Do number and location of plates impact infection rates after definitive fixation of high energy tibial plateau fractures?

PURPOSE: Surgical trauma may confer additional infectious risk after operative fixation for high energy tibial plateau fractures. This study aims to determine the impact of plate number and location on infection rates after these injuries. METHODS: This retrospective cohort study completed at two level one trauma centers included patients who underwent staged fixation for a tibial plateau fracture between 2015 and 2019. Plate number and location (lateral, medial, posteromedial, and anterior quadrants) used in the definitive fixation construct were collected from post-operative radiographs. Deep infection rate was primary the outcome. RESULTS: A total of 244 patients met inclusion criteria. The overall infection rate was 13.9% (34/244). Infection rates increased with each additional quadrant utilized (8.0% one quadrant, 13.0% two quadrants, 27.3% three quadrants, 100% four quadrants; p < 0.001), independent of plate number, fracture severity, operative time, number of incisions, external fixator pin and plate construct overlap, and days in the external fixator on multivariate analysis. CONCLUSIONS: Infection risk increases with each quadrant utilized in the fixation of high energy tibial plateau fractures. Providers should attempt to limit the dissection of soft tissue for hardware placement in the fixation of these injuries to limit infection risk. LEVEL OF EVIDENCE: Level III, retrospective therapeutic study.

Oblique anterior pelvic external fixator for intraoperative reduction of rotationally unstable pelvic ring injuries.

Incomplete sacroiliac joint injuries are often associated with external rotation and extension deformities on the injured hemipelvis. To appropriately correct this deformity, an oblique reduction force from caudal to cranial and lateral to medial is helpful. These injuries are often associated with traumatic disruption of the pubic symphysis. However, in injuries without traumatic disruption to the pubic symphysis, a two-pin oblique anterior external fixator can be used to obtain and maintain reduction of the sacroiliac joint, while percutaneous fixation is subsequently placed. Through a small case series and three specific patient examples, we demonstrate that the oblique anterior external fixator frame is a simple and effective strategy with the reduction and stabilization process of these multiplanar hemipelvis deformities.

External fixator pin placement during initial management of tibial plateau fractures: are there parameters to minimize pin-plate overlap?

PURPOSE: External fixator pin site overlap with definitive fixation implants (pin-plate overlap) has been identified as a risk factor for surgical site infection in tibial plateau fractures. Despite this, pin-plate overlap occurs in 24-38% of patients. This study sought to identify radiographic characteristics associated with pin-plate overlap to help minimize occurrences. METHODS: 283 patients at two Level I trauma centers were retrospectively reviewed. Radiographic measurements were recorded including fracture length, distance from fracture to proximal tibial pin site, and pin site distance-to-fracture (PSF) ratio. RESULTS: 70 (24.7%) cases of pin-plate overlap were identified. Pin-plate overlap was associated with increased fracture length (81.5 ± 32.1 mm vs 56.9 ± 26.1 mm, p < 0.001) and decreased distance from fracture to proximal tibial pin site (84.5 ± 37.1 mm vs 126.9 ± 35.8 mm). Pins placed greater than 100 mm and 150 mm from the fracture eliminated 36/70 (51%) and 67/70 (96%) pin-plate overlaps, respectively. Pins placed with a PSF ratio greater than 1.5 and 2.0 eliminated 47/70 (67%), and 57/70 (81%) of pin-plate overlaps, respectively. CONCLUSIONS: Longer fractures, pins closer to the fracture, and decreased PSF ratio were associated with overlap. Placing proximal tibial pins more than 100 mm from the fracture eliminated most pin-plate overlaps.

Tranexamic acid improves early postoperative mobilization in cancer patients undergoing endoprosthetic reconstruction.

BACKGROUND AND OBJECTIVES: Tranexamic acid (TXA) has been shown to decrease perioperative blood loss, transfusions, and cost in patients undergoing resection of aggressive bone tumors and endoprosthetic reconstruction. This study explored the effect of TXA administration on postoperative mobilization in these patients. METHODS: This study included 126 patients who underwent resection of an aggressive bone tumor and endoprosthetic reconstruction; 61 patients in the TXA cohort and 65 patients in the non-TXA cohort. Postoperative physical therapy (PT) and occupational therapy notes were reviewed; patient ambulation distance and duration of therapies were recorded. RESULTS: Patients in the TXA cohort ambulated further on all postoperative days, which was significant on postoperative Day 1 (POD1) (p = 0.002) and postoperative Day 2 (POD2) (p < 0.001). The TXA cohort ambulated 85% further per PT session 87.7 versus 47.4 ft (p < 0.001) and participated 14% longer, 36.1 versus 31.7 min (p < 0.001). Multivariate analysis identified a significant inverse association between postoperative hospitalization length and POD1, POD2, postoperative Day 3, and total ambulation (p < 0.001). Blood transfusion was independently associated with a 1.5 day increase in postoperative hospitalization (95% confidence interval: 0.64-2.5; p < 0.001). CONCLUSIONS: TXA administration was associated with increased postoperative ambulation and endurance. Increased postoperative ambulation was associated with decreased length of stay and increased likelihood to discharge home.

A comparison of depth of necrosis among adjuvant therapies used for the treatment of benign bone tumors.

BACKGROUND AND OBJECTIVES: Benign bone tumors are often treated with extended curettage utilizing an adjuvant therapy to eliminate any remaining tumor cells. The purpose of this study was to explore and compare the histologic depth of necrosis created by various adjuvant therapies used in the treatment of benign bone tumors. METHODS: A high-speed burr was utilized to create cortical defects within porcine humeri and femora. Phenol, polymethyl methacrylate (PMMA), argon beam coagulation (ABC), liquid nitrogen, and the Bipolar Hemostatic Sealer (BHS) were each applied to five defects, with an additional five defects left untreated as a control. The maximal depth of necrosis was determined under microscopic examination. RESULTS: The phenol, PMMA, ABC, liquid nitrogen, and BHS demonstrated an average histologic depth of necrosis of 0.30, 0.78, 2.54, 2.54, and 0.92 mm, respectively, each of which was significantly increased compared to the control group (p = .001, .003, .003, .01, and  <.001). Their respective variances, a measure of reproducibility, were 0.01, 0.09, 0.96, 1.93, and 0.03 mm2 . CONCLUSION: This study confirms, through histologic analysis, adjuvant therapies create a rim of cellular necrosis beyond that of burring during extended curettage, supporting their use in the treatment of benign bone tumors. Furthermore, it provides a head-to-head comparison.

Multidimensional Fluoroscopy to Assess Closed Reduction in Displaced Young Femoral Neck Fractures: A Report of 3 Cases.

CASE: The authors present 3 physiologically young patients with displaced femoral neck fractures who underwent initial closed reduction and provisional fixation. Multidimensional fluoroscopy was used to assess fracture reduction before definitive fixation, with 1 patient requiring an open approach because of inadequate fracture reduction after closed attempts. CONCLUSION: Displaced femoral neck fractures in young patients remain difficult injuries to treat. Reduction quality is a significant predictor of patient outcomes. Intraoperative multidimensional fluoroscopy provides treating surgeons with a tool to assess fracture reduction after closed reduction maneuvers and allows for intraoperative treatment adjustment as needed.

Patients With Simple Posterior Hip Dislocations Have Higher Rates of Hip Dysplasia and Borderline Dysplasia.

OBJECTIVES: To determine if patients suffering simple, posterior hip dislocations are more likely to display dysplastic characteristics of their acetabulum as compared with those suffering fracture dislocations. DESIGN: Retrospective cohort study. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Eighty-six patients suffering posterior, native hip dislocations over a 5-year period. MAIN OUTCOME MEASUREMENT: The primary outcome was measurement of the lateral center edge angle (LCEA), acetabular index (AI), acetabular version, and femoro-epiphyseal acetabular roof (FEAR) index. RESULTS: Eighteen patients (20.9%) sustained simple dislocations, whereas 68 patients (79.1%) suffered fracture dislocations. Patients with simple dislocations had decreased LCEA (25.7 vs. 34.3; P < 0.001), increased AI (7.4 vs. 5.8; P = 0.019), and decreased acetabular anteversion (14.02 vs. 18.45; P = 0.011). Additionally, patients with simple dislocations had higher rates of dysplasia and borderline dysplasia (61.1% vs. 7.3%; P < 0.001). Patients with fracture dislocations had higher rates of concomitant injuries (60.9% vs. 29.4%; P = 0.039) and higher injury severity scores (8.1 vs. 12.3; P = 0.022). CONCLUSION: Patients who sustain simple hip dislocations are more likely to have undercoverage of the femoral head by the acetabulum as compared with patients suffering fracture dislocations. In addition, the simple dislocation group had a lower ISS and fewer concomitant injuries, which likely relates to a lower energy required for dislocation in the setting of lesser bony constraint. Surgeons treating these complicated injuries should consider measurements of LCE and AI when counseling patients on treatment strategies. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Maintenance of an Intraoperative External Fixator Is Associated With Decreased Postoperative Stiffness After Definitive Management of High-Energy Tibial Plateau Fractures.

Introduction Postoperative stiffness is a common complication after high-energy tibial plateau fractures. Investigation into reported surgical techniques for the prevention of postoperative stiffness is limited. The purpose of this study was to compare the rates of postoperative stiffness after second-stage definitive surgery for high-energy tibial plateau fractures between groups of patients who had the external fixator prepped into the surgical field and those who did not. Methods Two hundred forty-four patients met the inclusion criteria between the two academic Level I trauma centers, representing the retrospective observational cohort. Patients were separated based on prepping of the external fixator into the surgical field during second-stage definitive open reduction and internal fixation. One hundred sixty-two patients were in the prepped group and 82 were in the non-prepped group. Post-operative stiffness was determined by the need to return to the operating room for subsequent procedures. Results At the final follow-up (mean = 14.6 months), patients in the non-prepped group had an increased rate of stiffness post-operatively (18.3% non-prepped versus 6.8% prepped; p = 0.006). No other investigated variables were associated with increased post-operative stiffness, including the number of days spent in the fixator and operative time. The relative risk for post-operative stiffness associated with complete fixator removal was 2.54 (95% CI 1.26-4.41; p = 0.008 on binary logistic regression; absolute risk reduction 11.5%). Conclusion At the final follow-up, maintenance of an intraoperative external fixator as a reduction aid was associated with a clinically significant decrease in post-operative stiffness after definitive management of high-energy tibial plateau fractures, when compared with complete removal prior to prepping.

Use of 3D Fluoroscopy to Assist in the Reduction and Fixation of Pelvic and Acetabular Fractures: A Safety and Quality Case Series.

SUMMARY: Multidimensional fluoroscopy has been increasingly used in orthopaedic trauma to improve the intraoperative assessment of articular reductions and implant placement. Owing to the complex osteology of the pelvis, cross-sectional imaging is imperative for accurate evaluation of pelvic ring and acetabular injuries both preoperatively and intraoperatively. The continued development of fluoroscopic technology over the past decade has resulted in improved ease of intraoperative multidimensional fluoroscopy use in pelvic and acetabular surgery. This has provided orthopaedic trauma surgeons with a valuable tool to better evaluate reduction and fixation at different stages during operative treatment of these injuries. Specifically, intraoperative 3D fluoroscopy during treatment of acetabulum and pelvis injuries assists with guiding intraoperative decisions, assessing reductions, ensuring implant safety, and confirming appropriate fixation. We outline the useful aspects of this technology during pelvic and acetabular surgery and report its utility with a consecutive case series at a single institution. The added benefits of this technology have improved the ability to effectively manage patients with pelvis and acetabulum injuries.

Perioperative allogenic blood transfusions are associated with increased fracture related infection rates, but not nonunion in operatively treated distal femur fractures.

INTRODUCTION: Distal femur fractures are common injuries that remain difficult for orthopedic surgeons to treat. High complication rates, including nonunion rates as high as 24% and infection rates of 8%, can lead to increased morbidity for these patients. Allogenic blood transfusions have previously been identified as risk factors for infection in total joint arthroplasty and spinal fusion surgeries. No studies have explored the relationship between blood transfusions and fracture related infection (FRI) or nonunion in distal femur fractures. METHODS: 418 patients with operatively treated distal femur fractures at two level I trauma centers were retrospectively reviewed. Patient demographics were collected including age, gender, BMI, medical comorbidities, and smoking. Injury and treatment information was also collected including open fracture, polytrauma status, implant, perioperative transfusions, FRI, and nonunion. Patients with less than three months of follow up were excluded. RESULTS: 366 patients were included in final analysis. One hundred thirty-nine (38%) patients received a perioperative blood transfusion. Forty-seven (13%) nonunions and 30 (8%) FRI were identified. Allogenic blood transfusion was not associated with nonunion (13% vs 12%, P = 0.87), but was associated with FRI (15% vs 4%, P<0.001). Binary logistic regression analysis identified a dose dependent relationship between number of perioperative blood transfusions and FRI: total transfusion ≥2 U PRBC RR= 3.47(1.29, 8.10, P = 0.02), ≥3 RR= 6.99 (3.01, 12.40, P<0.001), and ≥4 RR= 8.94 (4.03, 14.42, P<0.001). DISCUSSION: In patients undergoing operative treatment of distal femur fractures, perioperative blood transfusions are associated with increased risk of fracture related infection, but not the development of a nonunion. This risk association increases in a dose-dependent relationship with increasing total blood transfusions received.

Radiographic parameters associated with fracture-related infection in high energy bicondylar tibial plateau fractures managed with two-stage treatment: Identifying the bad actors.

INTRODUCTION: High energy tibial plateau fractures are fraught with complications, particularly fracture-related infection (FRI). Previous studies have evaluated patient demographics, fracture classification, and injury characteristics as risk factors for FRI in patients with these injuries. This study evaluated the relationship between radiographic parameters (fracture length relative to femoral condyle width (FLF ratio), initial femoral displacement (FD ratio), and tibial widening (TW ratio)) and fracture-related infection following internal fixation in high energy bicondylar tibial plateau fractures. METHODS: 225 patients treated for bicondylar tibial plateau fractures at two level I trauma centers were retrospectively reviewed. Patient characteristics, fracture classification, and radiographic measurements were analyzed to determine association with FRI. RESULTS: The rate of FRI was 13.8%. Increased fracture length, FLF ratio, FD ratio, TW ratio, and fibula fracture were each associated with FRI on regression analysis, independent of clinical variables. Cutoff values were identified for each parameter and patients were risk stratified based on these radiographic parameters. High-risk patients had a 2.68- and 12.36-times risk of FRI compared to medium and low-risk patients, respectively. DISCUSSION: This study is the first to examine the relationship between radiographic parameters and FRI in high energy bicondylar tibial plateau fractures. Fracture length, FLF ratio, FD ratio, TW ratio, and fibula fracture were identified as radiographic parameters associated with FRI. More importantly, risk stratifying patients based on these parameters accurately identified patients at increased risk of FRI. Not all bicondylar tibial plateau fractures are created equal and radiographic parameters can be utilized to help identify the bad actors.

Are Infection Rates Increased After Sterilization of the External Fixator During Staged Internal Fixation of High-Energy Tibial Plateau Fractures?

OBJECTIVES: To compare infection rates after second-stage definitive surgery for high-energy tibial plateau fractures between groups of patients who had the external fixator prepped into the surgical field and those who did not. DESIGN: Retrospective cohort study. SETTING: Two academic Level 1 trauma centers. PATIENTS/PARTICIPANTS: Two hundred forty-four patients met inclusion and exclusion criteria between the 2 institutions. INTERVENTION: Prepping of the external fixator into the surgical field during second-stage definitive open reduction and internal fixation. 162 patients were in the prepped group, and 82 patients were in the nonprepped group. MAIN OUTCOME MEASUREMENTS: The primary outcome was the rate of deep infection after definitive fixation. Secondary outcome was operative time. RESULTS: There were no significant differences in infection rates between prepped (11.7%) and nonprepped (18.3%) groups ( P = 0.162). Patients in the prepped groups had significantly decreased operative time (168.2 minutes vs. 221.9 minutes, P < 0.001) even after controlling for confounders in regression analysis. CONCLUSIONS: There is no increased risk of infection associated with prepping and maintenance of the external fixator during definitive internal fixation for high-energy tibial plateau fractures. These data suggest that this practice may lead to shorter operative times as well. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Is pin-plate overlap in tibial plateau fractures associated with increased infection rates?

INTRODUCTION: Despite advances in the treatment of high energy proximal tibia fractures, including the utilization of staged management with external fixation, the infection rate remains high. Overlap between external fixator pin sites and definitive internal fixation has been proposed as a risk factor for infection. METHODS: This retrospective study reviews 244 patients with staged knee-spanning external fixation followed by delayed definitive internal fixation at two separate level one trauma centers. Presence of pin-plate overlap as well as several other known risk factors for infection were recorded and measured to include open fractures, compartment syndrome, operative time and number of incisions. Development of deep infection was the primary outcome. Both univariate and multivariate statistics were applied to determine differences in rates of infection. RESULTS: 65 (26.6%) patients had presence of pin-plate overlap while 179 (73.4%) patients had no overlap. There were no differences between overlapping and non-overlapping groups with respect to other infectious risk factors. Deep infection occurred in 34 (13.9%) total patients, 18 (27.7%) were in patients with pin-plate overlap and 16 (8.9%) in those without overlap. (P = 0.003; RR 3.01, 95% CI 1.51-4.76). DISCUSSION: This large, multicenter study demonstrated a statistically significant association between pin-plate overlap and the development of deep infection in tibial plateau fractures. On multivariate analysis, pin-plate overlap was identified as an independent risk factor for infection. When treating these complex injuries, surgeons should consider the definitive fixation construct when placing external fixation pins.

Is the timing of fixation associated with fracture-related infection among tibial plateau fracture patients with compartment syndrome? A multicenter retrospective cohort study of 729 patients.

BACKGROUND: Tibial plateau fractures with an ipsilateral compartment syndrome are a clinical challenge with limited guidance regarding the best time to perform open reduction and internal fixation (ORIF) relative to fasciotomy wound closure. This study aimed to determine if the risk of fracture-related infection (FRI) differs based on the timing of tibial plateau ORIF relative to closure of ipsilateral fasciotomy wounds. METHODS: A retrospective cohort study identified patients with tibial plateau fractures and an ipsilateral compartment syndrome treated with 4-compartment fasciotomy at 22 US trauma centers from 2009 to 2019. The primary outcome measure was FRI requiring operative debridement after ORIF. The ORIF timing relative to fasciotomy closure was categorized as ORIF before, at the same time as, or after fasciotomy closure. Bayesian hierarchical regression models with a neutral prior were used to determine the association between timing of ORIF and infection. The posterior probability of treatment benefit for ORIF was also determined for the three timings of ORIF relative to fasciotomy closure. RESULTS: Of the 729 patients who underwent ORIF of their tibial plateau fracture, 143 (19.6%) subsequently developed a FRI requiring operative treatment. Patients sustaining infections were: 21.0% of those with ORIF before (43 of 205), 15.9% at the same time as (37 of 232), and 21.6% after fasciotomy wound closure (63 of 292). ORIF at the same time as fasciotomy closure demonstrated a 91% probability of being superior to before closure (RR, 0.75; 95% CrI, 0.38 to 1.10). ORIF after fasciotomy closure had a lower likelihood (45%) of a superior outcome than before closure (RR, 1.02; 95% CrI; 0.64 to 1.39). CONCLUSION: Data from this multicenter cohort confirms previous reports of a high FRI risk in patients with a tibial plateau fracture and ipsilateral compartment syndrome. Our results suggest that ORIF at the time of fasciotomy closure has the highest probability of treatment benefit, but that infection was common with all three timings of ORIF in this difficult clinical situation.

Adolescent Athlete Stress Fractures Associated with Vitamin D Insufficiency: Three Cases with Review of the Literature.

CASE: The authors present 3 adolescent athletes who presented with stress fractures in their lower extremities, initially diagnosed as tumors. All 3 patients received an inconclusive magnetic resonance imaging before referral; fractures were confirmed on radiographs and computed tomography. All were found to have vitamin D insufficiency. CONCLUSIONS: Vitamin D insufficiency is a global epidemic mainly focused on adults and young-adult athletes. These case reports raise concerns about a growing prevalence of vitamin D insufficiency in adolescents, the potential risk of stress fracture, and the need for screening and possible supplementation in adolescent athletes to improve their bone health.

Tranexamic Acid in Patients With Cancer Undergoing Endoprosthetic Reconstruction: A Cost Analysis.

INTRODUCTION: Tranexamic acid (TXA) decreases blood loss, perioperative transfusion rates, and cost in total hip and total knee arthroplasty. In a previous study, topical TXA decreased both perioperative blood loss and transfusions in patients undergoing resection of aggressive bone tumors and endoprosthetic reconstruction. The purpose of this study was to explore the cost effectiveness of TXA in patients undergoing resection of an aggressive bone tumor and endoprosthetic reconstruction, assessing transfusion cost, TXA administration cost, postoperative hospitalization cost, posthospital disposition, and 30-day readmissions. METHODS: This study included 126 patients who underwent resection of an aggressive bone tumor and endoprosthetic resection at a single academic medical center; 61 patients in the TXA cohort and 65 patients in the non-TXA cohort. The cost of 1 unit of packed red blood cells, not including administration or complications, was estimated at our institution. The cost of hospitalization was estimated for lodging and basic care. The cost of TXA was $55 per patient. Patients were followed up for 30 days to identify hospital readmissions. RESULTS: Patients in the TXA cohort experienced a TXA and blood transfusion cost reduction of $155.88 per patient (P = 0.007). Proximal femur replacement patients experienced a $282.05 transfusion cost reduction (P = 0.008), whereas distal femur replacement patients only experienced a transfusion cost reduction of $32.64 (P = 0.43). An average hospital admission cost reduction of $5,072.23 per patient (P < 0.001) was associated with TXA use. Proximal femur replacement patients who received TXA experienced a hospital cost reduction of $5,728.38 (P < 0.001), whereas distal femur replacement patients experienced a reduction of $3,724.90 (P = 0.01). No differences between the cohorts were identified in discharge to home (P = 0.37) or readmissions (P = 0.77). DISCUSSION: TXA administration is cost effective in patients undergoing resection of an aggressive bone tumor and endoprosthetic reconstruction through reducing both perioperative transfusion rates and postoperative hospitalization. LEVEL OF EVIDENCE: III-Retrospective Cohort Study.

Engineering Functional Vasculature in Decellularized Lungs Depends on Comprehensive Endothelial Cell Tropism.

Tissue engineering using decellularized whole lungs as matrix scaffolds began as a promise for creating autologous transplantable lungs for patients with end-stage lung disease and can also be used to study strategies for lung regeneration. Vascularization remains a critical component for all solid organ bioengineering, yet there has been limited success in generating functional re-endothelialization of most pulmonary vascular segments. We evaluated recellularization of the blood vessel conduits of acellular mouse scaffolds with highly proliferating, rat pulmonary microvascular endothelial progenitor cells (RMEPCs), pulmonary arterial endothelial cells (PAECs) or microvascular endothelial cells (MVECs). After 8 days of pulsatile perfusion, histological analysis showed that PAECs and MVECs possessed selective tropism for larger vessels or microvasculature, respectively. In contrast, RMEPCs lacked site preference and repopulated all vascular segments. RMEPC-derived endothelium exhibited thrombomodulin activity, expression of junctional genes, ability to synthesize endothelial signaling molecules, and formation of a restrictive barrier. The RMEPC phenotype described here could be useful for identifying endothelial progenitors suitable for efficient vascular organ and tissue engineering, regeneration and repair.

Tranexamic Acid in Patients With Cancer Undergoing Endoprosthetic Reconstruction: A Retrospective Review.

INTRODUCTION: Endoprosthetic reconstruction presents a significant risk of perioperative blood loss. Tranexamic acid (TXA) is an antifibrinolytic agent used to reduce blood loss in orthopaedic procedures. The safety and efficacy of TXA in arthroplasty are well documented. There is, however, a dearth of literature exploring the safety and efficacy of TXA in musculoskeletal oncology patients. This retrospective, comparative study explores the effects of TXA on perioperative blood loss, blood transfusion rates, venous thromboembolism (VTE) occurrence, and hospital stay in patients undergoing resection of an aggressive bone tumor and endoprosthetic reconstruction. METHODS: For the study, charts from a total of 90 patients who underwent resection of an aggressive bone tumor and endoprosthetic reconstruction were reviewed; of these patients, 34 were in the TXA group and 56 in the non-TXA group. Study participants composed of a heterogeneous group of patients with primary bone sarcoma and metastatic osseous disease. Patients in the TXA group received 1 g of topical TXA administered into the wound bed before closure. The Hemoglobin Balance method was used to calculate blood loss. Patients were followed for 6 weeks. RESULTS: Patients undergoing proximal femur replacement and distal femur replacement in the TXA group experienced a 796 and 687 mL reduction in 72-hour mean blood loss, respectively (P = 0.0003 and P = 0.006). Average blood transfusions decreased by 0.45 U of packed red blood cells per patient in the TXA group (P = 0.048) and transfusion incidence decreased by 21.1% compared with the non-TXA group (P = 0.04). Patients undergoing proximal femur replacement in the TXA group left the hospital 2.2 days earlier than those in the non-TXA group (P = 0.0004). No increase in VTE rate was observed with TXA use. DISCUSSION: This study found results similar to total joint arthroplasty with regard to TXA's effect on perioperative blood loss, transfusion rates, hospital stay, and VTE occurrence. It provides initial data to support the efficacy of topical TXA use in this patient cohort. LEVEL OF EVIDENCE: Level III, retrospective cohort study.