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.

Purpose. Transfusion rates after primary total hip has been reported up to 39.2%. The purpose of our study was to evaluate the efficacy of TXA in minimizing risk of allogeneic blood transfusion after primary total hip and hip resurfacing arthroplasty. Method. Retrospective data on a cohort of 88 patients undergoing total hip arthroplasty and 44 who undergoing hip resurfacing arthroplasty who received a single pre-operative bolus of 1g TXA was compared with a control group matched for starting haemoglobin (Hg), body mass index (BMI), age, gender, blood loss, surgical time, and surgeon. All procedures were completed at a single institution with standardized post-operative care. Endpoints included allogeneic blood transfusion rate, post operative day one Hg, and overall Hg decrease. Results. Transfusion rate among the total hip TXA group was 5.7% and among control patients 22.7% (p=0.001). Transfusion rates among resurfacing patients showed no statistical difference between the treatment group and matched controls. Mean overall haemoglobin decrease was found to be significantly lower in the TXA treatment groups for both total hip and hip resurfacing arthroplasty (p<0.0001 and p=0.01 respectively). Patients who received TXA and allogeneic blood transfusion were found to have a significantly lower pre-operative Hg versus transfusion negative TXA treated patients (113.7 g/dL and 141.5 g/dL respectively). Conclusion. We have shown TXA use in primary total hip arthroplasty significantly decreases allogeneic blood transfusion rate. TXA use in hip resurfacing arthroplasty failed to show significant difference in transfusion rate yet calculated blood loss was less. Patients presenting with low pre-operative Hb remain high risk for allogeneic blood transfusion despite TXA treatment

Background. Intraoperative blood loss is a known potential complication of total knee arthroplasty (TKA). Tranexamic acid (TXA) has been shown to reduce intraoperative blood loss and postoperative transfusion in patients undergoing TKA. While there are numerous studies demonstrating the efficacy of intravenous and topical TXA in patients undergoing TKA, there are comparatively few demonstrating the effectiveness and appropriate dosing recommendations of oral formulations. Methods. A retrospective cohort study of 2230 TKA procedures at a single institution identified 3 treatment cohorts: patients undergoing TKA without the use of TXA (no-OTA, n=968), patients undergoing TKA with administration of a single-dose of oral TXA (single-dose OTA, n=164), and patients undergoing TKR with administration of preoperative and postoperative oral TXA (two-dose OTA, n=1098). The primary outcome was transfusion rate. Secondary outcomes included maximum postoperative decline in hemoglobin, number of blood units transfused, length of hospital stay, total drain output, cell salvage volume, and operating room time. Results. Transfusion rates decreased from 24.1% in the no-OTA group to 13.6% in the single-dose OTA group (p<0.001) and 11.1% in the two-dose OTA group (p<0.001), with no significant difference in transfusion rates between single- and two-dose OTA groups (p=0.357). Operating room time was reduced from 154 minutes in the no-OTA group to 144 minutes in the one-dose OTA group and 144 minutes in the two-dose OTA group (p<0.01). Additionally, maximum postoperative decline in hemoglobin was reduced from 4.3 g/dL in the no-OTA group to 3.5 g/dL in the single-dose OTA group (p<0.01) and 3.4 g/dL in the two-dose OTA group (p<0.01), without a significant difference between the single- and two-dose regimens (p=0.233). Conclusions. OTA reduces transfusions and operating room time, with the potential advantages of greater ease of administration and improved cost effectiveness relative to other routes of administration. Further study such as a randomized clinical trial is needed to verify the effectiveness of OTA and further optimize dosing regimens in the TKA setting. Level of Evidence. Therapeutic Level III

Anterior supine intermuscular total hip arthroplasty (ASI-THA) has emerged as a muscle sparing, less-invasive procedure. The anterior interval is both intermuscular and internervous, providing the advantages of little or no muscle dissection, and a true minimally invasive alternative. It is versatile, with reported use expanding beyond the primary realm to revision and resurfacing THA as well as treatment of acute fracture in elderly patients, who due to their diminished regenerative capacity may benefit more from the muscle-sparing nature of the anterior approach. The ASI approach involves the use of a standard radiolucent operative table with the table extender at the foot of the bed and the patient supine. Fluoroscopy is used in every case. A table-mounted femur elevator is utilised to facilitate femoral preparation. A retrospective review identified 824 patients undergoing 934 consecutive primary ASI-THA performed between January 2007 and December 2010. Age averaged 63.2 years (27‐92), BMI averaged 29.9 kg/m2 (16.9–59.2). Gender was 49% males and 51% females. Stem types were short in 82% and standard length in 18%. Follow-up averaged 23.1 months (1‐73). Operative time averaged 63.1 minutes (29‐143). Blood loss averaged 145.3 mL (25‐1000). Transfusion rate was 3.3% (30 of 914) in single procedures and 80% (8 of 10) in simultaneous bilateral procedures. Length of stay averaged 1.7 days (1‐12). Intraoperatively there were 3 calcar cracks and 1 canal perforation treated with cerclage cables. There were 6 wound complications requiring debridement. Four hips had significant lateral femoral cutaneous nerve parathesias not resolved at 12 months. One femoral nerve palsy occurred. At up to 73 months follow-up there have been 21 revisions (2.2%): 2 infection, 1 malpositioned cup corrected same day, 5 metal complications, 2 dislocations, 2 loose cups with one requiring concomitant stem revision secondary to inability to disarticulate trunnion, 1 femoral subsidence and 8 periprosthetic femoral fractures. Primary THA can be safely performed utilising this muscle-sparing approach. We did not see an alarmingly high rate of complications. Instead, rapid recovery and quick return to function were observed. ASI-THA appears to be safe. The recovery advantage utilising this surgical approach is irrefutable. There are complications, most notably periprosthetic femur fracture. The rate, however, appears to be low and decreases with increased experience. There is no need for a special operative or fracture table to perform the procedure. Whether the complication rate is higher with the use of these expensive devices is unknown, but our results demonstrate a 2.2% reoperation rate with the use of the ASI approach performed on a standard OR table. Continued refinement of the technical aspects of ASI-THA may lessen the complication rate

Anterior supine intermuscular total hip arthroplasty (ASI-THA) has emerged as a muscle sparing, less-invasive procedure. The anterior interval is both intermuscular and internervous, providing the advantages of little or no muscle dissection, and a true minimally invasive alternative. It is versatile, with reported use expanding beyond the primary realm to revision and resurfacing THA as well as treatment of acute fracture in elderly patients, who due to their diminished regenerative capacity may benefit more from the muscle-sparing nature of the anterior approach. The ASI approach involves the use of a standard radiolucent operative table with the table extender at the foot of the bed and the patient supine. Fluoroscopy is used in every case. A table-mounted femur elevator is utilised to facilitate femoral preparation. A retrospective review identified 824 patients undergoing 934 consecutive primary ASI-THA performed between January 2007 and December 2010. Age averaged 63.2 years (27–92), BMI averaged 29.9 kg/m2 (16.9–59.2). Gender was 49% males and 51% females. Stem types were short in 82% and standard length in 18%. Follow-up averaged 23.1 months (1–73). Operative time averaged 63.1 minutes (29–143). Blood loss averaged 145.3 minutes (25–1000). Transfusion rate was 3.3% (30 of 914) in single procedures and 80% (8 of 10) in simultaneous bilateral procedures. Length of stay averaged 1.7 days (1–12). Intraoperatively there were 3 calcar cracks and 1 canal perforation treated with cerclage cables. There were 6 wound complications requiring debridement. Four hips had significant lateral femoral cutaneous nerve parathesias not resolved at 12 months. One femoral nerve palsy occurred. At up to 73 months follow-up there have been 21 revisions (2.2%): 2 infection, 1 malpositioned cup corrected same day, 5 metal complications, 2 dislocations, 2 loose cups with one requiring concomitant stem revision secondary to inability to disarticulate trunnion, 1 femoral subsidence and 8 periprosthetic femoral fractures. Primary THA can be safely performed utilising this muscle-sparing approach. We did not see an alarmingly high rate of complications. Instead, rapid recovery and quick return to function were observed. ASI-THA appears to be safe. The recovery advantage utilising this surgical approach is irrefutable. There are complications, most notably periprosthetic femur fracture. The rate, however, appears to be low and decreases with increased experience. There is no need for a special operative or fracture table to perform the procedure. Whether the complication rate is higher with the use of these expensive devices is unknown, but our results demonstrate a 2.2% reoperation rate with the use of the ASI approach performed on a standard OR table. Continued refinement of the technical aspects of ASI-THA may lessen the complication rate

Introduction:. Primary total knee arthroplasty (TKA) is associated with perioperative bleeding, and some patients will require allogenic blood transfusion during their inpatient admission. While blood safety has improved in the last several decades, blood transfusion still carries significant complications and costs. Transfusion indications and alternative methods of blood conservation are being explored. However, there is limited nationally representative data on allogenic blood product utilization among TKA patients, and its associated outcomes and financial burden. The purpose of this study was to use a national administrative database to investigate the trends in utilization and outcomes (i.e. in-hospital mortality, length of stay, admission costs, acute complications) of allogenic blood transfusion in primary TKA patients. Methods:. The Nationwide Inpatient Sample (NIS), the largest all-payer inpatient care database representing a 20% stratified sample of United States hospitals, was utilized. Primary TKA (ICD-9-CM 81.54) cases from 2000 to 2009 were retrospectively queried (n = 4,544,999; weighted national frequency). A total of 67,841 admissions were excluded (Figure 1). The remaining 4,477,158 cases were separated into two study cohorts: (1) patients transfused with allogenic blood products (red blood cells, platelets, serum) (n = 540,270) and (2) patients not transfused (n = 3,936,888). Multivariable regression and generalized estimating equations were used to examine the effect of transfusion on outcomes, adjusting for patient/hospital characteristics and comorbidity. Results:. During the study period, the overall allogenic blood transfusion rate in primary TKA patients was 12.1%. The rate increased ∼5% from 2000 to 2009, and stayed constant around 13% from 2006 to 2009. Transfusion rates were higher in older patients (80–89 yrs, 21.4%; ≥ 90 yrs, 30.7%), blacks (19.6%), females (14.0%), Medicare patients (14.6%), and Medicaid patients (14.4%). Transfused TKA patients had a greater percent of comorbidities than their non-transfused peers. The largest differences in comorbidity prevalence among transfused and non-transfused patients were: deficiency anemia (27.5% vs. 10.1%), renal failure (4.0% vs. 1.4%), chronic blood loss (3.7% vs. 1.4%), and coagulopathy (3.1% vs. 1.0%) (p < 0.001). Unadjusted trends show that from 2000 to 2009, in-hospital mortality rate decreased (Figure 2A), mean length of stay decreased (Figure 2B), and mean admission cost increased (Figure 2C) for both transfused and non-transfused patients following TKA. Adjusting for patient and hospital characteristics, transfused patients had a 22% (95% CI, 4%–43%) greater likelihood of in-hospital mortality (p = 0.013), 0.68 ± 0.02 days longer length of stay (p < 0.001), and $2,237 ± 76 increased admission costs (p < 0.001). Additionally, patients who received a transfusion had a greater adjusted risk of a postoperative infection (odds ratio, 2.35), pulmonary insufficiency (odds ratio, 1.60), and other complications (p < 0.001) (Figure 3). Conclusions:. The allogenic blood transfusion rate increased between 2000 and 2009 in the United States. Transfusion has a considerable burden on patients and healthcare institutions, increasing in-hospital mortality, length of stay, admission costs, and acute complications. Preoperative optimization strategies, transfusion criteria, and hemostatic agents for at-risk patients need to be further researched as possible ways to reduce transfusion occurrence and its effects