Hip fractures are a common cause of morbidity and mortality in the elderly, with approximately 30,000 hip fractures a year in Canada. Many hip fracture patients are prone to heart failure and present anticoagulated with Warfarin for medical comorbidities including atrial fibrillation or previous thromboembolic disease. Reversal of warfarin anticoagulation to an INR < 1.5 preferred for surgery but this often contributes to a delay to hip fracture surgery, which increases patient pain, morbidity, mortality, and length of stay Octaplex is a small-volume prothrombin complex concentrate (PCC) that reverses Warfarin-related anticoagulation in 15–60 minutes. It has been shown to be safe and effective in the management of intracranial and gastrointestinal bleeding in warfarinised patients. It is recommended by Bone and Joint Canada as an option for urgent warfarin reversal in hip fracture patients. However, there has been no published literature on the use of Octaplex or other PCCs in orthopaedic patients. Our objective is to assess the effectiveness of Octaplex for rapid reversal of warfarin anticoagulation in hip fracture patients. A database review of all patients who received Octaplex was performed. Medical records of all hip fracture patients in Calgary who received Octaplex between December 2009 and February 2015 were reviewed. After application of inclusion and exclusion criteria, 33 patients were identified. A timeline of International Normalised Ratio (INR), Octaplex administration, and hip fracture surgery was recorded. Mortality and complications were assessed at 30 days. A single dose of Octaplex corrected the INR to < 1.5 in 29 cases (88%). Median time from administration of Octaplex to a measured INR < 1.5 was 1.1 hours. Median time from admission to hip fracture surgery was 22 hours. Mortality at 30 days was 15.2%, mostly from cardiac arrest. A further 12% of patients developed cardiac or thrombotic complications. Multiple medical comorbidities were common including coronary artery disease (55%), congestive heart failure (45%), and chronic pulmonary disease (39%). Patients who received both fresh frozen plasma (FFP) and Octaplex for warfarin reversal had much higher mortality than those who only received Octaplex (40% vs 4.3% mortality at 30 days), but also had more medical comorbidities. Octaplex is effective at rapidly reversing warfarin anticoagulation and reducing time to surgery, potentially reducing the morbidity and mortality of hip fractures. Administration of both Octaplex and FFP were associated with higher early mortality in this case series. Further research is required to assess the safety of Octaplex, vitamin K, and FFP for reversal of warfarin anticoagulation in this population

Patients with hip fractures should have surgery within 36 hours of admission to hospital. This reduces mortality and is required for hospitals to receive the NHS Best Practice Tariff. Many patients with hip fractures take Warfarin and reversing the effect of this frequently delays surgery. We report the results of a case-control study. The primary outcome measure was the number of patients with an INR of 1.7 or less on the day following admission to hospital. This is considered an acceptable INR for hip fracture surgery in our department. In the control group the dose of Vitamin K given was decided by the admitting doctor based on the patients' INR. In the intervention group all patients received 5mg of IV Vitamin K on admission. They had their INR rechecked at 6:00am the following morning and a further 2.5mg of Vitamin K was given if it was 1.8 to 2.0 and a further 5mg of Vitamin K was given if it was greater than 2.0. 350 patients with hip fractures were admitted to our department and 26 (7.4%) of these were taking Warfarin. The control group contained fourteen patients who had a mean INR of 3.3 on admission. The time taken to achieve an INR of 1.7 or less was one day for four patients; two days for nine patients and three days for one patient. The intervention group contained twelve patients who had a mean INR of 2.7 on admission. The time taken to achieve an INR of 1.7 or less was one day for eleven patients and two days for one patient. There were no complications caused by Warfarin reversal. A high proportion of patients with hip fractures take Warfarin. This can be reversed promptly and safely using our protocol

There is a narrow line between the benefits and risks of anticoagulant therapy. Many factors influence a patient’s response to warfarin, and careful monitoring is required to ensure that the therapeutic level of anticoagulation is achieved. The purpose of this retrospective review was to examine the relationship between the postoperative response to warfarin and the preoperative level of haemoglobin. The results showed that lower preoperative levels of haemoglobin are associated with an increased response to warfarin (p = 0.01)

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

Introduction. There are no specific and clear guidelines regarding management of trauma patients who are on Warfarin. The objective of this study was to compare two methods of anticoagulation management in the pre-operative period for this group. Methods. This study was conducted in two phases. In the first half (October 2005 to April 2006) the trauma patients on Warfarin were managed by the traditional method. The second group of patients who were admitted during May to December 2006 was given a single stat dose of Vitamin K (1 mg IV) in addition to stopping Warfarin and starting low molecular weight Heparin. There were 90 patients in this study, 45 in each group. There was no statistically significant difference in age distribution, INR on admission and medical co-morbidities in the two groups. Majority of patients were admitted with fracture neck of femur (43 in each group). All the patients had INR more than 1.5 on admission. Results. INR levels decreased to 1.5 or less in 3.8 days in the first group and 1.6 days in the second group (p< 0.05). The delay in surgery was 6.6 days in group one and was 2.8 days in the patients in group two (p< 0.05). Four patients in the group who did not receive Vitamin K developed medical complications in the pre-operative period. Patients given one dose of Vitamin K did not have any complications pre-operatively. There was no adverse effect of Vitamin K therapy like haemorrhage or clinically evident thrombosis. Conclusion. In our experience 1 mg of intravenous Vitamin K on admission for Warfarin reversal in patients requiring operative management of femur fractures is a safe and effective treatment to avoid delay in treatment

Introduction. Management of a patient with a neck of femur (NOF) fracture is a key aspect of orthopaedic trauma care, with around 75 000 new cases in the United Kingdom annually costing the health care over £ 2 billion. Delaying time to theatre for operative intervention of hip fractures negatively impacts on patient outcome and is one of the key aspects of the hip fracture best practice tariff (BPT). One aspect of the peri-operative management of patients with hip fractures implicated in delayed surgery is the use of long term warfarin for anticoagulation. Anticoagulation reversal is a common cause of operative delay. Aim. The aim was to establish the impact this cohort of population had on achieving the BPT and how we could improve it. Material and Methods. Retrospective data was collected over a period of 12 months using the national hip fracture data base (NHFD). The delay to theatre specifically those who were on warfarin was identified. 10 % of the identified cohort was delayed to theatre due to high international normalised ratio (>1.5) and failed to achieve BPT. This cost the trust a loss of around £ 43,200. We have now introduced a simple hand-held warfarin testing device in accident and emergency. All patients on warfarin from history will have a pin prick and instantaneous INR estimated while the routine bloods are dispatched to the laboratory. If INR > 1.5 a stat 2mg intra venous Vit K (IVK) is initiated and INR rechecked at 6 hrs and if indicated further IVK is administered. The device costs £ 800 which is one off investment. Each patient will cost £ 6 for the strips and controls. This will avoid potential huge revenue loss and aid better medical practice. Conclusion. By the use of this simple device and its introduction in the A and E department, we can avoid the time lost for the anticoagulation reversal. This will mean improved patient care and compliance with BPT can be achieved in this cohort of NOF fracture patients

Introduction. It is estimated 5% of patients over 65 years receive warfarin therapy. This paper aims to analyse whether a time delay to hip fracture fixation while waiting for the patients International Normalised Ratio (INR) to return to normal increases the mortality risk. Methods. A prospective database of 937 hip fractures was analysed. Patient demographics and time from admission to operation were recorded. The patients' INR on admission and during the preoperative period, the need for vitamin K reversal, and any postoperative thromboembolic compilations were recorded. Thirty-day mortality was obtained from the General Register Office for Scotland. Patients with a therapeutic INR were categorised into two groups: those who received vitamin K within 24 hours of admission and those who did not. Results. There were 27 patients (74% female, mean age 80.9 years) receiving warfarin for atrial fibrillation. Two patients had a subtherapeutic INR on admission and were excluded from further analysis. Nine of eleven patients receiving vitamin K (mean dose 1.3mg) had surgery within 48 hours of admission, whereas only five of the fourteen patients who did not receive vitamin K had surgery within this time (OR3.6, p=0.047). There were no thromboembolic complications during admission for either group. Thirty-day mortality was increased for both groups relative to standard rate (OR1.5, p=0.5, and OR2.4 p=0.2 respectively), but there was no significant difference between the groups (p=0.9). Conclusion. Patients with a fractured hip who are receiving warfarin for atrial fibrillation and have a therapeutic INR should receive low dose vitamin K on admission to facilitate early operative intervention and rehabilitation

Introduction. Peak incidence of pulmonary embolism (PE) typically occurs weeks after total hip (THA) or knee (TKA) arthroplasty, long after hospital discharge. We investigated risk factors for acute PE occurring during index hospitalisation. Methods. Retrospective review of an IRB-approved database identified 329 arthroplasties performed by a single surgeon between 2002 and 2007 at two University teaching hospitals. Warfarin (goal INR 2.0) was standard venous thromboembolism prophylaxis. Results. There were 126 (38.6%) primary THA, 86 (26.1%) primary TKA and 117 (35.3%) revision arthroplasties. Seven patients (7/329; 2.1%) experienced clinically evident non-fatal pulmonary embolism, including 5 after TKA (5/128; 3.9%) and 2 after THA (2/194; 1.0%). In-hospital PE occurred in 4 (1.2%) patients (3 TKA, 1 THA) at a mean 2.7 days (range 2-4 days) after operation, compared with 3 symptomatic events (2 TKA, 1 THA) occurring after discharge (mean 19.3 days; range 8-27 days). Three of four patients suffering acute in-hospital PE were on pre-operative warfarin for chronic atrial fibrillation. Among all patients on pre-operative warfarin, 3 (12.5%) sustained an early PE, with a relative risk of 38.1 times that of controls not on chronic warfarin therapy (p=0.001). Body mass index greater than 30 kg/m2, a history of previous venous thromboembolism, coronary artery disease, ASA score, and type of operation were all found to not be associated with increased risk of in-hospital PE. Conclusion. Acute symptomatic in-hospital pulmonary embolism was correlated with chronic pre-operative warfarin anticoagulation. Compared to historical controls, time to PE was shorter in patients on chronic warfarin. Rebound hypercoagulability after discontinuation of chronic warfarin in preparation for total joint arthroplasty represents a greater hazard than excessive bleeding; we advocate bridging anticoagulation with LMWH in these patients

Bleeding related wound complications including deep infection, superficial infection and haematoma cause significant morbidity in lower limb joint arthroplasty surgery. It has been observed anecdotally that patients requiring therapeutic anti-coagulation within the peri-operative period have higher rates of bleeding related complications and those requiring intravenous heparin particularly appear to do poorly. The aim of this study is to investigate the relationship between post-operative bleeding and wound complications in the patient requiring therapeutic warfarin, plus or minus heparin, in total hip arthroplasty surgery. This is a retrospective cohort study reviewing 1047 primary total hip replacements performed in a single centre over a five year period and comparing outcomes of the patients on warfarin (89) with a double-matched control group of patients not on warfarin (179). Outcomes included rates of deep infection, excessive wound ooze or haematoma, superficial infection, return to OT for washout and need for revision operation. The study group was then sub analysed comparing those on IV heparin plus oral warfarin, to those on warfarin alone. The warfarin group had significantly higher risk of deep joint infection (9% vs 2.2% p= 0.023), haematoma/wound ooze (28% vs 4% p < 0.001) and superficial infection (13.5% vs 2.2% p < 0.001) compared to the control group. In the sub analysis of the study group, those on IV heparin had significantly higher risk of haematoma/wound ooze (44% vs 28% p= 0.023) than those on warfarin alone. The requirement of therapeutic anti-coagulation in the peri-operative period is a tenuous balance between the complications of thrombo-embolic disease and bleeding-related morbidity. In the past, perhaps the full burden of bleeding related complications has not been appreciated, but now improved understanding will enable the both the surgeon and the patient to make more informed decisions regarding therapeutic anticoagulation in elective arthroplasty surgery

Background. Venous thromboembolism (VTE) is a common complication of pelvic and acetabular fracture fixation. There is, however, currently limited data to guide clinical decisions on thromboprophylaxis choice in these patients. Methods. This is a prospective study with retrospective analysis of all the patients who were admitted to the Northern General Hospital between August 2009 and March 2011. 2 consultants using same technique and peri-operative regime carried out all procedures. All patients were administered prophylactic enoxaparin and those who were admitted via another hospital had a pre-operative Doppler scan. Post-operatively all patients were commenced on warfarin, or low molecular weight heparin (enoxaprin) if warfarin was contra-indicated, and was continued for three months after discharge. Results. Eighty-nine patients were admitted during this period of which 25 were treated conservatively and were excluded from the study. The mean age of patients was 39.7 years (range 17 to 83) & 73% of those were men. 65% were involved in RTA and 49% had more than one injury. 46 patients were transferred from another hospital. Of those 3 had DVT confirmed on Dopplers and had IVC filters inserted preoperatively. 52 patients were treated with warfarin and 12 with Clexane. Two patients had warfarin related complications (thigh haematoma and small subdural haematoma). Both were treated conservatively and made a full recovery. Two of the warfarin-treated (3.8%) and one of enoxaparin-treated (8%) patients developed DVT/PE. One of the two warfarin-treated patients had a PE despite having an INR of 4.2 and the other patient upon transferring to local hospital had his warfarin stopped prematurely. Conclusions. The study shows that preoperative enoxaparin followed by postoperative warfarin is an effective thromboprophylaxis regime and is associated with low complication rate

Fractures of the Proximal Femur are a common and disabling injury requiring hospital admission and surgical treatment leading to approximately 86,000 inpatient episodes annually in the UK, with such patients occupying more than 20% of NHS orthopaedic beds. Based on current trends the number of hip fractures may rise to 120,000 per annum by 2015. As the age of the population increases, so does the prevalence of concomitant medical conditions. Atrial Fibrillation is rising in the general population. Recently, the benefit of treating these patients with warfarin to prevent stroke has been shown; as a consequence, the number of patients being treated with warfarin is on the increase. We have performed a retrospective study of all patients admitted to our unit with Fractures of the neck of the femur between 2001 and 2006, from the Accident and Emergency department with a primary diagnosis of Proximal Femoral Fracture (1987 patients). 138 patients were on long term warfarin at the time of their admission (6.9% of admissions). 90.4% were being warfarinised for AF, 7.6% for DVT and the rest for other indications. Of these Patients only 12 (8.7%) received active reversal to their warfarin. (All received vitamin K either orally or Intravenously). The average delay to theatre attributable to warfarin therapy was 41.1 hours (p-0.001). Active reversal allowed this delay to be negated (p-0.01), and did not delay the reloading of warfarin post-operatively (p-0.012). It also allowed an average of 10.2 days earlier discharge from the orthopaedic unit (p-0.001). This study shows that significant delays occur because of Warfarinisation of these patients and that active reversal seems to be beneficial in expediting surgical treatment and discharge from the orthopaedic unit

The timely management of anticoagulated elderly trauma patients remains a contentious issue. Presently, the literature consists of largely contradictory expert opinions without evidence from randomised control trials. This study seeks to audit the practices of a non-metropolitan orthopaedic service, as a prelude to developing a local protocol for optimal management. All orthopaedic admissions to Toowoomba Hospital from January 2004 to December 2008 were reviewed. Approximately 700 patients over the age of 60 years were admitted with lower limb trauma. Those patients with pre-injury medication with warfarin and clopidogrel were identified, along with chronologically matched untreated patients. Those patients with coexisting head-injures, and those with sub therapeutic INR (INR <1.5) on admission were excluded from the study groups. Groups were analysed with respect to age, Injury Severity Score, ASA, time to theatre, time to discharge, transfusion requirement, and complications. Statistical analysis was completed using the T-test. Of the 700 patients identified, 24 were treated with warfarin and 28 treated with clopidogrel. Two patients with pre-injury warfarin use were excluded due to sub therapeutic INR on admission (INR 1.0 and 1.3). The control and treatment groups were statistically similar with respect to age, Injury Severity Score, and ASA. Injury patterns were similar across groups with over 80% proximal femoral fractures in each group. In both the warfarin and clopidogrel groups there was a statistically significant increase in time from admission to theatre compared with their matched controls (P<0.001). Average number of days to theatre was seven days and five days for the clopidogrel and warfarin groups respectively, compared to two days for both control groups. There was no significant difference between the groups in length of time from operation to the end of their acute care. There was no increase in transfusion requirement in those patients with pre-injury clopidogrel use. Pre-injury warfarinisation demonstrated a trend toward increased transfusion requirement compared with the matched controls (P=0.052); however, this was not significant. There was no clinically significant increase in complications in those patients with pre-injury use of warfarin or clopidogrel. This study demonstrated no increased morbidity in elderly patients with lower limb trauma when being treated with anticoagulants prior to injury. However, there is a significant delay in operative intervention in these patients. We believe this presents a case for early reversal of anticoagulant therapy in order to expedite treatment

Total knee arthroplasty (TKA) is one of the most successful surgeries to relieve pain and dysfunction caused by severe arthritis of the knee. Despite developments in prophylactic methods, deep venous thrombosis (DVT) and pulmonary embolism (PE) continue to be a serious complication following TKA. Otherwise DVT/PE is known to be a relatively low incidence in Asian patients, its accurate incidence is still controversial. Therefore, we prospectively investigated the incidence of DVT/PE after primary TKA by contrast enhanced computed tomography (CE-CT) and venous ultrasonography (US) in Japanese Patients. Methods. We prospectively investigated 51 patients who underwent primary TKA at the hospital from July 2013 to December 2013. All were of Japanese ethnicity. The mean age at the surgery was 74.9 years and average BMI was 26.0. There were 45 (88.2%) cases of osteoarthritis and 5 (9.8%) of rheumatoid arthritis. A single knee surgery team performed all operations with cemented type prostheses by utilizing pneumatic tourniquet. There were 21 cases of one-staged bilateral TKA and 30 of unilateral TKA. All patients were applied intermittent pneumatic compression (IPC) until 24 hours and graduated compression stockings for 3[高木1] weeks after the operation. Beginning from the day after the surgery, the patients were allowed walking with walker, along with the gradual range of motion exercise for physical thromboprophylaxis. Low-dose unfractionated heparin (LDUH) as a chemical thromboprophylaxis was administered subcutaneously for 3 days after the surgery. Informed consent was obtained regarding this thromboprophylaxis protocol. CE-CT and venous US were performed at the 4th day after surgery and images were read by a single senior radiologist team. The patients without DVT/PE by examination, they did not take additional chemical thromboprophylaxis. In cases of existence of DVT, continuous heparin administration and oral warfarin were applied and adjusted in appropriate dose for treatment. Warfarin was continued to be applied for at least three months until the patients had no symptoms and normal D-dimer level. In cases of PE, additional ultrasonic echocardiography (UCG) was performed, and then we consulted cardiologist to treat for PE. Results. CE-CT was performed in 42 patients (82.3%), otherwise nine patients (17.7%) could not take the examination because of exclusion criteria. There was no side-effect regard to contrast medium. The incidence of DVT and/or PE was 32 patients (62.7%), including two PE (3.9%), 21 DVT (41.1%) and nine both PE and DVT (17.6%). Six-teen patients were used LDUH routinely for 3 days after surgery. Five patients were used continuous heparin administration and oral warfarin instead of using LDUH because of medical co-morbidities. Additional continuous heparin administration and oral warfarin after LDUH use was needed in 26 patients. Three patients who had duodenal ulcer with chronic pancreatitis, massive PE with right heart strain and multiple DVT/PE with HIT antibody were needed another treatment. Conclusion. We prospectively investigated 51 patients for DVT/PE after primary TKA using CE-CT and venous US. The incidence of DVT/PE after primary TKA was 62.7%, including 21.5% of PE, as high frequency in Japanese patients

Aim:. This prospective cohort study investigated whether the use of preoperative anticoagulants is an independent risk factor for the outcomes of surgical treatment of patients with a neck of femur fracture. Methods:. Data was obtained from a prospectively collected database. All patients admitted for a neck of femur fracture between Nov 2010 and Oct 2011 were included. This resulted in three hundred twenty-eight patients with 330 neck of femur fractures. Four groups were defined; patients preoperatively (i) on aspirin (n = 105); (ii) on clopidogrel (n = 28); (iii) on warfarin (n = 30); and (iv) without any anticoagulation history (n = 167, the control group). The non-warfarin group included the aspirin group, clopidogrel group and the control group. Primary outcome was the in-hospital mortality. Secondary outcomes were the postoperative complications, return to theatre and length of stay. Results:. Thirteen in-hospital deaths were identified, 4 deaths in the aspirin group, 1 death in the clopidogrel group, 2 deaths in the warfarin group and 6 deaths in the control group. No significant difference in the mortality rates was found between the different groups. Also in the secondary outcomes, no significant difference was found between the four groups. A trend to a higher wound complication rate for the warfarin group was detected. Conclusion:. The use of clopidrogel or aspirin pre operatively is not an influence on short term patient outcome for patients with a neck of femur fracture. Surgical procedures should not be delayed to reverse their influence

Financial impact and patient satisfaction with four different anticoagulants for hip and knee arthroplasty in patients with a previous history of VTE- A prospective randomised trial. Introduction. New generation oral anticoagulants (dabigatran/rivaroxaban) have recently become available for the prevention of venous thromboembolism (VTE) following hip and knee arthroplasty. Traditional therapies (warfarin/low molecular weight heparins) are less costly, but have several limitations. The aim of this study was to evaluate the financial impact of substituting enoxaparin and warfarin with newer therapies dabigatran and rivaroxaban. A secondary objective was to investigate patient satisfaction with these treatments. Methods. A randomised prospective study was conducted over a 12 month period. Patients with a history of VTE undergoing hip or knee replacement were randomised to receive one of four anticoagulants for five weeks post surgery. Information was gathered during the hospital stay and then post discharge, by telephone, for five weeks(35 days)to determine costs. The costs included cost of drug, nursing time, blood monitoring and transport costs. The patients were also asked to complete the Duke Anticoagulation Satisfaction Scale (DASS). The DASS is a 26 item questionnaire which has 7 responses for each question. Results. Although dabigatran and rivaroxaban had higher drug acquisition costs, warfarin and enoxaparin were financially more costly overall. These additional costs were mainly due to increased blood monitoring and time for training and administration which is not required for newer therapies. DASS scores were significantly better with dabigatran (38.5±5.1) and rivaroxaban (38.6±8.3) compared to warfarin (71.8±16.2) and enoxaparin (68.5±14.2) (p< 0.001). This indicates more satisfaction for patients prescribed dabigatran or rivaroxaban compared to traditional therapies. Conclusion. The use of new generation oral anticoagulants has the potential to significantly reduce the financial burden of thromboprophylaxis on the NHS with an additional benefit of better patient satisfaction when compared to traditional therapies

Purpose. To review the outcomes of patients undergoing manipulation under anaesthetic (MUA) after primary total knee arthroplasty (TKA) and predict those that may require such a procedure. Methods. Prospective analysis of patients who required MUA post TKA performed by two surgeons using the same prosthesis from 2003 to 2008. Compared to a control group of primary TKA matched for age, gender and surgeon. All patients in both groups had pre- and post-operative measurements of range of movement. Risk factors were identified including warfarin and statin use, diabetes and body mass index. Results. Seventy-two patients required an MUA out of 1313 TKAs (5.5%) compared to a control group of 50 patients. The mean arc of motion preoperatively was 89.0° (MUA group) vs 92.2° (control) (p=0.47), at discharge 71.0° vs 76.8° (p< 0.05) and 6 weeks follow-up 64.0° vs 97.3° (p< 0.0001). Post manipulation the mean arc of motion was 108° on table, 83.1° at 3 months follow-up and 81.9° at 12 months. Patients whose manipulation was within 3 months of TKA (23 patients) improved their mean arc of motion from 53.6° to 78.0° (p< 0.0025), those 3–12 months (42 patients) from 67° to 83.0° (p< 0.0001) and those >12 months (7 patients) 81° to 89° (p=0.32). Mean increase of extension was 3.7° on table and 3.6° at 12 months. Mean flexion increase was 40.5° on table and 15.7° at 12 months. The relative risk factor for requiring an MUA was 6.97 warfarin (p< 0.05), 1.58 statins, 2.85 diabetes and 1.17 obesity. Conclusions. MUA following primary TKA improves their range of motion if done within 12 months, however only 50% improvement is maintained. Patients with less than 75° flexion at discharge or those on warfarin therapy are likely to require a manipulation to improve their range of movement

The introduction of direct thrombin inhibitors in arthroplasty surgery has reignited the debate on the risk of wound complications when using chemical thromboprophylaxis. It has been suggested that direct thrombin inhibitors might lead to an increased risk of systemic and operative site bleeding and wound sepsis when compared to low molecular weight heparin. In July 2009, departmental thromboprophylaxis policy for patients undergoing hip and knee replacement surgery (including revision) was changed from subcutaneous enoxaparin for the duration of inpatient stay to dabigatran for 10 days (knees) or 28 days (hips) unless contraindicated. In the 2 years prior to policy change, 1091 patients underwent hip or knee arthroplasty (Group A), with 1150 patients undergoing the same procedures in the 2 years following July 2009 (Group B). A minority of patients were already on warfarin (2% in group 1, 3% in group 2). This study presents a retrospective analysis of all patients who returned to theatre within 30 days of joint replacement surgery to assess whether the change in unit policy caused any discernible increase in bleeding-related complications. In group A, 20 / 1091 patients (1.8%) returned to theatre within 30 days. 9 were for reasons unrelated to thromboprophylaxis (mainly dislocated hips), 4 for gastrointestinal bleeding and 7 for wound complications (haematoma, wound breakdown, or infection). In group B, 22 / 1150 patients (1.9%) returned to theatre within 30 days. 13 were for unrelated reasons, 4 for gastrointestinal bleeding, and 5 for wound complications. One patient with a wound complication was on warfarin and therefore did not receive dabigatran. The lower wound complication rate in group B was not statistically different. This study, in a large heterogeneous group of patients, suggests that a change from enoxaparin to dabigatran does not increase the incidence of early infection, or the risk of bleeding at the operative site or the gastrointestinal tract

The introduction of direct thrombin inhibitors in arthroplasty surgery has reignited the debate on the risk of wound complications when using chemical thromboprophylaxis. It has been suggested that direct thrombin inhibitors might lead to an increased risk of systemic and operative site bleeding and wound sepsis when compared to low molecular weight heparin. In July 2009, departmental thromboprophylaxis policy for patients undergoing hip and knee replacement surgery (including revision) was changed from subcutaneous enoxaparin for the duration of inpatient stay to dabigatran for 10 days (knees) or 28 days (hips) unless contraindicated. In the 2 years prior to policy change, 1091 patients underwent hip or knee arthroplasty (Group A), with1150 patients undergoing the same procedures in the 2 years following July 2009 (Group B). A minority of patients were already on warfarin (2% in group 1, 3% in group 2). This study presents a retrospective analysis of all patients who returned to theatre within 30 days of joint replacement surgery to assess whether the change in unit policy caused any discernible increase in bleeding-related complications. In group A, 20/1091 patients (1.8%) returned to theatre within 30 days. 9 were for reasons unrelated to thromboprophylaxis (mainly dislocated hips), 4 for gastrointestinal bleeding and 7 for wound complications (haematoma, wound breakdown, or infection). In group B, 22/1150 patients (1.9%) returned to theatre within 30 days. 13 were for unrelated reasons, 4 for gastrointestinal bleeding, and 5 for wound complications. One patient with a wound complication was on warfarin and therefore did not receive dabigatran. The lower wound complication rate in group B was not statistically different. This study, in a large heterogeneous group of patients, suggests that a change from enoxaparin to dabigatran does not increase the incidence of local or systemic complications of sufficient severity to warrant return to theatre

Following the outcomes of the RECORD trials the protocol of extended thromboprophylaxis in patients undergoing elective primary total hip or knee arthroplasty has been changed in our institution. Between June 2008 and May 2009 patients were offered extended thromboprophylaxis with 150mg of aspirin daily, commencing preoperatively on admission and continuing for a total of six weeks. From June 2009 onwards patients were treated with 10mg of rivaroxaban once daily for two weeks following total knee and five weeks following total hip arthroplasty commencing 4 to 6 hours postoperatively. Our cohorts were 700 patients before and after the introduction of the new regimen. The two groups were matched for age, sex and type of operation. All patients with no contraindication to treatment with aspirin or rivaroxaban respectively undergoing elective primary total hip or knee arthroplasty were included in the study. Patients receiving warfarin on admission were treated with warfarin postoperatively and were excluded. We have compared the two treatment protocols in terms of safety and efficacy. Results focus on 4 safety outcome measures including mortality, haemorrhagic complications, transfusion requirements and infection rates and 2 efficacy outcome measures including thromboembolic complications and length of inpatient stay. Rates of DVT were equal in the two cohorts (P< 0.005) as were the mortality rates. Transfusion requirements post-operatively were not affected by the introduction of the new regimen however there was a significant increase in both return to theatre rates and prolonged wound ooze (P< 0.005). Infection rates were slightly higher in the cohort treated with rivaroxaban but this was not statistically significant. We conclude that further trials need to be done to confirm the suitability of routine use of rivaroxiban

There were 70000 people admitted to hospital with fractured hips in 2007 and the incidence is rising by 2% each year. Hip fractures represent significant morbidity and mortality to patients and cost the NHS £1.8 billion annually. In 2008 the British Orthopaedic Association Standards for Trauma (BOAST) issued a 14-point guideline to be followed for the management of hip fractures. The aim was to improve secondary prevention of osteoporosis, reduce the falls risk and further fractures. This aimed to provide better care to improve the outcomes for patients and reduce the burden of hip fractures on society. The aim of the audit was to see if the BOAST guidelines are met before and after the transition to a level 1 MTC (Major Trauma Centre) and to measure any impact the change had. Methods: Prospective data was collected for three months in 2010, 2011 and 2012. 94 case notes were reviewed and compared to the outcomes laid out in the BOAST guidelines to see if standards were met. Overall adherence to the guideline's recommendations was high throughout the 3 sample months. For each of the 3 sample months 100% adherence was seen in all of the following criteria: further imaging if x-rays unclear, appropriate analgesia, pre-op assessment, seniority of surgeon, orthogeriatrician involvement, seniority of surgeons and submission to the National Hip Fracture Database. The main common area where adherence was less than 100% was with A and E breaches (i.e. greater than 4 hours referral to the ward). Despite relocation and transition to a level 1 MTC, the management of fractured neck of femur patients compared to the BOAST guidelines remained of a high standard. Further improvements have also been made since moving to the new hospital site where shortcomings in management have been identified. Improvements from year one to three include prophylactic antibiotics and warfarin reversal; there is now a new trust protocol in place for warfarin reversal in the case of hip fractures. Elsewhere adherence to the guidelines remains high across the sample months. Confirming that despite moving to a level 1 status the trauma team continues to be performing well and managing this group appropriately. In January 2012 BOAST published a second version of the hip fracture guidelines: A and E breaches were removed from the guidelines. There have also been several new additions to the guidelines, which prompt a further re-audit in the future