Alcohol hand rubs, endorsed by WHO and NICE guidelines, are integral to modern surgical practices. Our objective was to assess how different scrubbing methods impact overall water usage by the surgical team, shedding light on variations among team members and their environmental implications. Over three consecutive arthroplasty lists spanning a week, water usage during scrubbing was observed for the operating team. Blinding all team members, including the anesthetist, consultant surgeon, orthopaedic registrar, orthopaedic SHO, and scrub nurse, during water usage calculations was implemented. Automated taps, using motion sensors, posed a challenge due to variable water quantity, necessitating water flow calculations per sensor movement. The senior surgeon, with over 20 years of experience, follows a traditional approach, starting with a morning prescrub and using an alcohol tub for each case, except when hands are soiled. We observed a total of 14 cases of lower limb primary arthroplasty. The cumulative water usage for scrubbing by the entire team was 193 liters, yielding a mean of 13.8 liters (±1.85) per case. The anaesthetist demonstrated the most conservative water usage, utilizing a total of 11.85 liters with a mean of 0.84 liters per case. Notably, alcohol rub was employed for half of the observed time, contributing to this efficient use. The senior operating surgeon used a total of 15.6 liters, averaging 1.1 liters per case. In contrast, the SHO and the registrar exhibited the highest water consumption, totaling 121.6 liters and yielding a mean of 5.7 liters per case. The nurses’ collective water usage for scrubbing amounted to 44.8 liters. Adopting alcohol rub, as endorsed by WHO, results in a remarkable 10-fold reduction in water usage, aligning with global health guidelines. This highlights significant potential for resource conservation in surgical procedures, presenting a practical and environmentally conscious approach to surgical scrubbing practices

Aim. Success rate of debridement, antimicrobial and implant retention (DAIR) in high suspicion of early PJI after primary arthroplasty is 70–80%. No studies have been performed focusing on outcome of DAIR after revision arthroplasty of the hip (THA) or knee (TKA). The aim of this study is to investigate the outcome of DAIR in suspected early PJI after revision THA or TKA and to identify risk factors for failure. Method. In this retrospective study, we identified early DAIRs after revision THA or TKA performed between January 2012 and August 2019. All patients received empirical antibiotics directly after the DAIR procedure. Antimicrobial treatment was adjusted to the tissue culture results. Success was defined as: 1) implant retention; 2) no repeated revision arthroplasty or supervised neglect after treatment; 3) no persistent or recurrent PJI after treatment and no administration of suppressive antimicrobial therapy; 4) survival of the patient. Infection free success was defined as: 1) no persistent or recurrent PJI after treatment; 2) no administration of suppressive antimicrobial therapy. Results. The overall success rate after one year of 100 cases with early DAIR after revision THA or TKA was 79% and infection free success rate was 85%. In PJI cases, empirical antimicrobial mismatch with causative micro-organisms was associated with lower success rate (70%) than non-mismatch (95%) (p=0.02). No patients from the non-PJI group failed after one year versus 13 failures within the PJI group. A consecutive DAIR within 90 days after the first DAIR was warranted in 24 cases. Only 4 of 20 PJI cases failed despite the consecutive DAIR. Conclusions. In high suspicion of early PJI after revision arthroplasty, DAIR is a good treatment option with comparable outcome with DAIR after primary arthroplasty. A consecutive DAIR should not be avoided when infection control fails within 90 days after the first DAIR to prevent explantation of the prosthesis. Antimicrobial mismatch is associated with failure and should be avoided

Primary arthroplasty of the hip and knee are amongst the most common elective surgical procedures carried out. Results are uniformly good with low complication rates. However, there is a subset of patients in whom a general malaise has been noted. Many of these patients have been seen to have elevated liver function tests. This study set out to examine the effects of primary arthroplasty on liver function and to establish differences between subsets of patients in a consecutive single surgeon series between June 2003 and September 2007 inclusive. In total, 374 procedures were carried out on 350 patients. There were 186 male and 164 female patients. The mean age of the patients was 64.97+/−10.02 years with no significant difference between sexes. Hip replacement accounted for 196 cases (69 cemented, 68 hybrid and 59 cementless) and there was 178 knee replacements. All 4 measurements (AST, ALT, Alk phos, Gamma GT) were significantly elevated at 1 week post-op compared to pre-op and 1 day post-op. All except Alk phos returned to normal at 6 weeks post-op. There were no differences recorded between males and females, hips and knees and the subsets of hips. It is clear from these results that liver function is affected by primary arthroplasty with no single subset providing a reason. Additional research is required to further evaluate these changes

Outsourcing elective surgery has become increasingly commonplace to meet increasing demand from a growing & aging population. There is concern that outsourcing was influencing the nature of residual workload that was unsuitable for treatment elsewhere. This led to the impression that our unit is operating on more complex patients orthopaedic problems, ASA and Body Mass Index (BMI). By losing a disproportionate number of straightforward patients our department's outcomes, productivity and training opportunities could be adversely affected. Retrospective analysis of prospectively collected data of primary hip / knee arthroplasties between July & December for 2014(pre-outsourcing), 2015 and 2016(post-outsourcing). ANOVA, Tukey Honest Significant Difference(HSD) and Pearson's correlation used. Total of 726 primary arthroplasties were performed with an almost 50 % reduction post outsourcing. Post-outsourcing, BMI and ASA were significantly worse with a ANOVA of p=0.001 and HSD p=0.003. Length of stay increased from 5.4 days in 2014 to 6.2 days in 2015 ANOVA p< 0.001 but decreased in 2016. BMI significantly affected operating time (Pearson's r =0.12, p< 0.05) and anaesthetic time (Pearson's r =0.19, p< 0.05). ASA significantly affected length of hospital stay, p< 0.01 and operation time, p=0.007 but no effect on anaesthetic time. In conclusion, we are operating on more complex patients due to current outsourcing setup. Implications for short-term were on anaesthetic and operation time, inpatient stay and training opportunity were affected, with possible long-term implications on individual surgeon and unit outcomes (complications, patient satisfaction)

Introduction: Following the successful introduction of a short stay programme for total hip replacements for selected cases in our unit, the effect of utilising an “Outreach Team” for all of our primary joint arthroplasties has been assessed. This team comprises a senior orthopaedic sister and a physiotherapy assistant. Their ethos is to provide continuity of care from the ward into the community, thereby allowing early, supported hospital discharge. We compared length of stay in a case-matched series of patients before and after the introduction of the service. Patient satisfaction was assessed and cost-benefit analysis carried out. Methods: 200 patients were enrolled on the Outreach Programme following primary joint arthroplasty. Results were compared with 200 case-matched primary arthroplasties prior to the introduction of the team. Discharge was only allowed when patients, carers and staff were happy. Patient satisfaction was assessed via questionnaires. Results: Following a cost-benefit analysis, we calculate a saving of approximately £235,000 annually, with 936 bed days saved. 99% of patients satisfied with Outreach. There were no readmissions from the Outreach group. Discussion: The use of an Outreach Team can be used to significantly reduce the length of hospital stay after primary joint arthroplasty. We feel that the use of the same carers on the ward and in the community gives a seamless transition of care, allowing patients to feel secure and confident about their early discharge with high levels of satisfaction. This simple service is highly efficient and cost-effective and we recommend our model to other units

Arthroplasty in patients who are intravenous drug abusers presents a complex challenge, frequently requiring intervention at a younger age. The cohort suffer increased complication rates due to significant co-morbidities and poor engagement in medical services, in comparison to other patients undergoing lower limb arthroplasty. Multiple small studies show arthroplasty in this patient cohort is associated with high complication and mortality rates.

A search of electronic databases were undertaken with the assistance of the library services from the Rotherham NHS Foundation Trust, including Chocraine, SCOPUS and PubMed.

Abstracts were reviewed and relevant studies extracted for full review. Full text articles were reviewed based on strict inclusion and exclusion criteria.

Searches identified Two thousand and forty-four papers; twenty-seven studies were identified for full review of the paper based on the inclusion criteria above. From this, nine studies were deemed appropriate to for data extraction.

These nine papers present one hundred and thirty-two cases of lower limb arthroplasty, fifty nine Total Knee Arthroplasty and seventy three Total Hip Arthroplasty. From this the authors examined incidences of implant failure due to infection, revision, mortality, dislocation, aseptic loosening, peri-prosthetic fracture, or other causes. Of these, 58% of patients (n = 77) with a history of intravenous drug abuse suffered some form of significant complication; 4% of this cohort (n = 5) were lost to follow up. Infection was reported in 32% of cases and a mortality rate of 4.7%.

The rising demand of lower limb arthroplasty for intra-venous drug abusers presents a very real problem for the modern Orthopaedic surgeon. Within the studies examined, more than half report implant failure. This study synthesises the available literature regarding treatment of these patients to help facilitate decision making and informed consent.

In response to the recent publication in April 2007 of NICE guidelines on venous thromboembolism, we report our practice and experience of VTE in adult hip and knee arthroplasty. It is generally agreed that the 2 major complications of VTE are sudden death as a result of pulmonary embolism and post thrombotic syndrome. NICE guidelines make 2 assumptions:. That chemical and mechanical prophylaxis can reduce these complications. That Orthopaedic surgery, in particular elective Primary Joint Replacements are particularly high risk procedures with respect to these 2 complications. We have studied a large cohort of patients who had Aspirin only as chemical prophylaxis to determine the incidence of clinical thromboembolism before and after discharge and the mortality from PE at 90 days. We performed a prospective analysis of consecutive patients undergoing primary total knee and hip replacement from November 2002 to November 2007. In total 2050 patients had total knee replacement and 2203 patients had total hip replacement. All patients were treated at one specialist centre under the care of one surgeon. Data was complete and accurate for all patients at 90 days post-operatively. Standard practice was the use of 150mg Aspirin from Day 1 post-operatively for a total of six weeks combined with spinal anaesthesia and early mobilisation. The overall rate for Fatal Pulmonary embolism 0.07% (3/4253), overall death rate 0.3%(13/4253), for treated non-fatal PE 0.66% (28/4253) and for treated above knee DVT was 0.33%(14/4253). Our data suggests that fatal pulmonary embolism is not common and does not account for most deaths following total hip and knee arthroplasty. We suggest there is no evidence that chemical/mechanical prophylaxis reduces the risk of sudden death from PE following elective primary joint replacement and with modern surgical practice elective hip and knee replacement should no longer be considered high risk procedures

In response to the recent publication in April 2007 of NICE guidelines on venous thromboembolism, we report our practice and experience of VTE in adult hip and knee arthroplasty. It is generally agreed that the 2 major complications of VTE are sudden death as a result of pulmonary embolism and post thrombotic syndrome. NICE guidelines make 2 assumptions:. That chemical and mechanical prophylaxis can reduce these complications. That Orthopaedic surgery, in particular elective Primary Joint Replacements are particularly high risk procedures with respect to these 2 complications. We have studied a large cohort of patients who had Aspirin only as chemical prophylaxis to determine the incidence of clinical thromboembolism before and after discharge and the mortality from PE at 90 days. We performed a retrospective analysis of consecutive patients undergoing primary total knee and hip replacement from November 2002 to November 2007. In total 2050 patients had total knee replacement and 2203 patients had total hip replacement. All patients were treated at one specialist centre under the care of one surgeon. Data was complete and accurate for all patients at 90 days post-operatively. Standard practice was the use of 150mg Aspirin from Day 1 post-operatively for a total of six weeks combined with spinal anaesthesia and early mobilisation. The overall rate for Fatal Pulmonary embolism 0.07% (3/4253), overall death rate 0.31%(13/4253), for treated non-fatal PE 0.66% (28/4253) and for treated above knee DVT was 0.33%(14/4253). Our data suggests that fatal pulmonary embolism is not common and does not account for most deaths following total hip and knee arthroplasty. We suggest there is no evidence that chemical/mechanical prophylaxis reduces the risk of sudden death from PE following elective primary joint replacement and with modern surgical practice elective hip and knee replacement should no longer be considered high risk procedures

Following the recent publication in April 2007 of NICE guidelines on venous thromboembolism, we report our practice and experience of VTE in adult hip and knee arthroplasty. It is generally agreed that the 2 major complications of VTE are sudden death as a result of pulmonary embolism and post thrombotic syndrome. NICE guide-lines make 2 assumptions:. That chemical and mechanical prophylaxis can reduce these complications. That Orthopaedic surgery, in particular elective Primary Joint Replacements are particularly high risk procedures with respect to these 2 complications. Methods and Results: We have studied a large cohort of patients who had Aspirin only as chemical prophylaxis to determine the incidence of clinical thromboembolism before and after discharge and the mortality from PE at 90 days. We performed a retrospective analysis of consecutive patients undergoing primary total knee and hip replacement from November 2002 to November 2007. In total 2050 patients had total knee replacement and 2203 patients had total hip replacement. All patients were treated at one specialist centre under the care of one surgeon. Data was complete and accurate for all patients at 90 days post-operatively. Standard practice was the use of 150mg Aspirin from Day 1 post-operatively for a total of six weeks combined with spinal anaesthesia and early mobilisation. The overall rate for Fatal Pulmonary embolism 0.07% (3/4253), overall death rate 0.31%(13/4253), for treated non-fatal PE 0.66% (28/4253) and for treated above knee DVT was 0.33%(14/4253). Conclusion: Our data suggests that fatal pulmonary embolism is not common and does not account for most deaths following total hip and knee arthroplasty. We suggest there is no evidence that chemical/mechanical prophylaxis reduces the risk of sudden death from PE following elective primary joint replacement and with modern surgical practice elective hip and knee replacement should no longer be considered high risk procedures

Purpose: The purpose of this study was to establish patient mortality following salvage treatment (debridement, retention of prosthesis and antibiotic therapy) for infection of primary joint replacement, performed at the unit. Method: A series of 89 patients underwent salvage treatment for infected primary total joint replacement (47 hips and 42 knees) between 1998 and 2003. The average age of the patients was 70.3 years (range 31.8 to 89.1). A survival analysis was performed using death as the sole endpoint and there were no patients lost to follow-up. Results: There were a total of 26 deaths with a mean time to death of 3.3 years (range 0.8 to 7.2). The 7-year cumulative patient survival of was 66% (CI 5, number at risk 21). Conclusions: The morbidity associated with infected total arthroplasty has been well documented. This study highlights that patients undergoing salvage treatment for this condition have significant mortality, with up to a third of patients potentially dying by 7 years

The majority of orthopaedic surgeons routinely review their patients after six weeks, following surgery. During the first six weeks, orthopaedic surgeons are blissfully unaware of how frequently their patients seek medical attention related to problems with their arthroplasty. During this period of time, General Practitioners play a vital role in the care of the post-operative arthroplasty patient. The aim of this study was to determine how frequently patients seek medical attention following primary joint replacement in this interim six-week period. 102 patients from a single practice who had undergone a primary hip or knee replacement from 2003 to 2011 were included and the notes of all these patients were analysed retrospectively. Within this group there were 33 men and 69 women. 45 (44.1%) patients sought medical attention during the 6-week period, which accounted for 69 GP led interventions. The maximum number of interventions was four and a minimum of zero. Of these, 45 patients (29.4%) were seen once, 9 (8.8%) were seen twice, 3 (2.9%) were seen three times and 3 (2.9%) were seen four times. The interventions were for the following reasons: 1(0.9%) for post operative anaemia, 5 (4.9%) for constipation, (1.9%) for post operative nausea, 8 (7.8%) for leg pain (1 scanned for DVT), 5 (4.9%) for leg swelling (2 scanned for DVT), 12 (11.7%) were administered antibiotics, of which 1 was for a chest infection (1 scanned for DVT), 7(6.8%) for a wound review (1 scanned for DVT) (2 patients were started on antibiotic) and 19.6% (20) patients were seen for post operative analgesia. In total, there were 5 (4.9%) patients scanned for DVT and all scans were negative. GPs play a vital, often underestimated role in the post operative care of primary arthroplasty patients. The majority of interventions were required simply because of inadequate post-operative analgesia being given to patients upon discharge. This is an issue that the orthopaedic department can address, which will improve patient care and ease the burden on primary care. Patients still continue to see their GPs for suspected wound infections despite being instructed to contact the hospital. This issue needs to be addressed with further education, as any infection, even superficial, can have devastating consequences if it spreads to the prosthesis

Aim

The aim of the present work was (i) to survey the situation of healthcare regarding the use of antibiotics in orthopaedics and trauma surgery in Germany, (ii) to determine which empiric antibiotic regimens are preferred in the treatment of periprosthethic joint infections (PJI) and (iii) to evaluate the hypothetical antibiotic adequacy of the applied empirical antibiotic therapy regimens based on a patient collective of a German university hospital.

Urinary retention following total hip and knee arthroplasty is a common problem frequently requiring catheterisation in the immediate post-operative period. The direct relationship between urinary tract instrumentation and deep sepsis in total hip replacements is well documented. Method: This prospective study analysed 164 male patients who underwent primary arthroplasty between September 2004 and March 2005 inclusive. Patients who had previous urological intervention for obstructive symptoms were excluded from the study. Upon admission and prior to surgery, all patients answered an 8-point urinary symptom questionnaire and were tested on their ability to micturate while supine. Result: 34 patients required urinary catheterisation – 130 did not. The average age of the catheterised group was 69.5+/−10.7 years (range 45–90) and the non catheterised group was 65.2+/−10.5 years (range 33–85). There was no difference between these groups (p=0.134, ANOVA). Similarly, there was not difference (p=0.919, ANOVA) between the blood loss in the 2 groups, 880.6+/−455.5 mls and 895+/−533.7 mls respectively. With regards to the symptom questionnaire, the average score in the catheter group was 3.1+/−2.4 and the non-catheter group was 2.0+/−1.8 (p=0.034, ANOVA). The ability to micturate in a supine position was of no predictive value with 22 patients in the catheter group able to do so. Conclusion: These results show the value of a urinary symptom questionnaire used pre-operatively in predicting those who may require post-operative urinary catheterisation. By appropriate use of this tool, patients with potential for post-operative retention may be identified before surgery. Consequently, this group should be catheterised pre-operatively thus reducing their risk of infection

Introduction

Hip and knee device sales representatives (reps) can provide intra-operative guidance through their knowledge of the products, especially in complicated cases such as revision hip and knee arthroplasty. However, for an experienced arthroplasty surgeon in the majority of straightforward primary cases, the rep's presence may not be required for clinical decision-makings. With recent challenges in cost savings and bundle payments, hospitals and surgeons have focused on reducing the implant costs, among others, with a “repless” model. The aim of this study was to describe the process of utilizing this model, assess its efficacy, and analyze the cost savings in primary hip arthroplasty.

Total elbow arthroplasty (TEA), as a primary procedure and open reduction and internal fixation (ORIF) have been used to treat complex intra-articular distal humeral fractures in elderly patients. The failure rate after ORIF is high and TEA has often been used as a salvage procedure. Although satisfactory results have been reported after TEA as a primary procedure, there are no publications reporting the results of TEA after failed internal fixation (FIF). In this study we compared the results of patients that had TEA after FIF with those that had had primary arthroplasty (PA). We reviewed the results of 9 consecutive patients who had FIF with 12 patients who had PA. All the operations were performed by one surgeon using the same technique and same prosthesis. Both groups of patients were similar with respect to ages, sex, co-morbidity and hand dominance. The mean follow-up for both groups of patients was 5 years. At final review, patients who had had FIF had a mean Mayo score of 68 and a range of flexion/extension of 90 degrees, there was 1 infection and 1 case of loosening. The PA group had a mean Mayo score of 88 and a range of flexion/extension of 96 degrees, there were no cases of infection or loosening. This study shows the results of TEA are satisfactory either as a PA or after FIF, however the results after PA are significantly better than after FIF

Aim

Prosthetic Joint Infection (PJI) remains one of the leading cause for revision arthroplasty.^1,2 Early recognition and appropriate initial treatment of early PJI with debridement, antibiotics and implant retention (DAIR) can eradicate infection on first attempt and prevent implant failure. We evaluated the outcome after one year of patients who were treated for an early PJI after primary total knee arthroplasty (TKA) or total hip arthroplasty (THA) with DAIR. Furthermore, we determined preoperative infection markers, microbiology, and treatment factors related to treatment failure after DAIR procedure.

Background

While many studies have investigated long-term outcomes after lower limb arthroplasty, rather less is known about the trajectory of short-term outcomes in the first post-operative year. It is difficult for a surgeon to know when, in terms of disease severity, it is best to operate, or to make an accurate prediction of the patient pattern of post-operative recovery. We explored the trajectory of change in pain and function following primary hip and knee arthroplasty and the influence of pre-operative self-reported symptoms on post-operative improvements.

Purpose: The purpose of this work was to study the radiological outcome more than seven years after implantation of 89 anatomic non-cemented femoral stems with hydroxyapatite coating around the metaphyseal circumference. Material: These 81 patients underwent primary arthroplasty (89 hips) between 1991 and 1994 for joint degeneration or necrosis: 48 men and 33 women, mean age 59 years (range 41–78). The inclusion criteria for this study were physical examination and complete radiographic work-up in the second half of 2001. Mean follow-up was nine years (range 7–10). Methods: All x-rays were analysed by four independent surgeons who used the Engh and Massin criteria. The evaluators, who had not participated in patient care, made their assessment on the basis of the last follow-up clinical report and x-rays. They search for radiographic evidence of stem stability and bony integration as well as signs of osteolysis using the Gruen criteria. Results: At last follow-up only one femoral stem was painful, but stable. This stem was revised at seven years. Six cups had been changed due to polyethylene wear with iliac osteolysis but without femoral participation. There were no other reoperations. Polyethylene wear was observed in about one-half the hips (44 hips) and was considered severe (1–2 mm) in nine cases. There were no lucent lines nor reactive lines in the metaphyseal area (zones 1 and 7) but 16% of the hips presented reactive lines along the lower, smooth, part of the stem. Endosteal ossification was observed in zones 2 and 6 in 72% of the hips, and less often (13%) in zones 9 and 13. Five hips (5.6%) exhibited bony growth at the tip of the stem producing a thickening in zone 5; these were the only cases with cortical thickening excepting the revised stem (thickening in zones 2 and 6). There was no case of cortical narrowing. Calcar atrophy was observed in 42 hips (47%) with five showing a “drop” aspect. Four hips exhibited osteolysis of the proximal femur in zone 1A, but there were no images of distal osteolysis of the femur. Discussion: This independent analysis of 89 x-ray files demonstrated that endosteal growth is frequent in the isthmic region. The radiological tolerance was good for this stem (no cortical changes) but there were modifications of the calcar which were difficult; it could be speculated that certain of these modifications might correspond to localised osteolysis at the lowest part of the joint, migration point of polyethyene debris. The role of hydroxyapatite in the observed absence of distal osteolysis is noteworthy. Conclusion: At nine years follow-up, the absence of osteolysis of the distal femur despite usual polyethylene wear allows the conclusion that hydoxyapatite coating of the metaphyseal circumference creates an effective barrier against wear debris

Administration of perioperative antibiotic prophylaxis (AP) reduces the risk of prosthetic joint infection (PJI) following primary total hip (THA) and knee (TKA) arthroplasty. The optimal type of antibiotic used, and duration of prophylaxis are subject to debate. We compared the risk of revision surgery for PJI in the first year following THA and TKA by AP regimen. A national survey collecting information on hospital-level AP regimen policy was conducted across the Netherlands and linked to data from the LROI arthroplasty registry for 2011–2015. PJI status was defined using the surgical indication reported at revision by surgeons in the registry form. Restricted cubic splines Poisson model adjusted for hospital clustering were used to conduct the comparisons on 130,712 THAs and 111,467 TKAs performed across 99 institutions. These included 399 THAs and 303 TKAs revised for an indication of PJI. Multiple shot of Cefazolin (MCZ), of cefuroxime (MCX) and single shot of Cefazolin (SCZ) were respectively administrated to 87%, 4% and 9% of patients. For THA, the rates of revision for PJI were respectively 31/10,000 person-years 95%CI[28, 35], 39[25, 59] and 23[15, 34] in the groups which received MCZ, MCX and SCZ; respectively, the rates for TKA were 27[24, 31], 40[24, 62] and 24[16, 36]. No evidence of difference between AP regimens was found in the unadjusted and adjusted model (age, gender, BMI and ASA grade). Further work is advocated to confirm whether there is an association between AP regimen collected at patient-level and the risk of subsequent revision for PJI.

Purpose: Multiple studies have demonstrated the efficacy of Tranexamic Acid (TA) in reducing blood loss and red blood cell transfusion in patients undergoing primary total hip (THA) or knee (TKA) arthroplasty. However, the dosing schedules of either an initial bolus followed by a 6–12 hour infusion or multiple intravenous bolus doses are not ‘user-friendly’ for regular application. The purpose of this study was to assess the efficacy and acceptance of a single dose protocol for the use of TA in primary THA or TKA.

Method: We selected a single dosing schedule of 20mg/kg TA given either prior to skin incision for THA or approximately ten minutes prior to tourniquet release for TKA. The hospital pharmacy supplied the TA rounded off to the nearest 5kg/100mg in a 100ml mini-bag. In March 2008, we introduced the routine use of TA to all patients undergoing primary THA or TKA at our institution. Mini-bags were pre-ordered at the time of the preoperative clinic visit and delivered to the pre-surgical preparation area on day of surgery. One month after implementation of this protocol we compared blood loss, transfusion rates, and hemoglobin at discharge between the patients operated on from April 1 to June 30, 2007 (when this protocol was not in place) to those from April 1 to June 30, 2008. No other routine patient care practices were altered during this time period.

Results: We found a significant reduction in the decrease in hemoglobin from 2007 compared to 2008 for both THA and TKA (46g/L to 39g/L, and 45g/L to 36g/L, respectively), which led to both a reduction in transfusion rates (13.5% to 3.6%, and 13.1% to 2.0%, respectively) and higher hemoglobin levels at discharge. All patients received the TA as ordered.

Conclusion: Dosing and timing of TA is critical to maximize its antifibrinolytic effect. Our weight increment dose protocol led to minimal dose variability, facilitated pharmacy drug preparation, and minimized wastage. This simple ‘user-friendly’ protocol was found to reduce the decrease in hemoglobin and transfusion rates, demonstrating similar efficacy to other more complex dosing schedules. This protocol was well received and accepted by surgeons, anesthesiologists, pharmacy, and nursing staff.