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

Popliteal artery injury (PAI) is a feared complication during knee replacement. Our aim was to investigate those injuries that occurred in association with knee replacement in terms of the type of injury, treatment and outcomes. From our national vascular registry (Swedvasc) and the Swedish Patient Insurance databases a total of 32 cases were identified. Prospective data from the registries was supplemented with case-records, including long-term follow-up. We estimated the incidence during 1998 to 2010 to be 0.017%. In our series of 32 patients with PAI occurring between 1987 and 2011, 25 (78%) were due to penetrating trauma and seven were caused by blunt trauma. The patients presented in three ways: bleeding (14), ischaemia (7) and false aneurysm formation (11), and five occurred during revision surgery. A total of 12 injuries were detected intra-operatively, eight within 24 hours (3 to 24) and 12 at more than 24 hours post-operatively (2 to 90 days). Treatment comprised open surgery in 28 patients. Patency of the vascular repair at 30 days was 97% (31 of 32, one amputation). At the time of follow-up (median 546 days, mean 677 days (24 to 1251)), 25 patients had residual symptoms. Of seven patients with a complete recovery, six had had an early diagnosis of the PAI during the procedure, and were treated by a vascular surgeon in the same hospital. PAI is a rare adverse event during knee replacement surgery. The outcome following such events is often adversely affected by diagnostic and therapeutic delay. Bleeding and false aneurysm were the most common clinical presentations. Cite this article: Bone Joint J 2013;95-B:1645–9

Introduction

We examined the effect on blood loss of two standardised intravenous bolus doses of 500 mg of Tranexamic Acid, a fibrinolytic inhibitor that reduces blood loss following Knee Arthroplasty (KA).

Aims. The optimal management of an infrapopliteal deep venous thrombosis (IDVT) following total knee arthroplasty (TKA) remains unknown. The risk of DVT propagation and symptom progression must be balanced against potential haemorrhagic complications associated with administration of anticoagulation therapy. The current study reports on a cohort of patients diagnosed with IDVT following TKA who were treated with aspirin, followed closely for development of symptoms, and scanned with ultrasound to determine resolution of IDVT. Methods. Among a cohort of 5,078 patients undergoing TKA, 532 patients (695 TKAs, 12.6%) developed an IDVT between 1 January 2014 to 31 December 2019 at a single institution, as diagnosed using Doppler ultrasound at the first postoperative visit. Of the entire cohort of 532 patients with IDVT, 91.4% (486/532) were treated with aspirin (325 mg twice daily) and followed closely. Repeat lower limb ultrasound was performed four weeks later to evaluate the status of IDVT. Results. Follow-up Doppler ultrasound was performed on 459/486 (94.4%) patients and demonstrated resolution of IDVT in 445/459 cases (96.9%). Doppler diagnosed propagation of IDVT to the popliteal vein had occurred in 10/459 (2.2%) cases. One patient with an IDVT developed a pulmonary embolus six weeks postoperatively. Conclusion. The results of this study demonstrate a low rate of IDVT propagation in patients managed with aspirin. Additionally, no significant bleeding episodes, wound-related complications, or other adverse events were noted from aspirin therapy. Cite this article: Bone Joint J 2021;103-B(6 Supple A):18–22

Introduction. Pulmonary embolism (PE) complicates up to 1% of total joint arthroplasties (TJA). Many PE treatment guidelines call for immediate initiation of therapeutic anticoagulation. Options include Xa inhibitors, Enoxaparin, and Warfarin. Deciding between these is a balance of the efficacy and the risks. Little data exists regarding the risks of each of these treatment options for treating PE in arthroplasty patients. Methods. We examined the records of 29,270 patients who underwent a primary total joint arthroplasty (TJA), defined as a unilateral total knee arthroplasty (TKA) (18,987) or total hip arthroplasty (THA) (10,283), between 2/2016 and 12/2018 at our institution and identified 338 (242 TKA, 96 THA) patients who developed an in-hospital PE treated with therapeutic anticoagulation. The patients were treated with therapeutic doses of Xa inhibitors, enoxaparin or warfarin. The type and frequency of complications were determined and classified as major or minor. Major complication included: bleeding requiring surgery, GI bleed requiring treatment, >2 unit transfusion and mortality. Minor complications included wound drainage, bleeding not requiring surgery, and thrombocytopenia. Results. Overall complication rates were high for all treatments. Xa inhibitors had the lowest complication rate at 14% compared to 20% for enoxaparin and 20.7% for warfarin though the difference did not quite reach statistical significance (p=.054). Both major and minor complication were lower with Xa inhibitors, but again the difference was not statistically significant (p=0.67). There was no significant difference in complications between TKA groups (p=0.73) or THA groups (p=0.83). Gender and body mass index were not predictive of major or minor complications. Discussion. Our results demonstrate high complication rates associated with modern therapeutic anticoagulation protocols for perioperative PE following TJA. Patients who receive therapeutic anticoagulation postoperatively are at high risk for complication. Xa inhibitors may decrease these risks, but larger studies are required

A total of 187 patients with primary osteoarthritis (OA) of the knee undergoing total knee replacement (TKR) were randomly divided into two groups, one of which underwent synovectomy. The patients and assessors were blinded to the randomisation both before and after surgery. The duration of surgery, hospitalisation period, concealed bleeding, drainage volume, blood transfusion rate and range of movement of the knee at three days after the operation were analysed. Patients were followed up at four weeks and 12 months after their operation, and a visual analogue score (VAS) for pain, Knee Society score (KSS) and a patellar ballottement test were compared between the groups. The mean amount of concealed bleeding was higher in the synovectomy group compared with the control group (1.24 l (0.08 to 3.28) vs 1.03 l (0.16 to 2.94); p = 0.042), as was the mean drainage volume (0.90 l (0.35 to 1.81) vs 0.81 (0.25 to 1.65); p = 0.030). The mean operating time was also higher in the synovectomy group compared with the controls (1.50 hours (1.34 to 1.75) vs 1.41 hours (1.21 to 1.79); p = 0.006). There were no significant differences in blood transfusion rate (p = 0.882), hospital stay (p = 0.805) or range of movement of the knee (p = 0.413) between the two groups. At four weeks and 12 months post-operatively there were no statistically significant differences in any of the measured parameters. We concluded that synovectomy confers no clinical advantages in TKR for primary OA while subjecting patients to higher levels of bleeding and longer operating times. Cite this article: Bone Joint J 2013;95-B:1197–200

Introduction. There is insufficient data on the trends of anticoagulation after total knee arthroplasty (TKA) in the USA, and the efficacy and safety of rivaroxaban, beyond randomized clinical trials and small cohort studies. Patients and Methods. Using the Truven Health MarketScan database, we retrospectively evaluated new anticoagulation prescriptions after elective TKA from 2010 to 2015. The frequency of deep vein thrombosis (DVT), pulmonary embolism (PE), and adverse events, within 90 days, were then evaluated in 24,856 new users of warfarin and 21,398 new users of rivaroxaban in commercially insured patients (COM), and 15,483 new users of warfarin and 8,997 new users of rivaroxaban in Medicare supplement patients (MED). Data was analyzed by odds ratios using logistic regression models with stabilized inverse probability treatment weighting. Results. Warfarin use decreased from approximately 50% to 17% in COM patients and 60% to 25% in MED patients. Rivaroxaban use increased from 0 to 35% in COM patients and from 0 to 39% in MED patients. Older patients, females, a history of DVT, renal impairment, use of antiplatelet agents or surgery performed as an outpatient had lower odds of getting rivaroxaban. Patients in Western region and having surgery in 2015 had higher odds of getting rivaroxaban. COM patients with capitated insurance plans and a history of PE had lower odds of rivaroxaban initiation. MED patients with atrial fibrillation, cardiovascular disease or hyperlipidemia had lower odds of rivaroxaban initiation. Warfarin users had significantly higher odds ratio of DVT (OR 2.06 in COM patients and OR 2.21 in MED patients) and PE (OR 2.03 in COM patients and OR 2.16 in MED patients) than rivaroxaban users. There were no statistically significant differences in the bleeding risk between the two agents, but warfarin users had a significantly higher odds ratio of periprosthetic infection in both COM (1.57) and MED (1.79) patients. Conclusions. There has been an increase in prophylaxis with rivaroxaban, and a decrease in both warfarin and LMWH use after elective TKA over four years. Rivaroxaban had lower odds ratio of both DVT and PE than warfarin, and bleeding risks were similar. For figures, tables, or references, please contact authors directly

Aims

To map literature on prognostic factors related to outcomes of revision total knee arthroplasty (rTKA), to identify extensively studied factors and to guide future research into what domains need further exploration.

Aims

To identify variables independently associated with same-day discharge (SDD) of patients following revision total knee arthroplasty (rTKA) and to develop machine learning algorithms to predict suitable candidates for outpatient rTKA.

PURPOSE OF STUDY. 20-70% of patients need blood transfusion postoperatively. There remain safety concerns regarding allogenic blood transfusion. Tranexamic acid (TA) is a synthetic antifibrinolytic agent that has been successfully used to stop bleeding in other specialties. We applied TA topically prior to the wound closure to find out the effect on blood loss as well as need for subsequent blood transfusion. This method of administration is quick, easy, has less systemic side effect and provides a higher concentration at the bleeding site. MATERIALS AND METHODS. A double blind randomised controlled trial of 154 patients who underwent unilateral primary cemented total knee replacement. Patients were randomised into tranexamic acid group (1g drug mixed with saline to make up 20mls) or placebo (20ml 0.9% saline). The administration technique and drain protocol was standardised for all patients. Drain output was measured at 24 hours, and both groups compared for need of Blood transfusion. Outcome measures - blood loss, transfusion, complications, Euroqol and Oxford Knee Score. RESULTS. The two groups were comparable in age, weight, height, BMI, and Tourniquet time. There was significant difference in the amount of blood loss and blood transfusion in favour of tranexamic acid (p=0.001 and 0.007 respectively). Fourteen patients needed blood transfusion (ranged from 2 to 6 units). Thirteen were in the Placebo group and only one in the Tranexamic acid. There was no significant difference among other outcomes, in particular complications rates such as DVT and PE. Use of Tranexamic acid is recommended as routine to reduce bleeding and blood transfusion rates following primary Total Knee replacement

Aims

As has been shown in larger animal models, knee immobilization can lead to arthrofibrotic phenotypes. Our study included 168 C57BL/6J female mice, with 24 serving as controls, and 144 undergoing a knee procedure to induce a contracture without osteoarthritis (OA).

Aims

Implantation of ultra-purified alginate (UPAL) gel is safe and effective in animal osteochondral defect models. This study aimed to examine the applicability of UPAL gel implantation to acellular therapy in humans with cartilage injury.

Aims

In the last decade, perioperative advancements have expanded the use of outpatient primary total knee arthroplasty (TKA). Despite this, there remains limited data on expedited discharge after revision TKA. This study compared 30-day readmissions and reoperations in patients undergoing revision TKA with a hospital stay greater or less than 24 hours. The authors hypothesized that expedited discharge in select patients would not be associated with increased 30-day readmissions and reoperations.

Aims

This study investigated the effects of transcatheter arterial embolization (TAE) on pain, function, and quality of life in people with early-stage symptomatic knee osteoarthritis (OA) compared to a sham procedure.

Aims

To explore the efficacy of extracorporeal shockwave therapy (ESWT) in the treatment of osteochondral defect (OCD), and its effects on the levels of transforming growth factor (TGF)-β, bone morphogenetic protein (BMP)-2, -3, -4, -5, and -7 in terms of cartilage and bone regeneration.

Introduction. Active robotics for total knee Arthroplasty (TKA) uses a CAD-CAM approach to plan the correct size and placement of implants and to surgically achieve planned limb alignment. The TSolution One Total Knee Application (THINK Surgical Inc., Fremont, CA) is an open-implant platform, CT-based active robotic surgical system. A multi-center, prospective, non-randomized clinical trial was performed to evaluate the safety and effectiveness of robotic-assisted TKA using the TSolution One Total Knee Application. This report details the findings from the IDE. Methods. Inclusion criteria for patients receiving robotic TKA were: primary unilateral TKA; Kellgren-Lawrence OA grade 3 or 4; BMI < 40 kg/m2; coronal plane deformity < 20° varus; sagittal flexion contracture < 15°. In addition to monitoring all adverse events (AE), a pre-defined list of relevant major AEs were specifically identified to evaluate safety (Healy et al, 2013): medial collateral ligament injury; extensor mechanism disruption; neural deficit; periprosthetic fracture; patellofemoral dislocation; tibiofemoral dislocation; and vascular injury. Bleeding complications were also assessed. Malalignment rate, defined as the percentage of patients with more than a ± 3° difference in varus-valgus alignment from the preoperative plan, was used to determine accuracy of the active robotic system. Knee Society Scores (KSS) and Short Form 12 (SF-12) Health Surveys were assessed as clinical outcome measures. For each outcome, results were compared to published values associated with manual TKA. Results. A total of 115 patients were enrolled at 6 US centers and followed for a maximum of 12 months after surgery. Mean surgical time (incision to close) improved consistently as the technique evolved (first 10 cases = 131.5 min, first 20 cases = 122.4 min), with mean robot time = 45.8 min. The incidence of pre-defined AEs identified was 0%, serving as a measure of safety of the procedure. Outside of the pre-defined list, only one AE was definitely associated with the use of the device; a metal pin was left inside the knee joint but no reoperation was performed. No patients required a blood transfusion. Alignment outside of the ± 3° goal was 11.2% with a difference of 0.5° ± 1.9° (mean ± STD), which represents a 45% statistically significant (posterior probability > 0.95) reduction in malalignment compared to the literature (Mason et al, 2007). Mean KSS Functional scores improved from 40.5 at baseline to 65.3 at 3 months, mean KSS Objective scores improved from 36.8 to 81.0, mean KSS Patient Satisfaction scores improved from 14.4 to 30.6, and mean SF-12 Physical Component scores improved from 32.9 to 43.5. Discussion. The TSolution One Total Knee Application is descended from an active robotic system used in >8000 cases outside the United States since 2002. This trial represents the first US based study of this technology for primary TKA. The clinical study demonstrated positive safety outcomes as none of the seven pre-defined AEs were observed and there were no cases requiring transfusion. A positive effectiveness outcome was also demonstrated as the malalignment rate found in this study showed a substantial reduction from the 32% malalignment rate published in the literature for conventional instruments. KSS and SF-12 scores were comparable to other published TKA series. For figures, tables, or references, please contact authors directly

Aims

The purpose of this study was to compare the clinical outcomes, mortalities, implant survival rates, and complications of total knee arthroplasty (TKA) in patients with or without hepatitis B virus (HBV) infection over at least ten years of follow-up.

Haemophilia is an x-linked inherited bleeding disorder which can cause severe arthropathy. We have reviewed the results of 70 primary total knee replacements (TKR) performed in 57 haemophilic patients between 1983 and 2007. The functional results were assessed using the Hospital for Special Surgery (HSS) knee scoring system and Kaplan-Meier survivorship analysis. Six patients died. HSS scores were available for 60 TKRs at a mean follow-up of 9.2 years (2 to 23); 57 (95%) had good or excellent results. Deep infection was recorded in one patient. Kaplan-Meier analysis using infection and aseptic loosening as endpoints showed the survival rate at 20 years to be 94.0%. A reduction in infection, spontaneous haemarthrosis and improvement in the quality of life were noted to justify surgery in our series of patients with a mean age of 43 (25 to 70). We have found that using the latest techniques of continuous infusion of clotting Factor have significantly helped to reduce the complication rates and have achieved results which match those of the non-haemophilic population undergoing TKR

Aims

Platelet-rich plasma (PRP) intra-articular injections may provide a simple and minimally invasive treatment for early-stage knee osteoarthritis (OA). This has led to an increase in its adoption as a treatment for knee OA, although there is uncertainty about its efficacy and benefit. We hypothesized that patients with early-stage symptomatic knee OA who receive multiple PRP injections will have better clinical outcomes than those receiving single PRP or placebo injections.

Aims

This study used an artificial neural network (ANN) model to determine the most important pre- and perioperative variables to predict same-day discharge in patients undergoing total knee arthroplasty (TKA).