Purpose: Single anesthetic bilateral total knee arthroplasty (SABTKA) is a controversial procedure with a questionable safety profile. The purpose of this study was to determine if specific, individual preoperative medical co-morbidities can predict perioperative complications in patients undergoing SABTKA. Method: The records of all SABTKA performed between 1997 and 2007 at 1 large community hospital and 1 academic, university hospital were retrospectively reviewed. Complete demographic data, preoperative co-morbidities (cardiovascular disease, COPD, diabetes, and hypertension), and perioperative complications for 156 patients were collected and analyzed using logistic multivariate regression analysis. Comparison was made to an age, gender, and co-morbidity matched cohort of patients treated with unilateral TKA. Results: In the SABTKA group only 11% of patients had a preoperative history of cardiovascular disease yet 89% of all post operative myocardial infarctions (MI) occurred in this population (p< 0.001, Odds Ratio 57.8). Cardiovascular disease also predicted need for admission to ICU (p< 0.001, Odds Ratio 50.8), and number of days spent in the ICU (p< 0.001). In those patients without preoperative cardiovascular disease or COPD the rate of MI was only 0.64%. All differences were significant when compared to the matched unilateral TKA cohort. Age, gender, diabetes, and hypertension did not predict perioperative complications in the SABTKA cohort. Conclusion: The literature indicates there are certain populations of patients at higher risk for perioperative complications after SABTKA. This study clearly identifies a subpopulation of patients that have cardiovascular disease and are at an unacceptably high risk of perioperative MI. Cardiovascular disease should likely be considered an absolute contraindication to SABTKA

Aim. A substantial portion of periprosthetic joint infections (PJI) literature is comprised of observational studies. The Strengthening the Reporting of Observational Studies in Epidemiology guidelines emphasize the importance of clearly defining variables and providing diagnostic criteria. Well-defined variables in these studies play a crucial role in ensuring data consistency, fostering comparability among studies, and laying a robust foundation for evidence-based decision-making. We aimed to determine the definition of these variables and determine the objectivity of the definitions. Method. We reviewed observational studies on hip or knee PJI that focused on variables and their association with treatment outcomes. The inclusion criteria comprised studies from Jan 2017 to Jan 2023. We focused on 13 variables that were possibly subjective. These were smoking, alcohol use, diabetes mellitus, hypertension, lung disease, rheumatoid arthritis, liver diseases, kidney diseases, cardiovascular diseases, malignancy, immunosuppression, use of antibiotics, and type of infection. The reviewers examined the text of the articles, along with any available online supplements or protocols, for definitions of the selected variables. We classified a definition as objective if there was the presence of time element, severity, staging, frequencies, laboratory cut-off, medication dependence, among others. Chart review was deemed subjective. Results. We included 75 studies in the analysis. The most common factors studied were diabetes mellitus (79%), cardiovascular disease, smoking history, and rheumatoid arthritis (47% each). The variables that were objectively defined most often were antibiotic use (100%) and type of infection (95%). Smoking history (16%) and alcohol use (20%) were the least frequently objectively defined variables. Further analysis revealed that a considerable number of studies incorporated variables into their primary analyses without clear definitions. For instance, out of the 59 studies where diabetes was considered a variable, 41 studies (70%) included diabetes in their main analyses as a factor for PJI treatment outcomes, despite only 34 studies having defined this variable. Moreover, of the 34 provided definitions of diabetes mellitus, only 12 provided objective criteria for diagnosis. The rest of the provided definitions relied on “chart review” without further specification. Table 1 outlines the proportion of studies with variables defined and included in their analysis. Conclusions. Study variables were not clearly defined in most of the observational studies raising concerns about the reproducibility and reliability of findings. Our study underscores the vital need for standardized variable definitions in PJI research. Professional societies may play a crucial role in setting standards for the definition of variables. For any tables or figures, please contact the authors directly

Background. 91% of blood loss in Total Hip Replacement (THR) occurs in the period after skin closure and the first 24 post-operative hours. TRAC-24 was established to identify if an additional 24-hour post-operative oral regime of Tranexamic acid (TXA) is superior to a once-only intravenous dose at surgery. Methods. This was a prospective, phase IV, single centered, open label, parallel group controlled trial on patients undergoing primary elective THR. A history of thromboembolic or cardiovascular disease were not exclusion criteria. The primary outcome was indirect calculated blood loss at 48 hours (IBL). 534 patients were randomized on a 2:2:1 ratio over three different groups. Group 1 received an intravenous dose of TXA at the time of surgery and an additional 24-hour post-operative oral regime, Group 2 only received the intra-operative dose and Group 3 did not receive any TXA. Results. 233, 235 and 66 patients were recruited to groups 1,2 and 3. All groups had comparable baseline characteristics. 3.2% of all patients had previous thromboembolism and 5.4% had previous cardiac stenting. Group 3 mean (SD) IBL was 1371 (630) ml whereas group 1 and 2 combined had a mean (SD) IBL of 846 (471), p<0.001. There was no overall difference in IBL between group 1 and group 2, but subgroup analysis observed 12% less blood loss in group 1 than group 2 in the 36 patients weighing >100kg. No differences in mortality or thromboembolic events were observed in any group. Conclusion. The use of a single, intravenous, peroperative, 1-gram dose of Tranexamic acid decreased the total blood loss associated with THA by 38%. The addition of another 24-hours oral tranexamic acid did not provide additional benefit but further study on the effect of patient weight is required. Tranexamic acid is safe in patients with history of thromboembolic and cardiovascular disease

Traumatic acute or chronic tendon injuries are a wide clinical problem in modern society, resulting in important economic burden to the health system and poor quality of life in patients. Due to the low cellularity and vascularity of tendon tissue the repair process is slow and inefficient, resulting in mechanically, structurally, and functionally inferior tissue. Tissue engineering and regenerative medicine are promising alternatives to the natural healing process for tendon repair, especially in the reconstruction of large damaged tissues. The aim of TRITONE project is to develop a smart, bioactive implantable 3D printed scaffold, able to reproduce the structural and functional properties of human tendon, using FDA approved materials and starting from MSC and their precursor, MPC cell mixtures from human donors. Total cohort selected in the last 12 months was divided in group 1 (N=20) of subjects with tendon injury and group 2 (N=20) of healthy subject. Groups were profiled and age and gender matched. Inclusion criteria were age>18 years and presence of informed consent. Ongoing pregnancy, antihypertensive treatment, cardiovascular diseases, ongoing treatment with anti-aggregants, acetylsalicylic-acid or lithium and age<18 years were exclusion criteria. Firstly, we defined clinical, biological, nutritional life style and genetic profile of the cohort. The deficiency of certain nutrients and sex hormonal differences were correlated with tendon-injured patients. It was established the optimal amount of MPC/MSC human cell (collected from different patients during femoral neck osteotomy). Finally, most suitable biomaterials for tendon regeneration and polymer tendon-like structure were identified. Hyaluronic acid, chemical surface and soft-molecular imprinting (SOFT-MI) was used to functionalize the scaffold. These preliminary results are promising. It will be necessary to enroll many more patients to identify genetic status connected with the onset of tendinopathy. The functional and structural characterization of smart bioactive tendon in dynamic environment will represent the next project step

The Canadian Cardiovascular Society (CCS) recommends performing daily troponin testing on postoperative days 0 through 3 for noncardiac surgical patients to decrease the mortality rate due to myocardial injury. Indications for testing include:. ->65 yo. -45-64 yo with significant cardiovascular disease. -a Revised Cardiac Risk Index score (RCRI) > 1. Troponin elevation > 30 ng/L is termed “myocardial injury after noncardiac surgery” (MINS). The study objective was to determine the prognostic relevance of applying CCS recommendations. 669 patients undergoing THA were included in the study. Based on the CCS recommendation there were 4 patient Groups depending on whether or not they met the MINS screening protocol criteria and whether or not it was applied:. -A - met & applied (n=181). -B - met & not applied (n=248). -C – not met & applied (n=10). -D – not met & not applied (n=230). 307 (45.8%) males and 363 (54.2%) females with an average age of 67.8 years were included. Group A- 24% incidence (43 patients) of troponin rise & 5% incidence (9 patients) of cardiac complications. Group B- 0.4% incidence (1 patient) of cardiac complications. Groups A + B – representing all patients who should have had the MINS screening protocol applied according to the CCS recommendations − 10 (2.3%) patients developed cardiac complication and one (0.2%) patient death. MINS screening protocol group (A & C) LOS was 4.0 days compared to 1.4 days for those not screened (p-value: <0.001). Applying the CCS MINS screening protocol to elective THA patients added no benefit in predicting/preventing postoperative cardiac events but was associated with a significant increase in LOS. Following current CCS recommendations without more specifications and clinical evidence is unwarranted

Backround: The etiology of Legg-Calvé-Perthes disease (LCPD) is incompletely understood. Previous studies suggest associations with coagulation problems, anatomical abnormalities in the femoral head blood supply and risks for cardiovascular disease. Therefore, we hypothesized that patients with LCPD might have a higher risk of cardiovascular diseases and diseases of blood and blood-forming organs. Methods: 3,141 patients with LCPD aged 2–15 years, diagnosed between 1965 and 2005 were identified using the Swedish inpatient register. 15,595 individuals without LCPD were randomly selected from among the Swedish general population, matched by year of birth, age, sex, and region of residence. Cox proportional hazard regression, adjusted for socioeconomic index, was used to estimate the relative risks. The patients were also compared with their same-sex siblings. Results: Patients with LCPD had a hazard ratio (HR) of 1.70 (95% CI 1.39–2.09) for cardiovascular disease compared with individuals without LCPD. The point estimate was slightly higher among those older than 30 at follow-up (HR=2.10, 95% CI: 1.52–2.91). There were statistically significant higher risks for diseases of blood and blood-forming organs (1.41, 1.07–1.86), which were more pronounced among those older than 30 years at follow-up (2.70. 1.50–4.84). Patients had also statistically significant higher risks for hypertensive disease (2.97, 1.87–4.72), and nutritional anemia (2.92, 1.58–5.40). When siblings were used as the comparison group, the results were consistent for cardiovascular disease. Conclusion: The results are consistent with the hypothesis that an insufficient blood supply to the femoral head due to vascular pathology and other causes are involved in the etiology of LCPD

Aims. The first death in the UK caused by COVID-19 occurred on 5 March 2020. We aim to describe the clinical characteristics and outcomes of major trauma and orthopaedic patients admitted in the early COVID-19 era. Methods. A prospective trauma registry was reviewed at a Level 1 Major Trauma Centre. We divided patients into Group A, 40 days prior to 5 March 2020, and into Group B, 40 days after. Results. A total of 657 consecutive trauma and orthopaedic patients were identified with a mean age of 55 years (8 to 98; standard deviation (SD) 22.52) and 393 (59.8%) were males. In all, 344 (approximately 50%) of admissions were major trauma. Group A had 421 patients, decreasing to 236 patients in Group B (36%). Mechanism of injury (MOI) was commonly a fall in 351 (52.4%) patients, but road traffic accidents (RTAs) increased from 56 (13.3%) in group A to 51 (21.6%) in group B (p = 0.030). ICU admissions decreased from 26 (6.2%) in group A to 5 (2.1%) in group B. Overall, 39 patients tested positive for COVID-19 with mean age of 73 years (28 to 98; SD 17.99) and 22 (56.4%) males. Common symptoms were dyspnoea, dry cough, and pyrexia. Of these patients, 27 (69.2%) were nosocomial infections and two (5.1%) of these patients required intensive care unit (ICU) admission with 8/39 mortality (20.5%). Of the patients who died, 50% were older and had underlying comorbidities (hypertension and cardiovascular disease, dementia, arthritis). Conclusion. Trauma admissions decreased in the lockdown phase with an increased incidence of RTAs. Nosocomial infection was common in 27 (69.2%) of those with COVID-19. Symptoms and comorbidities were consistent with previous reports with noted inclusion of dementia and arthritis. The mortality rate of trauma and COVID-19 was 20.5%, mainly in octogenarians, and COVID-19 surgical mortality was 15.4%. Cite this article: Bone Joint Open 2020;1-7:330–338

Purpose. We compared visible blood loss and calculated blood loss after bipolar hemiarthroplasty in femoral neck fracture, and evaluated correlation between blood loss and its risk factors. Materials and Methods: A total of 356 patients who underwent bipolar hemiarthroplasty in femoral neck fracture between 2004 and 2010 were enrolled in this study. The total blood loss was calculated using the formula reported by Mercuiali and Brecher. We analyzed several factors, including gender, age, body mass index (BMI), anesthesia method, cardiovascular and cerebrovascular disease, preoperative anemia, American Society of Anesthesiologists (ASA) score, use of cement, and use of antithrombotic agents. Results: Total calculated blood loss (1,408±72 ml) differed significantly from visible blood loss(980±102 ml). In addition, calculated blood loss differed between risk factors (1,526±369 ml in cardiovascular disease, 1,588±279 ml in general anesthesia, 1,645±920 ml in obesity, and 1,605±439 ml in use of antithrombotic agents). Conclusion: Total calculated blood loss was much greater than visible blood loss. Patients with risk factors such as cardiovascular disease, obesity, use of antithrombotic agents, and general anesthesia should be treated with care in order to reduce blood loss

Aims. The safe resumption of elective orthopaedic surgery following the peak of the COVID-19 pandemic remains a significant challenge. A number of institutions have developed a COVID-free pathway for elective surgery patients in order to minimize the risk of viral transmission. The aim of this study is to identify the perioperative viral transmission rate in elective orthopaedic patients following the restart of elective surgery. Methods. This is a prospective study of 121 patients who underwent elective orthopaedic procedures through a COVID-free pathway. All patients underwent a 14-day period of self-isolation, had a negative COVID-19 test within 72 hours of surgery, and underwent surgery at a COVID-free site. Baseline patient characteristics were recorded including age, American Society of Anaesthesiologists (ASA) grade, body mass index (BMI), procedure, and admission type. Patients were contacted 14 days following discharge to determine if they had had a positive COVID-19 test (COVID-confirmed) or developed symptoms consistent with COVID-19 (COVID-19-presumed). Results. The study included 74 females (61.2%) and 47 males (38.8%) with a mean age of 52.3 years ± 17.6 years (18 to 83 years). The ASA grade was grade I in 26 patients (21.5%), grade II in 70 patients (57.9%), grade III in 24 patients (19.8%), and grade IV in one patient (0.8%). A total of 18 patients (14.9%) had underlying cardiovascular disease, 17 (14.0%) had pulmonary disease, and eight (6.6%) had diabetes mellitus. No patients (0%) had a positive COVID-19 test in the postoperative period. One patient (0.8%) developed anosmia postoperatively without respiratory symptoms or a fever. The patient did not undergo a COVID-19 test and self-isolated for seven days. Her symptoms resolved within a few days. Conclusion. The development of a COVID-free pathway for elective orthopaedic patients results in very low viral transmission rates. While both surgeons and patients should remain vigilant, elective surgery can be safely restarted using dedicated pathways and procedures. Cite this article: Bone Joint Open 2020;1-9:562–567

Introduction and Objective. Global prevalence of obesity has risen almost three-fold between 1975 and 2016. Alongside the more well-known health implications of obesity such as cardiovascular disease, cancer and type II diabetes, is the effect of male obesity on testosterone depletion and hypogonadism. Hypogonadism is a well-known contributor to the acceleration of bone loss during aging, and obesity is the single biggest risk factor for testosterone deficiency in men. Understanding the micro and macro structural changes to bone in response to testosterone depletion in combination with a high fat ‘Western’ diet, will advance our understanding of the relationship between obesity and bone metabolism. This study investigated the impact of surgically induced testosterone depletion and subsequent testosterone treatment upon bone remodelling in mice fed a high fat diet. Materials and Methods. Male ApoE. −/−. mice were split into 3 groups at 7 weeks of age and fed a high fat diet: Sham surgery with placebo treatment, orchiectomy surgery with placebo treatment, and orchiectomy surgery with testosterone treatment. Surgeries were performed at 8 weeks of age, followed by fortnightly testosterone treatment via injection. Mice were sacrificed at 25 weeks of age. Tibiae were collected and scanned ex-vivo at 4.3μm on a SkyScan 1272 Micro-CT scanner (Bruker). Left tibiae were used for assessment of trabecular and cortical Volumes of Interest (VOIs) 0.2mm and 1.0mm respectively from the growth-plate bridge break. Tibiae were subsequently paraffin embedded and sectioned at 4μm prior to immunohistochemical evaluation of alkaline phosphatase. Results. Trabecular bone volume and mineral density were significantly reduced in orchiectomised mice compared to sham-operated controls; and these parameters were normalised to control levels in orchiectomised mice treated with testosterone. In contrast, Trabecular thickness was significantly higher in testosterone depleted animals. Cortical bone parameters and body weights did not significantly differ between groups. Levels of alkaline phosphatase did not differ significantly in cortical or trabecular osteoblasts between groups. Conclusions. Findings suggest that testosterone deficiency significantly reduces trabecular bone parameters, and testosterone therapy may be a useful intervention for the loss of bone mass in testosterone deficient males. These results indicate that testosterone therapy may be useful for the treatment of trabecular bone frailty in testosterone deficient males. Observed changes in trabecular bone do not appear to be due to decreased mineralisation caused by osteoblast alkaline phosphatase. Ongoing work includes histology analysis to elucidate the mechanisms underpinning the changes seen in the bones of testosterone deficient animals

Aims. The new COVID-19 variant was reported by the authorities of the UK to the World Health Organization (WHO) on 14 December 2020. We aim to describe the clinical characteristics and nosocomial infection rates in major trauma and orthopaedic patients comparing the first and second wave of COVID-19 infection. Methods. A retrospective analysis of a prospectively collected trauma database was reviewed at a level 1 major trauma centre from 1 December 2020 to 18 February 2021 looking at demographics, clinical characteristics, and nosocomial infections and compared to our previously published first wave data (26 January 2020 to 14 April 2020). Results. From 1 December 2020 to 18 February 2021, 522 major trauma patients were identified with a mean age of 54.6 years, and 53.4% (n = 279) were male. Common admissions were falls (318; 60.9%) and road traffic accidents (RTAs; 71 (13.6%); 262 of these patients (50.2%) had surgery. In all, 75 patients (14.4%) tested positive for COVID-19, of which 51 (68%) were nosocomial. Surgery on COVID-19 patients increased to 46 (61.3%) in the second wave compared to 13 (33.3%) in the first wave (p = 0.005). ICU admissions of patients with COVID-19 infection increased from two (5.1%) to 16 (20.5%), respectively (p = 0.024). Second wave mortality was 6.1% (n = 32) compared to first wave of 4.7% (n = 31). Cardiovascular (CV) disease (35.9%; n = 14); p = 0.027) and dementia (17.9%; n = 7); p = 0.030) were less in second wave than the first. Overall, 13 patients (25.5%) were Black, Asian and Minority ethnic (BAME), and five (9.8%) had a BMI > 30 kg/m. 2. The mean time from admission to diagnosis of COVID-19 was 13.9 days (3 to 44). Overall, 12/75 (16%) of all COVID-19 patients died. Conclusion. During the second wave, COVID-19 infected three-times more patients. There were double the number of operative cases, and quadruple the cases of ICU admissions. The patients were younger with less dementia and CV disease with lower mortality. Concomitant COVID-19 and the necessity of major trauma surgery showed 13% mortality in the second wave compared with 15.4% in the first wave. In contrast to the literature, we showed a high percentage of nosocomial infection, normal BMI, and limited BAME infections. Cite this article: Bone Jt Open 2021;2(8):661–670

Introduction. The aim of research was estimating risk factors for lower limbs DVT after hip and knee replacement. Material. We reviewed series of 80 patients (58 women and 22 men) who had performed 13 cemented THA, 38 uncemented THA, 19 TKA and 10 revisions after THA. Average patients age was 63 (range 45 to 82). Methods. All patients were preoperatively taken precise history data and examined physically. We noticed their age and BMI. All patients were asked about past DVT, cardiovascular diseases and others, past operations, drug taking, condiments. We examined both lower limbs in suspicion of DVT. All patients were taken laboratory tests, D-dimers test, and two-dimensional and Doppler ultrasonography. During the operation we noticed its time, kind of anaesthesia, amount of blood and other transfusions, loss of blood, time of using the tourniquet (in TKA). After operation we noticed amount of blood and other transfusions, loss of blood, time of patients postoperative tilting to vertical position. All patients were precisely examined physically every day after joint replacement. They were taken laboratory tests in 1st, 4th, 7th and 14th day after operation. In 7th and 14th day we performed two-dimensional and Doppler ultrasonography. In all patients we used the same scheme of DVT prophylaxis. We administered Enoxaparine once a day subcutaneously (first dose 12 hours before operation). Prophylaxis lasted 6 weeks after joint replacement. Results. Average DVT rate was 24,24%. We found the highest rate of DVT after replacement revisions (75%). The lowest rate was after uncemented THA (6,25%). There were no difference in DVT rate between women and men. We found significantly higher DVT rate in patient older than 60 yr. We found significantly higher DVT rate in patient with BMI over 30. We found significantly higher DVT rate in group of smokers. We found the operation was longer the DVT rate was higher. In case of delaying patients tilting to vertical position, DVT rate was higher. We did not find using tourniquet influence DVT rate. Conclusions. The risk factors for DVT after hip and knee replacement are: age over 60 yr, BMI over 30, smoking, long lasting operation, delayed tilting to vertical position, accompanying cardiovascular diseases and past DVT

Introduction. There is insufficient data on the trends of anticoagulation after total knee arthroplasty (TKA) in the USA, and the efficacy and safety of rivaroxaban, beyond randomized clinical trials and small cohort studies. Patients and Methods. Using the Truven Health MarketScan database, we retrospectively evaluated new anticoagulation prescriptions after elective TKA from 2010 to 2015. The frequency of deep vein thrombosis (DVT), pulmonary embolism (PE), and adverse events, within 90 days, were then evaluated in 24,856 new users of warfarin and 21,398 new users of rivaroxaban in commercially insured patients (COM), and 15,483 new users of warfarin and 8,997 new users of rivaroxaban in Medicare supplement patients (MED). Data was analyzed by odds ratios using logistic regression models with stabilized inverse probability treatment weighting. Results. Warfarin use decreased from approximately 50% to 17% in COM patients and 60% to 25% in MED patients. Rivaroxaban use increased from 0 to 35% in COM patients and from 0 to 39% in MED patients. Older patients, females, a history of DVT, renal impairment, use of antiplatelet agents or surgery performed as an outpatient had lower odds of getting rivaroxaban. Patients in Western region and having surgery in 2015 had higher odds of getting rivaroxaban. COM patients with capitated insurance plans and a history of PE had lower odds of rivaroxaban initiation. MED patients with atrial fibrillation, cardiovascular disease or hyperlipidemia had lower odds of rivaroxaban initiation. Warfarin users had significantly higher odds ratio of DVT (OR 2.06 in COM patients and OR 2.21 in MED patients) and PE (OR 2.03 in COM patients and OR 2.16 in MED patients) than rivaroxaban users. There were no statistically significant differences in the bleeding risk between the two agents, but warfarin users had a significantly higher odds ratio of periprosthetic infection in both COM (1.57) and MED (1.79) patients. Conclusions. There has been an increase in prophylaxis with rivaroxaban, and a decrease in both warfarin and LMWH use after elective TKA over four years. Rivaroxaban had lower odds ratio of both DVT and PE than warfarin, and bleeding risks were similar. For figures, tables, or references, please contact authors directly

Introduction. Many pharmacologic agents have been used for venous thromboembolism (VTE) prophylaxis after elective total hip arthroplasty (THA). Rivaroxaban was the first novel oral anticoagulant approved for THA patients, but its actual efficacy and safety in clinical practice, beyond randomized trials, is unknown. Materials and Methods. This is a retrospective study, using the Truven Health MarketScan database, of anticoagulation medication prescriptions after elective THA, in both commercially insured (CI) and Medicare supplement insured (MS) patients, from 2010 to 2015. After exclusions, there were 83,179 CI and 50,534 MS patients available for analysis. There were 12,876 new users of warfarin (W) and 10,892 new users of rivaroxaban (R) in CI patients, and 7,416 new users of W and 4,739 new users of R in MS patients. We asked the following questions: (1) What were the trends and predictive factors for anticoagulant use after elective THA? (2) What was the actual clinical efficacy: frequency of deep vein thrombosis (DVT) and pulmonary embolism (PE), and frequency of adverse events within 90 days with the two most commonly used oral agents, rivaroxaban and warfarin, from June 2011 to September 2015? Data was analyzed for each anticoagulant by odds ratios using logistic regression models with stabilized inverse probability treatment weighting. Results. There was a change in use of anticoagulants after R approval. Use of W decreased from approximately 50% each in 2010 in both insurance cohorts to 10% in CI patients and 30% in MS patients in 4th quarter 2015. The use of R increased from 0 to 33% in both cohorts from 2011 to 2015. In the multivariate analysis, in CI patients, females had lower odds of getting R, and patients in Western region had higher odds of getting R; in MS patients, increasing age had reduced odds of getting rivaroxiban, but Western region and surgery in 2015 had higher odds. Patients with capitated insurance plans and renal impairment had lower odds of R initiation, but a history of cardiovascular disease or hypertension had higher odds. In 90 days after THA, patients given R had significantly lower odds ratio of both DVT and PE in both CI patients (DVT: 1.54 with W, 0.54 with R; PE: 2.12 with W, 0.73 with R) and MS patients (DVT: 3.01 W, 1.73 R; PE: 4.09 W, 1.88 R). With logistic regression analysis, users of W had significantly higher odds ratio of both DVT (CI 2.63 and MS 1.78) and PE (CI 2.60 and MS 2.09) than R. There was no significant difference in rates of bleeding between W and R, but W had higher odds ratio than R of prosthetic joint infection (PJI) in both CI (1.574) and MS (1.790) cohorts. Conclusions. There has been an increase in VTE prophylaxis with R, and a decrease in both W and LMWH use after elective THA over four years. Patient factors, insurance type, and comorbidities were associated with this change. In actual clinical efficacy, R had lower odds ratio of both DVT and PE than W, and bleeding risks were similar. The association of W with an increased odds ratio of PJI compared to R requires further study

Of the 6075 patients enrolled in EU-CORE registry, 206 patients had orthopaedic device-related infections. Significant underlying diseases were reported in 71% patients, most frequently cardiovascular disease (38%). The common sites of infection were knee (40%) and hip (33%). Among the 170 patients with available culture results, 135 (79%) were positive. Coagulase-negative staphylococci (CoNS, 44%) and Staphylococcus aureus (43%, of those 47% were methicillin resistant) were the most commonly isolated pathogens. Daptomycin was used empirically in 48% patients and as second-line therapy in 67% patients. During daptomycin therapy, 67% patients had undergone surgery (debridement, 61%; removal of foreign device, 39%; incision and drainage, 9%). Over half of the inpatients (54%) received concomitant antibiotics. Daptomycin was most frequently prescribed at a dose of 6 mg/kg/day (48%), with a median duration of therapy of 16 (range, 1–176) days. The overall clinical success rate was 85%, and was similar whether daptomycin was administered as first- or second-line therapy. The success rates achieved for infections caused by S. aureus and CoNS were 86% and 83%, respectively. Among the 79 patients who entered the long-term follow-up, 85% had a sustained response. Adverse events (AEs) and serious AEs possibly related to daptomycin were reported in 4.4% and 1.9% patients, respectively. Results from this real-world clinical experience showed that daptomycin is an effective and well-tolerated treatment option for orthopaedic device-related infections with a high success rate up to 2 years of follow-up

Cartilage is known to have limited intrinsic repair capabilities and cartilage defects can progress to osteoarthritis (OA). OA is a major economic burden of the 21st century, being among the leading causes of disability. The risk of disability from knee OA is as great as that derived from cardiovascular disease; a fact that becomes even more concerning when considering that even isolated cartilage defects can cause pain and disability comparable to that of severe OA. Several cartilage repair procedures are in current clinical application, including microfracture, osteochondral autograft transfer, osteochondral allograft transplantation, and autologous chondrocyte implantation (ACI). Given the economic challenges facing our health care system, it appears prudent to choose procedures that provide the most durable long-term outcome. Comparatively few studies have examined long-term outcomes, an important factor when considering the substantial differences in cost and morbidity among the various treatment options. This study reviews the clinical outcomes of autologous chondrocyte implantation at a minimum of 10 years after treatment of chondral defects of the knee. Mean age at surgery was 36 ± 9 years; mean defect size measured 8.4 ± 5.5cm2. Outcome scores were prospectively collected pre- and postoperatively at the last follow up. We further analyzed potential factors contributing to failure in hopes of refining the indications for this procedure. Conclusions: ACI provided durable outcomes with a survivorship of 71% at 10 years and improved function in 75% of patients with symptomatic cartilage defects of the knee at a minimum of 10 years after surgery. A history of prior marrow stimulation as well as the treatment of very large defects was associated with an increased risk of failure

Erythropoetin is currently licensed for use in adult patients scheduled for major elective orthopaedic surgery. It has been shown to be useful in reducing exposure to allogeneic blood transfusions in non-iron deficient patients prior to major elective orthopaedic surgery, having a high-perceived risk for transfusion complications. Use is generally restricted to patients with moderate anaemia (e.g. Hb 10–13 g/dl) with expected moderate blood loss (900 to 1800 ml). Allogeneic blood transfusions have been shown to be associated with increased morbidity and hospital stay and preoperative treatment with subcutaneous r-HuEPO has been shown to significantly reduce the allogeneic transfusion exposure in patients undergoing major elective orthopaedic surgery. Impact of Perioperative Haemoglobin Levels Perioperative anaemia can have detrimental effects on postoperative outcome. . Carson et al, 1996. , demonstrated, in 1958 surgical patients who declined blood transfusions, that overall risk of mortality increases as the haemoglobin decreases, and that even mild anaemia may be associated with an increased risk of death. Furthermore, patients with underlying cardiovascular disease are less tolerant of anaemia than those without cardiovascular disease, for any haemoglobin concentration (both preoperative and postoperative). To further define the impact of allogeneic blood transfusions, . Dunne et al (2002). sought to investigate the incidence of preoperative anaemia in noncardiac surgical patients. Preoperative anaemia (haematocrit < 36) was found in 33.9% and postoperative anaemia in 84.1% of the study cohort (n=6301). Multiple logistic regression analysis revealed that low pre-operative haematocrit, low postoperative haematocrit and increased blood transfusion rates were all associated with increased mortality (P< 0.01), increased postoperative pneumonia (P ≤0.01) and increased hospital length of stay (P< 0.05). These results underline the importance of maintaining higher haemoglobin levels and reducing allogeneic blood usage in surgical patients. Preoperative haemoglobin levels are also an important predictor of transfusion risk. . Faris et al, 1996. performed a statistical analysis of data from double-blind placebo controlled trials, evaluating the risk of exposure to allogeneic blood in patients treated with r-HuEPO or placebo to determine the pre-treatment clinical variables, that are prognostic for transfusion risk in orthopaedic surgical patients. The analysis also confirmed which patients are most likely to benefit from recombinant human erythropoietin. Placebo treated patients with Hb > 10 to ≤13g/dl had an approximately two fold greater risk of transfusion than patient with Hb ≥13g/dl. Moreover, r-HuEPO significantly reduced the transfusion risk in patients with haemoglobin > 10g/dl to ≤13g/dl at baseline. r-HuEPO Use in Surgery Three major double blind placebo controlled studies (. Faris et al, 1999. ; . Canadian Orthopaedic Perioperative Erythropoietin Study Group, 1993. ; . De Andrade et al, 1996. ) involving a total of 724 patients undergoing major elective orthopaedic surgery have demonstrated that treatment with 300IU/kg r-HuEPO daily for at least 14 days, beginning 10 days prior to surgery and continuing until the 3rd or 4th day after surgery, significantly decreased the percentage of patients with haemoglobin (Hb) levels ≥10g/dl to ≤13g/dl requiring transfusion. The administration of daily 300IU/kg r-HuEPO may be inconvenient. Data has demonstrated that less frequent dosing regimens may be as efficacious. An open-label, randomised, multicentre study was conducted by . Goldberg et al (1996). , to compare the safety and efficacy of two dosage regimens of r-HuEPO. Patients were scheduled for major elective orthopaedic surgery involving hip or knee replacement. Entry criteria included a Hb level > 10g/dl to ≤13g/dl, and a serum iron to total iron binding capacity (TIBC) ratio ≥0.20 and a serum ferritin ≥50ng/ml. Patients were randomised at least three weeks before the scheduled surgery to one of two treatment groups. Group 1 (n=73) received 600IU/kg sc once weekly, on days −21, −14, and −7 prior to surgery and on the day of surgery (total 2,400IU/kg). Group 2 (n=72) received 300IU/kg sc daily for 15 days starting 10 days prior to surgery, on the day of surgery, and for 4 days postoperatively (total dose 4,500 IU/kg), as used in previous studies. In addition patients received a polysaccharide-iron complex, which provided a minimum of 200mg of elemental iron per day. Patients also received standard anticoagulation therapy. The data showed that weekly dosing with 600IU/kg SC for three weeks before surgery produced an erythropoietic response at least as good as that achieved with a daily dosing regimen of 300IU/kg. The weekly regimen was similar to the daily regimen with respect to avoidance of allogeneic transfusion. In addition, the once-weekly dosing regimen of Epoetin alfa offers the potential advantages of greater convenience for patients, and would be less costly since 47% less Epoetin alfa is administered. Other related agents are also being studied. Darbopoetin has a longer half-life and may allow a reduced dosing schedule with similar efficacy. There is no conclusive evidence that there is a higher complication rate with EPO than with placebo, in particular the incidence of thromboembolic events. The published studies have all utilised chemical prophylaxis however. Use of EPO is contraindicated with uncontrolled hypertension. Iron Therapy Anaemia is present in a significant percentage of preoperative patients and is almost universal in rheumatoid patients. Iron therapy can play an important role as part of a strategy to reduce transfusion requirements. This can be utilised alone to correct anaemia or in conjunction with EPO therapy to optimise its efficiency. Absorption of oral iron is poor and the time scales are often limited which makes IV administration more effective. There remains some resistance to the IV route due to the potential side effects and also the costs and organisational problems. A dose of 700–900mg of elemental iron is recommended. Oral iron is probably better than nothing but there is little conclusive data about its use pre and post-operatively. Algorithm to Reduce Blood Transfusion With the aim of reducing unnecessary allogeneic red blood cell transfusion in orthopaedic surgery, . Slappendel et al (2003). have created an algorithm, which has resulted in an 80% reduction in transfusion. Analysis of 29,000 patients, revealed several factors which required evaluation. There were two that were of special interest in the preoperative setting: use of NSAIDs that can disturb coagulation of the blood during surgery and preoperative laboratory studies for full blood count to determine whether erythropoietin should be given. Single measures to reduce blood transfusion may not have any impact but use of a complete algorithm and specific measures for each hospital can dramatically reduce the number of units transfused. Transfusions are associated with immunomodulation, which may increase the incidence of postoperative infections, delay healing of postoperative wounds and thereby prolong hospitalisation. Subsequent analysis of the database revealed a 42% reduction in postoperative infections. In conclusion, the use of a comprehensive algorithm in orthopaedic surgery resulted in an 80% reduction in the need for blood transfusion

Cardiovascular disease is now the leading cause of morbidity and mortality worldwide. Raised blood pressures (BP) are associated with increased cardiovascular risks such as myocardial infarction, stroke and arteriosclerosis. During surgery the haemodynamic effects of stress are closely monitored and stabilised by the anaesthetist. Although there have been many studies assessing the effects of intraoperative stress on the patient, little is known about the impact on the surgeon. A prospective cohort study was carried out using an ambulatory blood pressure monitor to measure the BP and heart rates (HR) of three consultants and their respective trainees during hallux valgus, hip and knee arthroplasty surgery. Our principle aim was to assess the physiological effects of performing routine operations on the surgeon. We noted if there were any differences in the stress response of the lead surgeon, in comparison to when the same individual was assisting. In addition, we recorded the trainee's BP and HR when they were operating independently. The intraoperative measurements were compared with their baseline readings and their stress response, assessed using the Bruce protocol. Many trends were noted in this pilot study. All of the surgeons had higher BP and HR readings on operating days compared to baseline. The physiological parameters normalised by one hour post-theatre list in all subjects. When the trainer was leading the operation, their BP gradually increased until implant placement, while their trainees remained stable. On the other hand, when the trainee was operating and the trainer assisting, the trainer's BP peaked at the beginning of the procedure, and slowly declined as it progressed. The trainee's BP remained elevated throughout. The highest peaks for trainees were noted during independent operating. We conclude that all surgery is stressful, and that trainees are more likely to be killing themselves than their trainers

Background. Navigation systems that increase alignment accuracies of the lower limbs have been applied widely in total knee arthroplasty and are currently being adopted for minimally invasive UKA (MIS UKA) with good alignment results. There is little debate that when compared with total knee arthroplasty (TKA), UKA is less invasive, causes less morbidity, better reproduces kinematics, and therefore offers quicker recovery, better range of movement and more physiologic function. However, despite improved alignment accuracies, advantages of use of navigation system in UKA in clinical outcomes and survivals are still debatable. To the best of our knowledge, no reports are available on the long-term results after UKA performing using a navigation system. The purpose of this prospective study was to compare the radiological, clinical, and survival outcomes of UKA that performed using the navigation system and using the conventional technique at average 8 years follows up. Methods. Between January 2003 and December 2005, Total of 98 UKAs were enrolled for this study, 56 UKAs in the navigation group and 42 UKAs in conventional group were included in this study after a average 8 years follow-up. At the final follow up, the radiological measurements with regard to the mechanical axis, the inclination of the femoral and tibial components, and radiolucent line or loosening were evaluated and compared between two groups. The clinical evaluations were performed using range of motion, Western Ontario and McMaster Arthritis index (WOMAC) scores and Knee Society (KS) score. Results. Of the 98 patients (98 UNI knees), 2 (2.0%) had died at a mean 5.8years after surgery because of cardiovascular disease, 3 (3.1%) underwent revision surgery that 1 cases of periprosthetic stress fractures in medial tibial plateaus in the navigation group and a case of tibial component loosening and polyethylene wear in conventional groups were observed. At a final follow up, the mean of mechanical axis was statistically different between two groups (2.7 vs. 3.9 of varus). And there were significant difference between 2 groups in terms of the mean values (p=0.042) for the tibial component coronal alignment, mean coronal alignments of tibial components were 89.1 ± 2.4° in the NA-MIS and 87.6 ± 1.8° in the MIS group, however outlier result were similar in the 2 group (5 and 5 knees, respectively, p=0.673). Sagittal alignments of femoral and tibial component were similar in the two groups (p>0.05) Significant differences were found in WOMAC or HSS knee scores, in which, stiffness did not show any difference between two groups, but pain and function showed difference at the last follow-up. The mean knee flexion has improved from 135.0 ± 14.8° and 135.0 ± 14.1° preoperatively to 137.1 ± 6.5° and 136.5 ± 7.2° in the NA-MIS and MIS groups on the latest follow-up, which was not significants different (p =0.883). Conclusion. The navigation system in UKA can provide improved alignment accuracy. And better clinical outcomes in pain and HSS score compared with conventional technique after a average of 8 year follow-up

Introduction: The recent BOA blue book on blood conservation in elective orthopaedic surgery highlighted the need for blood saving strategies to be implemented. Perioperative management guidelines of oral anti-coagulation and anti-thrombosis medication have to date concentrated on warfarin use. Information and guidelines on aspirin usage in elective orthopaedics and its effects post operatively are limited. Methods: Data was collected prospectively from 1936 patients who underwent 2024 primary unilateral total hip replacement in a single institution. All patients were treated with the same postoperative transfusion regime and thromboembolic prophylaxis. Preoperative medication, haemoglobin levels and patient demographics were recorded by a standard assessment. Post op transfusion requirements and haemoglobin levels were noted throughout the postoperative period. Results: Multivariate analysis revealed that preoperative aspirin use was a significant independent predictor of postoperative transfusion requirement (p< 0.001). Discussion: Expanding indications for the use of aspirin for primary and secondary cardiovascular disease prevention have meant that large numbers of our patients undergoing total hip replacement are concurrently taking the drug. With increasing and emerging evidence of the risks involved in blood transfusion, including vCJD transmission and immune related reactions coupled with reduced supplies of donor blood further measures to reduce transfusion requirement are needed. We recommend that in the absence of absolute contraindications to stopping aspirin therapy, it should be omitted for 1 week prior to total hip replacement