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found to significantly affect its reduction of calculated blood loss or the need for transfusion during the perioperative episode of a primary TJA. Strength of Recommendation: Strong Rationale: Due to a limited number of studies, direct meta-analysis could not be performed on the six high quality publications that solely investigated the dose effect of either IV or topical TXA.2, 3 Only two of the published studies observed a difference in favor of higher doses of IV or topical TXA.4,5 However, two different studies investigating the same comparative doses of topical TXA (1.5g and 3g) in primary TKA did not observe a difference in calculated blood loss or risk of transfusion with higher doses of topical TXA.6,7 Additionally, two publications of IV TXA in THA or TKA did not favor higher doses of IV TXA.8, 9 When a network meta-analysis was performed regarding the dose effect of IV or topical TXA, it demonstrated limited evidence for a reduction in either transfusion risk or calculated blood loss with higher doses of TXA.2,3 Although a dose response has only been observed in the analysis of TKA for IV TXA with the risk of transfusion, it does not preclude the presence of a dose response for IV or topical TXA. The anticipated dose response is likely not present at the levels of blood loss or the doses of TXA utilized for primary THA or TKA. In the network meta- analysis of primary THA and TKA, the range of IV TXA doses were 10 mg/kg and three doses of 15 mg/kg while for topical TXA doses the range was between 0.5g and 3g. 2,3 Intravenous Tranexamic Acid Network meta-analysis demonstrates no additional reduction in blood loss following a hip or knee arthroplasty with high dose IV (≥ 20mg/kg or > 1g) TXA compared to low dose IV (< 20mg/kg or ≤ 1g) TXA.4, 5 A dose response was observed in the network meta-analysis with a reduced risk of transfusion for higher doses of TXA in primary TKA, but similar results were not found for primary THA.2, 3 Additional evidence shows no significant difference comparing single-dose and multiple doses of IV TXA, which further supports the notion that higher doses of IV TXA are not necessarily clinically needed to improve the blood-sparing effects in the setting of hip or knee arthroplasties.2-3 Topical Tranexamic Acid Direct meta-analysis and network meta-analysis consistently reported no statistical difference between low dose (≤ 1.5g) and high dose (> 1.5g) topical TXA.2-3 A dose response was not observed for either blood loss or risk of transfusion regarding low dose or high dose topical TXA following hip or knee arthroplasty.2, Quality of Modern Total Ankle Arthroplasty Research Daniel Bohl, MD, MPH, Emily Vafek, MD, Simon Lee, MD, Johnny Lin, MD, George Holmes, MD, Kamran Hamid, MD, MPH Category: Ankle Arthritis Keywords: Total ankle arthroplasty; research; quality; level of evidence Introduction/Purpose: Total ankle arthroplasty (TAA) is gaining popularity as an alternative to ankle arthrodesis in the setting of end-stage ankle arthritis. However, compared to hip and knee arthroplasty, there is a relative dearth of evidence to support its use. This study assesses the quality of literature surrounding modern TAA designs. Methods: A search of all peer-reviewed, English-language journals was conducted to identify publications involving TAA. The initial search identified 444 articles published during 2006-2016. Of these, 182 were excluded because they were not clinical outcomes studies, 46 because the TAA implant was no longer available, and 15 because the primary outcome of the study was not related to TAA, leaving 201 articles for analysis. Results: No Level I studies were identified. Seventeen (8%) studies were Level II, 48 (24%) Level III, 128 (64%) Level IV, and 8 (4%) Level V. One hundred forty-three studies (71%) were retrospective in nature. Stratification by study design revealed 128 (64%) case series, 33 (16%) experimental cohort studies, 19 (10%) case-control studies, 13 (6%) observational cohort studies, and 8 (4%) case reports. The number of studies published each year steadily increased from 2006 to 2016. A total of 51% of TAA research was published in only two journals: Foot and Ankle International and the Journal of Bone and Joint Surgery. Publications from the United States accounted for 36% of total publications. The most published implant was the Scandinavian Total Ankle Replacement (Figure 1). Conclusion: While the number of TAA studies published each year has steadily increased since 2006, the quality of this research as measured by level of evidence remains suboptimal. This analysis highlights the need for continued improvement in methodology and development of robust prospective registries to advance our knowledge of TAA as a treatment for end-stage ankle arthritis. Foot & Ankle Orthopaedics, 3(3) DOI: 10.1177/2473011418S00160 ©The Author(s) 2018 This open-access article is published and distributed under the Creative Commons Attribution - NonCommercial - No Derivatives License (http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits the noncommercial use, distribution, and reproduction of the article in any medium, provided the original author and source are credited. You may not alter, transform, or build upon this article without the permission of the Author(s). Patients’ Perceptions of the Costs of Total Hip and Knee Arthroplasty Joseph D. Maratt,
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