Aims. Alcoholism is a well-known detrimental factor in fracture healing. However, the underlying mechanism of alcohol-inhibited fracture healing remains poorly understood. Methods. MicroRNA (miR) sequencing was performed on bone mesenchymal stem cells (BMSCs). The effects of alcohol and miR-19a-3p on vascularization and osteogenic differentiation were analyzed in vitro using BMSCs and human umbilical vein endothelial cells (HUVECs). An in vivo alcohol-fed mouse model of femur fracture healing was also established, and radiological and histomorphometric analyses were used to evaluate the role of miR-19a-3p. The binding of miR-19a-3p to forkhead box F2 (FOXF2) was analyzed using a luciferase reporter assay. Results. miR-19a-3p was identified as one of the key regulators in the osteogenic differentiation of BMSCs, and was found to be downregulated in the alcohol-fed mouse model of fracture healing. In vitro, miR-19a-3p expression was downregulated after ethanol administration in both BMSCs and HUVECs. Vascularization and osteogenic differentiation were independently suppressed by ethanol and reversed by miR-19a-3p. In addition, the luciferase reporter assay showed that FOXF2 is the direct binding target of miR-19a-3p. In vivo, miR-19a-3p agomir stimulated callus transformation and improved the alcohol-impaired fracture healing. Conclusion. This study is the first to demonstrate that the miR-19a-3p/FOXF2 axis has a pivotal role in alcohol-impaired fracture healing, and may be a potential therapeutic target. Cite this article: Bone Joint Res 2022;11(6):386–397

Damage to the dorsomedial branch of the medial dorsal cutaneous nerve is not uncommon in surgery of the hallux. The resultant morbidity can be disabling. In the light of the senior author’s operative observation of a sentinel vein, we undertook a cadaver study to investigate the anatomical relationships of the dorsomedial branch of the medial dorsal cutaneous nerve. This established that in 14 of 16 cadaver great toes exposed via a modified medial incision, there is an easily identified vein which runs transversely superficial and proximal to the nerve. In a prospective clinical study of 171 operations on the great toe using this approach, we confirmed this anatomical relationship in 142 procedures (83%), with no complaint of numbness or pain in the scar at follow-up. We attribute this to careful identification of the ‘sentinel’ vein and the subjacent sensory nerve, which had been successfully protected from damage. We recommend this technique when operating on the great toe.

We carried out a cadaver study of 16 iliolumbar veins in order to define the surgical anatomy. Two variants were found; a single vein at a mean distance of 3.74 cm from the inferior vena cava (11 of 16) and two separate draining veins at a mean distance from the vena cava of 2.98 cm for the proximal and 6.24 cm for the distal stem (5 of 16). Consistently, the proximal vein tore on attempted medial retraction of the great vessels. The mean length of the vein was 1.6 cm and its mean width 1.07 cm. Three stems were shorter than 0.5 cm. Two or more tributaries usually drained the iliacus and psoas muscles, and the fifth lumbar vertebral body. The obturator nerve crossed all veins superficially at a mean of 2.76 cm lateral to the mouth. In four of these, this distance was less than 1.5 cm. Usually, the lumbosacral trunk crossed deep, at a mean distance of 2.5 cm lateral to the mouth, but in three veins, this distance was 1 cm or less. Our findings emphasise the need for proper dissection of the iliolumbar vein before ligature during exposure of the anterior lumbar spine

Objective: To establish the anatomy of the iliolumbar vein. Design: Prosections of human cadavers were examined. Subjects: Sixteen iliolumbar veins in eight cadavers. Outcome measures: Width, length, pattern of drainage, tributaries, distance from IVC to the iho lumbar vein, structures drained and immediate relations. The risk of avulsion on great vessel retraction to expose the L4/L5 disc. Results: Two variants encountered; a single vein an average 3.74cms from the IVC (11/16), or two stems, an average of 2.98cms to the proximal and 6.04cms to the distal (5/16). All 16 veins tore on great vessel retraction. In all veins the obturator nerve was found to cross superficially an average 2.76cms lateral to the mouth, in four cases, the actual distance was less than 1.5cms. In 15 veins the lumbosacral trunk crossed deep, in one superficial. The average distance from the mouth was 2.5 cms, in three veins the actual distance was 1cm or less. Conclusion: This study confirms variability in the vein with vulnerability to avulsion on retraction of the great vessels. The close relationship with the obturator nerve and lumbosacral trunk further emphasise the need for proper exposure of the vein prior to ligature and safe surgical exposure of the anterior lumbar spine. Other findings are also presented

Deep vein thrombosis is a common complication of immobilising the lower limb after surgery. We hypothesised that intermittent pneumatic compression (IPC) therapy in outpatients who had undergone surgical repair of acute ruptures of the Achilles tendon could reduce the incidence of this problem. A total of 150 patients who had undergone surgical repair of the Achilles tendon were randomised to either treatment with IPC for six hours per day (n = 74) under an orthosis or treatment as usual (n = 74) in a plaster cast without IPC. At two weeks post-operatively, the incidence of deep vein thrombosis was assessed using blinded, double-reported compression duplex ultrasound. At this point, IPC was discontinued and all patients were immobilised in an orthosis for a further four weeks. At six weeks post-operatively, a second compression duplex ultrasound scan was performed. At two weeks, the incidence of deep vein thrombosis was 21% in the treated group and 37% in the control group (p = 0.042). Age over 39 years was found to be a strong risk factor for deep vein thrombosis (odds ratio (OR) = 4.84, 95% confidence interval (CI) 2.14 to 10.96). Treatment with IPC, corrected for age differences between groups, reduced the risk of deep vein thrombosis at the two-week point (OR = 2.60; 95% CI 1.15 to 5.91; p =0.022). At six weeks, the incidence of deep vein thrombosis was 52% in the treated group and 48% in the control group (OR 0.94, 95% CI 0.49 to 1.83). IPC appears to be an effective method of reducing the risk of deep vein thrombosis in the early stages of post-operative immobilisation of outpatients. Further research is necessary to elucidate whether it can confer similar benefits over longer periods of immobilisation and in a more heterogeneous group of patients. Cite this article: Bone Joint J 2015;97-B:675–80

Aims. The aims of this study were to assess the pre- and postoperative incidence of deep vein thrombosis (DVT) using routine duplex Doppler ultrasound (DUS), to assess the incidence of pulmonary embolism (PE) using CT angiography, and to identify the factors that predict postoperative DVT in patients with a pelvic and/or acetabular fracture. Methods. All patients treated surgically for a pelvic and/or acetabular fracture between October 2016 and January 2020 were enrolled into this prospective single-centre study. The demographic, medical, and surgical details of the patients were recorded. DVT screening of the lower limbs was routinely performed using DUS before and at six to ten days after surgery. CT angiography was used in patients who were suspected of having PE. Age-adjusted univariate and stepwise multiple logistic regression analysis were used to determine the association between explanatory variables and postoperative DVT. Results. A total of 191 patients were included. A DVT was found preoperatively in 12 patients (6.3%), of which six were proximal. A postoperative DVT was found in 42 patients (22%), of which 27 were proximal. Eight patients (4.2%) had a PE, which was secondary to a DVT in three. None of the 12 patients in whom a vena cava filter was implanted prophylactically had a PE. Multivariate logistic regression analysis indicated that the association with the need for spinal surgery (odds ratio (OR) 19.78 (95% confidence interval (CI) 1.12 to 348.08); p = 0.041), intramedullary nailing of a long bone fracture (OR 4.44 (95% CI 1.05 to 18.86); p = 0.043), an operating time > two hours (OR 3.28 (95% CI 1.09 to 9.88); p = 0.035), and additional trauma surgery (OR 3.1 (95% CI 1.03 to 9.45); p = 0.045) were statistically the most relevant independent predictors of a postoperative DVT. Conclusion. The acknowledgement of the risk factors for the development of a DVT and their weight is crucial to set a threshold for the index of suspicion for this diagnosis by medical staff. We suggest the routine use of the DUS screening for DVT in patients with a pelvic and/or acetabular fracture before and six to ten days after surgery. Cite this article: Bone Joint J 2022;104-B(2):283–289

Deep vein thrombosis is uncommon in children but can occur given certain circumstances. Protein C deficiency has recently been described in a child with deep vein thrombosis complicating septic arthritis. We present four case reports of children who developed deep vein thrombosis in association with musculoskeletal sepsis. All had evidence of musculoskeletal sepsis and thrombosis. One child died. Prothrombotic screens were performed demonstrating normal haematological parameters in the three surviving children. The high mortality of deep vein thrombosis complicating musculoskeletal sepsis is emphasised, particularly the potential for septic embolic complications. Deep vein thrombosis should be considered in any child with musculoskeletal sepsis and generalised limb swelling. Early recognition and treatment can lead to favourable outcomes

Aims. The purpose of this article was to review the current literature pertaining to the use of mobile compression devices (MCDs) for venous thromboembolism (VTE) following total joint arthroplasty (TJA), and to discuss the results of data from our institution. Patients and Methods. Previous studies have illustrated higher rates of post-operative wound complications, re-operation and re-admission with the use of more aggressive anticoagulation regimens, such as warfarin and factor Xa inhibitors. This highlights the importance of the safety, as well as efficacy, of the chemoprophylactic regimen. Results. Studies have shown a symptomatic VTE rate of 0.92% with use of MCDs for prophylaxis, which is comparable with rates seen with more aggressive anticoagulation protocols. A prior prospective study found that use of a pre-operative risk stratification protocol based on personal history of deep vein thrombosis, family history of VTE, active cancer, or a hypercoaguable state allowed for the avoidance of aggressive prophylactic anticoagulation in over 70% of patients while maintaining a low incidence of symptomatic VTE. Conclusion. Further investigation is needed into the role of aspirin in VTE prophylaxis as well as the efficacy of MCDs as stand-alone prophylactic treatment. Cite this article: Bone Joint J 2017;99-B(1 Supple A):8–13

Bilateral venography was performed between 12 and 15 days after total hip replacement in 745 consecutive patients, all of whom had heparin prophylaxis. Of these, 81 patients (10.8%) showed evidence of recent deep vein thrombosis: 23 (3%) distal, 44 (5.9%) isolated proximal, five (0.7%) both proximal and distal, and nine (1.2%) extensive thrombosis from calf to thigh. Compared with previous reports heparin appeared to have reduced the number of distal and contralateral thromboses, but was far less effective in reducing proximal femoral thrombosis. In a cadaver study, the femoral veins were inspected during simulated total hip replacement by either an anterior or a posterior approach. In every case the femoral vein became kinked or folded in the thigh position imposed during the preparation of the femur. Local damage appears to be an important factor in proximal thrombosis; care at operation could help to minimise trauma to the femoral veins and reduce the number of such cases

The incidence of deep vein thrombosis in 244 patients who had total knee replacement has been studied. In 120 the prosthesis was cemented and in 124 it was cementless. In all cases the replacement was primary and a porous-coated prosthesis with a porous-coated central tibial stem was used. Deep vein thrombosis was diagnosed by venography, and pulmonary embolism by perfusion scanning. The incidence of deep vein thrombosis in the cementless knees (23.8%) and in the cemented (25%) was approximately the same. The only significant predisposing factors for deep vein thrombosis in both groups were obesity, prolonged postoperative immobilisation, previous venous disease and hyperlipidaemia

The aim was to study the outcome of the vein wrap technique in the treatment of post carpal tunnel causalgia (CRPS type II). Five patients with a diagnosis of post carpal tunnel release causalgia were treated with the vein wrap technique. This involves performing an extended carpal tunnel release gently freeing all nerve adhesions and then wrapping the endothelial surface of a longitudinally split segment of the cephalic vein around the median nerve from proximal to the carpal tunnel to the commencement of the distal divisions. The wrap is secured with 6.0 Novafil sutures. Post surgery the wrist and hand are supported in a volar slab and bandage for two weeks followed by patient managed mobilising exercises. There were three females and two males with follow-up ranging from six months to three years. Time from onset of causalgia to surgery ranged from 6 months to 13 years. In three patients there was immediate and profound relief of causalgic symptoms; in one, symptoms completely resolved over six weeks and in one, in which the nerve had been severely crushed prior to initial surgery, the causalgic symptoms markedly improved but the post injury numbness has persisted. In none has there been recurrence or deterioration. Post carpal tunnel release causalgia is a devastating and disabling complication. It is often resistant to a range of treatment modalities but the vein wrap is a simple procedure which in the author’s experience can be dramatically effective even in patients with very long standing causalgia

The effect of hypobaric spinal anaesthesia or narcotic-halothane-relaxant general anaesthesia on the incidence of postoperative deep vein thrombosis was studied in 140 elective total hip replacements in a prospective randomised manner. Deep vein thrombosis was diagnosed using impedance plethysmography and the 125I fibrinogen uptake test, combined, in selected cases, with ascending contrast venography. The overall incidence of deep vein thrombosis was 20%. Nine patients (13%) developed deep vein thrombosis in the spinal group and nineteen (27%) in the general anaesthetic group (p less than 0.05). The incidences of proximal thrombosis and of bilateral thrombi were also less with spinal anaesthesia than with general anaesthesia. It is concluded that spinal anaesthesia reduces the risks of postoperative thromboembolism in hip replacement surgery. The presence of varicose veins, being a non-smoker and having a low body mass index were associated with an increased incidence of deep vein thrombosis

Deep vein thrombosis remains a significant and common complication following joint replacement and debate exists over which contributing factors are important. This study investigates the effect of a number of variables on the incidence of symptomatic deep vein thrombosis in knee arthroplasty surgery. Data was collected prospectively on 3449 knee replacements including procedure type, tourniquet time, surgeon, patient age, and gender. These variables were assessed by the use of generalised linear modelling against the presence or absence of symptomatic deep vein thrombosis demonstrated on duplex ultrasonography. The overall deep vein thrombosis rate was 1.6%. The only variable which had an association with confirmed symptomatic DVT was operation type with total knee replacements having a higher incidence than unicompartmental knee replacements (2.2% vs 0.3% p=0.0003). Tourniquet time did not exhibit a statistically significant effect (p=0.63) These data show that the DVT rate in unicompartmental knee replacement is statistically significantly lower than that of total knee replacement. They do not support the notion that increased tourniquet time is associated with an increased risk of DVT

The anatomical integrity of the epi- and para-nevrium is the most relevant factor for the correct gliding of the median nerve, and when they are surrounded by scar tissue, the result is a chronic neuropathy. This recurrent compressive neuropathy represents a very challenging clinical and surgical problem. Neurolysis can not always improve the recovery of nerve function, and the soft tissue coverage is necessary to prevent recurrent scar and to achieve a useful mobilization of the median nerve. The autogenous vein graft wrapping technique has shown great promise for the treatment of chronic compressive neuropathy after other procedures have failed. The author present their experience using the Basilic vein grafting as a valid alternative to the Saphenous one. All our patients presented symptoms in the median nerve distribution, including pain, swelling and numbness, and grip strength reduction. Four of these patients presented a CRPS and have been evaluated before treatment in a multidisciplinary dedicated equipe to plan the surgical procedure. The vein graft wrapping represents a simple technique without problem in donor area. In the authors’ casuistry it presented also as a very useful technique in the treatment of median neuropathy in CRPS

A study of the natural history and aetiology of deep vein thrombosis in 499 patients after total hip replacement is presented. Deep vein thrombosis was diagnosed by scanning the leg for 125Iodine-labelled fibrinogen for a period of 14 to 18 days and by ascending phlebography. It has been shown that deep vein thrombosis occurs ater than in patients who have undergone abdominal operations, and the risk period is longer. The peak of onset of thrombosis is on the fourth day after the hip replacement. Attempts at prophylaxis using subcutaneous heparin or intermittent pneumatic compression of the calves delay the appearance of thrombosis. Analysis of possible aetiology factors shows that the age of the patient, the degenerative disease of the hip, the surgical approach, and under-transfusion of blood, all have a significant effect on the incidence of thrombosis

Aims: To present our experience from the diagnosis and treatment of axillary vein thrombosis in seven cases. Methods: We reviewed the medical records and x-rays of all the patients who were admitted and treated for axillary vein thrombosis (AVT) in the Orthopaedic and Vascular Surgery Departments of our hospital between 1995 and 2001. Results: We reviewed seven patients (þve males and two females, mean age 52.3 years old) presented in our hospital with AVT. Two of these cases occurred following musculoskeletal injuries (extrinsic trauma), three after central line insertion for oncological treatment (intrinsic trauma), one was related to the oral contraceptive pill (thrombophilic tendency) and one case was effort related (Paget-Schroetter syndrome). Clinically there was plethoria, arm swelling and persistent superþcial veins which were aggravated with activity and dependency. Venography or Duplex scan was used to establish the diagnosis. Causing factors and associated morbidity were assessed and treated. All of the cases of vein thrombosis responded well to conservative treatment (heparin/low molecular weight heparin for three months). None of the cases developed pulmonary embolism and we had no mortality. Conclusions: This study demonstrates that the innocent appearance of upper limb swelling should raise the index of suspicion of a potential underlying vascular lesion. Although quite rare, missed AVT may cause associated morbidity but very rarely mortality

Aims. Patients with an acute Achilles tendon rupture (ATR) take a long time to heal, have a high incidence of deep vein thrombosis (DVT) and widely variable functional outcomes. This variation in outcome may be explained by a lack of knowledge of adverse factors, and a subsequent shortage of appropriate interventions. . Patients and Methods. A total of 111 patients (95 men, 16 women; mean age 40.3, standard deviation 8.4) with an acute total ATR were prospectively assessed. At one year post-operatively a uniform outcome score, Achilles Combined Outcome Score (ACOS), was obtained by combining three validated, independent, outcome measures: Achilles tendon Total Rupture Score, heel-rise height test, and limb symmetry heel-rise height. Predictors of ACOS included treatment; gender; age; smoking; body mass index; time to surgery; physical activity level pre- and post-injury; symptoms; quality of life and incidence of DVT. . Results. There were three independent variables that correlated significantly with the dichotomised outcome score (ACOS), while there was no correlation with other factors. An age of less than 40 years old was the strongest independent predictor of a good outcome one year after ATR (odds ratio (OR) 0.20, 95% confidence interval (CI) 0.08 to 0.51), followed by female gender (OR) 4.18, 95% CI 1.01 to 17.24). Notably, patients who did not have a DVT while immobilised post-operatively had a better outcome (OR 0.31, 95% CI 0.12 to 0.80). . Conclusion. Over the age of 40 years, male gender and having a DVT while immobilised are independent negative predictors of outcome in patients with an acute ATR. . Cite this article: Bone Joint J 2016;98-B:1635–41

The incidence of venous thromboembolism after elective knee surgery has previously been studied almost exclusively in patients receiving total knee replacements, in whom the risk of a deep vein thrombosis is approximately 60%. We report the results of ipsilateral ascending venography in 312 patients undergoing a wide variety of elective knee operations under tourniquet ischaemia, none of whom received any specific prophylaxis against thromboembolism. Total knee replacement was confirmed to carry a high risk with ipsilateral deep vein thrombosis in 56.4% and symptomatic pulmonary embolism in 1.9%. By contrast, arthroscopy was associated with a low incidence of venous thrombosis (4.2%). Meniscectomy, arthrotomy, patellectomy, synovectomy and arthrodesis were all high-risk procedures, particularly in patients over 40 years of age, and were associated with deep vein thrombosis rates of 25% to 67%. On the basis of these findings, we advise prophylaxis against venous thromboembolism in all patients over 40 years of age undergoing elective knee surgery other than arthroscopy

Objectives. The length of the tourniquet time during total knee arthroplasty (TKA) is related to the incidence of post-operative deep vein thrombosis (DVT). Our aim in this study was to investigate the effect of the early release of the tourniquet on the incidence of DVT in patients undergoing TKA. Methods. A total of 200 patients who underwent TKA between November 2015 and November 2016 were prospectively enrolled. The tourniquet was inflated before surgery and released immediately after the introduction of the components (early release group). This group was compared with a retrospective cohort of 200 primary TKAs, in which the tourniquet was released after the dressings had been applied (late release group). The presence of a DVT was detected using bilateral lower limb ultrasonography. Peri-operative clinical and follow-up data were collected for analysis. Results. The incidence of DVT in the early release group (9 of 196, 4.6%) was significantly lower compared with the late release group (24 of 200, 12%; odds ratio (OR) 0.35, 95% confidence interval (CI) 0.16 to 0.78, p = 0.008). The incidence of proximal DVT in the early release group (1 of 196 (0.5%)) was significantly lower than in the late release group (8 of 196, 4%; OR 0.12, 95% CI 0.02 to 0.99, p = 0.020). Although the mean intra-operative blood loss was higher in the early release group, the mean post-operative drainage, total blood loss, transfusion requirements and complications were not significantly different in the two groups. Conclusion. In patients who undergo TKA, releasing the tourniquet early is associated with a decreased incidence of DVT, without increasing the rate of complications. Cite this article: Bone Joint Res 2017;6:535–541

INTRODUCTION. Venous thromboembolism (VTE), especially, deep vein thrombosis (DVT) in lower extremities, often seriously combined with pulmonary embolism (PE), is a major and critical complication after total hip arthroplasty (THA). For better disgonsis of VTEs, D-dimer test is one of the useful methods. The aim of this study was to evaluate the efficacy of D-dimer levels before THA. MATERIALS AND METHODS. Medical records of patients with osteoarthritis who received THA between April 2009 and March 2010 were reviewed. Value of D-dimer at preoperative day 1, postoperative day 3 and 14 was examined in those patients. D-dimer levels were examined by Latex Immunity Nephelometry Measurement Method and the Kit (Sysmex Corporation, Kobe, Japan). A total of 327 patients with D-dimer values were examined. The values D-dimer of the available patients were under 1.0 μg/ml. Ninety-nine patients (30%) had a high D-dimer level. DVT was diagnosed by doppler ultrasonography at preoperative day 1, postoperative day 3 and 14. The sensitivity and specificity of D-dimer in different cutoffs were verified by Receiver Operating Characteristic (ROC) curve. The ROC curve was constructed to describe the relationship between the sensitivity and the false positive rate for different values of D-dimer to patients suspected of VTEs. The study protocol was approved by the institutional ethics committee. RESULTS. Eighty-two patients (83%) were females and 17 (18%) were males. Mean age was 67.3 (51–88) years. Mean value of D-dimer was 2.6 (1.1–10.3) μg/mL. DVT was detected in 21 patients (21%) at the preoperative day 1 (DVT positive group). Average of age of this (or DVT positive) group was 71.9 (52–88) years. There was significant difference in D-dimer level between DVT negative group, DVT was not detected at the preoperative day 1, and DVT positive group (p<0.05). The areas under the receiver operating characteristic curve of D-dimer were larger than those of other parameters in the ROC curve (p=0.76). The cutoff value from the Youden index was 1.95 μg/mL, and the sensitivity and specificity values were 84.2% and 62.7%, respectively. The incidence of DVT in the positive group was 19% and 16%, respectively. DISCUSSION AND CONCLUSION. Even DVT in the calf has the potential to propagate proximally, which led to a risk of PE. Therefore, screening for detection of DVT is important, even if the DVT was asymptomatic distal DVT. In some countries, it is thought that if the value of D-dimer is less than 0.5 μg/mL, VTEs are excluded in patients without surgeries, but some D-dimer kits, frequently used in Japan, have different cutoff values for the exclusion of DVT. Assessment of D-dimer is simple and reliable, as to be one of the beneficial methods to detect high-risk patients of VT and/or occult DVT before THA. In conclusion, it is important to evaluate preoperative screening of VTE before THA, as the existence of pre-operative DVT has high risk of postoperative DVT occurrences. The D-dimer test is one of useful methods to evaluate the perioperative state of the patients with VTE risk