'On Table' Versus 'Off Table' Direct Anterior Approach Total Hip Arthroplasty: Is There a Difference?

Background: The purpose of this study was to evaluate whether there were differences in patient-reported outcomes, operative times, satisfaction scores, and complications between patients undergoing total hip arthroplasty (THA) performed through a direct anterior approach on a specialized traction table or a regular operating room table. Methods: Patients who underwent a direct anterior approach THA on a specialized table or a regular table with a minimum 1-year follow-up were included. Patient-reported outcome measures and THA satisfaction were recorded. Demographics, complications, and operative times (both in-room and surgical time) were evaluated. Three hundred twenty-two patients were included with 217 (67.4%) undergoing anterior THA on the specialized table and 105 (32.6%) on a regular table. Results: Outcome measures were similar at 4 months and 1 year postoperatively. Average operative time was 87 minutes (range, 50-160) and 90 minutes (range, 35-197) for the specialized table and regular table groups (P = .314). Average total in room time was 123 minutes (range, 87-201) and 120 minutes (range, 62-255) for the specialized table and regular table groups (P = .564). Satisfaction rates between groups did not differ (P = .564). No differences were found in complication rates at 4 months (P = .814) or 1 year (P = .547). Conclusions: This study shows that the direct anterior approach for THA can be safely and efficiently performed on either a specialized traction table or a regular table. Surgeons should continue to utilize the approach and set-up they are most comfortable with to achieve an optimal outcome for the patient.

No Difference in Blood Loss and Risk of Transfusion Between Patients Treated with One or Two Doses of Intravenous Tranexamic Acid After Simultaneous Bilateral TKA.

BACKGROUND: Tranexamic acid (TXA) is often used to prevent excessive blood loss during bilateral TKA. Although it diminishes blood loss, TXA may have a potentially elevated thrombogenic risk with extra, unnecessary doses of TXA in this high-risk population. To date, the most efficacious dosing protocol in this setting has not yet been ascertained. QUESTIONS/PURPOSES: We compared one versus two doses of intravenous TXA in the setting of same-day bilateral TKA in terms of (1) perioperative blood loss that occurred during the hospital stay, (2) transfusion usage during the hospital stay, and (3) major complications occurring within 30 days of surgery. METHODS: Between August 2013 and October 2016, 309 patients underwent simultaneous bilateral TKA performed by one of five attending surgeons. During that time, indications for same-day bilateral TKA included bilateral knee pathology in which each knee was independently indicated for TKA and the patient preferred bilateral simultaneous TKAs versus staged bilateral surgeries. Patients who had cardiac disease or an American Society for Anesthesiologists physical classification score of greater than 2 were not generally indicated for bilateral simultaneous TKAs. After preoperative clearance from the primary physician and/or specialists as necessary, the decision for bilateral TKA was at the judgment of the operating surgeons. Input from anesthesia occurred at the time of the surgery as the procedure was performed in a sequential fashion allowing for the surgery to be restrained to a single limb if anesthesia identified concerns at the completion of the first TKA. The current retrospective, comparative series compared generally sequential groups in terms of TXA usage. Between August 2013 and July 2015, we used two TXA doses. Patients received 1 g of intravenous TXA as a bolus immediately after the last tourniquet release and were given a 1-g intravenous bolus 6 hours after the initial dose. A total of 167 patients were treated with this approach, of whom 96% (161) are fully analyzed here. Between August 2015 and October 2016, our approach changed to a single TXA dose. The dosing regimen change occurred as a group decision for change of practice and occurred mid-year to coincide with the fellowship year cycle. Patients received a 1-g bolus of intravenous TXA immediately after the final tourniquet release. A total of 105 patients were treated with this approach, of whom 89% (93) are fully analyzed here. An additional 37 patients were excluded because they did not receive any TXA because of a medical contraindication such as history of venous thromboembolism, history of thrombotic stroke, cardiac stent in the past 2 years, atrial fibrillation, or long-term anticoagulation therapy. We compared patients who received one versus two doses in terms of blood loss, transfusion usage, and 30-day major complications. The mean age was 65 years for patients receiving one dose and 67 years for patients receiving two doses (p = 0.17). The one-dose group comprised 67% (62 of 93) women and the two-dose group comprised 61% (98 of 161) women (p = 0.36). Blood loss was defined as change in the hemoglobin level (the last recorded value before discharge subtracted from the preoperative value). During the study period, the decision to transfuse was based on a hemoglobin level less than 8.0 g/dL or at higher levels for symptomatic patients, patients with cardiac disease, or at the discretion of the attending surgeon. We defined complications as major medical events that included cerebrovascular accidents, myocardial infarction, deep vein thrombosis, and pulmonary embolism. RESULTS: With the numbers available, there was no difference in blood loss between patients treated with one and those treated with two doses of TXA (mean hemoglobin decrease -3.5 ± 1.2 g/dL versus -3.5 ± 1.0 g/dL, respectively; mean difference 0.03 g/dL [95% CI -0.2 to 0.3 g/dL]; p = 0.80). No patient in either group received a transfusion. There was no difference in the proportion of patients in either group who experienced a cerebrovascular accident (0% [0 of 93] versus 1% [1 of 161]; p > 0.99), deep vein thrombosis (1% [1 of 93] versus 0% [0 of 161]; p = 0.37), or pulmonary embolism (1% [1 of 93] versus 1% [1 of 161]; p > 0.99). No patient in either the one-dose or two-dose TXA groups experienced a myocardial infarction. CONCLUSION: The findings of this study suggest that a single dose of intravenous TXA may be adequate to control excessive blood loss and reduce blood transfusion in simultaneous bilateral TKA. Despite its short half-life, TXA still appears to be effective in this demanding procedure without requiring prolonged plasma concentrations obtained from multiple doses. Additional high-quality studies are still needed to determine the most appropriate dosing regimen. LEVEL OF EVIDENCE: Level III, therapeutic study.

One Dose of Intravenous Tranexamic Acid Is Equivalent to Two Doses in Total Hip and Knee Arthroplasty.

BACKGROUND: Tranexamic acid (TXA) helps to prevent excessive blood loss during total hip arthroplasty (THA) and total knee arthroplasty (TKA), but the most efficacious dosing protocol has not been ascertained. The purpose of this study was to identify whether 1 dose of intravenous TXA is equivalent to 2 doses for reducing blood loss and transfusion rates following THA and TKA without an increase in complications. METHODS: We identified 1,736 patients who underwent THA (592 who did not receive TXA, 454 who received 1 dose of TXA, and 690 who received 2 doses) and 2,042 patients who underwent TKA (744 who did not receive TXA, 499 who received 1 dose, and 799 who received 2 doses) from 2012 to 2016. The differences among groups with regard to the change in hemoglobin levels, rate of allogeneic blood transfusions, and rate of complications were assessed. RESULTS: Patients who underwent THA and received 1 dose or 2 doses of TXA had similar drops in the mean hemoglobin levels postoperatively (2.9 g/dL and 3.1 g/dL, respectively; p = 0.197) and both had a smaller drop than the control group (3.6 g/dL; p < 0.001 compared with the 1 and 2-dose groups). These findings were confirmed by a multivariate analysis that controlled for age, sex, and preoperative hemoglobin level. Transfusion was required for 12.5% of the patients who underwent THA without receiving TXA, no patient who received 1 dose, and 0.7% of the patients who received 2 doses. The patients who underwent TKA and received 1 dose or 2 doses of TXA had similar mean drops in the hemoglobin level postoperatively (2.4 g/dL and 2.4 g/dL, respectively; p = 0.891), and both had less of a drop than the control group (2.9 g/dL; p < 0.001 compared with the 1 and 2-dose groups). These findings were also confirmed by a multivariate analysis that controlled for age, sex, and preoperative hemoglobin level. Transfusion was required for 4.3% of the patients who underwent TKA without receiving TXA, 0.4% of those who received 1 dose, and 0.3% of those who received 2 doses. Similar rates of perioperative complications occurred among all groups. CONCLUSIONS: One dose of TXA was as effective as 2 doses for decreasing blood loss and transfusion rates after THA and TKA without an increase in complications. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Inhibition of p38 mitogen-activated protein kinase signaling reduces fibrosis and lipid accumulation after rotator cuff repair.

BACKGROUND: The repair of rotator cuff tears is often complicated by fatty degeneration, which is the combination of lipid accumulation, fibrosis, inflammation, and muscle weakness. A signaling molecule that plays a central role in these processes is p38 mitogen-activated protein kinase (MAPK). The purpose of this study was to evaluate the ability of a small molecule inhibitor of p38 MAPK, SB203580, to reduce fatty degeneration in a preclinical model of rotator cuff injury and repair. MATERIALS AND METHODS: Adult rats underwent a bilateral supraspinatus tenotomy that was repaired 30 days later. Rats were treated with SB203580 or vehicle every 2 days, with injections beginning 3 days before surgery and continuing until 7 days after surgery. Two weeks after surgical repair, muscles were analyzed using histology, lipid profiling, gene expression, and permeabilized muscle fiber contractility. RESULTS: Inhibition of p38 MAPK resulted in a nearly 49% reduction in fat accumulation and a 29% reduction in collagen content, along with changes in corresponding genes regulating adipogenesis and matrix accumulation. There was also a marked 40% to 80% decrease in the expression of several proinflammatory genes, including IL1B, IL6, and COX2, and a 360% increase in the anti-inflammatory gene IL10. No differences were observed for muscle fiber force production. CONCLUSION: Inhibition of p38 MAPK was found to result in a significant decrease in intramuscular lipid accumulation and fibrosis that is usually seen in the degenerative cascade of rotator cuff tears, without having negative effects on the contractile properties of the rotator cuff muscle tissue.