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.

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

Purpose: As the prevalence of diabetes mellitus (DM) in people over 60 years of age is expected to increase, the number of diabetic patients who undergo total hip and knee arthroplasty should increase concordantly. In general, patients with DM have significantly increased risk for adverse events following arthroplasty. The goal of this study was to determine whether the quality of glycemic control affected the incidence of perioperative complications in the hospital following joint replacement. Method: From 1988 to 2003, the Nationwide Inpatient Survey (NIS) recognized 65,769 patients who had DM and underwent joint replacement surgery. In this retrospective study, bivariate and multivariate analyses compared patients with uncontrolled (n=2,872) and not uncontrolled (n=62,897) DM regarding common surgical and systemic complications, mortality, and hospital course alterations. Glycemic control was determined by physicians’ assessments based upon the American Diabetes Association guidelines using a combination of patients’ self-monitoring of blood-glucose testing, the hemoglobin A1C, and related complications. Results: Patients with uncontrolled DM routinely had an increased length of stay and increased inflation-adjusted costs after surgery (p< 0.001). Uncontrolled patients also had significant increases in the incidence of stroke, pneumonia, urinary tract infection, post-operative hemorrhage, wound infection, and death (p< 0.001). Conclusion: Patients with well-managed glycemic control have fewer comorbidities in general. Patients with uncontrolled DM exhibited significantly increased risks for surgical and systemic complications, higher mortality, increased length of stay, and higher hospital charges during the index hospitalization following arthroplasty. The consequences are increased cost, greater burden on the healthcare system, and greater risk to these patients

(Introduction). In Total Knee Arthroplasty (TKA), closed drains have been conventionally used to prevent hematoma. Recently reported “no-drain” methods have been demonstrated to be safe and effective, especially for decreasing hemorrhage. However, there has been no report of a major study on a no-drain method in simultaneous bilateral TKA, only a few small studies. Therefore, this study evaluated the efficacy of no-drain placement in simultaneous bilateral TKA. (Methods). Our study included 75 patients (150joints) with preoperative hemoglobin(Hb) level of at least 11.0 g/dl who underwent simultaneous bilateral TKA performed by the same surgeon in our department between January 2012 and December 2013. There were 12men and 63women, of average age 70.7 ± 7.9years (mean ± SD) and BMI 25.6± 3.8 (mean ± SD). Among them 72 patients had knee osteoarthritis and 3 patients had rheumatoid arthritis. The patella was not replaced in any of the cases. TKAs were performed separately on each knee. A tourniquet was applied between the initial skin incision and the postoperative dressing, and 1000 mg of tranexamic acid was injected into each joint after wound closure. (Results). The surgical time per patient was 136.6 ± 30.3 minutes (mean ± SD). The Hb levels (mean ± SD) were 13.0 ± 1.1 g/dl before surgery, 10.9 ± 1.2 g/dl on the day after surgery. The estimated total blood loss until the day after surgery was 558.4 ± 253.9 ml (mean ± SD). No patient experienced hypotension requiring vasopressor or rapid fluid therapy between the end of surgery and the day after surgery, and no complication caused by a sudden change of hemodynamics was found in any case of bilateral TKA. A gait training/range of motion exercise while bearing full load of the body weight was initiated from the day after surgery. This allowed patients to be discharged from our hospital in an average of 6.1days (range 5–11days)after surgery. There were no serious complications that occurred within three months after surgery. (Discussion). In cases of TKA with closed drain, even in unilateral surgery, excessive hemorrhage may be discharged through drain tubes for the first few hours after surgery. Hypotension caused by postoperative sudden hemorrhage or burden on the cardiovascular system seem to be major issues. In this study, simultaneous bilateral TKA were performed without suction drainage. The estimated blood loss until the day after surgery was approximately 560 ml. As sudden hypotension causing shock was not found, the post-operative hemorrhage seemed to have gradually progressed naturally. So we did not need the blood transfusion or rapid fluid therapy to any patient. This is one of the advantage of no-drainage method. (Conclusion). The simultaneous bilateral TKA without drain placement can be applied safely

Purpose: The management of degenerative arthritis of the knee in the younger, active patient often presents a challenge to the orthopaedic surgeon. Surgical treatment options include: high tibial osteotomy (HTO), uni-compartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA). The purpose of this study was to examine the long-term survival of closing wedge HTO in a large series of patients 8–19 years after surgery. Method: The results of 458 consecutive patients undergoing lateral closing wedge HTO for medial compartment osteoarthritis (MCOA) between 1990 and 2001 were reviewed. Between 2008–2009, patients were contacted via telephone and assessment included: incidence of further surgery, Oxford Knee Score, and British Orthopaedic Association (BOA) Patient Satisfaction Scale. Failure was defined as the need for revision HTO or conversion to UKA or TKA. Survival analysis was completed using the Kaplan-Meier method. Results: We were able to contact 400/458 (87%) patients for follow-up via telephone interview. Five patients (1%) who declined participation were excluded. Fifty-eight patients (13%) were lost to follow-up. Of the 395 patients, 12 (3%) had died of unrelated causes and 124 (31%) required further knee surgery. The remaining 259 (66%) completed the BOA patient satisfaction score and Oxford Knee Score. The probability of survival for HTO at 5, 10 and 15 years was 95%, 79% and 55% respectively. Multivariate regression analysis showed that only age < 50 years (p< 0.001) was associated with significantly longer survival. Mean Oxford Knee Score was 40/48 (range 17–60). Ninety-two percent (239/259 patients) were enthusiastic or satisfied and 90% (234/259 patients) would undergo HTO again at mean 11 years follow-up. Complications included: 5 pulmonary embolisms, 8 deep vein thromboses, 1 non-union, 1 post-operative subarachnoid hemorrhage and 1 transient peroneal nerve palsy. Conclusion: To our knowledge, we have reported the long-term follow-up of lateral closing wedge HTO in the largest group of patients in the literature. We found that the results of HTO do deteriorate over time but that HTO can be effective for as long as 19 years. In appropriately selected patients and circumstances, HTO gives high patient satisfaction and affords patients unrestricted activity for many years

Aims

The aim of this study was to present data on 11 459 patients who underwent total hip (THA), total knee (TKA) or unicompartmental knee arthroplasty (UKA) between November 2002 and April 2014 with aspirin as the primary agent for pharmacological thromboprophylaxis.

The February 2014 Knee Roundup³⁶⁰ looks at: whether sham surgery is as good as arthroscopic meniscectomy; distraction in knee osteoarthritis; whether trans-tibial tunnel placement increases the risk of graft failure in ACL surgery; whether joint replacements prevent cardiac events; the size of the pulmonary embolism problem; tranexamic acid and knee replacement haemostasis; matching the demand for knee replacement and follow-up; predicting the length of stay after knee replacement; and popliteal artery injury in TKR.

The February 2014 Research Roundup³⁶⁰ looks at: blood supply to the femoral head after dislocation; diabetes and hip replacement; bone remodelling over two decades following hip replacement; sham surgery as good as arthroscopic meniscectomy; distraction in knee osteoarthritis; whether joint replacement prevent cardiac events; tranexamic acid and knee replacement haemostasis; cartilage colonisation in bipolar ankle grafts; CTs and proof of fusion; atorvastatin for muscle re-innervation after sciatic nerve transection; microfracture and short-term pain in cuff repair; promising early results from L-PRF augmented cuff repairs; and fatty degeneration in a rodent model.

Thromboprophylaxis after elective orthopaedic surgery remains controversial. Recent guidelines from the National Institute for Clinical Excellence (NICE) have suggested that low molecular weight heparin should be given to all patients undergoing total hip replacement. The British Orthopaedic Association is currently debating this guideline with NICE, as it is not clear whether published evidence supports this view. We present the early mortality in our unit after total hip replacement using aspirin as chemical thromboprophylaxis. The 30-day and 90-day mortality after primary total hip arthroplasty was zero. We compare this with that reported previously from our unit without using chemical thromboprophylaxis. With the introduction of routine aspirin thromboprophylaxis, deaths from cardiovascular causes have dropped from 0.75% to zero.

These results demonstrate that there is a strong argument for the routine administration of aspirin after elective total hip replacement.

We describe a patient with a painful sciatic neuropathy after total hip arthroplasty. Treatment was confined to neuroleptic and analgesic agents until neurolysis at seven years abolished pain and restored function.