Tranexamic acid (TXA) is proven to reduce blood loss following total knee arthroplasty (TKA), but there are limited data on the impact of similar dosing regimens in revision TKA. The purpose of this multicentre randomized clinical trial was to determine the optimal regimen to maximize the blood-sparing properties of TXA in revision TKA. From six-centres, 233 revision TKAs were randomized to one of four regimens: 1 g of intravenous (IV) TXA given prior to the skin incision, a double-dose regimen of 1 g IV TXA given both prior to skin incision and at time of wound closure, a combination of 1 g IV TXA given prior to skin incision and 1 g of intraoperative topical TXA, or three doses of 1950 mg oral TXA given two hours preoperatively, six hours postoperatively, and on the morning of postoperative day one. Randomization was performed based on the type of revision procedure to ensure equivalent distribution among groups. Power analysis determined that 40 patients per group were necessary to identify a 1 g/dl difference in the reduction of haemoglobin postoperatively between groups with an alpha of 0.05 and power of 0.80. Per-protocol analysis involved regression analysis and two one-sided Aims
Patients and Methods
Opioids are an important component of multimodal analgesia, but improper utilization places patients at risk for overdose and addiction. The purpose of this randomized controlled trial is to determine whether the quantity of opioid pills prescribed at discharge is associated with the total amount of opioids consumed or unused by patients after total hip (THA) and knee (TKA) arthroplasty. 304 Opioid naïve patients undergoing THA or TKA were randomized to receive a prescription for either 30 or 90 5mg oxycodone immediate release (OxyIR) tablets at discharge. All patients received acetaminophen, meloxicam, tramadol and gabapentin perioperatively. Daily opioid consumption, reported in morphine equivalent dose (MED), number of unused OxyIR, and pain scores were calculated for 30 days postoperatively with a patient-completed medication diary. The number of OxyIR refills and total MED received were recorded for 90 days postoperatively. Power analysis determined that 141 patients per group were necessary to detect a 25% reduction in means in opiate consumption between groups. Statistical analysis involved t-test, rank sum, and chi-squared tests with alpha=0.05.Introduction
Methods
Tranexamic acid (TXA) is proven to reduce blood loss following total knee arthroplasty (TKA), but there are limited data on the impact of similar dosing regimens in revision TKA that is associated with greater blood loss. The purpose of this multi-center randomized trial was to determine the optimal regimen to maximize the blood-sparing properties of TXA in revision TKA. 233 Septic and aseptic revision TKA from six-centers were randomized to either receive 1g pre-incision intravenous (IV) TXA, 1g pre- and post-incision IV TXA, 1g pre-incision IV and 1g intra-operative topical TXA, or three doses of 1950mg oral TXA given 2 hours pre-operatively, 6 hours post-operatively, and the morning of postoperative day 1. Randomization was performed based on type of revision to ensure equivalent distribution among groups. The primary outcome was reduction in hemoglobin. Power analysis determined 40 patients per group were necessary to identify a 1g/dL difference with an alpha of 0.05 and beta of 0.80. Per-protocol analysis involved regression analysis and two one-sided t-tests for equivalence.Introduction
Methods
Accurate placement of the acetabular component is essential in
total hip arthroplasty (THA). The purpose of this study was to determine
if the ability to achieve inclination of the acetabular component
within the ‘safe-zone’ of 30° to 50° could be improved with the
use of an inclinometer. We reviewed 167 primary THAs performed by a single surgeon over
a period of 14 months. Procedures were performed at two institutions:
an inpatient hospital, where an inclinometer was used (inclinometer
group); and an ambulatory centre, where an inclinometer was not
used as it could not be adequately sterilized (control group). We excluded
47 patients with a body mass index (BMI) of > 40 kg/m2,
age of > 68 years, or a surgical indication other than osteoarthritis
whose treatment could not be undertaken in the ambulatory centre.
There were thus 120 patients in the study, 68 in the inclinometer
group and 52 in the control group. The inclination angles of the acetabular
component were measured from de-identified plain radiographs by
two blinded investigators who were not involved in the surgery.
The effect of the use of the inclinometer on the inclination angle
was determined using multivariate regression analysis.Aims
Patients and Methods
Instability remains a challenging problem in both primary and
revision total hip arthroplasty (THA). Dual mobility components
confer increased stability, but there are concerns about the unique
complications associated with these designs, as well as the long-term
survivorship. We performed a systematic review of all English language articles
dealing with dual mobility THAs published between 2007 and 2016
in the MEDLINE and Embase electronic databases. A total of 54 articles
met inclusion criteria for the final analysis of primary and revision
dual mobility THAs and dual mobility THAs used in the treatment
of fractures of the femoral neck. We analysed the survivorship and
rates of aseptic loosening and of intraprosthetic and extra-articular
dislocation.Aims
Materials and Methods
Accurate placement of the acetabular component is essential in Total Hip Arthroplasty (THA). The purpose of this study is to determine if an analog spirit level can improve the surgeon's ability to achieve acetabular inclination within the “safe-zone” of 30 to 50 degrees. We reviewed 167 primary THAs performed by a single surgeon over 14 months. Procedures were performed at two facilities, an inpatient hospital where a spirit level was utilized and an ambulatory facility where it was not. We excluded 47 patients with a BMI>40, age>68 or a surgical indication other than osteoarthritis who were not candidates for the ambulatory center. Cup inclination angles were measured from de-identified plain radiographs by two blinded investigators not involved in the index procedures. The effect of level usage on inclination angle was determined using multivariate regression analysis. The mean inclination angle for the 68 hips performed with the level was 42.9 degrees (95% CI: 41.7–44.0) compared to 46.5 degrees (95% CI: 45.2–47.7) for the 52 hips without it (p<.001). Regression analysis demonstrated a 9.1% difference in cup inclination due to the level (p<.001), and THAs performed without the level were 3 times more likely to result in inclinations > 50 degrees (OR 2.8, p=.036). The two investigators' measurements demonstrated a correlation of 0.95 (95% CI: 0.93–0.97). Use of a simple spirit level resulted in a significant reduction in the number of outliers compared to the freehand technique. The spirit level may be a simple and inexpensive tool to improve acetabular component abduction angles.
The purpose of this study is to determine if higher volume hospitals
have lower costs in revision hip and knee arthroplasty. We questioned the Centres for Medicare and Medicaid Services
(CMS) Inpatient Charge Data and identified 789 hospitals performing
a total of 29 580 revision arthroplasties in 2014. Centres were
dichotomised into high-volume (performing over 50 revision cases
per year) and low-volume. Mean total hospital-specific charges and
inpatient payments were obtained from the database and stratified
based on Diagnosis Related Group (DRG) codes. Patient satisfaction
scores were obtained from the multiyear CMS Hospital Compare database.Aims
Materials and Methods
Malnutrition is a potentially modifiable risk factor that may contribute to complications following geriatric hip fracture surgery. The purpose of this study was to investigate the association between preoperative hypoalbuminemia, a marker for malnutrition, and complications during the thirty days following surgery for geriatric hip fracture. The American College of Surgeons National Surgical Quality Improvement Program was used to conduct a retrospective cohort study of geriatric patients (>65 years) undergoing surgery for hip fracture. Patients without preoperative serum albumin concentration were excluded. Outcomes were compared between patients with and without hypoalbuminemia (defined as serum albumin concentration <3.5g/dL). All comparisons were adjusted for baseline differences between populations. 17,651 Patients were identified. Of these, 8,272 (46.9%) underwent hemiarthroplasty, 759 (4.3%) total joint arthroplasty, 324 (1.9%) percutaneous fixation, 2,445 (13.9%) plate/screw fixation, and 5,833 (33.1%) intramedullary fixation. The prevalence of hypoalbuminemia was 45.9% (Figure 1). The risk for death was strongly associated with serum albumin concentration, with a linear increase in risk observed as albumin fell below 3.5 g/dL (p<0.001; Figure 2). Following adjustment for all demographic, comorbidity, and procedural characteristics, patients with hypoalbuminemia had higher rates of death (9.94% versus 5.53%, adjusted relative risk [RR]=1.54, p<0.001), pneumonia (5.30% versus 3.77%, adjusted RR=1.20, p=0.012), sepsis (1.19% versus 0.53%, adjusted RR=1.90, p<0.001), and hospital readmission (10.91% versus 9.03%, adjusted RR=1.11, p<0.036; Table 1). The present study suggests that hypoalbuminemia is a powerful independent risk factor for death following surgery for geriatric hip fracture. This association persists over-and-above any associations of death with age, sex, body mass index, and comorbidities. Based on these data, we propose that the nutritional status of hip fracture patients should receive greater attention, and that randomized trials testing for efficacy of aggressive postoperative nutritional interventions may be warranted. For any figures or tables, please contact the authors directly by clicking on ‘Info & Metrics’ above to access author contact details.
