Combined Intra-Articular and Intravenous Tranexamic Acid Reduces Blood Loss in Total Knee Arthroplasty: A Randomized, Double-Blind, Placebo-Controlled Trial.

BACKGROUND: In total knee arthroplasty, both intravenous (IV) and intra-articular (IA) administration of tranexamic acid (TXA) have been shown to reduce blood loss in several randomized controlled trials, although routine use of systemic TXA is considerably more common. However, to our knowledge, the additional benefit of IA administration of TXA when combined with IV administration, without the use of a tourniquet, has not been previously investigated. Thus, the aim of this study was to evaluate whether combined IV and IA administration of TXA reduced total blood loss compared with IV-only administration of TXA. METHODS: In this randomized, double-blind, placebo-controlled trial, 60 patients scheduled for total knee arthroplasty were randomized to one of two interventions. The TXA IV and IA group received combined administration of TXA consisting of 1 g administered intravenously preoperatively and 3 g diluted in 100 mL of saline solution administered intra-articularly after closure of the capsule. The TXA IV and placebo group received 1 g of TXA administered intravenously only and 100 mL of saline solution administered intra-articularly. IA TXA was administrated through a needle. The primary outcome was the 24-hour calculated blood loss. Secondary outcomes were blood loss on postoperative day 2, thromboembolic complications, and transfusion rate. Blood loss was calculated by hemoglobin differences using the Gross formula. RESULTS: Data on the primary outcome were available for all 60 included patients. Baseline characteristics were comparable between the allocation groups. The mean 24-hour blood loss (and standard deviation) was 466 ± 313 mL in the TXA IV and IA group compared with 743 ± 358 mL in the TXA IV and placebo group; treatment effect (difference), 277 mL (95% confidence interval [CI], 103 to 451 mL) (p = 0.002). Second-day blood loss was 644 ± 382 mL in the TXA IV and IA group compared with 1017 ± 519 mL in the TXA IV and placebo group; treatment effect, 373 mL (95% CI, 132 to 614 mL) (p = 0.003). No thromboembolic complications were observed within 90 days postoperatively. CONCLUSIONS: The combined administration of IV and IA TXA resulted in a clinically relevant reduction in blood loss of 37% compared with IV TXA alone both at 24 hours postoperatively and on postoperative day 2. No thromboembolic complications were observed. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Morbidity and mortality after bilateral simultaneous total knee arthroplasty in a fast-track setting.

Background and purpose - The safety aspects of bilateral simultaneous total knee arthroplasty (BSTKA) are still debated. In this retrospective single-center study, we investigated early morbidity and mortality following BSTKA in a modern fast-track setting. We also identified risk factors for re-admission within 90 days and for a length of stay (LOS) of more than 5 days. Patients and methods - 284 patients were selected to receive BSTKA at our institution from 2008 through 2014 in a well-described, standardized fast-track setup (Husted 2012a, b). All re-admissions within 90 days were identified and mortality rates and time until death were recorded. Transfusion rates and numbers of transfusions were also recorded. Logistic regression analysis was used to identify risk factors for re-admission within 90 days, and also for a LOS of more than 5 days. Results - 90-day mortality was 0%. 10% of the patients were re-admitted within 90 days. Median time to re-admission was 18 (3-75) days. 153 patients (54%) received postoperative blood transfusions. An ASA score of 3 was identified as an independent risk factor for re-admission within 90 days (OR = 5, 95% CI: 1.3-19) and for LOS of > 5 days (OR = 6, 95% CI: 1.6-21). Higher BMI was a weak risk factor for re-admission within 90 days. Interpretation - BSTKA in selected patients without cardiopulmonary disease in a fast-track setting appears to be safe with respect to early postoperative morbidity and mortality. Surgeons should be aware that patients with an ASA score of 3 have an increased risk of re-admission and a prolonged length of stay, while patients with higher BMI have an increased risk of re-admission following BSTKA.

Removal of restrictions following primary THA with posterolateral approach does not increase the risk of early dislocation.

BACKGROUND AND PURPOSE: Patient education and mobilization restrictions are often used in an attempt to reduce the risk of dislocation following primary THA. To date, there have been no studies investigating the safety of removal of mobilization restrictions following THA performed using a posterolateral approach. In this retrospective non-inferiority study, we investigated the rate of early dislocation following primary THA in an unselected patient cohort before and after removal of postoperative mobilization restrictions. PATIENTS AND METHODS: From the Danish National Health Registry, we identified patients with early dislocation in 2 consecutive and unselected cohorts of patients who received primary THA at our institution from 2004 through 2008 (n = 946) and from 2010 through 2014 (n = 1,329). Patients in the first cohort were mobilized with functional restrictions following primary THA whereas patients in the second cohort were allowed unrestricted mobilization. Risk of early dislocation (within 90 days) was compared in the 2 groups and odds ratio (OR)-adjusted for possible confounders-was calculated. Reasons for early dislocation in the 2 groups were identified. RESULTS: When we adjusted for potential confounders, we found no increased risk of early dislocation within 90 days in patients who were mobilized without restrictions. Risk of dislocation within 90 days was lower (3.4% vs 2.8%), risk of dislocation within 30 days was lower (2.1% vs 2.0%), and risk of multiple dislocations (1.8% vs 1.1%) was lower in patients who were mobilized without restrictions, but not statistically significantly so. Increasing age was an independent risk factor for dislocation. INTERPRETATION: Removal of mobilization restrictions from the mobilization protocol following primary THA performed with a posterolateral approach did not lead to an increased risk of dislocation within 90 days.

Indications for knee arthroplasty have remained consistent over time.

INTRODUCTION: Between 2004 and 2009, the incidence of primary total knee arthroplasty (TKA) in Denmark has almost doubled. It has been speculated that this increase may be a result of patients being operated on weaker indications. The purpose of this study was to compare preoperative degrees of osteoarthritis and health-related quality of life (QoL) in patients receiving primary TKA in 2004 and 2009. MATERIAL AND METHODS: We identified 154 and 369 primary TKAs inserted at our institution in 2004 and 2009, respectively. Patients had been invited to complete the Short Form (SF)-36 questionnaire preoperatively. Two groups of patients that were representative with regard to age and gender were randomly sampled and compared (n = 44 in 2004 versus n = 106 in 2009). The Kellgren-Lawrence (K-L) grade of osteoarthritis was assessed on preoperative radiographs in all patients. RESULTS: We found no statistically significant differences in gender distribution or mean age at surgery. We reached K-L grades of 3-4 in 52.4% and 49.6% in 2004 and 2009, respectively (p = 0.57). The preoperative mean SF-36 physical component scores were 32.6 and 33.7, respectively (p = 0.44). The preoperative mean SF-36 mental component scores were 43.0 in 2004 and 49.3 (i.e. 6.3 points higher) in 2009 (p = 0.003). CONCLUSION: Preoperative degrees of osteoarthritis and physical health-related QoL did not change from 2004 to 2009. Thus, it seems that these components of operative indications have not weakened. The increased preoperative SF-36 mental component score of these patients may have had a positive effect on postoperative outcomes. FUNDING: not relevant. TRIAL REGISTRATION: not relevant. TRIAL REGISTRATION: not relevant.

Bilateral simultaneous total hip arthroplasty in a fast track setting.

Simultaneous bilateral hip arthroplasty has been reported to have varying results in the literature when performed using conventional postoperative care. Unilateral hip and knee arthroplasty as well as bilateral simultaneous knee arthroplasty may be associated with reduced length of stay and low complication rates when performed in a fast-track setting. We believed it would be useful to assess hip arthroplasty in this context, and we report 50 consecutive fast-track simultaneous bilateral hip arthroplasty procedures. The median length of stay was 4 days. Mortality within 90 days was 4% and 8% required a further operative procedure. The overall complication rate was 22%. 55% of the complications were considered to be caused by failures in surgical technique and 45% by other factors. Bilateral simultaneous hip arthroplasty may have a high complication rate in a fast-track setting and further evaluation may be warranted.

Low risk of thromboembolic complications after fast-track hip and knee arthroplasty.

BACKGROUND AND PURPOSE: Pharmacological prophylaxis can reduce the risk of deep venous thrombosis (DVT), pulmonary embolism (PE), and death, and it is recommended 10­35 days after total hip arthroplasty (THA) and at least 10 days after total knee arthroplasty (TKA). However, early mobilization might also reduce the risk of DVT and thereby the need for prolonged prophylaxis, but this has not been considered in the previous literature. Here we report our results with short-duration pharmacological prophylaxis combined with early mobilization and reduced hospitalization. PATIENTS AND METHODS: 1,977 consecutive, unselected patients were operated with primary THA, TKA, or bilateral simultaneous TKA (BSTKA) in a well-described standardized fast-track set-up from 2004­2008. Patients received DVT prophylaxis with low-molecular-weight heparin starting 6­8 h after surgery until discharge. All re-admissions and deaths within 30 and 90 days were analyzed using the national health register, concentrating especially on clinical DVT (confirmed by ultrasound and elevated D-dimer), PE, or sudden death. Numbers were correlated to days of prophylaxis (LOS). RESULTS: The mean LOS decreased from 7.3 days in 2004 to 3.1 days in 2008. 3 deaths (0.15%) were associated with clotting episodes and overall, 11 clinical DVTs (0.56%) and 6 PEs (0.30%) were found. The vast majority of events took place within 30 days; only 1 death and 2 DVTs occurred between 30 and 90 days. During the last 2 years (854 patients), when patients were mobilized within 4 h postoperatively and the duration of DVT prophylaxis was shortest (1­4 days), the mortality was 0% (95% CI: 0­0.5). Incident cases of DVT in TKA was 0.60% (CI: 0.2­2.2), in THA it was 0.51% (CI: 0.1­1.8), and in BSTKA it was 0% (CI: 0­2.9). Incident cases of PE in TKA was 0.30% (CI: 0.1­1.7), in THA it was 0% (CI: 0­1.0), and in BSTKA it was 0% (CI: 0­2.9). INTERPRETATION: The risk of clinical DVT, and of fatal and non-fatal PE after THA and TKA following a fast-track set-up with early mobilization, short hospitalization, and short duration of DVT prophylaxis compares favorably with published regimens with extended prophylaxis (up to 36 days) and hospitalization up to 11 days. This calls for a reconsideration of optimal duration of chemical thromboprophylaxis.

Readmissions after fast-track hip and knee arthroplasty.

INTRODUCTION: With the implementation of fast-track surgery with optimization of both logistical and clinical features, the postoperative convalescence has been reduced as functional milestones have been achieved earlier and consequently length of stay (LOS) in hospital has been reduced. However, it has been speculated that a decrease in LOS may be associated with an increase in readmissions in general, including risk of dislocation after total hip arthroplasty (THA) or manipulation after total knee arthroplasty (TKA). MATERIALS AND METHODS: 1,731 consecutive, unselected patients were operated with primary THA or TKA in a well-described standardized fast-track setup from 2004 to 2008. All readmissions and deaths within 90 days were analyzed using the national health register. RESULTS: Mean LOS decreased from 6.3 to 3.1 days. Within 90 days, 15.6% of patients following TKA were readmitted as opposed to 10.9% after THA (p = 0.005). Three deaths (0.17%) were associated with clotting episodes. Suspicion of DVT (not found) and suspicion of infection made up half of the readmissions. Readmissions in general and for thromboembolic events, dislocations and manipulations in specific did not increase with decreasing LOS. There was no difference between readmission rates per year for either TKA or THA but there was a significantly reduced risk of dislocation found with decreasing LOS comparing each year from 2005 to 2007 with the index year of 2004 (with the longest LOS and the highest incidence of dislocation). CONCLUSION: Fast-track TKA and THA do not increase the readmission rate. Readmissions are more frequent after TKA than THA, but dislocation after THA and manipulation after TKA do not increase as LOS is decreasing.