Aims. To determine whether platelet-rich plasma (PRP) injection improves outcomes two years after acute Achilles tendon rupture. Methods. A randomized multicentre two-arm parallel-group, participant- and assessor-blinded superiority trial was undertaken. Recruitment commenced on 28 July 2015 and two-year follow-up was completed in 21 October 2019. Participants were 230 adults aged 18 years and over, with acute Achilles tendon rupture managed with non-surgical treatment from 19 UK hospitals. Exclusions were insertion or musculotendinous junction injuries, major leg injury or deformity, diabetes, platelet or haematological disorder, medication with systemic corticosteroids, anticoagulation therapy treatment, and other contraindicating conditions. Participants were randomized via a central online system 1:1 to PRP or placebo injection. The main outcome measure was Achilles Tendon Rupture Score (ATRS) at two years via postal questionnaire. Other outcomes were pain, recovery goal attainment, and quality of life. Analysis was by intention-to-treat. Results. A total of 230 participants were randomized, 114 to PRP and 116 to placebo. Two-year questionnaires were sent to 216 participants who completed a six-month questionnaire. Overall, 182/216 participants (84%) completed the two-year questionnaire. Participants were aged a mean of 46 years (SD 13.0) and 25% were female (57/230). The majority of participants received the allocated intervention (219/229, 96%). Mean ATRS scores at two years were 82.2 (SD 18.3) in the PRP group (n = 85) and 83.8 (SD 16.0) in the placebo group (n = 92). There was no evidence of a difference in the ATRS at two years (adjusted mean difference -0.752, 95% confidence interval -5.523 to 4.020; p = 0.757) or in other secondary outcomes, and there were no re-ruptures between 24 weeks and two years. Conclusion. PRP injection did not improve patient-reported function or quality of life two years after acute Achilles tendon rupture compared with placebo. The evidence from this study indicates that PRP offers no patient benefit in the longer term for patients with acute Achilles tendon rupture. Cite this article: Bone Joint J 2022;104-B(11):1256–1265

Background of study

There has been an exponential increase in the use of direct thrombin (DT) and factor Xa inhibitors (FXI) in patients with cardiovascular problems. Premature cessation of DT/FXI in patients with cardiac conditions can increase the risk of coronary events. Our aim was to ascertain whether it is necessary to stop DT and FXI preoperatively to avoid postoperative complications following hip fracture surgery.

Aim

To evaluate safety and efficacy of performing a total knee arthroplasty (TKA) on patients receiving continuous Warfarin therapy

Aims. Periprosthetic joint infection (PJI) demonstrates the most feared complication after total joint replacement (TJR). The current work analyzes the demographic, comorbidity, and complication profiles of all patients who had in-hospital treatment due to PJI. Furthermore, it aims to evaluate the in-hospital mortality of patients with PJI and analyze possible risk factors in terms of secondary diagnosis, diagnostic procedures, and complications. Methods. In a retrospective, cross-sectional study design, we gathered all patients with PJI (International Classification of Diseases (ICD)-10 code: T84.5) and resulting in-hospital treatment in Germany between 1 January 2019 and 31 December 2022. Data were provided by the Institute for the Hospital Remuneration System in Germany. Demographic data, in-hospital deaths, need for intensive care therapy, secondary diagnosis, complications, and use of diagnostic instruments were assessed. Odds ratios (ORs) with 95% confidence intervals (CIs) for in-hospital mortality were calculated. Results. A total of 52,286 patients were included, of whom 1,804 (3.5%) died. Hypertension, diabetes mellitus, and obesity, the most frequent comorbidities, were not associated with higher in-hospital mortality. Cardiac diseases as atrial fibrillation, cardiac pacemaker, or three-vessel coronary heart disease showed the highest risk for in-hospital mortality. Postoperative anaemia occurred in two-thirds of patients and showed an increased in-hospital mortality (OR 1.72; p < 0.001). Severe complications, such as organ failure, systemic inflammatory response syndrome (SIRS), or septic shock syndrome showed by far the highest association with in-hospital mortality (OR 39.20; 95% CI 33.07 to 46.46; p < 0.001). Conclusion. These findings highlight the menace coming from PJI. It can culminate in multi-organ failure, SIRS, or septic shock syndrome, along with very high rates of in-hospital mortality, thereby highlighting the vulnerability of these patients. Particular attention should be paid to patients with cardiac comorbidities such as atrial fibrillation or three-vessel coronary heart disease. Risk factors should be optimized preoperatively, anticoagulant therapy stopped and restarted on time, and sufficient patient blood management should be emphasized. Cite this article: Bone Jt Open 2024;5(4):367–373

Aim. Prosthetic joint replacement is more commonly done in the elderly group of patients due to an increase pathology related to joint degeneration that comes with age. In this age group is also more frequent having underling condition that may predispose to a prosthetic joint infection. Also, the pharmacological intervention in those patients may play an important role as a risk factor for infection after joint replacement surgery. The use of oral anticoagulants seems to be particularly increased in elderly patients but there aren't enough data published to support an association between prosthetic joint infection and the use of oral anticoagulants. Identifying risk factors in elderly patients age >75 years old with a special focus on the oral anticoagulation therapy is the aim of the study. Methods. In a retrospective study from 2011 till 2018 all the patients >75 years old with knee and hip replacement surgery have been review looking for acute prosthetic infection and risk factors that may be predispose to it. Patients with previous surgery or any other mechanical complication that needed intervention on the same area have been excluded. Results. A total of 1220 patients have been included (801 knee replacement surgery and 419 hip replacement surgery). The mean age was 79.5 ± 3.44 years and most of the patients were women (72,6%). The infection rate was 2,5%. Several factors have been identified to be associated with acute infection. (Table.1.). The patients receiving oral anticoagulants had an increased risk of infection (OR 3.63 (1.60–7.74), p=0.002). Conclusions. Even all the risk factors associated with risk infection have been described previously, the relevant aspect is the increased risk of prosthetic joint infection in patients receiving oral anticoagulants

Background. The PATH-2 trial found no evidence of a benefit of Platelet Rich Plasma (PRP) injection versus a placebo after Achilles tendon rupture (ATR) at six-months. ATR often leave longer-term functional deficiencies beyond six-months. This study aim is to determine if PRP affect tendon functional outcomes at two-years after rupture. Study design. Randomised multi-centre two-arm parallel-group, participant- and assessor-blinded, superiority trial. Methods. Adults with acute ATR managed non-surgically were recruited in 19 UK hospitals from 2015 to 2019. Exclusions were insertion or musculotendinous injuries, leg injury or deformity, diabetes, haematological disorder, corticosteroids and anticoagulation therapy. Participants were randomised via an online system 1:1 to PRP or placebo. Primary outcome was Achilles Tendon Rupture Score (ATRS) at two-years. Secondary outcomes were pain, Patient-Specific Functional Scale (PSFS), SF-12 and re-rupture. Assessors were blinded. Intention-to-treat and Compliance Average Causal effects (CACE) analyses were carried out. Consistency of effects across subgroups age, BMI, smoking and gender were assessed using Forest plots. Pearson's correlation was used to explore ATRS correlation with blood and growth factors. Results. 216/230 (94%) participants completed the 6-months follow-up were contacted. 182/216 (84%) completed the two-year follow-up. Participants were aged mean 46 (SD 13.0), 57 female/159 male. 96% received the allocated intervention. Two-years ATRS scores were 82.2 (SD 18.3) in the PRP group (n=85) and 83.8 (SD 16.0) in the placebo group (n=92). There was no evidence of a difference in the two-years ATRS (adjusted-mean difference −0.752 95%CI −5.523 to 4.020, p=0.757), or in any secondary outcome, and no re-rupture between at two-years. Neither PRP cellular or growth factors correlated with the two-year ATRS. Conclusion. PRP did not improve patient-reported function or quality of life two-years after acute Achilles tendon rupture, compared with placebo, indicating that PRP offers no patient benefit in the longer term

Background. Intravenous and topical tranexamic acid (TXA) has become increasingly popular in total joint arthroplasty to decrease perioperative blood loss. In direct comparison, the outcomes and risks of either modality have been found to be equivalent. In addition, current literature has also demonstrated that topical TXA is safe and effective in the healthy population. To our knowledge, there is a scarcity of studies demonstrating the safety of topical TXA in high risk patient populations undergoing total joint arthroplasty or revision joint arthroplasty. The purpose of this study is to determine the safety of topical TXA in patients undergoing total or revision arthroplasty that are also on chronic anticoagulant or anti-platelet therapy. Methods. We performeded a retrospective review of patients undergoing primary and revision total hip or knee arthroplasties that received topical TXA (3g/100mL NS) from November 2012 to March 2015. All patients, regardless of co-morbidities, were included in the study population. Patients were divided into 3 groups:. Group 1: Patients without any antiplatelet or anticoagulant therapy within 90 days of surgery. Group 2: Patients receiving antiplatelet therapy (Aspirin and/or Plavix) within 90 days of surgery. Group 3: Patients receiving anti-coagulant therapy within 90 days of surgery (low molecular weight heparin, unfractionated heparin, warfarin, dabigatran, rivaroxaban, apixaban). Chart review analyzing ICD-9 and ICD-10 coding was then utilized to establish any peri-operative complications within the 30 day post-operative period in all groups. Complications amongst the groups were evaluated via chi-squared testing as well as multivariate linear regression. Review of current literature and CMS protocols were used to establish reportable peri-operative complications. Wound infections, thromboembolic events and vascular complications such as myocardial infarction, pulmonary embolism, deep venous thrombosis, stroke, aortic dissection were included. Results. During the study period, a total 1471 total joint arthroplasties were performed on 1324 patients (88.7% knee arthroplasty, 11.3% hip arthroplasty). Group 1 included 1033 patients who were not on any prior anti-platelet or anticoagulant therapy. Group 2 included 254 patients receiving chronic antiplatelet therapy 90 days prior to surgery. Group 3 included 184 patients receiving chronic anticoagulant therapy 90 days prior to surgery. No statistically significant differences were found between the groups for any of the included peri-operative complications. The most common complication occurring amongst all the groups was superficial wound infection, which occurred in a total of 60 (4.1%) patients in contrast to 18 (1.2%) patients who sustained an acute deep peri-prosthetic infection. Twenty (1.4%) patients sustained an ultrasound proven deep vein thrombosis, with the highest prevalence occurring in those patients receiving no anticoagulation prior to surgery (15/20, 75%), however this was not statistically significant following linear regression analysis. Conclusions. To our knowledge, this is the first study that demonstrates that topical tranexamic acid is safe to use in so-called high risk patients who are being treated prior to surgery with anti-platelet or anti-coagulation therapy

Introduction. Embolism in total arthroplasty or hip fractures, coagulation disorders, such as a variety of ways for the prevention of complications of anticoagulation therapy with medication is being done well. The purpose of this study, a representative of the anticoagulation therapy with enoxaparin and drug rivaroxaban of coagulation tests performed in patients between the two groups was to determine whether statistically significant differences. Methods. 47 patients who underwent arthroscopic surgery were randomly divided into two groups to rivaroxaban and enoxaparin group, and we performed coagulation tests before and 5 days after arthroscopic surgery to two drugs groups in order to investigate about the difference in clotting capacity. Results. Preoperative coagulation tests coagulation tests before the item was not significantly different between the two groups. (p=0.584) 5 days after surgery, the coagulation tests coagulation tests performed on all items, rivaroxaban showed an increase in the anticoagulation activity Between the two groups showed statistically significant difference (p=0.001),. Discussion and Conclusion. Our results indicate that orthopaedic surgery can induce a lot of bleeding will be careful for use of rivaroxaban. Rivaroxaban(Xarelto®) showed more bleeding tendency than Enoxaparin(Clexane®). So we should take more attentions in postoperative care after Total Joint Arthroplasty

Background: Paralysis of the crural nerve secondary to a compressive haematoma of the psoas in the pelvis is a well-known complication of anticoagulant therapy. This complication has also been described after hip or pelvic surgery. Its occurrence in a context of trauma is exceptional. Case report: A 16-year-old female adolescent sought emergency care for total deficit of knee extension. The patient had an enlarged painful knee subsequent to a skateboard fall. She reported knee trauma involving the patella and a direct shock to the homolateral hip, on the trochanter. Physical examination confirmed the knee and hip pain. Rest was advised. One and a half month after the accident, the patient again consulted for total deficit of active knee extension. The initial diagnosis suggested was posttraumatic rupture of the patellar tendon. An emergency MRI was normal, ruling out this diagnosis. More attentive physical examination revealed the presence of a complete paralysis of the quadriceps muscle by crural nerve palsy. MRI of the pelvic region revealed the presence of a voluminous haematoma of the psoas compressing the crural nerve. Emergency evacuation of the haematoma was performed. The patient underwent rehabilitation for one year and achieved progressive and complete recovery of the quadriceps function. An electromyogram obtained at one year was normal. Conclusion: This was an exceptional case of crural nerve palsy secondary to a posttraumatic haematoma of the psoas, with no notion of anticoagulation therapy. The initial knee injury was misinterpreted as involving a local patellar problem but in reality had caused a paralysis of the quadriceps muscle. MRI provided the diagnosis of psoas haematoma

Aim: Evaluate the incidence of complications related to timing (time between admission ad operation) and oral antiplatelet/anticoagulant therapy in patients treated for a hip fracture. Materials and Methods: We prospectively evaluated 5 groups of 30 patients each, selected out of 875 consecutive patients admitted at the First Aid Unit of our Hospital with a proximal femoral fracture: group A – patients on Warfarin therapy, treated more than 5 days after admission (in order to allow the wash-out of Warfarin, as advised by many Anaesthesiologist Associations); B – patients treated more than 5 days after admission, not on Warfarin therapy; C – patients treated less than 48 hours after admission, not on Warfarin therapy; D – patients on Aspirin/NSAIDS therapy, treated more than 5 days after admission; E – patients on Ticlopidine/Clopidogrel therapy, treated more than 5 days after admission. The groups were comparable regarding age, gender, pre-trauma walking ability, mental state, fracture type and treatment. Blood loss, number of RBC transfusions, complications during hospitalization and up to 6 months after discharge, duration of hospitalization, degree of functional recovery and 2 years mortality were recorded. Statistical analysis included Kruskall-Wallis, U-Mann-Whitney and Logistic Regression Tests (SPSS 13.0 software). Results: Group A showed higher preoperative blood loss (p=0.002), and longer hospitalization (p< 0.001), compared to all other groups. Groups D and E showed no higher complication and mortality rate in comparison to group B and C, while group A showed higher complication and mortality rate. Standing alone, timing and Warfarin appear not to be significant risk factors, while taken together they represent a high risk factor for complications ad mortality (p=0.009). Conclusion: Patients on Warfarin therapy, affected by hip fracture, are at high risk of complications and mortality, if the recommendation of postponing treatment until drug wash-out is accepted. Reversal of anticoagulation using vitamin K and straight-forward treatment should be considered. Antiplatelet therapy appears not to have the same adverse effect as anticoagulant therapy

Newer irreversible oral anticoagulants such as rivaroxaban, a direct factor 10a inhibitor, are increasingly employed to prevent thromboembolic events in atrial fibrillation (AF) patients, and to manage venous thromboembolism (VTE). Unlike warfarin, these agents require no monitoring and involve infrequent dose adjustment. We report the case of a patient treated with rivaroxaban for AF. Patient presented with unprovoked sudden onset right shoulder pain which clinically resembled shoulder haemarthrosis. A single case was anonymised and retrospectively reviewed through examination of clinical and radiographic data. A 70 year old female with known AF presented to Accident and Emergency with sudden onset of right shoulder pain and limited movement, which developed over one hour. The pain was constant, localised to the shoulder and without trauma. Past medical history included severe aortic regurgitation and associated thoracic aortic aneurysm, heart failure, atrial fibrillation and hypertension. Observations were normal upon admission with no haemodynamic compromise or pyrexia. Examining the right shoulder demonstrated distension of shoulder joint capsule, tenderness and a reduced range of movement. Temperature and neurovascular status in the right arm were normal. Investigations upon admission included an INR of 1.2. An anteroposterior right shoulder radiograph showed no evidence of fracture. Patient was managed conservatively with simple oral analgesia. Importantly, rivaroxaban was withheld for 5 days and symptoms resolved. Warfarin therapy was subsequently commenced instead as treatment for AF. Patient was discharged one week later and seen in clinic two weeks post-discharge. A full recovery occurred and with a full range of movement in the right shoulder. In the UK, current National Institute for Health and Care Excellence (NICE) guidelines recommend the use of factor 10a inhibitors, for prevention of stroke in AF patients, and following elective total hip and knee replacement operations to prevent VTE. In turn, rivaroxaban is increasingly prescribed as first line therapy. Whereas warfarin has a documented association with haemarthrosis, there is no primary literature evaluating the incidence of factor 10a therapy associated haemarthrosis. In our case, the unprovoked shoulder haemarthrosis resolved following rivaroxaban cessation. In comparison with warfarin, rivaroxaban is irreversible. With warfarin and a high INR, vitamin K can be used to reverse the anticoagulation. There is no equivalent for rivaroxaban. We suggest further studies into incidence of haemarthrosis associated with oral anticoagulant therapy be undertaken, and treating physicians be aware of such complication

Aims

Transfusion after primary total hip arthroplasty (THA) has become rare, and identification of causative factors allows preventive measures. The aim of this study was to determine patient-specific factors that increase the risk of needing a blood transfusion.

Aims

Limited implant survival due to aseptic cup loosening is most commonly responsible for revision total hip arthroplasty (THA). Advances in implant designs and materials have been crucial in addressing those challenges. Vitamin E-infused highly cross-linked polyethylene (VEPE) promises strong wear resistance, high oxidative stability, and superior mechanical strength. Although VEPE monoblock cups have shown good mid-term performance and excellent wear patterns, long-term results remain unclear. This study evaluated migration and wear patterns and clinical and radiological outcomes at a minimum of ten years’ follow-up.

Objective:. To observe the incidence of intra-operative vascular injuries during anterior cervical decompression and fusion (ACDF). Secondly, management and monitoring of the outcome post vascular injury during ACDF. Methods:. This a prospective study. A review of all spinal patients' records was performed from June 2006 to April 2011. A comprehensive literature review was also utilized. Inclusion criteria – all patients had ACDF post trauma. All non-traumatic cases were excluded. Results:. The study consisted of 55 patients; 15 were females and 40 were males. The age distribution was 23–65 years. Two patients were excluded due to non-traumatic causes. Of the remaining 53 patients, four sustained intra-operative vascular injuries during ACDF surgery. All 4 patients had corpectomies, and one case was an iatrogenic injury. The commonly injured vessel during the ACDF surgery was the left vertebral artery. Haemostatic control was achieved via tamponade and haemostatic agents. The left common carotid was iatrogenically injured in one case and was treated by microvascular repair. Three patients were treated with antiplatelet therapy for three months duration. The patient with an iatrogenic injury was treated with anticoagulation therapy for three months duration. All computerized tomographic angiograms at three months follow up illustrated patent vessels. Conclusion:. There is an increased incidence of intra operative vascular injuries during ACDF associated with corpectomies. It is essential to be aware of the low incidence of intra operative arterial injury during ACDF and to have a management approach, such as tamponade or microvascular repair. Anticoagulation and antiplatelet therapy is effective in decreasing the complications of vascular injuries post ACDF

Introduction. Rivaroxaban, an oral factor Xa inhibitor, has been approved by USFDA for prophylaxis of deep vein thrombosis (DVT) and pulmonary embolism (PE) in hip and knee arthroplasties. Its indication in hip fracture surgery has been recently recommended in Asian venous thromboembolism (VTE) guidelines. Phase II dose-ranging study demonstrated that 5 mg rivaroxaban is as effective as enoxaparin for VTE prophylaxis with lower incidence of bleeding complication than the recommended 10 mg dose. Rivaroxaban is recommended to be given 6–8 hours after operation. However, many surgeons are hesitated to follow this guideline since it might increase post-operative blood loss and wound complication. Elderly patients, such as hip fracture patients, are generally at more risk of bleeding and wound complications. These patients may benefit from using the delayed and reduced-dose regimen. Methods. Since July 2011, all eligible hip fracture patients treated by single group of surgeons were given 5mg daily dose of rivaroxaban for VTE prophylaxis. Initial dose of rivaroxaban was given after drain had been removed (24–36 hours post-operatively) and continued for 14 days. Inclusion criteria are femoral neck fracture or intertrochanteric fracture in patients age 60 and over. Exclusion criteria are pathologic fracture, reoperation for failed fixation, chronic anticoagulant therapy, and allergy to rivaroxaban. Criteria by Aniwan and Rojnackarin were used for clinical diagnosis of DVT and PE. Suspected case of DVT and PE were sent for confirmation with Doppler U/S and Pulmonary Artery CT scan, respectively. All bleeding and wound complications were recorded. Numbers of blood transfusion were also recorded. Patients were followed for at least 6 weeks, all complications were recorded. Results. There were 79 hip fracture patients matching our criteria. They were composed of 54 femoral neck fractures and 25 intertrochanteric fractures. Mean age of patients was 76.3 years. All femoral neck fractures were treated with bipolar hemiarthroplasty and intertrochanteric fractures were treated with short cephalomedullary nail. Two patients (2.6%) were compatible with clinical criteria of DVT. However, Doppler ultrasound examinations do not demonstrate thrombus or intraluminal filling defect. There was no suspected case of PE. There was no major hemorrhagic wound complication requiring reoperation. Minor wound complications include 7 (8.9%) cases of prolong serous oozing and 1 (1.3%) superficial wound infection. Extrasurgical site bleeding includes 1 (1.3%) upper GI bleeding and 2 (2.5%) hematuria. None of the patients received more than 2 units of blood transfusion. Discussion and Conclusion. Delayed and reduced-dose regimen of rivaroxaban is effective for VTE prophylaxis in hip fracture patients. There is no major hemorrhagic wound complication. Nonetheless, extrasurgical site bleeding is frequent. Further randomized comparative study with larger number of patients should be performed to demonstrate whether the benefits of the modified regimen existed or not

Purpose of the study. To determine the effectiveness, complications and side effects of Rivaroxaban when used for extended thromboprophylaxis in patients undergoing primary and revision knee arthroplasty. Methods. Venous Thromboembolism (VTE) prophylaxis following knee arthroplasty remains controversial. As an Orthopaedic Unit, in July 2009 we developed guidelines to help ensure that our patient management was fully compliant with National Institute for Health and Clinical Excellence (NICE) guidelines regarding risk assessment and extended oral prophylaxis following primary and revision knee arthroplasty. We opted to trial the oral anticoagulant drug Rivaroxaban for an initial period of 12 months. All patients undergoing primary or revision knee arthroplasty between 1. st. July 2009 and 30. th. June 2010 and who had no contraindications to the prescription of Rivaroxaban were included in a prospective audit aimed at determining compliance with the newly developed unit guidelines as well as the effectiveness and possible side effects/complications associated with the drug therapy. All patients were monitored for a period of 90 days post operatively. Results. A total of 415 patients were included in the audit (336 primary knee arthroplasty, 27 revision knee arthroplasty, 6 patello-femoral resurfacing, 46 medial unicompartmental knee arthroplasty). Of this group eight had a confirmed VTE (six deep vein thrombosis, two pulmonary embolism). A further 29 patients had post-operative complications which may be attributed in part to the action of Rivaroxaban. The drug was discontinued prematurely for 22 patients. Conclusions. Our results indicate that Rivaroxaban is effective in providing extended VTE prophylaxis to patients undergoing knee arthroplasty surgery. However, as anticipated, anticoagulation therapy does cause associated wound problems

Thromboembolism is a potentially fatal complication of total joint replacement. Some surgeons follow a ‘prophylaxis without compromise’ policy, while others, who realise that there are risks attached to the use of prophylactic drugs, go to the opposite extreme and administer no prophylaxis and no anti-thrombotic drugs, even for pulmonary embolism. We believe the results of surveillance should determine the administration of anticoagulation therapy. In over 1 500 patients, anticoagulants have been administered only when clinically indicated and after positive Duplex diagnosis. Death due to pulmonary embolism has occurred in only two patients in six years, a reduction from 1.0% to less than 0.05%. Our treatment protocol divides our patients into high and low risk cases. The results of Doppler and blood tests dictate the method and extent of prophylaxis for high-risk cases, and the therapeutic handling of positive clot formation in the low-risk population

There is no consensus on the management of the most lethal complication of total joint replacement. One school follows the traditional ‘prophylaxis without compromise’ policy, while the other, realising the dangers of prophylactic drugs, especially in total joint replacement, goes to the other extreme of ‘no prophylaxis and no anti-thrombotic drugs even for pulmonary embolism’. We follow a middle of the road principle, believing that ‘surveillance determines anticoagulation therapy’. Our treatment protocol divides patients into high and low-risk cases. Regular surveillance (Doppler and blood examination) determines the method and extent of prophylaxis for high-risk cases and the therapeutic handling of positive clot formation in low-risk patients. Treating over 1055 patients over 8 years, we selectively administered anticoagulants only when clinically indicated and after positive Duplex diagnosis. Mortality due to pulmonary embolism was reduced by this regime from 1.0% to less than 0.05% (two cases in 6 years). Guidelines have been laid down regarding the value of blood tests in combination with Duplex in an effective and affordable way, not only to detect thrombo-embolism but also to manage treatment, even after discharge

Primary total knee arthroplasty is associated with considerable blood loss, and allergenic blood transfusions are frequently necessary. Because of the cost and risks of allogenic blood transfusions, the autologous drainage blood reinfusion technique has been developed as an alternative. A number of studies have compared reinfusion techniques with standard suction drainage, but few reports compared with no drain use. We analyzed early results after primary total knee arthroplasty using autologous drainage blood reinfusion and no drain. We selected 30 patients who underwent primary total knee arthroplasty using no drain between November 2005 and March 2006 and matched for age and gender with 30 patients who underwent primary total knee arthroplasty using autologous drainage blood reinfusion technique between January 2003 and October 2005. All operations were done under pneumatic tourniquet and meticulous hemostasis was performed after deflation of the tourniquet. We have retrospectively reviewed the preoperative data (age, gender, body mass index, diagnosis, history of the knee surgery, infection and anticoagulant therapy, and medical cormorbidities) and the postoperative data (hemoglobin, hematocrit and platelet during hospitalization, the amount of allogenic blood transfusion and narcotics, complications, rehabilitation process, and clinical scores). All preoperative and postoperative variables except the postoperative second and seventh days hemoglobin and 2nd day hematocrit showed no significant differences between two groups. The hemoglobin and hematocrit also showed no significant differences at the postoperative fourteenth day. The autologous drainage blood reinfusion method in primary total knee arthroplasty does not have significant clinical benefit over no-drain method with regards to allogenic blood transfusions, narcotics uses, the incidence of complications and rehabilitation processes

Purpose: The report of a case o f a patient, who underwent a total hip arthroplasty and sustained cerebral hemorrhage due to low molecular weight heparin. Case report: A 46-years-old woman had a total hip replacement due to secondary osteoarthritis after a congenital hip dislocation. She had a free medical record. Treatment with LMWH started the day of the surgery. The patient was dismissed from the hospital the sixth postoperative day, being well, and came back the ninth postoperative day, complaining of hypertension, headache and motor disturbances of her left upper limb. Neurological examination did not revealed any particular findings except reduced strength of her left upper limb. A brain CT scanning showed no significant findings, while her blood platelet count was126000 while immediately postoperatively was 180000 and preoperatively 220000. The following day the patient established a paresis of her left arm and the platelet count fell to 35000, while a new CT scan, revealed small hemorrhages in both parietal cortexes of the brain. LMWH was discontinued. The patient deceased the 11th postoperative day. Conclusion: Heparin Induced Thrombocytopenia type II and hemorrhage due to LMWH is very rare but should be bared in mind from the orthopaedic surgeon who uses LMWH for DVT prophylaxis. Clinical suspicion mandates immediate discontinuation of the agent and consideration of an alternative anticoagulation therapy along with general support of the patient