"Coronal Split/Overlap Repair" Patellar Tendon Shortening in Skeletally Immature Patients.

Background: "Coronal split/overlap repair" patellar tendon shortening (PTS) is a technique that is utilized to treat patella alta and can be combined with distal femoral extension osteotomy (DFEO) for the treatment of crouch gait in skeletally immature patients with cerebral palsy. Description: The patellar tendon is split in the coronal plane. The ventral patellar tendon flap is released from its patellar attachment and is reflected distally over its tibial attachment, exposing a dorsal flap. Two patellar/tibial no. 5 Ethibond (Ethicon) sutures are passed through 2 crossing patellar tunnels and 2 parallel tibial tunnels. The patella is then pushed distally until its distal pole lies at the level of the tibiofemoral joint. The Ethibond sutures are tied and tensioned to the desired level. The knee should be able to be passively flexed to 90°. The intact redundant dorsal flap of the patellar tendon is imbricated. Lastly, the ventral flap is advanced proximally and sutured to the anterior surface of the patella and to the edges of the dorsal flap without shortening. A hinged knee brace is utilized postoperatively with a range of motion of 0° to 30°, progressing to 90° by 6 weeks. No resistive quadriceps contractions are permitted for the first 3 weeks. Alternatives: Patellar tendon advancement in skeletally immature patients can be performed by releasing the tibial attachment and the free end is advanced deep to the T-shaped tibial periosteal flap1-3. Other PTS techniques can be grouped into the categories of (1) patellar tendon imbrication4, (2) patellar tendon detaching techniques in which the tendon is detached from the patellar attachment or cut in its midsubstance and shortened2,5-7, and (3) patellar tendon semi-detaching techniques in which patellar tendon flaps are created and shortened8,9. Rationale: The presently described technique is a semi-detaching technique, preserving a good part of the patellar tendon while avoiding complete dehiscence of the extensor mechanism. Moreover, the 2 patellar/tibial sutures would protect the patellar tendon repair and allow early rehabilitation and knee range-of-motion exercises. Expected Outcomes: Satisfactory correction of the patella alta was reported with PTS techniques with or without DFEO to correct concomitant fixed flexion deformity in patients with cerebral palsy. Furthermore, there was reported improvement of total knee range of motion with restoration of adequate knee extension during the stance phase1,3,8. Reported complications with this technique were mainly superficial infection. Important Tips: Any substantial fixed flexion deformity of the knee (>10°) should be corrected with hamstring lengthening or DFEO prior to PTS.A mid-patellar coronal split is made with use of a no.-15 blade and extended proximally and distally with use of 2 mosquito clips.To avoid difficulties with crossing of the patellar sutures, always keep the straight needle inside the 1st tunnel until the 2nd tunnel is created and its respective suture is passed.To distalize the patella, the patellar/tibial sutures are tied in a simple knot and held by a mosquito clip in order to allow retensioning until the desired patellar height is reached.The 2 patellar/tibial suture knots are slid to the proximal and distal ends of the surgical field. Acronyms and Abbreviations: 3DGA = 3-dimensional gait analysisADL = activities of daily livingCP = cerebral palsyCPM = continuous passive motionDFEO = distal femoral extension osteotomyFAQ = Functional Assessment QuestionnaireFMS = Functional Mobility ScaleGMFCS = Gross Motor Function Classification SystemGMFM = Gross Motor Function MeasureGPS = Gait Profile ScoreGVS = Gait Variable ScoreK-wires = Kirschner wiresPTA = patellar tendon advancementPTS = patellar tendon shorteningSEMLS = single event multi-level surgery.

Prognostic factors for failed Pavlik harness treatment in infants with developmental dysplasia of the hip: a retrospective cohort study.

PURPOSE: Pavlik harness treatment is the most common treatment in newborns diagnosed with developmental dysplasia of the hip (DDH). The success rates and predictors for failure have been debated over the last decade. In this study, we explored our treatment failure rate and potential prognostic factors that could predict the failure of Pavlik harness (PH) treatment in patients with DDH. METHODS: Two hundred and sixty-five patients were treated with PH based on the Graf hip types of classification. Age, gender, first born status, family history, foot deformity, plagiocephaly, breech presentation, hip abduction, hip stability, Graf hip type, Galeazzi sign, bilateralism, and femoral nerve palsy were tested as predictors for failure in multivariate logistic regression mode. Success and failure were determined by the normalization of the hip based on the Graf hip classification. RESULTS: The failure rate of patients treated with Pavlik harness was 16.6% which is within the reported range of failure rate. The mean age of patients who were successfully treated was 6.73 weeks in comparison to 8.84 weeks for those who failed. Age, plagiocephaly, hip instability, Graf classification, and the development of femoral nerve palsy were found to be predictors for failure of PH treatment upon univariate analysis only. However, only the presence of Galeazzi sign, hip instability, high grades of Graf hip classification, and the development of femoral nerve palsy proved to be independent predictors for failed PH treatment upon multivariate logistic regression analysis. CONCLUSIONS: Pavlik harness treatment is a successful treatment with an average success of 83.4%. Several independent predictors for failure of PH treatment have been identified. These include a positive Galeazzi sign, a frankly dislocated hip, Graf types III and IV, and the development of femoral nerve palsy.

The genomic landscape of rare disorders in the Middle East.

BACKGROUND: Rare diseases collectively impose a significant burden on healthcare systems, especially in underserved regions, like the Middle East, which lack access to genomic diagnostic services and the associated personalized management plans. METHODS: We established a clinical genomics and genetic counseling facility, within a multidisciplinary tertiary pediatric center, in the United Arab Emirates to locally diagnose and manage patients with rare diseases. Clinical genomic investigations included exome-based sequencing, chromosomal microarrays, and/or targeted testing. We assessed the diagnostic yield and implications for clinical management among this population. Variables were compared using the Fisher exact test. Tests were 2-tailed, and P < .05 was considered statistically significant. RESULTS: We present data on 1000 patients with rare diseases (46.2% females; average age, 4.6 years) representing 47 countries primarily from the Arabian Peninsula, the Levant, Africa, and Asia. The cumulative diagnostic yield was 32.5% (95% CI, 29.7-35.5%) and was higher for genomic sequencing-based testing than chromosomal microarrays (37.9% versus 17.2%, P = 0.0001) across all indications, consistent with the higher burden of single gene disorders. Of the 221 Mendelian disorders identified in this cohort, the majority (N = 184) were encountered only once, and those with recessive inheritance accounted for ~ 62% of sequencing diagnoses. Of patients with positive genetic findings (N = 325), 67.7% were less than 5 years of age, and 60% were offered modified management and/or intervention plans. Interestingly, 24% of patients with positive genetic findings received delayed diagnoses (average age, 12.4 years; range 7-37 years), most likely due to a lack of access to genomic investigations in this region. One such genetic finding ended a 15-year-long diagnostic odyssey, leading to a life-threatening diagnosis in one patient, who was then successfully treated using an experimental allogenic bone marrow transplant. Finally, we present cases with candidate genes within regions of homozygosity, likely underlying novel recessive disorders. CONCLUSIONS: Early access to genomic diagnostics for patients with suspected rare disorders in the Middle East is likely to improve clinical outcomes while driving gene discovery in this genetically underrepresented population.

Adolescent-Acquired Flatfeet: The Tip of the Iceberg.

There has been a substantive change in our lifestyle over the last two decades. The widespread availability of entertaining digital devices created an unhealthy culture of a sedentary lifestyle, with our children hooked to their digital devices for countless hours. The mental and social consequences have been well explored in several studies. Leading a sedentary lifestyle has been shown to be associated with obesity, diabetes, cardiovascular diseases, and even early death. The adolescent-acquired flatfeet is another addition to the ever-growing list. The lack of physical activities among children nowadays has led to a pandemic of long muscles tightness in children, particularly during the growth spurt. The mismatch between the long bones and adjacent muscles growth caused relative muscles shortening, particularly the muscles that cross more than one growth center, such as the hamstring muscles and gastrocnemius muscles. As a result, it has become common to see children who cannot touch the floor on forward bending because of hamstring muscles tightness or inability to walk on their heels because of gastrocnemius muscles tightness. While muscles tightness is relatively benign, its consequences, such as adolescent-acquired flatfeet, are not. In this review, we have explored the condition, its prevention, and treatment to raise awareness among the public and professionals.

The Y-Pelvic Osteotomy in Treating Bladder Exstrophy: A Surgical Technique.

Bladder exstrophy (BE) is a rare congenital anomaly caused by an embryological defect in the closure of the abdominal wall. It comprises a spectrum of defects about severity, including epispadias in the mildest form and cloacal exstrophy in the worst. Surgical correction is required to achieve urinary continence, maintain normal renal function, achieve secured abdominal wall closure, and create cosmetically and functionally satisfactory genitalia. Iliac bone osteotomy is considered essential to achieve the above goals in most patients by reducing the tension of the closed abdominal wall layers, particularly when present late in infancy. Several types of pelvic iliac bone osteotomy have been described to aid bladder and cloacal exstrophy closure. They can be grouped into posterior iliac osteotomy, anterior iliac osteotomy, oblique (also called diagonal) iliac osteotomy, and a combination of posterior and anterior iliac osteotomy. We described here the Y-pelvic osteotomy, which was developed by the Manchester Orthopaedic Group in the United Kingdom. It has the advantage of anterior and posterior osteotomies but also has less risk to the neurovascular structures, less blood loss, and ease of surgical technique. The osteotomy was named the Y-pelvic osteotomy due to the morphological shape it resembles.

Comparison of Three Circular Frames in Lower Limb Deformity Correction: A Biomechanical Study.

Background The use of circular frames in correcting lower limb deformity is well-established and has evolved dramatically over the years. Three new frames have been introduced recently, and this study is set to compare them in terms of accuracy and efficiency in correcting a similar long bone deformity. These frames are the Taylor Spatial Frame (TSF; Smith & Nephew, London, United Kingdom), the Truelok Hexapod System (TL-HEX; Orthofix, Lewisville, Texas), and Orthex (OrthoPediatrics, Warsaw, Indiana). Methods This is a biomechanical study comparing the above three types of circular frames to correct similar deformities in Sawbones models. The deformities that are compared were: (1) 30° valgus deformity of the distal femur; (2) 30° varus deformity of the proximal tibia. Each frame was applied to the deformed bone in the standard way that we apply to normal bone. X-rays were taken before and after the deformity correction. The frames' software was used to estimate the deformities. The variations between the software's estimations and the known bone deformities were compared. Residual deformity after initial correction and the number of re-programmings was compared among these three frames. The least residual deformity and re-programming is the favorable outcome. Results All the Sawbones models had a 30° actual coronal angulation. The Orthex software estimated the deformity at around 25.35° (SD 4.6), TSF 25.6° (SD 2), and TL-HEX 29.87° (SD 2.1). One-way analysis of variance (ANOVA) showed a significant difference in the findings (P-value 0.014). Accuracy was measured by comparing the residual deformity in angulation in the coronal plane after the first and second correction. The Orthex median residual deformity was 1°, TSF was 2.5°, and TL-HEX was 3° with a range of less than 5° for all of them. The independent samples Kruskal-Wallis test shows that there is no significant difference between the three groups (P=0.549). The frequency of strut changes required throughout the correction was not significant among the three frames using the Fisher exact test (P=0.336). TSF struts are not designed to be readjusted. Conclusion The three frames were comparable in terms of accurate correction of the two deformities, strut changes, and strut adjustments. The TL-HEX frame software was superior to other frames in terms of analyzing the deformity but the difference, although statistically significant clinically, was not.

Paediatric orthopaedic surgery during the SARS-CoV-2 pandemic. A safe and pragmatic approach to service provision.

The SARS-COV-2 pandemic has brought unparalleled challenges to healthcare provision. Being a newly discovered virus, there is a lack of previous experience and published evidence to guide healthcare providers on how to deliver services. We would like to share our approach to service delivery in a newly open children's hospital in the United Arab Emirates with a particular focus on paediatric orthopaedic services.

Evidence based treatment for developmental dysplasia of the hip in children under 6 months of age. Systematic review and exploratory analysis.

INTRODUCTION: Developmental dysplasia of the hip (DDH) is a common paediatric orthopaedic condition that attracts a substantive amount of controversy. The treatments vary because of the wide spectrum of the condition and the age of children at presentation. Although conservative and surgical treatments exist; it is widely accepted that conservative treatment is the first line of treatment in the first 6 months of life. Several devices have been proposed as the treatment of choice; however, to the best of our knowledge these have not been critically appraised. Therefore, we conducted this review. METHODS: A modified Cochrane method was followed with a preplanned detailed research protocol that was developed to guide all aspects of the review. Treatment failure of the devices was chosen as the primary outcome. Secondary outcomes included femoral nerve palsy (FNP), avascular necrosis of the femoral head (AVN), residual dysplasia, skin problems, failure of subsequent surgical treatment, compliance and tolerance issues. Results are reported according to the PRISMA guidelines. RESULTS: A total of 30 studies were included in the review comparing 5 devices (The Pavlik harness, the Von Rosen splint, the Tubingen brace, the Frejka pillow, and the Aberdeen splint). The devices were compared in terms of success rate, AVN rate and residual dysplasia. The von Rosen splint has been shown to be superior to other devices in term of success rates and residual dysplasia (Χ2: P < 0.05). CONCLUSION: The review findings should be interpreted with caution as there are substantive flaws in the literature and a randomized control trail is warranted to confirm the best device to treat DDH. This is feasible given the magnitude of the problem, the clear diagnostic criteria and the treatment options.

Self-mutilation of Fingers Following Median Nerve Injury: Case Reports and Literature Review.

Self-mutilation of fingers following nerve injuries is extremely rare, but it can lead to serious complications, including amputation if not treated timely. We report here what we believe to be the first English language reports of self-mutilation of fingers following median nerve injury caused by a supracondylar humeral fracture.

Moon (or Eid) Crescent Sign of the Femoral Head.

Avascular necrosis (AVN) of the femoral head following slipped capital femoral epiphysis (SCFE) is a serious complication that often leads to a permanent disability. Radiological findings of AVN may take up to two years to become apparent. This means painful waiting for children, parents, and treating teams. We would like to describe a new radiological sign that we noted in four patients. The sign has been named as the crescent moon sign or eid crescent sign. It may become visible as early as six weeks following surgery, and it carries a good prognosis that the femoral head is viable and will not develop AVN. Two out of the four patients were treated in our hospital by Ganz surgical dislocation. The other two patients had been featured in other publications, but the significance of the moon crescent signs, which were present, was not recognized or appreciated. All four patients did not develop AVN. A relatively similar radiological sign has been described in talus bone fractures (Hawkins' sign). Like SCFE, talus bone fractures have a high AVN rate. Both, the crescent moon sign and Hawkins' sign carry a good prognosis and indicate that the bone blood supply is restored.

Simple Step Add-in to Improve Patient Safety: A Technical Note.

Human factors and systems factors can affect surgical performance, including the operating room (OR) environment, teamwork and communication, technology and equipment, tasks and workload factors, and organizational variables. Patient safety is a new healthcare discipline that emphasizes the reporting, analysis, and prevention of medical errors that often lead to adverse healthcare events. We are highlighting a potential error and hazardous situation, which may occur due to the difficulty in reading the embossed letters of some ampoules because of the typeface of these ampoules. This problem is particularly important in the ORs, which require special sterile conditions. We are adding a simple step to help in the differentiation between plastic, embossed ampoules. This simple and easy-to-do step makes it possible for accurate and correct identification, without jeopardizing the safety of the patients and health care professionals.

Case Reports of Bacillus Calmette-Guérin (BCG) Osteomyelitis: A Rare Complication in Immunocompetent Infants.

Bacillus Calmette-Guérin (BCG) vaccine is a live attenuated vaccine used globally since 1921, and in the United Arab Emirates (UAE), it is administered to all newborns within the first few days of life for well-established benefits. BCG osteomyelitis is a rare complication that should be considered while assessing osteomyelitis in children. This report describes three cases of BCG osteomyelitis involving proximal metaphysis of the humerus in 11 months and three months old immunocompetent male infants and the left proximal tibia in a two-year-old immunocompetent female. To the best of our knowledge, these are the first cases to be reported in the UAE. The report outlines in detail how to make a timely diagnosis by explaining the insidious clinical presentation of BCG osteomyelitis, including its radiologic, microbiologic, and histologic aspects. As well, it outlines the treatment course carried out for these three patients. As such, this report will aid physicians in staying vigilant for such rare complication and commencing early treatment.

The effect of tranexamic acid on wound complications in primary total Hip Arthroplasty: A meta-analysis.

BACKGROUND: Allogeneic blood transfusion has been linked with an increase in the risk of surgical site infections (SSIs) through the mechanism of immunomodulation. However, no studies to date have investigated the direct relationship between blood conserving strategies including antifibrinolytics and wound complications after total hip arthroplasties (THA). METHODS: A systematic review and meta-analysis of published randomised controlled trials (RCTs) to investigate the effect of tranexamic acid (TXA) on wound complications after THAs has been conducted. RESULTS: We identified 25 clinical trials which were suitable for detailed data extraction. There were no trials which utilised TXA in revision THA. All studies reported on wound complications including a total of 1608 patients. Using TXA led to a 2% reduction in the risk of developing wound complications compared to the control group with no significant statistical heterogeneity among the study groups (Risk Difference -0.02, 95%, confidence interval CI -0.04 to -0.00, P = 0.01, Heterogeneity I2 = 0%). However, there was no significant difference in clinical outcomes in terms of antibiotic treatment or surgical intervention among the study groups. TXA also reduced intraoperative, postoperative and total blood loss and led to a significant reduction in the proportion of patients requiring allogeneic blood transfusion with no significant differences in deep venous thrombosis, pulmonary embolisms, or other complications between the study groups. CONCLUSION: TXA reduced blood loss and transfusion rates after primary THA surgery. It also reduced wound complication rates but the clinical significance of this needs further investigation through well designed and adequately powered RCTs.

International Interdisciplinary Consensus Meeting on the Evaluation of Developmental Dysplasia of the Hip.

In September 2018, an international meeting of doctors of various disciplines, with expertise in the detection and treatment of DDH, was held in Csolyospalos, Hungary. The aim was to achieve consensus on the detection and early treatment of the condition and to develop a standardized system of teaching and training for hip ultrasound. There was strong agreement that US screening is essential. Specifically the Graf technique was selected as the technique of choice. Universal US screening was strongly favored. Screening should be carried out as soon as possible, but not later than the sixth week of age. US screening is cost-effective, does not result in overtreatment, and contributes to a reduction of long-term consequences. The essential principle of treatment is timely application of a device to achieve reduction, retention and maturation, by holding the hips in flexion, and a safe degree of abduction. It was agreed that the effectiveness of any screening policy depends on the correct scanning technique. Therefore, standardization of teaching and training of the Graf technique is mandatory. A unified teaching policy and materials should be developed for this purpose. Certification, re-certification and audit were discussed. The group, which has been formalized as the International Interdisciplinary Consensus Committee On DDH Evaluation (ICODE), will continue to meet and work towards establishing international consensus on DDH, standardizing and developing teaching and training of the Graf technique for hip US, and maintaining standards for detection and management.

Total hip arthroplasty in patients with Trisomy 21: Systematic review and exploratory patient level analysis.

INTRODUCTION: Trisomy 21 is the most common chromosomal disorders in humans; it is caused by an extra copy of chromosome number 21. This extra chromosomal material causes widespread abnormalities involving nearly every part of human body. Hip disorders are the second most serious musculoskeletal disorder in patients with T21 with a reported incidence between 2 and 28%. The outcomes of these hip disorders in patients with T21 are much less favorable than similar hip diagnoses in normal patients and a substantive number of these patients develop severe osteoarthritis that require total hip arthroplasty (THA). The outcome of THA in this cohort of patient is not well studied. METHODS: A modified Cochrane review methodology has been utilized in this review. An extended literature search was performed of the medical databases. A hierarchical approach was used to include relevant studies. Search, published papers and extracted data were checked by authors independently then jointly to ensure accuracy. RESULTS: Nine studies (321 patients with Trisomy 21) who underwent total hip arthroplasty (THA) were included. The functional hip scores (Harris and WOMAC hip scores) improved substantively after hip arthroplasty. The 5-year cumulative revision rate was 7.5%; twice as high as age matched control. Medical and surgical complications were 3 times higher than matched controls. CONCLUSION: Total hip arthroplasty can be offered to patients with T21 and severe arthritis although the increased revision and complication rates must be appreciated by patients and care givers.

The effect of tranexamic acid on artificial joint materials: a biomechanical study (the bioTRANX study).

BACKGROUND: Tranexamic acid (TXA) has been successfully used to reduce bleeding in joint replacement. Recently local TXA has been advocated to reduce blood loss in total knee or hip replacement; however, this raised concerns about potential adverse effects of TXA upon the artificial joint replacement. MATERIALS AND METHODS: In this biomechanical study we compared the effects of TXA and saline upon the following biomechanical properties of artificial joint materials-(1) tensile properties (ultimate strength, stiffness and Young's modulus), (2) the wear rate using a multi-directional pin-on-plate machine, and (3) the surface topography of pins and plates before and after wear rate testing. RESULTS: There were no significant differences in tensile strength, wear rates or surface topography of either ultra-high-molecular-weight polyethylene pins or cobalt chromium molybdenum metal plates between specimens soaked in TXA and specimens soaked in saline. CONCLUSION: Biomechanical testing shows that there are no biomechanical adverse affects on the properties of common artificial joint materials from using topical TXA. LEVEL OF EVIDENCE: V.

Severe slipped upper femoral epiphysis; fish osteotomy versus pinning-in-situ: an eleven year perspective.

PURPOSE: Slipped upper femoral epiphysis (SUFE) is not common with a reported incidence of 10 per 100 000. The management of SUFE is controversial and evolving, with advancing surgical skills and expertise. The infrequency of cases, the various classifications in use, the various surgical treatments, and lack of robust evidence for outcomes, has resulted in the lack of clear, evidence-based recommendations for treatment. Although mild slip can be treated with pinning-in-situ (PIS) with predictably good outcome, moderate and severe slips present a challenge for the treating surgeons. It is logical to reduce the slip to near anatomical position; however, this desire has always been tempered by concerns about the potentially devastating complications of osteonecrosis and Chondrolysis METHODS: This is a single centre, retrospective study comparing (PIS) and Fish femoral neck osteotomy. Seventy four children presented with SUFE (90 hips). The mild and the moderate groups were treated with a single pining-in-situ (PIS). The severe group had either a surgical reduction by Fish femoral neck osteotomy or PIS. The study was approved by the regional and local ethic committee. Demographic data, clinical findings, radiographic features were collected. RESULTS: Avascular necrosis of the femoral head (osteonecrosis) was the primary outcome. There were 11 cases of osteonecrosis (12.2%): 3/41(6.9%) in the stable group compared to 7/22 (31.8%) in the unstable group, statistically significant [P < 0.001]. In the severe slip group, the osteonecrosis rate was 33.3% in the PIS group and 26.6% in the Fish osteotomy (P = 0.539). This is not statistically significant, but the trend favours surgical reduction. CONCLUSIONS: Then reduction of the deformity is valuable. The majority of cases that do not suffer osteonecrosis will benefit by reduction of the deformity; those who are destined to develop osteonecrosis are still better off with the femoral head in a reduced position. The unstable slip is more likely to be severe and more likely therefore to receive surgical reduction than a stable and less severe hip. The implication here is that the osteotomy might not be the cause of the osteonecrosis; it is the vascular damage due to the instability of the slip that is responsible.

Topical (intra-articular) tranexamic acid reduces blood loss and transfusion rates following total knee replacement: a randomized controlled trial (TRANX-K).

BACKGROUND: Approximately one-third of patients undergoing total knee replacement require one to three units of blood postoperatively. Tranexamic acid (TXA) is a synthetic antifibrinolytic agent that has been successfully used intravenously to stop bleeding after total knee replacement. A topical application is easy to administer, provides a maximum concentration of tranexamic acid at the bleeding site, and is associated with little or no systemic absorption of the tranexamic acid. METHODS: A double-blind, randomized controlled trial of 157 patients undergoing unilateral primary cemented total knee replacement investigated the effect of topical (intra-articular) application of tranexamic acid on blood loss. The primary outcome was the blood transfusion rate. Secondary outcomes included the drain blood loss, hemoglobin concentration drop, generic quality of life (EuroQol), Oxford Knee Score, length of stay, a cost analysis, and complications as per the protocol definitions. RESULTS: Tranexamic acid reduced the absolute risk of blood transfusion by 15.4% (95% confidence interval [CI], 7.5% to 25.4%; p = 0.001), from 16.7% to 1.3%, and reduced blood loss by 168 mL (95% CI, 80 to 256 mL; p = 0.0003), the length of stay by 1.2 days (95% CI, 0.05 to 2.43 days; p = 0.041), and the cost per episode by £333 (95% CI, £37 to £630; p = 0.028). (In 2008, £1 = 1.6 U.S. dollars.) Oxford Knee Scores and EuroQol EQ-5D scores were similar at three months. CONCLUSIONS: Topically applied tranexamic acid was effective in reducing the need for blood transfusion following total knee replacement without important additional adverse effects. LEVEL OF EVIDENCE: Therapeutic level I. See Instructions for Authors for a complete description of levels of evidence.

Topical (intra-articular) tranexamic acid reduces blood loss and transfusion rates following total hip replacement: a randomized controlled trial (TRANX-H).

BACKGROUND: Approximately one-third of patients undergoing total hip replacement surgery require one to three units of blood postoperatively. Tranexamic acid is a synthetic antifibrinolytic agent that has been successfully used intravenously to control bleeding after total hip replacement. A topical application is easy to administer, provides a maximum concentration of tranexamic acid at the bleeding site, and is associated with little or no systemic absorption of the tranexamic acid. METHODS: A double-blind, randomized controlled trial of 161 patients undergoing unilateral primary total hip replacement investigated the effect of topical (intra-articular) application of tranexamic acid on blood loss. The primary outcome was the blood transfusion rate. Secondary outcomes included the drain blood loss, hemoglobin concentration drop, generic quality of life (EuroQol), Oxford Hip Score, length of stay, a cost analysis, and complications. RESULTS: Tranexamic acid reduced the absolute risk of blood transfusion by 19.6% (95% confidence interval [CI], 6.9% to 32.1%; p = 0.004), from 32.1% to 12.5%, and reduced blood loss by 129 mL (95% CI, 47 to 211 mL; p = 0.002), the hemoglobin concentration drop by 0.84 g/dL (95% CI, 0.41 to 1.27; p < 0.0001), the length of stay by 1.0 days (95% CI, -0.2 to 2.3 days; p = 0.109), and the cost per episode by £305 (95% CI, £0 to £610; p = 0.05). (In 2010, £1 = 1.5 U.S. dollars.) Oxford Hip Scores and EuroQol scores were similar at three months. CONCLUSIONS: Topically applied tranexamic acid was effective in reducing blood loss and the need for blood transfusion following total hip replacement, avoiding the potential complications of intravenous tranexamic acid administration. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.