The effectiveness of low-dose and high-dose tranexamic acid in posterior lumbar interbody fusion: a double-blinded, placebo-controlled randomized study.

PURPOSE: Tranexamic acid is a proven drug used for reduction of intraoperative blood loss in spinal surgery. However, optimal dosing considering risk/benefits is not well established owing to the heterogeneity in patient selection and surgical procedures of previous studies. This study aimed to evaluate the effectiveness and safety of various tranexamic acid regimens in reducing perioperative blood loss in single-level posterior lumbar interbody fusion (PLIF). METHODS: Patients were randomly grouped into three different interventions: low-dose tranexamic acid (LD), high-dose tranexamic acid (HD), and placebo-controlled (PC) groups. The HD and LD groups received 10 and 5 mg/kg of bolus loading dose and 2 and 1 mg/kg of continuous infusion until 5 h after surgery, respectively. Data on patient demographics and preoperative and 24-h postoperative laboratory values were collected. Outcome parameters include intraoperative blood loss, 24-h postoperative blood loss, and blood loss during removal of the last drain. RESULTS: Seventy-two patients (mean age 63.3 ± 7.6 years) showed similar baseline characteristics. Intraoperatively, blood loss was reduced by the administration of tranexamic acid (P = 0.04), contributed predominantly by a difference between the LD and HD groups (123 mL; P < 0.01). The 24-h postoperative blood loss was reduced (P < 0.01), contributed predominantly by a difference between the PC and LD groups (144 mL; P = 0.02). During the removal of the last drain, statistical difference was found between the PC and HD groups (125 mL; P = 0.00). No complications or side effects from tranexamic acid use were noted. CONCLUSION: Tranexamic acid administration for single-level PLIF was effective and safe in reducing perioperative blood loss in a dose-dependent manner. An HD regimen comprising 10 mg/kg of bolus loading dose and 2 mg/kg/h of continuous infusion is recommended. LEVEL OF EVIDENCE: Level 1 study according to Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence.

Pneumatic compression device does not show effective thromboprophylaxis following total knee arthroplasty in a low incidence population.

INTRODUCTION: Purpose of this study was to assess whether the intermittent pneumatic compression (IPC) device would be an effective prophylaxis for deep vein thrombosis (DVT) following total knee arthroplasty (TKA) in a low incidence population. HYPOTHESIS: The mechanical thromboprophylaxis could reduce the incidence of DVT compared to non-prophylaxis group and would have similar efficacy as the chemoprophylaxis following TKA in a low DVT incidence population. MATERIALS AND METHODS: From January 2009 to June 2016, 1259 elective primary TKA with preoperative diagnosis of primary osteoarthritis in a single institute were enrolled. Patients were divided into three groups: those who were managed with chemoprophylaxis (CPX group, 414 cases), with mechanical prophylaxis (IPC group, 425 cases), or without pharmacological and mechanical prophylaxis (control group, 420 cases). All patients underwent preoperative ultrasonography and computed tomographic venography on postoperative day 6 to assess development of DVT. The incidence of overall, proximal, symptomatic DVT and symptomatic pulmonary embolism (PE) were compared among the groups. Major and minor bleeding complications were also evaluated. RESULTS: The incidence of overall DVT was 14.8% in control group, 6.3% in CPX group and 11.3% in IPC group respectively and CPX group showed significantly lower incidence than other two groups (p<0.001). The incidence of proximal DVT was 1.9% in control group, 0.7% in CPX group and 0.9% in IPC group respectively (p>0.05). The incidence of symptomatic DVT was 0.7% in control group, 0% in CPX group and 0.7% in IPC group respectively (p>0.05). There was no case of symptomatic PE diagnosed during hospital stay in all patients. DISCUSSION: Single use of IPC device could not reach significant level of DVT prophylaxis compared to control group and only chemoprophylaxis showed significantly reduce the incidence of overall DVT following TKA. Single use of IPC device does not show effective thromboprophylaxis in a low DVT incidence population. LEVEL OF EVIDENCE: III, case control study.

Radiologic Comparison of Humeral Position according to the Implant Designs Following Reverse Shoulder Arthroplasty: Analysis between Medial Glenoid/Medial Humerus, Lateral Glenoid/Medial Humerus, and Medial Glenoid/Lateral Humerus Designs.

BACKGROUND: The currently available reverse shoulder arthroplasty (RSA) designs can be classified into medial glenoid/medial humerus (MGMH), lateral glenoid/medial humerus (LGMH), and medial glenoid/lateral humerus (MGLH) prosthesis designs. The purpose of this study was to radiologically analyze the effect of different RSA designs on humeral position following RSA. METHODS: A total of 50 patients who underwent primary RSA were retrospectively analyzed. Among 50 patients, 33 patients (group A: MGMH) underwent RSA with Aequalis system (Wright, Inc, Bloomington, MN, USA), 6 (group B: LGMH) with Aequalis system using bony increased offset, and 11 (group C: MGLH) with Aequalis Ascend Flex system. The acromiohumeral distance, acromioepiphyseal distance (AED), lateral humeral offset (LHO), LHO from the center of rotation (LHOCOR), and deltoid length were radiologically measured to quantify the distalization and lateralization of the humerus. RESULTS: The increment in postoperative AED was 19.92 ± 3.93 mm in group A, 24.52 ± 5.25 mm in group B, and 25.97 ± 5.29 mm in group C, respectively (p=0.001). The increment in postoperative LHO was 0.13 ± 6.30 mm, 8.00 ± 12.14 mm, and 7.42 ± 6.88 mm, respectively (p=0.005). The increment in postoperative LHOCOR was 20.76 ± 6.06 mm, 22.04 ± 5.15 mm, and 28.11 ± 4.14 mm, respectively (p=0.002). CONCLUSIONS: The radiologic analysis of the effect of different RSA designs on humeral position following RSA showed significant differences in the increment in postoperative AED, LHO, and LHOCOR between the 3 groups. Therefore, MGLH design seems to be more effective for humeral distalization and lateralization compared to original Grammont design.

Arthroscopic Knot Removal for Failed Superior Labrum Anterior-Posterior Repair Secondary to Knot-Induced Pain.

BACKGROUND: Studies on failed superior labrum anterior-posterior (SLAP) repair are increasing. However, the number of reports on treatment options for failed SLAP repair remains quite low, and the clinical results vary between different study groups. PURPOSE: To describe the clinical presentation of failed SLAP repair due to knot-induced pain and evaluate the efficacy of arthroscopic knot removal. STUDY DESIGN: Case series; Level of evidence, 4. METHODS: The authors retrospectively reviewed records of 11 patients (mean age, 24.6 ± 8.6 years; range, 17-43 years) with stable, healed SLAP lesions with knot-induced pain after arthroscopic fixation of unstable type II SLAP lesions. All patients demonstrated a positive compression-rotation test before knot removal. The mean follow-up duration after knot removal was 48.0 ± 37.4 months (range, 24-156 months). The mean duration between primary fixation and knot removal was 21.2 ± 14.7 months (range, 8-56 months). RESULTS: Sharp pain (100%) and clicking (64%) were the most common symptoms. The knot was positioned on the glenoid side in 5 patients and the labral side in 6 patients. The knots on the glenoid side had associated humeral head cartilage damage. The mean University of California at Los Angeles score significantly improved from 15.2 points to 31.7 points after knot removal ( P = .003) Additionally, the mean Constant score greatly improved from a mean of 56.5 points to 89.8 points ( P = .003). At a mean of 3 weeks after surgery, we observed dramatic pain relief. Six weeks after surgery, the compression-rotation test was negative in all patients. CONCLUSION: The most common symptom of knot-induced pain after SLAP repair was persistent sharp pain followed by clicking. The knot appears to be a cause of pain in failed SLAP repairs, and arthroscopic knot removal can provide dramatic pain relief and significant improvement of clinical outcomes.

Comparison of Clinical and Radiological Results in the Arthroscopic Repair of Full-Thickness Rotator Cuff Tears With and Without the Anterior Attachment of the Rotator Cable.

BACKGROUND: The anterior rotator cable is critical in force transmission of the rotator cuff. However, few clinical studies have examined the correlation between the integrity of the anterior supraspinatus tendon and surgical outcomes in patients with rotator cuff tears. PURPOSE: To compare the clinical and structural outcomes of the arthroscopic repair of full-thickness rotator cuff tears with and without anterior disruption of the supraspinatus tendon. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: One hundred eighty-one shoulders available for magnetic resonance imaging (MRI) at least 6 months after arthroscopic rotator cuff repair, with a minimum 1-year follow-up, were enrolled. The anterior attachment of the rotator cable was disrupted in 113 shoulders (group A) and intact in 68 shoulders (group B). The mean age at the time of surgery in groups A and B was 59.6 and 59.2 years, respectively, and the mean follow-up period was 24.2 and 25.1 months, respectively. RESULTS: There were statistically significant differences in the preoperative tear size and pattern and muscle fatty degeneration between the 2 groups ( P = .004, P = .008, and P < .001, respectively). At final follow-up, the mean visual analog scale (VAS) for pain score during motion was 1.31 ± 0.98 and 1.24 ± 0.90 in groups A and B, respectively ( P = .587). The mean Constant score was 77.5 ± 11.2 and 78.0 ± 11.9 points in groups A and B, respectively ( P = .875). The mean University of California, Los Angeles score was 30.5 ± 4.1 and 31.0 ± 3.0 points in groups A and B, respectively ( P = .652). In assessing the repair integrity on postoperative MRI, the retear rate was 23.9% and 14.7% in groups A and B, respectively ( P = .029). CONCLUSION: Irrespective of involvement in the anterior attachment of the rotator cable, the mean 24-month follow-up demonstrated excellent pain relief and improvement in the ability to perform activities of daily living after arthroscopic rotator cuff repair. However, tears with anterior disruption of the rotator cable showed a significantly larger and more complex tear pattern and more advanced fatty degeneration. Additionally, the retear rate was significantly higher in patients with a tear involving the anterior attachment of the rotator cable.