Oral as compared to intravenous tranexamic acid to limit peri-operative blood loss associated with primary total hip arthroplasty: A randomised noninferiority trial.

BACKGROUND: Oral as compared to intravenous tranexamic acid (TXA) is an attractive option, in terms of cost and safety, to reduce blood loss and transfusion in total hip arthroplasty. Exclusion criteria applied in the most recent randomised trials may have limited the generalisability of oral tranexamic acid in this indication. Larger and more inclusive studies are needed to definitively establish oral administration as a credible alternative to intravenous administration. OBJECTIVES: To assess the noninferiority of oral to intravenous TXA at reducing intra-operative and postoperative total blood loss (TBL) in primary posterolateral approached total hip arthroplasty (PLTHA). DESIGN: Noninferiority, single centre, randomised, double-blind controlled study. SETTING: Patients scheduled for primary PLTHA. Data acquisition occurred between May 2021 and November 2022 at the University Hospital of Liège, Belgium. PATIENTS: Two hundred and twenty-eight patients, randomised in a 1 : 1 ratio from a computer-generated list, completed the trial. INTERVENTIONS: Administration of 2 g of oral TXA 2 h before total hip arthroplasty and 4 h after incision (Group oral) was compared to the intravenous administration of 1 g of TXA 30 min before surgery and 4 h after incision (Group i.v.). MAIN OUTCOME MEASURES: TBL (measured intra-operative and drainage blood loss up to 48 h after surgery, primary outcome), decrease in haemoglobin concentration, D-Dimer at day 1 and day 3, transfusion rate (secondary outcomes). RESULTS: Analyses were performed on 108 out of 114 participants (Group i.v.) and 104 out of 114 participants (Group oral). Group oral was noninferior to Group i.v. with regard to TBL, with a difference between medians (95% CI) of 35 ml (-103.77 to 33.77) within the noninferiority margins. Median [IQR] of estimated TBL was 480 ml [350 to 565] and 445 ml [323 to 558], respectively. No significant interaction between group and time was observed regarding the evolution of TBL and haemoglobin over time. CONCLUSIONS: TXA as an oral premedication before PLTHA is noninferior to its intravenous administration regarding peri-operative TBL. TRIAL REGISTRATION: European Clinical Trial Register under EudraCT-number 2020-004167-29 ( https://www.clinicaltrialsregister.eu/ctr-search/trial/2020-004167-29/BE ).

Effect of preoperative warming on intraoperative hypothermia and postoperative functional recovery in total hip arthroplasty: a randomized clinical trial.

BACKGROUND: Intraoperative hypothermia is associated with increased morbidity and impaired postoperative recovery. Direct anterior-approached total hip arthroplasty (ATHA) may lead to significant thermal loss. We aimed to assess whether preoperative warming had an impact on intraoperative hypothermia and postoperative functional recovery after ATHA. METHODS: In this prospective randomized controlled clinical trial 40 patients scheduled for ATHA were randomly divided into two groups of 20 patients each. Group W received, prior to the induction of general anesthesia, a 30 minutes 43 °C forced-air preoperative warming. Group C did not receive any preoperative warming. A blinded observer noted the core body temperature at the time of induction and at fixed time points, i.e. every five minutes during the first hour of surgery. The evolution of postoperative patient perceived thermal comfort (TC) and functional recovery (QoR-15) was assessed 24, 48 and 72 hours after surgery. Length of stay in the post-anesthesia care unit (PACU) was noted. RESULTS: The temperature drop was significantly faster and of higher amplitude in group C than in group W, during first hour of surgery (P<0.001). Evolution of QoR-15 and TC was significantly better in group W than in group C (P<0.001 for QoR-15 and P<0.001 for thermal comfort), with shorter length of stay (median [IQR]) in the PACU (minutes; 73 [61-79] for group C and 98 [83-129] for group W, P<0.001). CONCLUSIONS: In ATHA, pre-warming delays and reduces intraoperative heat loss, impacting patient comfort and postoperative functional recovery.

Comparison between supra-inguinal fascia iliaca and pericapsular nerve group blocks on postoperative pain and functional recovery after total hip arthroplasty: A noninferiority randomised clinical trial.

BACKGROUND: Pain after a posterolateral approach for total hip arthroplasty (THA) may affect early functional recovery. Supra-inguinal fascia iliaca (SFIB) and pericapsular nerve group (PENG) blocks have been proposed as promising analgesia techniques. OBJECTIVES: This trial was conducted to compare a PENG with a SFIB for controlling postoperative pain and for providing functional recovery. DESIGN: Noninferiority monocentric randomised controlled study. SETTING: One hundred and two patients scheduled for a total hip arthroplasty via the posterolateral approach under spinal anaesthesia were prospectively allocated to two groups. Data acquisition occurred between October 2021 and July 2022 at the University Hospital of Liege. PATIENTS: One hundred and two patients completed the trial. INTERVENTIONS: Group SFIB received supra-inguinal fascia iliaca block (SFIB) (40 ml ropivacaine 0.375%), whereas group PENG received a PENG block (20 ml ropivacaine 0.75%). MAIN OUTCOME MEASURES: Rest and mobilisation pain on a 0 to 10 numeric rating scale at fixed time points: 1 and 6 h after surgery, on day-1 and day-2 at 8 a.m.,1 p.m. and 6 p.m. On day-1 and day-2, evolution of quality-of-recovery-15 score was assessed, and timed-up-and-go, 2 and 6 min-walking tests. The noninferiority margin was set as 1 numeric rating scale point 6 h after surgery. RESULTS: Six hours after surgery, pain scores in group PENG were noninferior to those of group SFIB, with a difference between medians at 0 (95% CI -0.93 to 0.93). There were no significant differences between the groups regarding rest and dynamic pain trajectories during the first 48 postoperative hours, with no significant effects of group (rest P  = 0.800; dynamic P  = 0.708) or interaction between group and time (rest P  = 0.803; dynamic P  = 0.187). Similarly, no significant differences were observed regarding motor and functional recovery as assessed by timed-up-and-go ( P  = 0.197), 2 min ( P  = 0.364), and 6 min walking ( P  = 0.347) tests and quality-of-recovery-15 ( P  = 0.417) score. CONCLUSION: Following a total hip arthroplasty via the posterolateral approach, a PENG block is noninferior to SFIB regarding postoperative pain control 6 h after surgery, and functional recovery. TRIAL REGISTRATION: European Clinical Trial Register under EudraCT-number 2020-005126-28 ( https://www.clinicaltrialsregister.eu/ctr-search/trial/2020-005126-28/BE ).

Effect of suprainguinal fascia iliaca compartment block on postoperative opioid consumption and functional recovery in posterolateral-approached total hip arthroplasty: a single-blind randomized controlled trial.

INTRODUCTION: Posterolateral-approached total hip arthroplasty (PLTHA) is followed by moderate to severe postoperative pain. Suprainguinal fascia iliaca compartment block (SFICB) has been proposed as a promising analgesia technique. METHODS: Data from 86 patients scheduled for PLTHA with spinal anesthesia were analyzed in this prospective randomized controlled trial. Patients were randomly divided into two groups of 43 patients each. As opposed to the control group (group C), ropivacaine group (group R) received additional SFICB using 40 mL of 0.375% ropivacaine. As primary endpoint, blind observers noted total morphine consumption at postoperative 48 hours. Secondary endpoints were pain at rest and mobilization on 0-10 Numeric Rating Scale (rest and dynamic NRS) at fixed time points (1 hour and 6 hours after surgery, and at day 1 and day 2 at 8:00, 13:00 and 18:00 hours), walking performance at day 1 and day 2; postoperative complications including morphine-related side effects or orthostatic intolerance symptoms such as dizziness, nausea, blurred vision or vasovagal syncope. RESULTS: A 48-hour morphine consumption (mg; median (IQR)) was significantly lower in group R than in group C (11 (8.5-15.5)) vs 26 (21-33.5), p<0001), as well as incidence of morphine-related side effects such as nausea at day 1 (p=0.04) and day 2 (p<0.01). Rest and dynamic NRS were globally significantly lower in group R than in group C (p<0.01). Group R showed less orthostatic intolerance at day 1 (p<0.001) and day 2 (p<0.01) and better functional walking performance at day 1 (<0.001) and day 2 (<0.001). DISCUSSION: In PLTHA, SFICB provides opioid sparing, improved postoperative pain control, and enhanced functional recovery. TRIAL REGISTRATION NUMBER: NCT04574479.

Intra-prosthetic dislocation of dual mobility hip prosthesis: an original and unusual complication.

A 78-year-old female presented with dislocation of a dual mobility hip prosthesis. On standard radiographs after closed reduction, the hip prosthesis appeared to be properly reduced, but clinically the hip was unstable. A Computed Tomography showed a round foreign body, that was in fact a dislocation of the intra-prosthetic implant. This was confirmed intra-operatively during revision surgery. Intra-prosthetic dislocation is a specific complication of dual mobility system. Classically, it's a late complication, linked to the wear of retention area of the polyethylene insert. In this case report we describe an unusual reason of intra-prosthetic dislocation caused by a reduction maneuver of a dislocated dual mobility total hip prosthesis, which to our knowledge has never been documented with Computed Tomography imagery and intra operative pictures. The aim of this article is to analyse the advantages and complications of this implant and to establish recommendations. Dealing with an intra-prosthetic dislocation of a dual mobility hip prosthesis, we recommend attempting a reduction under general anesthesia to avoid mechanical complications. In case of persistent instability after reduction, we recommend performing a Computed Tomography scan.

Comparison of clinical scores in their ability to detect hypoxemic severe OSA patients.

BACKGROUND: Severe obstructive sleep apnea (sOSA) and preoperative hypoxemia are risk factors of postoperative complications. Patients exhibiting the combination of both factors are probably at higher perioperative risk. Four scores (STOP-Bang, P-SAP, OSA50, and DES-OSA) are currently used to detect OSA patients preoperatively. This study compared their ability to specifically detect hypoxemic sOSA patients. METHODS: One hundred and fifty-nine patients scheduled for an overnight polysomnography (PSG) were prospectively enrolled. The ability of the four scores to predict the occurrence of hypoxemic episodes in sOSA patients was compared using sensitivity (Se), specificity (Sp), Youden Index, Cohen kappa coefficient, and the area under ROC curve (AUROC) analyses. RESULTS: OSA50 elicited the highest Se [95% CI] at detecting hypoxemic sOSA patients (1 [0.89-1]) and was significantly more sensitive than STOP-Bang in that respect. DES-OSA was significantly more specific (0.58 [0.49-0.66]) than the three other scores. The Youden Index of DES-OSA (1.45 [1.33-1.58]) was significantly higher than those of STOP-Bang, P-SAP, and OSA50. The AUROC of DES-OSA (0.8 [0.71-0.89]) was significantly the largest. The highest Kappa value was obtained for DES-OSA (0.33 [0.21-0.45]) and was significantly higher than those of STOP-Bang, and OSA50. CONCLUSIONS: In our population, DES-OSA appears to be more effective than the three other scores to specifically detect hypoxemic sOSA patients. However prospective studies are needed to confirm these findings in a perioperative setting. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov: NCT02050685.

Isolated heptadactylia: A case report of central polydactyly of the foot.

RATIONALE: Heptadactylia is a rare congenital disorder from the polydactyly family. Polydactyly is generally classified into 3 major groups: preaxial (medial ray), postaxial (lateral ray), and central polydactyly. Most common cases are related to preaxial or postaxial polydactyly. The rarity of central polydactyly can be explained in 3 ways. First, central polydactyly with duplication appearing on metatarsal is pretty uncommon. Second, the duplication appears isolated on the foot. Polydactyly is mostly associated with other physical defects or others duplications. Last, the duplication of the digital rays does not appear once but twice concerning all the digital rays and makes 7 functional toes appear. We describe this malformation with supporting iconography and radiography as well as its surgical management and functional results. PATIENT CONCERNS: We analyzed an original case of isolated heptadactylia on the foot of a 14-month-old girl. The supernumerary toes made it impossible for the child to wear standard shoes and her parents were worried about this problem. DIAGNOSES: Clinical foot examination and radiographs revealed the presence of 7 complete rays. Every toe was composed of phalanx and metatarsal ray. There was no other congenital deformity. INTERVENTIONS: Decision was made to resect the second and third rays (the two most misaligned toes in our consideration). The first stage of surgery was the ray resection and the second stage was the reconstruction of the intermetatarsal ligament to achieve a good functional and cosmetic results. OUTCOMES: After wound healing, the child was able to walk alone while wearing normal shoes. LESSONS: We demonstrated that treatment of foot polydactyly requires careful preoperative assessment, including radiographs and photography. A good clinical evaluation of the medial polydactyly improves type-specific recognition which may enhance the accuracy of surgical treatment. Polydactyly is frequently associated with other malformations. We recommend performing a general clinical examination to exclude concomitant malformations. We recommend surgical treatment around the onset of walking.