Patients with pelvic and acetabular fractures have a high risk of developing thromboembolic complications. Despite routine screening, the risk of PE remains high and may develop in patients with negative DVT screening. The search for a means to identify the patient ‘at risk’ has been elusive. 537 consecutive patients, referred to Royal Adelaide Hospital over a 20 year period for treatment of pelvic and acetabular fractures, were evaluated prospectively for pulmonary embolus (PE). 352 patients referred directly to the author were treated with variable dose heparin as prophylaxis to venous thromboembolic (VTE) disease. 184 patients primarily admitted under the general surgeons or to ITU, prior to referral to the author, were treated with fixed dose heparin or Enoxaparin. All patients were followed prospectively to determine the rate of pulmonary embolus. The heparin dosage requirements of those who developed pulmonary emboli were compared to those who did not. Patients were also identified for whom a clinical diagnosis of deep venous thrombosis (DVT) was made during the study and their heparin dosage requirements were determined. 7 of 352 patients treated with variable dose heparin developed PE (1.98%). 13 of 184 patients treated with fixed dose heparin, Enoxaparin, or combinations, developed PE (7.06%). An incidental finding of DVT was made in 36 patients. Of these, 10 patients (2.8%) were treated with variable dose heparin and 26 patients (14.1%) with fixed dose heparin or Enoxaparin. The average Injury Severity Score was higher in patients treated with variable dose heparin than those treated with fixed dose regimes. Patients treated with variable dose heparin who developed PE showed a progressively increasing heparin requirement. The majority of patients who did not develop PE (72%) showed a progressively decreasing heparin requirement (suggesting reversal of a prothrombotic state). 21% showed an initial increasing heparin requirement followed by a decreasing requirement (suggesting a prothrombotic state that was reversed, e.g. a DVT successfully treated by the increasing heparin dose provided by a variable dose regime). 4% manifested a static heparin requirement (suggesting maintenance of a prothrombotic state). 8 patients treated with variable dose heparin developed DVT. 6/8 patients manifested a phase of progressively increasing heparin requirement, followed by a decreased requirement, and 2/8 patients manifested a sustained level of heparin requirement. Patients with pelvic and acetabular fractures treated with variable dose heparin showed a rate of PE (1.98%). This is remarkably low compared with published rates of PE in such patients, and particularly compared with those patients treated only with chemoprophylaxis. The rate of PE was 3.5x higher and the rate of DVT was 5x higher in patients treated with fixed dose heparin or Enoxaparin. Patients who developed PE or DVT manifested an increasing heparin requirement. An increasing dosage of heparin may protect the ‘at risk’ patient from venous thromboembolism. Fixed dose unfractionated heparin/LMWH may be insufficient to treat the ‘at risk’ patient. An increasing heparin requirement may identify the patient ‘at risk’

Recent recommendations by the National Institute for Health and Care Excellence (NICE) suggest that all patients undergoing elective orthopaedic surgery should be assessed for the risk of venous thromboembolism (VTE). Little is known about the incidence of symptomatic VTE after elective external fixation. We studied a consecutive series of adult patients who had undergone elective Ilizarov surgery without routine pharmacological prophylaxis to establish the incidence of symptomatic VTE. . A review of a prospectively maintained database of consecutive patients who were treated between October 1998 and February 2011 identified 457 frames in 442 adults whose mean age was 42.6 years (16.0 to 84.6). There were 425 lower limb and 32 upper limb frames. The mean duration of treatment was 25.7 weeks (1.6 to 85.3). According to NICE guidelines all the patients had at least one risk factor for VTE, 246 had two, 172 had three and 31 had four or more. . One patient (0.23%) developed a pulmonary embolus after surgery and was later found to have an inherited thrombophilia. There were 27 deaths, all unrelated to VTE. The cost of providing VTE prophylaxis according to NICE guidelines in this group of patients would be £89 493.40 (£195.80 per patient) even if the cheapest recommended medication was used. . The rate of symptomatic VTE after Ilizarov surgery was low despite using no pharmacological prophylaxis. This study leads us to question whether NICE guidelines are applicable to these patients. . Cite this article: Bone Joint J 2014;96-B:426–30

The extraordinary majesty of THR, as it burst onto the scene 60 years ago, both dazzled and blinded. It dazzled patients and surgeons alike and simultaneously obstructed a clear eyed assessment of the human costs. It behooves current practitioners, who have benefited mightily by our progress, to pause and reflect thoughtfully on that progress. Look no further than the fact that the treatment of a benign disease left one patient out of every 50 dead. Dead from a pulmonary embolus and that over 25% of the patients threw pulmonary emboli. What were the big six major disadvantages: 1) Fatal pulmonary emboli; 2) Prosthetic joint infection; 3) Failure of fixation; 4) Dislocation; 5) Periprosthetic osteolysis; 6) Prolonged hospitalization. Start with the observation that THR in the modern era began with Charnley's experiment with Teflon articulations. Of the nearly 300 such operations done, nearly 300 failed. Ultrahigh molecular weight polyethylene was better- much better. But still it produced wear and periprosthetic osteolysis, afflicting an estimated 1 million patients. Periprosthetic osteolysis became the most common reason for failure, the most common reason for reoperation, the most common reason for fracture, and the most common reason for extremely difficult re-operations requiring major grafting. Reoperation rates in certain series were 20 to 30% from loosening and 20 to 40% from osteolysis. Dislocation catapulted the unsuspecting patient to the floor at a rate of one out of 20 patients and the initial rate of prosthetic joint infection was 10%. Most patients were hospitalised in the new neighborhood of 2.5 weeks, at huge expense. Massive progress has been made but forget not that this striking progress was not obsessively linear. Recall the recent, extraordinary and continuing massive failure of metal-on-metal total hip replacements, despite 40 prior years of experience, predicting that metal-on-metal total joints should be ‘just fine’. Over the past six decades every one of the six major disadvantages listed above has been reduced by an order of magnitude. The challenge to you is to continue that progress

Introduction:. Hallux surgery is the most commonly performed elective surgery in the foot and ankle. As with all surgery, there are many potential complications quoted in the literature. Venous thromboembolism (deep vein thrombosis and pulmonary embolism) incidence and prophylaxis, however, is not adequately addressed and remains controversial. Material and Method:. This prospective study includes one hundred patients who underwent hallux surgery. Risk factors implicated to increase the risk of developing venous thromboembolic disease as well as anaesthetic time, thigh tourniquet time and regional anaesthetic blocks were documented. Compressive ultrasonography was performed in all the patients postoperatively to assess for deep vein thrombosis. Results:. There was one incident of calf deep vein thrombosis (DVT). No patient developed a pulmonary embolus. The one patient who developed a DVT was not at any higher risk than the average patient in the study. Conclusion:. As a result of the low incidence of venous thromboembolic disease in this study, the authors do not recommend the routine use of chemical venous thrombo-prophylaxis in patients undergoing hallux surgery. The decision to give postoperative anticoagulation remains the surgeon's responsibility. The duration of prophylaxis will depend on when the patient is fully mobile

Background. This retrospective analysis was prompted by the authors' observation of the relatively high incidence of venous thromboembolism (VTE) in the surgical repair of acute Achilles tendon ruptures. Method. 88 patients were treated surgically for an acute Achilles tendon rupture. No prophylactic anticoagulation was given to any patients. The incidence of VTE was then reviewed retrospectively. Results. Five patients developed symptomatic deep vein thrombosis (5.7%) and one a near-fatal pulmonary embolus (1.1%). There were no major bleeding or cardiovascular adverse events. One patient developed a thrombus of the the lesser saphenous vein (1.1%) and there was one superficial sepsis (1.1%). A temporary peroneal nerve palsy occurred in one patient (1.1%). There were two re-ruptures (2.3%). Conclusion. There is no doubt that thromboprophylaxis must be given to the high risk patient and is also recommended for major orthopaedic surgery. Limited data is available for the use of thromboprophylaxis in foot and ankle surgery. In light of the unacceptably high incidence of venous thromboembolism in this study, the authors suggest that routine venous thromboembolism prophylaxis should be considered for these patients. MULTIPLE DISCLOSURES

Hip fractures are among the most common orthopaedic injuries and represent a growing burden on healthcare as our population ages. Despite improvements in preoperative optimisation, surgical technique and postoperative care, complication rates remain high. Time to surgery is one of the few variables that may be influenced by the medical team. The aim of the present study was to evaluate the impact of time to surgery on mortality and major complications following surgical fixation of hip fractures. Utilising the American College of Surgeons' National Quality Improvement Program (NSQIP) database, we analysed all hip fractures (femoral neck, inter-trochanteric, and sub-trochanteric) treated from 2011 to 2013 inclusively. We divided patients into three groups based on time to surgery: less than one day (<24h), one to two days (24–48h), and two to five days (48–120h). Baseline characteristics were compared between groups and a multivariate analysis performed to compare 30-day mortality and major complications (return to surgery, deep wound infection, pneumonia, pulmonary embolus, acute renal failure, cerebrovascular accident, cardiac arrest, myocardial infarction, or coma) between groups. A total of 14,730 patients underwent surgical fixation of a hip fracture and were included in our analysis. There were 3,475 (24%) treated <24h, 9,960 (67%) treated 24–48h, and 1,295 (9%) treated 48–120h. Thirty-day mortality and major complication rates were 5.0% and 6.2% for the <24h group, 5.3% and 7.0% for the 24–48h group, 7.9% and 9.7% for the 48–120h group respectively. After controlling for baseline demographic differences between groups (age, sex, race) as well as pertinent comorbidities (diabetes, dyspnea, chronic obstructive pulmonary disease, chronic steroid use, hypertension, cancer, bleeding disorders, and renal failure), time to surgery beyond 48h resulted in greater odds of both mortality (1.45, 95%CI 1.10–1.91) and major complications (1.45, 95%CI 1.12–1.84). Time to surgery is one of the few variables that can be influenced by timely medical assessment and access to the operation room. Expediting surgery within 48h of hip fracture is of paramount importance as it may significantly reduce the risk of mortality as well as major complications

Severe deformity and bone loss in patients with degenerative changes of the knee present a challenging surgical dilemma to the knee surgeon. We present the outcome following complex primary total knee replacements at our unit over 12 years undertaken by a single surgeon. Method:. 65 patients were followed up prospectively with regards to their pre- and post-operative Oxford knee scores, diagnoses, preoperative deformity, bone loss, surgical technique, type of implant used, bone substitutes, and perioperative, or long term complications. These patients were followed up annually. Result:. 70 complex primary total knee replacements were performed in 65 patients. The mean age was 70.5 years and the mean follow up was 62.4 months. Sleeve/wedge augmentation, and stemmed implant (Sigma®TC3- DePuy) were used in general. Bone grafting was utilized for contained bone defects. All except 4 patients were allowed to fully weight bear immediately postoperatively. The mean range of flexion was 112.5 degrees at their last follow up. The mean preoperative Oxford Knee Score was 12.8, and 41.5 postoperatively. 89.4% of patients had either an excellent or good, and the rest a fair outcome. Radiological appearance has been satisfactory in all patients at subsequent follow up, with no evidence of implant loosening. None required revision surgery. 6 patients required blood transfusion postoperatively. 2 patents developed symptomatic deep vein thrombosis and a further 2 had pulmonary embolus. Conclusion:. Our experience with complex primary total knee replacements has been promising with a good outcome

Aim. To assess the incidence of fatal pulmonary embolism (PE) following elective total knee replacement (TKR) with a standardised multi-modal prophylaxis regime in a large teaching DGH over a 10 year period. Material and methods. Information was gathered from a prospective audit database, utilising clinical coding for TKR and those that had died within 42 and 90 days. The 10 years from April 2000 were analysed to establish both 42 and 90 day mortality rates. A multi-modal prophylaxis regime for all patients included regional anaesthesia (when possible), mechanical prophylaxis (Flo-tron calf garment per-operatively, AV impulse boots until mobile and anti-embolism stockings for 6 weeks), mobilisation within 24 hours and 75mg aspirin for 4 weeks. A case note review was performed to ascertain the causes of death. Where a patient had been referred to the coroner, the coroner's office was contacted for PM results. Results. There were 6,584 cases; the mortality rates at 42 and 90 days were 0.36 and 0.52%. There were no fatal PE's within 42 days of surgery. 2 fatal PE's occurred subsequently at 48 and 57 days (0.03%) The leading causes of death were myocardial infarction and cerebro-vascular accident. Conclusion. Fatal pulmonary embolus following elective TKR with a multi-modal prophylaxis regime is not a significant cause of mortality

NICE technology appraisal guidance 157 suggests that the oral anticoagulation medication Dabigatran etexilate can be used for the primary prevention of venous thromboembolic events (VTE's) in adult patients who have undergone elective total hip or knee replacement surgery. The NICE guidance reports that 13.8% of patients receiving recommended doses of Dabigatran experienced adverse bleeding events. In the pivotal hip and knee VTE trial, wound secretion only accounted for 4.9% of patients treated with Dabigatran (cf 3.0% of patients treated with Enoxaparin). We report our wound secretion experience after Dabigatran use at Warwick Hospital from March 2009 to March 2010. Of the 788 lower-limb arthroplasties performed, 55 patients (6.9%) had oozing wounds after discharge (Mean=8 days, Range=1-39 days). This resulted in 226 extra home-visits by discharge nurses, 26 positive microbiology cultures and 5 confirmed wound infections needing antibiotic treatment and/or surgical intervention. Incidentally, there were also 2 known cases each of deep vein thrombosis and pulmonary embolus in this cohort. The number of complications was markedly increased from previous years when LMWH was the VTE prophylaxis used. This data suggests that the use of Dabigatran in Warwick Hospital may significantly increase surgical site morbidity and resource output after lower limb arthroplasty

Purpose of the study:. The purpose of the study was to evaluate the possible causes or risk factors for the occurrence of venous thrombotic events (VTE) after shoulder arthroscopy. Methods:. Two cases that occurred in the practice were evaluated for the study. Evaluation of their medical history, procedures and post-operative care was made. The information was evaluated for possible risk factors that could have led to the VTE. Literature reports were also evaluated. All the relevant data (personal and literature) was used to determine risk factors that could help identify high risk patients undergoing arthroscopic shoulder surgery. Results:. Results revealed no intra operative risk factors for the VTE to occur. An underlying genetic predisposition in the one case and a previous history of VTE in the other were indentified as the major risk factors/causes. Literature review revealed that underlying mechanical causes should also be considered as possible risk factors. The rate of VTE occurring after a shoulder arthroscopy (0.6/1000 procedures) is much lower than when compared to knee, hip or spinal surgery. It should be noted however that upper limb VTE's have the highest risk of a pulmonary embolus developing as compared to a lower limb VTE. Conclusion:. Surgeons performing arthroscopic shoulder surgery also run the risk of their patients developing a VTE (upper or lower limb). The attending surgeon should assess and examine their patients preoperatively with as much scrutiny as they would their patients with upcoming knee, hip or spine surgery. Surgeons should have protocols in place to identify high risk patients. These should assess extrinsic as well as intrinsic risk factors. A high index of suspicion should also be maintained in the post-operative period

Background. In 2011 20% of intracapsular fractured neck of femurs were treated with an uncemented hemiarthroplasty in the English NHS. National guidelines recommend cemented implants, based on evidence of less pain, better mobility and lower costs. We aimed to compare complications following cemented and uncemented hemiarthroplasty using the national hospital episode statistics (HES) database in England. Methods. Dislocation, revision, return to theatre and medical complications were extracted for all patients with NOF fracture who underwent either cemented or uncemented hemiarthroplasty between January 2005 and December 2008. To make a ‘like for like’ comparison all 30424 patients with an uncemented impant were matched to 30424 cemented implants (from a total of 42838) in terms of age, sex and Charlson co-morbidity score. Results. In patients with an uncemented implant, 18-month revision (1.62% versus 0.57% (OR 2.90 [2.44–3.45], p< 0.001)), 4-year revision (2.45% vs 1.11% (OR 2.28 [1.45–3.65], p< 0.001)) and 30-day chest infection (8.14% versus 7.23% (OR 1.14 [1.08–1.21], p=0.028)) were significantly higher. Interestingly, 4-year dislocation rate was higher in cemented implants (0.60% versus 0.26% (OR 0.45 [0.36–0.55], p< 0.001). No significant differences were seen in 30-day return to theatre, myocardial infarction, cerebrovascular event or 90-day pulmonary embolus. Discussion. In this national analysis of matched patients short and medium term revision rate, and perioperative chest infection was significantly higher in the uncemented group. This supports the published evidence and national guidelines recommending cement fixation of hemiarthroplasty

Background. The most appropriate form of chemical thromboprophylaxis following knee replacement is a contentious issue. Most national guidelines recommend the use of low molecular weight Heparin (LMWH) whilst opposing the use of aspirin. We compared thromboembolic events, major haemorrhage and death after knee replacement in patients receiving either aspirin or LMWH. Methods. Data from the National Joint Registry for England and Wales was linked to an administrative database of hospital admissions in the English National Health Service. A total of 156 798 patients undergoing knee replacement between April 2003 and September 2008 were included and followed up for 90 days. Multivariable risk modelling was used to estimate odds ratios adjusted for baseline risk factors (AOR). An AOR < 1 indicates that risk rates are lower with LMWH than with aspirin. Results. In all, 23.1% of patients were prescribed aspirin and 76.9% LMWH. We found no statistically significant differences in the rate of pulmonary embolism (aspirin 0.49%, LMWH 0.45%, AOR 0.88; 95% confidence intervals (CI) 0.74 to 1.05), 90-day mortality (0.39% versus 0.45%, AOR 1.13; 95% CI 0.94–1.37) and major haemorrhage (0.37% versus 0.39%, AOR 1.01; 95% CI 0.83–1.22). There was a significantly greater likelihood of requirement for return to theatre in the aspirin group (0.26% versus 0.19%, AOR 0.73; 95% CI 0.58–0.94). Discussion. Between patients receiving LMWH or aspirin, there was no difference in the risk of pulmonary embolus, 90-day mortality and major haemorrhage. These results should be considered when the existing guidelines for thromboprophylaxis after knee replacement are reviewed

Background. Medical complications and death are rare events following elective orthopaedic surgery. Diagnostic and operative codes are routinely collected on every patient admitted to English NHS hospitals. This is the first study investigating rates of these events following total joint replacement (TJR) on a national scale. Methods. All patients (585177 patients) who underwent TJR (hip arthroplasty [THR], knee arthroplasty [TKR], or hip resurfacing) between 2005 and 2010 were identified. Patients were subdivided based on Charlson co-morbidity score. Data was extracted on 30-day complication rates for myocardial infarction (MI), cerebrovascular event (CVA), chest infection (LRTI), renal failure (RF), pulmonary embolus (PE) and inpatient 90-day mortality (MR). Results. The overall 90-day MR after THR was 0.44% (1116 of 256013 patients), after hip resurfacing 0.06% (17 in 27314), and after TKR 0.34% (1023 of 301850). MI rate was 0.39% (2257 of 585177). Of these 15.8% (356) died. CVA rate was 0.01% (53). Of these 32.1% (17) died. LRTI rate was 0.60% (3389). Of these 12.1% (410) died. RF rate was 0.35% (2066). Of these 13.9% (287) died. PE rate was 0.71% (4144). Of these 3.9% (161) died. For patients with no co-morbidities, no personal history of PE or DVT, and no post-operative complications (70.8% of all patients in this study, 414061 of 585177), MR was 0.09% (394 patients). Discussion. This national data analysis allows a greater understanding of mortality risk following post-operative complications. Despite the concerns regarding VTE and the high investment in prevention, fatal PE is in fact far less common than mortality after MI, LRTI and RF. This data also shows that the risk of mortality for fit patients without post-operative complications was very low

Aims. Revision total hip arthroplasty is a common operation. The MP Link (Waldemar Link, Hamburg, Germany) system is a distally loading, modular, tapered femoral stem component for revision hip surgery. MP Link in revision total hip arthoplasty was investigated clinically, radiologically and with Oxford hip scores. Methods. A prospective study was conducted of 43 patients undergoing revision total hip arthroplasty with MP Link prostheses between 2004 and 2010. The patients were operated upon by one of the senior authors (JM, JS, RC). Outcome data was collected in clinic and via patient questionnaires. Results. Of the 43 patients, 18 were males. The mean age at surgery was 70.88 years (range 37–97 years). The mean follow up was 33.1 months (range 10–61 months). Indications for revision surgery ranged from aseptic loosening in 34 patients (79.1%), infection in 7 (16.3%), periprosthetic fractures in 1 (2.3%) and recurrent dislocations in 1 (2.3%). None of the patients were lost to follow up. 4 patients died with asymptomatic, well-fixed stems. 2 patients requested to have their follow up referred to their local hospital after 6 and 28 months respectively. 1 patient developed a post-operative pulmonary embolus which was treated with warfarin and caused no further problems. The average Birmingham hip score following the revision surgery was 13.5/48. 100% of the patients had osteointegration of the stem and there were no cases of loosening or osteolysis. There was no radiographic evidence of distal migration of the stems. One patient who underwent revision for infection, became re-infected and underwent further revision surgery. Kaplan-Meier survivorship was 98%. Discussion. The early to mid term results of the uncemented, modular femoral MP link prosthesis are encouraging in complex revision total hip arthoplasty. Long term results are awaited

Background. The optimal strategy for postoperative deep venous thrombosis (DVT) prophylaxis remains among the most controversial topics in hip and knee arthroplasty. Warfarin, the most commonly used chemical anticoagulant, initially causes transient hypercoagulability; however the optimal timing of treatment with respect to surgery remains unclear. Our purpose was to evaluate the effects of pre- versus postoperative initiation of warfarin therapy with a primary endpoint of perioperative change in hemoglobin (pre- minus post-operative level), with secondary endpoints of postoperative International Normalized Ratio (INR), drain output, and bleeding/thrombotic events. Methods. A quasi-experimental study design was employed, under which patients were assigned to begin taking warfarin the night prior to surgery or the night following surgery based on day of the week seen in clinic. An a priori power analysis was conducted in order to ensure appropriate enrollment to detect a 0.5 g/dL difference in perioperative change in hemoglobin between groups, given an alpha level of 0.05 and beta of 0.80. Based on the results, the study included all primary, elective total hip and knee arthroplasties performed by a single surgeon over a 12 month period. Fifteen patients were excluded (7 chronic anticoagulation, 3 hip fractures, 2 medical contraindications, 3 simultaneous procedures), leaving 165 cases (108 hips, 57 knees) available for study. Of these, 73 received warfarin preoperatively (49 hips, 24 knees) and 92 postoperatively (59 hips, 33 knees). Warfarin was dosed according to a standard nomogram in both groups. INR (on postoperative days 1 and 2), perioperative decrease in hemoglobin (difference between level preoperatively and on postoperative days 1 and 2), and drain outputs were compared between groups using a student t test. Adverse events (transfusions, hematomas, epidural complications, and pulmonary embolus) were compared using two-tailed Fischer's exact test. Results. No statistically significant difference in perioperative hemoglobin change was observed between treatment groups on either postoperative day 1 (mean 3.279 versus 3.377, p=0.6824) or 2 (mean 4.0 versus 4.12, p=0.6831). As expected, the preoperative warfarin group demonstrated higher INRs on both postoperative days 1 (mean 1.18 versus 1.12, p=0.0023) and 2 (mean 1.46 versus 1.31, p=0.0006). Of note, preoperative warfarin dosing was also associated with significantly lower drain outputs (mean 185.4 versus 268.7, p=0.0025). 9 transfusions (4 preoperative dosing, 5 postoperative dosing), 3 hematomas (1 preoperative dosing, 2 postoperative dosing), and 1 pulmonary embolus (preoperative dosing) occurred, but no significant difference could be detected given the numbers available for study. Conclusions. Initiation of warfarin pre- rather than postoperatively was not associated with a significant difference in perioperative hemoglobin change, although a significant reduction in drain output was observed. Larger studies are needed to determine whether the risk of adverse events is increased with either dosing strategy

Assessing risk is a key skill for all surgeons, playing a vital role in such diverse settings informed consent, audit and surgical planning. We undertook this study to define what is an acceptable level of risk for orthopaedic surgeons undertaking lower limb arthroplasty in today's medicolegal climate. We surveyed all consultants and trainees registered with the NZOA and asked them what change in their complication rate would cause them to consider changing their practice. We also asked them how certain they would have to be that this change was real and not simply due to chance (the so-called “cluster effect”). The specific complications we considered were DVT/PE, dislocation of total hip replacement or deep infection in lower limb arthroplasty patients. This allowed us to calculate with 95% accuracy the levels of complication surgeons would deem unacceptable. Using Cochrane's criteria for statistically valid survey results we obtained a greater than 95% representative sample. From these responses we calculated levels of complication which would worry the “average” surgeon (median value), the “vast majority” (95%) of surgeons and a change in complication rate which would be required to satisfy “statistical significance” (i.e. the level set literature proof with p<0.05 and power of 0.8). When considering deep infection following hip or knee arthroplasty: using a baseline of 0.9% as an average published rate, the average surgeon would consider changing their practice if their rate reached 2.5% and 95% of surgeons would consider changing if their rate reached 5%. For hip dislocation the baseline was set at 2.5% with the average surgeon intervening if their rate rose to 4% and the vast majority of surgeons intervening at 10%. For fatal PE the baseline was given as 0.2% with the average surgeon auditing their practice at 0.8% and the vast majority of surgeons concerned with a rate of 2.2% or higher. No difference was found in consultant/trainee responses except in the reason given for use of thromboprophylaxis where consultants used it for prevention of fatal PE and registrars for non-fatal PE. These results could be used both as a potential guide for trainees and consultants in audit and also in guiding the use of, for instance, thromboprophylaxis where the “number needed to treat” for low molecular weight heparin to prevent one fatal pulmonary embolus in a year would necessitate national use/guidelines

Purpose:. Starting February 2012, our institution changed from enoxaparin (Lovenox) to the Factor Xa inhibitor, rivaroxaban (Xarelto) for venous thromboembolism prophylaxis after primary total hip (THA) and total knee arthroplasty (TKA). The purpose of our study was to compare rates of venous thromboembolism and rates of major bleeding between these two medications when used for venous thromboembolism prophylaxis after primary THA and TKA. Methods:. A retrospective review was performed on 1795 patients who underwent THA or TKA at our institution between January 1, 2011 and December 31, 2012. Patients were excluded if they had a bilateral procedure, partial arthroplasty (hip hemiarthroplasty, unicompartmental knee arthroplasty), revision surgery, and cases designated as complex. Patients were excluded if they were on other anticoagulants (dabigatran, aspirin, clopidogrel, warfarin, heparin, fondaparinux), or if pre-operative creatinine was 1.2 or greater. After excluding these patients, there were 1089 patients included in the study. Chart review recorded demographics (age, gender), comorbidities (BMI, ASA, creatinine), surgery performed (primary THA or TKA), length of stay (LOS), venous thromboembolic events (deep venous thrombosis [DVT], pulmonary embolus [PE]), post-operative infections, and major bleeding events (stroke, post-operative bleeding requiring transfusion). Periprosthetic infection rates are also currently being reviewed. T-tests were used to compare continuous variables between treatment groups, and Chi-square tests were used to compare categorical variables between treatment groups (α = 0.05). Results:. There were 779 patients (71.5%) who received enoxaparin and 310 patients (28.5%) who received rivaroxaban during the study period. Demographics of the patients are presented in Table 1. A comparison of venous thromboembolism rates. Pre-operative creatinine was higher in the enoxaparin group (0.81 ± 0.19 vs. 0.72 ± 0.18, p < 0.001). With the numbers available for study, there were no demonstrable differences in DVT (p = 0.400, power = 0.125), PE (p = 0.679, power = 0.066), cerebrovascular events (p = 0.913, power = 0.049), or transfusion rates (p = 0.412, power = 0.121). Conclusion:. To our knowledge this is one of, if not the largest non-industry funded studies comparing these two medications. There were no statistically demonstrable differences between the enoxaparin and rivaroxaban groups in terms of venous thromboembolism or major bleeding complications

Total knee arthroplasty has been associated with substantial blood loss in the perioperative period necessitating a substantial risk for blood transfusions. There are various methodologies utilized to decrease postoperative anemia and minimize the need for allogeneic blood transfusions. These include autologous pre-donation, the use of erythropoietin and the use of perioperative cell salvage. Although all of these are successful in decreasing postoperative anemia, there is still a significant risk of allogeneic blood transfusions in the postoperative period. This is a retrospective review of a consecutive series of total knee replacements investigating blood loss and the need for postoperative blood transfusions utilizing MIS surgical techniques and Symphony (tm) platelet gel as the sole means of blood conservation. PATIENT DEMOGRPAHICS. Between January 1, 2005 to December 31, 2005, 83 total knee arthroplasties were performed in a variety of community hospitals by a single orthopedic surgeon. The mean age was 64 years (SD 11.6, range 28-90) and the mean BMI was 34.1 (SD 7.6, range 21.3 to 53.4). 71% of the patients were females and 29% males. All patients, regardless of deformity, age or size, had a quad sparing MIS total knee arthroplasty performed utilizing cemented posterior stabilized components and all patellae were resurfaced. No patients pre-donated any blood products or had erythropoietin and no drains were utilized postoperatively. All patients had application of Symphony (tm) platelet gel prior to the interoperative release of the tourniquet. All patients received Coumadin on the day of surgery and were managed for four weeks postoperatively to keep their INR approximately 2.0. RESULTS. The mean preoperative hemoglobin was 14 (SD 1.2, range 10.7 to 16.6). The average postoperative hemoglobin was 10.0 (SD 1.1, range 8.0 to 14.2). The average drop in hemoglobin was 4.0 with a SD of 1.1. A total of two patients were transfused in this series of 83 patients for a total transfusion rate of 2.4%. The average length of stay was 3.4 days with the SD of 3.7. No patients suffered a CVA, myocardial infarction or pulmonary embolus in the two-month postoperative period. CONCLUSIONS. The results show that even utilizing MIS surgical techniques and Symphony (tm) platelet gel, there is still substantial blood loss in patients undergoing unilateral total knee arthroplasty utilizing cemented components with a mean drop of hemoglobin of four grams or 20% of their mean preoperative hemoglobin. However, in spite of significant loss of hemoglobin, most patients tolerated the postoperative anemia very well and there were no complications in this series related to anemia and this did not prolong their length of stay, which was an average of 3.4 days. Only a very low percentage of patient's in this series required a postoperative transfusion (2.4%). This report supports the continued use of MIS surgical techniques along with Symphony (tm) platelet gel to minimize the need for postoperative transfusions in total knee arthroplasties

Introduction:. A pulmonary embolus (PE) occurs frequently in medical patients and acutely in post surgical total joint patients. While the two groups seem vastly different, there has never been an analysis of the location, number of emboli a patient has and size of the emboli in post-operative total joint arthroplasty patients compared to general medical patients. Studies have looked at the size of PEs relative to symptomatic patients; recent data have suggested the timeline of PE development is usually within the first few days after total knee arthroplasty (TKA) or total hip arthroplasty (THA). Methods:. We conducted a retrospective chart review at Providence Hospital from 2006 to 2011 of all THA and TKA patients who had a post-operative PE diagnosis and looked at their medical comorbidities, sex, age, procedure, post-operative day of PE, and size/location of PE using a novel pulmonary mapping tree database based on location of the PE on spiral computed tomography (CT). The same data, except for post-operative day, was collected for the medical population with a PE diagnosis. Size was defined based on level of blockage with small emboli occurring at different points within a lobe, medium being at the level of lobe, and large being either a saddle embolus or at the right or left pulmonary artery. Inclusion criteria for orthopaedic patients included THA or TKA performed prior to PE, PE within 1 month of surgery and CT confirming diagnosis of a PE. Medical patients meeting criteria had to have an admitting diagnosis of PE with CT confirmation of the PE. Exclusion criteria included V/Q scan alone to diagnose the PE. Results:. Of the 2878 TKA (2024 women, 854 men) and 1270 THA (749 women, 521 men) patients reviewed between 2006 and the first half of 2011, 51 developed a PE. Although 67% of all total joint patients were women, they comprised 92% (n = 47) of all PE patients (P < 0.0001). In 51 patients, there were 218 total emboli (mean of 4.3 emboli/patient). Medical patients had fewer emboli per patient (mean = 2.55, P = .001) and also had larger emboli than the total joint arthroplasty group (P = .01). Discussion:. Our study showed an overwhelmingly disproportionate amount of PEs in female orthopaedic patients, thus making them a higher risk to develop PE post-operatively. When we analyzed the distribution of the PEs, multiple small emboli were more common than solitary emboli. The clinical significance of this is unknown. Medical patients, however, had fewer and larger emboli per patient. The treatment of PEs has largely been ascribed to radiologic reports documenting the PE. We postulate a different therapy may be warranted in post-operative total joint arthroplasty patients, given the difference in the characterization of their emboli. Conclusions:. Women undergoing total joint arthroplasty had a significantly higher risk of developing a PE at our institution. The size and distribution of PEs have been elaborated in this study and may suggest that orthopaedic patients may not need the same anti-thrombotic therapy as medical patients with PE. A larger scale, descriptive analysis of PE is warranted in order to begin to question the appropriate anti-thrombotic therapy for post-operative THA or TKA patients compared to medical patients

This population-based study investigated the incidence and trends in venous thromboembolic disease after total hip and knee arthroplasty over a ten-year period. Death or readmission for venous thromboembolic disease up to two years after surgery for all patients in Scotland was the primary outcome. The incidence of venous thromboembolic disease, including fatal pulmonary embolism, three months after surgery was 2.27% for primary hip arthroplasty and 1.79% for total knee arthroplasty. The incidence of fatal pulmonary embolism within three months was 0.22% for total hip arthroplasty and 0.15% for total knee arthroplasty. The majority of events occurred after hospital discharge, with no apparent trend over the period. The data support current advice that prophylaxis should be continued for at least six weeks following surgery. Despite the increased use of policies for prophylaxis and earlier mobilisation, there has been no change in the incidence of venous thromboembolic disease.