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). Patients and Methods. In this randomized controlled trial, 200 patients were randomized
to receive a single dose of 2.0 g of TXA orally two hours preoperatively
(group A), a single dose of TXA followed by 1.0 g orally three hours
postoperatively (group B), a single dose of TXA followed by 1.0 g
three and nine hours postoperatively (group C), or a single dose
of TXA followed by 1.0 g orally three, nine, and 15 hours postoperatively
(group D). All patients followed a routine enhanced-recovery protocol.
The primary outcome measure was the
Tranexamic acid (TEA), an inhibitor of fibrinolysis,
reduces blood loss after routine total knee replacement (TKR). However,
controversy persists regarding the dosage and timing of administration
of this drug during surgery. We performed a prospective randomised
controlled study to examine the optimum blood-saving effect of TEA
in minimally invasive TKR. We randomly assigned 151 patients who underwent unilateral minimally
invasive TKR to three groups: 1) a placebo group (50 patients);
2) a one-dose TEA group (52 patients), who received one injection
of TEA (10 mg/kg) intra-operatively on deflation of the tourniquet;
and 3) a two-dose TEA group (49 patients), who received two injections
of TEA (10 mg/kg) given pre-operatively and intra-operatively. Total
blood loss was calculated from the maximum loss of haemoglobin.
All patients were followed clinically for the presence of venous
thromboembolism (VTE). The mean
We prospectively randomised 100 patients undergoing cemented total knee replacement to receive either a single deep closed-suction drain or no drain. The
We performed a randomised, controlled trial involving 150 patients with a pre-operative level of haemoglobin of 13.0 g/dl or less, to compare the effect of either topical fibrin spray or intravenous tranexamic acid on blood loss after total knee replacement. A total of 50 patients in the topical fibrin spray group had 10 ml of the reconstituted product applied intra-operatively to the operation site. The 50 patients in the tranexamic acid group received 500 mg of tranexamic acid intravenously five minutes before deflation of the tourniquet and a repeat dose three hours later, and a control group of 50 patients received no pharmacological intervention. There was a significant reduction in the
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. We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled trials, and trial registries up to 26 March 2020. We included randomized controlled trials (RCTs), comparing TKA with a tourniquet versus without a tourniquet. Outcomes included: pain, function, serious adverse events (SAEs), blood loss, implant stability, duration of surgery, and length of hospital stay.Aims
Methods
Aims. The aims of this study were to compare the efficacy and safety
of intra-articular and intravenous (IV) tranexamic acid (TXA) in
controlling perioperative
The aim of this study was to evaluate the effects of using a
portable, accelerometer-based surgical navigation system (KneeAlign2)
in total knee arthroplasty (TKA) on the alignment of the femoral
component, and blood loss. A total of 241 consecutive patients with primary osteoarthritis
of the knee were enrolled in this prospective, randomised controlled
study. There were 207 women and 34 men. The mean age of the patients
was 74.0 years (57 to 89). The KneeAlign2 system was used for distal
femoral resection in 121 patients (KA2 group) and a conventional intramedullary
femoral guide was used in 120 patients (IM group).Aims
Patients and Methods
Blood loss during total knee replacement (TKR)
remains a significant concern. In this study, 114 patients underwent TKR,
and were divided into two groups based on whether they received
a new generation fibrin sealant intra-operatively, or a local infiltration
containing adrenaline. Groups were then compared for mean calculated
total blood volume (TBV) loss, transfusion rates, and knee range
of movement. Mean TBV loss was similar between groups: fibrin sealant
mean was 705 ml (281 to 1744), local adrenaline mean was 712 ml
(261 to 2308) (p = 0.929). Overall, significantly fewer units of
blood were transfused in the fibrin sealant group (seven units)
compared with the local adrenaline group (15 units) (p = 0.0479).
Per patient transfused, significantly fewer units of blood were transfused
in the fibrin sealant group (1.0 units) compared with the local
adrenaline group (1.67 units) (p = 0.027), suggesting that the fibrin
sealant may reduce the need for multiple unit transfusions. Knee
range of movement was similar between groups. From our results,
it appears that application of this newer fibrin sealant results
in blood loss and transfusion rates that are low and similar to
previously applied fibrin sealants. Cite this article:
In an initial randomised controlled trial (RCT)
we segregated 180 patients to one of two knee positions following total
knee replacement (TKR): six hours of knee flexion using either a
jig or knee extension. Outcome measures included post-operative
blood loss, fall in haemoglobin, blood transfusion requirements,
knee range of movement, limb swelling and functional scores. A second
RCT consisted of 420 TKR patients randomised to one of three post-operative
knee positions: flexion for three or six hours post-operatively,
or knee extension. Positioning of the knee in flexion for six hours immediately
after surgery significantly reduced blood loss (p = 0.002). There
were no significant differences in post-operative range of movement,
swelling, pain or outcome scores between the various knee positions
in either study. Post-operative knee flexion may offer a simple
and cost-effective way to reduce blood loss and transfusion requirements
following TKR. We also report a cautionary note regarding the potential risks
of prolonged knee flexion for more than six hours observed during
clinical practice in the intervening period between the two trials,
with 14 of 289 patients (4.7%) reporting lower limb sensory neuropathy
at their three-month review. Cite this article:
Total knee replacement (TKR) is an operation
that can be performed with or without the use of a tourniquet. Meta-analyses
of the available Level-1 studies have demonstrated that the use
of a tourniquet leads to a significant reduction in blood loss.
The opponents for use of a tourniquet cite development of complications
such as skin bruising, neurovascular injury, and metabolic disturbance
as drawbacks. Although there may certainly be reason for concern
in arteriopathic patients, there is little evidence that routine
use of a tourniquet during TKR results in any of the above complications.
The use of a tourniquet, on the other hand, provides a bloodless
field that allows the surgeon to perform the procedure with expediency
and optimal visualisation. Blood conservation has gained great importance
in recent years due to increased understanding of the problems associated
with blood transfusion, such as increased surgical site infection
(due to immunomodulation effect), increased length of hospital stay
and increased cost. Based on the authors’ understanding of the available
evidence, the routine use of a tourniquet during TKR is justified
as good surgical practice. Cite this article:
We prospectively randomised 78 patients into two groups, ‘drains’ or ‘no drains’ to assess the effectiveness of suction drains in reducing haematoma and effusion in the joint and its effect on wound healing after total knee replacement. Ultrasound was used to measure the formation of haematoma and effusion on the fourth post-operative day. This was a semi-quantitative assessment of volume estimation. There was no difference in the mean effusion between the groups (5.91 mm in the drain group versus 6.08 mm in the no-drain, p = 0.82). The mean amount of haematoma in the no-drain group was greater (11.07 mm versus 8.41 mm, p = 0.03). However, this was not clinically significant judged by the lack of difference in the mean reduction in the post-operative haemoglobin between the groups (drain group 3.4 g/dl; no-drain group 3.0 g/dl, p = 0.38). There were no cases of wound infection or problems with wound healing at six weeks in any patient. Our findings indicate that drains do not reduce joint effusion but do reduce haematoma formation. They have no effect on wound healing.
This prospective study compares the outcome of
157 hydroxyapatite (HA)-coated tibial components with 164 cemented
components in the ROCC Rotating Platform total knee replacement
in 291 patients. The mean follow-up was 7.6 years (5.2 to 11). There
were two revisions for loosening: one for an HA-coated and one for
a cemented tibial component. Radiological evaluation demonstrated
no radiolucent lines with the HA-coated femoral components. A total
of three HA-coated tibial components exhibited radiolucent lines
at three months post-operatively and these disappeared after three
further months of protected weight-bearing. With HA-coated components
the operating time was shorter (p <
0.006) and the radiological
assessment of the tibial interface was more stable (p <
0.01).
Using revision for aseptic loosening of the tibial component as
the end point, the survival rates at nine years was identical for
both groups at 99.1%. Our results suggest that HA-coated components perform at least
as well as the same design with cemented components and compare
favourably with those of series describing cemented or porous-coated
knee replacements, suggesting that fixation of both components with
hydroxyapatite is a reliable option in primary total knee replacement.
We conducted a retrospective study to investigate the effect of femoral bowing on the placement of components in total knee replacement (TKR), with regard to its effect on reestablishing the correct mechanical axis, as we hypothesised that computer-assisted total knee replacement (CAS-TKR) would produce more accurate alignment than conventional TKR. Between January 2006 and December 2009, 212 patients (306 knees) underwent TKR. The conventional TKR was compared with CAS-TKR for accuracy of placement of the components and post-operative alignment, as determined by five radiological measurements. There were significant differences in the reconstructed mechanical axes between the bowed and the non-bowed group after conventional TKR (176.2° ( For patients with significant femoral bowing, the reconstructed mechanical axes were significantly closer to normal in the CAS group than in the conventional group (179.2° (
We carried out a prospective randomised study to evaluate the blood loss in 60 patients having a total knee arthroplasty and divided randomly into two equal groups, one having a computer-assisted procedure and the other a standard operation. The surgery was carried out by a single surgeon at one institution using a uniform approach. The only variable in the groups was the use of intramedullary femoral and tibial alignment jigs in the standard group and single tracker pins of the imageless navigation system in the tibia and femur in the navigated group. The mean drainage of blood was 1351 ml (715 to 2890; 95% confidence interval (CI) 1183 to 1518) in the computer-aided group and 1747 ml (1100 to 3030; CI 1581 to 1912) in the conventional group. This difference was statistically significant (p = 0.001). The mean calculated loss of haemoglobin was 36 g/dl in the navigated group There was a highly significant reduction in blood drainage and the calculated Hb loss between the computer-assisted and the conventional techniques. This allows the ordering of less blood before the operation, reduces risks at transfusion and gives financial saving. Computer-assisted surgery may also be useful for patients in whom blood products are not acceptable.
We wished to determine whether simultaneous bilateral sequential total knee replacement (TKR) carried increased rates of mortality and complications compared with unilateral TKR in low- and high-risk patients. Our study included 2385 patients who had undergone bilateral sequential TKR under one anaesthetic and 719 who had unilateral TKR. There were no significant pre-operative differences between the groups in terms of age, gender, height, weight, body mass index, diagnosis, comorbidity and duration of follow-up, which was a mean of 10.2 years (5 to 14) in the bilateral and 10.4 years (5 to 14) in the unilateral group. The peri-operative mortality rate (eight patients, 0.3%) of patients who had bilateral sequential TKR was similar to that (five patients, 0.7%) of those undergoing unilateral TKR. In bilateral cases the peri-operative mortality rate (three patients, 0.4%) of patients at high risk was similar to that (five patients, 0.3%) of patients at low risk as it was also in unilateral cases (two patients, 1.0% vs three patients, 0.6%). There was no significant difference (p = 0.735) in either the overall number of major complications between bilateral and unilateral cases or between low- (p = 0.57) and high-risk (p = 0.61) patients. Also, the overall number of minor complications was not significantly different between the bilateral and unilateral group (p = 0.143). Simultaneous bilateral sequential TKR can be offered to patients at low and high risk and has an expected rate of complications similar to that of unilateral TKR.