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Orthopaedic Proceedings
Vol. 100-B, Issue SUPP_8 | Pages 45 - 45
1 May 2018
Jahangir N Umar M Rajkumar T Davis N Alshryda S Majid I
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Purpose of study

To review the treatment and outcomes of paediatric pelvic ring injuries in the UK

Methods and results

We performed a retrospective review of all pelvic fracture admissions to an English paediatric major trauma centre (MTC) from 2012 to 2016. A total of 29 patients were admitted with pelvic ring injuries with a mean age of 11 years (4- 16yrs). Road traffic accident was the mechanism in majority (72%), followed by fall from height (24%). Femoral shaft fracture was present in 5 (17%), head injury in 5 (17%), chest injuries in 5 (17%) and bladder injury in one child. 48% patients needed surgical procedures for fractures or associated injuries. We differentiated injuries according to the classification system of Torode and Zeig. 17% were Type A, 3% Type B, 48% Type C and 31% Type D. Almost all (93%) patients were treated conservatively. 51% of patients were allowed to mobilize full weight bearing after a period of bed rest. Non-weight bearing mobilization was recommended for fractures extending into the acetabulum, sacral fractures, unstable fracture patterns or associated fractures (neck of femur, femoral shaft and tibial shaft). Surgical fixation occurred in two patients. Both of these patients had significantly displaced Type D fractures. Only 44% of patients were back to sports at six months.


The Bone & Joint Journal
Vol. 96-B, Issue 8 | Pages 1005 - 1015
1 Aug 2014
Alshryda S Sukeik M Sarda P Blenkinsopp J Haddad FS Mason JM

Intravenous tranexamic acid (TXA) has been shown to be effective in reducing blood loss and the need for transfusion after joint replacement. Recently, there has been interest in applying it topically before the closure of surgical wounds. This has the advantages of ease of application, maximum concentration at the site of bleeding, minimising its systemic absorption and, consequently, concerns about possible side-effects.

We conducted a systematic review and meta-analysis which included 14 randomised controlled trials (11 in knee replacement, two in hip replacement and one in both) which investigated the effect of topical TXA on blood loss and rates of transfusion. Topical TXA significantly reduced the rate of blood transfusion (total knee replacement: risk ratio (RR) 4.51; 95% confidence interval (CI): 3.02 to 6.72; p < 0.001 (nine trials, I2 = 0%); total hip replacement: RR 2.56; 95% CI: 1.32 to 4.97, p = 0.004 (one trial)). The rate of thromboembolic events with topical TXA were similar to those found with a placebo. Indirect comparison of placebo-controlled trials of topical and intravenous TXA indicates that topical administration is superior to the intravenous route.

In conclusion, topical TXA is an effective and safe method of reducing the need for blood transfusion after total knee and hip replacement. Further research is required to find its optimum dose for topical use.

Cite this article: Bone Joint J 2014;96-B:1005–15.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXXIX | Pages 154 - 154
1 Sep 2012
Tsang K Alshryda S Ahmad M Adedapo S Montgomery R
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Aim

(1) To determine whether any difference exists in AVN risk between surgical reduction [Fish] or pinning-in-situ [PIS] of severe slips. (2) To review the different classifications of SUFE in relation to AVN.

Materials and Methods

56 children presented with slipped upper femoral epiphysis (SUFE) from 1998 to 2008; 29 males, 27 females; mean age 12.8 years. The Loder & Southwick classifications were used. All slips were treated surgically. The mild and moderate groups were treated with a single pin-in-situ. The severe group had either surgical reduction [Fish femoral neck osteotomy], alternatively a single pin-in-situ, randomised by day of admission. Avascular necrosis of the femoral head (AVN) was the primary outcome measurement.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_XXV | Pages 229 - 229
1 Jun 2012
Sukeik M Alshryda S Nargol A Mason J
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Introduction

Total knee replacements (TKR) are among the commonest operations performed in orthopaedic practice. Literature review showed that 10-30% of patients who underwent TKR needed 1-3 units of blood.

Tranexamic acid (TXA) has been popularised as an effective way to reduce blood loss and subsequent blood transfusion.

Our aim was to investigate the value of TXA in reducing blood loss and blood transfusion after TKR and other clinical outcomes such as deep venous thrombosis (DVT), pulmonary embolism (PE), ischaemic heart diseases and mortality.

Patients and Methods

A systematic review and meta-analysis of published randomised and quasi-randomised trials which used TXA to reduce blood loss in knee arthroplasty were conducted.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_IX | Pages 94 - 94
1 Mar 2012
Sukeik M Alshryda S Sharda P Lou T Nargol A Mason J
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Objectives

To investigate the value of tranexamic acid (TA) in reducing blood loss and blood transfusion after TKR and other clinical outcomes such as deep venous thrombosis (DVT), pulmonary embolism (PE), ischaemic heart diseases and mortality.

Methods

A systematic review and meta-analysis of published randomised and quasi-randomised trials which used TA to reduce blood loss in knee arthroplasty was conducted. The data was evaluated using the generic evaluation tool designed by the Cochrane Bone, Joint and Muscle Trauma Group.


Orthopaedic Proceedings
Vol. 94-B, Issue SUPP_IX | Pages 21 - 21
1 Mar 2012
Sharda P Alshryda S Shetty A Kalia P Nargol A Maheswaran S
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PURPOSE OF STUDY

20-70% of patients need blood transfusion postoperatively. There remain safety concerns regarding allogenic blood transfusion. Tranexamic acid (TA) is a synthetic antifibrinolytic agent that has been successfully used to stop bleeding in other specialties. We applied TA topically prior to the wound closure to find out the effect on blood loss as well as need for subsequent blood transfusion. This method of administration is quick, easy, has less systemic side effect and provides a higher concentration at the bleeding site.

MATERIALS AND METHODS

A double blind randomised controlled trial of 154 patients who underwent unilateral primary cemented total knee replacement. Patients were randomised into tranexamic acid group (1g drug mixed with saline to make up 20mls) or placebo (20ml 0.9% saline). The administration technique and drain protocol was standardised for all patients. Drain output was measured at 24 hours, and both groups compared for need of Blood transfusion. Outcome measures - blood loss, transfusion, complications, Euroqol and Oxford Knee Score.


The Journal of Bone & Joint Surgery British Volume
Vol. 93-B, Issue 12 | Pages 1577 - 1585
1 Dec 2011
Alshryda S Sarda P Sukeik M Nargol A Blenkinsopp J Mason JM

We conducted a systematic review and meta-analysis of randomised controlled trials evaluating the effect of tranexamic acid (TXA) upon blood loss and transfusion in primary total knee replacement. The review used the generic evaluation tool designed by the Cochrane Bone, Joint and Muscle Trauma Group. A total of 19 trials were eligible: 18 used intravenous administration, one also evaluated oral dosing and one trial evaluated topical use. TXA led to a significant reduction in the proportion of patients requiring blood transfusion (risk ratio (RR) 2.56, 95% confidence interval (CI) 2.1 to 3.1, p < 0.001; heterogeneity I2 = 75%; 14 trials, 824 patients). Using TXA also reduced total blood loss by a mean of 591 ml (95% CI 536 to 647, p < 0.001; I2 = 78%; nine trials, 763 patients). The clinical interpretation of these findings is limited by substantial heterogeneity. However, subgroup analysis of high-dose (> 4 g) TXA showed a plausible consistent reduction in blood transfusion requirements (RR 5.33; 95% CI 2.44 to 11.65, p < 0.001; I2 = 0%), a finding that should be confirmed by a further well-designed trial. The current evidence from trials does not support an increased risk of deep-vein thrombosis (13 trials, 801 patients) or pulmonary embolism (18 trials, 971 patients) due to TXA administration.


Orthopaedic Proceedings
Vol. 93-B, Issue SUPP_II | Pages 91 - 91
1 May 2011
Sukeik M Alshryda S Lou T Haddad F
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Background: Total hip replacement (THR) is one of the commonest operations in orthopaedic practice.

Literature review showed that 20–70% of patients who underwent THR needed 1–3 units of blood. Although safer than ever, allogeneic transfusion is still associated with risks for the recipient. There has been unsettled search for ways to reduce such blood loss and transfusion.

Tranexamic acid has been popularised as an effective way to reduce blood loss and subsequent blood transfusion.

Objectives: To investigate the value of Tranexamic acid in reducing blood loss and blood transfusion after THR and other clinical outcomes such as deep venous thrombosis (DVT), pulmonary embolism (PE), ischaemic heart diseases and mortality.

Patients and Methods: A systematic review and meta-analysis of published randomised and quasi-randomised trials which used tranexamic acid to reduce blood loss in hip arthroplasty was conducted. The data was evaluated using the generic evaluation tool designed by the Cochrane Bone, Joint and Muscle Trauma Group.

Results:

Blood loss

Seven studies (250 patients) were eligible for this outcome. Using Tranexamic acid reduced blood loss by an average of 155 ml (P-value < 0.00001, 95% CI (87–224), Heterogeneity I2 69 %.)

Blood transfusion

Nine studies (463 patients) were eligible for this outcome. Tranexamic acid led to a reduction in the proportion of patients requiring blood transfusion (Odds Ratio of 0.35, P- value < 0.00001, 95% CI (0.22–0.55), Heterogeneity I2 25 %.)

Other outcomes

There were no significant differences in the length of stay, DVT, PE, mortality, wound haematoma or infections between the study groups.

Conclusion: The use of Tranexamic acid in THR results in significant reduction of blood loss and blood transfusion.


Orthopaedic Proceedings
Vol. 93-B, Issue SUPP_II | Pages 95 - 95
1 May 2011
Alshryda S Sharda P Shetty A Vaghela M Logishetty R Tulloch C Antoni N Mason J
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Introduction: Today’s aging population has resulted in an increase in the number of major orthopaedic surgical interventions in the elderly. Total knee replacement (TKR) is one of the commonest operations in orthopaedic practice. The fourth annual report of the National Joint Registry showed that there were 60 986 TKR performed in England and Wales in 2006. The true figure is probably much higher. Literature showed that 20–70% of patients who had TKR needed 1–3 units of blood.

Although safer than ever, allogeneic transfusion is still associated with risks for the recipient (haemolysis, infection, immunosuppression, transfusion-related acute lung injury and even death).

Tranexamic acid (TA) is a synthetic antifibrinolytic agent that has been successfully used to stop bleeding after dental operation, removal of tonsils, prostate surgery, heavy menstrual bleeding, eye injuries and in patients with Haemophilia.

In this study Tranexamic acid was applied topically to the exposed tissue around the knee joint prior to the wound closure and tourniquet release. It is anticipated that this method of administration is quick, easy, associated with less systemic side effect. Also, it provides a higher concentration of the Tranexamic acid at the bleeding site.

Objectives: To find out whether Tranexamic acid can reduce blood loss and subsequent blood transfusion significantly after total knee replacement when applied topically without extra side effects.

Design: A double blind randomised controlled trial of 150 patients who underwent unilateral primary cemented total knee replacement. This number gives a 90% power to detect a 50% reduction in blood loss and 80% power to detect a reduction in blood transfusion from current local standard 30% to 10%.

Outcome Measures: Blood loss, transfusion, Length of stay, complications, Euroqol and Oxford Knee Score.

Results: The two groups were comparable in age, weight, height, BMI, Tourniquet time, and type of anaesthesia. There has been significant differences in the amount of blood loss and blood transfusion in favour of tranexamic acid (p-values are 0.001 and 0.007 respectively). Fourteen patients needed blood transfusion ranged from 2–6 units. Thirteen were in the Placebo group and only one in the Tranexamic acid. There has been no significant difference among other outcomes in particular complications rates such as DVT and pulmonary embolism.


The Journal of Bone & Joint Surgery British Volume
Vol. 93-B, Issue 1 | Pages 39 - 46
1 Jan 2011
Sukeik M Alshryda S Haddad FS Mason JM

We report a systematic review and meta-analysis of published randomised controlled trials evaluating the efficacy of tranexamic acid (TXA) in reducing blood loss and transfusion in total hip replacement (THR). The data were evaluated using the generic evaluation tool designed by the Cochrane Bone, Joint and Muscle Trauma Group. We identified 11 clinical trials which were suitable for detailed extraction of data. There were no trials that used TXA in revision THR. A total of seven studies (comprising 350 patients) were eligible for the blood loss outcome data. The use of TXA reduced intra-operative blood loss by a mean of 104 ml (95% confidence interval (CI) −164 to −44, p = 0.0006, heterogeneity I2 0%), postoperative blood loss by a mean of 172 ml (95% CI −263 to −81, p = 0.0002, heterogeneity I2 63%) and total blood loss by a mean of 289 ml (95% CI −440 to −138, p < 0.0002, heterogeneity I2 54%).

TXA led to a significant reduction in the proportion of patients requiring allogeneic blood transfusion (risk difference −0.20, 95% CI −0.29 to −0.11, p < 0.00001, I2 15%). There were no significant differences in deep-vein thrombosis, pulmonary embolism, infection rates or other complications among the study groups.


Orthopaedic Proceedings
Vol. 92-B, Issue SUPP_IV | Pages 542 - 542
1 Oct 2010
Sukeik M Alshryda S Mason J Nargol A
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Since the era of total knee replacement (TKR) began in the late 1960s, total knee replacement has become one of the commonest operations in orthopaedic practice.

TKR is frequently associated with transfusion of allogenic blood Benoni G 1995; Seppo T 1997. In our centre, 30 % of patients who had undergone TKR received allogenc blood transfusion perioperatively. Although, serological screening has reduced the risk for viral infection to a very low levelKlein HG 1995; Schreiber GB 1996, the public is still concerned about this potential serious complication. Allogenic blood transfusion can be also associated with other non infectious complications such as haemolysis, immunosuppression, transfusion-related acute lung injury and even death.Madjdpour C 2005 Therefore, further refinement of strategies to avoid exposure to allogeneic blood is needed.

Amongst the technologies to minimise the need for blood transfusion is the use of the anti-fibrinolytic drugs aprotinin, tranexamic acid (TXA), and epsilon amino-caproic acid (EACA).New Reference

Objectives: The purpose of this review is to investigate the evidence for the efficacy of Tranexamic acid in reducing peri-operative blood loss and blood transfusion after total knee replacement, and the evidence for any effect on clinical outcomes such as reduction in re-operation rates or increase in complication rates (e.g. deep venous thrombosis, pulmonary embolism, ischaemic heart diseases and mortality).

Method: Systematic review and metananalysis based on Cochrane guidelines of all randomised and quasirandomised trials.

Results: Fiften RCTs were included in the study; there has been a significant reduction of blood loss (P value 0.00001, I2 = 89%), blood transfusion without increase in systeanatic side effects such as ischaemic heart diseases, DVT, pulmondary embolisms. There was no singnificant difference in length of stay.


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_III | Pages 538 - 538
1 Aug 2008
Jameson SS Tripurneni V Collin S Alshryda S Nargol AVF
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Introduction: The return of haemoglobin (Hb) to preoperative levels at 1–6 months following elective lower limb joint arthroplasty is well documented. Previous reports have suggested in healthy, elective patients there is no significant improvement in Hb levels following iron supplementation compared with placebo. There may also be unpleasant side effects. However, there is little published on this topic in the elderly population who suffer a femoral neck fracture and undergo emergency surgery, and often have poorer iron reserves.

Methods: We examined the blood results and discharge prescriptions of consecutive patients who underwent femoral neck fracture surgery at our institute in a 12 month period. Patients who had received a blood transfusion were excluded. 82 patients remained. Normal Hb levels at the time of surgery and 1–6 months post-operatively (late Hb) were collected.

Results: Thirteen patients (16%) were prescribed iron supplementation on discharge. No patients who went on to receive iron had a normal Hb (11.5 – 15.5g/dL in females, 13– 8g/dL in males) immediately following surgery (mean Hb 9.17g/dL) compared with 26% (mean Hb 10.41g/dL) in those who received no iron. At 115.2 days (range 28–284) following surgery 88.9% of patients prescribed iron had a normal Hb compared with only 48.1% of those who received no treatment (P=0.0167).

Discussion: The low level of iron prescribing was surprising, and may be the result of published evidence in elective patients. Our numbers are small, but we show a statistically significant difference which warrants further investigation. We suggest that, unlike the younger, healthier elective arthroplasty patients, femoral neck fracture patients may benefit from dietary iron supplement.


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_II | Pages 296 - 296
1 Jul 2008
Shah A Alshryda S Hegab A Doyle J Brewood T Ilango B McGivney R
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Background: Several hospitals within the NHS now run specialist teams that look after assisted discharge plans for patients following elective surgeries. Joint replacements form a significant segment of elective majors in orthopaedics. In the second half of the last year alone, the National Joint Registry estimated that there were over 100,000 joint replacements carried out within England and Wales. Such schemes are designed to: 1. Enable patients to be discharged to their home as quickly and safely as possible, to maximise recovery and rehabilitation. 2. Ensure the most effective use of acute orthopaedic beds. 3. Reduce risks of hospital acquired infection 4. Streamline inpatient care so as to positively impact upon inpatient and outpatient waiting times. There is scarce information available about the experience of NHS hospitals with such schemes.

Aims And Objectives: 1. Investigate patient expectations of and satisfaction with discharge planning on the early discharge scheme. 2. Assess areas of concern to the patient and difficulties encountered by the patient in the home environment. 3. Improve our understanding of patient requirements, functional recovery and planning of discharge. 4. Investigate whether our lengths of stay compare with others in the NHS/literature and what factors are influencing the figures. 5. Investigate overall success of the scheme.

Patient And Methods: The study identified 100 consecutive patients who have had joint replacement surgery after August 2003 and have been discharged under the scheme. A Patient Satisfaction Questionnaire was used and the patients completed different sections at discharge and then at about six. Notes were reviewed for any complications or problems.

Conclusions: The scheme to discharge patients early is highly successful and well received by staff and patients. All consultants now use the service and the initial aims have been met, saving approximately 335 bed days in the first six months. The average inpatient stay has been reduced by half in the last 18 months. 98% of patients stated that the scheme met their needs. The majority of comments were positive. Only two patients needed readmission within the first fortnight from discharge, one with a dislocated hip and the other was a knee with wound infection. There were two complaints, which were deemed serious enough for a mention.


Orthopaedic Proceedings
Vol. 90-B, Issue SUPP_II | Pages 360 - 360
1 Jul 2008
Alshryda S Tripurneni V Vinayagam R Raju P Bayliss NC
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Background: One stop shoulder clinic was established in the North Tees University Hospital as part of conjoint effort between the department of trauma and orthopaedics and radiology in the year 2005. A consultant shoulder surgeon, consultant radiologist, extended scope shoulder physiotherapist and shoulder nurse practitioners run the clinic on weekly basis.

The aims are:

Immediate and more accurate diagnosis and plan accordingly.

Avoid unnecessary or inappropriate treatment while waiting for radiological test.

High patient satisfaction.

Reduce waiting time for definitive treatment.

Reduce number of patients’ visits.

Improve and advance clinical and radiological skills.

Reduce the cost to the NHS.

Promote a multi-disciplinary approach to patient healthcare.

Methods and materials: A retrospective study of 150 patients who had been seen in the one stop shoulder clinic and conventional clinic. We studied the number of hospital visits, the waiting time for final intervention and or discharge, the accuracy of initial diagnosis and treatment and the cost-benefit analysis.

Results and discussions: One-stop clinics have been successfully established in a few fields of medicine. One stop breast lump clinic has been running for almost 10 years with a very good reputation of rapid, accurate and cost-effective diagnosis of breast lumps. Similar successful examples have been emerged in gynaecology such as fertility clinic and uterine bleeding clinic; and in urology such as haematuria clinic. To our best knowledge, this is the first study that investigated the one-stop clinic in shoulder problems. Our results showed similar trend of success in term of reduction of patients’ hospital visits, waiting time to treatment and accuracy of the diagnosis. We also conducted a cost-benefit analysis of the one stop shoulder clinic in comparison with the conventional shoulder clinic and we concluded that it is cost effectiveness.