Aims. To determine whether platelet-rich plasma (PRP) injection improves outcomes two years after acute Achilles tendon rupture. Methods. A randomized multicentre two-arm parallel-group, participant- and assessor-blinded superiority trial was undertaken. Recruitment commenced on 28 July 2015 and two-year follow-up was completed in 21 October 2019. Participants were 230 adults aged 18 years and over, with acute Achilles tendon rupture managed with non-surgical treatment from 19 UK hospitals. Exclusions were insertion or musculotendinous junction injuries, major leg injury or deformity, diabetes, platelet or haematological disorder, medication with systemic corticosteroids, anticoagulation therapy treatment, and other contraindicating conditions. Participants were randomized via a central online system 1:1 to PRP or placebo injection. The main outcome measure was Achilles Tendon Rupture Score (ATRS) at two years via postal questionnaire. Other outcomes were pain, recovery goal attainment, and quality of life. Analysis was by intention-to-treat. Results. A total of 230 participants were randomized, 114 to PRP and 116 to placebo. Two-year questionnaires were sent to 216 participants who completed a six-month questionnaire. Overall, 182/216 participants (84%) completed the two-year questionnaire. Participants were aged a mean of 46 years (SD 13.0) and 25% were female (57/230). The majority of participants received the allocated intervention (219/229, 96%). Mean ATRS scores at two years were 82.2 (SD 18.3) in the PRP group (n = 85) and 83.8 (SD 16.0) in the placebo group (n = 92). There was no evidence of a difference in the ATRS at two years (adjusted mean difference -0.752, 95% confidence interval -5.523 to 4.020; p = 0.757) or in other secondary outcomes, and there were no re-ruptures between 24 weeks and two years. Conclusion. PRP injection did not improve patient-reported function or quality of life two years after acute Achilles tendon rupture compared with placebo. The evidence from this study indicates that PRP offers no patient benefit in the longer term for patients with acute Achilles tendon rupture. Cite this article: Bone Joint J 2022;104-B(11):1256–1265

Introduction. Nowadays, autologous platelet-rich plasma is used commonly in wound treatment. However, platelet gel, which was derived from allogeneic platelet-rich plasma (PRP) [1,2], has never been studied about efficacy in vivo or animal models. We aimed to determine efficacy of allogeneic platelet-gel on wound healing in rats by comparing with untreated, antibiotic-gel (Mupirocin 2%) treated and gel (sodium carboxymethylcellulose(NaCMC))-treated control. Methods. Fresh frozen plasma was centrifuged at 1200-G for 15 minutes to extract PRP which would be freeze-dried at −70°c, sterilized with gamma ray of Cobalt source 25 kGy and stored at −70°c. Then, processed freeze-dried PRP was mixed with gel base (NaCMC) as in form of allogeneic platelet-gel concentrated 30 mg/1g by sterilization process (table 1). Full-thickness of 6-mm-diameter skin punch biopsies were performed on 18 female Wistar rats which each rat had four wounds at back. Each wound was applied with untreated care, antibiotic-gel, NaCMC-gel and platelet-gel, respectively. Wound healing was studied from day 0–12. Animals were sacrificed with wound tissues removal on day 3, 7, 12 post-biopsy. Digital planimetric measurement device (VISITRAK, Smith and Nephew) was used in evaluation of total wound area on day 0, 3, 7, 12 post-biopsy. Histopathological changes of wound healing were studied, using 4-μm thickness section with haematoxylin-eosin (H&E) and Masson's trichrome-stain, under light microscope. Results. Platelet-gel reduced wound size more rapidly on day 3, 7 than other groups with statistical significance (p<0.05), although no statistically significant difference compared to antibiotic-treated wounds. Histological study confirmed earlier granulation forming and more collagen fibers in platelet-gel treated group when compared with others. discussion & Conclusions. Allogeneic platelet gel produced the satisfactory efficacy on acute wound healing in rat. This platelet gel needs further study in human for efficacy and safety that might be developed for using in acute wound treatment in the future

Chronic plantar fasciitis is a common but sometimes difficult condition to successfully treat. Platelet rich plasma (PRP), a concentrated bioactive component of autologous blood that is rich in cytokines and other growth factors, was compared with cortisone injection in the treatment of severe cases of plantar fasciitis resistant to traditional non-operative paradigms. Thirty-six patients (16 males 20 females) were prospectively block-randomized into two study groups. All patients had pre-treatment MRI and ultrasound studies consistent with plantar fasciitis. The first group was treated with a single ultrasound guided injection of 40 mg Depo-Medrol at the injury site and the second group was treated with a single ultrasound guided injection of un-buffered autologous PRP at the injury site. The cortisone group had an average age of 59 (24–74) and had failed 4 months (3–24) of standard non-operative management (rest, heel lifts, PT, NSAIDS, cam walker immobilization, night splinting, local modalities) and had pre-treatment AOFAS scores of 52 (24–60). The PRP group had an average age of 51 (21–67) and had failed 5 months (3–26) of standard non-operative management (rest, heel lifts, PT, NSAIDS, cam walker immobilization, night splinting, local modalities) and had pre-treatment AOFAS scores of 37 (30–56). All patients were then immobilized fully weight bearing in a cam walker for 2 weeks, started on eccentric home exercises and then allowed to return to normal activities as tolerated and without support. Post-treatment AOFAS scores in the cortisone initially improved to 81(60–90) at 3 months but decreased to 74 (56–85) at 6 months. Post-treatment AOFAS scores in the PRP group improved to 95 (84–90) at 3 months and remained excellent at 94 (87–100) at 6 months follow-up. This study suggests that platelet rich plasma injection is more effective and durable than cortisone injection for the treatment of severe chronic plantar fasciitis refractory to traditional non-operative management

Introduction. The delay looks radiographically as a fracture callus not very evident or absent 6 months after osteosynthesis. Patients undergo a long period of immobilization and this fact causes the increase the social cost of the disease. The technique we suggest aims to the reduce the period of immobilization and as a consequence the management costs of the disease. Materials and methods. Our technique includes the infiltration of the delay focus with platelet rich fibrin, bone marrow concentrated and demineralized bone matrix. Outpatients and radiographic checks were carried out 3, 6 and 12 months after surgery. The treatment was considered fail in case of absence of bone callus at 3 out of 4 corticals at the rx after 6 months from surgery. Results. From November 2008 we treated 14 patients (average age 35 years, range 18 to 53). The treatment was performed after an average period of 14 months (range 5 to 38) from the fracture. The average follow up was 12 months (range 3–30). After 3 months from surgery, seven patients bear full load, did not feel pain and X-ray showed an increase of osteogenesis. Two cases failed; in one of them the patient underwent another infiltration and in the other one we replaced the fixation. Conclusion. Our tecnique lets a reduction of healing times in patients with delay and can be performed through the One Day Surgery programme

Aims. The primary aim was to assess the independent influence of coronavirus disease (COVID-19) on 30-day mortality for patients with a hip fracture. The secondary aims were to determine whether: 1) there were clinical predictors of COVID-19 status; and 2) whether social lockdown influenced the incidence and epidemiology of hip fractures. Methods. A national multicentre retrospective study was conducted of all patients presenting to six trauma centres or units with a hip fracture over a 46-day period (23 days pre- and 23 days post-lockdown). Patient demographics, type of residence, place of injury, presentation blood tests, Nottingham Hip Fracture Score, time to surgery, operation, American Society of Anesthesiologists (ASA) grade, anaesthetic, length of stay, COVID-19 status, and 30-day mortality were recorded. Results. Of 317 patients with acute hip fracture, 27 (8.5%) had a positive COVID-19 test. Only seven (26%) had suggestive symptoms on admission. COVID-19-positive patients had a significantly lower 30-day survival compared to those without COVID-19 (64.5%, 95% confidence interval (CI) 45.7 to 83.3 vs 91.7%, 95% CI 88.2 to 94.8; p < 0.001). COVID-19 was independently associated with increased 30-day mortality risk adjusting for: 1) age, sex, type of residence (hazard ratio (HR) 2.93; p = 0.008); 2) Nottingham Hip Fracture Score (HR 3.52; p = 0.001); and 3) ASA (HR 3.45; p = 0.004). Presentation platelet count predicted subsequent COVID-19 status; a value of < 217 × 10. 9. /l was associated with 68% area under the curve (95% CI 58 to 77; p = 0.002) and a sensitivity and specificity of 63%. A similar number of patients presented with hip fracture in the 23 days pre-lockdown (n = 160) and 23 days post-lockdown (n = 157) with no significant (all p ≥ 0.130) difference in patient demographics, residence, place of injury, Nottingham Hip Fracture Score, time to surgery, ASA, or management. Conclusion. COVID-19 was independently associated with an increased 30-day mortality rate for patients with a hip fracture. Notably, most patients with hip fracture and COVID-19 lacked suggestive symptoms at presentation. Platelet count was an indicator of risk of COVID-19 infection. These findings have implications for the management of hip fractures, in particular the need for COVID-19 testing. Cite this article: Bone Joint J 2020;102-B(9):1219–1228

The aims were: (1) assess the influence of COVID-19 on mortality in hip fracture; (2) identify predictors of COVID-19 status, and (3) investigate whether social lockdown influenced the epidemiology of hip fracture. A multicentre retrospective study was conducted of all patients presenting to six hospitals with hip fracture over a 46-day period (23 days pre-/post-lockdown). Demographics, residence, place of injury, presentation blood tests, Nottingham Hip Fracture Score, time to surgery, operation, ASA grade, anaesthetic, length of stay, COVID-19 status, and 30-day mortality were recorded. Of 317 patients with hip fracture 27 (8.5%) had a positive COVID-19 test; only 7 (26%) had symptoms on admission. COVID-19-positive patients had significantly lower 30-day survival compared to those without COVID-19 (67% versus 92%, p<0.001). COVID-19 was independently associated with increased 30-day mortality adjusting for: (1) age, sex, residence (HR 2.93, p=0.008); (2) Nottingham Hip Fracture Score (HR 3.52, p=0.001), and (3) ASA (HR 3.45, p=0.004). Platelet count predicted subsequent COVID-19 status; a value <217 ×109/L was 68% specific and sensitive (95% CI 58 to 77, p=0.002). A similar number of patients presented with hip fracture pre-lockdown (n=160) and post-lockdown (n=157); there was no significant difference in demographics, place of injury, Nottingham Hip Fracture Score, time to surgery, ASA, or management. COVID-19 was independently associated with an increased 30-day mortality in hip fracture. Most patients with COVID-19 lacked suggestive symptoms at presentation. Platelet count was an indicator of risk of COVID-19 infection. These findings have urgent implications for the delivery of hip fracture services

Introduction. Increasing numbers of elderly patients are being prescribed Clopidogrel, an anti-platelet agent for medical reasons. There are no international guidelines as to the management of patients with hip fractures on Clopidogrel in peri-operative period especially in relation to timing of the surgery. In Waterford Regional Hospital in Ireland, hip fracture surgery is deferred for 4 days and platelets are reserved for the operative/post-operative period, in case they have significant bleeding or an associated complication. We conducted a retrospective study on patients admitted over a period of 1 year. Materials and methods. A retrospective review of case notes was performed on all the hip fractures on Clopidogrel that had been admitted over last 1 year. Age, Sex, ASA, number of cancellations, operation performed, length of stay, post-op complications including wound, blood & platelet transfusions data were recorded. Results. Over this period, we admitted 53 patients who sustained hip fractures who were on plavix. The mean age was 80.6 years and the male:female ratio was 25:28. The mean length of stay was 23.4 days (range 3 to 63 days). There was an average delay of 5.37 days between admission and surgery (range 1 to 11 days). An average drop of 1.16 gm between pre-operative and post-operative hemoglobin was noted (range 8.7 gm to 15.7 gm pre-operatively and 7.3 gm to 15 gm post-operatively). There were no wound hematomas or prolonged wound oozes. Only 2 of those patients needed platelet transfusions intra-operatively. The RCC transfusion rate was 0.86 units of blood/per patient. Conclusion. The policy of delaying surgery for 4 days needs to be questioned. There were no incidences of bleeding or hematoma formation in all of our patients. The ideal time to operate on hip fracture patients is within 24–48 hours of admission after medical optimisation

Aims

Frailty greatly increases the risk of adverse outcome of trauma in older people. Frailty detection tools appear to be unsuitable for use in traumatically injured older patients. We therefore aimed to develop a method for detecting frailty in older people sustaining trauma using routinely collected clinical data.

Early mortality in patients with hip fractures due to bony metastases is unknown. The aim was to quantify 30 and 90-day mortality in patients with metastatic hip fractures and identify markers associated with early death. Consecutive patients referred to orthopaedics with a metastatic proximal femoral fracture/impending fracture over a six-year period were compared to a matched control group of non-malignant hip fractures. Minimum follow-up was 1 year and data was analysed using the student´s t-test (significance p<0.05). From Jan 2010-Dec 2015, 163 patients were referred with metastatic proximal femoral lesions. 90-day mortality was three times higher than controls (44% 71/163 vs. 12% 4/33, p<0.01). Mean time from referral to surgery was longer in impending versus completed fractures (11 and 4 days respectively, p<0.05). Multiple biochemical markers were associated with early mortality in the metastatic group. Patients who died early were more likely to demonstrate low haemoglobin and albumin, and high c-reactive protein, platelets, urea, alkaline phosphatase and calcium (p<0.05). Several biochemical markers associated with early mortality reached clinical and statistical significance. These markers were combined into a score out of 7 and indicated a higher early mortality in metastatic patients compared to controls. Patients with a score of 5–6/7 were 31 times more likely to die within 90 days versus controls. This scoring system could be utilised to predict early mortality and guide management. The average delay to surgery of 4 days (completed) and 11 days (impending fractures) identifies a window to intervene and correct these abnormalities to improve survival

We measured the changes during operation in seven markers of coagulation in a prospective series of 84 patients with fractures of the tibia or femur who were undergoing reamed intramedullary nailing. All patients were also continually monitored using transoesophageal echocardiography to assess marrow embolism. In a subset of 40 patients, intraoperative cardiopulmonary function was monitored, using pulmonary and systemic arterial catheterisation. The procedure produced a significant increase in prothrombin time, activated partial thromboplastin time, the level of prothrombin fragments F. 1+2. and D-dimers, and a decrease in the fibrinogen level, suggesting activation of both the coagulation and fibrinolytic pathways. There was evidence of both platelet hyper-reactivity and depletion, as estimated by an increase in β-thromboglobulin levels and a decrease in the platelet count. In the patients who had invasive monitoring there was an incremental increase in mean pulmonary arterial pressure, with the changes being greatest during insertion of the guide-wire and reaming. The change in markers of coagulation, pulmonary artery pressure and arterial oxygen partial pressures correlated with the intraoperative embolic response. Greater changes in these parameters were observed during stabilisation of pathological fractures and in those patients in whom surgery had been delayed for more than 48 hours. Seven patients with pathological fractures developed more severe hypoxic episodes during reaming, which were associated with significantly greater arterial hypoxaemia, a fall in the right ventricular ejection fraction and an increase in the mean pulmonary artery pressure, pulmonary capillary wedge pressure, central venous pressure and the pulmonary vascular resistance index. These changes suggested that the patients had transient intraoperative right heart strain. Eight patients developed significant postoperative respiratory compromise. They all had severe intraoperative embolic responses and, in the three who had invasive monitoring, there was a significantly greater increase in pulmonary artery pressure and alveolar-arterial oxygen gradient, and a fall in the ratio of arterial partial pressure of oxygen to the inspired oxygen concentration. Operative delay, intraoperative paradoxical embolisation and the scores for the severity of the coagulative and embolic responses were predictive of the development of postoperative respiratory complications on univariate logistic regression analysis. On multivariate analysis, however, only the embolic and coagulative scores were significant independent predictors of respiratory complications

Lateral Epicondylitis is a common condition caused by angiofibroblastic hyperplasia of the tendinous insertion. Its treatment is varied and includes rest, physiotherapy, corticosteroid injection and surgical release. Of late, the role of Platelet Rich Plasma (PRP) injections have been explored, with positive results. We prospectively assessed the outcomes of lateral epicondylitis treated with PRP injections and compared the outcomes of ultrasound guided and ‘blind’ injection. This was a single centre prospective cohort study. Patient were assessed with the Disabilities of the Arm, Shoulder and Hand (DASH) Score. PRP was injected into and around the common extensor origin either with or without ultrasound guidance. The primary outcome measure was DASH score at 3 months. 45 (23F:22M) patients were recruited. The mean age was 50 years (range 35 to 79). The mean duration of follow-up was 106 days. The average pre-injection DASH score for both groups combined was 45.5 (11.7–87.5). The mean DASH score at 3 months follow-up was 27.7. The ultrasound guided injection group had a mean improvement in DASH score from 45.5 to 31.2. The “blind” injection group had a mean improvement in DASH from 44.4 to 27.7. No complications were noted. There was no statistically significant difference in improvement in DASH score between the two groups. Our study provides further evidence to support of the use of PRP injections in the treatment of epicondylitis of the elbow. Interestingly, however, we found that the use of Ultrasound guidance does not appear to improve patient outcomes

Purpose. To evaluate the long term results of the use of a postoperative autologous blood reinfusion system in total knee arthroplasty. Material and method. In a prospective study, 176 patients who underwent unilateral total knee replacement, during the period 2004–2008, were evaluated (study group or group A). In all these patients a reinfusion system of unwashed blood salvaged was applied, while supplementary homologous blood transfusion was performed when required. The admission of banked blood transfusion determined by haemoglobin value (<9mg/dL) and/or clinical signs (blood pressure, pulses, etc). The value of haemoglobin, haematocrite and platelets recorded preoperatively and the 1st, 5th and 15th day after operation. Results were compared with the material of our previous prospective randomized controlled study (control groups B and C), where in 60 patients, between the years 2002–2004, the effectiveness of postoperative autologous blood reinfusion had been proved. Results. 19 patients of group A required postoperatively 23 units of homologous blood (total study group requirements23 blood units or 0.13 units per patient) while in group B required 1.5 units/patient and in group C 0.3 units/patient. In the study group the total homologous blood requirements reduced by 91% compared with group B (patients without autotransfusion system applied) and by 47% compared with group C (patients with autotransfusion system applied). There was no statistically significant difference in the postoperative values of Hb and Ht between the groups. None of the patients developed any adverse reactions after reinfusion. The cost of blood management was reduced in study group by 76%. Conclusions. The use of an autotransfusion system postoperatively minimizes practically the demands for homologous banked blood transfusion in total knee arthroplasty

Introduction. Femoral neck fractures are an increasingly common injury in the elderly. Frequently these patients present taking Clopidogrel, an irreversible inhibitor of platelet aggregation. Although this is associated with an increased risk of intra-operative bleeding and also an increased risk of spinal haematoma where regional anaesthesia is employed, the recent SIGN (Scottish Intercollegiate Guidance Network) guidelines recommend that surgery should not be delayed. Methods. We conducted a retrospective review of consecutive patients admitted with femoral neck fractures between April 2008 and October 2009. Patients on Clopidogrel were identified and data including ASA grade, time to operation, medical co-morbidities, and post-admission complications were recorded. Comparative information from the National Hip Fracture Database was used. Results. 405 patients were included. 27 patients were taking Clopidogrel on admission and they were mainly ASA 3 or 4. Mean time to theatre was 8 days. Post-admission medical complications occurred in 7 patients (25.9%). A further 4 patients (14.8%) died, 3 of them postoperatively. From the study population a control group of 72 ASA 3 and 4 patients was further studied. The mean time to operation was 2.3 days. Post-admission medical complications occurred in 13 patients (18%) and 8 patients (11%) died postoperatively. In 2009 the national mean time to operation was 2.19 days with an associated mortality rate of 8.67%. Discussion and Conclusion. Patients receiving Clopidogrel have complex medical co-morbidities and a higher anaesthetic risk. Delaying operative management might be contributing to the increased rate of mortality and morbidity. In accordance with the SIGN guidelines we recommend early operative intervention in these high risk patients

Purpose. To evaluate the effectiveness of the perioperative erythropoietin administration, as an alternative to homologous banked blood transfusions, in total hip arthroplasty. Material and Methods. In a prospective randomized, controlled study, 101 patients who underwent unilateral total hip replacement, during the period 2004–2009, were evaluated. In all these patients, the same surgical team applied the same surgical technique (hybrid THA) and they followed the same rehabilitation program. In 50 patients (group A or study group) we administered 40,000 units of erythropoietin subcutaneously one day before the operation followed by 40,000 units (sc) every 3 days in a total scheme of 4 doses. All these patients received intraoperatively one unit of homologous blood transfusion (1 unit/patient) and additional blood transfusions postoperatively when required. A control group of 51 patients (group B) received intraoperatively one or two units of homologous blood transfusion (1.35 units/patient), according to the volume of blood collected in the suction device and to the anaesthesiologists estimation, and also additional blood transfusions postoperatively when required. The admission of banked blood transfusion was determined by the haemoglobin value (< 9mg/dl) and/or clinical signs (blood pressure, pulse etc.). The values of haemoglobin, haematocrit and platelets were recorded preoperatively and the 1st, 5th, and 15th day postoperatively. Results. 15 patients of group A required postoperatively 15 units of homologous blood (total amount for group A 65 banked blood units 1.3 units/patient). 20 patients of group B required additional 26 banked blood units postoperatively (totally 95 banked blood units, or 1.86 units/patient). In the group A (study group), the total homologous blood requirements were reduced by 30%, the postoperative blood requirements were reduced by 42% and the number of patients that required additional blood transfusion was reduced by 25%. There was no significant difference in the postoperative haematocrit and haemoglobin values between the two groups. Conclusions. The perioperative use of erythropoietin reduces effectively the total demands of homologous banked blood transfusion in total hip arthroplasty

Introduction. In total hip arthroplasty ceramic on ceramic bearing couples are used more and more frequently and on a wordwide basis. The main reason of this choice is reduction of wear debris and osteolysis. The tribological properties and the mechanical behaviour of the implanted ceramic must remain the same throughout the patient's life. The aim of this study was to evaluate the resistance of Alumina Matrix Composite to environmental degradation. Material and method. The alumina matrix composite or BIOLOX ® delta is manufactured in Germany by CeramTec. It is made up of 80 vol.% Al2O3, 17 vol.% Yttria Stabilized ZrO2 and 3vol.% strontium aluminate platelets. The zirconia grains account for 1.3 mol.% of the Yttria content. Accelerated aging tests in water steam at 142°C, 134°C, 121°C, and 105°C were performed to evaluate the aging kinetics of the composite. X-ray diffraction was used to determine the monoclinic phase content on the material surface. Phase transformation is associated with weakness and increase in roughness of zirconia ceramic implants. Results. The data below shows average monoclinic contents before and after aging in water vapour according to the ISO standard test (134°C, 2 bars water steam, 10 h) on the surface and inside the 28 mm taper(12/14 taper) femoral ball heads manufactured in alumina ceramic composite. There are precisions concerning the roughness and the load to failure before and after aging concerning 28mm diameter heads. Before Aging 13%+/-3% of Monoclinic content. After 10 H at 134°C23%+/-3% of Monoclinic content the roughness of the polished surface remain the same (5nm+/− 2). The load to failure of 28 mm heads before aging is 76 kN +/− 5kN, and 72 kN +/− 5kN after aging. The results show that although a rise in monoclinic content is predictable after long aging duration in vivo, the impact of the transformation is quite different to monolithic zirconia. A zirconia femoral head exhibits an important increase of roughness from 2 nm to more than 50 nm when submitted to the same duration of ageing. Other tests with hip simulators under severe micro separation have been done to analyse the impact of aging on wear performance. The main wear zone on femoral heads underwent a phase transformation from tetragonal to monoclinic (23% monoclinic) at 5 milion cycles duration without any change in roughness after 5Mc duration. Conclusion. This experimental testing program has enabled a prediction for the long-term in vivo environmental resistance of prostheses made out of Alumina Matrix Composite. The substantial improvement in mechanical properties and the excellent wear behaviour, even under severe microseparation conditions has been clinically confirmed. Today more than 960,000 ceramic ball heads and more than 450 000 ceramic inserts made of the alumina matrix composite have been implanted. Additionally, due to enhanced mechanical behaviour, new applications in orthopaedics are possible

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

Aims

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.

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.

This paper reports the cost of outpatient venous thromboembolism (VTE) prophylaxis following 388 injuries of the lower limb requiring immobilisation in our institution, from a total of 7408 new patients presenting between May and November 2011. Prophylaxis was by either self-administered subcutaneous dalteparin (n = 128) or oral dabigatran (n = 260). The mean duration of prophylaxis per patient was 46 days (6 to 168). The total cost (pay and non-pay) for prophylaxis with dalteparin was £107.54 and with dabigatran was £143.99. However, five patients in the dalteparin group required nurse administration (£23 per home visit), increasing the cost of dalteparin to £1142.54 per patient. The annual cost of VTE prophylaxis in a busy trauma clinic treating 12 700 new patients (2010/11), would be £92 526.33 in the context of an income for trauma of £1.82 million, which represents 5.3% of the outpatient tariff.

Outpatient prophylaxis in a busy trauma clinic is achievable and affordable in the context of the clinical and financial risks involved.

Cite this article: Bone Joint J 2013;95-B:673–7.

There have been many advances in the resuscitation and early management of patients with severe injuries during the last decade. These have come about as a result of the reorganisation of civilian trauma services in countries such as Germany, Australia and the United States, where the development of trauma systems has allowed a concentration of expertise and research. The continuing conflicts in the Middle East have also generated a significant increase in expertise in the management of severe injuries, and soldiers now survive injuries that would have been fatal in previous wars. This military experience is being translated into civilian practice.

The aim of this paper is to give orthopaedic surgeons a practical, evidence-based guide to the current management of patients with severe, multiple injuries. It must be emphasised that this depends upon the expertise, experience and facilities available within the local health-care system, and that the proposed guidelines will inevitably have to be adapted to suit the local resources.