Nam, Denis

AbstractPeriprosthetic fractures around a total knee arthroplasty (TKA), comminuted and intra-articular femur fractures, or fracture nonunions in osteoporotic bone represent technically challenging problems. This is particularly true when the fracture involves a loose femoral component or the pattern results in suboptimal fixation potential. These clinical indications often arise in an older and comorbid patient population in whom a principal goal of treatment includes allowing for early mobilization. Limited data indicate that arthroplasty via distal femoral replacement (DFR) is a reasonable alternative to open reduction and internal fixation, allowing for early ambulation with low complication rates. We performed a retrospective review of trauma and arthroplasty surgeries at three tertiary referral institutions. Adult patients treated for the above with a DFR were included. Patients with active infection, open and/or high-energy injuries and revisions unrelated to fracture were excluded. Patient demographics, treatment details, and outcomes were assessed. Between 2002 and 2017, 90 DFR's were performed for the above indications with a mean follow-up of 24 months. Postoperatively, 80 patients (88%) were allowed to weight bear as tolerated, and at final follow-up, 9 patients (10%) remained dependent on a wheelchair. The average arc of motion at final follow-up was 95 degrees. There were seven (8%) implant-related complications requiring secondary surgeries: two infections, one with associated component loosening; one fracture of the hinge mechanism and one femoral component failure in conjunction with a patellofemoral dislocation (both requiring revision); one case of patellofemoral arthrosis in a patient with an unresurfaced patella; one periprosthetic fracture with associated wound dehiscence; and one case of arthrofibrosis. In each of these cases, only modular components of the DFR were exchanged. All nonmodular components cemented into the femur or tibia were retained. DFR provides a viable reconstruction option in the treatment of acute distal femur fractures, periprosthetic femur fractures, and fracture nonunions. We noted that in an elderly patient population with high comorbidities, the complication and secondary surgery rates remained relatively low, while allowing for immediate weight bearing.

Background: The purpose of this multicenter, randomized trial was to determine the optimal dosing regimen of tranexamic acid (TXA) to minimize perioperative blood loss in revision total hip arthroplasty. Methods: Six centers prospectively randomized 175 patients to 1 of 4 regimens: (1) 1-g intravenous (IV) TXA prior to incision (the single-dose IV group), (2) 1-g IV TXA prior to incision followed by 1-g IV TXA after arthrotomy wound closure (the double-dose IV group), (3) a combination of 1-g IV TXA prior to incision and 1-g intraoperative topical TXA (the combined IV and topical group), or (4) 3 doses totaling 1,950-mg oral TXA (the multidose oral group). Randomization was based on revision subgroups to ensure equivalent group distribution. An a priori power analysis (α = 0.05; β = 0.80) determined that 40 patients per group were required to identify a >1-g/dL difference in postoperative hemoglobin reduction between groups. Per-protocol analysis involved an analysis of variance, Fisher exact tests, and two 1-sided t tests for equivalence. Demographic and surgical variables were equivalent between groups. Results: No significant differences were found between TXA regimens when evaluating reduction in hemoglobin (3.4 g/dL for the single-dose IV group, 3.6 g/dL for the double-dose IV group, 3.5 g/dL for the combined IV and topical group, and 3.4 g/dL for the multidose oral group; p = 0.95), calculated blood loss (p = 0.90), or transfusion rates (14% for the single-dose IV group, 18% for the double-dose IV group, 17% for the combined group, and 17% for the multidose oral group; p = 0.96). Equivalence testing revealed that all possible pairings were statistically equivalent, assuming a >1-g/dL difference in hemoglobin reduction as clinically relevant. There was 1 venous thromboembolism, with no differences found between groups (p = 1.00). Conclusions: All 4 TXA groups tested had equivalent blood-sparing properties in the setting of revision total hip arthroplasty, with a single venous thromboembolism reported in this high-risk population. Based on the equivalence between groups, surgeons should utilize whichever of the 4 investigated regimens is best suited for their practice and hospital setting. Given the transfusion rate in revision total hip arthroplasty despite TXA utilization, further work is required in this area. Level of Evidence: Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.