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Purpose The surgical stress of total knee arthroplasty (TKA) procedure and the application of intra‐operative pneumatic thigh tourniquet increases local fibrinolytic activity, which contributes significantly to post‐operative blood loss. Tranexamic acid, an antifibrinolytic drug, is commonly used to control post‐operative blood loss. The recommended mode of administration of tranexamic acid is either oral or intravenous. However, the mechanism of action of the tranexamic acid points towards the possible effectiveness it may have following local/intra‐articular application. This prospective, double‐blinded, randomized preliminary study evaluated the efficacy of intra‐articular tranexamic acid in reducing TKA‐associated post‐operative blood loss. Methods Fifty consenting patients with osteoarthritis of the knee scheduled for primary unilateral cemented‐TKA were randomly allocated to one of the two groups: Tranexamic Acid (TA) group (n = 25, 500 mg/5 ml tranexamic acid) and the control group (n = 25, 5 ml 0.9% saline). The drug and control solution were administered intra‐articularly through the drain tube immediately after the wound closure. Parameters related to blood loss (drop in haemoglobin, haematocrit differential) and the drain output [volume (ml)] were compared between the two groups. Results On a comparative basis, TA‐group obtained significant reduction in the drain output [95% CI: 360.41–539.59, p < 0.001] at 48 h post‐operatively. Even though the control group received sixfold more blood transfusion than TA‐group, it showed a greater drop in haemoglobin and haematocrit (p < 0.05). Conclusions Local application of tranexamic acid seems to be effective in reducing post‐TKA blood loss as well as blood transfusion requirements. Level of evidence Therapeutic study, Level II.

Skeletal tuberculosis constitutes 1% to 3% of extrapulmonary cases and involvement of foot bones is rare. Lack of awareness and a confusing clinical and radiological picture often lead to a delay in diagnosis. We reviewed 23 feet seen over a 3.5-year period. Most cases were children or young adults less than 40 years of age; isolated bony involvement was seen in 10 feet, with the calcaneus being involved in five cases. Articular involvement at presentation was seen in 13 cases and these cases had significantly higher delays in diagnosis. Twenty cases responded to antitubercular therapy alone while one case had to be operated (there was one fatal outcome). Complete resolution of sequestra was seen with antitubercular therapy alone. The results were better in cases with isolated bony involvement, while cases with joint involvement had residual sequelae in the form of stiffness or pain. Two patients were advised arthrodesis. Early diagnosis and antitubercular therapy is essential to prevent joint involvement from periarticular bony lesions; surgical intervention is rarely needed. A high index of suspicion has to be maintained in high risk groups like Asian immigrants. Concomitant extraskeletal lesions may not always be present.

Neglected fractures of the femoral neck, common in young adults in underdeveloped countries, may be complicated by nonunion or avascular necrosis (AVN). We treated 52 cases by open reduction, fixation by compression screw and a free fibular graft. The mean delay between injury and operation was 5.1 months. Of 40 fractures assessed at a mean of 58.8 months (24 to 153), 38 were found to be united and two, owing to surgical errors, were not. Seven of eight heads which were avascular before operation revascularised without collapse, while seven others developed AVN after the procedure. At the last follow-up considerable collapse was apparent in five femoral heads, and 11 hips had developed coxa vara. The fibular graft had fractured in four cases. The hip had been penetrated by the screw in six cases and by the graft in three. Hip function was excellent in seven patients, good in 21 and fair in seven. Five patients had poor results. Incorporation of the fibular graft was seen after four years: in many cases the graft had been almost completely resorbed. We recommend this procedure for the treatment of neglected fractures of the neck of the femur in young adults to reduce resorption of the neck, AVN and nonunion.

Twenty-six patients with femoral neck fractures were treated by open reduction, cancellous screw fixation and free fibular grafting. The patients were between 14 and 50 years ofage. There were 16 old and 10 fresh fractures. Four patients had radiological signs of avascular necrosis before the treatment was instituted. Bony union was achieved in all patients except one, where the failure occurred because of a technical error. The patients were followed up for at least two years. No new case of avascular necrosis was detected after improvement in all four patients with pre-operative Fig. I Diagram showing the incision in the anterior capsule. stopping I cm short ofthe intertrochanteric line, thus sparing the arterial ring. \'Ot.. 68 B. No.

Isolated dislocations of the navicular are rare injuries; we present our experience of six cases in which the navicular was dislocated without fracture. All patients had complex injuries, with considerable disruption of the midfoot. Five patients had open reduction and stabilisation with Kirschner wires. One developed subluxation and deformity of the midfoot because of inadequate stabilisation of the lateral column, and there was one patient with ischaemic necrosis. We believe that the navicular cannot dislocate in isolation because of the rigid bony supports around it; there has to be significant disruption of both longitudinal columns of the foot. Most commonly, an abduction/pronation injury causes a midtarsal dislocation, and on spontaneous reduction the navicular may dislocate medially. This mechanism is similar to a perilunate dislocation. Stabilisation of both medial and lateral columns of the foot may sometimes be essential for isolated dislocations. In spite of our low incidence of ischaemic necrosis, there is always a likelihood of this complication.

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