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Published 2/1/2016
Jennie McKee

THA, Tranexamic Acid, Bupivacaine Papers Receive Awards

A study on conversion total hip arthroplasty (THA), the procedure in which a previous hemiarthroplasty or other reconstruction is converted to a total joint replacement, was recognized for outstanding research during the 2015 annual meeting of the American Association of Hip and Knee Surgeons. Two other studies were also honored, including one that explored whether oral tranexamic acid (TXA) is equivalent to intravenous (IV) TXA in reducing blood loss in TKA, and another that investigated the efficacy of liposomal bupivacaine in managing postoperative pain in unilateral total knee arthroplasty (TKA) patients.

Lawrence D. Dorr Surgical Techniques & Technologies Award
The Lawrence D. Dorr Surgical Techniques & Technologies Award was presented to Ran Schwarzkopf, MD, MSc, author of "Conversion Total Hip Arthroplasty: Is It a Primary or Revision Hip Arthroplasty?" Dr. Schwarzkopf's co-author was Mahta Baghoolizadeh, BS.

Although conversion THA is included in a diagnosis-related group (DRG) with primary THA, it is unclear whether conversion THA patients are more like primary THA or revision THA patients. Using data from the American College of Surgeons National Surgical Quality Improvement Project (ACS-NSQIP) database, researchers compared conversion THA patients to primary and revision THA patients, focusing on preoperative characteristics, intraoperative factors, and 30-day postoperative complications. They aimed to shed light on whether conversion THA procedures should be in the same DRG with primary THA.

The investigators obtained data gathered from 2009 to 2014 and used univariate analysis to compare 53 preoperative, intraoperative, and postoperative variables among 2,009 conversion THA patients, 5,089 revision THA patients, and 67,854 primary THA patients. They found that 17 variables had a significant difference only between conversion and primary THA patients. They identified one variable that had a difference only between conversion and revision THA, and found that three variables exhibited a difference between both conversion and primary as well as conversion and revision THA.

"The disproportionate number of differences between conversion and primary THAs suggests that patients undergoing conversion THAs better resemble patients undergoing revision THAs," wrote the authors. This suggests that conversion THA should be bundled in the same DRG as revision THA rather than primary THA, because DRGs traditionally group procedures that have similar diagnoses and require similar levels of resources from a hospital. Bundling conversion THA in the same DRG with revision THA, they said, would "be a step forward in improving the documentation of procedures in order to receive appropriate institutional reimbursement." 

James A. Rand Young Investigator's Award
Yale A. Fillingham, MD,
received the James A. Rand Young Investigator's Award for "A Randomized Controlled Trial of Oral and IV Tranexamic Acid: The Same Efficacy at Lower Cost?" Co-authors included Erdan Kayupov, MS; Darren Plummer, MD; Mario Moric, MS; COL (ret) Tad Gerlinger, MD; and senior author Craig J. Della Valle, MD.

The purpose of this double-blinded, placebo-controlled trial was to identify whether oral TXA is as efficacious as IV TXA in reducing blood loss during TKA, using the reduction of hemoglobin as the primary outcome. Of 73 primary TKA patients, 36 were randomized to receive 1.95 mL of TXA orally 2 hours preoperatively, 32 to receive a 1 mL IV bolus prior to undergoing wound closure, and 5 were excluded due to protocol deviations.

The researchers found no difference in mean reduction of hemoglobin between the oral and IV groups. In addition, they found equivalent total blood loss for oral and IV administrations at 1,267 mL versus 1,229 mL, respectively. One patient in each treatment group received a transfusion, and none experienced a thromboembolic event.

The researchers concluded that "oral TXA provides equivalent reductions in blood loss in the setting of primary TKA, at a cost of $14 compared to $47 to $108, depending on the IV formulation selected." Based on these findings, the investigators noted that using oral TXA rather than IV TXA could save from $23 million to $67 million for the estimated 700,000 primary TKAs performed each year in the United States.

AAHKS Clinical Research Award
"Liposomal Bupivacaine and Peri-articular Injection Are Not Superior to Single Shot Intra-articular Injection for Pain Control in Total Knee Arthroplasty," authored by Rajesh K. Jain, MD, MPH, and co-authors Scott D. Schoifet, MD, FACS; Manny D. Porat, MD; Gregory G. Klingenstein, MD; Jeremy J. Reid, MD; and Robert E. Post, MD, received the AAHKS Clinical Research Award.

The single-blinded, prospective, randomized study involved 207 consecutive patients undergoing unilateral TKA. All patients had been diagnosed with posttraumatic arthritis, rheumatoid arthritis, or osteoarthritis, and received standardized pain management, anesthesia, and physical therapy. Patients were randomized intraoperatively into one of the following treatment groups:

  • an intra-articular injection of bupivacaine and morphine at the conclusion of the procedure
  • a periarticular injection of bupivacaine and morphine
  • a periarticular injection of liposomal bupivacaine

The investigators recorded and compared postoperative visual analog pain scores (VAS) and mean morphine equivalents (MME). Mean VAS scores for the three groups were 3.95, 3.97, and 3.86, respectively, while the MME consumed per day was 100.7, 100.1, and 98.9, respectively.

"Liposomal bupivacaine does not alter mean pain scores or postoperative narcotic consumption in patients undergoing unilateral TKA," concluded the authors, adding that they did not detect any differences between patients who received a single intra-articular injection and those who received a periarticular injection. 

Jennie McKee is a senior science writer for AAOS Now. She can be reached at mckee@aaos.org

Bottom Line

  • Patients undergoing conversion THAs are more like patients undergoing revision THAs than patients undergoing primary THAs, according to the winners of the Lawrence D. Dorr Surgical Techniques & Technologies Award. Bundling conversion THA in the same DRG with revision THA would help improve documentation of procedures for appropriate institutional reimbursement.
  • Using oral TXA rather than IV TXA for primary TKA could save $23 million to $67 million annually in the United States alone, according to winners of the James A. Rand Young Investigator's Award.
  • Liposomal bupivacaine does not alter mean pain scores or postoperative narcotic consumption in patients undergoing unilateral TKA, concluded the winners of the AAHKS Clinical Research Award.