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

Blood loss following total hip replacement is a major contributor to increase morbidity and length of stay. Various techniques have been described to reduce its occurrence. We now follow a set protocol, combining rivaroxaban for thrombo-prophylaxis and tranexamic acid to reduce immediate postoperative bleeding.

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

Background. Tranexamic acid is an antifibrinolytic drug that has been shown to successfully reduce postoperative blood loss in total knee and hip arthroplasty. However, the efficacy of TXA following total shoulder arthroplasty has not been reported. Purpose. The purpose of the present study was to evaluate the impact of intravenous TXA on postoperative blood loss and transfusion rates in total shoulder reconstruction. Methods. Between July and December 2014, 50 patients scheduled for primary total shoulder arthroplasty of the shoulder were included in this blinded, randomized study. Patients received either 1000mg intravenous TXA within thirty minutes before skin incision and another 1000mg intravenously administered TXA during wound closure (group 1), or a placebo (group 2). The perioperative blood loss and the rate of blood transfusions were analyzed. Results. Early postoperative blood loss was 80.0±105.5ml in the TXA group (group 1), and 202.1±195.8ml in the placebo group (group 2). The administration of blood products was not necessary during the study period. Conclusion. The administration of intravenous tranexamic acid significantly reduced the postoperative blood loss following total shoulder arthroplasty

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.

A prospective, randomized, double-blind study was done on 50 patients undergoing primary cementless total hip arthroplasty to determine the effect of tranexamic acid on intra- and postoperative blood losses and on the transfusions requirements. 50 patients were randomized to tranexamic acid (15 mg/kg) given as a bolus intravenous injection or placebo (normal saline) given intravenously, 15 minutes before the incision. The intraoperative and postoperative blood loss (at removal of the drain 24 hours after the operation) and the number of blood transfusions required were recorded. The patients were screened for deep venous thrombosis with bilateral compression Ultrasonography using Colour Doppler imaging on the tenth postoperative day. The Hemoglobin level was measured preoperatively and on the 3rd postoperative day. The D-dimer levels were measured preoperatively and 24 hrs postoperatively. Patients receiving tranexamic acid had a mean intraoperative blood loss of 410 ml (range, 300–510 ml) versus 615 ml (range, 515–750ml) (p value<0.05) in patients receiving placebo, a postoperative blood loss of 210 ml(range, 150–325ml) versus 490 ml(range, 370–540ml) (p value<0.05), and a total need for 8 blood transfusions versus 30. Only 6 out 25 patients in tranexamic acid group required blood transfusion whereas 18 out of 25 patients in the placebo group required transfusion. In the group receiving placebo the mean fall in hemoglobin was 2.9g/dl (range, 2.5–3.2) and in the group treated with tranexamic acid 1.6 g/dl (1.3–2) (p<0.05). At 24 hrs postoperatively, mean plasma D-dimer concentration in the Tranexamic group was half of that in the control group. No patient in either group had any evidence of deep vein thrombosis on bilateral compression Ultrasonography using Colour Doppler imaging done on the tenth postoperative day. Tranexamic acid 15 mg/kg given as a single preoperative bolus dose reduces peroperative and postoperative and total blood loss, and transfusion requirements in primary cementless total hip replacement surgery without any increased risk of thrombus formation

A prospective, randomized, double-blind study was done on 50 patients undergoing primary cementless total hip arthroplasty to determine the effect of tranexamic acid on intra- and postoperative blood losses and on the transfusions requirements. 50 patients were randomized to tranexamic acid (15 mg/kg) given as a bolus intravenous injection or placebo (normal saline) given intravenously, 15 minutes before the incision. The intraoperative and postoperative blood loss (at removal of the drain 24 hours after the operation) and the number of blood transfusions required were recorded. The patients were screened for deep venous thrombosis with bilateral compression Ultrasonography using Colour Doppler imaging on the tenth postoperative day. The Haemoglobin level was measured preoperatively and on the 3rd postoperative day. The D-dimer levels were measured preoperatively and 24 hrs postoperatively. Patients receiving tranexamic acid had a mean intraoperative blood loss of 410 ml (range, 300-510 ml) versus 615 ml (range, 515-750ml) (p value<0.05) in patients receiving placebo, a postoperative blood loss of 210 ml(range, 150-325ml) versus 490 ml(range,370-540ml) (p value<0.05), and a total need for 8 blood transfusions versus 30. Only 6 out 25 patients in tranexamic acid group required blood transfusion whereas 18 out of 25 patients in the placebo group required transfusion. In the group receiving placebo the mean fall in haemoglobin was 2.9g/dl (range, 2.5-3.2) and in the group treated with tranexamic acid 1.6 g/dl (1.3-2) (p<0.05). At 24 hrs postoperatively, mean plasma D-dimer concentration in the Tranexamic group was half of that in the control group. No patient in either group had any evidence of deep vein thrombosis on bilateral compression Ultrasonography using Colour Doppler imaging done on the tenth postoperative day. Tranexamic acid 15 mg/kg given as a single preoperative bolus dose reduces peroperative and postoperative and total blood loss, and transfusion requirements in primary cementless total hip replacement surgery without any increased risk of thrombus formation

Purpose. This meta-analysis was designed to evaluate the effects of computer navigation on blood conservation after total knee arthroplasty (TKA) by comparing postoperative blood loss and need for allogenic blood transfusion in patients undergoing computer navigation and conventional primary TKAs. Methods. Studies were included in this meta-analysis if they compared change in haemoglobin concentration before and after surgery, postoperative blood loss via drainage or calculated total blood loss, and/or allogenic blood transfusion rate following TKA using computer navigation and conventional methods. For all comparisons, odds ratios and 95 % confidence intervals (CI) were calculated for binary outcomes, while mean difference and 95 % CI were calculated for continuous outcomes. Results. Twelve studies were included in this meta-analysis. The change in haemoglobin concentration was 0.39 g/dl lower with computer navigation than with conventional TKA (P = 0.006). Blood loss via drainage was 83.1 ml (P = 0.03) lower and calculated blood loss was 185.4 ml (P = 0.002) lower with computer navigation than with conventional TKA. However, the need for blood transfusion was similar for the two approaches (n.s.). Conclusions. The primary TKA with computer navigation was effective in reducing haemoglobin loss and blood loss, but had no effect on transfusion requirement, compared with conventional primary TKA. These findings suggest the importance of analysing several blood loss parameters, because each may not always accurately reflect true postsurgical bleeding

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

Tranexamic acid (TXA) has been shown to reduce post-operative blood loss, but the dosage and method of administration remains controversial. The purpose of our study was to study the effectiveness of topical TXA in a cohort of patients (n=224) undergoing TKA by a single surgeon. Two groups of patients who received topical TXA were compared to patients who did not receive TXA. Patients that received topical TXA had the least early postoperative blood loss, with patients that received topical TXA with a tourniquet and a drain having the least. Patients receiving TXA required fewer transfusions than patients who did not receive TXA and there was no difference in the rate of symptomatic DVT/PE. Our results support the use of topical TXA during 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

Background:. Blood loss, pain and wound healing contribute significantly to the perioperative morbidity after total knee arthroplasty. Prospective randomized controlled studies are lacking, to our knowledge. The purpose of this study was to determine whether platelet rich plasma (PRP) might prevent blood loss and postoperative pain and expedite wound healing following TKA. Methods:. Forty consecutive age, sex and BMI-matched patients who had unilateral or bilateral arthritis of the knee with similar deformity and preoperative range of motion were enrolled for this prospective randomized controlled double blinded clinical trial. Preoperative haemoglobin, range of motion, WOMAC and KSS scores were noted. Platelet-rich plasma was applied over the wound including the capsule, medial and lateral recesses in seventeen patients. Twentythree served as controls. Postoperative haemoglobin, blood loss, blood transfusion, VAS score, Wound score, KSS and WOMAC score were recorded and evaluated. Results:. Autologous platelet gel (APG) group had a smaller decrease in haemoglobin (Preop Hb–POD3 Hb) compared to control (1.97/3.56; p = 0.00). Postoperative blood loss was 173.2 ml vs 220.4 ml (p = 0.02). Blood transfusion was significantly less in the APG group (0.59 units/1.43 units; p = 0.001). APG group experienced less pain immediately, at 6 weeks and 12 weeks postoperatively (VAS 6.5/7.39, 2.67/3.84, 1.61/2.31; p = 0.00, 0.00, 0.00) and required fewer narcotics than control (15.24/22.65; p = 0.00). There was statistically significant difference in ROM at 5. th. day, 6 weeks and 3 months (79.44°/74.22°, 96.11°/87°, 97.6°/93.9° respectively; p = 0.00, 0.00, 0.01). There was no significant difference in the wound scores of two groups (30.96/34.23; p = 0.311). Significant difference was observed in KSS and WOMAC scores at 6 weeks (158.96/148.77, 17.3/23; p = 0.00, 0.00) and 12 weeks (166.96/161.42, 10.86/14.61; p = 0.00, 0.00). However no significant difference was found at 6 months. Conclusions:. We found significant reduction in blood loss, postoperative pain and need for narcotics after the use of autologous platelet gel in patients of total knee arthroplasty. Quicker and better functional outcome was observed in the APG group. However, at six months and later follow up, both groups had similar functional scores. Its role on wound healing was statistically insignificant. Level of Evidence: Therapeutic Level II

Perioperative blood conservation remains an important topic today in order to reduce complications, improve function, and facilitate recovery after a total knee replacement (TKR). Studies have shown that the degree of postoperative anemia is related to an increase in complications. A greater blood loss and need for transfusion is associated with a higher risk of infection, a slower recovery process, increased morbidity to patients, as well as an increased cost to the health care system. Typical blood loss estimates range from 800cc to over 1700cc, when accounting not only for intraoperative but postoperative blood loss. Several strategies have been developed to help mitigate the risk of perioperative blood loss and need for subsequent transfusion. Firstly, preoperative measures such as vitamin and mineral supplementation can ensure the starting hemoglobin and red cell count are maximised. Additionally, erythropoietin can be helpful in refractory cases of preoperative anemia. Preoperative autologous blood donation was used extensively in the past, but has fallen out of favor due to its inefficiency and cost. Intraoperatively, measures such as the use of a tourniquet, meticulous technique, and expeditious surgery can help reduce blood loss. The most effective method, however, has been the use of tranexamic acid (TXA). TXA, an antifibrinolytic compound, has been extremely effective at reducing perioperative blood loss without increasing the risk of thromboembolic events. TXA can be used topically or intravenously. Other methods that can reduce intraoperative blood loss include the use of fibrin sealants, applied to the soft tissues and bony surfaces around the knee. Postoperatively, the avoidance of wound drains is associated with a higher blood count and reduced transfusion risk. Alternatively, drainage reinfusion systems can be used to raise the postoperative blood count, particularly in cases of bilateral TKR

Purpose. Topical application of tranexamic acid (TXA) to bleeding wound surfaces reduces blood loss in patients undergoing some major surgeries, without systemic complications. The objective of this study was to determine if TXA applied topically reduced postoperative bleeding and transfusion rates after primary total hip arthroplasty (THA) and primary bipolar hemiarthroplasty (BA). Methods. We retrospectively compared 77 patients undergoing hip arthroplasty surgery in which tranexamic acid was routinely used, to a group of 70 patients from a similar time frame prior to the introduction of tranexamic acid use. In the former group 40 patients had THA and 37 patients BA; in the latter group 35 patients underwent THA and 35 patients BA. In both THA and BA, the joint was bathed in TXA solution (at a concentration of 3.0 g TXA per 100 mL saline) at three points during the procedure. The primary outcome was blood loss calculated from the difference between the preoperative hemoglobin level and the corresponding lowest postoperative value or hemoglobin level prior to transfusion. Results. Postoperative transfusions decreased significantly with TXA, dropping from 50.0% to 27.5%, and from 63% to 48%, in the THA and BA groups, respectively. We also found significant reductions in hemoglobin loss and blood loss of 8 g/dL and 336 mL respectively for THAs and 6 g/dL and 176 mL respectively for BAs following the introduction of tranexamic acid. There was no difference in the rates of deep-vein thrombosis or pulmonary embolism between the two groups. Discussion and Conclusion. Topical application of TXA significantly reduces postoperative blood loss and transfusion risk in THA and BA, with no clinically important increase in complications being identified

Introduction. A large proportion of patients with osteoarthritis of the knee, present with bilateral symptoms at the outpatient department. A simultaneous total knee arthroplasty (TKA) procedure is available for such patients. The first operation in a simultaneous surgery may provide information to the operator to determine component size, soft tissue balancing, and estimate gap size for the second operation, while the second team usually conducts an operation in a confined space on the contralateral side during closure for the first operation, which can disturb cooperation during the second operation and may lead to more intra-operative surgical errors. We hypothesized that the circumstances of the two consecutive operations of a simultaneous bilateral TKA are different, could lead to different outcomes of overlapping bilateral TKAs. We therefore addressed the following research questions to determine whether there would be differences in short-term clinical outcomes, radiographic results, and implanted component size between the two sides. Methods. A retrospective review of 451 consecutive patients, who underwent simultaneous bilateral TKA between January 2011 and April 2012, was conducted. Bilateral TKAs were performed with the senior surgeon conducting the main procedure (from skin incision to implantation of first prosthesis until prior closure of the first knee) on the right side first and subsequently the left side with a second team. At 1 year after surgery, clinical outcome scores (the Knee Society Knee and Function scores, WOMAC score), radiologic findings were evaluated and clinical results as postoperative blood loss, operation time were compared between bilateral sides. Results. A greater incidence (16.1%) of outliers during postoperative coronal limb alignment (>±3o) were identified in the second TKA than those in the first TKA (9.0%) (p =0.003). Multivariate analysis for the association of outlier rates in the second TKA relative to the first revealed a significance for severity of the preoperative deformity (pre-op. coronal limb alignment, p = 0.002) and decreased ROM (p = 0.042) from the GEE analysis. The second knee also showed more blood loss (735 vs. 656mL), and longer operation time (61, 58 minutes respectively), as compared to the first TKA, while no significant differences in clinical outcomes. Discussion and Conclusion. There were no significant differences in the clinical outcomes even though few distinct outcomes due to different circumstances of the surgery. Awareness of these findings can help the continued success of bilateral TKA in an increasing patient population

Perioperative blood conservation remains an important topic today in order to reduce complications, improve function, and facilitate recovery after a total knee replacement (TKR). Studies have shown that the degree of postoperative anemia is related to an increase in complications. A greater blood loss and need for transfusion is associated with a higher risk of infection, a slower recovery process, increased morbidity to patients, as well as an increased cost to the healthcare system. Typical blood loss estimates range from 800cc to over 1700cc, when accounting not only for intraoperative but postoperative blood loss. Several strategies have been developed to help mitigate the risk of perioperative blood loss and need for subsequent transfusion. Firstly, preoperative measures such as vitamin and mineral supplementation can ensure the starting hemoglobin and red cell count are maximised. Additionally, erythropoietin can be helpful in refractory cases of preoperative anemia. Preoperative autologous blood donation was used extensively in the past, but has fallen out of favor due to its inefficiency and cost. Intraoperatively, measures such as the use of a tourniquet, meticulous technique, and expeditious surgery can help reduce blood loss. The most effective method, however, has been the use of tranexamic acid (TXA). TXA, an antifibrinolytic compound, has been extremely effective at reducing perioperative blood loss without increasing the risk of thromboembolic events. TXA can be used topically or intravenously. Other methods that can reduce intraoperative blood loss include the use of fibrin sealants, applied to the soft tissues and bony surfaces around the knee. Postoperatively, the avoidance of wound drains is associated with a higher blood count and reduced transfusion risk. Alternatively, drainage reinfusion systems can be used to raise the postoperative blood count, particularly in cases of bilateral TKR

We present a prospective, randomised, single-centre, multi-surgeon, controlled trial comparing minimally invasive (MIS) and standard approach total knee arthroplasty (TKA). 86 patients undergoing 92 total knee replacements were recruited. 46 operations were randomised to the MIS treatment arm, 46 to the standard control arm. Data collected included postoperative blood loss, length of stay and complications. Patients underwent surgery via a quadriceps sparing or standard medial parapatella approach. All operations were performed using MIS instruments and an identical postoperative care pathway. The MIS group had a significantly shorter length of stay (1.4 days, p=0.004) and fewer complications (p=0.003). Demographics, operative time blood loss and radiographic alignment were comparable between the groups. There were no deaths, pulmonary emboli or surgical site infections. 1 patient developed DVT and 1 required revision for pain and failure to regain flexion within 9 months of surgery, both in the control group. Nine percent of MIS patients versus 35% controls suffered a complication delaying discharge, of which 2% and 17% related to surgical site problems respectively. MIS resulted in a shorter admission and fewer complications, whilst achieving satisfactory component alignment. We discuss the potential economic implications

Total hip arthroplasty (THA) is associated with high intraoperative and postoperative blood loss. Antifibrinolytic drugs have been used to minimize the potential risks of bleeding and blood transfusion. Studies on the effect of tranexamic acid on decreasing blood loss in THA have revealed interesting results, but most have focused on cemented THA. Yet its benefits in THA, especially in cementless THA, have not been proved. We conducted a prospective double-blind randomized controlled study on 64 patients who were candidates for cementless THA under epidural anesthesia between 2006 and 2008. Patients were randomly assigned into study and control groups. Patients in both groups were well matched regarding preoperative characteristics. Five minutes preoperatively 32 patients of the study and control groups received 15 mg/kg tranexamic acid or normal saline intravenously respectively. Our findings showed a significantly smaller decrease in 6- and 24-hour postoperative hemoglobin levels, less intraoperative and postoperative bleeding, and less need for allogenic blood transfusion in the tranexamic acid group. Our results also revealed a higher mean of 6- and 24-hour hematocrit level and shorter hospital stay in the tranexamic acid group compared to the control group, which were not statistically meaningful. In our study no thromboembolic event was seen; except 1 patient in the control group. Our study showed that administering tranexamic acid before the start of cementless THA under epidural anesthesia can reduce intraoperative and postoperative bleeding as well as need for blood transfusion

The aim of tissue sparing surgery in total knee arthroplasty is to reduce surgical invasivity to the entire knee joint. Surgical invasion should not be limited only toward soft tissues but also toward bone. The classic technique for total knee arthroplasty implies intramedullary canal invasion for proper femoral component positioning. This phase is associated to fat embolism, activation of coagulation, and occult bleeding from the reamed canal. The purpose of our study was to validate a new extramedullary device which relies on templated data. Two-hundred patients in four different orthopaedics centres were randomized to undergo primary total knee arthroplasty either using standard intramedullary femoral instruments (IM group) or using a new extramedullary device (EM group). A new set of instruments was developed to control the sagittal and coranl plane of the distal femoral resection. The extramedullary instrument was calibrated referencing to templated data obtained from the preoperative long-limb radiograph (Fig 1, 2). Varus-valgus orientation of the resection were established by moving the two paddles according to templated data. An L-shaped sliding tool (5 centimetres long) over the anterior cortex controls the flexion-extension parameter of the resection and is intended to allow a cut flush with the anterior cortex at 0° of angulation with the distal aspect of the femoral diaphysis on the sagittal plane. Femoral component coronal alignment was within 0±3° of the mechanical axis in 86% of the IM group and 88% of the EM group. Sagittal alignment of the femoral component was 0±3° in 80% of the IM group and 94% of the EM group. There was no difference in the average operative time between the two groups. The EM group showed a trend toward less postoperative blood loss. Extramedullary reference with careful preoperative templating can be safely utilized during total knee arthroplasty