Aims. The aim of this study is to compare the effectiveness and safety of thromboprophylactic treatments in patients undergoing primary total knee arthroplasty (TKA). Methods. Using nationwide medical registries, we identified patients with a primary TKA performed in Denmark between 1 January 2013 and 31 December 2018 who received thromboprophylactic treatment. We examined the 90-day risk of venous thromboembolism (VTE), major bleeding, and all-cause mortality following surgery. We used a Cox regression model to compute hazard ratios (HRs) with 95% confidence intervals (CIs) for each outcome, pairwise comparing treatment with dalteparin or dabigatran with rivaroxaban as the reference. The HRs were both computed using a multivariable and a propensity score matched analysis. Results. We identified 27,736 primary TKA patients who received thromboprophylactic treatment (rivaroxaban (n = 18,846); dalteparin (n = 5,767); dabigatran (n = 1,443); tinzaparin (n = 1,372); and enoxaparin (n = 308)). In the adjusted multivariable analysis and compared with rivaroxaban, treatment with dalteparin (HR 0.68 (95% CI 0.49 to 0.92)) or dabigatran (HR 0.31 (95% CI 0.13 to 0.70)) was associated with a decreased risk of VTE. No statistically significant differences were observed for major bleeding or all-cause mortality. The propensity score matched analysis yielded similar results. Conclusion. Treatment with dalteparin or dabigatran was associated with a decreased 90-day risk of VTE following primary TKA surgery compared with treatment with rivaroxaban. Cite this article: Bone Joint J 2021;103-B(10):1571–1577

We examined the risk of thrombotic and major bleeding events in patients undergoing total hip and knee replacement (THR and TKR) treated with thromboprophylaxis, using nationwide population-based databases. We identified 83 756 primary procedures performed between 1997 and 2011. The outcomes were symptomatic venous thromboembolism (VTE), myocardial infarction (MI), stroke, death and major bleeding requiring hospitalisation within 90 days of surgery. A total of 1114 (1.3%) and 483 (0.6%) patients experienced VTE and bleeding, respectively. The annual risk of VTE varied between 0.9% and 1.6%, and of bleeding between 0.4% and 0.8%. The risk of VTE and bleeding was unchanged over a 15-year period. A total of 0.7% of patients died within 90 days, with a decrease from 1% in 1997 to 0.6% in 2011 (p < 0.001). A high level of comorbidity and general anaesthesia were strong risk factors for both VTE and bleeding, with no difference between THR and TKR patients. The risk of both MI and stroke was 0.5%, which remained unchanged during the study period. . In this cohort study of patients undergoing THR and TKR patients in routine clinical practice, approximately 3% experienced VTE, MI, stroke or bleeding. These risks did not decline during the 15-year study period, but the risk of dying fell substantially. Cite this article: Bone Joint J 2014;96-B:479–85

Aims. The benefit of MRI in the preoperative assessment of scaphoid proximal fragment vascularity remains controversial. The purpose of this study is to compare preoperative MRI findings to intraoperative bleeding of the proximal scaphoid. Methods. A retrospective review of 102 patients who underwent surgery for scaphoid nonunion between January 2000 and December 2020 at a single institution were identified. Inclusion criteria were: isolated scaphoid nonunion; preoperative MRI assessing the proximal fragment vascularity; and operative details of the vascularity of the proximal fragment with the tourniquet deflated. MRI results and intraoperative findings were dichotomized as either ‘yes’ or ‘no’ for the presence of vascularity. A four-fold contingency table was used to analyze the utility of preoperative MRI with 95% confidence intervals. Relative risk was calculated for subgroups to analyze the association between variables and MRI accuracy. Results. Preoperative MRI identified 55 proximal scaphoid fragments with ischaemia and 47 with vascularized proximal fragments. After the proximal fragment was prepared, the tourniquet was deflated and assessed for bleeding; 63 proximal fragments had no bleeding and 39 demonstrated bleeding. MRI was not reliable or accurate in the assessment of proximal fragment vascularity when compared with intraoperative assessment of bleeding. No patient or MRI factors were identified to have a statistical impact on MRI accuracy. Conclusion. Current preoperative MRI protocols and diagnostic criteria do not provide a high degree of correlation with observed intraoperative assessment of proximal fragment bleeding. While preoperative MRI may assist in surgical planning, intraoperative assessment remains the best means for assessing proximal fragment vascularity in scaphoid nonunion. Future efforts should focus on the development of objective measures of osseous blood flow that may be performed intraoperatively. Cite this article: Bone Joint J 2023;105-B(6):657–662

Background. The incidence of bleeding following primary TKR has increased with the use of chemical thromboprophylaxis. Our aim was to compare Clexane, Apixaban and Rivaroxaban in terms of frequency and volume of bleeding episodes, need for blood transfusion, return to theatre and incidence of VTE events. Methods. Between February and May 2014, a consecutive series of 132 primary TKRs were studied prospectively. The wound dressings of these patients were assessed daily to look for signs of bleeding and classified into: Mild (< 50p size coin), moderate (> 50p size coin) or Severe (blood seeping through the dressing). Follow up was up to minimum of 30 days post discharge. Results. Apixaban, Rivaroxaban & Clexane were used in 64, 23 and 45 patients respectively. Eleven patients had at least 1 day of mild bleeding, 8 had at least 1 day of moderate bleeding and 11 had at least 1 day of severe bleeding. Ten patients had 1 or more doses omitted because of bleeding. However, there was no statistical significance in distribution of bleeding episodes or doses omitted due to bleeding amongst the three drugs (chi squared test). There was also no correlation between number of severe bleeding episodes and the need for blood transfusion. There were two VTE events recorded; 1 PE each in the Apixaban and Rivaroxaban groups. Two cases in the Apixaban group and 1 case in the Clexane group returned to theatre for washout of haematoma. Conclusion. There was an 8% incidence of severe bleeding in our study group. The incidence of bleeding problems following TKR was similar in the Apixaban, Rivaroxaban & Clexane groups. Level of evidence. III - Evidence from case, correlation, and comparative studies

Introduction. Deep venous thrombosis (DVT) is a potentially serious complication after total hip (THA) and knee (TKA) arthroplasty, traditionally justifying aggressive prophylaxis with low molecular weight heparin (LMWH) or direct oral anticoagulants (DOA) at the cost of an increased risk of bleeding. However, fast-track procedures might reduce the DVT risk and decrease the cost-benefit ratio of the current recommendations. The objective of this study was to compare thrombotic and bleeding risk in an unselected population of elective THA and TKA with a fast-track procedure. MATERIAL - METHODS. A series of 1,949 patients were analyzed prospectively. There were 1,136 women and 813 men, with a mean age of 70 years. In particular, 16% were previously treated by antiplatelet agents and 8% by anticoagulants. All patients followed a fast-track procedure including early walking within 24 hours of surgery, and 80% of patients returned home after surgery, with a mean length of stay of 3 days (THA) or 4 days (TKA). The occurrence of a thromboembolic event or hemorrhagic complication has been identified. Results. Out of the 1,110 THAs, 5 thromboembolic events were identified (0.4%): 2 non-fatal pulmonary embolism and 3 DVTs. There was no impact of these complications on the final result. 19 hemorrhagic complications were identified (1.7%): 10 significant haematomas (3 of which were complicated by infection), 9 anemias (with 4 transfusions). Out of the 839 TKAs, 9 thromboembolic events were identified (1.0%): 4 non-fatal pulmonary embolism and 5 DVTs. There was no impact of these complications on the final result. 14 hemorrhagic complications were identified (1.7%): 8 haematomas including 4 reoperations, 6 anemias (with 5 transfusions). Discussion. Thromboembolic complications after elective THA and TKA have virtually disappeared, with a rate of 0.7%. On the other hand, bleeding complications are now more frequent, with a rate of 1.7%. This suggests that the cost-benefit ratio of preventive treatments with LMWH or DOA should be reassessed. Prescribing LMWH or DOA after elective THA and TKA with fast-track procedures exposes the patient to a much higher risk of bleeding than thrombotic risk. The use of aspirin may represent an acceptable compromise in these patients

Bleeding from cancellous bone causes lamination within bone cement and at its prosthetic interfaces, and weakens the fixation of joint replacements. We examined the effects of anaesthesia and blood pressure on bleeding in human cancellous bone, and investigated the local response to freezing saline, 1:200,000 adrenaline and hydrogen peroxide. Spinal anaesthesia reduced cancellous bleeding by an average of 44%, local freezing saline by 24%. Saline at room temperature, adrenaline solution and hydrogen peroxide each reduced it by 14%. The effects of spinal anaesthesia and of freezing saline were additive: used together they reduced bleeding by 56%. The reduction of blood contamination of cement and its interfaces should contribute to better prosthetic fixation

Introduction: Substitution treatment and radiosynoviorthesis has a leading role in preventing irreversible hemophilic arthropaties. Aim: The aim of the study is to evaluate the effects of radiosynovectomy on the length of intervals between subsequent bleedings in patients with hemophilic synovitis. Materials and Methods: 33 joints were treated with radiosynovectomy in 28 patients with bleeding disorders. 90Y colloid was used in knees and 186Re colloid for elbow, shoulder and ankle. 20 patients were on prophylaxis. X-rays of treated joints were evaluated on Peterson scale between 0 (normal) and 13 (severe joint destruction). In observation period (range 6 – 44 months) bleeding episodes were recorded and data statistically analyzed. Results: Before RS, the average interval between haemorrhages was 16.4 days. Immediately after RS, the average interval between haemorrhages more than tripled. Namely, the average length of the first non-bleeding interval after RS was almost 60 days. In the period covering the first five bleeding episodes after RS, the average non-bleeding interval increased to 47.1 days. Therapeutic effects of RS considerably depend on location (joint) of bleeding, damage of the joint and of the patient. But controlling for location and damage of the joint and age of the patient, after RS every sub sequent non-bleeding interval was 11% shorter (p=0.05) than previous non-bleeding interval. After more than 10 bleeding episodes had occurred since RS, the non-bleeding intervals were no longer significantly shorter than before RS (at p=0.05). Therapeutic response to RS could be, therefore, observed in the period of more than 430 days after the procedure. Conclusion: Radiosynovectomy significantly reduces hemorrhages in target joints for the average period of 14 months. It is more efficient in patients with less affected joints and less efficient in younger patients. The therapeutic effect of RS diminished with the elapse of time

Preoperative anaemia and intraoperative blood loss result in ∼90% of individuals being anaemic following hip and knee arthroplasty. Reducing blood loss offers the opportunity to improve outcomes and reduce the risk of transfusion and costs. This review's aim was to determine the effectiveness of drugs for preventing blood loss, and identify optimal dose, route, and timing of administration. Cochrane network meta-analysis of randomised controlled trials was conducted. Inclusion criteria: adults undergoing primary or revision elective hip or knee arthroplasty. Drugs studied: tranexamic acid (TXA), aprotinin, epsilon-aminocaproic acid, desmopressin, factor VIIa and XIII, fibrinogen, fibrin sealants, and non-fibrin sealants. Primary outcomes: need for allogenic blood transfusion, all• cause mortality (within 30 days). Secondary outcomes: mean number of transfusion episodes, re-operation, length of hospital stay and adverse events (DVT, PE, CVA, MI). 102 studies with 8418 participants. Trials included more women (63%). 47 studies (4398 participants) were included within the blood transfusion NMA. TXA given intra-articularly and orally at a total dose of greater than 3g pre-incision, intraoperatively and postoperatively ranked the highest, with anticipated absolute effect of 147 fewer transfusions per 1000 (53% chance ranking 1st) (relative risk(RR) 0.02, 95% credible interval(CrI) 0–0.31); moderate-certainty). Aprotinin (RR 0.59, 95%:CrI 0.36–0.86; low certainty evidence), fibrin (RR 0.86, CrI 0.25–2.93; very-low certainty) and EACA (RR 0.60, 95%:CrI 0.29–1.27; very-low certainty) were not shown to be as effective as TXA. TXA was the most effective drug for preventing bleeding in lower limb arthroplasty. Aprotinin and EACA were not as effective. Currently, the optimal dose, route and timing of administration of TXA is unclear. However, TXA given at higher doses and via mixed routes ranked higher in the treatment hierarchy. Oral TXA may be as effective as intavenous. There was no evidence of harm associated with higher doses of TXA

Common reasons for higher-than-average cost for a total hip arthroplasty are prolonged patient hospitalisation, which can be caused by among other factors, bleeding complications. The incidence of perioperative anemia has direct costs (blood transfusions), but also numerous indirect costs such as longer hospital stays, poor performance in physical therapy, and the potential for blood-borne infection. The incidence of pre-operative anemia in patients undergoing total hip arthroplasty has been reported to be as high as 44%, while total peri-operative blood loss for total hip arthroplasty may average between 750 and 1,000 mL. Anemia negatively impacts length of stay, patient function during rehabilitation, and patient mortality. Transfusions carry well known risks, including infection and fatal anaphylaxis, which are important factors considering that the transfusion rate has been reported to be as high as 45% and that transfused patients receive, on average, two units of blood. Methods that have been described in the literature include pre-treatment with erythropoietin, pre-operative hemodilution with intra-operative blood salvage, surgical techniques such as gentle soft tissue handling and meticulous hemostasis, bipolar sealers, intravascular occlusion, hemostatic agents, and early removal of drains. Pharmacologic approaches include treatment with erythropoietin, iron and folate. Randomised trials have demonstrated reduction in the risk for transfusion in patients treated with erythropoietin. Several studies have established a once-weekly dosing schedule of 40,000 international units (300–600 IU/kg) to be effective, and synergism has been observed in patients treated in combination with iron (ferrous sulfate, 325 mg three times a day). Patients with hemoglobin values between 10 and 14 g/dL are most likely to benefit. Intra-operatively, antifibrinolytics such as tranexamic acid (10 mg/kg) given as a single dose pre-operatively has been shown to decrease blood loss and the transfusion rate. Hypotensive anesthesia also effectively decreases blood loss without impairing renal function, but is technically demanding. Post-operatively, re-infusion drains may reduce the need for transfusions in total hip and total knee arthroplasty, but cannot be used in cases of infection or malignancy. By minimising peri-operative bleeding and bleeding complications through pre-operative optimisation, intra-operative surgical techniques that minimise blood loss, and post-operative care, patient disposition can be streamlined and delays for patient discharge can be avoided

Aims: To evaluate the outcome after early angiographic embolization in pelvic ring injuries associated with massive bleeding. Methods: We evaluated prospectively 32 consecutive patients. Special attention was paid to the þndings in angiography, the reliability of embolization, and the þnal result (survive or death). The causes of deaths were evaluated as well as the parameters correlating to this. Results: Angiography showed an isolated arterial injury in 16 (50%) and multiple arterial injuries also in 16 patients (50%). 9 patients had bilateral bleeding. Internal iliac artery and/or its main branches was the source of bleeding in 27 (85%), external iliac artery or its main branches in 2 (6%), and branches of both internal and external iliac arteries in 3 patients (9%). The embolization was successful in all cases. 11 patients (34%) died. The early deaths (< 24h) were the result of massive bleeding in 4 out of 5 patients. One died to cardiac failure. Six late deaths were the result of MODS. All the died patients had more than one bleeding artery, and 6 had bilateral bleeding. The non-survivors had more severe injuries (mean ISS 51) and were older (mean age 50,2 yrs) than the survivors (mean ISS 41; mean age 43,9 yrs). Conclusions: Angiographic embolization is an effective and life saving procedure. It should be considered in hypotensive patients with unstable pelvic ring injuries who remain haemodynamically unstable following adequate resuscitation with component therapy and external þxation

Shoulder Arthroscopy techniques may pose surgical risk to vascular structures that may cause active bleeding during surgery. The vascularity of the subacromial structures showed constant patterns of distribution and specific sources of bleeding were analyzed. Knowledge of the vascular anatomy may decrease the bleeding during subacromial arthroscopy surgery. Shoulder Arthroscopy techniques may pose surgical risk to vascular structures that may cause active bleeding during surgery. A detailed anatomy map of frequent sources of bleeding is more than desired in order to properly identify these bleeding points, and avoid the unnecessary overuse of thermal tools and pressure pumps to control the hemorrhage. Our purpose is to study the vascular anatomy of the subacromial space, and to map the major sources of expected bleeding during subacromial arthroscopy surgery. Ten shoulders of five adult cadavers underwent whole body arterial perfusion with a mixture of lead oxide, gelatin and water. The shoulders were dissected, photographed, tissue specimens were radio graphed, scanned and analyzed with a digital software analyzer. Careful dissection of the different arteries of the subacromial bursa, and anatomic landmarks of the walls were documented. Correlations of bleeding areas during subacromial arthroscopic surgery and cadaver dissection were carried out. A vascular map of the bursa was created. The vascularity of the subacromial structures showed constant patterns of distribution and specific sources of bleeding were analyzed. We divided this space into walls with their major arteries as follows: Anterior wall: Acromial branch of the thoracoacromial artery. Posterior wall: Acromial branch of the suprascapular artery. Medial wall: Anterior and posterior Arteries of the AC joint. Lateral wall: No major arteries identified. Vascularity of the roof and floor is also described. The subacromial space is highly vascular. Knowledge of the vascular anatomy may decrease the bleeding during subacromial arthroscopy surgery

Introduction: Though underutilized, there are currently several pharmacological options available for the prevention of venous thromboembolism (VTE) following major orthopedic surgery. The use of different agents depends on the orthopedic surgeon’s perception of the benefit in prevention of thrombosis versus the risk of bleeding, as well as the bleeding origin (surgical or not). Here we report the results of an international survey assessing the orthopedic surgeon’s perception of the importance of different types of bleeding and how these relate to the bleeding endpoints used in clinical trials. Methods: Orthopedic surgeons from Germany, Spain, France, USA, and the UK were invited to participate in this survey. Each responder was asked 13 questions. The answers provided by the first 100 responders from each country were used in subsequent analyses. Once 100 surveys had been completed in each country, no further data were collected. Only in France, the physicians invited to participate also included anesthetists, therefore data from this country were obtained from 50 orthopedic surgeons and 50 anesthetists. In all other countries the physicians invited were exclusively orthopaedic surgeons. Results: In total, 5303 physicians from across Germany, Spain, France, USA, and the UK were invited to participate in the survey. Of these, 789 responded to the invitation. Surgical site bleedings were a great concern in 50–71% of surgeons across participating countries whereas a lower proportion of surgeons appeared to be concerned regarding extra surgical bleeding (2–11%). Importantly, up to 79% and 71% of surgeons across participating countries considered an increase in surgical site bleeding to be very likely associated with a longer hospital stay and delay or difficulty in postoperative rehabilitation, respectively. When asked to decide between anticoagulant A with reduced bleeding risk (versus current agents with similar efficacy) and a second agent (anticoagulant B), which was associated with increased prophylactic efficacy (versus current agents with similar bleeding rate), 52–67% of responders reported that they would select anticoagulant A. Conclusions: Our survey suggests that surgical site bleedings are of major concern among surgeons across different countries. Up to approximately 80% of surgeons consider that an increase in surgical site bleedings has an impact on patients’ duration of hospitalization and rehabilitation process. Reduced risk for bleeding may be considered a more important factor compared with an increase in efficacy among orthopedic surgeons, when determining the choice of anticoagulant prophylaxis

We report the results of simple laboratory experiments which showed that bleeding pressures known to occur at the bone surface during total hip arthroplasty may compromise the integrity of the bone-cement interface and the cement itself. Such undesirable effects can be prevented by maintaining adequate pressure on the cement until its increased viscosity can resist displacement caused by the bleeding pressure

Aims. This phase II safety study aimed to investigate the bleeding side effect profile in patients treated with Rivaroxaban as a new agent for venous thromboembolism (VTE) prophylaxis following hip or knee arthroplasty. Methods. A retrospective study of complications was conducted in 88 consecutive patients undergoing hip and knee arthroplasty at one centre. Patients received chemical and/or mechanical VTE prophylaxis according to local guidelines. Data was collected from notes and evaluated using Fisher's exact test and t-Test. Significance was determined if p< =0.05. The primary end-point was local wound site oozing or bleeding. Secondary end-points were drop in haemoglobin, drain output and infection. Results. 55 patients were treated with Rivaroxaban, 18 with mechanical prophylaxis only, 10 with Enoxaparin and 5 with aspirin, clopidogrel or warfarin. The Rivaroxaban cohort demonstrated a statistically significant amount of increased major bleeding (24% vs. 0% p=0.03) and wound oozing (27% vs. 0% p=0.02) when compared to patients treated with Enoxaparin. Compared to those treated with other methods of VTE prophylaxis, Rivaroxaban also significantly increased major bleeding (24% vs. 6% p=0.01) and wound oozing (27% vs. 12% p=0.03). The Rivaroxaban cohort demonstrated a significantly larger drop in haemoglobin compared to the combined non-Rivaroxaban group (3.0 vs. 2.4 g/dL p=0.04). There was no significant difference in drain volume or rate of infection between groups. Conclusions. Rivaroxaban appears to cause increased wound site bleeding in comparison to Enoxaparin and other methods of thromboembolism prophylaxis. Further use of Rivaroxaban at this centre was therefore discontinued; however, the small group sizes and retrospective non-randomised design of this study introduce bias and limit the reliability of its findings. Prospective randomised controlled trial focused on wound complications is required to eliminate selection and reporter biases

Introduction: The standard length of hospital stay after total hip arthroplasty (THA) can be as short as 4 days. However, the risk of venous thromboembolism (VTE) extends beyond this period of hospitalization. A pooled analysis of the RECORD1 and RECORD2 studies evaluated the efficacy, safety, and timing of events with rivaroxaban compared with enoxaparin for the prevention of VTE after THA. Methods: Patients (N=7,050) were randomized to receive oral rivaroxaban 10 mg once daily starting postoperatively (for 31–39 days) or subcutaneous enoxaparin 40 mg once daily starting preoperatively (for 31–39 days in RECORD1, and 10–14 days followed by placebo in RECORD2). The primary efficacy endpoint was the composite of symptomatic VTE and all-cause mortality. The safety endpoints were treatment-emergent major bleeding, major bleeding including surgical-site bleeding, major bleeding plus clinically relevant non-major (CRNM) bleeding, and any bleeding. The primary efficacy endpoint was assessed during treatment. The incidence and timing of the safety endpoints were assessed after the first dose of study medication and up to 2 days after the last dose. Results: Rivaroxaban significantly reduced the incidence of symptomatic VTE and all-cause mortality compared with enoxaparin regimens (0.44% vs 1.01%, respectively; p=0.006), with no significant differences in major bleeding (0.2% vs 0.09%; p=0.219) or the composite of major plus CRNM bleeding (3.23% vs 2.61%; p=0.141). Of the symptomatic VTE and all-cause mortality events, 73% and 86% occurred after day 4 with the rivaroxaban and enoxaparin regimens, respectively. For the composite of major plus CRNM bleeding, 48% and 33% of events occurred after day 4 with the rivaroxaban and enoxaparin regimens, respectively. Conclusion: Rivaroxaban significantly reduced symptomatic VTE and all-cause mortality after THA compared with the enoxaparin regimens, with no significant difference in bleeding events. Major plus CRNM bleeding was more likely to occur earlier than day 4, whereas the majority of symptomatic venous thromboembolic events occurred after day 4. These results highlight the relevance of extended duration of thromboprophylaxis after THA as most VTE events occur post-discharge

Bleeding is a major complication of revision total hip replacement. We report a case where the inflated balloon of a urinary catheter was used to temporarily control intrapelvic bleeding from the superior gluteal artery, while definitive measures for endovascular embolisation were made

Introduction: The risk of venous thromboembolism (VTE) remains a major concern beyond the standard period of hospitalization of about 4 days after total knee arthroplasty (TKA). A pooled analysis of the RECORD3 and RECORD4 studies evaluated the efficacy, safety, and timing of events with rivaroxaban compared with enoxaparin for the prevention of VTE after TKA. Methods: Patients (N=5,679) were randomized to receive oral rivaroxaban 10 mg once daily starting postoperatively or subcutaneous enoxaparin 40 mg once daily starting preoperatively (European Union regimen; RECORD3) or enoxaparin 30 mg every 12 hours starting postoperatively (North American regimen; RECORD4) for 10–14 days. The primary efficacy endpoint was the composite of symptomatic VTE and all-cause mortality, and this was analyzed over the treatment period. The safety endpoints were treatment-emergent major bleeding, major bleeding including surgical-site bleeding, major bleeding plus clinically relevant non-major (CRNM) bleeding, and any bleeding. The incidence and timing of the safety endpoints were assessed after the first dose of study medication and up to 2 days after the last dose. Results: Rivaroxaban significantly reduced symptomatic VTE and all-cause mortality compared with enoxaparin regimens (0.73% vs 1.71%, respectively; p=0.001) with no significant differences in major bleeding (0.62% vs 0.36%, p=0.185) or composite of major plus CRNM bleeding (3.13% vs 2.48%, p=0.145). The majority of venous thromboembolic events occurred after day 4 for both regimens (rivaroxaban: 70%; enoxaparin: 68%). For the composite of major plus CRNM bleeding events, 44% occurred after day 4 with rivaroxaban regimens and 38% occurred after day 4 with enoxaparin regimens. Conclusion: Rivaroxaban significantly reduced symptomatic VTE and all-cause mortality compared with enoxaparin regimens after TKA, with no significant difference in bleeding events between regimens. Major plus CRNM bleeding was more likely to occur before day 4, whereas the majority of symptomatic venous thromboembolic events occurred after day 4. These results highlight the importance of continuing thromboprophylaxis beyond the normal time of hospital discharge for TKA

Introduction A complex challenge to trauma surgeon is the choice of clinical pathway management in hemodynamic unstable patients with pelvic ring disruption and potential intraperitoneal or other extrapelvic hemorrhage. Aim of the study In multi-trauma bleeding patients with pelvic ring injuries causing increased pelvic volume, the main source of hemorrhage is the fracture itself; in biomechanical stable the priority is to search and to treat extrapelvic sources of hemorrhage; CESCT is critical in the selection of appriopriate therapeutic approach in the case of bleeding pelvic injury. Material and Methods Patients admitted as major trauma are immediately evaluated by a multidisciplinary team in a dedicated room where ABC resuscitation, plain radiographs, abdominal ultrasound/DPL may be all performed. The comprehensive Tile pelvic disruption classification combines the mechanism of injury and the degree of pelvic stability. Previous works correlated pelvic fracture pattern with the risk of pelvic fracture hemorrhage. Classically, APC and VS mechanisms were associated with pelvic hemorrhage and LC mechanims with abdominal organ injuries. In this work we included in group A patterns of pelvic fracture where increased pelvic volume and major ligamentous disruption (Tile B1, B3 and C or APC and VS), Patterns of pelvic fractures with low risk of bleeding, such as those without ligament lacerations (Tile A) or with reduced pelvic volume (Tile B2 or LC) or isolated acetabular fractures, have been included in group B. Results Between October 2002 and January 2004, significant bleeding was observed in 87 of 142 pelvic fractures (61.26%). Thirty-seven of 87 (42.5%) had a pelvic fracture pattern attributable to group A and 50 to group B. All patients included had multiple sites of bleeding, but predominant hemorrhage from pelvic fracture was observed in 87% of group A patients and in only 6% of group B, while predominant hemorrhage from extra-pelvic sites was identified in 94% of group B and in only 13% of group A (p< .001). Conclusion Pattern of pelvic seems to be suggestive of the predominant site of bleeding; early application of measures of temporary pelvic stabilization should be considered a completion of resuscitation protocol; CESCT is the best diagnostic tool to choice the appropriate way to manage bleeding pelvic injuries and associated intraperitoneal injuries; availability of equipped CT scan and angiographic suitesand of short response time interventional radiologist is a crucial point for this diagnostic and therapeutic work-up

Material and methods: Two series of 35 total hip arthroplasties (THA) implanted by the same surgeon using the posterior approach were compared. The first group underwent surgery in 1999 and the second in 2001. Ligation of the posterior medial circumflex artery was systematically performed in the second group. The same prosthesis was used in all cases: an omnicase stem and a Schuster (Centerpulse) or polyethylene cup. The series included cemented (n=37) and non-cemented (n=32) prostheses with one hybrid implant. We analysed retrospectively, intra- and postoperative bleeding, haematocrit before and just after surgery, and the number of packed red cell units transfused during and after surgery in order to determine the degree of intra- and postoperative bleeding. Statistical tests were applied. Technique: Via the posterior approach, before sectioning the pelvitrochanteric muscles, the upper third of the fibres of the quadratus femoris muscle were dissociated. The artery runs upwardly and anterior toward the posterior border of the greater trochanter and is difficult to identify in the fatty tissue. Ligation is performed at this level with the satellite veins. Ligation decreases bleeding when the pelvitrochanteric muscles and the capsule are sectioned. Likewise, section of the femoral neck appears to be less haemorrhagic as is the preparation of the proximal greater trochanter. Results: Intra- and postoperative bleed, expressed in ml, was significantly decreased by ligation of the posterior circumflex artery and its two satellite veins. Mean intraoperative bleeding was decreased by more than half. Six of the 35 patients who did not have ligation lost more than 600 cc blood during the operation. This degree of bleeding was not observed in the ligation group. The postoperative haematocrit was significantly higher in the ligation group and the difference in pre- and postoperative haematocrit was decreased 7-fold. Postoperative transfusion became exceptional. Finally, it is interesting to note that among the variables studied, mode of implant fixation did not affect blood loss. Discussion: The conventional technique without ligation of the posterior circumflex artery does not always lead to significant bleeding. It is quite possible to perform such procedures with less than 200 cc blood loss. Use of posterior circumflex artery ligation leads to much more regular control of intraoperative bleeding, making autologous blood collection and postoperative transfusions unnecessary. The ligation is a simple procedure. Electric coagulation is generally insufficient for the calibre of these vessels and veins are not always accessible to effective coagulation. Intraoperative bleeding due to section of the circumflex artery is underevaluated due to the tension created by the forced internal rotation. Haemostasis after section is difficult due to retraction of the proximal segment under the muscles

The clinical features, management and outcome of bleeding into the muscles of the upper limb of 44 patients are reported. Of 158 episodes of bleeding, 99% were treated within two hours of onset of symptoms and the mean time to complete restoration of function was 2.1 days. The most frequent site of bleeding was the deltoid muscle (24%), followed by the forearm flexors (23.5%), brachioradialis (19.5%), biceps (14%), forearm extensors (11%) and triceps (8%). The majority of bleeds presented with pain, either on movement or at rest, or with tenderness. Bleeds into the biceps required the most transfusions (mean 2.00) and took the longest to resolve (mean 4 days). Bleeding into the flexors and extensors of the forearm resolved most rapidly. The policy of early treatment has been shown to be effective in prompting early and complete recovery