction in postoperative blood loss, compared with placebo group. No adverse perioperative complications were observed. This study supports the combined intravenous and topical administration of TXA in bilateral cementless PTHA

Background. The reductions of perioperative blood loss and inflammatory response are important in total knee arthroplasty. Tranexamic acid reduced blood loss and the inflammatory response in several studies. However, the effect of epinephrine administration plus tranexamic acid has not been intensively investigated, to our knowledge. In this study, we evaluated whether the combined administration of low-dose epinephrine plus tranexamic acid reduced perioperative blood loss or inflammatory response further compared with tranexamic acid alone. Methods. This randomized placebo-controlled trial consisted of 179 consecutive patients who underwent primary total knee arthroplasty. Patients were randomized into 3 interventions: Group IV received intravenous low-dose epinephrine plus tranexamic acid, Group TP received topical diluted epinephrine plus tranexamic acid, and Group CT received tranexamic acid alone. The primary outcome was perioperative blood loss on postoperative day 1. Secondary outcomes included perioperative blood loss on postoperative day 3, coagulation and fibrinolysis parameters (measured by thromboelastography), inflammatory cytokine levels, transfusion values (rate and volume), thromboembolic complications, length of hospital stay, wound score, range of motion, and Hospital for Special Surgery (HSS) score. Results. The mean calculated total blood loss (and standard deviation) in Group IV was 348.1 ± 158.2 mL on postoperative day 1 and 458.0 ± 183.4 mL on postoperative day 3, which were significantly reduced (p < 0.05) compared with Group TP at 420.5 ± 188.4 mL on postoperative day 1 and 531.1 ± 231.4 mL on postoperative day 3 and Group CT at 520.4 ± 228.4 mL on postoperative day 1 and 633.7 ± 237.3 mL on postoperative day 3. Intravenous low-dose epinephrine exhibited a net anti-inflammatory activity in total knee arthroplasty and did not induce an obvious hypercoagulable status. Transfusion values were significantly (p=0.023 and 0.032) reduced in Group IV, but no significant differences were observed in the incidence of thromboembolic complications, wound score, range of motion, and HSS score among the 3 groups (p > 0.05). Conclusions. The combined administration of low-dose epinephrine and tranexamic acid demonstrated an increased effect in reducing perioperative blood loss and the inflammatory response compared with tranexamic acid alone, with no apparent increased incidence of thromboembolic and other complications

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 issue regarding whether suction drainage should be used during TKA continues to be debated as both methods have disadvantages. The use of a drain may increase estimated blood loss and incidence of blood transfusion, while no drainage may be associated with ecchymosis formation surrounding the surgical site and wound problems. This prospective randomized study aimed to clarify the need for suction drainage in TKA by assessing the short-term postoperative outcome. Patients and Methods. We randomized 39 patients undergoing TKAs either with or without an intra-articular suction drain and divided to two groups. All the TKAs were performed by a single surgeon using cemented prostheses. As the perioperative blood management, air tourniquet was used during surgery, the knee arthrotomy was closed water-tightly, and all the patients were received both intra-articular and intra-venous administrations of tranexamic acid. After the surgery, a bulky compression dressing was applied to prevent the third space leakage of the blood for four days and rivaroxaban was used for venous thromboembolism prophylaxis for one week. The two groups were compared in terms of hemoglobin decrease, recovery of knee flexion, postoperative pain, and examined both the knee circumference and knee swelling. The incidence of short-term complications also evaluated. Results. TKAs were performed in 24 patients with (Group 1) and 15 patients without (Group 2) suction drain and there was no major complication in both groups. We found no significant differences in the mean postoperative blood loss, postoperative pain, and ROM during two weeks after TKA between the two groups. The amount of the intra-articular fluid measured with computed tomography as the postoperative knee swelling was similar between the two groups. Discussion and Conclusions. Recently, as the pharmacologic agents have been routinely used for venous thromboembolism prophylaxis after TKA for more than one week, perioperative bleeding should be managed more intensively. The administration of tranexamic acid has been widely reported to decrease the postoperative blood loss, and water-tightness of the arthrotomy closure can reduce hemarthrosis and arthrotomy leakage to the third space by a tamponade effect. The advantage of the bulky compression dressing reportedly is to reduce soft tissue edema and bleeding in an effort to promote venous drainage. Furthermore, this study did not demonstrate that intra-articular suction drain contributed to decrease the amount of intra-articular fluid at two weeks after the surgery. In conclusion, under the condition of routine pharmacologic VTE prophylaxis with intensive perioperative blood management, intra-articular suction drain has no advantage in TKA