Effect of Perioperative Tranexamic Acid on Allogeneic Blood Transfusions for Total Knee Arthroplasty Patients at a Community Hospital.

Introduction Tranexamic acid (TXA) has been shown to be a cost-effective method for reducing blood loss and postoperative transfusions in patients undergoing total knee arthroplasty (TKA) at tertiary care centers. However, the efficacy of TXA has not been studied in community hospitals, and the potential cost savings may be especially beneficial for these institutions. The purpose of this study was to assess the effectiveness of TXA in reducing postoperative transfusions and blood loss following TKA at a community hospital. Methods Institutional approval was obtained for the retrospective review of a consecutive series of patients that underwent a total knee arthroplasty procedure between January 1, 2019, and December 31, 2019. Patients undergoing bilateral TKA were excluded from the analysis, yielding a total of 190 TKA procedures of which 131 patients received TXA. Fisher's exact test was conducted to compare rates of transfusion between the groups. A difference in difference analysis was conducted to assess TXA's effect on patient hemoglobin levels (Hgb) on postoperative Days 1 and 2. All analyses were conducted using R studio (Vienna, Austria). A p-value of 0.05 was set as the threshold for statistical significance. Results There was no difference in group characteristics in terms of age (70 years vs 68 years, p=0.17; no-TXA vs TXA, respectively). Fisher's exact test revealed no difference in the rates of allogeneic transfusion between TKA patients who did not receive a TXA and TKA patients who received a TXA (3.4% vs 0.8%; p=0.228). However, our difference in differences analysis revealed that TXA patients had a mean reduction in hemoglobin (Hgb)-related blood loss of 0.876 Hgb/dl (95% CI: 0.56 to 1.19; p<0.001) between the preoperative period and postoperative Day 1. Similarly, our difference in differences analysis revealed a mean reduction in Hgb-related blood loss of 0.972 Hgb/dl (95% CI: 0.593 to 1.349; p<0.001) between the preoperative period and postoperative Day 2. Conclusion The present study shows TXA to be effective for reducing blood loss and transfusions following TKAs performed at a small community hospital. Given the cost-savings previously reported with TXA use, as well as the medical benefits reported in this study, TXA may have a niche in small community hospitals where cost savings from reduced transfusions and shorter hospital stays are important. Further studies should assess the exact amount of financial savings from TXA utilization in small community hospitals.

Articulating Spacers as a Modified One-Stage Revision Total Knee Arthroplasty: A Preliminary Analysis.

INTRODUCTION: Periprosthetic joint infection (PJI) following primary total knee arthroplasty (TKA) is a challenging complication for surgeons and patients alike. Although two-stage revision arthroplasty remains the gold standard PJI management in the United States, one-stage revision has had success in many parts of Europe. The aim of this study was to retrospectively review: 1) ultimate treatment success; 2) necessary antibiotic duration; 3) change in knee range of motion (ROM); and 4) final Knee Society Scores (KSS) in a case series of patients managed with retention of articulating antibiotic spacers following PJI. MATERIALS AND METHODS: A retrospective review was performed on all patients treated for chronic PJI after primary TKA with retention of articulating antibiotic spacers at a minimum of one-year follow-up. Descriptive analysis was utilized to evaluate demographic characteristics, discharge destination, follow-up and antibiotic durations, Knee Society Score (KSS), and rates of treatment failure. Paired-Samples t-Tests were utilized to evaluate mean changes in flexion and extension between the preoperative and postoperative time periods. RESULTS: Our final cohort included 29 patients who were managed with articulating spacer retention at a mean follow-up of 16.8 (range, 12.0 to 23.1) months, with 21 patients (72.4%) medically unfit for multiple surgeons and eight patients (27.6%) satisfied with their function. Mean age was 61.3 (range, 41 to 85) years and mean Charlson Comorbidity Index (CCI) was 6.1 (mean, 0 to 12). The predominant infecting organism was Methicillin-Resistant Staphylococcus aureus (MRSA), which was involved in eight patients (27.6%). There was a significant increase in postoperative knee flexion (+14.7°; p<0.001) and no decrease in postoperative knee extension (+2.3°; p=0.361). Treatment success in our cohort was 79.3% (23 patients), with four patients (13.8%) having chronic wound drainage and two patients (6.9%) requiring multiple spacer exchanges. Sixteen patients (55.2%) were able to complete their antibiotic regimen, with the remaining patients unable to discontinue their antibiotics by latest clinic follow-up. DISCUSSION: One-stage exchange arthroplasty offers the advantage of a single procedure with analogous failure rates compared to two-stage exchange, decreases hospitalization, and improves cost-effectiveness, which is paramount in today's healthcare environment. To our knowledge, this is the first study in the United States to evaluate outcome scores, function, and success rate of a modified one-stage revision TKA technique. Although we are unable to make definitive conclusions based on the small sample size, the outcomes in this study are encouraging.

Reconstruction Using Expandable Endoprostheses for Skeletally Immature Patients With Sarcoma.

Expandable endoprostheses have become an acceptable modality to address the issue of limb-length inequality in limb-sparing procedures for skeletally immature patients afflicted with lower extremity bone sarcomas. This study retrospectively analyzed postoperative outcomes and complications for 7 patients (8 limbs) who underwent minimally invasive or noninvasive reconstruction during a 12-year period. Musculoskeletal Tumor Society (MSTS) scores and complication rates were reported. Mean functional outcome (MSTS scores) at final follow-up was 93.3%. Functional outcomes for the noninvasive and minimally invasive expandable prostheses were 97% and 85%, respectively. Complications included temporary peroneal nerve palsy (2 limbs), infection (2 limbs), prosthesis revision (3 limbs), stiffness (3 limbs), and wound healing problems (3 limbs). None of the patients required amputation. Both minimally and noninvasive expandable prostheses appear to be safe and reliable means of reconstruction that permit limb salvage in skeletally immature patients and provide good functional results considering the alternative is above-knee amputation or hip disarticulation. Although complications are frequent (range, 13%-38%), they often can be managed successfully without amputation, thus providing a good quality of life and functional limb. The noninvasive prosthesis may prove to be a more attractive option by potentially negating additional surgeries and reducing infection rates; however, the short-term experience with this prosthesis warrants further investigations with more patients and longer follow-up. [Orthopedics. 2017; 40(1):e157-e163.].

Management strategies for total hip arthroplasty in sickle cell patients.

Sickle cell anemia is an inherited hemoglobinopathy in which there is a structural change to the erythrocyte from round to crescent shaped or sickled. These abnormally shaped cells can block small vessels resulting in compromise of vascular supply, pain, and end-organ damage. These patients are particularly susceptible to hip osteonecrosis, which in late stages may require a total hip arthroplasty. Historically, total hip arthroplasty had inferior outcomes in this patient population due to poorer clinical outcomes and higher perioperative complications. During recent decades, however, there have been some improvements in the medical management of these patients, which has potentially improved the clinical outcomes of this procedure. In this article, we review all reported management strategies for the perioperative care of sickle cell anemia patients undergoing total hip arthroplasty.

Patient activity after total hip arthroplasty: a comparison of three different bearing surfaces.

Patients who receive hip arthroplasty today desire prostheses that not only have great longevity, but are also suitable for a very active lifestyle. Advances in metallurgy, tribologic behavior, surgical technique, as well as improvements in strength and microstructure, have made ceramic-on-ceramic and metal-on-metal bearings available for young patients requiring a great deal of mobility. The purpose of this study was to assess if the bearing surface had an effect, if any, on postoperative activity levels and clinical outcomes in patients receiving three different types of hip arthroplasty. This study includes three groups of 30 patients who had each received conventional metal-on-polyethylene total hip arthroplasty (THA), ceramic-on-ceramic THA, or hip resurfacing arthroplasty. All groups were matched by men to women ratio, age, body mass index, diagnosis, preoperative activity levels, and length of follow-up. Clinical outcomes evaluated included weighted postoperative activity levels, Harris hip scores, patient satisfaction scores, revision rates, and complication rates. Patients who had received a metal-on-metal resurfacing had achieved significantly higher activity scores (mean 10.5 points; range, 1-28 points) compared to patients who had received ceramic-on-ceramic (mean 6.9 points; range, 0-34 points) or metal-on-polyethylene bearings (mean 5.6 points; range, 1-18 points). The mean postoperative Harris hip scores (94 vs 92 vs 91 points), patient satisfaction scores (9 vs 8.4 vs 8.3 points), aseptic revision (3% vs 0% vs 0%), and complication rates (3% vs 3% vs 3%) were similar between resurfacing, ceramic-on-ceramic, and metal-on-polyethylene bearing groups, respectively. This study showed that in cohorts of similarly matched arthroplasty patients in multiple demographics factors and preoperative activity levels, metal-on-metal resurfacing arthroplasty may offer higher postoperative activity levels. For patients with higher activity levels, resurfacing arthroplasty may be advantageous compared to other types of bearings.