What is the Ideal Route of Administration of Tranexamic Acid in TKA? A Randomized Controlled Trial

Background

TKA commonly involves substantial blood loss and tranexamic acid has been used to reduce blood loss after TKA. Numerous clinical trials have documented the efficacy and safety of intravenous (IV) or intraarticular (IA) use of tranexamic acid. Combined administration of tranexamic acid also has been suggested; however, there is no consensus regarding the ideal route of tranexamic acid administration.

Questions/Purposes

(1) To compare the efficacy of tranexamic acid in terms of total blood loss and the allogeneic transfusion rate among three routes of administration: IV alone, IA alone, and combined IV and IA. (2) To compare these regimens in terms of venous thromboembolism (VTE) and the frequency of wound complications.

Methods

In total, 376 patients undergoing TKA between March 2014 and March 2015 were randomized to four groups by the route of tranexamic acid administration: IV only, IA only, low-dose combined (IV + IA injection of 1 g), and high-dose combined (IV + IA injection of 2 g). The calculated total blood loss, allogeneic transfusion rate, decrease in hemoglobin, the frequency of symptomatic deep vein thrombosis and pulmonary embolism, wound complications, and periprosthetic joint infection were compared among the groups. Total blood loss was calculated using estimated total body blood volume and hemoglobin loss. The decision regarding when to transfuse was determined based on preset criteria.

Results

The high- and low-dose combined groups and the IA-only group had lower total blood loss (564 ± 242 mL, 642 ± 242 mL, and 633 ± 205 mL, respectively) than the IV-only group (764 ± 217 mL; mean differences = 199 mL [95% CI, 116–283 mL], p < 0.001; 121 mL [95% CI, 38–205 mL], p = 0.001; 131 mL [95% CI, 47–214 mL], p < 0.001); no differences were found among the other three groups. No patients in any study group received an allogeneic transfusion. One patient in the IV-only group had a symptomatic pulmonary embolism develop, but no other symptomatic VTE events occurred in any group. In addition, no differences were observed in wound complications, such as superficial wound necrosis (one patient in the IV-only and the high-dose combined group, respectively) and oozing (IV-only, IA-only, low-dose combined, high-dose combined = 3%, 4%, 4%, and 7%; p = 0.572) between the groups. No patients had a periprosthetic joint infection.

Conclusion

IA tranexamic acid administration further reduces blood loss after TKA in comparison to IV use alone; no additional effect in further reducing blood loss was found in combination with IV tranexamic acid. Appropriately powered studies are needed to confirm the safety of this route of administration as the preferred route of administration in TKA.

Level of Evidence

Level I, therapeutic study.

     

OBTAIN A: Outcome Benefits of Tranexamic Acid in Hip Arthroplasty. A Randomized Double-Blinded Controlled Trial

Background

We examined whether the blood conserving effect of tranexamic acid (TXA) in total hip arthroplasty using the direct anterior approach, translates to an effect on functional outcomes in the perioperative period.

Resurfacing in a Posterior-Stabilized Total Knee Arthroplasty Reduces Patellar Crepitus Complication: A Randomized,Controlled Trial

BackgroundPatellar crepitus (PC) is a common complication after total knee arthroplasty (TKA) using a posterior-stabilized (PS) prosthesis. While numerous factors have been associated with PC development after PS-TKA, patellar resurfacing (PR) which directly impacts the patellofemoral joint kinematics has been underinvestigated. A prospective, randomized, controlled trial was conducted to (1) compare the PC incidence in PR and non-PR PS-TKA, (2) determine the time of PC presentation in PS-TKA, (3) identify radiographic parameters associated with PC, and (4) compare clinical outcomes of patients with and without PR.MethodsA total of 84 patients who underwent unilateral TKA using the Legion PS Total Knee System were randomized into PR group or non-PR group. PC incidence, time of PC presentation, radiographic parameters associated with PC development, and clinical outcomes were evaluated at 3 months, 6 months, 9 months, and 1 year postoperatively.ResultsPC occurred significantly more in the non-PR group (23.1% vs 7.3%, P = .048). Time of PC presentation in both groups was not different. Anterior knee pain was found in 16.7% of crepitus patients, and none required any surgical procedure. The non-PR knees had significant decreases in patellar shift index, patellar displacement, Insall-Salvati ratio, and patellar component height and increase in change in posterior femoral offset. Oxford and patellar scores were significantly better in the PR group at 9 months and 1 year.ConclusionGiven higher PC incidence and several worse clinical outcomes in the non-PR, we recommend resurfacing during PS-TKA with this knee system to avoid PC development.     

Does Barbed Suture Lower Cost and Improve Outcome in Total Knee Arthroplasty? A Randomized Controlled Trial

Background

Wound closure is key to prevent infection, facilitate immediate rehabilitation, and improve efficiency of total knee arthroplasty (TKA). Continuous knotless suturing with barbed suture can potentially save time and distribute tension more evenly. However, its role in TKA in terms of cost-effectiveness and wound complications is not clear. This study aims at comparing barbed and traditional sutures' wound closure time and cost in primary TKA.

Preoperative Immunonutrition Suppresses Perioperative Inflammatory Response in Patients with Major Abdominal Surgery—A Randomized Controlled Pilot Study

Background/Aim Perioperative administration of immunoenriched diets attenuates the perioperative inflammatory response and reduces postoperative infection complications. However, many questions still remain unresolved in this area, such as the length of diet administration, diet composition, and the mechanisms involved. We performed an open, randomized, triple-arm study comparing the effect of two perioperative feeding regimens with a postoperative one. Methods 46 candidates for major elective surgery for malignancy in the upper gastrointestinal tract were randomized to drink preoperatively either 1 L of an immunoenriched formula (Impact) for 5 days (IEF group) or 1 L of Impact plus (Impact enriched with glycine) for 2 days (IEF plus group). The same product as the patient received preoperatively was given to both groups for 7 days postoperatively. In the control group (CON group), patients only received Impact for 7 days postoperatively; there was no preoperative treatment. The main outcome measures were postoperative C-reactive protein (CRP) serum levels. Results In the two preoperatively supplemented groups (treatment groups), perioperative endotoxin levels, CRP (postoperative day 7), and TNF-α (postoperative days 1 and 3) levels were significantly lower compared to the CON group (p < .01). Furthermore, the length of postoperative IMU/ICU stay (Impact 1.9 ± 1.3 days; Impact plus 2.2 ± 1.1 days; control group 5.9 ± 0.8 days) and length of hospital stay (Impact 19.7 ± 2.3 days; Impact plus 20.1 ± 1.3 days; control group 29.1 ± 3.6 days) were both reduced in the treatment groups compared to the control group. Infectious complications (Impact 2/14 (14%); Impact plus 5/17 (29%); control group 10/15 (67%)) also showed a trend toward reduction in the treatment groups. Conclusions Perioperative administration of an immunoenriched diet significantly reduces systemic perioperative inflammation and postoperative complications in patients undergoing major abdominal cancer surgery, when compared with postoperative diet administration alone. A shortened preoperative feeding regimen of 2 days with Impact enriched with glycine (Impact plus) was as effective as Impact administered for 5 days preoperatively.     

Is a Titanium Implant for Total Knee Arthroplasty Better? A Randomized Controlled Study

BackgroundLighter weight and lower modulus are potential advantages of titanium (Ti) implants over cobalt chrome (CoCr) implants in total knee arthroplasty (TKA). This study was conducted to determine whether Ti implants in TKA resulted in better clinical outcomes and radiologic results.MethodsOne hundred and eight patients (216 knees) with knee arthritis warranting bilateral primary TKA were randomly allocated to undergo Ti rotating-platform TKA in one knee and CoCr rotating-platform TKA in the contralateral knee. The mean follow-up period was 5.3 years (range, 1-7 years). The weight of Ti implants was one-third lighter than that of CoCr implants (133.9 g vs 390.1 g, P < .01). Clinical outcomes were evaluated using clinical scores, patient preferences (lightness, comfort, naturalness, and satisfaction), gait analysis (kinetic and kinematic data), range of motion, and degree of pain. Radiologic results were evaluated based on the radiolucent line (RLL), degree of medial tibial bone loss, and loosening as seen on X-ray.ResultsNo significant differences were observed in clinical scores or patient preference. Regarding implant weight, approximately 70% of patients did not perceive the Ti implant as lighter. No significant differences were observed in gait analysis, range of motion, or degree of pain. The RLL was seen in 9% of the Ti implant group and 19% of the CoCr implant group.ConclusionThe lighter Ti implant did not show any clinical benefit over CoCr implants. The lightness of the Ti implant is not sufficient to matter or be noticeable. However, the Ti implant showed lower rate of RLL than the CoCr implant.Level of Evidencelevel I, randomized controlled trial.     

Patella Denervation in Primary Total Knee Arthroplasty – A Randomized Controlled Trial with 2 Years of Follow-Up

We randomized 126 consecutive patients undergoing primary total knee arthroplasty into group 1: patella denervation (n = 63) and group 2: no patella denervation (n = 63). Assessment was performed preoperatively and at 3, 12 and 24 months post-operatively. Average follow-up of patients was 26.5 months for denervation group and 26.3 months for no denervation group (P = 0.84). Pain scores for anterior knee pain were significantly better in the denervation group at 3 months but not at 12 and 24 months. Patient satisfaction was higher in the denervation group. Flexion range was higher in the denervation group at 3, 12 and 24 months review (P < 0.01). There were, however, no statistically significant differences with other validated knee scores.     

Does Tranexamic Acid Save Blood in Minimally Invasive Total Knee Arthroplasty?

Background  

Tranexamic acid (TEA) reportedly reduces perioperative blood loss in TKA. However, whether it does so in minimally invasive TKA is not clear.     

Early Oral Feeding vs. Traditional Feeding in Patients Undergoing Elective Open Bowel Surgery—a Randomized Controlled Trial

Objective

This prospective randomized controlled trial was conducted to compare the safety, tolerability and outcome of early oral feeding vs. traditional feeding in patients undergoing elective open bowel surgery.

Methods

A total of 120 consecutive patients who underwent elective open bowel surgeries were randomized into either early feeding (n?=?60) or traditional feeding group (n?=?60). Patients in the early feeding group were started on oral fluids on post-operative day 1, while those in the traditional feeding group were started orals after the resolution of ileus. Patient characteristics, surgical procedures, co-morbidity, first flatus, first defecation, time of starting solid diet, complications and length of hospitalization were assessed between the two groups.

Results

The two groups were similar in demographic and baseline data. The number of days to first flatus (p?<?0.0001), first defecation (p?<?0.0001), length of post-operative stay (p?=?0.011) and time of starting solid diet (p?<?0.0001) were significantly earlier in the early feeding group. Anastomotic leak, wound infection, fever, vomiting, abdominal distention and other complications were similar. Multivariate analysis showed that patients in the early oral feeding group were discharged 3.4 days earlier (p?=?0.037).

Conclusion

In patients undergoing elective open bowel surgeries, early post-operative feeding is safe, is well tolerated and reduces the length of hospitalization.     

Does Dexamethasone Reduce Hospital Readiness for Discharge,Pain, Nausea,and Early Patient Satisfaction in Hip and Knee Arthroplasty? A Randomized,Controlled Trial

Background

Reduction in postoperative pain, nausea, and vomiting in patients undergoing total joint arthroplasty may facilitate earlier discharge from hospital and reduce healthcare costs. This study was performed to primarily assess whether perioperative dexamethasone reduced hospital length of stay and to assess the effect on pain, nausea and vomiting, and patient satisfaction.

Electroacupuncture in Reduction of Discomfort Associated with Barostat-Induced Rectal Distension—A Randomized Controlled Study

Background  

This pilot study aims to explore the effectiveness of electroacupuncture in reduction of colorectal discomfort caused by Barostat-induced rectal distension.     

Patellar Resurfacing in Primary Total Knee Arthroplasty: A Meta-Analysis of Randomized Controlled Trials

BackgroundThe management of the patella during total knee arthroplasty (TKA) remains controversial. The aim of this study is to evaluate the evidence regarding the use of patellar resurfacing in TKA.MethodsA meta-analysis of randomized controlled trials (RCTs) was performed to compare outcomes between knees receiving patellar resurfacing vs those not receiving resurfacing during primary TKA. Outcomes of interest were the Knee Society Scores, reoperation rates, anterior knee pain, patient satisfaction, Oxford Knee Score, Knee Injury and Osteoarthritis Outcome Score subscores, and range of motion.ResultsTwenty RCTs met all eligibility criteria and were included in the analysis. There were statistically significant differences favoring the resurfaced group in the knee component and functional component of Knee Society Scores that were not clinically significant. There was an increased risk of reoperation among knees that did not receive resurfacing with number needed to treat to prevent one case of reoperation of 25 knees (for reoperation for any reason) and 33 knees (for reoperation for anterior knee pain). There were no statistically significant differences in any other outcomes.ConclusionThe only clear relationship is that knees that do not receive patellar resurfacing are more likely to receive reoperation, most often for secondary resurfacing. However, the disease burden of differing complication profiles associated with resurfacing and nonresurfacing groups remains unclear. Continuing to collect data from large, well-designed RCTs would be beneficial in guiding management of the patella during TKA.     

Does Nefopam Provide Analgesic Effect and Reduce Morphine Consumption After Primary Total Knee Arthroplasty? A Prospective,Double-Blind,Randomized Controlled Trial

BackgroundOne of the most undesirable results after total knee arthroplasty (TKA) is severe immediate postoperative pain, resulting in patient dissatisfaction. We aimed to evaluate nefopam’s analgesic efficacy after primary TKA along with related outcomes, including morphine consumption and adverse events.MethodsWe conducted a double-blind, randomized controlled trial of patients undergoing unilateral primary TKA, comparing 24 hours of 80 mg of continuous intravenous nefopam to placebo infusion. A 100-mm Visual Analog Scale (VAS) for pain-at-rest and in-motion ≤48 hours was the primary outcome measure. Secondary outcomes were morphine and antiemetic consumption, adverse events, and functional outcomes: time-to-walk, timed up-and-go test, postoperative knee range of motion at 24 and 48 hours, time-to-discharge, and patient satisfaction scores.ResultsPatients in the nefopam group had significantly lower VAS at rest 6 hours postop (20.3 ± 27.3 vs 35 ± 24.3, P = .01). Other timepoints and in-motion VAS did not significantly differ. Total morphine consumption (0-48 hours) was 37% less, significantly lower, in the nefopam group (5.3 ± 4.5 vs 8.4 ± 7.5 mg, P = .03). Antiemetic consumption was also 61% lower in the nefopam group but not statistically significant (0.8 ± 2.3 vs 2.0 ± 3.8 mg, P = .08). There were no variations in adverse events, functional outcomes, and satisfaction scores between groups.ConclusionContinuous nefopam administration as part of multimodal analgesia for 24 hours post-TKA produced a significant analgesic effect but only within the first 6 hours. However, there was a notable reduction in morphine use 48 hours postop. Nefopam is a useful agent for contemporary pain control after TKA.Level of EvidenceTherapeutic Level I.     

Treatment of Deep Cartilage Defects of the Knee Using Autologous Chondrograft Transplantation and by Abrasive Techniques — A Randomized Controlled Study

Aim of the study: To compare outcomes of surgical treatment of deep cartilage defects of the knee in a group of patients treated by autologous chondrograft transplantation versus patients treated by abrasive techniques. Materials and methods: An original method of chondrograft preparation based on cultivated autologous chondrocytes in a three-dimensional carrier-fibrin glue (Tissucol, Baxter, Austria) has been described. Preclinical tests in human cadavres and porcine models have established the possibility of chondrograft use in humans.

Of the 50 patients included in the study, 25 patients (50%) underwent autologous chondrograft transplantation (group I) and 25 patients (50%) were treated using abrasive techniques according to Johnson (group II). These two groups were similar with respect to age, size of defect, depth and localization, and presence of concomitant knee injuries. The Lysholm knee and IKDC (International Knee Documentation Committee) subjective scores were used to evaluate the results.

Results: The preoperative value of the Lysholm knee score for patients in group I was 47.60 points; 5 months after surgery 77.20 points; and 12 months after surgery 86.48 points. The values for the Lysholm knee score for patients in group II preoperatively, 5 months postop, and 12 months postop were 52.60, 69.20, and 74.48 respectively. Results 12 months after surgery were significantly better in group I as compared to group II (p < 0.001). The preoperative value of the IKDC subjective score in group I was 41.28 points; 5 months after surgery 67.00 points; and 12 months after surgery 76.48 points. The values for the IKDC subjective score in group II preoperatively, 5 months postop, and 12 months postop were 45.00, 62.28, and 68.08 respectively. Results 12 months after surgery were significantly better in group I when compared to group II (p < 0.05).

Conclusions: The results obtained in this study have confirmed the better outcome in patients treated with autologous chondrograft transplantation. This original method was found to be just as effective as abrasive techniques. We recommend its use in clinical practice.