Abstract. Background. The European population is consistently getting older and this trend is expected to continue with fastest rise seen in those over 85 years old. As a consequence there will be more nonagenarians (over 90 years old) having lower limb arthroplasty. Objectives. To compare the length of stay, readmission and one year mortality between nonagenarians and people aged between 70 to 80 years after having lower limb arthroplasty. Methods. Retrospective review of patients electronic records over 90 years following total knee replacement (TKR) or total hip replacement (THR). The length of stay after surgery, 30 day readmission rate and one year mortality were compared with control group aged between 70 to 80 years who had lower limb arthroplasty during the same period. Results. There were 31 nonagenarians with mean age of 91.6 years and the control group consisted of 31 patients with the mean age of 74.6 years. The average length of stay was 5 days in the nonagenarians compared to 4 days in the younger group. There was no difference in the 1 year mortality. 30 day readmission's was 16% in the older cohort and 5% in the younger. There was an increase in trend of nonagenarians having lower limb arthroplasty over the years. Conclusions. There is increasing number of nonagenarians undergoing lower limb arthroplasty. Nonagenarians and those aged between 70 to 80 years have comparable length of stay and 1 year mortality but higher rate of readmissions after lower limb arthroplasty

Abstract. Aim. This study was aimed to look into factors responsible for delayed mobilization after lower limb arthroplasty and effect on length of stay. Methods. It is an observational study conducted at Kings Mill Hospital from August to October 2021. All patients undergoing primary knee or hip arthroplasty were included in the study, while patients with revision surgeries were excluded. A proforma was designed to record demographics and different variables including medications, type of anaesthesia, orthostatic hypotension, dizziness, preop and post op pain score, fall in haemoglobin, analgesia and length of stay. Patients were assessed on day one and data was recorded in the proforma. Data was analysed using SPSS. Results. There were 60 patients (32 females and 28 males) which were included in the study. Mean age was 69.62 years. Thirty patients underwent TKA while in the rest of 30 patients THA was done. Fifty patients were mobilized on day one while 10 patients failed to mobilise. Out of different variables assessed orthostatic hypotension, dizziness, pre mobilization pain score and pain score during mobilization were found to be significant. Mean length of stay was longer in patients with delayed mobilization (P=0.018). Conclusion. Pain, dizziness and orthostatic hypotension were independent factors affecting mobilization after lower limb arthroplasty and indirectly increasing the length of stay

Acute post-operative urinary retention (POUR) is a recognized complication following lower limb arthroplasty. Its occurrence may have patient and ultimately medico-legal implications. Identifying high-risk patients and the associated risk factors pre-operatively, is vital to tackle this issue and reduce its occurrence, which ultimately, may enhance the overall success of our operations. Our aim was to assess the incidence of POUR following elective lower limb arthroplasty and analyze the related factors that could potentially predict the likelihood of developing POUR in our patient cohort. A prospective audit of 158 patients was conducted in our department. POUR was defined as inability to pass urine voluntarily within the first 24 hours following elective lower limb arthroplasty leading to the insertion of a urinary catheter. Surgical-related factors including intra-operative fluid use, type of spinal anesthetic, duration of surgery, time from surgery till insertion of a urinary catheter as well as patient-related factors including medication, urological history and Body Mass index (BMI) was collected and analyzed. 21 (13.3%) patients developed post-operative urinary retention, 11 (52%) and 10 (48%) following knee and hip replacements respectively. Of which, 19 (90.5%) were male and 2 (9.5%) were female with an average age of 66 yrs. 13 (62%) had a previous urological history and 10 (48%) were on retention associated medication. Bupivacaine as a spinal anesthetic was associated with an increased risk of developing post-operative urinary retention. The average time till catheter insertion was 14 hrs. Only 2 (10%) had an unsuccessful TWOC on discharge. Bupivacaine as a spinal anesthetic and a previous urological history can be considered as risk factors for the development of POUR. Pre-operative urinary catheterization should be considered in this high-risk group of patients

Aims. The COVID-19 pandemic has caused unprecedented disruption to elective orthopaedic services. The primary objective of this study was to examine changes in functional scores in patients awaiting total hip arthroplasty (THA), total knee arthroplasty (TKA), and unicompartmental knee arthroplasty (UKA). Secondary objectives were to investigate differences between these groups and identify those in a health state ‘worse than death’ (WTD). Methods. In this prospective cohort study, preoperative Oxford hip and knee scores (OHS/OKS) were recorded for patients added to a waiting list for THA, TKA, or UKA, during the initial eight months of the COVID-19 pandemic, and repeated at 14 months into the pandemic (mean interval nine months (SD 2.84)). EuroQoL five-dimension five-level health questionnaire (EQ-5D-5L) index scores were also calculated at this point in time, with a negative score representing a state WTD. OHS/OKS were analyzed over time and in relation to the EQ-5D-5L. Results. A total of 174 patients (58 THA, 74 TKA, 42 UKA) were eligible, after 27 were excluded (one died, seven underwent surgery, 19 non-responders). The overall mean OHS/OKS deteriorated from 15.43 (SD 6.92), when patients were added to the waiting list, to 11.77 (SD 6.45) during the pandemic (p < 0.001). There were significantly worse EQ-5D-5L index scores in the THA group (p = 0.005), with 22 of these patients (38%) in a health state WTD, than either the TKA group (20 patients; 27% WTD), or the UKA group (nine patients; 21% WTD). A strong positive correlation between the EQ-5D-5L index score and OHS/OKS was observed (r = 0.818; p < 0.001). Receiver operating characteristic analysis revealed that an OHS/OKS lower than nine predicted a health state WTD (88% sensitivity and 73% specificity). Conclusion. OHS/OKS deteriorated significantly among patients awaiting lower limb arthroplasty during the COVID-19 pandemic. Overall, 51 patients were in a health state WTD, representing 29% of our entire cohort, which is considerably worse than existing pre-pandemic data. Cite this article: Bone Jt Open 2023;4(3):138–145

Charlson Index has been found to predict functional outcome, implant survival, mortality, length of hospital stay and resource use after arthroplasty. Obesity can influence the outcome following lower limb arthroplasty. Our aim was to identify if there was a relationship between Charlson index, obesity and disability and whether this relationship had altered in recent years. Demographic details, Charlson index, BMI, SF-12 and oxford score were recorded prospectively for 88 consecutive patients undergoing lower limb arthroplasty between August 2011 and January 2012(Group B). The results were compared with Charlson index of 92 consecutive patients between August 2005 and March 2006(Group A). The mean age for Group A was 70 years (range 41–90). 56(61%) were female and 36(39%) male. The mean Carlson index was 3 (range 0–6) and median was 3. The mean age for Group B was 67 years (range 45–91). 53(60%) were female and 35(40%) male. The mean Charlson index was 2.2 (range 0–11) and median was 0. The difference between the groups was statistically significant with a P value of 0.001. The mean BMI for Group B was 31 (range 15–56) and median 30. Thirteen patients (15%) had BMI<25, 29 patients (33%) had BMI between 25–29. 9(Pre-Obese), 23 patients (26%) had BMI between 30–34. 9(Obese-Class 1), 10 patients (11%) had BMI between 35–39. 9(Obese-Class 2)and 13 patients (15%) had BMI>40 (Obese-Class 3). The only difference between group B1(BMI<30) and B2(BMI>30) was of age with a P value of 0.0003 (72 vs 59 years). The current group had less comorbidity but 85% of patients were overweight or obese. These patients were younger but there was no difference in their health or disability before surgery. The high prevalence of obesity may represent treatment selection of these patients away from waiting list centres. Consideration about the treatment of obesity should be given before lower limb arthroplasty

Acute Kidney Injury (AKI) formerly known as “acute renal failure” results in rapid reduction in kidney function associated with a failure to maintain fluid, electrolyte and acid-base homeostasis. The UK NCEPOD published a report in 2010 on AKI that revealed many deficiencies in the care of patients with AKI. The UK Renal Association has published the final draft of Clinical Practice Guidelines for Acute Kidney Injury on the 08/01/2011. In our study we determined retrospectively the occurrence of this problem in a District General Hospital and its impact on recovery after lower limb arthroplasty. Data was collected retrospective study over 3 months between Oct to Dec 2010 from theatre registers and the hospital database system. 359 patients were identified. Preoperative (baseline) and postoperative blood investigations included Creatinine, Urea, K+, Na+, GFR, Haemoglobin were analysed. Data collection also included type of anaesthesia, timing of operation, duration of procedure and estimated blood loss. From the hospital database system and clinic letters we collected length of stay and time required for blood results to come back to baseline. A diagnosis of Acute Kidney Injury was based on the International Kidney Disease Improving Global Outcomes (KDIGO) staging classification as recently recommended by UK Renal Association. Stage I Creatinine increase by ≥ 26 μmol/L from baseline, Stage II Creatinine increase by 200-300% and Stage III Creatinine increase ≥ 300%. In our study 11.97% (43/359) of patients developed acute kidney injury following lower limb Arthroplasty. 18 patients (42%) developed Stage I (Cre increase ≥ 26 μmol/L), 17(39%) developed Stage II (Cre increase 200-300%) and 8 patients (19%) developed Stage III (Cre increase ≥ 300%) AKI. Most of these patients were operated during the afternoon session. Patients with acute kidney injury stayed longer in hospital (11.7days) compared to similar age group of patients (6.35days) admitted during the same period. 25% of patients took more than a month for renal parameters to come down to normal. AKI is a new definition and the incidence in our hospital is higher than the 1% expected nationally. Patients with AKI are often complex to treat and specialist timely referral and transfer to renal services if appropriate should be considered. The etiology of Acute Renal Injury is very complex and includes gentamicin antibiotic prophylactic, rapid blood loss in elderly frail patients, non-steroidal pain killers and preexisting cardiac and renal pathology. The need for careful postoperative observation cannot be overemphasised together with judicious blood replacement as required. Acute Kidney Injury following lower limb arthroplasty is a sensitive marker of postoperative care. A successful surgical outcome may not mean a successful renal outcome. Patients with AKI are often complex to treat the new AKI definition and staging system allows an earlier detection and management of this condition. Further prospective audit with large number of patients are required

Aim: To assess the infection rate following Lower Limb Arthroplasty using single dose gentamicin antibiotic prophylaxis compared to a traditional three doses of cephalosporin. Material and Methods: All patients undergoing Total Hip and Knee joint replacements over 6 months (October 2007 to March 2008) at 3 participating hospitals were prospectively followed up to assess perioperative infection rates. Joint replacements were defined as having infection by the UK Health Protection Agency Surgical Site Surveillance criteria. All patients received single dose antibiotic prophylaxis using intravenous Gentamicin 4.5mg/kg body weight adjusted for body mass index. This group of patients were compared with previous data collected over a 6 month period (Jan to Mar 2007 and Oct to Dec 2005) from the same hospitals for infection rates in Lower Limb Arthroplasty using 3 doses of Cefuroxime 750mg as antibiotic prophylaxis. Results: 408 patients underwent Total Hip Replacements (THR) and 458 patients underwent Total Knee Replacements (TKR) during the study period. This was compared with 414 patients who underwent THR and 421 patients who underwent TKR during a 6 month period over 2 years. Surgical site infection was detected in 9 THRs (2.2%) and 2 TKRs (0.44%) in the study group as compared to infection in 13 THRs (3.1%) and 12 TKRs (2.9%) in the control group. Using the Fisher Exact test the infection rates in THRs were not significantly different between the 2 groups (p value – 0.52) but the infection rates were significantly reduced in the study group for TKRs (p value – 0.005). There were no complications with the use of Gentamicin as antibiotic prophylaxis. Cefuroxime is known to promote Clostridium difficile infection and was removed from the hospital pharmacy to help meet a UK government targets to reduce the incidence. The rate of Clostridium difficile infection was reduced within the hospital with the use of single dose antibiotic prophylaxis although other measures to reduce its incidence were also introduced. Conclusions: This study shows that the use of single dose antibiotic prophylaxis using Gentamicin is effective for elective Lower Limb Arthroplasty. This is recommended for routine use in all elective joint replacements as it is safe, effective and easy to administer

Introduction. Enhanced recovery programmes (ERP) have recently been adopted in the UK, enabling patients to recover quickly and return home sooner. Choice of anaesthetic is an important factor effecting post-operative outcome; studies show regional anaesthesia is more cost-effective, decreasing the incidence of venous thromboembolic events and reducing intra-operative blood loss, the need for transfusion and the length of hospital stay. Objectives. The objective of this study was to compare the short-term outcome of patients enrolled in our ERP who underwent either general or spinal +/− epidural anaesthesia. Methods. We prospectively studied 1222 patients (age- and sex-matched) who underwent lower limb arthroplasty enrolled in our ERP between March 2010-December 2011. Patients were given the opportunity to discuss their preferred mode of anaesthesia with their anaesthetist. Group 1 underwent general anaesthesia (GA), Group 2 underwent spinal +/− epidural anaesthesia (SA+/−EA). Results. 1222 patients underwent lower limb arthroplasty during our study period; 690 patients underwent GA, and 532 patients received SA+/−EA. There were similar ratios of THRs and TKRs in each group 343:347 and 257:275, respectively. Group 1 had an average age of 67.8 years (range 23–92; 65% female, 35% male), group 2 average age was 70 years (range 29–96; 58% female, 42% male). Average length of stay was 4.65 days in group 1 and 4.75 days in group 2 (Median 4, range 1–23). Similar rates of post-operative wound complications were noted in each group. Both groups had just two incidences of venous thromboembolic events. Conclusion. Enhanced Recovery Programmes have been initiated to reduce hospital stay following lower limb arthroplasty. We have shown no statistically significant difference between the patient being asleep or awake during surgery in the short-term outcome following surgery. The biggest contributing factors to the mode of anaesthesia used were individual anaesthetists' preference and patient choice

The aims of the study were to determine the prevalence of post thrombotic syndrome following lower limb arthroplasty in patients who did not receive chemical thromboprophylaxis, and identify morbidity associated with the condition. From the Trent regional arthroplasty database patients 5 years post elective total knee or hip replacement were identified. All patients were under the care of two senior orthopaedic consultants who performed surveillance venography between the 7th and 10th postoperative day. Prophylaxis for DVT was in the form of below knee compression stockings. Above knee DVTs were anticoagulated, below knee compression stockings was administered for below knee DVT. Two doctors conducted a clinical review in the manner suggested by the American Venous Forum Executive Committee. Clinical examination was used to assess the presence and class of post-thrombotic syndrome. 71 patients were reviewed. With respect to the ipsilateral limb, there were 32 patients with a DVT and 39 without DVT. Six classes excluding normal, class 0, are used to describe the clinical findings. 17 (24%) patients had no visible sign of venous disease (class 0). 14 (20%) patients suffered minor venous disease (class 1). 28 (39%) patients had established varicose veins (class 2). 2 (3%) patients had oedema without skin changes (class 3). 8 (11%) patients had skin changes ascribed to venous disease ie. pigmentation, venous eczema, lipodermato-sclerosis (class 4). 2 (3%) patient had skin changes as defined with healed ulceration. No patient had skin changes as defined previously with active ulceration (class 6). Minor venous disease (classes 1 & 2) is common and seen in 44% of DVT negative and 78% of DVT positive patients in this study. Severe venous (classes 3,4 & 5) disease is uncommon and seen in 20% of DVT negative and 13% of DVT positive patients in the study. Symptomatic patients were equally distributed between DVT positive and negative groups. Severe venous disease was more common in the DVT negative group. Concluding, minor venous disease is common post lower limb arthroplasty, severe disease occurred in 17% of patients and appeared unrelated to a previous DVT. The presence of a DVT does not influence the development of skin changes of post-thrombotic limb

Introduction Chronic venous insufficiency can be a disabling complication following otherwise successful arthroplasty. The objectives of this study were 1) To evaluate correlation between the CIVIQ (questionnaire) score and the clinical score in a cohort of patients with lower limb arthroplasty. 2) To evaluate if CIVIQ score can predict post-phlebitic syndrome. Methods A cohort of 44 patients at least three years following primary lower limb arthroplasty was selected. The control group included 22 patients who did not have DVT. The study group included 22 age matched patients who had DVT following the index procedure. CIVIQ score and clinical score was obtained. Statistical analysis included correlations, linear regression analysis and independent sample t-test. Results The CIVIQ and clinical scores showed significant correlations, with r=0.66 (p 0.01). The linear regression yielded the formula; CIVIQ score equals 32 plus 1.7 (clinical score) with power of 0.9. There was statistically significant difference in the CIVIQ score in the study and control groups (p 0.013, power 0.9). Conclusions CIVIQ is an effective tool to predict post-phlebitic syndrome in patients with arthroplasty. This is especially useful as it is self administered and hence can be done as a postal or telephone survey

Acute Kidney Injury (AKI) is an increasingly prevalent complication of lower limb arthroplasty (LLA). Even a transient decrease in kidney function has been shown to be associated with increased mortality and development of subsequent Chronic Kidney Disease (CKD). We set out to determine which perioperative factors are associated with AKI development at our institution through a retrospective cohort methodology. Patients who underwent primary elective LLA from 01/10/16 to 31/09/17 were included, with relevant perioperative data collected from electronic patient records. AKI was classified according to the Acute Kidney Injury Network (AKIN) criteria. Overall 6.6% of 686 patients developed an AKI post-operatively. These individuals had a significantly longer length of stay (Median 7 days vs 5 days for no AKI [p<0.001]). Independent predictors of AKI on multivariate regression analysis included: Diabetes (OR 3.10, 95% CI 1.34 to 7.20; p=0.008) CKD (OR 5.07, 95% CI 2.60 to 9.86; p=<0.001) and male sex (OR female sex 0.33, 95% CI 0.17 to 0.63; p=0.001). A model including any of these three risk factors predicted 82.2% of patients with an AKI. The overall AKI rate for this model was 11.2% compared to 2.3% for those without any of the three criteria. Only 11% of patients had IV fluid continued beyond the recovery room. AKI is a significant problem in LLA. Knowledge of associated risk factors will allow for targeted interventions to decrease AKI incidence. Continuation of IV fluids until the first post-operative morning for high risk individuals may be a simple method of reducing AKI

Purpose: To assess the infection rate following Lower Limb Arthroplasty using single dose gentamicin antibiotic prophylaxis compared to a traditional three doses of cephalosporin. Method: All patients undergoing Total Hip and Knee replacements over six months (October 2007 to March 2008) at three participating hospitals were prospectively followed to assess perioperative infection rates using Surgical Site Surveillance(SSI) criteria. All patients received single dose antibiotic prophylaxis using intravenous Gentamicin 4.5mg/kg. This was compared with previous data collected over a 6 month period (Jan to Mar 2007 and Oct to Dec 2005) from the same hospitals using 3 doses of Cefuroxime 750mg. Return to theatre data was collected independently after introduction of gentamicin to compare with previous data. The change in creatinine level postoperatively was also measured in a selected group of patients. Results: Four hundred and eight patients underwent Total Hip Replacements (THR) and 458 patients Total Knee Replacements (TKR) during the study period. This was compared with 414 and 421 patients who underwent THRs and TKRs respectively during a previous six month period. SSI was detected in 9 THRs(2.2%) and 2 TKRs(0.44%) in the study group as compared to 13 THRs(3.1%) and 12 TKRs(2.9%) in the control group. The infection rates in THRs were not significantly different between the 2 groups(p value−0.52) but were significantly reduced in the study group for TKRs(p value−0.005). The rate of Clostridium difficile infection was reduced within the hospital with the use of gentamicin, although other measures to reduce its incidence were also introduced. The return to theatre was 1.64%(23/1402) after introduction of Gentamicin as compared with 1.05%(21/2005) [p value−0.092] before this. This was a cause for concern although not significant. The day1 postoperative creatinine level increased by more than 30 units in 6% of patients on Gentamicin. Conclusion: This study shows that the use of single dose prophylaxis using Gentamicin is effective for Lower Limb Arthroplasty. However, be wary of increased rate of return to theatre and the rise in creatinine level following use of gentamicin. Further period of evaluation and study is needed before it is recommended for routine use in present or modified form

Introduction and Aims: This study was designed to assess the impact of lower limb arthroplasty on performance and other outcome measures in active golfers. The aim was to obtain justification data prior to proceeding with a much larger prospective study. Method: Subjects were selected for inclusion in the study on the basis of having undergone lower limb arthroplasty surgery and actively playing golf at a social or competitive level at least fortnightly. Data was collected retrospectively by the use of a self-administered, patient-orientated questionnaire. Pre- and post-joint replacement data was obtained for: Australian Golf Union (AGU) handicap; driving and longest iron distances; frequency and duration of golf rounds played; use of motorised assistance; and pain, stiffness, swelling and subjective performance scores. Demographics, length of time to return to playing golf post-operatively and post-operative complications were also recorded. Results: Results were obtained from 25 subjects with 33 joints in total replaced, 24 male and one female, mean age 70.6 years (range 53–81 years) and average time to survey post-arthroplasty was five years and 10 months. The right knee was replaced in 30.3% of subjects, left knee 27.3%, right hip 24.2% and left hip 18.2%. Eight of the 25 subjects reported complications with three requiring further surgery. There were no reports of dislocation. The average time taken to resume golfing activity post-arthroplasty was 15.4 weeks (range 5–52 weeks). Subjects demonstrated a mean increase in their AGU handicap of 1.6 strokes (p< 0.05). Average drive distance off the tee shortened by 8.6 metres (p< 0.05), with a similar change for average longest iron length, in the magnitude of 7.4 metres (p< 0.05). There was no significant change in the numbers of rounds played per month, with a mean of 8.9 pre-joint replacement and 8.3 after surgery. Wilcoxon signed-ranks test values were significant (p < 0.05) for comparison of pre to post-joint replacement, showing a decrease in reported symptoms of pain, stiffness and swelling following joint replacement. A highly significant (p< 0.001) finding was a reduction in the subjective impact of joint symptoms on golf performance post-arthroplasty. Conclusion: Although subjects seem to be more satisfied with their golf by playing with less joint pain, stiffness and swelling, they appear to do so with an actual decrease in objective performance. These significant findings support conducting a much larger prospective study looking at the impact of arthroplasty on golf activity, and vice versa

Aim: To assess the infection rate following Primary Lower Limb Arthroplasty using single dose gentamicin antibiotic prophylaxis compared to a traditional three doses of cephalosporin. Material And Methods: All patients undergoing primary Total Hip and Knee joint replacements over 6 months (October 2007 to March 2008) at 3 participating hospitals were prospectively followed up to assess perioperative infection rates. Joint replacements were defined as having infection by the UK Health Protection Agency Surgical Site Surveillance (SSI) criteria. All patients received single dose antibiotic prophylaxis using intravenous Gentamicin 4.5mg/kg body weight adjusted for body mass index. This group of patients were compared with previous data collected over a 6 month period (Jan to Mar 2007 and Oct to Dec 2005) from the same hospitals for infection rates in Lower Limb Arthroplasty using 3 doses of Cefuroxime 750mg as antibiotic prophylaxis. Return to theatre data was collected independently after introduction of gentamicin to compare with previous data. Results: 408 patients underwent Total Hip Replacements (THR) and 458 patients underwent Total Knee Replacements (TKR) during the study period. This was compared with 414 patients who underwent THR and 421 patients who underwent TKR during a 6 month period over 2 years. Surgical site infection was detected in 9 THRs (2.2%) and 2 TKRs (0.44%) in the study group as compared to infection in 13 THRs (3.1%) and 12 TKRs (2.9%) in the control group. Using the Fisher Exact test the infection rates in THRs were not significantly different between the 2 groups (p value – 0.52) but the infection rates were significantly reduced in the study group for TKRs (p value – 0.005). There were no complications with the use of Gentamicin as antibiotic prophylaxis. The return to theatre was 2.42% (28/1157) after introduction of Gentamicin as compared with 1.85% (37/2005) [p value – 0.172] before this. This was a cause for concern, although not a significant difference. Cefuroxime is known to promote Clostridium difficile infection and was removed from the hospital pharmacy to help meet a UK government targets to reduce the incidence. The rate of Clostridium difficile infection was reduced within the hospital with the use of single dose antibiotic prophylaxis although other measures to reduce its incidence were also introduced. Conclusions: This study shows that the use of single dose antibiotic prophylaxis using Gentamicin is effective in preventing SSI as defined in the HPA definition. It is safe to use and reduces rate of Clostridium difficile associated diarrhoea. However, be wary of increased rate of return to theatre following use of gentamicin. Further period of evaluation and study is needed before it is recommended for routine use in present or modified form

Introduction. The National Institute for Health and Clinical Effectiveness recommends both low molecular weight heparin (LMWH) and Rivaroxaban for venous thromboembolic (VTE) prophylaxis following lower limb arthroplasty. Despite evidence in the literature that suggests Rivaroxaban reduces VTE events, there are emerging concerns from the orthopaedic community regarding an increase in wound complications following its use. Methods. Through the orthopaedic clinical directors forum, Trusts replacing LMWH with Rivaroxaban for lower limb arthroplasty thromboprophylaxis during 2009 were identified. Prospectively collected Hospital episode statistics (HES) data was then analysed for these units so as to determine rates of 90-day symptomatic deep venous thrombosis (DVT), pulmonary thromboembolism (PTE), major bleed (cerebrovascular accident or gastrointestinal haemorrhage), all-cause mortality, and 30-day wound infection and readmission rates before and after the change to Rivaroxaban. 2752 patients prescribed Rivaroxaban following TKR or THR were compared to 10358 patients prescribed LMWH. Data was analysed using odds ratios (OR). Results. There were significantly more wound infections in the Rivaroxaban group (3.85% vs. 2.81%, OR=0.72; 95% CI 0.58-0.90). There were no significant differences between the two groups for PTE (OR=1.52; 0.77-2.97), major bleed (OR=0.73; 0.48-1.12), all-cause mortality (OR=0.93; 0.46-1.87) and re-admission rate (OR=1.21; 0.88-1.67). There were significantly fewer symptomatic DVTs in the Rivaroxaban group (0.91% vs. 0.36%, OR=2.51; 1.30-4.82). Conclusion. This study is the first to describe the real impact of the use of Rivaroxaban in the NHS. When compared with LMWH in lower limb arthroplasty patients, wound infection rates were significantly higher following Rivaroxaban use whilst providing no reduction in symptomatic PTE or all-cause mortality

Recent debate about changing population demographics and growing demands of younger patients has suggested a future explosion in the requirements for primary and revision lower limb arthroplasty (TKA/THA). This could represent a significant challenge for healthcare providers. This study aimed to predict the demands for lower limb arthroplasty in Scotland from 2010–2035. Population figures (2004–2010) and projected population data (five year increments) were obtained from the National Records of Scotland. The numbers of arthroplasties from 2004–2010 were provided by the Scottish Arthroplasty Project. Data were divided into three age groups (40–69, 60–79, 80+). The first model used mean incidence for each age group from 2006–2010 applied to the projected population figures. The second used linear regression to give predicted incidences 2015–2035 which were then applied to the projected population. The third-for revisions – used incidence per number of primary arthroplasties. For primary TKA model 1, comparing to 2010, showed demand increasing by 10% in 2020 and by 31% (to 8,650 procedures) in 2035. Model 2 gave increases of 60% and 161% respectively. An increase was found across all age groups with 60–79 more than doubling and 80+ increasing fourfold by 2035 (model 2). The revision TKA models predicted between 670 and 2,000 procedures by 2035. For primary THA models 1 and 2 showed demand increasing by 40% in 2020 and then by 60% and 110% (11,000 and 14,500 procedures) in 2035 respectively. All age groups had increasing demand with 60–79 doubling and 80+ tripling by 2035 (model 2). The revision THA models predicted between 1,300 and 2,100 procedures by 2035. These projections show large increases in the numbers of both primaries and revisions over the next two decades. They highlight that current resources may be insufficient or the selection criteria for surgery may need to be revisited

Aims. Calcium sulphate has traditionally been used as a filler of dead space arising during surgery. Various complications have been described following the use of Stimulan bio-absorbable calcium sulphate beads. This study is a prospective observational study to assess the safety profile of these beads when used in revision arthroplasty, comparing the complication rates with those reported in the literature. Methods. A total of 755 patients who underwent 456 revision total knee arthroplasties (TKA) and 299 revision total hip arthroplasties (THA), with a mean follow-up of 35 months (0 to 78) were included in the study. Results. A total of 32 patients (4.2%) had wound drainage, and this was higher with higher bead volumes and in McPherson grade C patients. There was also a significantly higher bead volume in the 41 patients who developed hypercalcaemia, two of which were symptomatic (p < 0.0001). A total of 13 patients (1.7%) had heterotopic ossification (HO). There was no statistically significant relationship between the development of HO and bead volume (p > 0.05). Conclusion. The strength of this study lies in the large number of patients and the detailed data collection, making it the most comprehensive report available in the literature on the use of calcium sulphate-based bone substitutes. Cite this article: R. Kallala, W. Edwin Harris, M. Ibrahim, M. Dipane, E. McPherson. Use of Stimulan absorbable calcium sulphate beads in revision lower limb arthroplasty: Safety profile and complication rates. Bone Joint Res 2018;7:570–579. DOI: 10.1302/2046-3758.710.BJR-2017-0319.R1

Aims

It is common practice for patients to have postoperative blood tests after total joint replacement (TJR). However, there have been significant improvements in perioperative care with arthroplasty surgery, and a drive to reduce the length of stay (LOS) and move towards day-case TJR. We should reconsider whether this intervention is necessary for all patients.

Excessive perioperative administration of intravenous fluid during lower limb arthroplasty may be associated with postoperative complications. There have only been five randomised trials that have evaluated the effects of intraoperative fluid on recovery time, none of which have looked at Orthopaedic patients. Intravenous fluid overload has been shown to decrease muscular oxygen tension, produce general oedema, delay tissue healing, compromise cardiorespiratory function and can cause coma. This study assesses the current practice in the administration of fluid and sodium during and after lower limb arthroplasty in our hospital. A series of 68 patients who have undergone elective THR (57) and TKR (11) were included in this prospective study. Current fluid management includes the use of Hartmans solution at a rate of 125mL per hour together with fluid boluses to maintain blood pressure and urine output. We looked at the weight of the patients before and after surgery and compared this with their pre and post operative serum sodium level. Our findings were that patients gained an average of 1.84 Kilograms (Range −1.6 to +6.4) which was age dependent and there was a mean fall in Serum Sodium of 5.26 mmols/L (Range −15 to +2). Of note there was a mean fall in serum Haemoglobin of 3.69g/dL (Range −2.8 to −5.9) which may be due to blood loss perioperatively but haemodilution due to excessive fluid administration may also contribute. We propose responding aggressively to low urine output and low blood pressure can cause detrimental effects on Sodium Haemostasis. Factors such as preoperative Bendroflumethiazide and enthusiastic nursing regimes to encourage oral water intake were found to be contributory factors. Our results suggest that anaesthetists should be aware of post operative hyponatreamia in these patients and a more cautious approach to fluid management is required in the perioperative period

Background. The National Institute for Health and Clinical Effectiveness recommends both low molecular weight heparin (LMWH) and Rivaroxaban for venous thromboembolic (VTE) prophylaxis following lower limb arthroplasty. Despite evidence in the literature that suggests Rivaroxaban reduces VTE events, there are emerging concerns from the orthopaedic community regarding an increase in wound complications following its use. Methods. Through the orthopaedic clinical directors forum, Trusts replacing LMWH with Rivaroxaban for lower limb arthroplasty thromboprophylaxis during 2009 were identified. Prospectively collected Hospital episode statistics (HES) data was then analysed for these units so as to determine rates of 90-day symptomatic deep venous thrombosis (DVT), pulmonary embolism (PE), major bleed (cerebrovascular accident or gastrointestinal haemorrhage), all-cause mortality, and 30-day wound infection and readmission rates before and after the change to Rivaroxaban. 2752 patients prescribed Rivaroxaban following TKR or THR were compared to 10358 patients prescribed LMWH. Data was analysed using odds ratios (OR). Results. There were significantly more wound infections in the Rivaroxaban group (3.85% vs. 2.81%, OR=0.72; 95% CI 0.58–0.90). There were no significant differences between the two groups for PE (OR=1.52; 0.77–2.97), major bleed (OR=0.73; 0.48–1.12), all-cause mortality (OR=0.93; 0.46–1.87) and re-admission rate (OR=1.21; 0.88–1.67). There were significantly fewer symptomatic DVTs in the Rivaroxaban group (0.91% vs. 0.36%, OR=2.51; 1.30–4.82). Discussion. This study is the first to describe the real impact of the use of Rivaroxaban in the NHS. When compared with LMWH in lower limb arthroplasty patients, there were fewer DVTs in the Rivaroxaban group. However, wound infection rates were significantly higher following Rivaroxaban use whilst providing no reduction in symptomatic PE or all-cause mortality