Comparison of Intravenous and Topical Tranexamic Acid in Total Joint Arthroplasty.

PURPOSE OF THE STUDY To compare topical and intravenous (IV) administration of tranexamic acid (TXA) 2 g in patients undergoing total hip arthroplasty (THA), or total knee arthroplasty (TKA). MATERIAL AND METHODS In total, 452 patients undergoing THA or TKA were randomised to 3 groups: 1) the IV TXA group received 2 doses of TXA 1 g intravenously 3 hours apart; 2) the topical TXA group received TXA 2 g topically, and 3) the NO TXA - control group. Furthermore, each group was divided in two subgroups by performed surgery (THA versus TKA). The following endpoints were used for final analysis: postoperative blood loss, transfusion requirement, haemoglobin drop and postoperative complications (haematoma, surgical site infection, thromboembolism, early surgical revision). RESULTS Both topical and IV administration of TXA significantly reduced postoperative bleeding (mean ± standard deviation) after THA and TKA (topical 504.4±281.0 ml, IV 497.3±251.7 ml, NO 863.1±326.4 ml, p<0.001). Topical use was superior to IV in reducing postoperative drainage output in THA (topical 377±213.3 ml, IV 518.1±259.0 ml, p<0.01). On the opposite, IV use was superior to topical in drainage output in TKA (topical 646.1±281.3 ml, IV 457.8±235.8 ml, p<0.01). The differences in transfusion requirement and Hb drop between these administration methods were not statistically significant (p≥0.05), but any TXA administration was significantly better than no TXA in all endpoints of efficacy (p<0.001). The lowest complication rate was observed in the topical group (NO 24%, IV 19%, topical 7.5%). DISCUSSION Consensus on optimal TXA dosing regime in primary hip and knee arthroplasties is still missing. Use of TXA therapy in routine clinical practice is highly individualized in accordance with the current approach of personalized medicine. Topical application seems to be the safest route of TXA administration. However, precise application technique is essential. IV TXA is beneficial especially in patients with some bleeding coagulopathies undergoing TKA with a tourniquet. Repeat doses of TXA are not usually necessary after completed primary arthroplasties. CONCLUSIONS IV and topical TXA 2 g have similar effect on reduction of transfusion requirements and haemoglobin drop in THA and TKA. The IV route is superior to topical in TKA while topical TXA reduces complications in both THA and TKA. Key words: tranexamic acid, total hip arthroplasty, total knee arthroplasty, topical administration, intravenous administration.

[Intramedullary Nailing of Supracondylar Femoral Fracture in Patient with Achondroplasia. Small Size Matters]. / Intramedulárna osteosyntéza suprakondylickej zlomeniny femuru u pacienta s achondropláziou. Malý rozmer obmedzuje.

In patients with defect bone growth and dwarfism, fractures of the weight bearing skeleton are relatively rare due to their reduced mobility. When they do occur, their treatment and potential surgery are complicated. The commonly used therapeutic procedures are not applicable, the available implants are not suitable, if a surgery is necessary. An individual approach and often times also improvisation is needed. It is important to realize that these patients do not suffer from an intellectual disability and are fully aware of their physical impairment, which we must not make worse without an effort for adequate treatment. This case study presents our solution of a supracondylar femoral fracture in a patient with achondroplasia and extreme obesity. A proximal humeral nail was used for distal femoral fracture osteosynthesis by a retrograde approach. To the knowledge of authors, this study reports on the first case of supracondylar femoral fracture surgery in patients with achondroplasia. Key words: achondroplasia, dwarfism, supracondylar femoral fracture, extreme obesity.

[Acute Limb Ischemia after Total Hip Arthroplasty in a High-Risk Patient - Is Tranexamic Acid to Blame?] / Akútna koncatinová ischémia po náhrade bedrového klbu u rizikového pacienta ­ môze za to kyselina tranexamová?

Tranexamic acid (TXA) is widely used to limit the blood loss during total joint arthroplasty without an increased risk of thromboembolic events. We present a case of acute limb ischaemia due to thrombotic occlusion of the superficial femoral artery on the non-operated limb following a total hip arthroplasty in a 64-year-old male patient. Untreated peripheral artery disease, intravenous TXA administration, surgery, obesity and hypertension were identified as predisposing factors of the occlusion. Good reperfusion of the limb was obtained after mechanical thrombectomy. Other cases report that antifibrinolytic agents such as TXA could be associated with arterial thrombosis. The necessity to detect the risk factors of thrombotic events in each patient scheduled for total joint arthroplasty is emphasized. Therefore, topical TXA administration could be a reasonable alternative in a high-risk patient. Key words: tranexamic acid complications, total hip arthroplasty, arterial thrombosis.

Effect of long-term oral anticoagulant therapy on bone mineral density and bone turnover markers: a prospective 12 month study.

INTRODUCTION: Vitamin K-dependent posttranslational modification of glutamate to gamma-carboxyglutamate is a biochemical feature of the vertebrate blood-clotting cascade. This conversion activates clotting factors and bone proteins, including osteocalcin, a widely accepted marker of osteoblastic activity. Vitamin K antagonists, such as warfarin, inhibit this process. OBJECTIVE: This study was aimed at evaluating the effect of warfarin treatment on BMD and bone turnover markers and determining the relationship between BMD and bone turnover markers. PATIENTS AND METHODS: Fifty-four warfarin users and 62 age- and sex-matched healthy controls were enrolled in 1-year prospective study. Bone mineral density, bone turnover markers, 25-hydroxyvitamin D, serum and urinary calcium measurements were done at baseline and after 12 months of warfarin treatment. RESULTS: No differences were observed between warfarin-treated and control groups in Ca-S, Ca-dU, ALP-S, 25-OHD and BMD after 12 months.The concentrations of serum CTx (306.48 +/- 29 ng/l) and osteocalcin (16.54 +/- 1.06 ig/l) were significantly lower (p < 0.001 and p < 0.05 respectively) after 12 month in warfarin-treated group compared to control group (403.29 +/- 24.7 ng/l and 22.88 +/- 1.33 ig/l). A significant increase in serum and urinary Ca values (p < 0.05) was observed in patients with oral anticoagulant therapy after 12 month compared to baseline levels. Biochemical markers of bone metabolism did not correlate with BMD in either group. CONCLUSION: The long-term use of coumarin was not associated with decreased bone mineral density in our study, but the significantly lower OC and CTx serum levels in coumarin-treated patients suggest that vitamin K has an influence on bone turnover (Tab. 3, Fig. 2, Ref. 29). Full Text in free PDF www.bmj.sk.

[The fate of first cup arthroplasty implanted in slovakia.]. / Osud prvej implantovanej cup artroplastiky na Slovensku.

Authors describe a case of a patient, by whom the first cup arthroplasty in Slovakia was implanted by prof. Cervenanský in 1948. 17 years after the implantation a gradual onset of limitation in motion began. A painfull contracture developed with a functional shortening of the lower extremity. 50 years after the implantation of the cup arthroplasty a conversion to a cemented total hip prosthesis was successfuly realised with a good result. Key words: cup arthroplasty, prof. Cervenanský, conversion.

[The shape of the acromion and its effect on the subacromial space]. / Tvar akromia a jeho vplyv na subakromiálny priestor.

PURPOSE OF THE STUDY: A great variability of the shape of acromion exists in the population. The shape of the acromion plays a great role in development of the pathology of the subacromial space. Quantification of the anatomical changes using radiological examination (X-ray. CT) is a major contribution to the diagnosis of the subacromial space disorders and to differential diagnosis of painful affections of the shoulder. The aim of the study was to assess the prevalence of the degenerative changes in the subacromial space and their relation to the shape of the inferior space of acromion in our population. MATERIAL AND METHODS: In 50 randomly chosen cadavers during autopsy both shoulders where surgically explored in order to evaluate the changes on the rotator cuff and the changes on the major tubercule, on the tendon of the long head of biceps brachii in correlation to the shape of the inferior surface of acromion. RESULTS: Rotator cuff lesions of variable size were found in 16 cadavers, in 10 cases the lesion was unilateral, in 6 cases bilateral. The lesions were more often seen in the older age group. With increasing concavity of the inferior surface of acromion not only the number of the rotator cuff lesions and degenerative changes in the subacromial space were increasing, but so was the amount of the changes. CONCLUSION: The shape of acromion and increasing concavity plays a major role in the development of the subacromial pathology, accelerate the degenerative changes in this space. Reshaping the undersurface of acromion and diminishing the concavity in first stages of clinical symptoms, which present mostly as impingement syndrome, is reasonable to prevent larger pathological deterioration in subacromial space. The authors conclude that according to the relation between the shape of the inferior surface of acromion and the amount of lesion an early operative procedure is valuable.

[Osteochondroma of the first rib.]. / Osteochondróm prvého rebra.

Authors describe a rare case of a solitary osteochondroma of the first rib in a 21 years old male. There have been only 3 cases reported in the medical literature so far. In those cases osteochondroma was never the cause of symptomatology from side of the vascular system. Clinical and CT examination definitely showed the cause of symptoms and the extent and localization of the osteochondroma. Complete resection and exstirpation was followed by rapid full recovery. Key words: osteochondroma of the first rib, CT diagnosis.

[Dislocation of the cemented total hip endoprosthesis - risk and therapy.]. / Luxácie cementovaných totálnych endoprotéz bedrového klbu - riziko a liecba.

In 11 out of 1699 patients, who underwent a total hip replacement with a cemented THR during a 10 year period, dislocation of the prosthesis occured in the postoperative period. The operations were made using an anterolateral approach. Dislocation occured in 7 patients after a primary implantation (0,42 %) and in 4 patients after a revision operation (1,6 %). Reorientation of the acetabular component was necessary in 1 case, in 5 cases closed reduction was successful, in 3 cases open reduction was needed. Acetabular augmentation using a polyethylen acetabular shell and cortical screws was performed in 2 patients with recurrent dislocation of the prosthesis. In all cases it was possible to regain the stability of the prosthesis. The results were reviewed in average 46 months (20 to 82 months) postoperatively. In 1 patient deep infection arised after open reduction. Key words: total hip prosthesis, complications, dislocation.