Aims. The aim of this study was to examine perioperative blood transfusion practice, and associations with clinical outcomes, in a national cohort of hip fracture patients. Methods. A retrospective cohort study was undertaken using linked data from the Scottish Hip Fracture Audit and the Scottish National Blood Transfusion Service between May 2016 and December 2020. All patients aged ≥ 50 years admitted to a Scottish hospital with a hip fracture were included. Assessment of the factors independently associated with red blood cell transfusion (RBCT) during admission was performed, alongside determination of the association between RBCT and hip fracture outcomes. Results. A total of 23,266 individual patient records from 18 hospitals were included. The overall rate of blood transfusion during admission was 28.7% (n = 6,685). There was inter-hospital variation in transfusion rate, ranging from 16.6% to 37.4%. Independent perioperative factors significantly associated with RBCT included older age (90 to 94 years, odds ratio (OR) 3.04 (95% confidence interval (CI) 2.28 to 4.04); p < 0.001), intramedullary fixation (OR 7.15 (95% CI 6.50 to 7.86); p < 0.001), and sliding hip screw constructs (OR 2.34 (95% CI 2.19 to 2.50); p < 0.001). Blood transfusion during admission was significantly associated with higher rates of 30-day mortality (OR 1.35 (95% CI 1.19 to 1.53); p < 0.001) and 60-day mortality (OR 1.54 (95% CI 1.43 to 1.67); p < 0.001), as well as delays to postoperative mobilization, higher likelihood of not returning to their home, and longer length of stay. Conclusion. Blood transfusion after hip fracture was common, although practice varied nationally. RBCT is associated with adverse outcomes, which is most likely a reflection of perioperative anaemia, rather than any causal effect. Use of RBCT does not appear to reverse this effect, highlighting the importance of perioperative blood loss reduction. Cite this article: Bone Joint J 2022;104-B(11):1266–1272

Aims. The aim of this study was to investigate the hypothesis that a single dose of tranexamic acid (TXA) would reduce blood loss and transfusion rates in elderly patients undergoing surgery for a subcapital or intertrochanteric (IT) fracture of the hip. Methods. In this single-centre, randomized controlled trial, elderly patients undergoing surgery for a hip fracture, either hemiarthroplasty for a subcapital fracture or intramedullary nailing for an IT fracture, were screened for inclusion. Patients were randomly allocated to a study group using a sealed envelope. The TXA group consisted of 77 patients, (35 with a subcapital fracture and 42 with an IT fracture), and the control group consisted of 88 patients (29 with a subcapital fracture and 59 with an IT fracture). One dose of 15 mg/kg of intravenous (IV) TXA diluted in 100 ml normal saline (NS,) or one dose of IV placebo 100 ml NS were administered before the incision was made. The haemoglobin (Hb) concentration was measured before surgery and daily until the fourth postoperative day. The primary outcomes were the total blood loss and the rate of transfusion from the time of surgery to the fourth postoperative day. Results. Homogeneity with respect to baseline characteristics was ensured between groups. The mean total blood loss was significantly lower in patients who received TXA (902.4 ml (-279.9 to 2,156.9) vs 1,226.3 ml (-269.7 to 3,429.7); p = 0.003), while the likelihood of requiring a transfusion of at least one unit of red blood cells was reduced by 22%. Subgroup analysis showed that these differences were larger in patients who had an IT fracture compared with those who had a subcapital fracture. Conclusion. Elderly patients who undergo intramedullary nailing for an IT fracture can benefit from a single dose of 15 mg/kg TXA before the onset of surgery. A similar tendency was identified in patients undergoing hemiarthroplasty for a subcapital fracture but not to a statistically significant level. Cite this article: Bone Joint J 2021;103-B(3):442–448

Aims. The aim of this study was to evaluate the diagnostic value of preoperative serum CRP, white blood cell count (WBC), percentage of neutrophils (%N), and neutrophil to lymphocyte ratio (NLR) when using the fracture-related infection (FRI) consensus definition. Methods. A cohort of 106 patients having surgery for suspected septic nonunion after failed fracture fixation were studied. Blood samples were collected preoperatively, and the concentration of serum CRP, WBC, and differential cell count were analyzed. The areas under the curve (AUCs) of diagnostic tests were compared using the z-test. Regression trees were constructed and internally cross-validated to derive a simple diagnostic decision tree. Results. Using the FRI consensus definition, 46 patients (43%) were identified as infected. Sensitivity, specificity, and AUC of CRP were 67% (95% confidence interval (CI) 52% to 80%), 61% (95% CI 47% to 74%), and 0.64 (95% CI 0.54 to 0.74); of WBC count were 17% (95% CI 9% to 31%), 95% (95% CI 86% to 99%), and 0.57 (95% CI 0.50 to 0.62); of %N 13% (95% CI 6% to 26%), 87% (95% CI 76% to 93%), and 0.50 (95% CI 0.43 to 0.56); and of NLR 28% (95% CI 17% to 43%), 80% (95% CI 68% to 88%), and 0.54 (95% CI 0.46 to 0.63), respectively. A better performance of serum CRP was shown in comparison to the leucocyte count (p = 0.006), %N (p < 0.001), and NLR (p = 0.001). A statistically lower serum CRP level was shown in patients with an infection caused by a low virulence microorganism in comparison to high virulence bacteria (p = 0.008). We found that a simple decision tree approach using only low serum neutrophils (< 3.615 × 10. 9. /l) and low CRP (< 2.45 mg/l) may allow better identification of aseptic cases. Conclusion. The evaluated serum inflammatory markers showed limited diagnostic value in the preoperative diagnosis of FRI when using the uniform FRI Consensus Definition. Therefore, they should remain as suggestive criteria in diagnosing FRI. Although CRP showed a higher performance in comparison to the other serum markers, it is insufficiently accurate to diagnose a septic nonunion, especially when caused by low virulence microorganisms. Cite this article: Bone Joint J 2020;102-B(7):904–911

Aims. Low haemoglobin (Hb) at admission has been identified as a risk factor for mortality for elderly patients with hip fractures in some studies. However, this remains controversial. This study aims to analyze the association between Hb level at admission and mortality in elderly patients with hip fracture undergoing surgery. Patients and Methods. All consecutive patients (prospective database) admitted with hip fracture operated in a tertiary hospital between 2012 and 2016 were analyzed. We collected patient characteristics, time to surgery, duration and type of surgery, comorbidities, Hb at admission, nadir of Hb after surgery, the use and amount of red blood cells (RBCs) transfusion products, postoperative complications, and death. The main outcome measures were mortality at 30 days, 90 days, 180 days, and one year after surgery. Results. We included 829 patients; the mean age was 81 years (. sd. 11). Mortality at 30 days, 90 days, 180 days, and one year was 5.7%, 12.3%, 18.1%, and 23.5%, respectively. The highest mortality was observed in patients aged over 80 years (162/557, 29%) and in male patients (85/267, 32%). Survival at 90 days, 180 days, and one year after surgery was significantly lower in patients with a Hb level below 120 g/l at admission. In multivariate analysis, Hb level below 120 g/l at admission was found to be an independent factor associated with mortality (adjusted hazard ratio (aHR) 1.68 (95% confidence interval (CI) 1.22 to 2.31); p = 0.001), along with age (aHR 1.06 (95% CI 1.04 to 1.06); p < 0.001), male sex (aHR 2.19 (95% CI 1.61 to 2.96); p < 0.001), and need for RBC transfusions (aHR 1.10 (95% CI 1.02 to 1.19); p = 0.01). Conclusion. Our results suggest that low Hb at admission along with age and RBC transfusions is significantly associated with short- and long-term mortality after hip fracture surgery, independently of comorbidity confounders. Further studies should be performed to understand how preoperative Hb could be taken into account in perioperative management. Cite this article: Bone Joint J 2019;101-B:1122–1128

Aims. Compartment syndrome results from increased intra-compartmental pressure (ICP) causing local tissue ischaemia and cell death, but the systemic effects are not well described. We hypothesised that compartment syndrome would have a profound effect not only on the affected limb, but also on remote organs. Methods. Using a rat model of compartment syndrome, its systemic effects on the viability of hepatocytes and on inflammation and circulation were directly visualised using intravital video microscopy. Results. We found that hepatocellular injury was significantly higher in the compartment syndrome group (192 PI-labelled cells/10. -1 . mm. 3. , standard error of the mean (. sem. ) 51) compared with controls (30 PI-labelled cells/10. -1 . mm. 3. , . sem . 12, p < 0.01). The number of adherent venular white blood cells was significantly higher for the compartment syndrome group (5 leukocytes/30s/10 000 μm. 2. , . sem 1. ) than controls (0.2 leukocytes/30 s/10 000 μm. 2. , . sem . 0.2, p < 0.01). Volumetric blood flow was not significantly different between the two groups, although there was an increase in the heterogeneity of perfusion. Conclusions. Compartment syndrome can be accompanied by severe systemic inflammation and end organ damage. This study provides evidence of the relationship between compartment syndrome in a limb and systemic inflammation and dysfunction in a remote organ. Cite this article: Bone Joint J 2016; 98-B:1132–7

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To determine whether platelet-rich plasma (PRP) injection improves outcomes two years after acute Achilles tendon rupture.

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The aim of this study was to assess the safety and clinical outcome of patients with a femoral shaft fracture and a previous complex post-traumatic femoral malunion who were treated with a clamshell osteotomy and fixation with an intramedullary nail (IMN).

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Musculoskeletal infection is a devastating complication in both trauma and elective orthopaedic surgeries that can result in significant morbidity. Aim of this study was to assess the effectiveness and complications of local antibiotic impregnated dissolvable synthetic calcium sulphate beads (Stimulan Rapid Cure) in the hands of different surgeons from multiple centres in surgically managed bone and joint infections.

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This study aimed to investigate the clinical characteristics and outcomes associated with culture-negative limb osteomyelitis patients.

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The aim of the present study was to assess the outcomes of the induced membrane technique (IMT) for the management of infected segmental bone defects, and to analyze predictive factors associated with unfavourable outcomes.

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Monocyte-lymphocyte ratio (MLR) or neutrophil-lymphocyte ratio (NLR) are useful for diagnosing periprosthetic joint infection (PJI), but their diagnostic values are unclear for screening fixation-related infection (FRI) in patients for whom conversion total hip arthroplasty (THA) is planned after failed internal fixation for femoral neck fracture.

A 7-day randomised controlled pre-clinical trial utilising an existing extremity war wound model compared the efficacy of saline soaked gauze to commercially available dressings. The Flexor Carpi Ulnaris of anaesthetised rabbits was exposed to high-energy trauma using a computer-controlled jig and inoculated with 10. 6. Staphylococcus aureus 3 hours prior to application of dressing. Quantitative microbiological assessment demonstrated reduced bacterial counts in INADINE (Iodine) and ACTICOAT (Nanocrystalline Silver) groups and an increase in ACTIVON TULLE (Manuka Honey) group (2-way ANOVA p<0.05). Clinical observations were made throughout the study. Haematology and plasma cytokines were analysed at intervals. Post-mortem histopathology included subjective semi-quantitative assessment of pathology severity using light microscopy to grade muscle injury and lymph node activation. Tissue samples were also examined using scanning electron microscopy (SEM). There were no bacteraemias, abscesses, purulent discharge or evidence of contralateral axillary lymph node activation. There were no significant differences in animal behaviour, weight change, maximum body temperature or white blood cell count elevation nor in pathology severity in muscle or lymph nodes (Kruskal-Wallis). There was no evidence of bacterial penetration or biofilm formation on SEM. Interleukin-4 and Tumour Necrosis Factor α levels were significantly higher in the ACTIVON TULLE group (1-way ANOVA p<0.05). This time-limited study demonstrated a statistically significant reduction in Staphylococcus aureus counts in wounds dressed with INADINE and ACTICOAT and an increase in wounds dressed with ACTIVON TULLE. There was no evidence that any of these dressings cause harm but nor have we established any definite clinical advantage associated with the use of the dressings tested in this study

Introduction. Surgical treatment of spinal metastasis belongs to the standards of oncology. The risk of spinal cord compression represents an operative indication. Intraoperative bleeding may vary, depending on the extent of the surgical technique. Some primary tumors, such as the renal cell carcinoma, present a major risk for hemorrhage and preoperative embolisation is mandatory. The purpose of this study is to evaluate the possible benefit of embolisation in different types of primary tumors. Material and Methods. The charts of 93 patients (42 women, 51 men, mean age 60.5 years) who were operated for spinal metastasis, 30 cases with multiple levels, were reviewed. Surgical procedures were classified as: (1) thoracolumbar laminectomy and instrumentation, (2) thoracolumbar corpectomy or vertebrectomy, (3) cervical corpectomy. A preoperative microsphere embolisation was performed in 35 patients. The following parameters, describing blood loss, were evaluated: hemoglobin variation from beginning to end of surgery, blood volume in suction during the intervention, number transfused packed red blood cells units until day 5 after surgery. A Poisson model was used for statistical evaluation. Results. The origins of spinal metastasis were: 28 breast cancer (30.1%), 19 pulmonary carcinoma (20.4%), 16 renal cell carcinoma (17.2%), 30 other cancers (32.3%). An embolisation was always performed in metastasis of renal cell carcinoma. An embolisation was performed in 8 cases in breast, 3 in pulmonary and 9 in other cancers. In the breast cancer group, there was no difference between embolisation versus non-embolisation concerning intraoperative blood loss and transfusion (P=0.404). In the pulmonary group, no difference was found either, but the number of embolisation cases was limited. For other metastasis types, the embolisation had no significant influence (P=0.697). The type of surgical intervention (2) increased intraoperative bleeding significantly in all groups: breast (P=0.002), pulmonary (P=0007), others (P=0.001). The average intraoperative hemoglobin decrease was: 2.3 in renal, 2.5 in breast, 3.0 in pulmonary, 1.9 in other metastasis (P=0.692). Conclusion. Several studies have clearly shown that the preoperative embolisation of renal cell carcinoma is recommended because of their risk of hemorrhage. However, the benefits of this procedure have been less described for other metastatic vertebral lesions. For breast cancer and other carcinoma (mainly digestive and prostate), the results of this study do not indicate a clear benefit for patients who received an embolisation. The same tendency was observed for pulmonary metastasis. The extent of the operation (corpectomy or vertebrectomy) represents the main factor that influences intraoperative bleeding

Background. Thromboembolic disease is a common complication of total hip replacement (THR). The administration of postoperative anticoagulants is therefore highly recommended. The purpose of this study was to compare rivaroxaban with fondaparinux with regards to their safety and effectiveness for the prevention of venous thromboembolic events (VTE) after THR. Methods. We conducted an independent prospective study comparing VTE prevention strategies in two successive series of patients (Groups A and B) undergoing elective unilateral THR. Group A (n=253) received fondaparinux daily 2.5 mg for 10 days, followed by tinzaparin 4500 IU daily for one month. Group B (n=229) received 10 mg rivaroxaban daily for 40 days without platelet monitoring. All surgeries were performed by a single surgeon under general anesthesia using an active blood transfusion-sparing plan. In the absence of contraindications, patients received intra-operative administration of tranexamic acid to reduce postoperative bleeding. Preoperative and postoperative hemoglobin levels were recorded at regular intervals. Bleeding events were documented. The bleeding index was calculated by adding the number of red blood cell units and the difference in the hemoglobin level (in g/dL) between the first morning after the day of surgery and the seventh postoperative day (POD 7). After 5 to 10 days, all patients underwent bilateral lower-extremity duplex ultrasonography to screen for deep venous thrombi. Any clinical symptoms of pulmonary embolism were evaluated with spiral computed tomography lung scans. Clinical evaluation to look for evidence of deep venous thrombi and pulmonary emboli was performed at eight weeks postoperatively. Results. Baseline characteristics between the two groups were comparable. The rate of major bleeding events, proximal deep venous thrombi, and pulmonary emboli was nil in each group. The incidence of blood transfusion was 0.8% in Group A (2 of 253 hips) and 0.4% (1 of 229 hips) in Group B (p=1.0). The bleeding index analysis excluded 8 hips for which the hemoglobin value at POD 7 was not measured. The bleeding index was 1.03 (standard deviation, 0.88) in Group A and 0.8 (standard deviation, 0.80) in Group B (p<0.001). The incidence of bleeding index >2 was 10.5% (27 of 247 hips) in Group A and 3% (7 of 227 hips) in Group B (p<0.001). Discussion. We compared two series of patients treated with THR undertaken with postoperative anticoagulation to prevent VTE. The high level of success these anticoagulant treatments had at preventing VTE in our series could be attributed at least partially to the combination of an active blood-sparing transfusion plan with the use of anticoagulant molecules reported in the literature to be quite potent. Conclusions. This prospective study comparing two anticoagulant regimens in patients treated with THR did not detect any difference with regards to the efficacy of the treatments, although there was significantly less bleeding index in patients who received rivaroxaban

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To assess the safety of tranexamic acid (TXA) in a large cohort of patients aged over 65 years who have sustained a hip fracture, with a focus on transfusion rates, mortality, and thromboembolic events.

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To clarify the effectiveness of the induced membrane technique (IMT) using beta-tricalcium phosphate (β-TCP) for reconstruction of segmental bone defects by evaluating clinical and radiological outcomes, and the effect of defect size and operated site on surgical outcomes.

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The aims of this study were to characterize the frequency of missing data in the National Surgical Quality Improvement Program (NSQIP) database and to determine how missing data can influence the results of studies dealing with elderly patients with a fracture of the hip.

This study compared the quality of reduction and complication rate when using a standard ilioinguinal approach and the new pararectus approach when treating acetabular fractures surgically. All acetabular fractures that underwent fixation using either approach between February 2005 and September 2014 were retrospectively reviewed and the demographics of the patients, the surgical details and complications were recorded.

A total of 100 patients (69 men, 31 women; mean age 57 years, 18 to 93) who were consecutively treated were included for analysis. The quality of reduction was assessed using standardised measurement of the gaps and steps in the articular surface on pre- and post-operative CT-scans.

There were no significant differences in the demographics of the patients, the surgical details or the complications between the two approaches. A significantly better reduction of the gap, however, was achieved with the pararectus approach (axial: p = 0.025, coronal: p = 0.013, sagittal: p = 0.001).

These data suggest that the pararectus approach is at least equal to, or in the case of reduction of the articular gap, superior to the ilioinguinal approach.

This approach allows direct buttressing of the dome of the acetabulum and the quadrilateral plate, which is particularly favourable in geriatric fracture patterns.

Cite this article: Bone Joint J 2015;97-B:1271-8.

Exsanguination is the second most common cause of death in patients who suffer severe trauma. The management of haemodynamically unstable high-energy pelvic injuries remains controversial, as there are no universally accepted guidelines to direct surgeons on the ideal use of pelvic packing or early angio-embolisation. Additionally, the optimal resuscitation strategy, which prevents or halts the progression of the trauma-induced coagulopathy, remains unknown. Although early and aggressive use of blood products in these patients appears to improve survival, over-enthusiastic resuscitative measures may not be the safest strategy.

This paper provides an overview of the classification of pelvic injuries and the current evidence on best-practice management of high-energy pelvic fractures, including resuscitation, transfusion of blood components, monitoring of coagulopathy, and procedural interventions including pre-peritoneal pelvic packing, external fixation and angiographic embolisation.

Cite this article: Bone Joint J 2014; 96-B:1143–54.

We describe the impact of a targeted performance improvement programme and the associated performance improvement interventions, on mortality rates, error rates and process of care for haemodynamically unstable patients with pelvic fractures. Clinical care and performance improvement data for 185 adult patients with exsanguinating pelvic trauma presenting to a United Kingdom Major Trauma Centre between January 2007 and January 2011 were analysed with univariate and multivariate regression and compared with National data. In total 62 patients (34%) died from their injuries and opportunities for improved care were identified in one third of deaths.

Three major interventions were introduced during the study period in response to the findings. These were a massive haemorrhage protocol, a decision-making algorithm and employment of specialist pelvic orthopaedic surgeons. Interventions which improved performance were associated with an annual reduction in mortality (odds ratio 0.64 (95% confidence interval (CI) 0.44 to 0.93), p = 0.02), a reduction in error rates (p = 0.024) and significant improvements in the targeted processes of care. Exsanguinating patients with pelvic trauma are complex to manage and are associated with high mortality rates; implementation of a targeted performance improvement programme achieved sustained improvements in mortality, error rates and trauma care in this group of severely injured patients.

Cite this article: Bone Joint J 2014;96-B:1090–7.