Low-volume formulation of intra-articular tranexamic acid, 25-ml tranexamic acid (2.5 g) plus 20-ml saline, is effective in decreasing blood transfusion rate in primary total knee replacement even without preoperative haemoglobin optimization.

UNLABELLED: The efficacy of intra-articular tranexamic acid (TXA) to decrease blood loss after total knee replacement (TKR) has been confirmed in randomised clinical trials (RCTs) and meta-analysis. However, insufficient data are still available about the efficacy in clinical practice of intra-articular TXA administration in reducing the rate of postoperative blood transfusion. To prove the efficacy of a low-volume formulation of intra-articular TXA in current clinical practice, and the role of preoperative variables to influence the transfusion risk after primary TKR. We performed a retrospective study (using data that were gathered concurrently with the treatments but without a specific protocol to address the research question) in patients undergoing cemented TKR and receiving a low-volume formulation (2.5 g-25 ml TXA plus 20-ml saline) of intra-articular TXA (group B, study group, N = 85), and compared it with a cohort of high volume (3 g-30 ml TXA plus 70-ml saline) half topical half intra-articular TXA (group A, N = 39). Lower volume may diffuse less into the knee joint, and effectiveness assessment is required. To further confirm the effectiveness of the strategy, we compared this cohort with the historical cohort in our centre without TXA (group C, N = 393). End-point variables were compared and a multiple regression model was adjusted to obtain the odds ratio for confounding preoperative variables. Transfusion rates significantly differed between groups B (7%) and C (30%), but not between group A and group B, proving effectiveness of the low-volume formulation of intra-articular administration of TXA, despite in group B 18% of patients has less than 13 g/dl haemoglobin (Hb) vs. 0% in group A. The effectiveness of intra-articular TXA after TKR has been confirmed for a low-volume formulation (2.5 g-25 ml TXA plus 20 ml saline) even if Hb is less than 13 g/dl. Preoperative HB optimization (>13 g/dl) is also important. LEVEL OF EVIDENCE: Level IV.

Revision knee arthroplasty with a rotating-hinge design in elderly patients with instability following total knee arthroplasty.

BACKGROUND: Revision knee arthroplasty with a rotating-hinge design could be an option for the treatment of instability following total knee arthroplasty (TKA) in elderly patients. PURPOSE: To evaluate the clinical and radiographic results of revision arthroplasties in TKAs with instability using a rotating-hinge design in elderly patients. METHODS: We retrospectively reviewed 96 rotating-hinge arthroplasties. The average age of the patients was 79 years (range, 75-86 years); the minimum follow-up was 5 years (mean, 7.3 years; range, 5-10 years). Patients were evaluated clinically (Knee Society score) and radiographically (position of prosthetic components, signs of loosening, bone loss). RESULTS: At a minimum followup of 5 years (mean, 7.3 years; range, 5-10 years), Knee Society pain scores improved from 37 preoperatively to 79 postoperatively, and function scores improved from 34 to 53. ROM improved on average from -15° of extension and 80° of flexion before surgery to -5° of extension and 120° of flexion at the last followup (p = 0.03). No loosening of implants was observed. Nonprogressive radiolucent lines were identified around the femoral and tibial components in 2 knees. One patient required reoperation because of a periprosthetic infection. CONCLUSIONS: Revision arthroplasty with a rotating-hinge design provided substantial improvement in function and a reduction in pain in elderly patients with instability following TKA. LEVEL OF EVIDENCE: Level IV, therapeutic study.

Arthroscopic debridement for ankle haemophilic arthropathy.

The purpose of this study is to describe the results of arthroscopic ankle debridement (AAD) with the aim of determining whether it is possible to avoid or delay ankle fusion or total ankle replacement for advanced haemophilic arthropathy of the ankle in young patients. In a 12-year period (2000-2011), 24 AADs (one bilateral in two stages) were performed for advanced haemophilic arthropathy of the ankle in 23 patients (22 had haemophilia A, 1 haemophilia B, 0 with inhibitors against the deficient factor). Their average age at operation was 25.3 years (range 21-36). Inclusion criteria were: more than 50% of ankle motion, good axial alignment of the ankle (increased varus or valgus angulation was a contraindication for AAD) and pain greater than 6 points on a visual analogue scale (0-no pain to 10 points). Follow-up was for an average of 5.4 years (range 2-14 years). The results were evaluated retrospectively by the American Orthopaedic Foot and Ankle Society Ankle-Hindfoot scale. The clinical results were excellent in 13 (54.2%), good in nine (37.5%) and fair in two (8.3%). There were two (8.3%) postoperative complications (haemarthroses resolved by join aspiration). Three patients (12.5%) required an ankle fusion. AAD should be considered in the young haemophiliac to delay ankle fusion or total ankle replacement. The operation may give the patient years of life without intense pain.

Arthroscopic BPTB graft reconstruction in ACL ruptures: 15-year results and survival.

PURPOSE: The aim of this study is to investigate the 15-year results and survival of arthroscopic ACL reconstruction using the central-third patellar bone-tendon-bone (BPTB) autograft. METHODS: ACL BPTB reconstruction was performed in 250 consecutive patients. Of these patients, 88% returned for a follow-up examination at 15 years after reconstruction. Therefore, 220 patients were studied. Mean time from injury to intervention was 3.4months (range 2 to 16). The parameters for assessment of results were subjective satisfaction, clinical examination (pivot-shift test, Lachman test with KT-1000), recovery of pre-injury activity level, and long-leg standing radiographs. We also evaluated the presence of meniscal and/or chondral injuries during the procedure. Failure rates were also evaluated. We defined a failure as severe instability not compatible with the activities of daily living (ADL) due to graft rupture. RESULTS: 8.2% of patients required a revision procedure because of graft rupture. In subjective terms, 98.1% of patients said that they were satisfied with the surgical outcomes after 15 years. Pivot shift test was normal in 93.5% at 15 years. Lachman test (KT-1000) was normal in 95.4% at 15 years. Fifteen years after surgery, 90% of patients recovered their pre-injury activity level. In 25.4% of patients symptomatic osteoarthritic changes in the knee were found at 15 years. CONCLUSIONS: The survival prevalence of arthroscopic ACL reconstruction using the central-third patellar bone-tendon-bone (BPTB) autograft at 15 years was 94.8%. Fifteen years after surgery, 90% of patients recovered their pre-injury activity level. In 25.4% of patients symptomatic osteoarthritic changes in the knee were found at 15 years. LEVEL OF EVIDENCE: Level IV.