Following the outcomes of the RECORD trials the protocol of extended thromboprophylaxis in patients undergoing elective primary total hip or knee arthroplasty has been changed in our institution. Between June 2008 and May 2009 patients were offered extended thromboprophylaxis with 150mg of aspirin daily, commencing preoperatively on admission and continuing for a total of six weeks. From June 2009 onwards patients were treated with 10mg of rivaroxaban once daily for two weeks following total knee and five weeks following total hip arthroplasty commencing 4 to 6 hours postoperatively. Our cohorts were 700 patients before and after the introduction of the new regimen. The two groups were matched for age, sex and type of operation. All patients with no contraindication to treatment with aspirin or rivaroxaban respectively undergoing elective primary total hip or knee arthroplasty were included in the study. Patients receiving warfarin on admission were treated with warfarin postoperatively and were excluded. We have compared the two treatment protocols in terms of safety and efficacy. Results focus on 4 safety outcome measures including mortality, haemorrhagic complications, transfusion requirements and infection rates and 2 efficacy outcome measures including thromboembolic complications and length of inpatient stay. Rates of DVT were equal in the two cohorts (P< 0.005) as were the mortality rates. Transfusion requirements post-operatively were not affected by the introduction of the new regimen however there was a significant increase in both return to theatre rates and prolonged wound ooze (P< 0.005). Infection rates were slightly higher in the cohort treated with rivaroxaban but this was not statistically significant. We conclude that further trials need to be done to confirm the suitability of routine use of rivaroxiban.
Reverse polarity total shoulder arthroplasty (RTSA) has gained popularity over recent years for the treatment of the painful cuff deficient shoulder. Although proposed over 20 years ago and despite good clinical outcomes the RTSA has struggled to gain popularity due to reported high levels of complications. One such complication is post-operative instability with frequencies of up to 30% (De Wilde 2002). The Bayley-Walker RTSA was designed specifically for patients with difficult reconstruction problems in whom an unconstrained prosthesis would not offer sufficient stability. It is a reverse anatomy fixed fulcrum constrained prosthesis. The glenoid component has a long HA-coated tapered helical screw, with large pitch and depth, fixation is augmented by a grooved HA coated glenoid plate. The purpose of this study was to review the clinical experience from The Royal National Orthopaedic Hospital Stanmore and to ascertain the rate of glenoid component loosening. We also carried out a radiographic review to correlate loosening with patterns of lucency on post-operative radiographs. One hundred and five B-W TSRs in 103 patients were included, 24% of which were performed as revision of previous failed arthroplasty. In total, 8/105 glenoids required revision. Of those eight patients, two were cases of septic loosening. Of all nine specified areas of glenoid, tip lucency on x-ray appeared to be most strongly associated with need for glenoid revision. 5/9 cases with tip lucency progressed to loosening of the glenoid. Where tip lucency was not seen, 93/96 glenoid components remained secure, giving tip lucency a negative predictive value of 97%. Excluding the two infected cases, the glenoid remained secure in 97/103 patients undergoing BW-TSR with follow-up up to 13 years. The BW-TSR is a satisfactory and durable solution to the cuff-deficient shoulder in variety of challenging groups including younger patients and as a salvage procedure following failed, cuff-deficient arthroplasty.
