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

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

There is currently limited information available on the benefits and risks of extended thromboprophylaxis after hip fracture surgery. SAVE-HIP3 was a randomised, double-blind study conducted to evaluate the efficacy and safety of extended thromboprophylaxis with the ultra-low molecular-weight heparin semuloparin compared with placebo in patients undergoing hip fracture surgery. After a seven- to ten-day open-label run-in phase with semuloparin (20 mg once daily subcutaneously, initiated post-operatively), patients were randomised to once-daily semuloparin (20 mg subcutaneously) or placebo for 19 to 23 additional days. The primary efficacy endpoint was a composite of any venous thromboembolism (VTE; any deep-vein thrombosis and non-fatal pulmonary embolism) or all-cause death until day 24 of the double-blind period. Safety parameters included major and clinically relevant non-major bleeding, laboratory data, and treatment-emergent adverse events (TEAEs). Extended thromboprophylaxis with semuloparin demonstrated a relative risk reduction of 79% in the rate of any VTE or all-cause death compared with placebo (3.9% vs 18.6%, respectively; odds ratio 0.18 (95% confidence interval 0.07 to 0.45), p < 0.001). Two patients in the semuloparin group and none in the placebo group experienced clinically relevant bleeding. TEAE rates were similar in both groups. In conclusion, the SAVE-HIP3 study results demonstrate that patients undergoing hip fracture surgery benefit from extended thromboprophylaxis. Cite this article: Bone Joint J 2013;95-B:459–66

Aims. In order to release the contracture band completely without damaging normal tissues (such as the sciatic nerve) in the surgical treatment of gluteal muscle contracture (GMC), we tried to display the relationship between normal tissue and contracture bands by magnetic resonance neurography (MRN) images, and to predesign a minimally invasive surgery based on the MRN images in advance. Methods. A total of 30 patients (60 hips) were included in this study. MRN scans of the pelvis were performed before surgery. The contracture band shape and external rotation angle (ERA) of the proximal femur were also analyzed. Then, the minimally invasive GMC releasing surgery was performed based on the images and measurements, and during the operation, incision lengths, surgery duration, intraoperative bleeding, and complications were recorded; the time of the first postoperative off-bed activity was also recorded. Furthermore, the patients’ clinical functions were evaluated by means of Hip Outcome Score (HOS) and Ye et al’s objective assessments, respectively. Results. The contracture bands exhibited three typical types of shape – feather-like, striped, and mixed shapes – in MR images. Guided by MRN images, we designed minimally invasive approaches directed to each hip. These approaches resulted in a shortened incision length in each hip (0.3 cm (SD 0.1)), shorter surgery duration (25.3 minutes (SD 5.8)), less intraoperative bleeding (8.0 ml (SD 3.6)), and shorter time between the end of the operation and the patient’s first off-bed activity (17.2 hours (SD 2.0)) in each patient. Meanwhile, no serious postoperative complications occurred in all patients. The mean HOS-Sports subscale of patients increased from 71.0 (SD 5.3) to 94.83 (SD 4.24) at six months postoperatively (p < 0.001). The follow-up outcomes from all patients were “good” and “excellent”, based on objective assessments. Conclusion. Preoperative MRN analysis can be used to facilitate the determination of the relationship between contracture band and normal tissues. The minimally invasive surgical design via MRN can avoid nerve damage and improve the release effect. Cite this article: Bone Jt Open 2024;5(9):776–784

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

Venous thromboembolism (VTE) is a preventable cause of morbidity and mortality in patients undergoing elective hip arthroplasty surgery. The balance of post-operative VTE prophylaxis and risk of post-operative haemorrhage remains at the forefront of surgeon's mind. The National Institute for Clinical Excellence (NICE) has altered their prophylaxis guidance in the setting of total hip arthroplasty (THA). The aim of this study was to present the VTE incidence in 8,890 patients who underwent total hip arthroplasty between January 1997 and March 2018 with Aspirin as the primary agent for pharmacological thromboprophylaxis. Analysis of prospective data collection from consecutive patients undergoing THA was performed with the incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE) occurring within 6 months of the index operation as the primary outcome measure. 90-day all-cause mortality of this cohort of patients was also analysed. 8890 patients were reviewed. This included 7235 primary, 224 complex primary and 1431 revision cases. The incidence of DVT was 0.64% after elective THA and the incidence of PE was 0.54%. There was no difference in the incidence between primary and revision cases. The 90-day all-cause mortality was 0.88%. Cardiovascular and respiratory disease were the main causes of death following surgery. Only 0.03% of deaths (n= 3) within 90 days of index surgery were due to VTE. Our results support the use of aspirin as an effective form of prophylaxis against VTE following THA. It is not associated with an increased incidence in symptomatic DVT, PE or death compared to other published studies. The fact that it is inexpensive, readily available, requires no monitoring and does not pose an increased risk of bleeding are other attractive advantages of using aspirin for VTE prophylaxis

Hip arthroscopy (HA) is an effective treatment for various hip conditions but has a steep learning curve and its effect on long-term joint preservation is unclear. This study uses population-level data to assess (1) the 90-day complication rate, and (2) the frequency and timing of revision HA, total hip replacement (THR), and pelvic osteotomy (PO) following primary HA. We performed a retrospective analysis of the National Hospital Episode Statistics database, examining all patients who underwent primary HA in NHS hospitals in England from 2010 to 2023 using relevant OPCS-4 codes. We evaluated patient demographics, 90-day complications, and reoperation rates for revision HA, THR, and PO. Descriptive statistical analyses were performed to calculate frequencies and average time to reoperations. We included 22,401 HA procedures in the study. The mean LOS was 0.82±2.04 days. The 90-day readmission rate was 0.17% at a mean of 54.4±8.1 days. The most common reasons for readmission were reoperation (0.071%), followed by infection (0.031%), pulmonary embolism (0.027%), pain (0.022%), bleeding (0.018%), and deep vein thrombosis (0.004%). One patient died within 90 days. Overall, 4942 patients (22.1%) required further surgery at a mean of 2.71±2.27 years. The rates of revision HA, conversion to THR, and PO were 6.94%, 14.6%, and 0.50% at a mean of 2.39±1.79, 2.87±2.46, and 2.26±1.80 years respectively. Female patients had higher rates of reoperation than males for conversion to THR (9.99% vs 4.63%), revision HA (4.92% vs 2.02%), and subsequent PO (0.43% vs. 0.06%) (p<0.001). This study demonstrates a low short-term complication rate after primary HA, supporting existing literature. However, a large proportion of patients required further surgery, especially females. These findings highlight the need for careful patient selection and counselling before HA to optimise outcomes, as well as further research on factors influencing longer-term outcomes and cost-effectiveness

Debate continues about the best treatment for patients over 65 years with non-displaced subcapital hip fractures: internal fixation (IF) or hemiarthroplasty (HA). Surgical aggression, mortality, complications and recovery of walking ability after 1year have been compared between both treatments. Match-paired comparison of 2 retrospective cohorts. 220 patients with IF vs 220 receiving a cemented bipolar HA. Matching by age (82.6±7.16 years (65–99)), sex (74.5% women), year of intervention (2013–2021) and ASA scale (24.2% ASA II, 55.8% III, 20.0% IV). Age (p=0.172), sex (p=0.912), year of intervention (p=0.638) and ASA scale (p=0.726) showed no differences. Surgical aggression smaller in IF: Surgical time (p< 0,00001), haemoglobin/haematocrit loss (p <0,00001), need for transfusion (p<0,00008), in-hospital stay (p<0,00001). Mortality: higher in-hospital for hemiarthroplasties (12 deaths (5.5%) vs 1 (0.5%) (p=0.004) (RR=12, 1.5–91.5)). But no significant differences in 1-month (13 hemiarthroplasties, 6%, vs 9 osteosynthesis, 4.1%) and 1-year mortality (33 hemiarthroplasties, 15%, vs 35, 16%). Medical complications: no differences in urinary/respiratory infections, heart failure, ictus, myocardial infarction, digestive bleeding, pressure sores or pulmonary embolus (p=0.055). Surgical complications: no significant differences. HA: 6 intraoperative (2,7%) and 5 postoperative periprosthetic fractures (2,3%), 5 infections (2,3%), 10 dislocations (4,5%), 3 neurovascular injuries. IF: 10 acute fixation failures (4,5%), 2 infections (0,9%), 9 non-unions (4,1%), 16 ischemic necrosis (7,3%). Functional results: no significant differences; 12 patients in each group (5,5%) never walked again (p=1), 110 HA (50%) and 100 IF (45.5%) suffered worsening of previous walking ability (p=0.575), 98 HA (44%) and 108 IF patients (49%) returned to pre-fracture walking ability (p=0.339). Fixation with cannulated screws may be a better option for non-displaced femoral neck fractures because recovery of walking ability and complications are similar, while surgical aggression and in-hospital mortality are lower

Aims. Cementless primary total hip arthroplasty (THA) is associated with risks of bleeding and thromboembolism. Anticoagulants are effective as venous thromboprophylaxis, but with an increased risk of bleeding. Tranexamic acid (TXA) is an efficient antifibrinolytic agent, but the mode and timing of its administration remain controversial. This study aimed to determine whether two intravenous (IV) TXA regimens (a three-hour two-dose (short-TXA) and 11-hour four-dose (long-TXA)) were more effective than placebo in reducing perioperative real blood loss (RBL, between baseline and day 3 postoperatively) in patients undergoing THA who receive rivaroxaban as thromboprophylaxis. The secondary aim was to assess the non-inferiority of the reduction of blood loss of the short protocol versus the long protocol. Patients and Methods. A multicentre, prospective, randomized, double-blind, placebo-controlled trial was undertaken involving 229 patients undergoing primary cementless THA using a posterior approach, whose extended rivaroxaban thromboprophylaxis started on the day of surgery. There were 98 male and 131 female patients, with a mean age of 65.5 years (32 to 91). The primary outcome, perioperative RBL, was evaluated at 72 hours postoperatively. The efficacy of short- and long-TXA protocols in the reduction of perioperative RBL was compared with a placebo group. Results. TXA significantly reduced perioperative blood loss compared with placebo (p < 0.001); the mean differences were 525.3 ml (short-TXA vs placebo) and 550.1 ml (long-TXA vs placebo). No venous or arterial thromboembolic complications were reported. The upper boundary of the 95% confidence interval, when comparing short and long protocols, was below the pre-specified margin of non-inferiority (p = 0.027). Conclusion. In patients undergoing primary cementless THA, using a posterior approach, who are treated with rivaroxaban for thromboembolic prophylaxis, short- and long-TXA IV protocols are significantly more effective than placebo in reducing perioperative RBL, without any thromboembolic complications. Non-inferiority of a short- versus a long-TXA protocol in reducing perioperative RBL was supported in a secondary analysis

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

Reported incidence of blood transfusion following primary and revision total hip arthroplasty (pTHA, rTHA) has decreased considerably compared to historical rates. However, it is not known if further adoption of techniques to limit transfusions has resulted in further reduction on a large scale. The purpose of this study was to assess recent trends in blood transfusions and contemporary risk factors for transfusions using a large, national database. The American College of Surgeons National Surgical Quality Improvement Program was queried to identify patients undergoing pTHA and rTHA between 2011 to 2019. pTHA for fracture, infection, tumor, and bilateral procedures were excluded. Only aseptic rTHA were included. Annual incidence of transfusions and proportion of patients with optimized preoperative hematocrit (HCT) (defined as ≥33%) were assessed. Risk factors for transfusion were evaluated with 2018 and 2019 data using multivariate analyses. 234,352 pTHA and 16,322 rTHA were included. Transfusion following pTHA decreased from 21.4% in 2011 to 2.5% in 2019 and from 33.5% in 2011 to 12.0% in 2019 for rTHA (p<0.0001). Patients with optimized HCT increased for pTHA (96.7% in 2011 vs 98.1% in 2019, p<0.0001) and did not change for rTHA (91.5% in 2011 vs 91.6% in 2019, p=0.27). Decreased HCT was most strongly associated with transfusions, with each three-point change corresponding to odds ratio of 1.90 and 1.78 for pTHA and rTHA, respectively. Increased age, female sex, history of bleeding disorders or preoperative transfusion, ASA score ≥3, non-spinal anesthesia, and longer operative times were also associated with increased odds for transfusion. Incidence of blood transfusion has continued to decrease following pTHA and rTHA. Despite care improvements, transfusions still occur in certain high-risk patients. While transfusion in pTHA may have reached the lower asymptote, further reduction in rTHA may be possible through further improvements in preoperative optimization and surgical technique

We report the use of porous metal acetabular revision shells in the treatment of contained bone loss. The outcomes of 53 patients with ≤ 50% acetabular bleeding host bone contact were compared with a control group of 49 patients with > 50% to 85% bleeding host bone contact. All patients were treated with the same type of trabecular metal acetabular revision shell. The mean age at revision was 62.4 years (42 to 80) and the mean follow-up of both groups was 72.4 months (60 to 102). Clinical, radiological and functional outcomes were assessed. There were four (7.5%) mechanical failures in the ≤ 50% host bone contact group and no failures in the > 50% host bone contact group (p = 0.068). Out of both groups combined there were four infections (3.9%) and five recurrent dislocations (4.9%) with a stable acetabular component construct that were revised to a constrained liner. Given the complexity of the reconstructive challenge, porous metal revision acetabular shells show acceptable failure rates at five to ten years’ follow-up in the setting of significant contained bone defects. This favourable outcome might be due to the improved initial stability achieved by a high coefficient of friction between the acetabular implant and the host bone, and the high porosity, which affords good bone ingrowth

Background. Few studies have compared aspirin with DOACs (direct oral anticoagulants = direct thrombin inhibitors and factor Xa inhibitors) for venous thromboembolism (VTE) prophylaxis following total hip and knee replacement (THR and TKR). We assessed the efficacy and safety of aspirin compared with DOACs for VTE prophylaxis following THR and TKR using the world's largest joint replacement registry. Methods. We studied the National Joint Registry linked to English hospital inpatient episodes for 218,650 THR and TKR patients. Patients receiving aspirin were matched separately to (1) direct thrombin inhibitors, and (2) factor Xa inhibitors using propensity scores. Outcomes assessed at 90 days included VTE, length of stay, and adverse events. Results. Following THR, the risk of VTE was significantly lower in patients receiving direct thrombin inhibitors (0.44%; odds ratio (OR)=0.69, 95% confidence interval (CI)=0.55–0.87, p=0.002) and factor Xa inhibitors (0.37%; OR=0.63, CI=0.47–0.85, p=0.003) compared with aspirin (0.63%). Following THR, direct thrombin inhibitors (coefficient=−0.37, CI=−0.43 to −0.31, p<0.001) and factor Xa inhibitors (coefficient=−0.80, CI=−0.87 to −0.74, p<0.001) reduced length of stay compared with aspirin. Similar findings for both outcomes were observed following TKR. Compared with aspirin, DOACs did not increase the risk of short-term revision surgery; reoperation; major haemorrhage; wound disruption; surgical site infection; and mortality. Conclusions. Following THR and TKR, the risk of VTE was lower in patients receiving DOACs compared with aspirin. DOACs were associated with a reduced length of stay, and DOACs did not increase the risk of further surgery, wound problems, bleeding complications, or mortality compared with aspirin

Little is known about the efficacy of graduated compression stockings in preventing venous thromboembolism after hip surgery. We conducted a prospective, randomised single-blind study to determine whether the addition of compression stockings to fondaparinux conferred any additional benefit. The study included 874 patients, of whom 795 could be evaluated (400 in the fondaparinux group and 395 in the fondaparinux plus compression stocking group). Fondaparinux was given post-operatively for five to nine days, either alone or combined with wearing stockings, which were worn for a mean 42 days (35 to 49). The study outcomes were venous thromboembolism, or sudden death before day 42. Duplex ultrasonography was scheduled within a week of day 42. Safety outcomes were bleeding and death from venous thromboembolism. The prevalence of deep-vein thrombosis was similar in the two groups 5.5% (22 of 400) in the fondaparinux group and 4.8 (19 of 395) in the fondaparinux plus stocking group (odds ratio 0.88, 95% confidence interval 0.46 to 1.65, p = 0.69). Major bleeding occurred in only one patient. The addition of graduated compression stockings to fondaparinux appears to offer no additional benefit over the use of fondaparinux alone

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

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

Aims

Large acetabular bone defects encountered in revision total hip arthroplasty (THA) are challenging to restore. Metal constructs for structural support are combined with bone graft materials for restoration. Autograft is restricted due to limited volume, and allogenic grafts have downsides including cost, availability, and operative processing. Bone graft substitutes (BGS) are an attractive alternative if they can demonstrate positive remodelling. One potential product is a biphasic injectable mixture (Cerament) that combines a fast-resorbing material (calcium sulphate) with the highly osteoconductive material hydroxyapatite. This study reviews the application of this biomaterial in large acetabular defects.

Vascular injuries during total hip arthroplasty (THA) are rare but when they occur, have serious consequences. These have traditionally been managed with open exploration and repair, but more recently there has been a trend towards percutaneous endovascular management. We performed a systematic review of the literature to assess if this change in trend has led to an improvement in the overall reported rates of morbidity and mortality during the last 22 years in comparison with the reviews of the literature published previously. . We found a total of 61 articles describing 138 vascular injuries in 124 patients. Injuries because of a laceration were the most prevalent (n = 51, 44%) and the most common presenting feature, when recorded, was bleeding (n = 41, 53.3%). Delay in diagnosis was associated with the type of vascular lesion (p < 0.001) and the clinical presentation (p = 0.002). Open exploration and repair was the most common form of management, however percutaneous endovascular intervention was used in one third of the injuries and more constantly during the last 13 years. The main overall reported complications included death (n = 9, 7.3%), amputation (n = 2, 1.6%), and persistent ischaemia (n = 9, 7.3%). When compared with previous reviews there was a similar rate of mortality but lower rates of amputation and permanent disability, especially in patients managed by endovascular strategies. Cite this article: Bone Joint J 2015;97-B:1447–55

Aims

Avascular femoral head necrosis in the context of gymnastics is a rare but serious complication, appearing similar to Perthes’ disease but occurring later during adolescence. Based on 3D CT animations, we propose repetitive impact between the main supplying vessels on the posterolateral femoral neck and the posterior acetabular wall in hyperextension and external rotation as a possible cause of direct vascular damage, and subsequent femoral head necrosis in three adolescent female gymnasts we are reporting on.

An uncemented hemispherical acetabular component is the mainstay of acetabular revision and gives excellent long-term results. Occasionally, the degree of acetabular bone loss means that a hemispherical component will be unstable when sited in the correct anatomical location or there is minimal bleeding host bone left for biological fixation. On these occasions an alternative method of reconstruction has to be used. A major column structural allograft has been shown to restore the deficient bone stock to some degree, but it needs to be off-loaded with a reconstruction cage to prevent collapse of the graft. The use of porous metal augments is a promising method of overcoming some of the problems associated with structural allograft. If the defect is large, the augment needs to be protected by a cage to allow ingrowth to occur. Cup-cage reconstruction is an effective method of treating chronic pelvic discontinuity and large contained or uncontained bone defects. . This paper presents the indications, surgical techniques and outcomes of various methods which use acetabular reconstruction cages for revision total hip arthroplasty. Cite this article: Bone Joint J 2016;98-B(1 Suppl A):73–7