Is there an optimal timing of administration of single-dose intravenous tranexamic acid in bilateral total knee arthroplasty? A comparison between preoperative and intraoperative dose.

PURPOSE: There is no consensus on the optimum timing of administration of tranexamic acid (TA) in bilateral total knee arthroplasty (TKA). We aimed to determine whether the timing of administration of single-dose intravenous TA (either given preoperatively or intraoperatively) has a significant effect on blood loss reduction. METHODS: We compared two cohorts of patients with end-stage arthritis of knees who underwent bilateral TKA and were given single-dose intravenous TA (1 g or 15 mg/kg) at different times during surgery. The retrospective cohort group consisting of 40 patients (preoperative (PO) group) received TA before the skin incision. The prospective cohort consisting of 40 patients (intraoperative (IO) group) received TA 10 min before deflating the tourniquet on the first knee. Primary outcome measures were mean hemoglobin difference, A (between PO and day 1 postoperative hemoglobin), mean hemoglobin difference, B (between PO and lowest postoperative hemoglobin), and rate of allogeneic blood transfusion. Secondary measure was drain blood loss. RESULTS: Both cohorts were well matched with respect to age, gender, duration of surgery, and length of hospital stay. The hemoglobin drop in the IO group was significantly lesser than the PO group on the first postoperative day (2 vs. 2.9 g/dL, p < 0.001). Although statistically insignificant, the patients in the IO group received less allogenic transfusion of packed cell units than in the PO group (11/40, 27.5% vs. 14/40, 35% ). Mean hemoglobin difference, B, and secondary drain loss were comparable in both groups. CONCLUSION: Single-dose intravenous TA given before the start of surgery is as effective as a dose given during arthroplasty of the first knee in reducing blood loss in bilateral TKA.

Predictors of change in 'discharge destination' following treatment for fracture neck of femur.

OBJECTIVES: The purpose of our study was to analyse the incidence and factors predicting the 'change in discharge destination' in patients with fractured neck of femur who were treated surgically. MATERIALS AND METHODS: Fifteen hundred and seventy-three consecutive patients admitted with a fractured neck of femur, residing in their own home prior to admission were studied. Patients who did not have an operation (n=70) for their hip fracture were excluded from the study. Residential location in the UK is broadly categorised as: RESULTS: A downward drift in "discharge destination" of 20% was noted after analysis. Univariate analysis revealed that age, gender, AMT score, place of fall, type of fracture, walking ability outdoor and indoor, ASA grade, medical co-morbidity requiring physician review and delay beyond 36h to surgery had a significant effect. Multiple logistic regression analysis revealed that increasing age, male gender (OR=1.67), accompaniment for outdoor mobilisation (OR=1.96), increasing ASA grade, AMT score <6 (OR=4.86), pre-operative medical condition requiring physician review (OR=2.27), delay greater than 36h for medical reasons (OR=4.38) were predictors of the change in discharge destination. CONCLUSION: The most important predictors of the change in the discharge destination were the medical condition, cognitive and physical function of the patient at admission. Male gender and increasing age were contributory. The only clinician dependent factor that seemed to affect this change of residential status was delay to surgery secondary to medical problems. Awareness of key predictors that affect the "discharge destination" can be useful for the multidisciplinary team and patients' families to evaluate and plan for an early, satisfactory and appropriate referral to either community services or institutional care, which in turn could have a significant socioeconomic impact.

In-hospital complications following primary total hip and knee arthroplasty in octogenarian and nonagenarian patients.

BACKGROUND: As life expectancy of patients increases, more elderly patients are undergoing primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). There is a general perception of increased risk of complications in elderly patients. Our objective was to analyse the incidence of in-hospital medical and surgical complications following THA and TKA in octogenarian and nonagenarians. MATERIALS AND METHODS: This was a prospective review of 202 consecutive patients aged more than 80 years who underwent total hip and total knee arthroplasty (101 THA, 101 TKA) over an 18-month period. In this single-centre observational study, collected data included patient demographics, American Society of Anethesiologists (ASA) grade, length of hospital stay and peri-operative medical and surgical complications during their hospital stay. RESULTS: Median age of patients was 83 years. Median ASA grade was 3. Mean length of hospital stay was 7.5 days. There were 14 major systemic complications in the THA group and 13 in the TKA group. While 1 major local complication occurred in each group, there were 6 minor local complications in THA and 7 in the TKA group. All the complications occurred within 5 post-operative days. There was no in-hospital mortality. CONCLUSION: In our study, we found that the incidence of peri-operative medical and surgical complications is higher in those over 80 years, compared to the published literature in patients of all age groups undergoing THA and TKA. Awareness of a higher incidence of major systemic complications should alert the treating surgeon to carry out comprehensive peri-operative management in this subset of patients, which could lead to better outcomes.

The management of wounds following primary lower limb arthroplasty: a prospective, randomised study comparing hydrofibre and central pad dressings.

Wound care following lower limb arthroplasty has not been subject to in-depth clinical research, primarily because such wounds usually heal without complication. However, when prosthetic implants are used, serious wound problems can be disastrous (Whitehouse et al. Infect Control Hosp Epidemiol 2002;23:183-9; Lindwell OM. Clin Orthop Relat Res 1986;211:91-103). We report the results of a prospective, randomised, controlled trial comparing a hydrofibre (Aquacel) and central pad (Mepore) dressing in the management of acute wounds following primary total hip or knee arthroplasty left to heal by primary intention. Dressing performance was measured in 61 patients receiving total hip or knee replacements. There was a significant reduction in the requirement for dressing changes before five postoperative days in the hydrofibre group (43% compared with 77% in the central pad group), and there were fewer blisters amongst patients in the hydrofibre group (13% compared with 26% in the central pad group). We conclude that there is a potential role for hydrofibre dressing in the management of arthroplasty wounds.