Introduction. Aged trauma patients with proximal femur fractures are prone to various complications. They may be associated with their comorbidities which also need to be adressed. These complications limit the patient”s postoperative health status and subsequently their activity and independency. As an attempt to improve the postoperative management of aged hip fracture patients a better understanding of the postoperative condition in these patients is necessary. Therefore, this meta-analysis is intended to provide an overview of postoperative complications in the elderly hip fracture patients and to improve the understanding of an adequate postoperative management. Material and method. Medline was used to screen for studies reporting on the complication rates of hip fracture patients > 65 years. The search criteria were: “proximal femur fracture, elderly, complication”. In addition to surgical studies, internal medicine and geriatric studies were also included. Randomized studies, retrospective studies as well as observation studies were included. Furthermore, reoperation rates as well as treatment-related complications were recorded. The 1-year mortality was calculated as outcome parameter. Results. Overall 54 studies were enrolled, published between 2011 and 2016. The mean age of the 9812 patients was 81 years (65–99 years). Follow-up was at least one year. The reoperation rate after osteosynthesis of pertrochanteric femur fractures was 8.7%. The reoperation rate was dependent on the type of fracture and the surgical method. Pneumonia (9,5%) and urinary tract infections (27%) were the most common postoperative infections. With 23%, delirium was one of the most common medical complications. The 1-year mortality rate was 18.7%. Conclusion. Orthogeriatric patients represent a complex patient population. Addressing the special needs of elderly patients reduces postoperative complications. Establishing comanagement or orthogeriatric wards can also be helpful to manage comorbidities and postoperative complications. It is important to not only choose the proper surgical procedure but to monitor orthogeriatric patients closely during their hospitalization

Objectives. We have increased the dose of tranexamic acid (TXA) in our enhanced total joint recovery protocol at our institution from 15 mg/kg to 30 mg/kg (maximum 2.5 g) as a single, intravenous (IV) dose. We report the clinical effect of this dosage change. Methods. We retrospectively compared two cohorts of consecutive patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA) surgery in our unit between 2008 and 2013. One group received IV TXA 15 mg/kg, maximum 1.2 g, and the other 30 mg/kg, maximum 2.5 g as a single pre-operative dose. The primary outcome for this study was the requirement for blood transfusion within 30 days of surgery. Secondary measures included length of hospital stay, critical care requirements, re-admission rate, medical complications and mortality rates. Results. A total of 1914 THA and 2537 TKA procedures were evaluated. In THA, the higher dose of TXA was associated with a significant reduction in transfusion (p = 0.02, risk ratio (RR) 0.74, 95% confidence interval (CI) 0.58 to 0.96) and rate of re-admission (p < 0.001, RR 0.50, 95% CI 0.35 to 0.71). There were reductions in the requirement for critical care (p = 0.06, RR 0.55, 95% CI 0.31 to 1.00), and in the length of stay from 4.7 to 4.3 days (p = 0.02). In TKA, transfusion requirements (p = 0.049, RR 0.64, 95% CI 0.41 to 0.99), re-admission rate (p = 0.001, RR 0.56, 95% CI 0.39 to 0.80) and critical care requirements (p < 0.003, RR 0.34, 95% CI 0.16 to 0.72) were reduced with the higher dose. Mean length of stay reduced from 4.6 days to 3.6 days (p < 0.01). There was no difference in the incidence of deep vein thrombosis, pulmonary embolism, gastrointestinal bleed, myocardial infarction, stroke or death in THA and TKA between cohorts. Conclusion. We suggest that a single pre-operative dose of TXA, 30 mg/kg, maximum 2.5g, results in a lower transfusion requirement compared with a lower dose in patients undergoing elective primary hip and knee arthroplasty. However, these findings should be interpreted in the context of the retrospective non-randomised study design. Cite this article: R. J. M. Morrison, B. Tsang, W. Fishley, I. Harper, J. C. Joseph, M. R. Reed. Dose optimisation of intravenous tranexamic acid for elective hip and knee arthroplasty: The effectiveness of a single pre-operative dose. Bone Joint Res 2017;6:499–505. DOI: 10.1302/2046-3758.68.BJR-2017-0005.R1

INTRODUCTION. Warfarin remains the treatment of choice for the majority of patients with venous thromboembolism, atrial fibrillation and valvular heart disease or valve replacement unless contraindicated. Poor management of patients on warfarin often leads to delay in surgery, life threatening bleeding during or after operation and unnecessary delay in discharge from hospitals in United Kingdom. METHODS. We carried out a prospective study on patients who were on warfarin and underwent elective and emergency orthopaedic procedures during period of study- August 2007 to April 2008. All patients included in the study were identified from admission notes during period of study. All data regarding indications for warfarin, pre and post procedures INR, elective or emergency orthopaedic procedures and complications were collected using a standard proforma. RESULTS. 18 patients, 12 male and 6 female were included into the study. Patients' age ranged from 47-87 with mean of 76. The indications for warfarin therapy were atrial fibrillation in 12 patients, deep vein thrombosis in 5 patients and left ventricular aneurysm in 1 patient. 18 procedures, 10 elective and 8 emergency orthopaedic procedures were carried out during period of study. Elective procedures - 7 primary joint arthroplasty, 1 revision hip arthroplasty, 1 removal of metalwork and 1 metatarsophalangeal joint fusion. Emergency procedures - 4 hip hemiarthroplasty, 2 dynamic hip screw fixation, 1 external fixator application and 1 open reduction and internal fixation of ankle. All elective admission patients were pre-assessed in clinic prior to admission and were advised to stop warfarin based on their INR level. Patients with INR 2-3 had their warfarin stopped 4 days prior to surgery while patients with INR 3-4.5 had their warfarin stopped 5 days prior to surgery. This group of patients had their INR check on admission and ranged from 1.1-1.5. This group of patients had no reversal therapy and no cancellations were made to their operation. 8 emergency admission patients had INR of 1.4-4.7 on admission with mean of 2.7. 5 patients had reversal therapy while 3 patients had no reversal therapy. Pharmacological methods used to reduce the INR were fresh frozen plasma in 1 patient and Vitamin K in 4 other patients. 2 patients that received reversal therapy had operation on day 1, 2 on day 3 and 1 on day 5. 1 patient that had no reversal therapy was operated on day 1, 1 on day 3 and 1 on day 5. Patient that received no reversal therapy and operated on day 5 of admission died post-operatively from medical complications. Mean delay for patient that had reversal therapy was 2.2 days compared to 3 days in patient with no reversal therapy. All patients in this study had prophylactic low molecular weight heparin while off warfarin. Patients were recommenced on their normal dose of warfarin the day after their operation. DISCUSSION & CONCLUSIONS. We conclude that patients on warfarin with INR 2-3 should have their warfarin stopped 4 days prior to surgery while patients with INR 3-4.5 should stop their warfarin 5 days prior to elective surgery. Trauma patients on warfarin requiring operation should have their INR reversed on admission to shorten delay in waiting time and improve outcomes