Introduction

Embolism in total arthroplasty or hip fractures, coagulation disorders, such as a variety of ways for the prevention of complications of anticoagulation therapy with medication is being done well. The purpose of this study, a representative of the anticoagulation therapy with enoxaparin and drug rivaroxaban of coagulation tests performed in patients between the two groups was to determine whether statistically significant differences.

It is known that patients who are undergoing major orthopaedic operations of the lower legs (fractures, total hip and knee arthroplasty) belong to a high-risk group, for the development of thromboembolic events.

20–40% of the patients develop deep vein thrombosis (DVT) of the calf and 2–4% fatal pulmonary embolism.

These patients may have remarkable activation of the coagulation system, which is important for the development of deep vein thrombosis of the lower legs.

Purpose: The aim of the study is to evaluate the activation of selected blood coagulation parameters, during the preoperative and postoperative period, in patients undergoing high risk of orthopaedic operation of lower limbs.

The exact estimation of these factors is necessary, so that these patients receive the suitable prophylactic antithrombotic therapy,

Patients and methods: We studied 24 patients, 16 women and 8 men, between 23–84 years old, 12 with femur fracture, 8 with total knee replacement and 4 with total hip replacement surgery.

All patients had normal renal function, and the platelets, count, the PT and aPTT were in a normal range.

The patients were hospitalized for 7 days and then they were observed as outpatients for the possibility of developing deep vein thrombosis and for a 4 weeks period.

All patients received a combination of LMWH and graduated compression elastic stockings as a prophylaxis against DVT.

Plasma concentration of Di-dimers and Thrombin -Antithrombin complex (TAT) were measured preoperatively and the second, the fourth and the sixth day postoperatively.

Di-dimers plasma concentration were measured by automated analyzer (VidasBiomerieux) and TAT plasma concentration were measured by an enzyme-linked microimmunoabsorbent assay (microelisa Dade-Berhing)

Results: Preoperative TAT concentration in patients with femur fracture were high. Postoperatively decreased with the major decreasement on the second day (p< 0.039). Till the 6th postoperative day TAT concentration remained above normal range. Di-dimers plasma concentrations were high preoperatively and remained also high postoperatively, without significant statistical difference.

In patients with total hip and knee arthroplasty TAT plasma concentration increased significantly the 12nd postoperative, day, decreased the 4th postoperative day and then increased again (p< 0.01). Di-dimers plasma concentration increased significantly the 2nd postoperative day and then decreased (p< 0,03).

Until the 6th postoperative day Di-dimcrs concentration remained above normal range. Patients with fractures had higher TAT levels preoperatively than patients with total hip and knee arthroplasty. (p< 0.027)

Conclusions: All patients with major orthopaedic surgery of lower limbs have shown significant activation of the coagulation system postoperatively. Patients with fractures present significant activation of the coagulation system post and preoperatively. So it may be necessary in patients with fractures, to start anticoagulation prophylaxis against DVT preoperatively, and the last dose of LMWH must be given 12 hours before the operation.

Backround: The etiology of Legg-Calvé-Perthes disease (LCPD) is incompletely understood. Previous studies suggest associations with coagulation problems, anatomical abnormalities in the femoral head blood supply and risks for cardiovascular disease. Therefore, we hypothesized that patients with LCPD might have a higher risk of cardiovascular diseases and diseases of blood and blood-forming organs.

Methods: 3,141 patients with LCPD aged 2–15 years, diagnosed between 1965 and 2005 were identified using the Swedish inpatient register. 15,595 individuals without LCPD were randomly selected from among the Swedish general population, matched by year of birth, age, sex, and region of residence. Cox proportional hazard regression, adjusted for socioeconomic index, was used to estimate the relative risks. The patients were also compared with their same-sex siblings.

Results: Patients with LCPD had a hazard ratio (HR) of 1.70 (95% CI 1.39–2.09) for cardiovascular disease compared with individuals without LCPD. The point estimate was slightly higher among those older than 30 at follow-up (HR=2.10, 95% CI: 1.52–2.91). There were statistically significant higher risks for diseases of blood and blood-forming organs (1.41, 1.07–1.86), which were more pronounced among those older than 30 years at follow-up (2.70. 1.50–4.84). Patients had also statistically significant higher risks for hypertensive disease (2.97, 1.87–4.72), and nutritional anemia (2.92, 1.58–5.40). When siblings were used as the comparison group, the results were consistent for cardiovascular disease.

Conclusion: The results are consistent with the hypothesis that an insufficient blood supply to the femoral head due to vascular pathology and other causes are involved in the etiology of LCPD.

To target postoperative patients in need for prolonged pharmacologic thromboprophylaxis due to persistent coagulation activation, we developed and evaluated a qualitative test method, which detects the urinary excretion of prothrombin fragment 1+2 (uF1+2). The test was developed as a dip-stick device consisting of a one step rapid lateral flow immunoassay with visual readout on one test line and one control line. The assay time was between 5 and 10 minutes.

Spot urine samples were collected in 113 patients undergoing elective hip arthroplasty preoperatively and on day 5 after operation. Specimens were frozen immediately and stored until batch analysis. Pharmacologic thromboprophylaxis was administered according to national guidelines until day 7±2 after the operation. The results of the new dip-stick device were compared with the results of a laboratory based enzyme-linked-immunosorbent-assay (ELISA) method and a predetermined cut-off value. Patients were followed for development of vascular thrombotic complications/unexpected death until day 90 after the operation.

10 (8.8%) patients experienced an event during the study: 2 (1.8%) died unexpectedly and 8 (7.1%) had a vascular thrombotic event. All patients with clinical events had significantly raised postoperative levels of uF1+2. The clinical accuracy of the dip-stick test was acceptable with a sensitivity of 100% and a negative predictive value of 100%. Compared to the standard ELISA method the dip-stick test had a sensitivity of 93% and a specificity of 48%.

Laboratory ELISA analysis of urinary excretion of uF1+2 is neither feasible nor applicable in postoperative patients. Bed-side testing of persistent coagulation activation, however, could help to determine the need for prolonged thromboprophylaxis. The new dip-stick urine test was very easy to use, had a high negative predictive value and sensitivity and thus appears to be safe. However, the number of false positive test results prompts a fine-tuning of the test device. In terms of clinical applicability the test was acceptable. The study showed that about one third of the patients could be excluded from further extension of thromboprophylaxis beyond the first week.

We investigated the incidence of PE (Pulmonary Embolism)and DVT (Deep Vein Thrombosis) after THA by the use of MDCT (multi-detect or row CT scan). The purpose of this study was to evaluate the meaning of blood coagulation molecular markers (FDP D-dimer, Soluble Fibrin Monomer Complex) for the prospect of PE and DVT after THA.

We studied 30 THA patients. There were 2 men and28 women. The value of D-dimer and SFMC before and after THA was examined. MDCT was carried out for DVT and PE investigation, in all cases 7 days after-THA. The relation between the values of blood coagulation molecular markers and existence of PE and DVT was evaluated.

PE occurred in 2 cases and DVT in 4 cases out of 30 cases. D-dimer values of these 2 PE cases in 7 days after THA were higher (18,39), compared with average values (12). Among DVT 4 cases, in 1 case DVT existed on thigh and in other 3 cases existed on calf. The SF values in 7 days showed extremely higher in only thigh DVT case (99), compared with average values (16.6). The value of SFMC fell down rapidly in a few days, representing the biphasic property.

MDCT is very effective for the diagnosis of PE and DVT. But it is difficult to make examination many times. It is very convenient to be able to evaluate PE and DVT by blood examination. From the results of this study, D-dimer may be sensitive for the diagnosis of PE and SFMC also may be useful for DVT. SFMC reacts more rapidly to abnormalities of thrombus and hemostasis. So it has possibilities to clarify the temporal responses of the DVT and PE more precisely.

Objective

Mortality rates reported by the National Joint Registry for England and Wales (NJR) were higher following cemented total knee replacement (TKR) compared with uncemented procedures. The aim of this study is to examine and compare the effects of cemented and uncemented TKR on the activation of selected markers of inflammation, endothelium, and coagulation, and on the activation of selected cytokines involved in the various aspects of the systemic response following surgery.

National guidelines suggest which investigations should be performed for patients admitted with an acute hip fracture. We have observed practice often deviates from these guidelines. Our study aims to identify the incidence of deviation with regards to blood investigations and review the effect of deviation on management, and the financial burden on the healthcare system. A total of 250 acute hip fracture admissions over 12-months period reviewed retrospectively. Admission blood tests, time of presentation, and time of operation were recorded. The cost of admission blood investigations was calculated. Seventy-nine percent of admissions had one or more non-routine blood investigation tested. Twenty-Nine percent of these tests had abnormal results and these were found to be clinically relevant in 6% of patients. The most commonly requested non-routine investigations were: LFT in 79%, Coagulation screen in 56%, and CRP in 48%. Fifteen percent of patients did not have surgery within the time frame of 36 hours. The total cost of non-routine investigations was £1995.04. Deviation from admission investigations guidelines for hip fractures without clinical indication adds little clinical value, has no effect on management, and can be a potential cause of unnecessary investigations. This in turn leads to further delays and extra costs

Recently, a special type of surface pitting found on metal implants was proposed to arise from “inflammatory cell-induced” corrosion (ICI, Figure 1) (1, 2). The actual mechanism of this was unknown, but similar features were suggested to be artefacts of electrocautery damage from revision surgery (3). Under lab conditions and without the influence of any cells, we aimed to reproduce the same surface pits and structures with electrocautery. Methods. A polished cobalt-chromium disk (40 mm diameter, 8 mm thick) was marked into 8 sections for various testing conditions (Figure 2a). A stainless steel Bovie tip with a unipolar electrocautery machine (SYSTEM 5000, ConMed, USA) was used at typical surgical coagulation conditions: (70 volt, 120 watts, 562 KHz frequency). We mimicked three types of surgical techniques with the electrocautery: “Dotting” was repeated, on and off, direct surface contact; “Dragging” was constant, direct surface contact; “Hovering” was pausing several millimeters above the surface. We also examined the interplay of these practices on diamond-tip-induced scratches and either dry or wet (normal saline) conditions. High magnification images (Keyence VHX-2000E) were taken after the disk was cleaned with laboratory soap, light mechanical scrubbing, and formalin soak. Results. Coagulation mode generated electrical sparks when dotting/dragging and electrical arcs when hovering. These left seared marks that persisted even after cleaning (Figure 2b). At higher magnification, the surface features were comparable in size and shape to those attributed to ICI (1, 2). Areas wet with saline (Figure 3a) showed an abundance of ringed pits with raised edges that closely resembled those observed in Figure 1. Furthermore we obtained images similar to the phenomenon of “cellular tracks” (Figure 3b) (1). Premade scratches did not influence the pit arrangement but scratches made by the Bovie tip produced the characteristic scratch-associated ICI features as observed on implant retrievals in the past (Figure 3c) (4). Discussion. In the absence of cells, pitting equivalent to proposed ICI features was successfully replicated using an electrocautery in coagulation mode. Previously (4), we found a high incidence but small surface area of these features on the majority of retrievals, predominantly located in a focal area of the superior aspect of the femoral ball next to the junction of the stem. There were fewer on the inferior aspect which is consistent with electocautery damage when dissecting the hip capsule. The effect of this damage on retained parts is unknown, but electrocautery damage around areas of implant fractures has been reported (3). Conclusion. The striking similarities of the recreated pit structures imaged here suggest that the noted features of “inflammatory cell induced corrosion” were artefacts of the electrocautery during revision surgery. Future implant retrieval analysis should acknowledge these structures are not related to any particular mode of failure but should check for them around implant fracture sites

1. Intertransverse fusion in the lumbar spine appears to have many advantages over previously described techniques. 2. The disadvantage of profuse bleeding can be overcome by the use of a Hastings frame and by an operative technique designed to demonstrate constant muscular and articular branches of the lumbar arteries. 3. Coagulation of these vessels by cautery and avoidance of dissection anterior to the plane of the transverse processes ensure that the operative procedure can be carried out with a blood loss averaging less than 500 millilitres

A 78 year old lady attended casualty with complaints of low back pain and calf pain following a fall. Radiographs of lumbar spine did not reveal any bony injury. Clinically deep vein thrombosis (DVT) of the calf could not be excluded. Hence, venogram was performed that confirmed the diagnosis of below knee DVT. Patient was then discharged. Patient attended casualty 2 months later with complaints of sudden increase in back pain and difficulty in mictuirition. Radiographs of lumbar spine revealed a collapse of L1 vertebra. Routine blood tests were all normal except for raised International Normalised Ratio (INR), 3.5. Patient developed parapaeresis within three days. Coagulation status was controlled but no obvious primary source could be identified. After discussion with Neurosurgeons, urgent Computerised Tomography (CT) guided biopsy was arranged which was performed one week after presentation. Histopathological examination of the specimens revealed only fibrous tissue and blood. At 3 weeks after presentation patient started recovering rapidly though there was some amount of residual power loss in the lower limbs. Patient did not regain bladder control. A repeat CT guided biopsy at 6 weeks, again revealed only fibrous tissue. This case is presented to discuss the rarer etiologies that can present as a metastatic spinal cord compression

Purpose of the study: Hemophilic arthropathy is often located in the knee joint. Total knee arthroplasty (TKA) is the ultimate solution to total joint destruction, often observed in young patients. The purpose of this study was to evaluate the outcome of TKA in hemophilic patients and to describe specific features. Material and methods: Hemophilics who underwent TKA between 1990 and 2004 were reviewed at mean 4.7 years follow-up: 30 TKA (7 posterior stabilized, 23 with preservation of the posterior cruciate) were implanted in 21 men, mean age 39 years, 17 with hemophilia A et 4 with hemophilia B. Seventeen patients were HBV-positive and eight were HIV-positive. Coagulation factors substitution was managed by the regional center for the treatment of hemophiliacs starting the day before the operation and for a minimal postoperative period of 21 days. The Knee Society score was used for assessment of clinical outcome. Results: Preoperatively, mean flexion was 75° (range 40–100°), mean permanent flexion was 20° (range 5–45°). Range of joint motion was 56° on average (range of range of motion 10–105°). Early postoperative hemarthrosis occurred in eleven knees and seven of these required revision from day 4 to day 15. The four others resolved spontaneously. Six late infections (20%) developed in five patients (one bilateral infection). One patient was treated by arthroscopic wash-out, and four by arthrotomy. One required revision TKA in a two-stage procedure. Five patients received an adapted antibiotic therapy for an identified germ; the germ could not be identified in one patient. At last follow-up, mean flexion was 85°, mean permanent flexion was 10°, and mean range of motion was 71°. None of the patients complained of pain both at rest and during exercise. Discussion: Hemophilic arthropathy is particularly painful, producing stiff joints in these immunodepressed patients. The known high rate of complications was again observed in this series, particularly infectious complications after TKA in hemophiliacs. These complications did not however alter the functional outcome. The gain in joint motion was modest but the absence of pain was a satisfactory result for these patients

We have evaluated prospectively the incidence and location of deep-vein thrombosis (DVT), the risk factors for pulmonary embolism, and the natural history of thrombosis after total knee replacement (TKR) in patients who did not receive prophylactic or therapeutic treatment for DVT. We studied 227 patients who underwent primary TKR; 116 had one-stage bilateral and 111 unilateral procedures. Coagulation assays, the full blood count and blood typing tests for the serum chemical profile were undertaken in all patients on three separate occasions. Bilateral simultaneous or unilateral venograms were carried out at six or seven days after operation. Perfusion lung scanning was undertaken before and at seven or eight days after operation. Bilateral simultaneous or unilateral venograms were repeated six months after operation in all patients who had thrombi. In the 116 patients with a bilateral replacement, 97 of 232 venograms (41.8%) were positive for fresh thrombi while there were 46 positive venograms (41.4%) in the 111 patients with a unilateral replacement (p = 1.000). Of the 116 venograms in knees with a cemented replacement, 45 (38.8%) were positive for thrombi while 52 of the 116 venograms (44.8%) were positive in those with a cementless replacement (p = 0.675). Further venograms at six months after operation in all 143 limbs which had thrombi showed that all had completely resolved regardless of the size or location. No pulmonary embolism occurred as shown by negative perfusion lung scans and the absence of symptoms. Although the current prevailing opinion is that patients with thrombosis in the proximal veins should receive anticoagulant treatment, our study has shown that all thrombi regardless of their size or location resolved without causing pulmonary embolism

Aims

Impaired fracture repair in patients with type 2 diabetes mellitus (T2DM) is not fully understood. In this study, we aimed to characterize the local changes in gene expression (GE) associated with diabetic fracture. We used an unbiased approach to compare GE in the fracture callus of Zucker diabetic fatty (ZDF) rats relative to wild-type (WT) littermates at three weeks following femoral osteotomy.

There are many reports concerning the aetiology and prophylaxis of deep-vein thrombosis (DVT) but little is known about its natural history. The purpose of our study was to identify the incidence and site of DVT, the risk factors for pulmonary embolism and the natural history of DVT after total hip replacement (THR) in patients who do not receive any form of prophylactic or therapeutic treatment for DVT. Two hundred patients who had a primary THR were included: 100 had one-staged bilateral THR and 100 had unilateral THR and 150 implants were cemented and 150 cementless. Coagulation assays, a full blood count, blood typing and serum chemical profile tests were performed for all patients on three separate occasions. Bilateral simultaneous or unilateral venograms were performed on the sixth or seventh postoperative day and perfusion lung scans preoperatively and on the seventh or eighth postoperative day. Further venograms were performed in all patients who had thrombi six months later. In the patients with bilateral THR, 52 (26%) venograms were positive for thrombi, while in the patients with unilateral THR 20 (20%) were positive (p = 0.89). In the patients with a cemented THR, 31 venograms (20.7%) were positive for thrombi, while in those with a cementless THR 41 (27.3%) were positive (p = 0.654). Further venograms in all 72 patients who had thrombi at six months after operation showed that they resolved completely and spontaneously regardless of their site and size. No patients had symptoms of pulmonary emboli and none were seen on the perfusion lung scans. Two patients died from unrelated causes. Although the prevailing opinion is that patients with proximal venous thrombosis should be treated with anticoagulants, our study has shown that all thrombi regardless of their site and size resolve spontaneously without associated pulmonary embolism

Aims

During the COVID-19 pandemic, many patients continue to require urgent surgery for hip fractures. However, the impact of COVID-19 on perioperative outcomes in these high-risk patients remains unknown. The objectives of this study were to establish the effects of COVID-19 on perioperative morbidity and mortality, and determine any risk factors for increased mortality in patients with COVID-19 undergoing hip fracture surgery.

Aims

Many case reports and small studies have suggested that cobalt ions are a potential cause of cardiac complications, specifically cardiomyopathy, after metal-on-metal (MoM) total hip arthroplasty (THA). The impact of metal ions on the incidence of cardiac disease after MoM THA has not been evaluated in large studies. The aim of this study was to compare the rate of onset of new cardiac symptoms in patients who have undergone MoM THA with those who have undergone metal-on-polyethylene (MoP) THA.

Aims

The aims of this study were to compare the efficacy of two agents, aspirin and warfarin, for the prevention of venous thromboembolism (VTE) after simultaneous bilateral total knee arthroplasty (SBTKA), and to elucidate the risk of VTE conferred by this procedure compared with unilateral TKA (UTKA).

Aims

Our aim was to perform a systematic review of the literature to assess the incidence of post-operative epidural haematomas and wound infections after one-, or two-level, non-complex, lumbar surgery for degenerative disease in patients with, or without post-operative wound drainage.

Symptomatic hip osteonecrosis is a disabling condition with a poorly understood aetiology and pathogenesis. Numerous treatment options for hip osteonecrosis are described, which include non-operative management and joint preserving procedures, as well as total hip replacement (THR). Non-operative or joint preserving treatment may improve outcomes when an early diagnosis is made before the lesion has become too large or there is radiographic evidence of femoral head collapse. The presence of a crescent sign, femoral head flattening, and acetabular involvement indicate a more advanced-stage disease in which joint preserving options are less effective than THR. Since many patients present after disease progression, primary THR is often the only reliable treatment option available. Prior to the 1990s, outcomes of THR for osteonecrosis were poor. However, according to recent reports and systemic reviews, it is encouraging that with the introduction of newer ceramic and/or highly cross-linked polyethylene bearings as well as highly-porous fixation interfaces, THR appears to be a reliable option in the management of end-stage arthritis following hip osteonecrosis in this historically difficult to treat patient population.

Cite this article: Bone Joint J 2013;95-B, Supple A:46–50.