Sattar Alshryda

Systematic review and meta-analysis of the use of tranexamic acid in total hip replacement

We report a systematic review and meta-analysis of published randomised controlled trials evaluating the efficacy of tranexamic acid (TXA) in reducing blood loss and transfusion in total hip replacement (THR). The data were evaluated using the generic evaluation tool designed by the Cochrane Bone, Joint and Muscle Trauma Group. We identified 11 clinical trials which were suitable for detailed extraction of data. There were no trials that used TXA in revision THR. A total of seven studies (comprising 350 patients) were eligible for the blood loss outcome data. The use of TXA reduced intra-operative blood loss by a mean of 104 ml (95% confidence interval (CI) -164 to -44, p = 0.0006, heterogeneity I(2) 0%), postoperative blood loss by a mean of 172 ml (95% CI -263 to -81, p = 0.0002, heterogeneity I(2) 63%) and total blood loss by a mean of 289 ml (95% CI -440 to -138, p < 0.0002, heterogeneity I(2) 54%). TXA led to a significant reduction in the proportion of patients requiring allogeneic blood transfusion (risk difference -0.20, 95% CI -0.29 to -0.11, p < 0.00001, I(2) 15%). There were no significant differences in deep-vein thrombosis, pulmonary embolism, infection rates or other complications among the study groups.

A systematic review and meta-analysis of the topical administration of tranexamic acid in total hip and knee replacement

Intravenous tranexamic acid (TXA) has been shown to be effective in reducing blood loss and the need for transfusion after joint replacement. Recently, there has been interest in applying it topically before the closure of surgical wounds. This has the advantages of ease of application, maximum concentration at the site of bleeding, minimising its systemic absorption and, consequently, concerns about possible side-effects. We conducted a systematic review and meta-analysis which included 14 randomised controlled trials (11 in knee replacement, two in hip replacement and one in both) which investigated the effect of topical TXA on blood loss and rates of transfusion. Topical TXA significantly reduced the rate of blood transfusion (total knee replacement: risk ratio (RR) 4.51; 95% confidence interval (CI): 3.02 to 6.72; p < 0.001 (nine trials, I(2) = 0%); total hip replacement: RR 2.56; 95% CI: 1.32 to 4.97, p = 0.004 (one trial)). The rate of thromboembolic events with topical TXA were similar to those found with a placebo. Indirect comparison of placebo-controlled trials of topical and intravenous TXA indicates that topical administration is superior to the intravenous route. In conclusion, topical TXA is an effective and safe method of reducing the need for blood transfusion after total knee and hip replacement. Further research is required to find its optimum dose for topical use.

Topical (Intra-Articular) Tranexamic Acid Reduces Blood Loss and Transfusion Rates Following Total Knee Replacement

BACKGROUND Approximately one-third of patients undergoing total knee replacement require one to three units of blood postoperatively. Tranexamic acid (TXA) is a synthetic antifibrinolytic agent that has been successfully used intravenously to stop bleeding after total knee replacement. A topical application is easy to administer, provides a maximum concentration of tranexamic acid at the bleeding site, and is associated with little or no systemic absorption of the tranexamic acid. METHODS A double-blind, randomized controlled trial of 157 patients undergoing unilateral primary cemented total knee replacement investigated the effect of topical (intra-articular) application of tranexamic acid on blood loss. The primary outcome was the blood transfusion rate. Secondary outcomes included the drain blood loss, hemoglobin concentration drop, generic quality of life (EuroQol), Oxford Knee Score, length of stay, a cost analysis, and complications as per the protocol definitions. RESULTS Tranexamic acid reduced the absolute risk of blood transfusion by 15.4% (95% confidence interval [CI], 7.5% to 25.4%; p = 0.001), from 16.7% to 1.3%, and reduced blood loss by 168 mL (95% CI, 80 to 256 mL; p = 0.0003), the length of stay by 1.2 days (95% CI, 0.05 to 2.43 days; p = 0.041), and the cost per episode by £333 (95% CI, £37 to £630; p = 0.028). (In 2008, £1 = 1.6 U.S. dollars.) Oxford Knee Scores and EuroQol EQ-5D scores were similar at three months. CONCLUSIONS Topically applied tranexamic acid was effective in reducing the need for blood transfusion following total knee replacement without important additional adverse effects. LEVEL OF EVIDENCE Therapeutic level I. See Instructions for Authors for a complete description of levels of evidence.

Acute fractures of the scaphoid bone: Systematic review and meta-analysis

BACKGROUND The scaphoid fractures account for 50%-80% of all carpal bone fractures in young individuals. Non-union of the fracture occurs in approximately 5%-10% of undisplaced scaphoid fractures. Current management varies significantly among different places and surgeons. OBJECTIVES The purpose of this review is to investigate the evidence of the effectiveness and safety of various treatments of acute scaphoid fractures. METHODOLOGY Systematic review and metanalysis of all the randomised and quasi-randomised trials comparing different treatments of acute scaphoid fractures. RESULTS Thirteen RCTs (Published 18 times) have met our inclusion criteria. The followings have been investigated: 1. Colles cast versus scaphoid cast. 2. Above elbow versus below elbow scaphoid cast. 3. Colles cast with the wrist in flexion versus Colles cast with the wrist in extension. 5. Operative versus non-operative treatment. 6. Union rate versus time to union. CONCLUSION Scaphoid fracture can be treated by Colles cast for up to 12 weeks. The wrist should not be in flexion. There is no advantage of an above elbow cast over a below elbow cast. Operative treatment for scaphoid does not provide a higher union rate in undisplaced fractures, but may do in displaced fracture. Open approach seems to be superior to percutaneous fixation.

Severe slipped upper femoral epiphysis; fish osteotomy versus pinning-in-situ: an eleven year perspective.

PURPOSE Slipped upper femoral epiphysis (SUFE) is not common with a reported incidence of 10 per 100 000. The management of SUFE is controversial and evolving, with advancing surgical skills and expertise. The infrequency of cases, the various classifications in use, the various surgical treatments, and lack of robust evidence for outcomes, has resulted in the lack of clear, evidence-based recommendations for treatment. Although mild slip can be treated with pinning-in-situ (PIS) with predictably good outcome, moderate and severe slips present a challenge for the treating surgeons. It is logical to reduce the slip to near anatomical position; however, this desire has always been tempered by concerns about the potentially devastating complications of osteonecrosis and Chondrolysis METHODS This is a single centre, retrospective study comparing (PIS) and Fish femoral neck osteotomy. Seventy four children presented with SUFE (90 hips). The mild and the moderate groups were treated with a single pining-in-situ (PIS). The severe group had either a surgical reduction by Fish femoral neck osteotomy or PIS. The study was approved by the regional and local ethic committee. Demographic data, clinical findings, radiographic features were collected. RESULTS Avascular necrosis of the femoral head (osteonecrosis) was the primary outcome. There were 11 cases of osteonecrosis (12.2%): 3/41(6.9%) in the stable group compared to 7/22 (31.8%) in the unstable group, statistically significant [P < 0.001]. In the severe slip group, the osteonecrosis rate was 33.3% in the PIS group and 26.6% in the Fish osteotomy (P = 0.539). This is not statistically significant, but the trend favours surgical reduction. CONCLUSIONS Then reduction of the deformity is valuable. The majority of cases that do not suffer osteonecrosis will benefit by reduction of the deformity; those who are destined to develop osteonecrosis are still better off with the femoral head in a reduced position. The unstable slip is more likely to be severe and more likely therefore to receive surgical reduction than a stable and less severe hip. The implication here is that the osteotomy might not be the cause of the osteonecrosis; it is the vascular damage due to the instability of the slip that is responsible.

The effect of tranexamic acid on artificial joint materials: a biomechanical study (the bioTRANX study)

BackgroundTranexamic acid (TXA) has been successfully used to reduce bleeding in joint replacement. Recently local TXA has been advocated to reduce blood loss in total knee or hip replacement; however, this raised concerns about potential adverse effects of TXA upon the artificial joint replacement.Materials and methodsIn this biomechanical study we compared the effects of TXA and saline upon the following biomechanical properties of artificial joint materials—(1) tensile properties (ultimate strength, stiffness and Young’s modulus), (2) the wear rate using a multi-directional pin-on-plate machine, and (3) the surface topography of pins and plates before and after wear rate testing.ResultsThere were no significant differences in tensile strength, wear rates or surface topography of either ultra-high-molecular-weight polyethylene pins or cobalt chromium molybdenum metal plates between specimens soaked in TXA and specimens soaked in saline.ConclusionBiomechanical testing shows that there are no biomechanical adverse affects on the properties of common artificial joint materials from using topical TXA.Level of evidenceV

Interventions for treating slipped upper femoral epiphysis (SUFE)

Although a rare condition, slipped upper femoral epiphysis (SUFE) is one of the most common types of paediatric and adolescent hip disorder. SUFE involves instability of the growth plate (often called the physis) at the junction between the head and neck of the thigh bone (femur) resulting in the head of the femur staying in the acetabulum and the neck slipping forward and outward. Although, the cause is poorly understood, several anatomical features and medical conditions have been implicated. The following features lead to an increase in the shear forces across the physis and can lead to SUFE (Herring 2008): 1. increased weight (> 80th centile); 2. femoral retroversion (> 10o); 3. increased physis height due to widened hypertrophic zone; 4. more vertical slope of the physis; and 5. trauma. Medical conditions associated with SUFE include endocrine disorders, renal failure osteodystrophy and previous radiation therapy (Loder 2000). About 30% of SUFE patients subsequently develop bilateral SUFE with the other hip slipping as well.

Total hip arthroplasty in patients with Trisomy 21: Systematic review and exploratory patient level analysis

INTRODUCTION Trisomy 21 is the most common chromosomal disorders in humans; it is caused by an extra copy of chromosome number 21. This extra chromosomal material causes widespread abnormalities involving nearly every part of human body. Hip disorders are the second most serious musculoskeletal disorder in patients with T21 with a reported incidence between 2 and 28%. The outcomes of these hip disorders in patients with T21 are much less favorable than similar hip diagnoses in normal patients and a substantive number of these patients develop severe osteoarthritis that require total hip arthroplasty (THA). The outcome of THA in this cohort of patient is not well studied. METHODS A modified Cochrane review methodology has been utilized in this review. An extended literature search was performed of the medical databases. A hierarchical approach was used to include relevant studies. Search, published papers and extracted data were checked by authors independently then jointly to ensure accuracy. RESULTS Nine studies (321 patients with Trisomy 21) who underwent total hip arthroplasty (THA) were included. The functional hip scores (Harris and WOMAC hip scores) improved substantively after hip arthroplasty. The 5-year cumulative revision rate was 7.5%; twice as high as age matched control. Medical and surgical complications were 3 times higher than matched controls. CONCLUSION Total hip arthroplasty can be offered to patients with T21 and severe arthritis although the increased revision and complication rates must be appreciated by patients and care givers.

Snapping Hip Syndrome: Result of Partial Release and Anterior Transposition of Iliotibial Band

Objectives Snapping hip syndrome has been a known entity for long, but has only recently been studied in detail. It however remains poorly understood and infrequently diagnosed due to the paucity of the condition. As a result, the literature remains scarce and scattered about the management, with most series limited to less than 15 patients. We present our experience in operative and conservative management of this condition in a series of 20 patients. We describe an out patient operative approach involving release and anterior transposition of the posterior half of the iliotibial band. Methods Review of results in 20 patients [25 hips] treated operatively over last 12 years after failed conservative treatment. Results Dramatic reduction in average visual analog scale and clicking score from 6 and 9 to 0.7 and 0.6, respectively. Significant improvement in quality of life score from 5 to 9 postoperatively [out of a maximum of 10]. All the patients reported good to excellent relief in symptoms postoperatively and walking distance was no longer limited by hip pain or clicking. Five patients had bilateral surgery and the rest replied in affirmative when asked if they would prefer this procedure in future if the other hip became symptomatic. Conclusions We did not have any major complications after the procedure and had a high satisfaction rate of 95 percent. None of the patients have needed a repeat surgery yet. Most patients reported impressive relief in their snapping symptoms, but pain relief was variable. This approach has yielded satisfactory and reproducible results and we would recommend this approach in snapping hip refractory to conservative treatment.