An experimental study performed in 16 mongrel dogs is presented, which shows that when venous stasis is combined with the local injection of non-esterified fatty acid an intense thrombosis results. This response is not produced by venous stasis alone, nor by the combination of venous stasis and triacylglycerol. Histologically it is quite different from the response produced by an inert intraluminal foreign body. It does resemble venous thrombosis described experimentally and in patients. The clinical relevance of these findings is that during accidental or operative trauma to a long bone, fat is commonly forced into the local venous circulation. If this event is combined with venous stasis or a tourniquet is used, then the circumstances of this experiment are reproduced. It is suggested that the venous thrombosis which commonly complicates long-bone injury or operation is in part caused by the thrombogenic nature of the introduced fat

We investigated the effect of a fibrinolytic inhibitor, tranexamic acid, on blood loss and blood transfusion in knee arthroplasty by a randomised, double-blind study of 86 patients. A dose of 10 mg/kg body-weight of either tranexamic acid or placebo was given intravenously shortly before the release of the tourniquet, and repeated three hours later. The mean total blood loss was 730 ± 280 ml in the tranexamic acid group as against 1410 ± 480 ml in the placebo group (p < 0.001). Both the number of patients receiving blood transfusion and the number of blood units transfused were reduced to one-third in the treated group, and mean postoperative Hb concentrations were significantly higher after prophylaxis. The number of thromboembolic complications was the same in both groups. Tranexamic acid should be given prophylactically in order to be effective

Using a scintigraphic technique based on anautologous injection of . 99m. Tc-labelled erythrocytes, we have evaluated the efficiency of different exsanguination procedures in the upper limb of ten healthy male volunteers. The methods were elevation alone, the use of the Esmarch bandage or a gauze bandage, the Pomidor roll-cuff, the squeeze method and the Urias bag. The various procedures gave the following median percentage reductions of blood volumes: elevation for 5 seconds 44%, 15 seconds 45%, 30 seconds 46%, 60 seconds 46% and 4 minutes 42%, the Esmarch bandage 69%, a gauze bandage 63%, the Pomidor roll-cuff 66%, the squeeze method 53%, and the Urias bag 57%. With regard to elevation alone no significant differences were found. All the external methods were significantly more effective than elevation alone. Overall, the squeeze method was found to be the best method of exsanguination before inflation of a tourniquet, because it is effective, fast, practical and inexpensive

We carried out 12 arthroscopies of the first metatarsophalangeal (MTP) joint in 11 patients over a five-year period. Their mean age was 30 years (15 to 58) and the mean duration of symptoms before surgery was eight months (1 to 24). Six patients had an injury to the joint; all had swelling and tenderness with a reduced range of movement. In six patients, radiographs revealed no abnormality. Under general anaesthesia with a tourniquet the hallux is suspended by a large Chinese finger trap to distract the joint. Using a 1.9 mm 30° oblique arthroscope the MTP joint is inspected through dorsomedial and dorsolateral portals with a medial portal if necessary. All patients were found to have intra-articular pathology, which was treated using small instruments. The mean follow-up was 19.3 months (6 to 62) and all patients had no or minimal pain, decreased swelling and an increased range of movement of the affected joint

Aims

We report the medium-term outcomes of a consecutive series of 118 Zenith total ankle arthroplasties (TAAs) from a single, non-designer centre.

1. Direct injection of contrast material into bone indicates its extreme vascularity, particularly near an epiphysis, and emphasises the extraordinary capacity of the minute periosteal vessels. The nutrient artery of a long bone appears to play little part in its nourishment and may be regarded as a vestigeal structure. 2. The vascular pattern of bone tumours may be investigated by injection of the appropriate artery, and sometimes, if a haemangioma is suspected, by direct injection into the lesion. 3. The examination is easily and quickly carried out by direct arterial puncture under local anaesthesia and injection of 35 per cent diodone. A tourniquet applied distally at the appropriate level is often helpful. 4. A study of the vascular pattern of suspected bone tumours has provided useful information in a positive and negative way, assisting both the diagnosis and the planning of treatment. The pathological diagnosis of some tumours, notably osteosarcomas and haemangiomas, may be made with such assurance that possible dissemination of the tumour by biopsy may be avoided

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

Traumatic uraemia is of particular significance to orthopaedic surgeons in so far as this complication is responsible for high mortality in cases of severe injury, crushing injury, traumatic shock, gun-shot wounds, incompatible blood transfusions, and the misuse of tourniquets. In this contribution the association between muscle injury and renal failure is reviewed. The syndrome of the "crush kidney," which at first was thought to be the result of deposition of myohaemoglobin in the renal tubules, is almost certainly due to the association of many factors, all of which lead to alteration of the renal circulation and renal ischaemia. Certainly the combination of ischaemia of the kidney with deposition of pigment and haemolysis of blood causes a high mortality in animals, and it is believed that this may account for the serious prognosis in human cases where there is both shock and haemolysis. Disturbance of water balance, allergic phenomena, and chemical nephrotoxic action are also discussed. The pathology is considered together with significant changes in the blood chemistry. A plea is made for early recognition of this clinical syndrome with its characteristic features. Important aspects of treatment are discussed. The dangers of excessive intravenous infusion are emphasised. Closer investigation and further research promise to throw light on the more accurate localisation of function in the nephron, to add to our knowledge of traumatic arterial spasm, and to explain many orthopaedic problems which hitherto appeared insoluble

Aims

For many designs of total knee arthroplasty (TKA) it remains unclear whether cemented or uncemented fixation provides optimal long-term survival. The main limitation in most studies is a retrospective or non-comparative study design. The same is true for comparative trials looking only at the survival rate as extensive sample sizes are needed to detect true differences in fixation and durability. Studies using radiostereometric analysis (RSA) techniques have shown to be highly predictive in detecting late occurring aseptic loosening at an early stage. To investigate the difference in predicted long-term survival between cemented, uncemented, and hybrid fixation of TKA, we performed a randomized controlled trial using RSA.

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Modern total knee arthroplasty (TKA) prostheses are designed to restore near normal kinematics including high flexion. Kneeling is a high flexion, kinematically demanding activity after TKA. The debate about design choice has not yet been informed by six-degrees-of-freedom in vivo kinematics. This prospective randomized clinical trial compared kneeling kinematics in three TKA designs.

Aims

Fixation of scaphoid nonunion with a volar locking plate and cancellous bone grafting has been shown to be a successful technique in small series. Few mid- or long-term follow-up studies have been reported. The aim of this study was to report the mid-term radiological and functional outcome of plate fixation for scaphoid nonunion.

The application of robotics in the operating theatre for knee arthroplasty remains controversial. As with all new technology, the introduction of new systems might be associated with a learning curve. However, guidelines on how to assess the introduction of robotics in the operating theatre are lacking. This systematic review aims to evaluate the current evidence on the learning curve of robot-assisted knee arthroplasty. An extensive literature search of PubMed, Medline, Embase, Web of Science, and Cochrane Library was conducted. Randomized controlled trials, comparative studies, and cohort studies were included. Outcomes assessed included: time required for surgery, stress levels of the surgical team, complications in regard to surgical experience level or time needed for surgery, size prediction of preoperative templating, and alignment according to the number of knee arthroplasties performed. A total of 11 studies met the inclusion criteria. Most were of medium to low quality. The operating time of robot-assisted total knee arthroplasty (TKA) and unicompartmental knee arthroplasty (UKA) is associated with a learning curve of between six to 20 cases and six to 36 cases respectively. Surgical team stress levels show a learning curve of seven cases in TKA and six cases for UKA. Experience with the robotic systems did not influence implant positioning, preoperative planning, and postoperative complications. Robot-assisted TKA and UKA is associated with a learning curve regarding operating time and surgical team stress levels. Future evaluation of robotics in the operating theatre should include detailed measurement of the various aspects of the total operating time, including total robotic time and time needed for preoperative planning. The prior experience of the surgical team should also be evaluated and reported.

Cite this article: Bone Joint J 2020;102-B(4):407–413.

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The aim of this study was to evaluate the need for hand trauma services during the COVID-19 pandemic lockdown, specifically related to surgical requirements. This will provide useful information for planning and resource allocation in the event of any further lockdown.

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Malignancy and surgery are risk factors for venous thromboembolism (VTE). We undertook a systematic review of the literature concerning the prophylactic management of VTE in orthopaedic oncology patients.

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The hypothesis of this study was that bone peg fixation in the treatment of osteochondral lesions of the talus would show satisfactory clinical and radiological results, without complications.

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Antifibrinolytic agents, including tranexamic acid (TXA) and epsilon-aminocaproic acid (EACA), have been shown to be safe and effective for decreasing perioperative blood loss and transfusion following total hip arthroplasty (THA) and total knee arthroplasty (TKA). However, there are few prospective studies that directly compare these agents. The purpose of this study was to compare the benefits of intraoperative intravenous TXA with EACA.

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The aim of this prospective multicentre study was to describe trends in length of stay and early complications and readmissions following unicompartmental knee arthroplasty (UKA) performed at eight different centres in Denmark using a fast-track protocol and to compare the length of stay between centres with high and low utilization of UKA.