Preoperative anaemia and intraoperative blood loss result in ∼90% of individuals being anaemic following hip and knee arthroplasty. Reducing blood loss offers the opportunity to improve outcomes and reduce the risk of transfusion and costs. This review's aim was to determine the effectiveness of drugs for preventing blood loss, and identify optimal dose, route, and timing of administration. Cochrane network meta-analysis of randomised controlled trials was conducted. Inclusion criteria: adults undergoing primary or revision elective hip or knee arthroplasty. Drugs studied: tranexamic acid (TXA), aprotinin, epsilon-aminocaproic acid, desmopressin, factor VIIa and XIII, fibrinogen, fibrin sealants, and non-fibrin sealants. Primary outcomes: need for allogenic blood transfusion, all• cause mortality (within 30 days). Secondary outcomes: mean number of transfusion episodes, re-operation, length of hospital stay and adverse events (DVT, PE, CVA, MI). 102 studies with 8418 participants. Trials included more women (63%). 47 studies (4398 participants) were included within the blood transfusion NMA. TXA given intra-articularly and orally at a total dose of greater than 3g pre-incision, intraoperatively and postoperatively ranked the highest, with anticipated absolute effect of 147 fewer transfusions per 1000 (53% chance ranking 1st) (relative risk(RR) 0.02, 95% credible interval(CrI) 0–0.31); moderate-certainty). Aprotinin (RR 0.59, 95%:CrI 0.36–0.86; low certainty evidence), fibrin (RR 0.86, CrI 0.25–2.93; very-low certainty) and EACA (RR 0.60, 95%:CrI 0.29–1.27; very-low certainty) were not shown to be as effective as TXA. TXA was the most effective drug for preventing bleeding in lower limb arthroplasty. Aprotinin and EACA were not as effective. Currently, the optimal dose, route and timing of administration of TXA is unclear. However, TXA given at higher doses and via mixed routes ranked higher in the treatment hierarchy. Oral TXA may be as effective as intavenous. There was no evidence of harm associated with higher doses of TXA

The aim of this study was to systemically review the evidence for the use of intra-operative cell salvage (ICS) among patients undergoing revision hip arthroplasty, and synthesis the available data to quantify any associated reduction in allogeneic blood transfusion. An electronic database search of MEDLINE (PubMed), EMBASE, Scopus and the Cochrane Library was completed from the date of inception to 9. th. February 2021, using a search strategy and protocol created in conjunction with the PRISMA statement. Inclusion criteria were (i) adult patients >18 years, (ii) ICS utilised in one study group, (iii) revision hip arthroplasty performed. Exclusion criteria were (i) pre-donation of red blood cells, (ii) mixed reporting without dedicated subgroup analysis for revision hip arthroplasty. Screening for eligibility, and quality assessment of included studies, was performed independently by two authors (TW and DH), and any disputes settled by third author (AK). Of the 187 records identified, 11 studies were included in the qualitative analysis, and 5 studies suitable for quantitative meta-analysis. Across the included studies there were 1856 participants, with a mean age of 63.86 years and a male: female ratio of 0.90. Quality assessment demonstrated low or medium risk of bias only. For revision hip arthroplasty patients receiving ICS, 37.07% required ABT with a mean transfusion of 1.92 units or 385ml per patient. For patients treated without ICS, 64.58% required ABT with a mean transfusion of 4.02 units or 803ml per patient. This difference achieved statistical significance (p < 0.05). This study has demonstrated a significant reduction in the need for allogenic blood transfusion associated with intra-operative cell salvage use among patients undergoing revision hip arthroplasty. This study therefore supports the routine use of ICS in this patient group. However, a major limitation is the lack of clinical outcomes reported by the available studies. Further research is required to determine whether this effect is associated with sub-groups of revision arthroplasty procedure, and whether ICS impacts clinical outcomes such as length of stay, rehabilitation progress and mortality

The purpose of this study was to determine the complications after Bernese periacetabular osteomy (PAO) performed by one experienced surgeon using a minimally invasive modified Smith-Petersen approach. Between May 2012 and December 2015, 224 periacetabular osteotomies (PAO) in 201 patients were performed. The perioperative complications were retrospectively reviewed after reviewing clinical notes and radiographs. The mean age was 28.8 years with 179 females and 22 males. The most common diagnosis was acetabular dysplasia with some cases of retroversion. The average lateral centre edge (LCE) angle was 16.5°(−18–45) and mean acetabular index (AI) 16.79° (−3–50). Postoperatively the mean LCE angle was 33.1°(20–51.3) and mean AI 3.0°. (−13.5–16.6). There were no deep infections, no major nerve or vascular injuries and only one allogenic blood transfusion. Nine superficial wound infections required oral antibiotics and two wounds needed a surgical debridement. There was one pulmonary embolus and one deep vein thrombosis. Nine (4%) cases underwent a subsequent hip arthroscopy and three (1.3%) PAO's were converted to a total hip arthroplasty after a mean follow-up of 22 months (3–50). Lateral femoral cutaneous nerve dysaesthesia was noted in 64 (28.6%) PAO's. In 55 (24.5%) an iliopsoas injection of local anaesthetic and steroid for persistent iliopsoas irritation during the recovery phase was given. The minimally invasive modified Smith-Petersen approach is suitable to perform a Bernese periacetabular osteotomy with a low perioperative complication rate. Persistent pain related to iliopsoas is a not uncommon finding and perhaps under-reported in the literature

Introduction. Periacetabular osteotomy has been described as an effective way of treating symptomatic hip dysplasia. We describe a new minimally invasive technique using a modification of the Smith Peterson approach. Patients/Materials & Methods. 189 consecutive patients operated on between March 2010 and March 2013 were included in the study. Patients who had undergone previous pelvic surgery for DDH were excluded. There were 174 females and 15 males. The mean age was 31 years (15–56) and the mean duration of follow-up was 29 months (14 – 53 months). 90% of cases were Tonnis grade 0 or 1. Twenty-three patients were operated on for primary acetabular retroversion. Functional outcomes were assessed using the NAHS, UCLA and Tegner activity scores. The surgical procedure is performed through an 8–10 cm skin crease incision; a soft tissue sleeve is elevated from the anterior superior iliac spine. The interval medial to the rectus femoris is developed. The hip joint is not opened and fixation of the osteotomy was with three 4.5mm cortical screws. A cell saver was routinely used. Results. For the dysplasia group the mean pre-operative lateral centre edge angle was 14.2degrees (−5degrees to 30degrees) and the mean acetabular index was 18.4degrees (4degrees to 40degrees). Post-operatively these were 31degrees (18degrees to 46degrees) and 3degrees (−7degrees to 29degrees) respectively. An allogenic blood transfusion was required in 3 patients (1.5%). The mean duration of surgery was 105 minutes. There were no major nerve or vascular complications and no wound infections. At the time of last follow-up, we noted a significant improvement in functional outcome scores: UCLA improved by 2.31 points, Tegner improved by 1.08 points, and the NAHS improved by 25.4 points. Conclusion. We have found this approach to be safe and effective, facilitating early recovery from surgery

Aims

Transfusion after primary total hip arthroplasty (THA) has become rare, and identification of causative factors allows preventive measures. The aim of this study was to determine patient-specific factors that increase the risk of needing a blood transfusion.

Aims

A typical pattern of blood loss associated with total hip arthroplasty (THA) is 200 ml intraoperatively and 1.3 l in the first 48 postoperative hours. Tranexamic acid (TXA) is most commonly given as a single preoperative dose only and is often withheld from patients with a history of thromboembolic disease as they are perceived to be “high-risk” with respect to postoperative venous thromboembolism (VTE). The TRanexamic ACid for 24 hours trial (TRAC-24) aimed to identify if an additional 24-hour postoperative TXA regime could further reduce blood loss beyond a once-only dose at the time of surgery, without excluding these high-risk patients.

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.

We have investigated the effect of using tranexamic acid (TXA) during peri-acetabular osteotomy (PAO) on peri-operative blood loss and blood transfusion requirements. In addition we analysed whether the use of TXA was associated with an increased risk of venous thromboembolism (VTE) following this procedure.

A consecutive series of 96 PAOs, performed by a single surgeon, were reviewed. A total of 48 patients received TXA and 48 did not. The TXA group received a continuous infusion of TXA at a rate of 10 mg/kg/h. The primary outcome measure was the requirement for blood transfusion. Secondary outcomes included total blood loss, the decrease in the level of haemoglobin in the blood, the length of hospital stay, and the complications of this treatment.

The mean rate of transfusion was significantly lower in the TXA group (62.5% vs 12.5%, p < 0.001). The mean blood loss was also significantly reduced in the TXA group (1.9 L (standard deviation (sd) 0.9) vs 1.5 L (sd 0.7), p < 0.01). No post-operative episodes of VTE were identified in either group.

The use of TXA reduced the blood loss and the rate of transfusion after PAO significantly, without adverse effects such as an increased rate of VTE.

Cite this article: Bone Joint J 2015;97-B:1604–7.

Tranexamic acid (TXA), an inhibitor of fibrinolysis, reduces blood loss after total knee arthroplasty. However, its effect on minimally invasive total hip arthroplasty (THA) is not clear. We performed a prospective, randomised double-blind study to evaluate the effect of two intravenous injections of TXA on blood loss in patients undergoing minimally invasive THA.

In total, 60 patients (35 women and 25 men with a mean age of 58.1 years; 17 to 84) who underwent unilateral minimally invasive uncemented THA were randomly divided into the study group (30 patients, 20 women and ten men with a mean age of 56.5 years; 17 to 79) that received two intravenous injections 1 g of TXA pre- and post-operatively (TXA group), and a placebo group (30 patients, 15 women and 15 men with a mean age of 59.5 years; 23 to 84). We compared the peri-operative blood loss of the two groups. Actual blood loss was calculated from the maximum reduction in the level of haemoglobin. All patients were followed clinically for the presence of venous thromboembolism.

The TXA group had a lower mean intra-operative blood loss of 441 ml (150 to 800) versus 615 ml (50 to 1580) in the placebo (p = 0.044), lower mean post-operative blood loss (285 ml (120 to 570) versus 392 ml (126 to 660) (p = 0.002), lower mean total blood loss (1070 ml (688 to 1478) versus 1337 ml (495 to 2238) (p = 0.004) and lower requirement for transfusion (p = 0.021). No patients in either group had symptoms of venous thromboembolism or wound complications.

This prospective, randomised controlled study showed that a regimen of two intravenous injections of 1 g TXA is effective for blood conservation after minimally invasive THA.

Cite this article: Bone Joint J 2015;97-B:905–10.

Periprosthetic joint infection (PJI) is a devastating complication which can follow a total joint arthroplasty (TJA). Although rare, this ongoing threat undermines the success of TJA, a historically reputable procedure. It has haunted the orthopedic community for decades and several ongoing studies have provided insights and new approaches to effectively battle this multilayered problem.