Aims

The ulna is an extremely rare location for primary bone tumours of the elbow in paediatrics. Although several reconstruction options are available, the optimal reconstruction method is still unknown due to the rarity of proximal ulna tumours. In this study, we report the outcomes of osteoarticular ulna allograft for the reconstruction of proximal ulna tumours.

Aims. Pneumatic tourniquets are often used during the surgical treatment of unstable traumatic ankle fractures. The aim of this study was to assess the risk of reoperation after open reduction and internal fixation of ankle fractures with and without the use of pneumatic tourniquets. Methods. This was a population-based cohort study using data from the Danish Fracture Database with a follow-up period of 24 months. Data were linked to the Danish National Patient Registry to ensure complete information regarding reoperations due to complications, which were divided into major and minor. The relative risk of reoperations for the tourniquet group compared with the non-tourniquet group was estimated using Cox proportional hazards modelling. Results. A total of 4,050 ankle fractures treated with open reduction and internal fixation between 15 March 2012 and 31 December 2016 were included, with 669 (16.5%) undergoing surgery with a tourniquet and 3,381 (83.5%) without a tourniquet. The overall reoperation risk was 28.2% with an adjusted relative risk of 1.46 (95% CI 0.91 to 2.32) for group comparison. The reoperation risk due to major complications was 3.1% with a tourniquet and 4.4% without a tourniquet, resulting in an adjusted relative risk of 1.45 (95% CI 0.91 to 2.32). For minor complications, there were 24.7% and 23.9% reoperations, resulting in an adjusted relative risk of 0.99 (95% CI 0.84 to 1.17). Conclusion. We found no significant difference in the reoperation rate when comparing ankle fractures treated surgically with and without the use of pneumatic tourniquets. Cite this article: Bone Joint J 2024;106-B(9):994–999

Aims

The mean age of patients undergoing total knee arthroplasty (TKA) has reduced with time. Younger patients have increased expectations following TKA. Aseptic loosening of the tibial component is the most common cause of failure of TKA in the UK. Interest in cementless TKA has re-emerged due to its encouraging results in the younger patient population. We review a large series of tantalum trabecular metal cementless implants in patients who are at the highest risk of revision surgery.

Aims

The aim of this study was to determine the prevalence and impact of tourniquet use in patients undergoing limb salvage surgery with endoprosthetic reconstruction for a tumour around the knee.

Aims

Although absorbable sutures for the repair of acute Achilles tendon rupture (ATR) have been attracting attention, the rationale for their use remains insufficient. This study prospectively compared the outcomes of absorbable and nonabsorbable sutures for the repair of acute ATR.

Aims

This study aims to report the outcomes in the treatment of unstable proximal third scaphoid nonunions with arthroscopic curettage, non-vascularized bone grafting, and percutaneous fixation.

Aims

In the UK, the NHS generates an estimated 25 megatonnes of carbon dioxide equivalents (4% to 5% of the nation’s total carbon emissions) and produces over 500,000 tonnes of waste annually. There is limited evidence demonstrating the principles of sustainability and its benefits within orthopaedic surgery. The primary aim of this study was to analyze the environmental impact of orthopaedic surgery and the environmentally sustainable initiatives undertaken to address this. The secondary aim of this study was to describe the barriers to making sustainable changes within orthopaedic surgery.

Aims

Recent improvements in surgical technique and perioperative blood management after total joint replacement (TJR) have decreased rates of transfusion. However, as many surgeons transition to outpatient TJR, obtaining routine postoperative blood tests becomes more challenging. Therefore, we sought to determine if a preoperative outpatient assessment tool that stratifies patients based on numerous medical comorbidities could predict who required postoperative haemoglobin (Hb) measurement.

Aims

We hypothesized that there is no difference in the clinical and radiological outcomes using local bone graft versus iliac graft for subtalar distraction arthrodesis in patients with calcaneal malunion. In addition, using local bone graft negates the donor site morbidity.

Aims

The crucial role of the radial head in the stability of the elbow in terrible triad injury is acknowledged. This retrospective study aims to compare the results of resection of a severely comminuted radial head with or without prosthetic arthroplasty as part of the reconstruction for this injury.

Aims

The objective of this study was to compare early postoperative functional outcomes and time to hospital discharge between conventional jig-based total knee arthroplasty (TKA) and robotic-arm assisted TKA.

Aims

The purpose of this study was to compare the clinical and radiographic outcomes of total ankle arthroplasty (TAA) in patients with pre-operatively moderate and severe arthritic varus ankles to those achieved for patients with neutral ankles.

Background. There are multiple documented advantages of undertaking total knee arthroplasty (TKA) without tourniquet, however, increased rates of blood loss and transfusion are often cited as contraindications to this approach. The aim of this study was to examine the effect of intra-operative TA administration on blood loss and transfusion rates in TKA without pneumatic tourniquet, using Rivaroxaban as thrombo-embolic prophylaxis. Method. 120 patients split into two continuous data sets, (A+B), underwent TKA without application of above knee tourniquet, receiving a post operative dose of oral Rivaroxaban within 8 hours. Group B patients received an intra-operative dose of 1 gram of Tranexamic Acid intravenously before the first cut, whilst those in group A did not. Haemoglobin and haematocrit levels were recorded peri-operatively. A revised Gross formula was used to calculate blood loss. Four patients were excluded from the study for incomplete data. Results. 58 patients (M34F24) in Group A, average age 6, had a mean haemoglobin drop of 33gram/litre, haematocrit drop of 0.097litre/litre (9.7%), with an average calculated blood loss of 1393ml. 58 (M34, F24) patients in group B, average age 67, had a haemoglobin drop of 25.2gram/litre, haemotocrit drop of 0.076litre/litre (7.6%) with an average calculated blood loss of1079ml. Thus Group A patients were seen to sustain significantly more blood loss without TA administration, with a 29.1% larger calculated blood loss, a 25.5% larger drop in haemoglobin and a 27.6% larger fall in haematocrit. Transfusion rate was 5.2% (3 patients) per group. Conclusion. TA was shown to be effective in reducing blood loss in TKA without tourniquet using Rivaroxaban. Transfusion rates of 5.2% across both groups is close to 1/10th of the transfusion rate reported for some major studies of TKA using Rivaroxaban with tourniquet application, and 1/8th of the transfusion rate in studies of TKA with administration of TA and use of tourniquet. Level of Evidence. Level-III. The authors report there are no relevant disclosures to make. Ethical approval was granted for the study

For as long as surgeons have been performing total and partial knee arthroplasty, surgeons have debated the efficacy, safety, and requirement of a pneumatic tourniquet. Advocates claim that blood loss is less, visualization is improved, and the cement technique is better with the use of a tourniquet. Others would argue that the use of the tourniquet or limited tourniquet use is safer, does not increase blood loss, and does not compromise visualization and cementing technique. Multiple meta-analyses have been performed that provide very little true evidence of superiority. One such study from Yi et al, concludes that the use of the tourniquet reduces surgical time, intraoperative and total blood loss, but increases postoperative total blood loss. They also conclude that DVT and SSI are “relatively augmented” with use. There may be issues with the timing of tourniquet release in these pooled studies, with others stating that releasing the tourniquet prior to wound closure, supposedly for hemostasis, significantly increases the total and calculated blood loss. Huang et al report that with proper control in the amount of pressure, a debatable topic in and of itself, and shorter duration of inflation, release after closure can reduce blood loss without increased complications. One additional issue is patellar tracking, and the need to lateral release. The tourniquet significantly affects assessment of tracking and the need for lateral release, potentially causing the surgeon to unnecessarily perform a lateral release with the tourniquet inflated. Lastly, research has suggested that using a tourniquet may affect recovery of lower extremity strength and function. Dennis et al compared quadriceps strength and found that use of the tourniquet resulted in “slightly” lower strength postoperatively out to 3 months. The fatal flaw in this study and others is that there is no accepted minimal clinically important difference for quad function, and thus they powered their study to detect a difference of 12 Nm, and the actual difference, while statistically significant, did not even meet their arbitrary power set point. Thus, while strength may be slightly impaired by the use of a tourniquet, it was not different enough to meet their criteria. Additionally, in their study, 64% of the “no-tourniquet” knees actually had a tourniquet used for cementation to “minimise blood at the bone-cement interface and maximise fixation”. Clearly, even these authors are concerned with the results of not using a tourniquet. These authors utilise a pneumatic tourniquet in all cases of primary TKA and release the tourniquet prior to closure to ensure hemostasis and accurately assess patellar tracking. In doing so, we use the methodology of limb occlusion pressure to minimise the pressure to that necessary for ensuring a clear field. Additionally, these authors emphasise the ultimate in surgical efficiency allowing for extremely short tourniquet times, even in the most difficult cases. As an example, in 1300 consecutive obese patients with BMI equal or greater than 35, the average tourniquet time for primary TKA was 49 minutes. These short times, with the minimum pressure allow for the best of both worlds and little to no downside

Objectives

Nylon sutures and skin staples are used commonly in total knee arthroplasty (TKA) surgical wound closure. However, there is no study that compares the wound healing efficacy and patient satisfaction scores of both techniques in the same knee.

Total knee arthroplasty (TKA) is one of the most successful surgeries to relieve pain and dysfunction caused by severe arthritis of the knee. Despite developments in prophylactic methods, deep venous thrombosis (DVT) and pulmonary embolism (PE) continue to be a serious complication following TKA. Otherwise DVT/PE is known to be a relatively low incidence in Asian patients, its accurate incidence is still controversial. Therefore, we prospectively investigated the incidence of DVT/PE after primary TKA by contrast enhanced computed tomography (CE-CT) and venous ultrasonography (US) in Japanese Patients. Methods. We prospectively investigated 51 patients who underwent primary TKA at the hospital from July 2013 to December 2013. All were of Japanese ethnicity. The mean age at the surgery was 74.9 years and average BMI was 26.0. There were 45 (88.2%) cases of osteoarthritis and 5 (9.8%) of rheumatoid arthritis. A single knee surgery team performed all operations with cemented type prostheses by utilizing pneumatic tourniquet. There were 21 cases of one-staged bilateral TKA and 30 of unilateral TKA. All patients were applied intermittent pneumatic compression (IPC) until 24 hours and graduated compression stockings for 3[高木1] weeks after the operation. Beginning from the day after the surgery, the patients were allowed walking with walker, along with the gradual range of motion exercise for physical thromboprophylaxis. Low-dose unfractionated heparin (LDUH) as a chemical thromboprophylaxis was administered subcutaneously for 3 days after the surgery. Informed consent was obtained regarding this thromboprophylaxis protocol. CE-CT and venous US were performed at the 4th day after surgery and images were read by a single senior radiologist team. The patients without DVT/PE by examination, they did not take additional chemical thromboprophylaxis. In cases of existence of DVT, continuous heparin administration and oral warfarin were applied and adjusted in appropriate dose for treatment. Warfarin was continued to be applied for at least three months until the patients had no symptoms and normal D-dimer level. In cases of PE, additional ultrasonic echocardiography (UCG) was performed, and then we consulted cardiologist to treat for PE. Results. CE-CT was performed in 42 patients (82.3%), otherwise nine patients (17.7%) could not take the examination because of exclusion criteria. There was no side-effect regard to contrast medium. The incidence of DVT and/or PE was 32 patients (62.7%), including two PE (3.9%), 21 DVT (41.1%) and nine both PE and DVT (17.6%). Six-teen patients were used LDUH routinely for 3 days after surgery. Five patients were used continuous heparin administration and oral warfarin instead of using LDUH because of medical co-morbidities. Additional continuous heparin administration and oral warfarin after LDUH use was needed in 26 patients. Three patients who had duodenal ulcer with chronic pancreatitis, massive PE with right heart strain and multiple DVT/PE with HIT antibody were needed another treatment. Conclusion. We prospectively investigated 51 patients for DVT/PE after primary TKA using CE-CT and venous US. The incidence of DVT/PE after primary TKA was 62.7%, including 21.5% of PE, as high frequency in Japanese patients

There is conflicting evidence about the benefit of using corticosteroid in periarticular injections for pain relief after total knee arthroplasty (TKA). We carried out a double-blinded, randomised controlled trial to assess the efficacy of using corticosteroid in a periarticular injection to control pain after TKA.

A total of 77 patients, 67 women and ten men, with a mean age of 74 years (47 to 88) who were about to undergo unilateral TKA were randomly assigned to have a periarticular injection with or without corticosteroid. The primary outcome was post-operative pain at rest during the first 24 hours after surgery, measured every two hours using a visual analogue pain scale score. The cumulative pain score was quantified using the area under the curve.

The corticosteroid group had a significantly lower cumulative pain score than the no-corticosteroid group during the first 24 hours after surgery (mean area under the curve 139, 0 to 560, and 264, 0 to 1460; p = 0.024). The rate of complications, including surgical site infection, was not significantly different between the two groups up to one year post-operatively.

The addition of corticosteroid to the periarticular injection significantly decreased early post-operative pain. Further studies are needed to confirm the safety of corticosteroid in periarticular injection.

Take home message: The use of corticosteroid in periarticular injection offered better pain relief during the initial 24 hours after TKA.

Cite this article: Bone Joint J 2016;98-B:194–200.

Introduction. Total knee arthroplasty [TKA] is a common procedure to relieve painful disability from advanced knee arthritis. However, related blood loss, ranging from 800 to 1200 ml, increase risk and disruption of recovery in anemic patients following TKA. Various methods for blood conservation had been proposed and examined. In the literature, the intra-articular administration of a solution mixing bupivacaine and epinephrine was commonly used after knee surgeries. Therefore, we conducted a retrospective, case controlled review of our primary TKAs to determine the hemostatic efficacy of this regimen following TKAs. Material and Methods. Over a period of 12 months, 135 eligible patients were divided two groups simply according to the intra-articular injection or not: a control group (N=63) and a treatment group (N=72). In the treatment group, a 40 ml vial of 0.5% bupivacaine with epinephrine 1: 200000 was given prior to the deflation of pneumatic tourniquet. No drainage was used in all TKAs. Without recordable drainage, a Gross formula, considering gender and body composition, was used for estimate blood loss following TKAs. In addition, serial changes in hemoglobin as well as the requirement of allogenic transfusion were also compared between groups. Results. The mean calculated blood loss in the treatment group was 650.4 +/− 257.1 ml, compared to 648.8+/− 222.1 ml in the control group (p=0.9). Similar decrease in hemoglobin as well as rates of allogenic transfusion needs were observed between groups.[2.5+/− 0.9 g/dl vs. 2.4+/− 0.8 g/dl; 13.9% vs. 12.7%, respectively]. Discussion and Conclusion. Although local analgesics mixing vasoconstrictive agents seem a logic solution to save blood loss and relieve pain simultaneously, the hypothesis that intra-articular injection of bupivacaine and epinephrine would save blood and even transfusion needs following TKAs is not supported by various bleeding parameters in this study. In addition to temporary benefit in pain relief, this regimen only has little effect on blood conservation. Therefore, new regimen as well as hemostatic means are still required and explored to reduce blood loss following TKAs

We examined the outcomes and levels of patient satisfaction in 202 consecutive cases of ultrasound-guided supraclavicular brachial plexus block (SBPB) in upper limb surgery performed between September 2007 and March 2010.

All blocks were performed by orthopaedic surgeons using ultrasound visualisation with a high-frequency linear probe. The probe was placed in the coronal–oblique plane in the supraclavicular fossa, and the puncture was ‘in-plane’ from lateral to medial. Most of the blocks were performed with 0.75% ropivacaine/1% lidocaine (1:1), with or without adrenaline in 1:200 000 dilution. In 201 patients (99.5%) the brachial plexus block permitted surgery without conversion to general anaesthesia. The mean procedure time for block was 3.9 min (2 to 12), the mean waiting time for surgery was 34.1 min (10 to 64), the mean surgical time was 75.2 min (6 to 232), and the mean duration of post-anaesthetic analgesia was 437 min (171 to 992). A total of 20 patients (10%) developed a transient Horner’s syndrome. No nerve injury, pneumothorax, arterial puncture or systemic anaesthetic toxicity were recorded. Most patients (96.7%) were satisfied with ultrasound-guided SBPB. This study demonstrates the efficacy and safety of ultrasound-guided SBPB for orthopaedic surgery on the upper limb.

Cite this article: Bone Joint J 2014;96-B:795–9.