Comparative effectiveness of combined peri-articular and intra-articular injection versus intravenous and intra-articular injection of tranexamic acid in total knee arthroplasty: a randomized controlled trial study.

INTRODUCTION: Tranexamic acid (TXA) administration is supported by numerous evidence in reducing blood loss after total knee arthroplasty (TKA). The combination of intravenous (IV) and intra-articular (IA) TXA administration revealed good result in blood loss reduction with less evidence of venous thromboembolism event (VTE). Several literature reviews portray that peri-articular (PA) administration yields similar hemostasis in comparison to IV route. However, there is no report on the clinical effect of combining PA + IA TXA in blood loss reduction and its complications, compared to combining IV + IA TXA after TKA. MATERIALS AND METHODS: We conducted a double-blind, randomized controlled trial comparing the use of PA + IA TXA administration and IV + IA TXA administration in 70 patients who were scheduled for unilateral primary TKA. Thirty-five patients were assigned for PA + IA injection (Group 1) and anoter 35 patients were assigned for IV + IA injection (Group 2). Primary outcomes included total blood loss at 48 h, and the need for blood transfusion. Secondary outcomes included thigh and leg circumference, degree of knee flexion, and postoperative complications. RESULTS: The calculated blood loss at 48 h showed no difference between Groups 1 and 2 (617 ml vs. 632 ml, p = 0.425). The total hemoglobin and hematocrit changes were not different (1.89 g/dL vs. 1.97 g/dL, p = 0.371 and 5.66% vs. 5.87%, p = 0.391). There was no need for blood transfusion in either group. However, lower thigh swelling was significant in Group 1 (2.15 cm vs. 2.79 cm, p = 0.04). Leg circumferences at 48 h was also lower in Group 1 (42.12 cm vs. 42.77 cm, p = 0.04). There was no significant difference in knee flexion decrease between the two groups (38° vs. 37°, p = 0.425). There were no VTE complications or infections found in either group. CONCLUSIONS: Combined PA + IA TXA administration had similar efficacy in blood loss reduction and blood transfusion when compared to combined IV + IA TXA. The first group displayed less soft tissue swelling. The combination of PA + IA TXA administration can be used as an alternative regimen to avoid IV TXA administration.

Cementless and Cemented Total Knee Arthroplasties Have Similar Outcomes but Cementless Patellar Component Migration was Observed in a Paired Randomized Control Trial.

BACKGROUND: Cementless total knee arthroplasty (TKA) has become increasingly popular. Some surgeons are concerned about pain, implant stability, and metal-backed patellar component survivorship. This study investigated the outcomes of cementless compared with cemented TKA in bilateral cases. METHODS: We randomized 80 knees in 40 osteoarthritic knee patients who underwent bilateral TKA with patellar resurfacing under one anesthesia. All participants received cementless prostheses in one knee and cemented prostheses in the other. The outcomes were knee function measured by the forgotten joint scores, modified Western Ontario and McMaster Universities Osteoarthritis Index, knee ranges of motion, pain levels, operative times, radiographic outcomes, and complications. All knees were followed for a minimum of 2 years (2 to 3 years). RESULTS: Cementless and cemented TKA had similar functional outcomes in forgotten joint score (97 ± 5 versus 98 ± 3 points, P = .52), modified Western Ontario and McMaster Universities Osteoarthritis Index score (3 ± 4 versus 3 ± 2 points, P = .96), and ranges of motion (134 ± 7° versus 134 ± 7°, P = .16). The postoperative pain was also similar (P > .05). There were 4 cementless patellar components had superior migration for an average of 3.5 mm (range, 1.77 to 4.16) without loosening. The mean time of migration was 4 (range, 2 to 6) weeks. CONCLUSIONS: Cementless TKA had similar functional outcomes and recovery patterns compared with cemented TKA. However, there was concern of cementless component migration at patellae.

Wide-awake local anesthesia for clavicle fracture fixation: A case report.

INTRODUCTION: The wide-awake local anesthesia no tourniquet (WALANT) technique has been used in many orthopedic surgeries. The benefits of this technique are the avoidance of the adverse effects of general anesthesia (GA) and the overall reduction of the cost of surgery. However, a literature search revealed no published report on performing the WALANT technique for clavicular fracture surgery. PRESENTATION OF CASE: We report a case of mid-shaft clavicular fracture that was treated with plate osteosynthesis using the WALANT technique in a patient with uncontrolled atrial fibrillation. During the operation, the patient did not experience any pain, and the procedure could be performed easily due to minimal bleeding in the operative field. The operation was completed successfully without any complications, and the patient was discharged from the hospital the day after surgery. Follow-up radiographs after three months showed union of the clavicle at the fracture site, and the patient could use his arm normally. DISCUSSION: Clavicular fracture is routinely treated with plate osteosynthesis under general anesthesia. In some patients with high morbidity and other risk factors for whom GA is unsuitable, the WALANT technique can prove to be an effective alternative. CONCLUSION: Clavicular fixation can be performed successfully and without any complication under WALANT technique.

Distally Based Sartorius Flap to Cover Knee Joint Defect.

INTRODUCTION: The coverage of soft-tissue defects around the knee joint has many reconstructive techniques depending on the size, location, and depth. We report a case with large soft-tissue defect at anterior knee joint that primary closure cannot be done with successfully used distally based sartorius flap and full-thickness skin graft to cover this defect. CASE REPORT: A 30-year-old man had a large skin defect at the knee following a motorcycle accident. The patella tendon and patella were exposed. We use the sartorius muscle flap to cover the wound defect. First, a skin incision was done on the muscle alignment. Then, the sartorius muscle was dissected, and the proximal set of segmental vessels was identified and ligated. Afterward, the sartorius was moved into subcutaneous tunnel and expanded to provide coverage for the wound defect. Finally, we used the full-thickness skin graft to cover over the muscle flap. The flap and graft were survived. The patient could return to work after 1 month after the operation. CONCLUSION: In the case with soft-tissue defects around knee joint, there are many operative techniques. Our case has a large wound at anterior aspect of knee joint. We used the distally based sartorius flap to cover the wound defect. Following the transposition, the sartorius remained viable through out its length, and the patient had full post-operativerecovery.