Aims. Hip fractures are some of the most common fractures encountered in orthopaedic practice. We aimed to identify whether perioperative hypotension is a predictor of 30-day mortality, and to stratify patient groups that would benefit from closer monitoring and early intervention. While there is literature on intraoperative blood pressure, there are limited studies examining pre- and postoperative blood pressure. Methods. We conducted a prospective observational cohort study over a one-year period from December 2021 to December 2022. Patient demographic details, biochemical results, and haemodynamic observations were taken from electronic medical records. Statistical analysis was conducted with the Cox proportional hazards model, and the effects of independent variables estimated with the Wald statistic. Kaplan-Meier survival curves were estimated with the log-rank test. Results. A total of 528 patients were identified as suitable for inclusion. On multivariate analysis, postoperative hypotension of a systolic blood pressure (SBP) < 90 mmHg two to 24 hours after surgery showed an increased hazard ratio (HR) for 30-day mortality (HR 4.6 (95% confidence interval (CI) 2.3 to 8.9); p < 0.001) and was an independent risk factor accounting for sex (HR 2.7 (95% CI 1.4 to 5.2); p = 0.003), age (HR 1.1 (95% CI 1.0 to 1.1); p = 0.016), American Society of Anesthesiologists grade (HR 2.7 (95% CI 1.5 to 4.6); p < 0.001), time to theatre > 24 hours (HR 2.1 (95% CI 1.1 to 4.2); p = 0.025), and preoperative anaemia (HR 2.3 (95% CI 1.0 to 5.2); p = 0.043). A preoperative SBP of < 120 mmHg was close to achieving significance (HR 1.9 (95% CI 0.99 to 3.6); p = 0.052). Conclusion. Our study is the first to demonstrate that postoperative hypotension within the first 24 hours is an independent risk factor for 30-day mortality after hip fracture surgery. Clinicians should recognize patients who have a SBP of < 90 mmHg in the early postoperative period, and be aware of the increased mortality risk in this specific cohort who may benefit from a closer level of monitoring and early intervention. Cite this article: Bone Joint J 2024;106-B(2):189–194

Introduction: Vertebroplasty (VP) is a relatively new procedure to treat osteoporotic compression fractures of vertebral bodies. During this procedure polymethyl-methacrylate (PMMA) is injected into vertebral bodies. However there is the concern, that fat embolism (FE) and acute hypotension could occur as in a variety of other orthopaedic procedures. Aim: To investigate whether FE and acute hypotension are potential complications of VP using an animal model. Methods: In six sheep, 6.0 ml PMMA were injected unilaterally into the L1 vertebral body. Transœsophageal echocardiography was used to monitor the pulmonary artery for bone marrow and fat particles until 30 minutes post-operatively. Pulse, arterial and venous pressures were also recorded. The lumbar spine and the lungs were harvested post mortem. The histopathologic score, (percentage of lung fields occupied by intravascular fat globules as seen through the microscope), was calculated. Results: The first showers of echogenic material were visible approximately seven seconds after the beginning of the cement injection and lasted for about 2.5 minutes. The injection of bone cement caused a very rapid decrease in the heart rate after two seconds followed by a fall in the mean arterial pressure after 6.0 seconds. A maximum fall in heart rate was accompanied by a delayed fall in mean arterial pressure of 33.0 mmHg (P=0.0003) at 36seconds. The heat rate had returned to the baseline by 89 seconds and had increased by 10 beats/min (P=0.02) at 25 minutes. Mean arterial pressure had recovered by 209 seconds and was not different from the baseline at 25 minutes. Post mortem examination showed that no leakage of cement into the spinal cord had occurred. The histology revealed fat globules and bone marrow cells in the smaller and larger vessels throughout the lungs. The histopathologic score was 5.2 ± 0.9%. Conclusions: This study clearly showed that VP resulted in FE with a two-phase decrease in heart rate and arterial blood pressure. The first phase was probably due to an autonomic reflex and the second phase was due to the passage of fat emboli through the right heart and obstructing the lungs

Vertebroplasty (VP) is a new prophylactic treatment for preventing osteoporotic compression fractures of vertebral bodies. During this procedure polymethylmethacrylate (PMMA) is injected into several vertebral bodies. However, there is the concern, that fat embolism (FE) and acute hypotension could occur as in a variety of other orthopaedic procedures. This study was undertaken to investigate whether FE and acute hypotension are potential complications of VP using an animal model. In six sheep 6.0 ml PMMA were injected unilaterally into L1. Transesophageal echocardiography was used to monitor the pulmonary artery for bone marrow and fat particles until 30 minutes postoperatively. Pulse, arterial and venous pressure were also recorded. Post mortem the lumbar spine and the lungs were harvested. The lungs were subjected to histological evaluation. The first showers of echogenic material were visible approximately 7.0 seconds after the beginning of the cement injection and lasted for about 2.5 minutes. Injection of bone cement elicited a very rapid decrease in heart rate after 2.0 seconds followed by a fall in mean arterial pressure after 6.0 seconds. A maximum fall in heart rate was accompanied by a delayed fall in mean arterial pressure of 33.0 mmHg (P=0.0003) at 36.0 seconds. Heat rate had returned to baseline by 89.0 seconds and had increased by 10.0 beats/min (P=0.02) at 25 minutes. Mean arterial pressure had recovered by 209.0 seconds and was not different to the baseline at 25 minutes. The post mortem inspection revealed disseminated haemorrhages on the lung surface and throughout the parenchyma mainly in the caudal lobes of all six animals. No leakage of cement into the spinal cord was detected. In histology fat globules and bone marrow cells were observed in both the smaller and larger vessels throughout the lung. This study clearly shows that VP resulted in a two-phase decrease in heart rate and arterial blood pressure. The first phase was probably due to an autonomic reflex and the second phase was due to the passage of fat emboli through the right heart and obstructing the lungs

Aims. Day-case arthroplasty is gaining popularity in Europe. We report outcomes from the first 12 months following implementation of a day-case pathway for unicompartmental knee arthroplasty (UKA) and total hip arthroplasty (THA) in an NHS hospital. Methods. A total of 47 total hip arthroplasty (THA) and 24 unicompartmental knee arthroplasty (UKA) patients were selected for the day-case arthroplasty pathway, based on preoperative fitness and agreement to participate. Data were likewise collected for a matched control group (n = 58) who followed the standard pathway three months prior to the implementation of the day-case pathway. We report same-day discharge (SDD) success, reasons for delayed discharge, and patient-reported outcomes. Overall length of stay (LOS) for all lower limb arthroplasty was recorded to determine the wider impact of implementing a day-case pathway. Results. Patients on the day-case pathway achieved SDD in 47% (22/47) of THAs and 67% (16/24) of UKAs. The most common reasons for failed SDD were nausea, hypotension, and pain, which were strongly associated with the use of fentanyl in the spinal anaesthetic. Complications and patient-reported outcomes were not significantly different between groups. Following the introduction of the day-case pathway, the mean LOS reduced significantly by 0.7, 0.6, and 0.5 days respectively in THA, UKA, and total knee arthroplasty cases (p < 0.001). Conclusion. Day-case pathways are feasible in an NHS set-up with only small changes required. We do not recommend fentanyl in the spinal anaesthetic for day-case patients. An important benefit seen in our unit is the so-called ‘day-case effect’, with a significant reduction in mean LOS seen across all lower limb arthroplasty. Cite this article: Bone Jt Open 2021;2(11):900–908

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

Same day home (SDH) discharge in total joint arthroplasty (TJA) has increased in popularity in recent years. The objective of this study was to evaluate the causes and predictors of failed discharges in planned SDH patients. A consecutive cohort of patients who underwent total knee (TKA) or total hip arthroplasty (THA) that were scheduled for SDH discharge between April 1, 2019 to March 31, 2021 were retrospectively reviewed. Patient demographics, causes of failed discharge, perioperative variables, 30-day readmissions and 6-month reoperation rates were collected. Multivariate regression analysis was undertaken to identify independent predictors of failed discharge. The cohort consisted of 527 consecutive patients. One hundred and one (19%) patients failed SDH discharge. The leading causes were postoperative hypotension (20%) and patients who were ineligible for the SDH pathway (19%). Two individual surgeons, later operative start time (OR 1.3, 95% CI, 1.15-1.55, p=0.001), ASA class IV (OR 3.4, 95% CI, 1.4-8.2; p=0.006) and undergoing a THA (OR 2.0, 95% CI, 1.2-3.1, p=0.004) were independent predictors of failed SDH discharge. No differences in age, BMI, gender, surgical approach or type of anesthetic were found (p>0.05). The 30-day readmission or 6-month reoperation were similar between groups (p>0.05). Hypotension and inappropriate patient selection were the leading causes of failed SDH discharge. Significant variability existed between individual surgeons failed discharge rates. Patients undergoing a THA, classified as ASA IV or had a later operative start time were all more likely to fail SDH discharge

Total Knee Arthroplasty (TKA) improves the quality of life of osteoarthritic and rheumatoid arthritis patients, however, is associated with moderate to severe postoperative pain. There are multiple methods of managing postoperative pain that include epidural anesthesia but it prevents early mobilization and results in postoperative hypotension and spinal infection. Controlling local pain pathways through intra-articular administration of analgesics is a novel method and is inexpensive and simple. Hence, we assess the effects of postoperative epidural bupivacaine injection along with intra-articular injection in total knee replacement patients. The methodology included 100 patients undergoing TKA randomly divided into two groups, one administered with only epidural bupivacaine injection and the other with intra-articular cocktail injection. The results were measured based on a 10-point pain assessment scale, knee's range of motion (ROM), and Lysholm knee score. The VAS score was lower in the intra-articular cocktail group compared to the bupivacaine injection group until the end of 1-week post-administration (p<0.01). Among inter-group comparisons, we observed that the range of motion was significantly more in cocktail injection as compared to the bupivacaine group till the end of one week (p<0.05). Lysholm's score was significantly more in cocktail injection as compared to the bupivacaine group till the end of one week (p<0.05). Our study showed that both epidural bupivacaine injection and intra-articular injection were effective in reducing pain after TKA and have a comparable functional outcome at the end of 4 weeks follow up. However, the pain relief was faster in cases with intra-articular injection, providing the opportunity for early rehabilitation. Thus, we recommend the use of intra-articular cocktail injection for postoperative management of pain after total knee arthroplasty, which enables early rehabilitation and faster functional recovery of these patients

Prompt mobilisation after the Fracture neck of femur surgery is one of the important key performance index (‘KPI caterpillar charts’ 2021) affecting the overall functional outcome and mortality. Better control of peri-operative blood pressure and minimal alteration of renal profile as a result of surgery and anaesthesia may have an implication on early post-operative mobilisation. Aim was to evaluate perioperative blood pressure measurements (duration of fall of systolic BP below the critical level of 90mmHg) and effect on the post-operative renal profile with the newer short acting spinal anaesthetic agent (prilocaine and chlorprocaine) used alongside the commonly used regional nerve block. 20 patients were randomly selected who were given the newer short acting spinal anaesthetic agent along with a regional nerve block between May 2019 and February 2020. Anaesthetic charts were reviewed from all patients for data collection. The assessment criteria for perioperative hypotension: Duration of systolic blood pressure less than 90 mm of Hg and change of pre and post operative renal functions. Only one patient had a significant drop in systolic BP less than 90mmHg (25 minutes). 3 other patients had a momentary fall of systolic BP of less than 5 minutes. None of the above patients had mortality and had negligible change in pre and post op renal function. Only one patient in this cohort had elevation of post-operative creatinine levels but did not have any mortality. Only 1 patient died on day 3 post operatively who had multiple comorbidities and was under evaluation for GI cancer. Even in this patient the peri-operative blood pressure was well maintained (never below 90mmHg systolic) and post-operative renal function was also shown to have improved (309 pre-operatively to 150 post-operatively) in this patient. The use of short-acting spinal anaesthesia has shown to be associated with a better control of blood pressure and end organ perfusion, less adverse effects on renal function leading to early mobilisation and a more favourable patient outcome with reduced mortality, earlier mobilisation, shorter hospital stay and earlier discharge in this elderly patient cohort

(Introduction). In Total Knee Arthroplasty (TKA), closed drains have been conventionally used to prevent hematoma. Recently reported “no-drain” methods have been demonstrated to be safe and effective, especially for decreasing hemorrhage. However, there has been no report of a major study on a no-drain method in simultaneous bilateral TKA, only a few small studies. Therefore, this study evaluated the efficacy of no-drain placement in simultaneous bilateral TKA. (Methods). Our study included 75 patients (150joints) with preoperative hemoglobin(Hb) level of at least 11.0 g/dl who underwent simultaneous bilateral TKA performed by the same surgeon in our department between January 2012 and December 2013. There were 12men and 63women, of average age 70.7 ± 7.9years (mean ± SD) and BMI 25.6± 3.8 (mean ± SD). Among them 72 patients had knee osteoarthritis and 3 patients had rheumatoid arthritis. The patella was not replaced in any of the cases. TKAs were performed separately on each knee. A tourniquet was applied between the initial skin incision and the postoperative dressing, and 1000 mg of tranexamic acid was injected into each joint after wound closure. (Results). The surgical time per patient was 136.6 ± 30.3 minutes (mean ± SD). The Hb levels (mean ± SD) were 13.0 ± 1.1 g/dl before surgery, 10.9 ± 1.2 g/dl on the day after surgery. The estimated total blood loss until the day after surgery was 558.4 ± 253.9 ml (mean ± SD). No patient experienced hypotension requiring vasopressor or rapid fluid therapy between the end of surgery and the day after surgery, and no complication caused by a sudden change of hemodynamics was found in any case of bilateral TKA. A gait training/range of motion exercise while bearing full load of the body weight was initiated from the day after surgery. This allowed patients to be discharged from our hospital in an average of 6.1days (range 5–11days)after surgery. There were no serious complications that occurred within three months after surgery. (Discussion). In cases of TKA with closed drain, even in unilateral surgery, excessive hemorrhage may be discharged through drain tubes for the first few hours after surgery. Hypotension caused by postoperative sudden hemorrhage or burden on the cardiovascular system seem to be major issues. In this study, simultaneous bilateral TKA were performed without suction drainage. The estimated blood loss until the day after surgery was approximately 560 ml. As sudden hypotension causing shock was not found, the post-operative hemorrhage seemed to have gradually progressed naturally. So we did not need the blood transfusion or rapid fluid therapy to any patient. This is one of the advantage of no-drainage method. (Conclusion). The simultaneous bilateral TKA without drain placement can be applied safely

Purpose: Cement implantation syndrome characterized by hypotension, hypoxemia, cardiac arrhythmia or arrest has been reported in the literature. Pulmonary embolization is thought to be the main reason. In our institute, however, we have not experienced major hypotension during THA. To improve longevity of THA, interface bioactive bone cement technique combined with modern cementing technique has been used in our institute. Main principle of this technique is smearing hydroxyapatite granules on the dry bony surface followed by cement pressurization. The purpose of the present study was to monitor blood pressure soon after cementing. Method: The present study includes 91 cases of primary THA with an average age at operation of 64 years old (ranging 35 to 85). Under general anesthesia, both components were cemented using antero-lateral approach. Systolic arterial blood pressure was monitored until 5 minutes with 1 minute interval. The maximum regulation (MR%) was calculated as (maximum change blood pressure – blood pressure before cement insertion) divided by blood pressure before cement insertion. Results: No major complications such as cardiac arrest were observed. In most of the cases, blood pressure increased until 4 minutes for the acetabular side and 2 minutes for the femoral side, and then returned to the blood pressure before cement insertion gradually. In the acetabular side, MR% was 10±13 (−19–40)%. In 52 joints (57.1%), MR% was between 10 to 40 %. In the femoral side, MR% was 5±12 (−20 to 31)%. In 32 joints (35.2%), MR% was between 10 to 31 %. Conclusion: In the present study, major hypotension was not observed. Blood pressure increases if left ventricle reacts to the pulmonary hypertension caused by micro-embolization. If major pulmonary embolization occurs, blood pressure decrease because left ventricle can not compensate for major pulmonary hypertension caused by mayor pulmonary embolization. By good cementing technique which includes washing out debris or fat and obtaining dry bony surface just before cementing, blood pressure soon after cementing was increased

Introduction: The ideal regimen for safe and effective post operative pain relief inspinal surgery remains elusive. Numerous studies have been conducted comparing epidural with patient controlled analgesia with no firm conclusion as to which is best. Aims: To determine the efficacy of acute pain relief between surgical placed epidural catheter and patient controlled analgesia for lumbar spinal surgery. Method: A 42 month retrospective survey of 82 spinal surgery patients case notes and anaesthetic charts performed by a consultant spinal surgeon and his registrar from 2002 to 2005. There were 34 epidural and 48 PCA patients. Visual analogue Score (0–10) at 6 hourly intervals up to 36 hours, complications and age of patient were looked at. Exclusion criteria for epidural were dural tear, history of hypotension, unexplained neurological symptoms, and bleeding disorders and surgeon choice. Epidural infusion consisted of bupivacaine 0.1% with 5mls loading dose and 10mls/ hour infusion and PCA consisted of morphine sulphate 2mg/ml with a 1ml loading dose and 5 minute lockout interval.All patients were on standard analgesia which included oromorph 5mg four hourly orally and paracetamol 1gram six hourly as required orally. No radiographic evidence of epidural catheter placement was performed. Post-operative complications which included hypotension, nausea, vomiting, and drowsiness were monitored. Results: The average age for the epidural group was 46.9 and PCA group 49.8. The most striking finding was that the average pain score at each six hourly interval waslower in the epidural group. This was significant in the first 18 hours post-operatively.However, 3 complications occurred in the epidural group which included hypotension. In addition, 3 epidural infusions were stopped and changed to PCA most likely due to improper placement of catheter. There were no complications with the PCA group. Conclusion: This observational study demonstrates clinically and statistically that in the acute post-operative phase and up to 36 hours that epidural analgesia for lumbar spine surgery is more effective than PCA. From this survey, the risk of epidural was higher, although no serious complications occurred. Surgeon placement of catheter is also important in the effective delivery of epidural pain relief. The lower efficacy of the PCA may have been due to poor patient understanding of the concept of PCA and thereforeits

Background. Cement implantation syndrome characterized by hypotension, hypoxemia, cardiac arrhythmia or arrest has been reported in the literature. The purpose of the present study was to monitor blood pressure soon after cementing. Methods. The present study includes 178 cases 204 joints of primary THA with an average age at operation of 64.5 years old (ranging 35 to 89). Under general anesthesia, both components were cemented using antero-lateral approach. Systolic arterial blood pressure during cementing acetabular and femoral components was monitored until 5 minutes with 1 minute interval. The maximum regulation ratio (MRR) was calculated as (maximum change blood pressure – blood pressure before cement insertion) divided by blood pressure before cement insertion. Results. No major complications such as cardiac arrest were observed. In most of the cases, blood pressure increased until 4 minutes for the acetabular side and 2 minutes for the femoral side, and then returned to the blood pressure before cement insertion gradually. In the acetabular side, average MRR was 11.2% (SD, 15.9; range, −26 to 80). Ｉn the femoral side, MRR was 6.4% (SD, 14.9; range, −31 to 65). There was statistical correlation between categories of MRR in the acetabular side and age at operation, the status of bleeding control of the acetabular side. When the bleeding control was judged as complete, blood pressure showed less tendency to decrease. When the bleeding control was judged as good, blood pressure showed more tendency to decrease. Conclusion. In the present study, major hypotension was not observed. Using third generation and IBBC cementing technique, when the bleeding control was judged as complete in the acetabular side, blood pressure showed less tendency to decrease

We would like to present a rare case report describing a case in which new-onset tonic-clonic seizures occurred following an unintentional durotomy during lumbar discectomy and decompression. Unintentional durotomy is a frequent complication of spinal surgical procedures, with a rate as high as 17%. To our knowledge a case of new onset epilepsy has never been reported in the literature. Although dural rupture during surgery and CSF hypovolemia are thought to be the main contributing factors, one can postulate on the effects of anti-psychiatirc medication with epileptogenic properties. Amisulpride and Olanzapine can lower seizure threshold and therefore should be used with caution in patients previously diagnosed with epilepsy. However manufacturers do not state that in cases were the seizure threshold is already lowered by CSF hypotension, new onset epilepsy might be commoner. Finally, strong caution and aggressive post-operative monitoring is advised for patients with CSF hypotension in combination with possible eplieptogenic medication. Conflict of Interest: None. Source of Funding: None

The first rule in properly cementing a femoral component is obtaining adequate exposure of the proximal femur. This is achieved reproducibly in anterior approach surgery with anterior and superior capsulotomy, combined with release of the conjoined tendon from the inner trochanter and piriformis tendon retraction, or flip behind the trochanter. This will be demonstrated. The steps of cementation are well established, and not specific to one approach. They involve entry to the proximal femur in a lateral and posterior position, achieving central alignment within the proximal femur with the broach, application of a cement restrictor to a point 1.5 to 2cm distal to the proposed tip of the implant, appropriate preparation of the cancellous bone to receive the cement, applying cement in a sufficiently doughy state to be able to achieve penetration into the cancellous bone, and mechanical pressurization into that cancellous bone. We routinely apply cement directly to the proximal aspect of the femoral component as the cement sticks to the metal, preventing marrow contents generated during the insertion from contacting the metal. In discussing the factors contributing to a dry surgical field, the importance of relative hypotension achieved from regional anesthesia cannot be overstated

INTRODUCTION. In recent years, there has been a shift toward outpatient and short-stay protocols for patients undergoing total hip arthroplasty (THA) and total knee arthroplasty (TKA). We developed a peri-operative THA and TKA short stay protocol following the Enhance Recovery After Surgery principles (ERAS), aiming at both optimizing patients’ outcomes and reducing the hospital length of stay. The objective of this study was to evaluate the implementation of our ERAS short-stay protocol. We hypothesized that our ERAS THA and TKA short-stay protocol would result in a lower complication rate, shorter hospital length of stay and reduced direct health care costs compared to our standard procedure. METHODS. We compared the complications rated according to Clavien-Dindo scale, hospital length of stay and costs of the episode of care between a prospective cohort of 120 ERAS short-stay THA or TKA and a matched historical control group of 150 THA or TKA. RESULTS. Significantly lower rate of Grade 1 and 2 complications in the ERAS short-stay group compared with the standard group (mean 0.8 vs 3.0, p<0.001). Postoperative complications that were experienced by significantly more patients in the control group included pain (67% vs 13%, p<0.001), nausea (42% vs 12%, p<0.001), vomiting (25% vs 0.9%, p<0.001), dizziness (15% vs 4%, p=0.006), headache (4% vs 0%, p=0.04), constipation (8% vs 0%, p=0.002), hypotension (26% vs 11%, p=0.003), anemia (8% vs 0%, p=0.002), oedema of the operated leg (9% vs 1%, p=0.005), persistent lameness (4% vs 0%, p=0.04), urinary retention (13% vs 4%, p=0.006) and anemia requiring blood or iron transfusion (8% vs 0%, p=0.002). No difference was found between the 2 groups for Grade 3, 4, or 5 complications. The mean hospital length of stay for the ERAS short-stay group decreased by 2.8 days for the THAs (0.1 vs 2.9 days, p bellow 0.001) and 3.9 days for the TKAs (1.0 vs 4.9 days, p<0.001). The mean estimated direct health care costs reduction with the ERAS short-stay protocol was 1489% per THA and 4206% per TKA. DISCUSSION AND CONCLUSION. Shorter hospitalization time after THA and TKA is associated with lower risk of nosocomial infections and adverse events related to reduced mobilization such as venous thromboembolism, pulmonary atelectasis, and constipation. In addition, it increases bed availability in a restricted environment and is very favorable economically for the care provider. Multiple strategies have been described to reduce hospital length of stay. One attractive option is to follow the ERAS principles to improve patient experience to a level where they will feel confident to leave for home earlier. Implementation of a ERAS short-stay protocol for patients undergoing THA or TKA at our institution resulted not only in reduced hospital length of stay, but also in improved patient care and reduced direct health care costs

Tranexamic acid (TXA) is an effective medication to limit blood loss and transfusion requirements in association with contemporary total joint arthroplasty. TXA is in a class of medications termed anti-fibrinolytics due to their action to limit the breakdown of clot that has already been formed. It is useful to note that TXA does not promote the formation of clot, it simply limits the breakdown of already established clot. A recent systematic review and meta-analysis of randomised clinical trials of TXA use in total hip replacement demonstrated: 1) a substantial reduction in the proportion of patients who required transfusion and 2) no increase in DVT or PE. Similarly a recent Cochrane Database systematic review assessed Anti-fibrinolytic Use for Minimizing Perioperative Blood Transfusion and found tranexamic acid to be effective in reducing blood loss during and after surgery and to be free of serious adverse effects. In orthopaedic surgery varying doses have been used over time. A pragmatic dosing approach for Total Knee and Total Hip patients has been used at the Mayo Clinic over the past 16 years: 1 gram IV over 10 minutes prior to incision (delivered at same time as pre-op antibiotics) followed by 1 gram IV over 10 minutes at the time wound closure is initiated. Infusion rates greater than 100 mg/minute have been associated with hypotension and thus the recommendation for 1 gram over 10 minutes. A recent review of 1500 TKA patients at Mayo Clinic revealed a very low prevalence of clinically symptomatic DVT and PE when tranexamic acid was used with 3 different thromboembolic prophylaxis regimens (aspirin and foot pumps; coumadin; low molecular weight heparin). The safety of TXA for patients with coronary stents has not been fully clarified

Aims

Cementing in arthroplasty for hip fracture is associated with improved postoperative function, but may have an increased risk of early mortality compared to uncemented fixation. Quantifying this mortality risk is important in providing safe patient care. This study investigated the association between cement use in arthroplasty and mortality at 30 days and one year in patients aged 50 years and over with hip fracture.

Total hip and knee arthroplasty is known to have a significant blood loss averaging 3–4 g/dL. Historically, transfusion rates have been as high as 70%. Despite years of work to optimise blood management, some published data suggests that transfusion rates (especially with allogeneic blood) are rising. There is wide variability between surgeons as well, suggesting that varying protocols can influence transfusion rates. Multiple studies now associate blood transfusions with negative outcomes including increased surgical site infection, costs, and length of stay. Preoperative measures can be employed. Identify patients that are at increased risk of blood transfusion. Smaller stature female patients, have pre-operative anemia (Hgb less than 13.0 gm/dl), or are undergoing revision or bilateral surgery are at high risk. We identify these patients and check a hemoglobin preoperatively, using a non-invasive finger monitor for screening. For anemic patients, iron administration (oral or IV) can be given, along with Procrit/Epogen in select cases. Insurance coverage for that medication has been challenging. Intraoperative measures that have been linked to reduced postoperative transfusions include regional anesthesia and intraoperative hypotension (mean arterial pressure <60mm/hg). Lowering the surgical time by practicing efficient, organised, and quality surgery, along with leaving a dry field at the completion of surgery can reduce blood loss. Tranexemic acid (TXA) is an antifibrinolytic agent that has been shown to be effective, reducing average blood loss by 300 cc per case. There are multiple different administration protocols: IV using either a weight-based dosing 10–20 mg/kg or standardised dosing for all patients. Our current regimen is 1 gm IV preoperatively, 1 gm IV in PACU. Topical TXA can be used, usually 2–3 gm mixed in 50–100 cc of saline, sprayed in wound and allow to soak for 3–5 minutes. Oral administration is attractive for ease of use and reduced cost, standard oral dosing is 1950 mg PO 2 hours prior to surgery. The American Association of Hip and Knee Surgeons, in collaboration with the American Association of Orthopedic Surgeons, American Society of Regional Anesthesiologists, and the Hip & Knee Society have developed a Clinical Practice Guideline with 8 recommendations for TXA as follows: All individual formulations are effective at reducing blood loss – strong; No method of administration is clearly superior at reducing blood loss and the risk of transfusion; The dose of IV or topical TXA does not significantly affect the drug's ability to reduce blood loss and risk of transfusion; Multiple doses of IV or oral TXA compared to a single dose does not significantly alter the risk of blood transfusion; Pre-incision IV TXA administration potentially reduces blood loss and risk of transfusion compared to post-incision administration; Administration of all TXA formulations in patients without history of VTE does not increase the risk of VTE; Administration of all TXA formulations in patients with a history of VTE, MI, CVA, TIA, or vascular stent does not appear to increase the risk of VTE; Administration of all TXA formulations does not appear to increase the risk of arterial thrombotic events; Postoperative measures to reduce transfusion rates include changing transfusion triggers. Instead of treating a “number”, use lower thresholds and employ safe algorithms established. In conclusion, a comprehensive blood management program can reduce transfusion rates to less than 3% for THA and 1% for TKA and facilitate outpatient total joint arthroplasty

Tranexamic acid (TXA) is an effective medication to limit blood loss and transfusion requirements in association with contemporary total joint arthroplasty. TXA is in a class of medications termed anti-fibrinolytics due to their action to limit the breakdown of a clot that has already been formed. It is useful to note that TXA does not promote the formation of a clot, it simply limits the breakdown of already established clots. A recent systematic review and meta-analysis of randomised clinical trials of TXA use in total hip replacement demonstrated: 1) a substantial reduction in the proportion of patients who required transfusion and 2) no increase in DVT or PE. Similarly a recent Cochrane Database systematic review assessed Anti-fibrinolytic Use for Minimizing Perioperative Blood Transfusion and found tranexamic acid to be effective in reducing blood loss during and after surgery and to be free of serious adverse effects. In orthopaedic surgery, varying doses have been used over time. A pragmatic dosing approach for Total Knee and Total Hip patients has been used at the Mayo Clinic over the past 16 years: 1 gram IV over 10 minutes prior to incision (delivered at same time as pre-operative antibiotics) followed by 1 gram IV over 10 minutes at the time wound closure is initiated. Infusion rates greater than 100 mg/minute have been associated with hypotension and thus the recommendation for 1 gram over 10 minutes. A recent review of 1500 TKA patients at Mayo Clinic revealed a very low prevalence of clinically symptomatic DVT and PE when tranexamic acid was used with 3 different thromboembolic prophylaxis regimens (aspirin and foot pumps; coumadin; low molecular weight heparin). The safety of TXA for patients with coronary stents has not been fully clarified

Aims

Cemented hemiarthroplasty is an effective form of treatment for most patients with an intracapsular fracture of the hip. However, it remains unclear whether there are subgroups of patients who may benefit from the alternative operation of a modern uncemented hemiarthroplasty – the aim of this study was to investigate this issue. Knowledge about the heterogeneity of treatment effects is important for surgeons in order to target operations towards specific subgroups who would benefit the most.