Reducing transfusion in hip arthroplasty: tranexemic acid diminishes influence of anesthesia administered.

BACKGROUND: The risk of transfusion following total hip arthroplasty (THA) continues to be problematic. The best choice of anesthesia (spinal vs general) and impact of tranexamic acid (TXA) use in reducing transfusions following surgery remain unclear. Therefore, the purpose of this study was to compare rates of blood transfusion following THA via the anterior approach using three different anesthesia protocols with and without TXA. MATERIALS AND METHODS: This retrospective review included 1399 patients (1659 hips), receiving spinal anesthesia (SA) without (248 patients) and with TXA (77 patients), general anesthesia (GA) without (151 patients) and with TXA (171) and general anesthesia with paravertebral block (GA-PVB) and TXA (748 patients). All procedures were performed by a single surgeon. Chi-Squared tests and logistic regression were performed to evaluate the rate and risks of transfusion between groups. RESULTS: Without TXA, transfusion rate with GA (24.5%) was higher than SA (13.4%) (p = 0.004). With TXA, there was no difference in transfusion rates between GA (4.6%), SA (3.9%) or GA-PVB (4.0%). The multivariable regression revealed bilateral (Odds Ratio (OR): 6.473; p < 0.001), female (OR: 2.046; p = 0.004), age (OR: 1.028; p = 0.012) and pre-operative anemia (OR: 2.604; p < 0.001) as increasing the risk of transfusion while use of TXA (OR: 0.168; p < 0.001) significantly reduced transfusion risk. CONCLUSION: The use of TXA during THA via the anterior approach removed the influence of anesthesia type regarding risk of transfusion. The use of TXA may reverse presumed disadvantages of GA alone, potentially facilitating rapid discharge following surgery.

Does femoral stem choice influence fracture type or incidence for direct anterior approach total hip arthroplasty?

INTRODUCTION: Despite similar fracture rates, the incidence of intraoperative and post-operative fractures between standard (ST) length and short (SH) femoral stems remains unclear. Therefore, this study compared the incidence of intraoperative and early postoperative fractures between three ST and a single tapered-wedge SH femoral stem. MATERIALS AND METHODS: Data were retrospectively collected on 1113 patients (1306 hips) having undergone total hip arthroplasty, via the anterior approach on a fracture table, between 2014 and 2019. One surgeon completed all ST procedures (314 hips), using one of three implants without discretion. One surgeon completed all SH procedures (992 hips), using one implant design. Differences between ST and SH groups were evaluated by independent t tests (continuous variables) and Chi-square tests (categorical variables). RESULTS: Patients in the SH group were significantly older (p < 0.001) and had a lower body mass index (p = 0.001) compared to the ST group. The total number of fractures was 12 (3.8%) and 14 (1.4%) in the ST and SH groups, respectively. The 12 ST fractures occurred intraoperatively, compared to two (0.2%) in the SH group. The remaining seven (0.7%) SH fractures occurred post-operatively. There was no difference in fracture rate between the three ST designs (p = 0.882). Interestingly, five (0.5%) insufficiency fractures were diagnosed in the SH group. CONCLUSION: The risk of intraoperative and post-operative fractures following anterior total hip arthroplasty may be biased toward ST and SH implants, respectively. These results, along with the presence of five insufficient fractures, identify potential fracture risks and mechanisms for specific implant designs.

Component positioning of the first 300 mobile bearing unicompartmental knee arthroplasties.

The Oxford® Partial Knee has excellent long-term survivorship but high surgical times indicate a learn curve. This retrospective review included a radiographic evaluation of component placement of the initial 300 procedures following conversion from fixed bearing implant use. The anteroposterior and sagittal femoral angles were considered inaccurate in 1.7% and 3.9% of cases, respectively. The anteroposterior and sagittal tibial angles were considered inaccurate in 18.7% and 6.0% of cases, respectively. Overall, a learning curve appears to be present regarding the anteroposterior tibial component angle, with the greatest percentage of inaccuracies occurring within the initial 20 cases.

Day of surgery discharge success after implementation of a rapid discharge protocol following unilateral unicompartmental knee arthroplasty.

BACKGROUND: Unilateral unicompartmental knee arthroplasty (UKA) is considered an outpatient procedure, however, previous research has reported a wide success rate range for day of surgery (DOS) discharge. Previous rapid discharge protocols (RDPs) have focused on pain management and nausea control but are commonly done in outpatient facilities, limiting the generalizability to the community hospital setting. Therefore, this study compared the rate of successful DOS discharge after the implementation of a RDP compared to the previous standard discharge protocol (SDP) following unilateral UKA. METHODS: A retrospective chart review was completed for 174 unselected consecutive patients having undergone unilateral UKA between January 2016 and May 2018. The RDP was implemented in March 2017, with the addition of an arthroplasty dedicated hospitalist, a change to patient discharge expectations and a change to post-operative patient navigation. All other surgical and patient care procedures were identical for both groups. RESULTS: Evaluation included 89 patients in the SDP group and 90 patients in the RDP group. Successful DOS discharge rate increased significantly from 11.2% for the SDP group to 72.2% for the RDP group (p = 0.000). Two patients from each group were treated with antibiotics for stitch abscess and no patient sustained a major complication within 90 days. CONCLUSIONS: Small, significant changes applied in the current study resulted in a significant increase in success of DOS discharge. These procedures can be easily implemented in all settings and may be more representative of the discharge capabilities for non-selected patients seen in the community hospital setting.