A once-daily dose of rivaroxaban 10 mg, an oral, direct Factor Xa inhibitor, was compared with enoxaparin 40 mg subcutaneously once daily for prevention of venous thromboembolism in three studies of patients undergoing elective hip and knee replacement (RECORD programme). A pooled analysis of data from these studies (n = 9581) showed that rivaroxaban was more effective than enoxaparin in reducing the incidence of the composite of symptomatic venous thromboembolism and all-cause mortality at two weeks (0.4% vs 0.8%, respectively, odds ratio 0.44; 95% confidence interval 0.23 to 0.79; p = 0.005), and at the end of the planned medication period (0.5% vs 1.3%, respectively; odds ratio 0.38; 95% confidence interval 0.22 to 0.62; p <
0.001). The rate of major bleeding was similar at two weeks (0.2% for both) and at the end of the planned medication period (0.3% vs 0.2%). Rivaroxaban started six to eight hours after surgery was more effective than enoxaparin started the previous evening in preventing symptomatic venous thromboembolism and all-cause mortality, without increasing major bleeding.
Drug therapy forms an integral part of the management
of many orthopaedic conditions. However, many medicines can produce
serious adverse reactions if prescribed inappropriately, either
alone or in combination with other drugs. Often these hazards are
not appreciated. In response to this, the European Union recently
issued legislation regarding safety measures which member states
must adopt to minimise the risk of errors of medication. In March 2014 the Medicines and Healthcare products Regulatory
Agency and NHS England released a Patient Safety Alert initiative
focussed on errors of medication. There have been similar initiatives
in the United States under the auspices of The National Coordinating
Council for Medication Error and The Joint Commission on the Accreditation
of Healthcare Organizations. These initiatives have highlighted
the importance of informing and educating clinicians. Here, we discuss common drug interactions and contra-indications
in orthopaedic practice. This is germane to safe and effective clinical
care. Cite this article:
The June 2012 Foot &
Ankle Roundup360 looks at: the Achilles tendon Total Rupture Score (ATRS); endoscopic treatment of Haglund’s syndrome; whether it is worth removing metalwork; hyaluronic acid injection; thromboembolic events after fracture fixation in the ankle; whether surgeons are as good as CT scans for OCD of the talus; proximal fractures of the fifth metatarsal; nerve blocks for hallux valgus surgery; chronic osteomyelitis in the non-diabetic patient; Charcot arthropathy.
The August 2014 Research Roundup360 looks at: Antibiotic loaded ceramic of use in osteomyelitis; fibronectin implicated in cartilage degeneration; Zinc Chloride accelerates fracture healing in rats; advertisements and false claims; Net Promoter Score: substance or rhetoric?; aspirin for venous thromboembolism prophylaxis and dissection, stress and the soul.
The August 2014 Spine Roundup360 looks at: rhBMP complicates cervical spine surgery; posterior longitudinal ligament revisited; thoracolumbar posterior instrumentation without fusion in burst fractures; risk modelling for VTE events in spinal surgery; the consequences of dural tears in microdiscectomy; trends in revision spinal surgery; radiofrequency denervation likely effective in facet joint pain and hooks optimally biomechanically transition posterior instrumentation.
Total knee arthroplasty (TKA) is known to lead
to a reduction in periprosthetic bone mineral density (BMD). In theory,
this may lead to migration, instability and aseptic loosening of
the prosthetic components. Bisphosphonates inhibit bone resorption
and may reduce this loss in BMD. We hypothesised that treatment
with bisphosphonates and calcium would lead to improved BMD and
clinical outcomes compared with treatment with calcium supplementation
alone following TKA. A total of 26 patients, (nine male and 17 female,
mean age 67 years) were prospectively randomised into two study
groups: alendronate and calcium (bisphosphonate group, n = 14) or calcium
only (control group, n = 12). Dual energy X-ray absorptiometry (DEXA)
measurements were performed post-operatively, and at three months,
six months, one, two, four, and seven years post-operatively. Mean femoral metaphyseal BMD was significantly higher in the
bisphosphonate group compared with controls, up to four years following
surgery in some areas of the femur (p = 0.045). BMD was observed
to increase in the lateral tibial metaphysis in the bisphosphonate
group until seven years (p = 0.002), and was significantly higher than
that observed in the control group throughout (p = 0.024). There
were no significant differences between the groups in the central
femoral metaphyseal, tibial medial metaphyseal or diaphyseal regions
of interest (ROI) of either the femur or tibia. Bisphosphonate treatment after TKA may be of benefit for patients
with poor bone quality. However, further studies with a larger number
of patients are necessary to assess whether this is clinically beneficial. Cite this article:
The April 2014 Hip & Pelvis Roundup360 looks at: Recent arthroplasty and flight; whether that squeak could be a fracture; diagnosing early infected hip replacement; impaction grafting at a decade; whether squeaking is more common than previously thought; femoral offset associated with post THR outcomes; and periprosthetic fracture stabilisation.
The June 2014 Hip &
Pelvis Roundup360 looks at: Modular femoral necks: early signs are not good; is corrosion to blame for modular neck failures; metal-on-metal is not quite a closed book; no excess failures in fixation of displaced femoral neck fractures; noise no problem in hip replacement; heterotopic ossification after hip arthroscopy: are NSAIDs the answer?; thrombotic and bleeding events surprisingly low in total joint replacement; and the elephant in the room: complications and surgical volume.
Total knee replacement (TKR) is an operation
that can be performed with or without the use of a tourniquet. Meta-analyses
of the available Level-1 studies have demonstrated that the use
of a tourniquet leads to a significant reduction in blood loss.
The opponents for use of a tourniquet cite development of complications
such as skin bruising, neurovascular injury, and metabolic disturbance
as drawbacks. Although there may certainly be reason for concern
in arteriopathic patients, there is little evidence that routine
use of a tourniquet during TKR results in any of the above complications.
The use of a tourniquet, on the other hand, provides a bloodless
field that allows the surgeon to perform the procedure with expediency
and optimal visualisation. Blood conservation has gained great importance
in recent years due to increased understanding of the problems associated
with blood transfusion, such as increased surgical site infection
(due to immunomodulation effect), increased length of hospital stay
and increased cost. Based on the authors’ understanding of the available
evidence, the routine use of a tourniquet during TKR is justified
as good surgical practice. Cite this article:
We investigated the capacity of patient warming
devices to disrupt the ultra-clean airflow system. We compared the effects
of two patient warming technologies, forced-air and conductive fabric,
on operating theatre ventilation during simulated hip replacement
and lumbar spinal procedures using a mannequin as a patient. Infection
data were reviewed to determine whether joint infection rates were
associated with the type of patient warming device that was used. Neutral-buoyancy detergent bubbles were released adjacent to
the mannequin’s head and at floor level to assess the movement of
non-sterile air into the clean airflow over the surgical site. During
simulated hip replacement, bubble counts over the surgical site
were greater for forced-air than for conductive fabric warming when
the anaesthesia/surgery drape was laid down (p = 0.010) and at half-height
(p <
0.001). For lumbar surgery, forced-air warming generated
convection currents that mobilised floor air into the surgical site
area. Conductive fabric warming had no such effect. A significant increase in deep joint infection, as demonstrated
by an elevated infection odds ratio (3.8, p = 0.024), was identified
during a period when forced-air warming was used compared to a period
when conductive fabric warming was used. Air-free warming is, therefore,
recommended over forced-air warming for orthopaedic procedures.
Little is known about the efficacy of graduated compression stockings in preventing venous thromboembolism after hip surgery. We conducted a prospective, randomised single-blind study to determine whether the addition of compression stockings to fondaparinux conferred any additional benefit. The study included 874 patients, of whom 795 could be evaluated (400 in the fondaparinux group and 395 in the fondaparinux plus compression stocking group). Fondaparinux was given post-operatively for five to nine days, either alone or combined with wearing stockings, which were worn for a mean 42 days (35 to 49). The study outcomes were venous thromboembolism, or sudden death before day 42. Duplex ultrasonography was scheduled within a week of day 42. Safety outcomes were bleeding and death from venous thromboembolism. The prevalence of deep-vein thrombosis was similar in the two groups 5.5% (22 of 400) in the fondaparinux group and 4.8 (19 of 395) in the fondaparinux plus stocking group (odds ratio 0.88, 95% confidence interval 0.46 to 1.65, p = 0.69). Major bleeding occurred in only one patient. The addition of graduated compression stockings to fondaparinux appears to offer no additional benefit over the use of fondaparinux alone.
We performed a retrospective study of a departmental database to assess the efficacy of a new model of orthopaedic care on the outcome of patients with a fracture of the proximal femur. All 1578 patients admitted to a university teaching hospital with a fracture of the proximal femur between December 2007 and December 2009 were included. The allocation of Foundation doctors years 1 and 2 was restructured from individual teams covering several wards to pairs covering individual wards. No alterations were made in the numbers of doctors, their hours, out-of-hours cover, or any other aspect of standard patient care. Outcome measures comprised 30-day mortality and cause, complications and length of stay. Mortality was reduced from 11.7% to 7.6% (p = 0.007, Cox’s regression analysis); adjusted odds ratio was 1.559 (95% confidence interval 1.128 to 2.156). Reductions were seen in These findings may have implications for all specialties caring for patients on several wards, and we believe they justify a prospective trial to further assess this effect.
A total of 80 patients with an acute rupture of tendo Achillis were randomised to operative repair using an open technique (39 patients) or non-operative treatment in a cast (41 patients). Patients were followed up for one year. Outcome measures included clinical complications, range of movement of the ankle, the Short Musculoskeletal Function Assessment (SMFA), and muscle function dynamometry evaluating dorsiflexion and plantar flexion of the ankle. The primary outcome measure was muscle dynamometry. Re-rupture occurred in two of 37 patients (5%) in the operative group and four of 39 (10%) in the non-operative group, which was not statistically significant (p = 0.68). There was a slightly greater range of plantar flexion and dorsiflexion of the ankle in the operative group at three months which was not statistically significant, but at four and six months the range of dorsiflexion was better in the non-operative group, although this did not reach statistically significance either. After 12 weeks the peak torque difference of plantar flexion compared with the normal side was less in the operative than the non-operative group (47% We were unable to show a convincing functional benefit from surgery for patients with an acute rupture of the tendo Achillis compared with conservative treatment in plaster.
In an initial randomised controlled trial (RCT)
we segregated 180 patients to one of two knee positions following total
knee replacement (TKR): six hours of knee flexion using either a
jig or knee extension. Outcome measures included post-operative
blood loss, fall in haemoglobin, blood transfusion requirements,
knee range of movement, limb swelling and functional scores. A second
RCT consisted of 420 TKR patients randomised to one of three post-operative
knee positions: flexion for three or six hours post-operatively,
or knee extension. Positioning of the knee in flexion for six hours immediately
after surgery significantly reduced blood loss (p = 0.002). There
were no significant differences in post-operative range of movement,
swelling, pain or outcome scores between the various knee positions
in either study. Post-operative knee flexion may offer a simple
and cost-effective way to reduce blood loss and transfusion requirements
following TKR. We also report a cautionary note regarding the potential risks
of prolonged knee flexion for more than six hours observed during
clinical practice in the intervening period between the two trials,
with 14 of 289 patients (4.7%) reporting lower limb sensory neuropathy
at their three-month review. Cite this article:
Following the publication in 2007 of the guidelines from the National Institute for Health and Clinical Excellence (NICE) for prophylaxis against venous thromboembolism (VTE) for patients undergoing surgery, concerns were raised by British orthopaedic surgeons as to the appropriateness of the recommendations for their clinical practice. In order to address these concerns NICE and the British Orthopaedic Association agreed to engage a representative panel of orthopaedic surgeons in the process of developing expanded VTE guidelines applicable to all patients admitted to hospital. The functions of this panel were to review the evidence and to consider the applicability and implications in orthopaedic practice in order to advise the main Guideline Development Group in framing recommendations. The panel considered both direct and indirect evidence of the safety and efficacy, the cost-effectiveness of prophylaxis and its implication in clinical practice for orthopaedic patients. We describe the process of selection of the orthopaedic panel, the evidence considered and the contribution of the panel to the latest guidelines from NICE on the prophylaxis against VTE, published in January 2010.
In our department we use an enhanced recovery
protocol for joint replacement of the lower limb. This incorporates the
use of intravenous tranexamic acid (IVTA; 15 mg/kg) at the induction
of anaesthesia. Recently there was a national shortage of IVTA for
18 weeks; during this period all patients received an oral preparation
of tranexamic acid (OTA; 25 mg/kg). This retrospective study compares
the safety (surgical and medical complications) and efficacy (reduction
of transfusion requirements) of OTA and IVTA. During the study period
a total of 2698 patients received IVTA and 302 received OTA. After
adjusting for a range of patient and surgical factors, the odds
ratio (OR) of receiving a blood transfusion was significantly higher
with IVTA than with OTA (OR 0.48 (95% confidence interval 0.26 to
0.89), p = 0.019), whereas the safety profile was similar, based
on length of stay, rate of readmission, return to theatre, deep
infection, stroke, gastrointestinal bleeding, myocardial infarction,
pneumonia, deep-vein thrombosis and pulmonary embolism. The financial
benefit of OTA is £2.04 for a 70 kg patient; this is amplified when
the cost saving associated with significantly fewer blood transfusions
is considered. Although the number of patients in the study is modest, this
work supports the use of OTA, and we recommend that a randomised
trial be undertaken to compare the different methods of administering
tranexamic acid. Cite this article: