Effect of Perioperative Tranexamic Acid on Allogeneic Blood Transfusions for Total Knee Arthroplasty Patients at a Community Hospital.

Introduction Tranexamic acid (TXA) has been shown to be a cost-effective method for reducing blood loss and postoperative transfusions in patients undergoing total knee arthroplasty (TKA) at tertiary care centers. However, the efficacy of TXA has not been studied in community hospitals, and the potential cost savings may be especially beneficial for these institutions. The purpose of this study was to assess the effectiveness of TXA in reducing postoperative transfusions and blood loss following TKA at a community hospital. Methods Institutional approval was obtained for the retrospective review of a consecutive series of patients that underwent a total knee arthroplasty procedure between January 1, 2019, and December 31, 2019. Patients undergoing bilateral TKA were excluded from the analysis, yielding a total of 190 TKA procedures of which 131 patients received TXA. Fisher's exact test was conducted to compare rates of transfusion between the groups. A difference in difference analysis was conducted to assess TXA's effect on patient hemoglobin levels (Hgb) on postoperative Days 1 and 2. All analyses were conducted using R studio (Vienna, Austria). A p-value of 0.05 was set as the threshold for statistical significance. Results There was no difference in group characteristics in terms of age (70 years vs 68 years, p=0.17; no-TXA vs TXA, respectively). Fisher's exact test revealed no difference in the rates of allogeneic transfusion between TKA patients who did not receive a TXA and TKA patients who received a TXA (3.4% vs 0.8%; p=0.228). However, our difference in differences analysis revealed that TXA patients had a mean reduction in hemoglobin (Hgb)-related blood loss of 0.876 Hgb/dl (95% CI: 0.56 to 1.19; p<0.001) between the preoperative period and postoperative Day 1. Similarly, our difference in differences analysis revealed a mean reduction in Hgb-related blood loss of 0.972 Hgb/dl (95% CI: 0.593 to 1.349; p<0.001) between the preoperative period and postoperative Day 2. Conclusion The present study shows TXA to be effective for reducing blood loss and transfusions following TKAs performed at a small community hospital. Given the cost-savings previously reported with TXA use, as well as the medical benefits reported in this study, TXA may have a niche in small community hospitals where cost savings from reduced transfusions and shorter hospital stays are important. Further studies should assess the exact amount of financial savings from TXA utilization in small community hospitals.

Comparison of 4 femoral tunnel drilling techniques in anterior cruciate ligament reconstruction.

PURPOSE: The purpose of this study was to determine which femoral tunnel drilling technique most closely reproduces the anatomic femoral footprint and has acceptable tunnel length and tunnel orientation. METHODS: We divided 20 cadaveric knees into 4 equal groups. Arthroscopically, the anatomic femoral footprint was marked with an awl as the tunnel starting point. In group 1 the femoral tunnel was drilled through a tibial tunnel. In groups 2 and 3 the femoral tunnel was drilled through the anteromedial arthroscopy portal, with a rigid drill and flexible drill, respectively. In group 4 the femoral tunnel was drilled with the outside-in technique over a pin positioned with an arthroscopic femoral guide. Measurements of the tunnel length, aperture, and placement were taken from 3-dimensional computed tomography scans. RESULTS: Tunnel length for groups 1, 2, 3, and 4 averaged 42.08 mm, 37.73 mm, 28.92 mm, and 31.96 mm (P = .039). The mean coronal angle of the tunnels as measured from the line tangent to the posterior femoral condyles was 63.30°, 61.22°, 51.77°, and 45.00° (P = .007), and the mean distance from the inferior articular surface to the edge of the tunnel was 5.60 mm, 4.36 mm, 2.42 mm, and -0.63 mm (P = .008) for groups 1, 2, 3, and 4, respectively. There was no statistical difference in footprint length, width, area, or distance from the posterior articular margin. CONCLUSION: Drilling by the transtibial technique produces the most vertical and longest tunnels. Independent drilling techniques produce the most anatomic tunnels but at the expense of tunnel length. CLINICAL RELEVANCE: When the orthopaedic surgeon is performing ACL reconstruction, it is critical to achieve anatomic placement of the graft, as well as maintain appropriate tunnel length.

Hospitalized cases of child abuse in America: who, what, when, and where.

BACKGROUND: Orthopaedic surgeons need to recognize features of child abuse. The purpose of this study was to identify common characteristics of child abuse and to delineate features of physical injury cases that would raise concern for child abuse. METHODS: A nationally representative sample of all pediatric inpatient discharges for calendar years 1997, 2000, and 2003 was queried for physical injury diagnoses. Cases were identified as those with a diagnosis of child abuse and controls were those without the diagnosis of child abuse. Incidence of coded child abuse and a comparison of rates across time, demographics, and injury pattern were determined. Cases were compared with controls, and relative risks for coded child abuse were computed using the generalized linear model specifying the Poisson distribution and a log link. RESULTS: There were 665,195 physical injury cases identified. Of these, 11,554 (1.74%) had a diagnosis of child abuse. Fracture requiring orthopaedic management was present in 28% of the child abuse cases. The 3 strongest demographic predictors of coded child abuse were age younger than 1 year, age 1 to younger than 2 years, and Medicaid as primary payer with adjusted relative risks of 11.46, 3.07, and 1.99, respectively. Winter and weekday presentation were significantly higher for coded child abuse. Fractures with the greatest adjusted relative risks for coded child abuse were rib or sternum (5.34) and scapula (3.22). Pelvic fracture was the only fracture significant for lowered adjusted relative risk of coded child abuse. CONCLUSIONS: This study shows that young age continues to be a strong predictor of child abuse in the setting of physical injury. Supporting features include Medicaid as primary payer and winter or weekday presentation. Orthopaedists should be particularly aware of child abuse as 28% of cases had a fracture requiring orthopaedic management. LEVEL OF EVIDENCE: Prognostic Study, Level III (case-control study).

Comparison of simultaneous bilateral with unilateral total knee arthroplasty in terms of perioperative complications.

BACKGROUND: Previous studies have demonstrated an increased rate of perioperative complications and morbidity following simultaneous bilateral total knee arthroplasty compared with the rate following unilateral total knee arthroplasty. The purpose of this study was to compare the rate of perioperative complications and morbidity associated with simultaneous bilateral total knee arthroplasty with that associated with unilateral total knee arthroplasty. METHODS: The records on all bilateral total knee arthroplasties performed between January 1994 and June 2000 and unilateral total knee arthroplasties performed between January 1995 and June 2000 were retrospectively reviewed. The records on 514 unilateral total knee arthroplasties and 255 bilateral total knee arthroplasties were analyzed to determine demographic information, preoperative comorbidities, perioperative complications, and thirty-day and one-year mortality rates. RESULTS: The rates of some perioperative complications, including myocardial infarction, postoperative confusion, and the need for intensive monitoring, were greater after the bilateral arthroplasties. However, the thirty-day and one-year mortality rates and the risks of pulmonary embolism, infection, and deep venous thrombosis were similar for the two groups. CONCLUSIONS: The risk of perioperative complications associated with bilateral simultaneous total knee arthroplasty was slightly increased compared with that associated with unilateral total knee arthroplasty, but the mortality rates were similar. Ultimately, the decision to proceed with simultaneous knee replacement should depend on patient preference through informed choice.