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AimsAntifibrinolytic agents, including tranexamic acid (TXA) and epsilon-aminocaproic acid (EACA), have been shown to be safe and effective for decreasing perioperative blood loss and transfusion following total hip arthroplasty (THA) and total knee arthroplasty (TKA). However, there are few prospective studies that directly compare these agents. The purpose of this study was to compare the benefits of intraoperative intravenous TXA with EACA.Patients and MethodsA total of 235 patients (90 THA and 145 TKA) were enrolled in this prospective, randomized controlled trial at a single tertiary-care referral centre. In the THA cohort, 53.3% of the patients were female with a median age of 59.8 years (interquartile range (IQR) 53.3 to 68.1). In the TKA cohort, 63.4% of the patients were female with a median age of 65.1 years (IQR 59.4 to 69.5). Patients received either TXA (n = 119) or EACA (n = 116) in two doses intraoperatively. The primary outcome measures included change in haemoglobin level and blood volume, postoperative drainage, and rate of transfusion. Secondary outcome measures included postoperative complications, cost, and length of stay (LOS).ResultsTKA patients who received EACA had greater drainage (median 320 ml (IQR 185 to 420) vs158 ml (IQR 110 to 238); p < 0.001), increased loss of blood volume (891 ml (IQR 612 to 1203) vs661 ml (IQR 514 to 980); p = 0.014), and increased haemoglobin change from the preoperative level (2.1 ml (IQR 1.7 to 2.8) vs1.9 ml (IQR 1.2 to 2.4); p = 0.016) compared with patients who received TXA. For the THA cohort, no statistically significant differences were observed in any haematological outcome measure. One patient in the EACA group required transfusion. No patient in the TXA group required transfusion. There were no statistically significant differences in number or type of postoperative complications or LOS for either THA or TKA patients regardless of whether they received TXA or EACA.ConclusionFor hip and knee arthroplasty procedures, EACA is associated with increased perioperative blood loss compared with TXA. However, there is no significant difference in transfusion rate. While further prospective studies are needed to compare the efficacy of each agent, we currently recommend orthopaedic surgeons to select their antifibrinolytic based on cost and regional availability.Cite this article: Bone Joint J2019;101-B:1093–1099.

Background:The Akin proximal phalangeal osteotomy is commonly used in conjunction with metatarsal osteotomies to treat hallux valgus. Multiple fixation methods including suture, wire, screw, and staple fixation have been described. The aims of this study were to assess the intraoperative and postoperative complications and to evaluate short-term postoperative outcomes in patients who underwent Akin osteotomy with staple fixation.Methods:Forty-four patients (51 feet) with painful hallux valgus were retrospectively reviewed at an average of 40.4 ± 15.8 (range, 25.9 to 79.9) weeks following an Akin osteotomy with staple fixation. Patient reported preoperative and postoperative Visual Analog Score (VAS) (0 to 10, 0 = no pain) was recorded. Level of activity was reported postoperatively. Hallux valgus angles (HVAs), intermetatarsal angles (IMAs), and hallux valgus interphalangeus angles (IPAs) were evaluated on preoperative as well as final postoperative radiographs. Postoperative clinical and radiographic examinations were used to evaluate for complications.Results:Mean VAS improved from 4.4 ± 2.6 to 1.0 ± 1.2 (P < .001). Activity level was classified as ability to bear weight as tolerated 3/51 (5.9%), ambulate 1 to 4 blocks 2/51 (3.9%), ambulate a minimum of 6 blocks 18/51 (35.3%), and ambulate an unlimited distance 28/51 (59.4%). Average HVA, IMA, and IPA improved from 25.6 ± 10.0 degrees to 14.1 ± 8.1 degrees (P < .001), 13.1 ± 4.6 degrees to 8.0 ± 3.0 degrees (P < .001), and 7.9 ± 3.4 degrees to −3.1 ± 6.4 degrees (P < .001), respectively. No major postoperative complications, including infections, nonunions, or recurrent deformities, were recorded. Two patients sustained breaches of the lateral cortex, but this was without appreciable complication. Three patients (5.9%) reported unilateral proximal-medial great phalanx tenderness. There was 1 revision for persistent deformity, specifically in the HVA and IPA angles.Conclusion:Akin osteotomy with staple fixation was a safe and effective procedure as part of a hallux valgus correction with improvement in pain and hallux valgus deformity with a low risk for complications.Level of Evidence:Level IV, case series.