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

Aims. We studied the safety and efficacy of multimodal thromboprophylaxis in patients with a history of venous thromboembolism (VTE) who undergo total hip arthroplasty (THA) within the first 120 postoperative days, and the mortality during the first year. Multimodal prophylaxis includes discontinuation of procoagulant medications, VTE risk stratification, regional anaesthesia, an intravenous bolus of unfractionated heparin prior to femoral preparation, rapid mobilization, the use of pneumatic compression devices, and chemoprophylaxis tailored to the patient’s risk of VTE. Methods. Between 2004 to 2018, 257 patients with a proven history of VTE underwent 277 primary elective THA procedures by two surgeons at a single institution. The patients had a history of deep vein thrombosis (DVT) (186, 67%), pulmonary embolism (PE) (43, 15.5%), or both (48, 17.5%). Chemoprophylaxis included aspirin (38 patients), anticoagulation (215 patients), or a combination of aspirin and anticoagulation (24 patients). A total of 50 patients (18%) had a vena cava filter in situ at the time of surgery. Patients were followed for 120 days to record complications, and for one year to record mortality. Results. Postoperative VTE was diagnosed in seven patients (2.5%): DVT in five, and PE with and without DVT in one patient each. After hospitalization, three patients required readmiss-ion for evacuation of a haematoma, one for wound drainage, and one for monitoring of an elevated international normalized ratio (INR). Seven patients died (2.5%). One patient died five months postoperatively of a PE during open thrombectomy. She had discontinued anticoagulation. One patient died of a haemorrhagic stroke while receiving Coumadin. PE or bleeding was not suspected in the remaining five fatalities. Conclusion. Multimodal prophylaxis is safe and effective in patients with a history of VTE. Postoperative anticoagulation should be prudent as very few patients developed VTE (2.5%) or died of suspected or confirmed PE. Mortality during the first year was mostly unrelated to either VTE or bleeding. Cite this article: Bone Joint J 2020;102-B(7 Supple B):71–77

Introduction. We studied the safety and efficacy of multimodal thromboprophylaxis (MMP) in patients with a history of venous thromboembolism (VTE) undergoing total hip arthroplasty (THA). MMP includes discontinuation of procoagulant medications, VTE risk stratification, regional anesthesia, an intravenous bolus of unfractionated heparin before femoral work, rapid mobilization, the use of pneumatic compression devices, and chemoprophylaxis tailored to the patient's risk. Material and methods. From 2004 to 2018, 257 patients (mean age: 67 years; range: 26–95) with a history of VTE underwent 277 primary, elective THAs procedures (128 right, 100 left, 9 single-stage bilateral, 20 staged bilateral) by two orthopaedic surgeons at a single institution. The patients had a history deep vein thrombosis (DVT) 186 (67%), pulmonary embolism (PE) 43 (15.5%), or both 48 (17.5%). Chemoprophylaxis included aspirin (38 patients) and anticoagulation (239 patients; Coumadin: 182, low-molecular-weight heparin: 3, clopidogrel: 1, rivaroxaban: 3, and a combination: 50). Forty eight patients (17.3%) had a vena cava filter at the time of surgery. Patients were followed for 120 days to detect complications, and for a year to detect mortality. Results. Postoperative VTE was diagnosed in seven patients (2.5%): DVT in five, and PE with and without DVT in one patient each. Bleeding complications occurred in 2 patients, one requiring surgical evacuation of a hematoma. Seven patients died during the first year (2.5%). One patient died 5 months postoperatively of a fatal PE during open thrombectomy, and one patient died of a hemorrhagic stroke while receiving Coumadin. PE or bleeding was not suspected in any of the remaining 5 fatalities. Conclusions. The result of this study spanning over 13 years, suggests that MMP is safe and effective. Postoperative anticoagulation should be prudent as very few patients developed postoperative VTE (2.5%) or died of suspected or confirmed PE. Mortality during the first year was mostly unrelated to VTE or bleeding. For any tables or figures, please contact the authors directly

Aims. Tranexamic acid (TXA) has been shown to significantly reduce transfusion rates in primary total hip arthroplasties (THAs), but high-quality evidence is limited in the revision setting. The purpose of the current study was to compare the rate of blood transfusions and symptomatic venous thromboembolic events (VTEs) in a large cohort of revision THAs treated with or without intravenous (IV) TXA. Patients and Methods. We performed a retrospective review of 3264 revision THAs (2645 patients) between 2005 and 2014, of which 1142 procedures received IV TXA (1 g at incision and 1 g at closure). The mean age in the revision group with TXA was 65 years (28 to 95), with 579 female patients (51%). The mean age in the revision group treated without TXA was 67 years (21 to 98), with 1160 female patients (55%). Outcomes analyzed included rates of transfusion and symptomatic VTEs between procedures undertaken with and without TXA. These comparisons were performed for the overall cohort, as well as within cases subcategorized for aseptic or septic aetiologies. A propensity score was developed to minimize bias between groups and utilized age at revision THA, sex, body mass index, American Society of Anesthesiologists (ASA) score, preoperative anticoagulation, and year of surgery. Results. Tranexamic acid significantly and substantially reduced the rate of blood transfusions after revision THA overall from 54% to 26% (p < 0.001; adjusted relative risk (RR) 1.6; 95% confidence interval (CI) 1.3 to 1.9), with a significant reduction in both aseptic (49% to 18%; p < 0.001) and septic (73% to 53%; p = 0.04) revisions. The rate of VTE was minimal overall, with three events (0.3%) in the TXA group and four events (0.2%) in the non-TXA group. There were no significant differences in VTE rates based on TXA use or aetiology of revision. Conclusion. Intravenous TXA significantly reduced transfusion rates during all-cause revision THAs, including a subgroup analysis of both aseptic and septic cohorts. Adjusted risk using propensity modelling showed no statistical difference in rates of VTEs between either group. Cite this article: Bone Joint J 2019;100-B(6 Supple B):104–109

Introduction. Early surgery for hip fractures is beneficial but is often delayed by anticoagulation. Direct acting anticoagulants (DOAC), Rivaroxaban and Apixiban, are increasingly used in primary and secondary care but there is no specific reversal agent. Current guidance is to delay surgery 48 hours. Anti-factorXa levels < 80 ug/l are considered safe for major surgery and for spinal anaesthesia. We investigated if delay in this cohort of patients can be predicted or reduced. Patients/Materials & Methods. 41 consecutive patients presenting with a hip fracture on therapeutic dose DOAC were identified. Anti- factorXa levels were collected at 24hours and repeated at 48hours if elevated. We investigated if renal function or clotting screen could help predict safe time to surgery. Results. 36/41 had levels taken at 24 hours. Of these 21 (58%) had levels of 80 ug/l of less (<30 – 80). The remaining 15 (42%) had elevated levels at 24hours (85–224). One patient had levels greater than 80 ug/l at 48 hours. Clearance rate did not differ between Rivaroxaban and Apixiban. There was no significant difference in the prothrombin time (PT) between groups. Mean PT was 12.1 (10.6 – 15.1) for patients with levels <80ug/l and 13.4 ug/l (11.9– 15.6) for those patients with levels >80ug/l. Renal function affected drug clearance with a mean eGFR of 61 ml/min/1.73m2 (31–>90) in those with levels <80ug/l compared to 51 ml/min/1.73m2 (29–86) in those with levels >80ug/l. Discussion. Drug clearance of DOACS is un-predictable and standard clotting screens cannot be used for assessment. Approximately 40% will still have high levels at 24 hours. Patients with renal impairment are more likely to possess high levels at 24 hours. Operating based on time from last dose could be associated with a bleeding risk or conversely delay surgery inappropriately. Conclusion. The measurement of Anti- factorXa levels could enable safe early surgery in the majority of patients

We report a retrospective review of the incidence of venous thromboembolism in 463 consecutive patients who underwent primary total hip arthroplasty (487 procedures). Treatment included both total hip replacement and hip resurfacing, and the patients were managed without anticoagulants. The thromboprophylaxis regimen included an antiplatelet agent, generally aspirin, hypotensive epidural anaesthesia, elastic compression stockings and early mobilisation. In 258 of these procedures (244 patients) performed in 2005 (cohort A) mechanical compression devices were not used, whereas in 229 (219 patients) performed during 2006 (cohort B) bilateral intermittent pneumatic calf compression was used. All operations were performed through a posterior mini-incision approach. Patients who required anticoagulation for pre-existing medical problems and those undergoing revision arthroplasty were excluded. Doppler ultrasonographic screening for deep-vein thrombosis was performed in all patients between the fourth and sixth post-operative days. All patients were reviewed at a follow-up clinic six to ten weeks after the operation. In addition, reponse to a questionnaire was obtained at the end of 12 weeks post-operatively. No symptomatic calf or above-knee deep-vein thrombosis or pulmonary embolism occurred. In 25 patients in cohort A (10.2%) and in ten patients in cohort B (4.6%) asymptomatic calf deep-vein thromboses were detected ultrasonographically. This difference was statistically significant (p = 0.03). The regimen followed by cohort B offers the prospect of a low incidence of venous thromboembolism without subjecting patients to the higher risk of bleeding associated with anticoagulant use

Introduction. Tranexamic acid (TXA) has been shown to significantly reduce transfusion rates in primary total hip arthroplasties (THAs), but data is limited in the revision setting. The purpose of the current study was to compare the rate of blood transfusions and symptomatic venous thromboembolic events (VTEs) in a large cohort of revision THAs treated with or without IV TXA. Methods. We performed a retrospective review of 3,264 revision THAs (2,645 patients) between 2005–2014, of which 1,142 patients received IV TXA (1g at incision and 1g at closure). The mean age was 65 years with 49% males in the revision group with TXA, and 67 years with 45% males in the revision group treated without TXA. Outcomes analyzed included rates of transfusion and VTE (within 90 days) between cases treated with TXA and cases not treated with TXA. These comparisons were performed for the overall cohort, as well as within the subset of aseptic cases and septic cases. In order to minimize potential bias between these two subgroups, the analyses were weighted with inverse probability of treatment weights based on a propensity score which included age at revision THA, sex, BMI, ASA score, preoperative anticoagulation, and year of surgery. Mean follow-up was 2 years. Results. Tranexamic acid significantly reduced the rate of blood transfusions after revision THA overall from 54% to 26% (p<0.001; unadjusted RR 2.1, adjusted RR 1.6), with a significant reduction in both septic (73% to 53%, p = 0.04) and aseptic (49% to 18%, p<0.001) revisions. The rate of VTE was minimal overall, with 3 events (0.3%) in the group with TXA and 4 events (0.2%) in the group without TXA. Similarly, there were no significant differences in VTE rates in those who did or did not receive IV TXA based upon the procedures being septic or aseptic in nature. Conclusions. Intravenous TXA significantly reduced transfusion rates during all-cause revision THAs, including a subgroup analysis of both aseptic and septic cohorts. Adjusted risk utilizing inverse probability of treatment weights based on a propensity model showed no statistical difference in rates of VTEs between either group. Summary. The use of IV TXA in revision THAs is associated with a significant reduction in transfusion rates, and a very low rate of VTEs (0.3%)

Aims

The purpose of this study is to report our updated results at a minimum follow-up of 30 years using a first generation uncemented tapered femoral component in primary total hip arthroplasty (THA).

Aims

Our objective was describing an algorithm to identify and prevent vascular injury in patients with intrapelvic components.

Introduction. Several surgical approaches are available for elective total hip arthroplasty (THA) for osteoarthritis. While posterior surgical approaches are the most common, interest in a direct anterior (Hueter) approach is increasing because of alleged advantages in convalescence. However, no studies have examined differences in patient-reported global and condition-specific measures of health across multiple institutions. The ongoing Pulmonary Embolism Prevention after Hip and Knee Replacement (PEPPER) study is a PCORI-funded multicenter pragmatic clinical trial randomizing patients to three different antithrombotic regimens. We analyzed operative data from PEPPER to compare pre-post changes in validated patient-reported outcome measures after THA based on surgical approach. Methods. Participants (age 21 or older) were recruited from 27 academic medical centers for the PEPPER trial. Eligibility screening, baseline measures, and operative detail were entered into a central database with standardized blinded post-operative data collection protocol. We included participants undergoing elective primary total hip arthroplasty, excluding those undergoing revision, resurfacing, bilateral procedures, on chronic preoperative anticoagulation, with a recent history of gastrointestinal, cerebral, or other hemorrhage, defective hemostasis, or uncontrolled hypertension. Participating centers reported the operative approach as “Posterior”, “Transgluteal”, or “Anterior”. The brief version of the Hip Dysfunction and Osteoarthritis Outcome Score (HOOS Jr.) and the Patient Reported Outcome Measurement Information System Global Survey (PROMIS10) were ascertained pre-operatively, and at 1, 3 and 6 months post-operatively. Mixed-effects linear regression was used to compare difference in patient-reported outcomes over time based on surgical approach, adjusting for baseline measures of health outcome, patient age, sex, race, ethnicity, BMI, comorbidity, education, work status, alcohol use, and smoking status. Results. As of 5/15/2018, a total of 1,238 patients had undergone primary THA as part of the PEPPER trial and were being monitored postoperatively, including 51.6% involving posterior, 18.1% transgluteal, and 30.3% anterior surgical approaches. Mean preoperative HOOS Jr. scores for posterior approach (47.6; 95%CI 46.4 – 48.7) were similar to transgluteal (47.4, 95%CI 45.4 – 49.5, p=0.654) and anterior (48.9, 95%CI 47.4 – 50.4, p=0.461) approaches. At 6-month follow-up, adjusted mean HOOS Jr. Scores significantly improved for all groups, but were not statistically different between groups. The adjusted mean HOOS Jr. score at 6 months was 85.6 for those undergoing a posterior (95%CI 83.7 – 87.5), 83.6 for transgluteal (95%CI 79.0 – 88.2, p=.474) and 85.0 for anterior approaches (95%CI 82.6 – 87.5, p=0.255). Baseline PROMIS-10 Physical Function scores were similar between posterior (40.1; 95%CI 40.2 – 41.3), transgluteal (40.6, 95%CI 39.6 – 41.6, p=0.716), and anterior approaches (41.5, 95%CI 40.8 – 42.3, p=0.390), with similar postoperative improvement through 6 months (posterior=52.1, 95%CI 51.2 – 53.0; transgluteal=52.4, 95%CI 50.2 – 54.5, p=0.734; anterior=52.8, 95%CI 51.6 – 53.9, p=0.414). These findings were robust utilizing a variety of methods to account for missing responses. Conclusion. We found similar short-term improvements in patient-reported global measures of health between posterior, transgluteal, and anterior surgical approaches for elective THA, and a trend suggesting inferior early patient-reported measures of function with a trans-gluteal surgical approach

Aims

This study assessed the impact of COVID-19 on hip and distal femur fracture patient outcomes across three successive UK lockdown periods over one year.

Aims

While interdisciplinary protocols and expedited surgical treatment improve the management of hip fractures in the elderly, the impact of such interventions on patients specifically undergoing arthroplasty for a femoral neck fracture is not clear. We sought to evaluate the efficacy of an interdisciplinary protocol for the management of patients with a femoral neck fracture who are treated with an arthroplasty.

Aims

The direct anterior approach (DAA) for total hip arthroplasty (THA) has potential advantages over other approaches and is most commonly performed with the patient in the supine position. We describe a technique for DAA THA with the patient in the lateral decubitus position and report the early clinical and radiological outcomes, the characteristics of the learning curve, and perioperative complications.

Aims

Improvements in functional results and long-term survival are variable following conversion of hip fusion to total hip arthroplasty (THA) and complications are high. The aim of the study was to analyze the clinical and functional results in patients who underwent conversion of hip fusion to THA using a consistent technique and uncemented implants.

Aims

We present the clinical and radiological results at a minimum follow-up of 20 years using a second-generation uncemented total hip arthroplasty (THA). These results are compared to our previously published results using a first-generation hip arthroplasty followed for 20 years.

Aims

The primary aim of this study was to compare the hip-specific functional outcome of robotic assisted total hip arthroplasty (rTHA) with manual total hip arthroplasty (mTHA) in patients with osteoarthritis (OA). Secondary aims were to compare general health improvement, patient satisfaction, and radiological component position and restoration of leg length between rTHA and mTHA.

Objectives

Modern metal-on-metal (MoM) hip resurfacing arthroplasty (HRA), while achieving good results with well-orientated, well-designed components in ideal patients, is contraindicated in women, men with head size under 50 mm, or metal hypersensitivity. These patients currently have no access to the benefits of HRA. Highly crosslinked polyethylene (XLPE) has demonstrated clinical success in total hip arthroplasty (THA) and, when used in HRA, potentially reduces metal ion-related sequelae. We report the early performance of HRA using a direct-to-bone cementless mono-bloc XLPE component coupled with a cobalt-chrome femoral head, in the patient group for whom HRA is currently contraindicated.

Aims

A variety of surgical approaches are used for total hip arthroplasty (THA), all with reported advantages and disadvantages. A number of common complications can occur following THA regardless of the approach used. The purpose of this study was to compare five commonly used surgical approaches with respect to the incidence of surgery-related complications.

Aims

The aims of this study were to review the surgical technique for a combined femoral head reduction osteotomy (FHRO) and periacetabular osteotomy (PAO), and to report the short-term clinical and radiological results of a combined FHRO/PAO for the treatment of selected severe femoral head deformities.

Aims

The aim of this study was to examine the efficacy and safety of multiple boluses of intravenous (IV) tranexamic acid (TXA) on the hidden blood loss (HBL) and inflammatory response following primary total hip arthroplasty (THA).