Aims: Whether the use of elastic stockings (ES) on top of pharmacological thromboprophylaxis is beneficial remains debated. In a worldwide phase III program including 7344 patients in major orthopaedic surgery, fondaparinux, the first synthetic selective factor Xa inhibitor, demonstrated a substantial benefit over enoxaparin in preventing venous thromboembolism (VTE); risk reduction > 50% without increasing clinically relevant bleeding. The aim of this study was to evaluate the influence of ES on this superior efficacy of fondaparinux. Methods: In all four randomized, double-blind trials, comparing a once daily 2.5 mg s.c. injection of fondaparinux to enoxaparin, the primary efficacy outcome was VTE up to day 11, defined as deep-vein thrombosis (DVT) detected by mandatory bilateral venography, or documented symptomatic DVT or pulmonary embolism. A post-hoc analysis on primary efficacy was performed according to the use of ES. Results: The table shows VTE incidences by day 11 without and with ES. Conclusions: In major orthopaedic surgery, fondaparinux showed a similar superior efficacy over enoxaparin in patients with and without ES, indicating that ES did not influenced the major benefit of this new agent. An additive effect of ES in enoxaparin-treated patients cannot be excluded but the effect is insufficient compared with fondaparinux alone

Currently, data on the complication rates of primary total hip arthroplasty (THA) in Ireland is not available. We surveyed all consultant members of the Irish Orthopaedic Association (IOA) to determine the self reported complication rates of primary THA and analysed national audit data from the Economic and Social Research Institute (ESRI) for 2002. We received an 83% response rate to our survey. 58 surgeons reported data on 5,424 primary THAs for the year 2003. The mean dislocation rate was 1.02% and those using a posterior approach reported a significantly higher dislocation rate (p< 0.05). Deep infection rates were 0.44% and 29% of these were MRSA infections. There was no significant benefit reported from the use of body exhaust operative attire. The mean rate of venous thrombo-embolism (VTE) was 3.5%. There was no statistical difference reported in VTE rates when prophylaxis was commenced pre or post operatively, neither was there any significant benefit reported from using VTE prophylaxis for an extended period beyond the length of inpatient stay, nor from patients wearing graduated compression elastic stockings. ESRI national audit rates for dislocation were 25.7%, and rates of deep infection and VTE were 0.87% and < 0.1% respectively in 2002. Deficiencies in available ESRI data and questionable reliability of self reported rates, underline the necessity for a national Hip Register database in Ireland. The accurate recording of objective data on primary THA could provide an evidence base to improve surgical THA practices and patient outcomes and provide significant healthcare savings

Unicompartmental knee prosthesis (UKP) has been used for 40 years but it is still controversial. Nevertheless, this procedure is positive and it can be a good alternative if it is correctly indicated. From January 2001 we implanted 51 UKP in 47 patients. The diagnoses were: primary arthritis in 45 cases, post-traumatic degeneration in five and arthritis secondary to meniscectomy and ACL reconstruction in one. The mean age was 64.5 (range 49–81), 32 women and 15 men. Mean follow-up was 26 months (range 6–36). Post-operative recovery starts with physical rehabilitation, rarely with kinetics, and full weight-bearing walking the first day. DVT is prevented by treatment with low-molecular-weight heparin for 25 days and elastic stockings. From September 2002 we performed this procedure by minimally invasive surgery with an 8-cm incision and extramedullary intraoperative tools. We did not observe any infections or loosening: we performed just one revision of the femoral component because of a technical error. In four other cases a malpositioning of the femoral component was reported that was pain-free at follow-up. Current studies are starting to show valid and encouraging results at mid- and long-term follow-up, too. The best candidates for UKP are patients over 60 years who are not overweight, with asymptomatic patellar degeneration and no anterior instability and who perform light sport activity. In comparison with high tibial osteotomy (HTO), UKP shows some advantages, such as faster recovery and better mid-term results. In comparison with total knee arthroplasty (TKA), UKP gives better range of motion, faster postoperative recovery and an easier operation in case of infection or loosening. Some features should be evaluated and the surgical technique should employ state-of-the-art hardware. We evaluate the advantages of this procedure with particular emphasis on the minimally invasive technique. In conclusion, although our study is still in progress, correct patient selection, the surgical technique and the updated design of the new prosthesis can give satisfactory results and represent a valid alternative to HTO and TKA. In addition, compared to TKA, UKP shows a real economic advantage

It is known that patients who are undergoing major orthopaedic operations of the lower legs (fractures, total hip and knee arthroplasty) belong to a high-risk group, for the development of thromboembolic events. 20–40% of the patients develop deep vein thrombosis (DVT) of the calf and 2–4% fatal pulmonary embolism. These patients may have remarkable activation of the coagulation system, which is important for the development of deep vein thrombosis of the lower legs. Purpose: The aim of the study is to evaluate the activation of selected blood coagulation parameters, during the preoperative and postoperative period, in patients undergoing high risk of orthopaedic operation of lower limbs. The exact estimation of these factors is necessary, so that these patients receive the suitable prophylactic antithrombotic therapy,. Patients and methods: We studied 24 patients, 16 women and 8 men, between 23–84 years old, 12 with femur fracture, 8 with total knee replacement and 4 with total hip replacement surgery. All patients had normal renal function, and the platelets, count, the PT and aPTT were in a normal range. The patients were hospitalized for 7 days and then they were observed as outpatients for the possibility of developing deep vein thrombosis and for a 4 weeks period. All patients received a combination of LMWH and graduated compression elastic stockings as a prophylaxis against DVT. Plasma concentration of Di-dimers and Thrombin -Antithrombin complex (TAT) were measured preoperatively and the second, the fourth and the sixth day postoperatively. Di-dimers plasma concentration were measured by automated analyzer (VidasBiomerieux) and TAT plasma concentration were measured by an enzyme-linked microimmunoabsorbent assay (microelisa Dade-Berhing). Results: Preoperative TAT concentration in patients with femur fracture were high. Postoperatively decreased with the major decreasement on the second day (p< 0.039). Till the 6th postoperative day TAT concentration remained above normal range. Di-dimers plasma concentrations were high preoperatively and remained also high postoperatively, without significant statistical difference. In patients with total hip and knee arthroplasty TAT plasma concentration increased significantly the 12nd postoperative, day, decreased the 4th postoperative day and then increased again (p< 0.01). Di-dimers plasma concentration increased significantly the 2nd postoperative day and then decreased (p< 0,03). Until the 6th postoperative day Di-dimcrs concentration remained above normal range. Patients with fractures had higher TAT levels preoperatively than patients with total hip and knee arthroplasty. (p< 0.027). Conclusions: All patients with major orthopaedic surgery of lower limbs have shown significant activation of the coagulation system postoperatively. Patients with fractures present significant activation of the coagulation system post and preoperatively. So it may be necessary in patients with fractures, to start anticoagulation prophylaxis against DVT preoperatively, and the last dose of LMWH must be given 12 hours before the operation

We used the D-dimer level as a measure for the early diagnosis of deep vein thrombosis (DVT), which can cause fatal pulmonary thromboembolism (PTE), following total hip arthroplasty (THA). Recently, we have performed anticoagulation therapy, in addition to the use of elastic stocking and intermittent pneumatic compression, for the prevention of DVT. In the present study, we examined the effect of administration of anticoagulation drugs on the changes in the D-dimer level. Of 123 patients who had undergone THA between April 2003 and October 2007, 70 patients who were available for 3 or more measurements of the D-dimer level were included in this study. These 70 patients were divided into the following three groups: N group consisting of 30 patients who were not given anticoagulation drugs (4 males, 26 females; mean age 69 years (45–87 years); mean body mass index (BMI) 24.1 (15.8–28.5)), W group consisting of 23 patients who were administered dose-adjusted warfarin at a dose of 5 mg within 3 days after surgery and at 1–3 mg following 1-day rest (3 males, 20 females; mean age 62 years (48–83 years); mean BMI 24.1 (17.8–35.9)), and F group composed of 15 patients who were given fondaparinux (2.5 mg) between postoperative days 1 and 14 (6 males, 11 females; mean age 64 years (51–81 years); mean BMI 23.1 (18.2–31.6)). There was no significant difference in sex ratio and BMI between the three groups, while a significant difference in age was found between the N and F groups. The D-dimer level was measured on days 3, 7, 10, 14 and 21 and changes in the median D-dimer level were compared between groups. In the N group, the D-dimer level was around 8 μg/ml between postoperative days 3 and 10 and exceeded 10 μg/ml on postoperative day 14. In the W group, the D-dimer level was around 8 μg/ml between postoperative days 3 and 14 and decreased thereafter. In the F group, the D-dimer level was less than 3 μg/ ml on postoperative day 3, increased gradually thereafter until postoperative day 14, reaching the maximum level of approximately 8 μg/ml, and then decreased thereafter. The D-dimer level was significantly different between the N and F groups and between the W and F groups on day 3, between the N and F groups and between the W and F groups on day 7, and between the N and W groups on day 21. With regard to hemorrhagic adverse events, neither major nor minor bleeding event was observed in either the W or F group. The present study suggested that fondaparinux is effective for preventing DVT in an early postoperative period, with relatively low D-dimer levels observed between postoperative days 3 and 10. We expect that various types of anticoagulation drugs will be used in the future. Elucidating the effect of these drugs on the D-dimer level will help in the early diagnosis of DVT

Aims

The tibial component of total knee arthroplasty can either be an all-polyethylene (AP) implant or a metal-backed (MB) implant. This study aims to compare the five-year functional outcomes of AP tibial components to MB components in patients aged over 70 years. Secondary aims are to compare quality of life, implant survivorship, and cost-effectiveness.

Objectives

Induced membrane technique is a relatively new technique in the reconstruction of large bone defects. It involves the implantation of polymethylmethacrylate (PMMA) cement in the bone defects to induce the formation of membranes after radical debridement and reconstruction of bone defects using an autologous cancellous bone graft in a span of four to eight weeks. The purpose of this study was to explore the clinical outcomes of the induced membrane technique for the treatment of post-traumatic osteomyelitis in 32 patients.

Over recent years hip arthroscopic surgery has evolved into one of the most rapidly expanding fields in orthopaedic surgery. Complications are largely transient and incidences between 0.5% and 6.4% have been reported. However, major complications can and do occur. This article analyses the reported complications and makes recommendations based on the literature review and personal experience on how to minimise them.