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 management of distal radius fractures has evolved with the availability of locking plates to control the fracture fragments from the volar surface. This study compares volar locking plates (VLP) with any other available treatment including K-wires, screws, non-locking plates, external fixateurs or any combination of these. Patients with distal radius fractures requiring surgical intervention were invited to participate and were randomised to the VLP group or the other surgical treatment group. Outcome was assessed on radiology(radial length, angle, inclination and articular step), function (range of motion and grip strength) and the Disability of Arm Shoulder and Hand (DASH) score. The final assessment was at one year. Complications were recorded. The target was one hundred and sixty patients. Comparisons of sub groups based on fracture classification are made, including intra-articular and extra-articular fractures. By August 2008, one hundred patients will have completed their one year follow up assessment. Initial results show no significant difference between the groups. New fixation techniques for common fractures require objective assessment under normal conditions of use. This prospective study compares locked plate fixation with techniques available before its introduction. It aims to examine a range of fracture severities to determine which fracture types are appropriate for this fixation technique.
