Limit the bleeding, limit the pain in total hip and knee arthroplasty

Comparisons of in-hospital complications between total hip arthroplasty and hip resurfacing arthroplasty

BACKGROUND

Hip resurfacing arthroplasty (HRA) is a less common but effective alternative method to total hip arthroplasty (THA) for hip reconstruction. In this study, we investigated the incidences of in-hospital complications between patients who had been subjected to THA and HRA.

METHODS

The National Inpatient Sample data that had been recorded from 2005 to 2014 was used in this study. Based on the International Classification of Disease, Ninth Revision, Clinical Modification, patients who underwent THA or HRA were included. Data on demographics, preoperative comorbidities, length of hospital stay, total charges, and in-hospital mortality and complications were compared. Multiple logistic regression analysis was used to determine whether different surgical options are independent risk factors for postoperative complications.

RESULTS

A total of 537,506 THAs and 9,744 HRAs were obtained from the NIS database. Patients who had been subjected to HRA exhibited less preoperative comorbidity rates, shorter length of stay and extra hospital charges. Moreover, HRA was associated with more in-hospital prosthesis loosening. Notably, patients who underwent HRA were younger and presented less preoperative comorbidities but did not show lower incidences in most complications.

CONCLUSIONS

The popularity of HRA gradually reduced from the year 2005 to 2014. Patients who underwent HRA were more likely to be younger, male, have less comorbidities and spend more money on medical costs. The risk of in-hospital prosthesis loosening after HRA was higher. The HRA-associated advantages with regards to most in-hospital complications were not markedly different from those of THA. In-hospital complications of HRA deserve more attention from surgeons.

Optimal Release Timing of Drain Clamping to Reduce Postoperative Bleeding after Total Knee Arthroplasty with Intraarticular Injection of Tranexamic Acid

Background and Objectives: Intraarticular injection of tranexamic acid (IA-TXA) plus drain-clamping is a preferred method of reducing bleeding after total knee arthroplasty (TKA). However, no consensus has been reached regarding the timing of the clamping. The purpose of this study was to determine the optimum duration of drain-clamping after TKA with IA-TXA. Materials and Methods: We retrospectively reviewed 151 patients that underwent unilateral TKA with IA-TXA plus drain-clamping for 30 min, 2 h, or 3 h. The total drained volume was reviewed as the primary outcome, and hematocrit (Hct) reductions, estimated blood loss (EBL), transfusion rates, and wound complications were reviewed as secondary outcomes. Results: The mean total drained volume, Hct reduction, and EBL were significantly less in the 3 h group than in the 30 min group. Between the 2 h and 3 h groups, there was no statistical difference in the mean total drained volume, Hct reduction, or EBL. The proportion of patients who drained lesser than 300 mL was high in the 3 h group. No significant intergroup difference was observed for transfusion volume, transfusion rate, and wound related complications. Conclusions: In comparison of the IA-TXA plus drain-clamping after TKA, there was no difference in EBL between the 2 h group and the 3 h group, but the amount of drainage volume was small in the 3 h group.

Risk factors of opioid use associated with an enhanced-recovery programme after total knee arthroplasty

Background

Characterizing the impacts of postoperative opioid use on total knee arthroplasty (TKA) patients may help optimize the pain management after TKA. The aim of the study is to examine the prevalence and risk factors for opioid use with an enhanced-recovery programme after primary TKA.

Methods

We identified 361 patients undergoing TKA, and separated those on the basis of whether to receive opioid use after surgery. Themultivariate logistic regression model was used to identify independent risk factors for opioid use after primary TKA. Length of stay (LOS) and postoperative complications were also recorded and compared.

Results

The prevalence of opioid use after primary TKA was 23.0%. The significant risk factor was the longer operative time (OR [odds ratio] = 1.017, 95% CI [confidence interval] = 1.001 to 1.032, p = 0.034) and the protective factor was the utilization of tranexamic acid(OR= 0.355, 95% CI = 0.161 to 0.780, p = 0.010). In addition, the LOS was longer in opioid group (p < 0.05).

Conclusion

Considering the adverse health effects of opioid use, strategies need to be developed to prevent persistent opioid use after TKA. Reducing operative time and the application of tranexamic acid could lower the risk of opioid use with an enhanced-recovery programme after primary TKA.

Efficiency and Safety of Intravenous Tranexamic Acid in Simultaneous Bilateral Total Knee Arthroplasty: A Systematic Review and Meta-analysis

The objective of this systematic review and meta-analysis was to evaluate the efficacy and safety of i.v. tranexamic acid (TXA) in simultaneous bilateral total knee arthroplasty (TKA). Potentially relevant published reports were identified from the following electronic databases: Medline, PubMed, Embase, ScienceDirect and Cochrane Library. RevMan v5.3was used to pool data. Two randomized controlled trials and four case-control studies met the inclusion criteria. The current meta-analysis identified significant differences between TXA group and control groups in terms of postoperative hemoglobin concentration (P < 0.01), drainage volume (P < 0.01), transfusion rate (P < 0.01) and units transfused (P = 0.006). There were no significant differences in length of stay (P = 0.66), operation time (P = 0.81) or and incidence of adverse effects such as infection (P = 0.42), deep venous thrombosis (DVT) (P = 0.88) and pulmonary embolism (PE) (P = 0.11). Our results show that i.v. administration of TXA in simultaneous bilateral TKA reduces postoperative drops in hemoglobin concentration, drainage volume, and transfusion requirements and does not prolong length of stay or operation time. Moreover, no adverse effects, such as infection, DVT or PE, were associated with TXA.

Use of a Bipolar Blood-Sealing System During Total Joint Arthroplasty

The goal of the clinical use of a bipolar blood-sealing system is to reduce perioperative blood loss in total joint arthroplasty (TJA). This study was performed to determine whether a bipolar sealer is safe and effective in TJA and whether there are any advantages over monopolar sealers. The authors searched electronic databases and reference lists of relevant articles; retrieved all published randomized, controlled trials concerning the subject; and then performed a meta-analysis. Nine clinical trials involving 871 patients were included. The results of the meta-analysis indicate that using a bipolar sealer in TJA could reduce total measured blood loss, intraoperative blood loss, and operative time, which was especially observed in revision TJA for infection and primary total knee arthroplasty without tourniquet use. However, there was no significant difference between the 2 groups in terms of calculated blood loss, hemoglobin decrease, transfusion requirements, length of stay, and complications. The results of the comparison between bipolar and monopolar sealers used in TJA indicate that the routine use of a bipolar sealer for TJA may be of limited benefit except in revision TJA and primary total knee arthroplasty without tourniquet use. In the future, more high-quality randomized, controlled trials are needed to provide robust evidence and confirm the best option.

The effect of peri-operative blood loss on postoperative pain following total knee arthroplasty

AIM

This study aimed to investigate a possible link between peri-operative blood loss and post-operative pain following primary total knee arthroplasty (TKA).

METHOD

A retrospective study was carried out using data from two RCTs (403 patients). Blood loss was estimated using Gross et al's formula. Blood transfusions were factored into calculations. Pain scores were obtained using a visual analogue score.

RESULTS

Multiple regression analysis showed no relationship (0.09) and analysis of variance showed no significant difference (p = 0.597). Null hypothesis accepted.

CONCLUSION

Minimising blood-loss remains an important goal during surgery. On-going efforts should be made to improve patient satisfaction following TKA.

Evaluation of the efficacy and safety of tranexamic acid for reducing blood loss in bilateral total knee arthroplasty

Tranexamic acid (TA) has been reported to reduce blood loss after total joint arthroplasty; however, the literature is sparse in evaluating its efficacy in simultaneous bilateral total knee arthroplasty (TKA). In this retrospective study of consecutive patients, TA use in bilateral TKA was associated with a significant reduction in perioperative serum hemoglobin drop, as well as allogeneic blood transfusion needs from 50% to 11% of patients. No autologous blood donation or drains were used. There were no venous thromboembolic events reported. Implementation of a systematic intravenous TA protocol in simultaneous bilateral TKA appears highly effective in reducing transfusion requirements, potentially reducing healthcare resource utilization as well as the morbidity and complications associated with allogeneic blood transfusions.

Randomized blinded study comparing a bipolar sealer and standard electrocautery in reducing transfusion requirements in anterior supine intermuscular total hip arthroplasty

Managing blood loss in total hip arthroplasty (THA) minimizes complications and decreases cost. Tissue-sparing anterior supine intermuscular THA (ASI-THA) may offer a quicker recovery but increases blood loss and transfusion requirements. This double-blinded prospective study compared a bipolar sealer (Aquamantys 6.0 bipolar sealer) to standard monopolar electrocautery in reducing blood loss in ASI-THA. Differences in calculated actual blood loss (ABL), hemoglobin, and transfusion requirements were examined. One hundred hips were randomized to each group. Transfusion rates were similar, 6% and 4%, respectively (p>0.05). ABL and change in hemoglobin were identical (1.35 and 3.3g). No significant differences in transfusion, blood loss, or hemoglobin were seen with a bipolar sealer device. Routine use of this bipolar sealer device has been discontinued in ASI-THA.