Intravenous tranexamic acid (TXA) has been shown to be effective in reducing blood loss and the need for transfusion after joint replacement. Recently, there has been interest in applying it topically before the closure of surgical wounds. This has the advantages of ease of application, maximum concentration at the site of bleeding, minimising its systemic absorption and, consequently, concerns about possible side-effects. We conducted a systematic review and meta-analysis which included 14 randomised controlled trials (11 in knee replacement, two in hip replacement and one in both) which investigated the effect of topical TXA on blood loss and rates of transfusion. Topical TXA significantly reduced the rate of blood transfusion (total knee replacement: risk ratio (RR) 4.51; 95% confidence interval (CI): 3.02 to 6.72; p < 0.001 (nine trials, I(2) = 0%); total hip replacement: RR 2.56; 95% CI: 1.32 to 4.97, p = 0.004 (one trial)). The rate of thromboembolic events with topical TXA were similar to those found with a placebo. Indirect comparison of placebo-controlled trials of topical and intravenous TXA indicates that topical administration is superior to the intravenous route. In conclusion, topical TXA is an effective and safe method of reducing the need for blood transfusion after total knee and hip replacement. Further research is required to find its optimum dose for topical use.

Therapeutic level I. See Instructions for Authors for a complete description of levels of evidence.

We conducted a systematic review and meta-analysis of randomised controlled trials evaluating the effect of tranexamic acid (TXA) upon blood loss and transfusion in primary total knee replacement. The review used the generic evaluation tool designed by the Cochrane Bone, Joint and Muscle Trauma Group. A total of 19 trials were eligible: 18 used intravenous administration, one also evaluated oral dosing and one trial evaluated topical use. TXA led to a significant reduction in the proportion of patients requiring blood transfusion (risk ratio (RR) 2.56, 95% confidence interval (CI) 2.1 to 3.1, p < 0.001; heterogeneity I(2) = 75%; 14 trials, 824 patients). Using TXA also reduced total blood loss by a mean of 591 ml (95% CI 536 to 647, p < 0.001; I(2) = 78%; nine trials, 763 patients). The clinical interpretation of these findings is limited by substantial heterogeneity. However, subgroup analysis of high-dose (> 4 g) TXA showed a plausible consistent reduction in blood transfusion requirements (RR 5.33; 95% CI 2.44 to 11.65, p < 0.001; I(2) = 0%), a finding that should be confirmed by a further well-designed trial. The current evidence from trials does not support an increased risk of deep-vein thrombosis (13 trials, 801 patients) or pulmonary embolism (18 trials, 971 patients) due to TXA administration.

Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Background:Ten to fifteen percent of knee arthritis is reported to be isolated patellofemoral arthritis. Total knee arthroplasty is not recommended for isolated patella femoral arthritis particularly in young patients. We present the retrospective review of 45 consecutive patellofemoral replacements performed in 41 such patients, between June 2002 and January 2007.Materials and Methods:All patients were operated by single surgeon (SM) or under his supervision. All forty five patients had minimum three year followup and had the data collected prospectively. No patient was lost to followup. This data was later collated by review of notes, radiographs, and a clinical followup. The patients were assessed using knee function score and Melbourne patellofemoral score.Results:The average followup was 4.5 years. The preoperative average Melbourne (Bartlett) score was 10 (range 5-21). Preoperative knee functional score averaged 57 (range 23–95). The average range of movement was 116° (range 100°–140°). Postoperatively, the average Melbourne knee score improved to 25 (range 11–30), while the knee function score was 85 (range 28 – 100). The difference was statistically significant (P<0.05). Eighty-five percent rated the result as good or excellent, while 12% rated it as fair. Five percent thought the result was poor. The most common complaint was clicking at 40° of flexion (n=7). Six patients underwent arthroscopic lateral release, which improved the symptoms in four patients. Two knees were revised one due to progression of tibiofemoral arthritis and the other due to persistent clicking, yielding a survival rate of 95.6% at an average five year followup.Conclusion:The Avon patellofemoral joint replacement provides predictably good results and excellent survivorship in the medium term, for isolated patellofemoral arthritis. However, progression of tibiofemoral arthritis remains unpredictable and therefore patient selection is crucial to ensure success. Clicking remains a potential problem and can compromise the postoperative results in upto 15% of the cases.