Despite improved body armour haemorrhage remains the leading cause of preventable death on the battlefield. Trauma to the junctional areas such as pelvis, goin and axilla can be life threatening and difficult to manage. The Abdominal Aortic Tourniquet (AAT) is a pre-hospital device capable of preventing pelvic and proximal lower limb haemorrhage by means of external aortic compression. The aim of the study was to evaluate the efficacy of the AAT. Serving soldiers under 25 years old were recruited. Basic demographic data, height, weight, blood pressure and abdominal girth were recorded. Doppler Ultrasound was used to identify blood flow in the Common Femoral Artery (CFA). The AAT was applied whilst the CFA flow was continuously monitored. The balloon was inflated until flow in the CFA ceased or the maximum pressure of the device was reached. 16 soldiers were recruited. All participants tolerated the device. No complications were reported. Blood flow in the CFA was eliminated in 15 out of 16 participants. The one unsuccessful subject was above average height, weight, BMI & abdominal girth. This study shows the Abdominal Aortic Tourniquet to be effective in the control of blood flow in the pelvis and proximal lower limb and potentially lifesaving

Introduction. Haemorrhage is the main cause of preventable death on the modern battlefield. As Improvised Explosive Devices (IED) in Afghanistan become increasingly powerful, more proximal limb injuries are occurring. Significant concerns now exist about the ability of the windlass Combat Application Tourniquet to control distal haemorrhage following mid-thigh application. Aim. To evaluate the efficacy of the CAT windlass tourniquet in comparison to the newer pneumatic Emergency Military Tourniquet (EMT). Method. Serving soldiers were recruited from a military orthopaedic outpatient clinic. Participants' age, Body Mass Index and blood pressure were recorded and a short medical history obtained to exclude any arteriopathic conditions. Doppler ultrasound was used to identify the popliteal pulses bilaterally. The CAT was randomly self-applied by the participant at mid-thigh level and the presence or absence of the popliteal pulse on Doppler was recorded. This process was repeated on the contra lateral leg with the CAT now applied by a trained researcher. Finally, the EMT tourniquet was applied to the first leg and the presence of a popliteal pulse on Doppler recorded again. Results. 50 consecutive patients were invited to participate in the study. 15 declined to participate. 1 was excluded via pre-determined exclusion criteria. A total of 24 participants were recruited. The self applied CAT occluded popliteal flow in only 4 subjects (16.6%). The CAT applied by a researcher occluded popliteal flow in 2 subjects (8.3%). The EMT prevented popliteal flow in 18 subjects (75%). Statistical analysis demonstrated significance in the performance difference between the two tourniquets (p=0.001), but no significant difference between the two applications of the CAT (p=0.25). The BMI and systolic BP were significantly higher in those patients in whom the EMT failed (p=0.01 & p=0.04 respectively). Conclusion. This study demonstrates that the CAT tourniquet is ineffective in controlling arterial blood flow when applied at mid-thigh level. The EMT was successful in a significantly larger number of participants, and its failures may be related to increased BMI and systolic pressure

The rate of arterial injury in trauma patients with pelvic ring fractures has been cited as high as 15%. Addressing this source of hemorrhage is essential in the management of these patients as mortality rates are reported as 50%. Percutaneous techniques to control arterial bleeding, such as embolization and REBOA, are being employed with increasing frequency due to their assumed lower morbidity and invasiveness than open exploration or cross clamping of the aorta. There are promising results with regards to the mortality benefits of angioembolization. However, there are concerns with regards to morbidity associated with embolization of the internal iliac vessels and its branches including surgical wound infection, gluteal muscle necrosis, nerve injury, bowel infarction, and thigh / buttock claudication. The primary aim of this study is to determine whether pelvic arterial embolization is associated with surgical site infection (SSI) in trauma patients undergoing pelvic ring fixation. This observational cohort study was conducted using US trauma registry data from the American College of Surgeons (ACS) National Trauma Database for the year of 2018. Patients over the age of 18 who were transported through emergency health services to an ACS Level 1 or 2 trauma hospital and sustained a pelvic ring fracture treated with surgical fixation were included. Patients who were transferred between facilities, presented to the emergency department with no signs of life, presented with isolated penetrating trauma, and pregnant patients were excluded from the study. The primary study outcome was surgical site infection. Multivariable logistic regression was performed to estimate treatment effects of angioembolization of pelvic vessels on surgical site infection, adjusting for known risk factors for infection. Study analysis included 6562 trauma patients, of which 508 (7.7%) of patients underwent pelvic angioembolization. Overall, 148 (2.2%) of patients had a surgical site infection, with a higher risk (7.1%) in patients undergoing angioembolization (unadjusted odds ratio (OR) 4.0; 95% CI 2.7, 6.0; p < 0 .0001). Controlling for potential confounding, including patient demographics, vitals on hospital arrival, open fracture, ISS, and select patient comorbidities, pelvic angioembolization was still significantly associated with increased odds for surgical site infection (adjusted OR 2.0; 95% CI 1.3, 3.2; p=0.003). This study demonstrates that trauma patients who undergo pelvic angioembolization and operative fixation of pelvic ring injuries have a higher surgical site infection risk. As the use of percutaneous hemorrhage control techniques increase, it is important to remain judicious in patient selection

Cerebral Palsy (CP) is a group of disorders that affect movement and posture caused by injury to the developing brain. While prematurity and low birth weight are common causes in developed countries, birth asphyxia, kernicterus, and infections have been identified as predominant aetiologies in Africa. There is, however, very little information on the aetiology of CP in South Africa. The purpose of this study was to determine the aetiology, severity, and topographical distribution of CP in children undergoing orthopaedic surgery at our tertiary paediatric unit. A retrospective folder review was performed for patients with CP that underwent orthopaedic surgery from July 2018 to June 2022. Data was collected on perinatal circumstances, aetiology or risk factors for developing CP, severity of disability as classified by the Gross Motor Function Classification Scale (GMFCS) and topographical distribution. Descriptive analysis was performed. Two-hundred-and-thirty-four patients were included in the analysis. No specific aetiology could be identified in 51 (21.9%) patients. Hypoxic ischaemic encephalopathy (HIE) accounted for 23.6% of patients and was the most common aetiology across the different categories except for patients graded as GMFCS 2, in whom prematurity was the most common aetiology. Congenital brain malformations (10.5%) and cerebral infections, including HIV encephalopathy (11.4%) were the next most frequent aetiologies, followed by prematurity (7.6%), ischaemic stroke (6.8%) and intraventricular haemorrhage (6.3%). Fifty-two percent of patients were classified as GMFCS 4 or 5. There was a predominance of quadriplegic patients (37%) compared to hemiplegics (29%), diplegics (30%) and monoplegics (4%). Most patients undergoing orthopaedic surgery for musculoskeletal sequelae of CP were severely disabled quadriplegic patients in whom HIE was the predominant cause of CP. This emphasises the need for intervention at a primary care level to decrease the incidence of this frequently preventable condition

Introduction. Deep venous thrombosis (DVT) is a potentially serious complication after total hip (THA) and knee (TKA) arthroplasty, traditionally justifying aggressive prophylaxis with low molecular weight heparin (LMWH) or direct oral anticoagulants (DOA) at the cost of an increased risk of bleeding. However, fast-track procedures might reduce the DVT risk and decrease the cost-benefit ratio of the current recommendations. The objective of this study was to compare thrombotic and bleeding risk in an unselected population of elective THA and TKA with a fast-track procedure. MATERIAL - METHODS. A series of 1,949 patients were analyzed prospectively. There were 1,136 women and 813 men, with a mean age of 70 years. In particular, 16% were previously treated by antiplatelet agents and 8% by anticoagulants. All patients followed a fast-track procedure including early walking within 24 hours of surgery, and 80% of patients returned home after surgery, with a mean length of stay of 3 days (THA) or 4 days (TKA). The occurrence of a thromboembolic event or hemorrhagic complication has been identified. Results. Out of the 1,110 THAs, 5 thromboembolic events were identified (0.4%): 2 non-fatal pulmonary embolism and 3 DVTs. There was no impact of these complications on the final result. 19 hemorrhagic complications were identified (1.7%): 10 significant haematomas (3 of which were complicated by infection), 9 anemias (with 4 transfusions). Out of the 839 TKAs, 9 thromboembolic events were identified (1.0%): 4 non-fatal pulmonary embolism and 5 DVTs. There was no impact of these complications on the final result. 14 hemorrhagic complications were identified (1.7%): 8 haematomas including 4 reoperations, 6 anemias (with 5 transfusions). Discussion. Thromboembolic complications after elective THA and TKA have virtually disappeared, with a rate of 0.7%. On the other hand, bleeding complications are now more frequent, with a rate of 1.7%. This suggests that the cost-benefit ratio of preventive treatments with LMWH or DOA should be reassessed. Prescribing LMWH or DOA after elective THA and TKA with fast-track procedures exposes the patient to a much higher risk of bleeding than thrombotic risk. The use of aspirin may represent an acceptable compromise in these patients

Aims. Orthopaedic surgeries are complex, frequently performed procedures associated with significant haemorrhage and perioperative blood transfusion. Given refinements in surgical techniques and changes to transfusion practices, we aim to describe contemporary transfusion practices in orthopaedic surgery in order to inform perioperative planning and blood banking requirements. Methods. We performed a retrospective cohort study of adult patients who underwent orthopaedic surgery at four Canadian hospitals between 2014 and 2016. We studied all patients admitted to hospital for nonarthroscopic joint surgeries, amputations, and fracture surgeries. For each surgery and surgical subgroup, we characterized the proportion of patients who received red blood cell (RBC) transfusion, the mean/median number of RBC units transfused, and exposure to platelets and plasma. Results. Of the 14,584 included patients, the most commonly performed surgeries were knee arthroplasty (24.8%), hip arthroplasty (24.6%), and hip fracture surgery (17.4%). A total of 10.3% of patients received RBC transfusion; the proportion of patients receiving RBC transfusions varied widely based on the surgical subgroup (0.0% to 33.1%). Primary knee arthroplasty and hip arthroplasty, the two most common surgeries, were associated with in-hospital transfusion frequencies of 2.8% and 4.5%, respectively. RBC transfusion occurred in 25.0% of hip fracture surgeries, accounting for the greatest total number of RBC units transfused in our cohort (38.0% of all transfused RBC units). Platelet and plasma transfusions were uncommon. Conclusion. Orthopaedic surgeries were associated with variable rates of transfusion. The rate of RBC transfusion is highly dependent on the surgery type. Identifying surgeries with the highest transfusion rates, and further evaluation of factors that contribute to transfusion in identified at-risk populations, can serve to inform perioperative planning and blood bank requirements, and facilitate pre-emptive transfusion mitigation strategies. Cite this article: Bone Jt Open 2021;2(10):850–857

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

This is a study to investigate the diagnostic and prognostic value of MRI in spinal cord injury. We performed this prospective study on sixty two patients of acute spinal trauma. We evaluated the epidemiology of spinal trauma & various traumatic findings by MRI. MRI findings were correlated with clinical findings at admission & discharge according to ASIA impairment scale. Four types of MR signal patterns were seen in association with spinal cord injury-cord edema / non haemmorhagic cord contusion (CC), severe cord compression (SCC), cord hemorrhage (CH) and epidural heamatoma (EH). Isolated lesion of cord contusion was found in 40%. All other MR signal patterns were found to be in combination. In cord contusion we further subdivided the group into contusion of size < 3 cm and contusion of size > 3 cm to evaluate any significance of length of cord contusion. In cord heammorhage involving >1cm of the cord, focus was said to be sizable. On bivariate analysis, there was a definitive correlation of cord contusion (CC) involving <3cm & > 3cm of cord with sensory outcome. In >3cm, chances of improvement was 5.75 times lesser than in patients with CC involving <3cm of cord (odds ratio = 5.75 (95% CI: 0.95, 36), Fisher's exact p = 0.0427 (p<.05). In severe cord compression (SCC) the risk of poor outcome was more (odds ratio 4.3 and p=0.149) however was not statistically significant. It was noted that the patients in which epidural hematoma (EH) was present, no improvement was seen, however, by statistical analysis it was not a risk factor and was not related with the outcome (odds ratio – 0.5 and p = 0.22). Presence of cord oedema / non haemorrhagic contusion was not associated with poor outcome (odds ratio 0.25 and p=0.178). On multiple logistic regression / multivariate analysis for estimating prognosis, sizable focus of haemorrhage was most consistently associated with poor outcome (odds ratio −6.73 and p= 0.32) however it was not statistically significant. The risk of retaining a complete cord injury at the time of follow up for patients who initially had significant haemorrhage in cord was more than 6 fold with patients without initial haemorrhage (odds ratio 6.97 and p= .0047). Besides being helpful in diagnosis, MRI findings may serve as a prognostic indicator for clinical, neurological and functional outcome in acute spinal trauma patients

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

Introduction. Rivaroxaban, an oral factor Xa inhibitor, has been approved by USFDA for prophylaxis of deep vein thrombosis (DVT) and pulmonary embolism (PE) in hip and knee arthroplasties. Its indication in hip fracture surgery has been recently recommended in Asian venous thromboembolism (VTE) guidelines. Phase II dose-ranging study demonstrated that 5 mg rivaroxaban is as effective as enoxaparin for VTE prophylaxis with lower incidence of bleeding complication than the recommended 10 mg dose. Rivaroxaban is recommended to be given 6–8 hours after operation. However, many surgeons are hesitated to follow this guideline since it might increase post-operative blood loss and wound complication. Elderly patients, such as hip fracture patients, are generally at more risk of bleeding and wound complications. These patients may benefit from using the delayed and reduced-dose regimen. Methods. Since July 2011, all eligible hip fracture patients treated by single group of surgeons were given 5mg daily dose of rivaroxaban for VTE prophylaxis. Initial dose of rivaroxaban was given after drain had been removed (24–36 hours post-operatively) and continued for 14 days. Inclusion criteria are femoral neck fracture or intertrochanteric fracture in patients age 60 and over. Exclusion criteria are pathologic fracture, reoperation for failed fixation, chronic anticoagulant therapy, and allergy to rivaroxaban. Criteria by Aniwan and Rojnackarin were used for clinical diagnosis of DVT and PE. Suspected case of DVT and PE were sent for confirmation with Doppler U/S and Pulmonary Artery CT scan, respectively. All bleeding and wound complications were recorded. Numbers of blood transfusion were also recorded. Patients were followed for at least 6 weeks, all complications were recorded. Results. There were 79 hip fracture patients matching our criteria. They were composed of 54 femoral neck fractures and 25 intertrochanteric fractures. Mean age of patients was 76.3 years. All femoral neck fractures were treated with bipolar hemiarthroplasty and intertrochanteric fractures were treated with short cephalomedullary nail. Two patients (2.6%) were compatible with clinical criteria of DVT. However, Doppler ultrasound examinations do not demonstrate thrombus or intraluminal filling defect. There was no suspected case of PE. There was no major hemorrhagic wound complication requiring reoperation. Minor wound complications include 7 (8.9%) cases of prolong serous oozing and 1 (1.3%) superficial wound infection. Extrasurgical site bleeding includes 1 (1.3%) upper GI bleeding and 2 (2.5%) hematuria. None of the patients received more than 2 units of blood transfusion. Discussion and Conclusion. Delayed and reduced-dose regimen of rivaroxaban is effective for VTE prophylaxis in hip fracture patients. There is no major hemorrhagic wound complication. Nonetheless, extrasurgical site bleeding is frequent. Further randomized comparative study with larger number of patients should be performed to demonstrate whether the benefits of the modified regimen existed or not

Purpose. Hip arthroplasty is a good treatment option for displaced femoral neck fracture in elderly patients. However, neuromuscular disease such as cerebral infarction or hemorrhage can be a concerning problem for THA since dislocation after operation can frequently occur. The purpose of this prospective study was to evaluate the functional results of modified minimally invasive (MI) two-incision total hip arthroplasty (THA) with the use of large-diameter (>38mm) metal-on-metal articulation in patients with muscle weakness. Patients and Methods. 19 consecutive patients (19 hips) with displaced femoral neck fracture with muscle weakness were enrolled. There were 11 patients with cerebral infarction, 4 patients with cerebral hemorrhage and 4 patients with Parkinson's disease. In the lateral position, an anterolateral approach between the gluteus medius and tensor fascia lata and a posterior approach between the piriformis and gluteus medius were used. Surgical morbidity, functional recovery, radiological implantation properties, range of motion (ROM) and complications were assessed. Results. The mean operation time was 73.5 minutes and the average perioperative blood loss was 725.9cc. The mean head diameter used was 44 mm (38–50). The mean lateral opening angle of the acetabular component was 38.4°, the mean anteversion of the acetabular component was 16.4°, and the mean stem position was 0.3° valgus. The average postoperative ambulation time was 2.4 days. The mean Harris hip score was 81.0 at final follow-up, and the mean WOMAC score was 42.9. At final follow-up, there was no case of dislocation. There was no hypersensitivity, no osteolysis, and no revision. Conclusions. Our study suggests that the functional results of modified MI two-incision THA with the use of large-diameter metal on metal articulation in patients with muscle weakness can produce satisfactory early functional recovery and can reduce the dislocation rate

Purpose of the Study:. Spontaneous intraarticular haemorrhages are the most frequent bleeding episodes encountered in the haemophiliac population, causing pain, joint deformity and arthropathy. Chronic haemophiliac arthropathy is characterised by persistent joint swelling, proliferative synovitis, and damage to or loss of articular cartilage. Elimination of the synovitis is the key to prevention of recurrent intraarticular haemorrhages and joint damage. The purpose of the study was to investigate the indications for, and outcome of, radioactive synoviorthesis for haemophiliac arthropathy. Methods:. A retrospective study was done to assess the results of 12 intra-articular injections of radioactive Yttrium-90 colloid, performed in 10 patients from November 1993 to December 2006. Patients were referred by the Haematology Unit if they had a target joint, as defined as >2 bleeds into the same joint in the preceding 6 months. Follow up was conducted at 6 monthly intervals, assessing clinical and radiological outcomes. The radiological involvement of the target joint, the pre- and post-treatment range of movement, presence of synovitis and bleeding events were compared from presentation to that at follow up. Range of movement of each target joint was assessed and compared to that at follow-up. Results:. The average age at time of injection was 10.6 years (range 6–15). The duration of follow-up was 35 months (range 6 to 60 months). The involved joints had an average of 2 bleeds each in the 6 months preceding the injection (24 events). Following Yttrium injection only 1 out of 12 joints had a bleed in the subsequent 6 months (1 event). Synovitis of the target joint resolved in 11 of 12 joints. Nine target joints (75%) showed a favourable improvement in range of movement. Those with a favourable radiological score had a better clinical outcome, but even those with a poor score showed improvement. Conclusion:. In this study, intra-articular injection of radioactive Yttrium-90 colloid was shown to:. –. Significantly reduce bleeding events in a Haemophiliac cohort. –. Resolve synovitis in 11 out of 12 joints with haemophiliac arthropathy. –. Improve range of movement in the majority of patients. –. This was best in those with a better radiological appearance at presentation. –. Those with a poorer radiological grade also showed some improvement suggesting that while results are less certain, patients may still benefit from the intervention

Little literature exists about how trauma-induced anemia affects bone healing. Moreover, the definition of anemia has now changed. Until recently, anemia was defined as peripheral Hemoglobin (Hgb) of less than 10 grams/deciliter (gm/dL). Contemporary literature defines anemia as Hgb < 8gm/dL. This re-definition prompted three questions: (1) Does the presence of hemorrhagic anemia (Hgb< 10gm/dL) alter bone healing rates?; (2) If not, does the newer definition (Hgb< 8gm/dL) influence bone healing?; (3) If so, does the newer definition result in more profound changes in bone healing than those previously seen?. We reviewed the charts of patients treated for long bone, diaphyseal fractures over a ten-year period at a Level 1 Trauma Centre to determine rates of fracture healing when anemia by either definition was present. Patients who were skeletally immature, died during hospitalisation, or had incomplete medical records were excluded. All charts were reviewed for: development of anemia, need for blood transfusion, quantity of blood administered and subsequent association with bone healing. Inclusion criteria were met by 627 patients (700 individual fractures). When anemia was defined as Hgb< 10gm/dL, there was an 81.5% healing rate among anemic patients vs 88.8% in non-anemic patients (p=0.013); with a definition of Hgb< 8gm/dL, healing rates were 81.3% and 86.2%, respectively (p=0.041). Tibial healing was especially noted to be influenced (p = 0.002 and 0.0001, respectively). Femoral healing was likewise, but less dramatically, affected (p = 0.0082 and 0.0843). ANOVA showed no significance for open vs closed status, or NSAID use. Our study found a statistically significant difference in long bone healing between patients who developed anemia and those who did not. This is the first evidence based clinical review demonstrating that hemorrhagic anemia has a significant impact on the healing rates of long bone fractures, especially those of the tibia

Introduction. Previous hemodynamics studies in shoulder arthroplasty only evaluated Western population and mainly focused on risk factors of transfusion. However, Asians are relatively small, and have higher bleeding risk due to prothrombin-clotting-factor polymorphisms. Therefore, it is not appropriate to apply the results of previously studies directly to Asians. Authors compare different hemodynamics depending on the types of shoulder arthroplasties, and evaluate predictors for transfusion in Asian population. Methods. Total 212 shoulder arthroplasties (26 fracture hemiarthroplasty (fHA), 49 anatomical total shoulder arthroplasty (aTSA), 132 reverse total shoulder arthroplasty (rTSA), and 5 revision surgery) from August 2004 to January 2016 were retrospectively reviewed. Demographics, surgical factors and perioperative hemodynamic factors were compared for each type of arthroplasty. Multivariate regression analysis was conducted to determine predictors for transfusion. Results. Preoperative Hb and Hct level were lower in fHA group (11.9 ± 1.8g/dL, 35.1 ± 5.4%; p < 0.001, 0.001). Total drain output was higher in rTSA and revision (349.1 ± 191.7mL, 408.6 ± 125.8mL; p<0.001, <0.001), however, there was no significant difference of estimated blood loss (p=0.269). There was significant, but very weak correlation between drain output with Hb decrease in postoperative one day (r = 0.192; p = 0.007). However, there were not significant correlation between drain output with Hb decrease after postoperative 2 and 3 days (r = 0.185, 0.001; p = 0.241, 0.997). The overall transfusion rate was 11.3% (24/212); fHA 30.8% (8/26), aTSA 10.2% (5/49), rTSA 7.6% (10/132), revision 20% (1/5). In multivariate regression analysis, lower Hb level of preoperative period and postoperative 1 day were predictors for transfusion (OR = 0.481, 0.499; p = 0.002, 0.017) and cutoff-value were 12.15g/dL and 10.0g/dL, respectively (OR = 7.404, 5.499; p = <0.001, 0.001; Sensitivity=80%, 70%; Specificity=80%, 84%). Conclusion. In Asian, overall transfusion rate after shoulder arthroplasties was 11.3%, varied by type of arthroplasty. Lower Hb level of preoperative period (<12.15g/dL) and postoperative 1 day (<10.0g/dL) were predictors for transfusion. Surgeons should consider different hemodynamics depending on different types of shoulder arthroplasty, and close monitoring of perioperative Hb level is essential to decrease hemorrhage-related complications, because drain output could not represent perioperative hemorrhage

We report a case of fatal heart failure caused by cobalt intoxication after revision THR in the patient who successfully underwent re-revision THR. 53-year old male presented to emergency room in our hospital with progressive shortness of breath. Symptom was started about 6 months ago so he visited local hospital. He worked up for worsening dyspnea. Simple chest radiograph and enhanced heart MRI study were performed and they showed bilateral pericardial and pleural effusion. There was no evidence of ischemic change. Transthoracic echocardiogram showed the evidence of heart failure, left ventricular ejection fraction(EF) was 40%. He was admitted at local hospital and started on vasopressors but urine output was decreased and follow-up echocardiogram showed a 25% of EF. Patient recommended heart transplantation and transferred our hospital emergency room. He underwent sequential bilateral total hip arthroplasties using CoP bearing surfaces. At 12 years postoperatively, he presented to the other hospital with acute onset of left hip pain. He was diagnosed ceramic head fracture on his left hip. Head and liner change revision surgery was performed using Cobalt-Chrome alloy 28mm metal head and Protruded cross-linked polyethylene liners. In our hospital, the patient admitted cardiovascular department of internal medicine. Patient complained nonspecific fatigue and general weakness but had no other symptoms such as visual and hearing loss, cognitive dysfuction. During work-up, patient presented progressive left hip pain and complaint of discomfort for the mass on the left groin. He also complained Left leg weakness and numbness. Simple radiograph and enhanced CT study was done. Simple radiograph image shows radiodense area around the hip joint and radiologist suspected heterotopic ossification. The cardiovascular department consulted orthopedic department. In the image findings showed huge mass combined hemorrhagic component lining acetabular component extending psoas compartment and eccentric wear on cobalt-chrome alloy metal head. Also highly radiodense material was seen around neck inferor portion and severly deformed metal head was seen. It was highly suspected that metal related granuloma, which means severe metallosis. Performed heavy metals screen, cobalt levels were 397,800 μg/Land chrome levels were 236,000 μg/L suggesting cobalt toxicity. Hip joint aspiration was done for decompression as radiologic intervention and EDTA (ethylenediamine tetraacetate) chelation therapy started immediately. After 10 cycle chelating therapy, metal level was lowered cobalt levels by 255.2μg/L and chrome levels by 39.5 μg/L. When hospital day after 134, Medical condition of the patient was getting improved, we underwent revision surgery using ceramic on ceramic bearing surface. The patient discharged postoperative 79 days. Final heavy metals screen results were 27.79μg/L on cobalt and 22.17μg/L on chrome. Although there were also reported a good clinical result of revision surgery using MoP bearing, and some surgeons reluctant to use CoC articulation because of concerns about re-fracture of ceramic. But take into account like this devastating complication after cobalt-chrome wear caused by remained ceramic particles, we should carefully select which bearing is safer

Hemorrhage and transfusion requirements in spine surgery are common. This is especially true for thoracic and lumbar fusion surgeries. The purpose of this papersi to determine predictive factors for transfusion and their effect on short-term post-operative outcomes for thoracic and lumbar fusions. The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was used to identify patients that underwent lumbar or thoracic fusion surgery from 2010 to 2013. Univariate and multivariate regression analysis was used to determine predictive factors and post-operative complications associated with transfusion. A total of 14,249 patients were included in this study; 13,586 had lumbar fusion and 663 had thoracic fusion surgery. The prevalence of transfusion was 35% for thoracic fusion and 17.5% for lumbar fusion. The multivariate analysis showed that age between 50–60 (OR 1.38, CI: 1.23–1.54), age between 61–70 (OR 1.65, CI: 1.40–1.95), dyspnea (OR 1.11, CI: 1.02–1.23), hypertension (OR 1.14, CI: 1.02–1.27), ASA class (OR 1.73, 1.18–1.45), pre-operative blood transfusion (OR 1.91, CI: 1.04–3.49), and extended surgical time (OR 4.51, CI: 4.09–4.98) were predictors of blood transfusion requirements for lumbar fusion. While only pre-operative BUN (OR 1.04, CI: 1.01–1.06) and extended surgical time (OR 4.70, CI: 3.12–6.96) were predictors of transfusion for thoracic fusion. In contrast, higher pre-operative hematocrit was protective against transfusion. Patients transfused who underwent lumbar fusion had an increased risk to develop superficial wound infection, deep wound infection, venous thromboembolism, myocardial infarction and had longer length of hospital stay. Patients transfused who underwent thoracic fusion were more likely to have venous thromboembolism and extended length of hospital stay. However, mortality was not associated with blood transfusion. This study used a large database to characterise the incidence, predictors and post-operative complications associated with blood transfusion in thoracic and lumbar fusion surgeries. Pre- and post-operative planning for patients deemed to be at high-risk of requiring blood transfusion should be considered to reduce post-operative complication in this population

This study presents an unusual recurrent case of pigmented villonodular synovitis (PVNS) around a ceramic-on-metal (COM) hip retrieved at 9-years. PVNS literature relates to metal-polyethylene and ceramic-ceramic bearings. Amstutz reported 2 cases with MOM resurfacing and Xiaomei reported PVNS recurring at 14 years with metal-on-polyethylene THA. Friedman reported on PVNS recurrence in a ceramic THA. Ours may be the first reported case of recurrent PVNS of a ceramic-on-metal articulation. This young female patient (now 38-years of age) had a total hip replacement in 2006 for PVNS in her left hip. In her initial work-up, this case was presumed to be a pseudotumor problem, typical of those related to CoCr debris with high metal-ion concentrations. She had an CoCr stem (AML), 36mm Biolox-delta head (Ceramtec), and a Pinnacle acetabular cup with CoCr liner (Ultramet, Depuy J&J). This patient had no concerns regarding subluxation, dislocation or squeaking. Three years ago she complained of mild to moderate groin and thigh pain in her left hip. This worsened in the past year. She noticed increased swelling now with an asymmetry to her right hip. She went to the emergency room in Dec-2014 and was referred to a plastic surgeon. In our consult we reviewed MARS-MRI and CT-scans that demonstrated multiple mass lesions surrounding the hip. Laboratory results presented Co=0.7, Cr=0.3 ESR=38 and Crp=0.3. At revision surgery, the joint fluid was hemorrhagic/bloody with hemosiderin staining the soft tissues. Multiple large 4–5×5cm nodules were present in anterior aspect of the hip as well as multiple nodules surrounding posterior capsule and sciatic nerve. Pathology demonstrated a very cellular matrix with hemosiderin-stained tissue and multiple giant cells, which was judged consistent with PVNS. The trunnion showed no fretting, no contamination and no discoloration. The superior neck showed impingement due to low-inclination cup. There was minimal evidence of metal-debris staining the tissues. There was a large metallic-like stripe across the ceramic head. This is a particularly interesting case and may be the first reported recurrent PVNS around a ceramic-on-metal bearing (COM). Data is scant regarding clinical results of COM bearings and here we have a nine-year result in a young and active female patient. She was believed to have a metalosis-related pseudotumor yet her metal-ion levels were not alarmingly high and there was no particular evidence of implant damage or gross wear products. In addition, the CoCr trunnion appeared pristine. Our work-up continues with analyses of wear and histopath-evidence. This case may demonstrate the need for a broadening of the differential diagnosis when dealing with hip failures

Suction drains provide an easy and feasible method for controlling hemorrhage after total knee arthroplasty. However, there has been no compromise regarding the optimal clamping time for these drains. We conducted a randomized clinical trial to compare 12-hour drain clamping and continuous drainage after total knee arthroplasty in terms of wound complications, blood loss and articular range of motion. In order to eliminate any other factor except duration of clamping, we chose to compare knees belonging to one single person, as well as restricting the study to those knees undergoing surgery due to osteoarthritis. From a total of 100 knees (50 patients) studied, the 12-hour clamping method resulted in a significantly smaller amount of post-operative blood loss (p<0.001). The passive ranges of motion and wound complications were not significantly different between the two groups

With the drawdown from Afghanistan focus turns towards future operations, and their demands on the DMS. Training for surgeons deploying to military operations will have to take into account the decreased opportunities and experience gained by current conflicts. The aim is to focus on current UK surgical training for military operations specifically. A comparison is made with US surgical training. A questionnaire was distributed to UK military surgical consultants in General Surgery, Trauma and Orthopaedics and Plastic Surgery. A similar questionnaire was sent to deployed US surgeons in SE Afghanistan. Response rates of 55% were achieved. Respondents were questioned on their confidence to perform several key procedures. Most UK consultants were satisfied with their overall training for deployment. Satisfaction rates were high for the MOST course and Danish Surgery. US satisfaction with pre-deployment training was poor. The majority of respondents felt confident to perform all haemorrhage and contamination control procedures in an emergency. However, most felt training for military personnel should be lengthened by a year or more to include greater exposure to other specialties. Whilst satisfaction with surgical training is high, many UK surgeons appear to suggest an increase in specialty exposure in preparation for future deployments

An interesting case with excellent accompanying images, highlighting the significance of tourniquets in controlling exsanguination, whilst also raising the issue of amputation versus reconstruction in severely injured limbs. A 39 year old male motorcyclist was BIBA to the Midland Regional Hospital in Tullamore, following a head-on collision with a bus at high velocity. On arrival, he was assessed via ATLS guidelines; A- intubated, B- respiratory rate 32, C - heart rate 140bpm, blood-pressure 55/15 and D- GCS 7/15. Injuries included partial traumatic amputation of the right lower limb with clearly visible posterior femoral condyles, a heavily comminuted distal tibial fracture and almost complete avulsion of the skin and fat at the popliteal fossa. Obvious massive blood loss at the scene had been tempered by a passer-by who applied a beach towel as a makeshift tourniquet. CT Brain demonstrated extra-dural and subarachnoid haemorrhages with gross midline shift. Unfortunately, the neurosurgical team in Beaumont concluded that surgical intervention would be inappropriate. However, his kidneys had not sustained ATN and were made available for donation. Two vital surgical issues were featured in this case. Firstly, it highlighted the importance of tourniquets in controlling exsanguination in a trauma situation. 1. Secondly, it raised the critical issue of amputation versus reconstruction in severely injured limbs. 2,3. . Without prompt placement of a make-shift tourniquet by a passer-by, this patient would have almost certainly died at the scene of the accident. Two kidneys were successfully donated as a result. The importance of appropriate tourniquet use cannot be overstated. This case highlights its potential life or limb-saving capabilities in emergency trauma situations. It also raises the critical issue of amputation versus reconstruction in acute emergency situations