Jerry Yongqiang Chen

Intravenous versus intra-articular tranexamic acid in total knee arthroplasty: A double-blinded randomised controlled noninferiority trial.

BACKGROUNDnDespite the proven efficacy of both intravenous (IV) and intra-articular (IA) tranexamic acid (TXA) in reducing blood loss during total knee arthroplasty (TKA), the ideal route of administration remained debatable. This study aimed to compare the effect of IV versus IA TXA on transfusion incidences, perioperative blood loss and postoperative lower limb swelling during TKA.nnnMETHODSnOne hundred patients were prospectively randomised into two groups: 1) IV TXA; and 2) IA TXA. In both groups, TXA was administered intraoperatively after cementing the prostheses. The perioperative blood loss was calculated using the haemoglobin balance method. The thigh, suprapatellar, and calf girths were measured preoperatively and on postoperative day (POD) 4.nnnRESULTSnTwo patients in the IV group and one patient in the IA group required blood transfusion (p=0.500). The median and interquartile range (IQR) of perioperative blood loss on POD1 and POD4 was 530 (IQR 386,704) and 730 (IQR 523,925) ml for the IV group, compared with 613 (IQR 506,703) and 799 (IQR 563,1067) ml for the IA group (p=0.090 and p=0.232 respectively). The median increment in thigh, suprapatellar, and calf girths were 1.5 (IQR 0, 3.0), 2.0 (IQR 0.5, 4.0) and 0 (IQR 0, 1.0) cm for the IV group, compared to 2.0 (IQR 1.0, 4.0), 2.0 (IQR 0, 4.5) and 0 (IQR 0, 1.5) cm for the IA group (p=0.246, p=0.562, and p=0.937 respectively).nnnCONCLUSIONSnBoth IV and IA TXA had comparable effect on transfusion incidences, perioperative blood loss, and postoperative lower limb swelling during TKA. IA TXA is an alternative to IV TXA.nnnLEVEL OF EVIDENCEnI.

Functional Outcome and Quality of Life after Patient-Specific Instrumentation in Total Knee Arthroplasty

Patient-specific instrumentation (PSI) surgery may represent the next advancement in total knee arthroplasty (TKA). In 2011, 60 patients were prospectively recruited and divided into two groups based on the patients choice: (1) PSI surgery; and (2) conventional TKA. At two years after surgery, the Knee Society Function Score, Oxford Knee Score and SF-36 scores were comparable between the two groups. Although the Knee Society Knee Score (KSKS) was 9 ± 3 points better in the PSI group (P=0.008), the two years improvement in KSKS was comparable between the two groups. None of the patients required revision surgery. These findings cannot justify the additional costs and waiting time incurred by the patients with PSI surgery in the practice of a high volume surgeon.

Outcomes following total knee arthroplasty with CT-based patient-specific instrumentation

AbstractPurposeA 24-month prospective follow-up study was carried out to compare perioperative clinical outcomes, radiographic limb alignment, component positioning, as well as functional outcomes following total knee arthroplasty (TKA) between patient-specific instrumentation (PSI) and conventional instrumentation (CI).MethodsNinety consecutive patients, satisfying the inclusion and exclusion criteria, were scheduled to undergo TKA with either PSI or CI. A CT-based PSI was used in this study, and a senior surgeon performed all surgeries. Patients were clinically and functionally assessed preoperatively, 6 and 24xa0months post-operatively. Perioperative outcomes were also analysed, including operating time, haemoglobin loss, the need for blood transfusion, length of hospitalisation, and radiographic features.nResultsAt 24-month follow-up, clinical and functional outcomes were comparable between the two groups. PSI performed no better than CI in restoring lower limb mechanical alignment or improving component positioning. There were no differences in operating time, haemoglobin loss, transfusion rate, or length of hospitalisation between PSI and CI.ConclusionNo significant clinical benefit could be demonstrated in using PSI over CI after 24xa0months, and routine use of PSI is not recommended in non-complicated TKA.Level of evidenceII.

Comparison of early outcome of Weil osteotomy and distal metatarsal mini-invasive osteotomy for lesser toe metatarsalgia

Purpose To compare the 6-month outcome of Weil osteotomy with distal metatarsal mini-invasive osteotomy (DMMO) in 33 patients with lesser toe metatarsalgia. Methods Records of 33 patients who underwent Weil osteotomy (n=20, 41 toes) or DMMO (n=13, 22 toes) for lesser toe metatarsalgia by a single surgeon were reviewed. 25 of them had a concurrent procedure on the 1st toe. Outcome at 6 months was assessed using the visual analogue score (VAS) for pain, American Orthopaedic Foot and Ankle Society (AOFAS) lesser toe metatarsophalangeal-interphalangeal (MTP-IP) score, and the RAND-36 score. Results The 2 groups were comparable in terms of age, gender, and preoperative MTP joint range of motion (ROM), VAS for pain, AOFAS lesser toe MTP-IP score, and RAND-36 scores. At 6 months, the Weil osteotomy group had a higher RAND-36 (mental) score (92 vs. 78, p=0.026), and the DMMO group had a higher percentage of toes with greater MTP joint ROM (p=0.043). All patients achieved bone union within 6 months. Two patients in the DMMO group had prolonged oedema until 3 months post-surgery. Conclusion DMMO is a safe and reliable alternative to Weil osteotomy for metatarsalgia and can preserve ROM of the MTP joints.

Intra-articular tranexamic acid wash during bilateral total knee arthroplasty.

Purpose. To compare the outcome after simultaneous bilateral total knee arthroplasty (TKA) with or without an intra-articular tranexamic acid (TXA) wash in terms of blood loss, haemoglobin change, and transfusion requirement. Methods. 35 women and 10 men (mean age, 67.5 years) who underwent primary simultaneous bilateral TKA by a single senior surgeon were compared with 45 matched controls. In the TXA group, 1500 mg of TXA diluted in 100 ml of 0.9% sodium chloride was administered as a wash after cementing of implant and before closure of the retinaculum. At least 5 minutes of contact time was allowed before wound closure and tourniquet deflation. No drain was used. Results. No patients had thromboembolic complication. Compared with controls, the TXA group had lower perioperative blood loss (920 vs. 657 ml, p=0.001), total blood loss (997 vs. 679 ml, p<0.001), blood transfusion rate (60% vs. 37.8%, p=0.035), percentage of patients requiring more than one blood unit (24.4% vs. 8.9%, p=0.048), and length of hospitalisation (6 vs. 4 days, p<0.001). Nonetheless, the 2 groups were comparable in blood units and volume transfused. Conclusion. An intra-articular TXA wash during simultaneous bilateral TXA reduced total blood loss and resulted in a difference of 22.2% in blood transfusion rate and a 2-day reduction in the length of hospital stay.

Minimal Clinically Important Differences for American Orthopaedic Foot & Ankle Society Score in Hallux Valgus Surgery

Background: The American Orthopaedic Foot & Ankle Society (AOFAS) score is one of the most common and adapted outcome scales in hallux valgus surgery. However, AOFAS is predominantly physician based and not patient based. Although it may be straightforward to derive statistical significance, it may not equate to the true subjective benefit of the patient’s experience. There is a paucity of literature defining MCID for AOFAS in hallux valgus surgery although it could have a great impact on the accuracy of analyzing surgical outcomes. Hence, the primary aim of this study was to define the Minimal Clinically Important Difference (MCID) for the AOFAS score in these patients, and the secondary aim was to correlate patients’ demographics to the MCID. Methods: We conducted a retrospective cross-sectional study. A total of 446 patients were reviewed preoperatively and followed up for 2 years. An anchor question was asked 2 years postoperation: “How would you rate the overall results of your treatment for your foot and ankle condition?” (excellent, very good, good, fair, poor, terrible). The MCID was derived using 4 methods, 3 from an anchor-based approach and 1 from a distribution-based approach. Anchor-based approaches were (1) mean difference in 2-year AOFAS scores of patients who answered “good” versus “fair” based on the anchor question; (2) mean change of AOFAS score preoperatively and at 2-year follow-up in patients who answered good; (3) receiver operating characteristic (ROC) curves method, where the area under the curve (AUC) represented the likelihood that the scoring system would accurately discriminate these 2 groups of patients. The distribution-based approach used to calculate MCID was the effect size method. There were 405 (90.8%) females and 41 (9.2%) males. Mean age was 51.2 (standard deviation [SD] = 13) years, mean preoperative BMI was 24.2 (SD = 4.1). Results: Mean preoperative AOFAS score was 55.6 (SD = 16.8), with significant improvement to 85.7 (SD = 14.4) in 2 years (P value < .001). There were no statistical differences between demographics or preoperative AOFAS scores of patients with good versus fair satisfaction levels. At 2 years, patients who had good satisfaction had higher AOFAS scores than fair satisfaction (83.9 vs 78.1, P < .001) and higher mean change (30.2 vs 22.3, P = .015). Mean change in AOFAS score in patients with good satisfaction was 30.2 (SD = 19.8). Mean difference in good versus fair satisfaction was 7.9. Using ROC analysis, the cut-off point is 29.0, with an area under the curve (AUC) of 0.62. Effect size method derived an MCID of 8.4 with a moderate effect size of 0.5. Multiple linear regression demonstrated increasing age (β = −0.129, CI = −0.245, –0.013, P = .030) and higher preoperative AOFAS score (β = −0.874, CI = −0.644, –0.081, P < .001) to significantly decrease the amount of change in the AOFAS score. Conclusion: The MCID of AOFAS score in hallux valgus surgery was 7.9 to 30.2. The MCID can ensure clinical improvement from a patient’s perspective and also aid in interpreting results from clinical trials and other studies. Level of Evidence: Level III, retrospective comparative series.

Fixed Flexion Deformity After Unicompartmental Knee Arthroplasty: How Much Is Too Much

BACKGROUNDnThe detrimental impact of postoperative fixed flexion deformity (FFD) after unicompartmental knee arthroplasty (UKA) is manifold. This study aims to define the amount of postoperative FFD that is clinically relevant after UKA.nnnMETHODSnBetween 2005 and 2012, 803 patients who underwent a primary UKA at a tertiary hospital were prospectively followed up. They were categorized into 3 groups based on the amount of postoperative FFD: (1) 0° (control); (2) 1°-10° (mild FFD); and (3) >10° (severe FFD).nnnRESULTSnThere were 26 patients (3%) with severe FFD at 2 years after UKA. The Knee Society Function Score and Knee Score in the severe FFD group were 10 ± 4 and 10 ± 2 points lower than in the control group, respectively (Pxa0= .017 and Pxa0= .001). Similarly, the Oxford Knee Score and Physical Component Score in the severe FFD group was 5 ± 1 and 7 ± 2 points lower than in the control group, respectively (Pxa0= .033 and P < .001).nnnCONCLUSIONnThis study suggests that postoperative FFD of >10° after UKA is associated with significantly poorer functional outcomes.

Drain use in total knee arthroplasty is neither associated with a greater transfusion rate nor a longer hospital stay

PurposeIn recent years, the exclusion of a drain in total knee arthroplasty (TKA) is gaining popularity. This retrospective study aims to investigate a tertiary hospital’s experience with the use of a drain in TKA. The authors hypothesise that the use of a drain will: (1) increase the peri-operative total blood loss (TBL) and transfusion rate; (2) increase the length of hospital stay (LOS); (3) reduce the 30-day readmission rate and incidence of additional surgical procedure performed.MethodsPatients who underwent a unilateral primary TKA in 2012 were included. Seven surgeons performed 575 TKAs with the use of drains, while nine other surgeons performed 902 TKAs without the use of drains. The patients were prospectively followed-up for two years. Peri-operative TBL was calculated using the haemoglobin balance method. All patients followed the hospital’s transfusion and post-operative rehabilitation protocol.ResultsThere was a bigger drop in haemoglobin level by 0.5xa0g/dl (95xa0% CI, 0.4, 0.6) and greater TBL by 169xa0ml (95xa0% CI, 126, 181) in the drain group (both pu2009<u20090.001). However, the transfusion rate was 37/575 (6.4xa0%) and 48/902 (5.3xa0%) in the drain and no drain groups respectively (pu2009=u20090.370), while the LOS was four (IQR, 4, 5) and four (IQR 3, 5) days respectively (pu2009=u20090.228). The 30-day readmission rate was 10/575 (1.7xa0%) in the drain group, compared with 26/902 (2.9xa0%) in the no-drain group (pu2009=u20090.165). The incidence of additional surgical procedure performed was 5/575 (0.9xa0%) in the drain group, compared with 15/902 (1.7xa0%) in the no-drain group (pu2009=u20090.198).ConclusionsAlthough the use of a drain in TKA is associated with greater peri-operative TBL, this additional amount of blood loss does not translate into an increased transfusion rate or a longer LOS. It also does not reduce the 30-day readmission rate and incidence of additional surgical procedure performed on the same knee.

Intra-articular versus intravenous tranexamic acid in primary total knee replacement.

We commend Gomez-Barrena E et al. on their recent study entitled “Topical intra-articular compared with intravenous tranexamic acid to reduce blood loss in primary total knee replacement: a double-blind, randomized, controlled, noninferiority clinical trial”. The study was well-designed and appropriate statistical analysis was performed. They compared 39 patients who received 3 grams of intraarticular tranexamic acid (TXA) with another 39 patients who had two doses of 15 milligrams/kilogram of intravenous TXA (one dose before tourniquet release and another three hours after surgery). There was zero incidence of blood transfusion. The visible blood loss as measured in the drain output at 24 hours postoperatively and the invisible blood loss estimated using the Nadler formula at 48 hours postoperatively were comparable in both groups of patients. They conclude that intra-articular TXA according to their described protocol demonstrated noninferiority when compared with intravenous TXA (1).

Preoperative haemoglobin cut-off values for the prediction of post-operative transfusion in total knee arthroplasty

PurposeThe purpose of this study is to determine preoperative haemoglobin cut-off values that could accurately predict post-operative transfusion outcome in patients undergoing primary unilateral total knee arthroplasty (TKA). This will allow surgeons to provide selective preoperative type and screen to only patients at high risk of transfusion.MethodsA total of 1457 patients diagnosed with osteoarthritis and underwent primary unilateral TKA between January 2012 and December 2014 were retrospectively reviewed. Logistic regression analyses were applied to identify factors that could predict transfusion outcome.ResultsA total of 37 patients (2.5xa0%) were transfused postoperatively. Univariate analysis revealed preoperative haemoglobin (pxa0<xa00.001), age (pxa0<xa00.001), preoperative haematocrit (pxa0<xa00.001), and preoperative creatinine (pxa0<xa00.001) to be significant predictors. In the multivariate analysis with patients dichotomised at 70xa0years of age, preoperative haemoglobin remained significant with adjusted odds ratio of 0.33. Receiver operating characteristic curve identified the preoperative haemoglobin cut-off values to be 12.4xa0g/dL (AUCxa0=xa00.86, sensitivityxa0=xa087.5xa0%, specificityxa0=xa077.2xa0%) and 12.1xa0g/dL (AUCxa0=xa00.85, sensitivityxa0=xa069.2xa0%, specificityxa0=xa087.1xa0%) for age above and below 70, respectively.ConclusionsThe authors recommend preoperative haemoglobin cut-off values of 12.4xa0g/dL for age above 70 and 12.1xa0g/dL for age below 70 to be used to predict post-operative transfusion requirements in TKA. To maximise the utilisation of blood resources, the authors recommend that only patients with haemoglobin level below the cut-off should receive routine preoperative type and screen before TKA.Level of evidenceIV.