Purpose: This study was designed to evaluate post-total joint arthroplasty patients who were sent for a chest CT scan in order to determine the clinical factors that were most likely to be associated with, and predictive of, a radiologic diagnosis of pulmonary embolism in the acute, postoperative period. Method: The current study involved a review of 540 total knee replacements and 543 total hip arthroplasty procedures performed from June 2008 to September 2009. All patients received postoperative VTE prophy-laxis using LMWH, as per the protocols established by the Alberta Bone and Joint Initiative, and consistent with the recommendations of the American College of Chest Physicians (2008). A pulmonary CT scan was ordered for patients in situations where. a pulmonary embolism was strongly suspected. for those who lacked a clear alternative diagnosis as an explanation for their findings. when steps to correct the suspected underlying condition failed to normalize results, or. in situations where the diagnosis (i.e. new-onset atrial fibrillation) warranted further investigation to rule out a PE as a possible cause. Patients referred for multidetector computed tomography to investigate the possibility of pulmonary embolus were identified, and subjected to a chart review. Results: Forty-two patients underwent a pulmonary CT scan investigation to rule out pulmonary embolus. Of these, 15 patients had undergone hip surgery, and 27 had undergone a total knee replacement. Of the 42 patients, 34 exhibited hypoxemia as their major presenting sign (oxygen saturation less than 90% on room air), with or without other signs or symptoms. Four patients presented with tachycardia alone, and 2 patients presented with chest pain, of which one patient had an associated arrhythmia. Of the 34 patients presenting with unexplained postoperative hypoxemia, 25 were patients who had undergone total knee replacement, and of these 25 patients, 14 (56%) were found to have a pulmonary embolus on CT scanning of the lungs. There were no PE’s identified in the post-hip population. None of the patients with PE’s presented with subjective dyspnea or chest pain. There were no fatalities as a result of PE. Conclusion: The overall high rate of detection of pulmonary embolism in our postoperative population is due the very close monitoring of pulse oximetry combined with the improved sensitivity of imaging modalities. Hypoxemia is emerging as the clinical sign that is most sensitive to the possibility of a PE in the post-knee arthroplasty patient. Reliance on clinical symptoms such as chest pain, dyspnea, or even tachycardia is no longer appropriate. It is recommended that oxygen saturation, as measured by pulse oximetry, should be monitored regularly on all post-arthroplasty patients. Hypoxemia should lead to a prompt and thorough medical workup. If an obvious explanation for the hypoxemia cannot be identified, the patient should undergo a multidetector CT scan to rule out a pulmonary embolus

Debate continues about the best treatment for patients over 65 years with non-displaced subcapital hip fractures: internal fixation (IF) or hemiarthroplasty (HA). Surgical aggression, mortality, complications and recovery of walking ability after 1year have been compared between both treatments. Match-paired comparison of 2 retrospective cohorts. 220 patients with IF vs 220 receiving a cemented bipolar HA. Matching by age (82.6±7.16 years (65–99)), sex (74.5% women), year of intervention (2013–2021) and ASA scale (24.2% ASA II, 55.8% III, 20.0% IV). Age (p=0.172), sex (p=0.912), year of intervention (p=0.638) and ASA scale (p=0.726) showed no differences. Surgical aggression smaller in IF: Surgical time (p< 0,00001), haemoglobin/haematocrit loss (p <0,00001), need for transfusion (p<0,00008), in-hospital stay (p<0,00001). Mortality: higher in-hospital for hemiarthroplasties (12 deaths (5.5%) vs 1 (0.5%) (p=0.004) (RR=12, 1.5–91.5)). But no significant differences in 1-month (13 hemiarthroplasties, 6%, vs 9 osteosynthesis, 4.1%) and 1-year mortality (33 hemiarthroplasties, 15%, vs 35, 16%). Medical complications: no differences in urinary/respiratory infections, heart failure, ictus, myocardial infarction, digestive bleeding, pressure sores or pulmonary embolus (p=0.055). Surgical complications: no significant differences. HA: 6 intraoperative (2,7%) and 5 postoperative periprosthetic fractures (2,3%), 5 infections (2,3%), 10 dislocations (4,5%), 3 neurovascular injuries. IF: 10 acute fixation failures (4,5%), 2 infections (0,9%), 9 non-unions (4,1%), 16 ischemic necrosis (7,3%). Functional results: no significant differences; 12 patients in each group (5,5%) never walked again (p=1), 110 HA (50%) and 100 IF (45.5%) suffered worsening of previous walking ability (p=0.575), 98 HA (44%) and 108 IF patients (49%) returned to pre-fracture walking ability (p=0.339). Fixation with cannulated screws may be a better option for non-displaced femoral neck fractures because recovery of walking ability and complications are similar, while surgical aggression and in-hospital mortality are lower

Background: Previous studies have reported mixed findings with regards to post operative complication rates and overall outcome in elderly patients undergoing total hip arthroplasty. The aim of this study was a prospective comparison of physical and functional outcome measurements following primary hip arthroplasty in patients aged 80–90 years to those aged 70–79. Methods: Data was prospectively recorded from 1998–2002. 144 patients aged 80–90 years underwent primary hip arthroplasty compared to 441 aged 70–79. A pre-operative Harris Hip Score was obtained on all patients and a standardized follow up regimen was used for assessment at 6, 18 and 36 months post surgery. Data collection included: intraoperative blood loss; post operative transfusion rate; incidence of wound infection, DVT and pulmonary embolus; dislocation and mortality rates. Statistical analysis involved two-sample t-test and chi-squared with Yates correction. Results: Pre-operative Harris Hip Scores were 41.6 (SD 11.2) in the younger cohort and 39.3 (SD 12.4) in the octogenarian (P = 0.04). This score had improved by 39.3 and 38.1 points respectively (P = 0.5) at 6 months; 42.3 and 37.7 at 18 months (P = 0.02); 43.4 and 39.8 at 36 months (P = 0.24). The mortality rate at 3 months following surgery was 4% in our octogenarian group compared to 1% (P=0.02). Mean length of hospital stay was significantly (P< 0.001) longer at 12.9 (SD 7.0) days compared to 10.1 (SD 4.7). The transfusion rate in our octogenarian group was 40% compared to 28% (P = 0.009). The incidence of deep infection was 1.4% in the older group compared to 0.5% (NS). Each group had a dislocation rate of 1%. and an incidence of DVT and pulmonary embolus that was comparable. Discussion: Total hip arthroplasty can be performed safely in octogenarians with excellent relief of pain and improved function

Introduction: Venous thromboembolism is a major cause of morbidity and mortality in hospitalised patients and patients undergoing major orthopaedic surgery are at high risk from venous thromboembolism. Thromboprophylaxis, both mechanical and chemical, is commonly administrated to reduce fatality from thromboembolism after surgery. However, there is no convincing evidence in the literature demonstrating that routine chemothromboprophylaxis reduces death rates from pulmonary embolus. Furthermore, it is unclear from the literature which thromboprophylactic agent, if any, should be used. Recent NICE guidelines have recommended that heparin should be routinely administered to patients under-going THR to prevent thromboembolism, although it is unclear from the existing evidence if heparin is the most effective. However, research has suggested that aspirin, which is a low cost prophylactic agent, is effective in preventing DVT and PE after orthopaedic surgery. The aim of this study was to determine the 90-day mortality rate after THR using aspirin as a prophylactic agent. Patients and Methods: Between 2003–2006, 2,286 patients underwent primary THR and 372 patients underwent revision hip replacement (RHR). Routine chemothromboprophylaxis consisting of aspirin 75mg daily for 6 weeks. In addition all patients were treated with anti-thromboembolic stockings. 40mg of subcutaneous clexane, in lieu of aspirin, was given daily to all patients who had previously suffered from a pulmonary embolus or deep venous thrombosis. Patients who died within 90 days of surgery had their death certificates examined. Retrieval at 90 days with regard to death was 100%. Results:. Primary THR. One patient (0.04%) died within 30 days of surgery and a further 3 (0.13%) died between day 30 and day 90, giving a total mortality at 90 days of 0.17% (4/2,286). One patient (0.04%) died from PE and the other 3 patients (0.13%) died from non-vascular causes. Revision hip replacement. One patient (0.27%) died within 30 days of surgery and a further 1 patient (0.27%) died between day 30 and day 90, giving a total mortality at 90 days of 0.54% (2/367). Both patients died from non-vascular causes. Discussion: This study found that the 30-day mortality rate for primary THR and RHR was 0.08% and the 90-day mortality rate was 0.23%. In this study, there was only one death from PE and no deaths from arterial complications. Therefore, although NICE guidelines suggest the use of heparin, this study found that routine aspirin administration is beneficial in protecting against early death after THR because of both thromboembolism and adverse arterial events

Patients with pelvic and acetabular fractures have a high risk of developing thromboembolic complications. Despite routine screening, the risk of PE remains high and may develop in patients with negative DVT screening. The search for a means to identify the patient ‘at risk’ has been elusive. 537 consecutive patients, referred to Royal Adelaide Hospital over a 20 year period for treatment of pelvic and acetabular fractures, were evaluated prospectively for pulmonary embolus (PE). 352 patients referred directly to the author were treated with variable dose heparin as prophylaxis to venous thromboembolic (VTE) disease. 184 patients primarily admitted under the general surgeons or to ITU, prior to referral to the author, were treated with fixed dose heparin or Enoxaparin. All patients were followed prospectively to determine the rate of pulmonary embolus. The heparin dosage requirements of those who developed pulmonary emboli were compared to those who did not. Patients were also identified for whom a clinical diagnosis of deep venous thrombosis (DVT) was made during the study and their heparin dosage requirements were determined. 7 of 352 patients treated with variable dose heparin developed PE (1.98%). 13 of 184 patients treated with fixed dose heparin, Enoxaparin, or combinations, developed PE (7.06%). An incidental finding of DVT was made in 36 patients. Of these, 10 patients (2.8%) were treated with variable dose heparin and 26 patients (14.1%) with fixed dose heparin or Enoxaparin. The average Injury Severity Score was higher in patients treated with variable dose heparin than those treated with fixed dose regimes. Patients treated with variable dose heparin who developed PE showed a progressively increasing heparin requirement. The majority of patients who did not develop PE (72%) showed a progressively decreasing heparin requirement (suggesting reversal of a prothrombotic state). 21% showed an initial increasing heparin requirement followed by a decreasing requirement (suggesting a prothrombotic state that was reversed, e.g. a DVT successfully treated by the increasing heparin dose provided by a variable dose regime). 4% manifested a static heparin requirement (suggesting maintenance of a prothrombotic state). 8 patients treated with variable dose heparin developed DVT. 6/8 patients manifested a phase of progressively increasing heparin requirement, followed by a decreased requirement, and 2/8 patients manifested a sustained level of heparin requirement. Patients with pelvic and acetabular fractures treated with variable dose heparin showed a rate of PE (1.98%). This is remarkably low compared with published rates of PE in such patients, and particularly compared with those patients treated only with chemoprophylaxis. The rate of PE was 3.5x higher and the rate of DVT was 5x higher in patients treated with fixed dose heparin or Enoxaparin. Patients who developed PE or DVT manifested an increasing heparin requirement. An increasing dosage of heparin may protect the ‘at risk’ patient from venous thromboembolism. Fixed dose unfractionated heparin/LMWH may be insufficient to treat the ‘at risk’ patient. An increasing heparin requirement may identify the patient ‘at risk’

The purpose of this study was to determine the complications after Bernese periacetabular osteomy (PAO) performed by one experienced surgeon using a minimally invasive modified Smith-Petersen approach. Between May 2012 and December 2015, 224 periacetabular osteotomies (PAO) in 201 patients were performed. The perioperative complications were retrospectively reviewed after reviewing clinical notes and radiographs. The mean age was 28.8 years with 179 females and 22 males. The most common diagnosis was acetabular dysplasia with some cases of retroversion. The average lateral centre edge (LCE) angle was 16.5°(−18–45) and mean acetabular index (AI) 16.79° (−3–50). Postoperatively the mean LCE angle was 33.1°(20–51.3) and mean AI 3.0°. (−13.5–16.6). There were no deep infections, no major nerve or vascular injuries and only one allogenic blood transfusion. Nine superficial wound infections required oral antibiotics and two wounds needed a surgical debridement. There was one pulmonary embolus and one deep vein thrombosis. Nine (4%) cases underwent a subsequent hip arthroscopy and three (1.3%) PAO's were converted to a total hip arthroplasty after a mean follow-up of 22 months (3–50). Lateral femoral cutaneous nerve dysaesthesia was noted in 64 (28.6%) PAO's. In 55 (24.5%) an iliopsoas injection of local anaesthetic and steroid for persistent iliopsoas irritation during the recovery phase was given. The minimally invasive modified Smith-Petersen approach is suitable to perform a Bernese periacetabular osteotomy with a low perioperative complication rate. Persistent pain related to iliopsoas is a not uncommon finding and perhaps under-reported in the literature

The extraordinary majesty of THR, as it burst onto the scene 60 years ago, both dazzled and blinded. It dazzled patients and surgeons alike and simultaneously obstructed a clear eyed assessment of the human costs. It behooves current practitioners, who have benefited mightily by our progress, to pause and reflect thoughtfully on that progress. Look no further than the fact that the treatment of a benign disease left one patient out of every 50 dead. Dead from a pulmonary embolus and that over 25% of the patients threw pulmonary emboli. What were the big six major disadvantages: 1) Fatal pulmonary emboli; 2) Prosthetic joint infection; 3) Failure of fixation; 4) Dislocation; 5) Periprosthetic osteolysis; 6) Prolonged hospitalization. Start with the observation that THR in the modern era began with Charnley's experiment with Teflon articulations. Of the nearly 300 such operations done, nearly 300 failed. Ultrahigh molecular weight polyethylene was better- much better. But still it produced wear and periprosthetic osteolysis, afflicting an estimated 1 million patients. Periprosthetic osteolysis became the most common reason for failure, the most common reason for reoperation, the most common reason for fracture, and the most common reason for extremely difficult re-operations requiring major grafting. Reoperation rates in certain series were 20 to 30% from loosening and 20 to 40% from osteolysis. Dislocation catapulted the unsuspecting patient to the floor at a rate of one out of 20 patients and the initial rate of prosthetic joint infection was 10%. Most patients were hospitalised in the new neighborhood of 2.5 weeks, at huge expense. Massive progress has been made but forget not that this striking progress was not obsessively linear. Recall the recent, extraordinary and continuing massive failure of metal-on-metal total hip replacements, despite 40 prior years of experience, predicting that metal-on-metal total joints should be ‘just fine’. Over the past six decades every one of the six major disadvantages listed above has been reduced by an order of magnitude. The challenge to you is to continue that progress

Introduction. Numerous musculoskeletal and systemic conditions may affect the hips of paediatric patients. While the large majority of patients go on to achieve positive outcomes, a small number will progress to end stage arthropathy with significant functional impairment. Management options have been significantly limited for this population. An adolescent hip arthroplasty program was developed with the aim to improve symptoms and quality of life for patients with pain and disability refractory to joint preserving management strategies. Methods. All patients were assessed jointly by a paediatric hip surgeon and an adult hip arthroplasty surgeon pre-operatively, with all procedures conducted at a dedicated tertiary care paediatric centre under general anesthesia. All procedures were completed through a direct lateral (trans-gluteal) approach, using uncemented components (Zimmer Biomet®, Warsaw, IN) and a ceramic on highly cross-linked polyethylene bearing. Data was collected prospectively after approval from the Institutional Review Board. All patients completed clinical examination and functional scores pre-operatively and at six months post-operatively. Results. Twenty-eight patients (29 hips) have undergone adolescent THA through this program. The most common diagnoses were avascular necrosis (n=18), idiopathic chondrolysis (n=2), chondrolysis secondary to slipped capital femoral epiphysis (n=2), and juvenile idiopathic arthritis (n=2). Numerous additional diagnoses accounted for 1 case each. Mean age at surgery was 16.0 years (11.8–18.7; SD=2.1). OHS improved from 24.8 (7–43; 10.9) pre-op to 39.3 (15–46; 7.6) at six months (p = p<0.00001). WOMAC improved from 49.4 (4–88; 23.1) to 10.4 (1–53; 12.1) (p<0.00001), while ASKp improved from 77.6 (32.7–99.2; 20.0) to 90.6 (48.3–100; 12.0) (p=0.009). There were 2 early complications: 1 intra-operative acetabular fracture (managed with primary components) and 1 post-operative pulmonary embolus (medical management). Conclusion. Adolescent patients with end-stage hip arthropathy who underwent THA demonstrated significant early improvements in symptoms and function. THA may be a viable management option in severely impaired adolescent patients with end stage hip arthropathy, in whom no joint preserving options remain. Longer term follow up is required to assess the longevity of THA in this population. Abbreviations:. THA -. Total hip arthroplasty. OHS -. Oxford Hip Score. WOMAC -. Western Ontario and McMaster Universities Osteoarthritis Index. ASKp -. Activity Scale for Kids - performance version

Tranexamic Acid (TA) has been shown to reduce transfusion rates in Total Knee Replacement (TKR) without complication. In our unit it was added to our routine enhanced recovery protocol. No other changes were made to the protocol at this time and as such we sought to examine the effects of TA on wound complication and transfusion rate. All patients undergoing primary TKR over a 12 month period were identified. Notes and online records were reviewed to collate demographics, length of stay, use of TA, thromboprophylaxis, blood transfusion, wound complications and haemoglobin levels. All patients received a Columbus navigated TKR with a tourniquet. Only patients who received 14 days of Dalteparin for thromboprophylaxis were included. 124 patients were included, 72 receiving TA and 52 not. Mean age was 70. Four patients required a blood transfusion all of whom did not receive TA (p = 0.029). Mean change in Hb was 22 without TA and 21 with (p = 0.859). Mean length of stay was 6.83 days without Tranexamic Acid and 5.15 with (p < 0.001). 15% of patients (n=11) of the TA group had a wound complication, with 40% of patients (n=21) in the non TA group (p = 0.003). There was one ultrasound confirmed DVT (non TA group). No patients were diagnosed with pulmonary embolus. In our unit we have demonstrated a significantly lower transfusion rate, wound complication rate and length of stay, without any significant increase in thromboembolic disease with the use of TA in TKR

Introduction:. Hallux surgery is the most commonly performed elective surgery in the foot and ankle. As with all surgery, there are many potential complications quoted in the literature. Venous thromboembolism (deep vein thrombosis and pulmonary embolism) incidence and prophylaxis, however, is not adequately addressed and remains controversial. Material and Method:. This prospective study includes one hundred patients who underwent hallux surgery. Risk factors implicated to increase the risk of developing venous thromboembolic disease as well as anaesthetic time, thigh tourniquet time and regional anaesthetic blocks were documented. Compressive ultrasonography was performed in all the patients postoperatively to assess for deep vein thrombosis. Results:. There was one incident of calf deep vein thrombosis (DVT). No patient developed a pulmonary embolus. The one patient who developed a DVT was not at any higher risk than the average patient in the study. Conclusion:. As a result of the low incidence of venous thromboembolic disease in this study, the authors do not recommend the routine use of chemical venous thrombo-prophylaxis in patients undergoing hallux surgery. The decision to give postoperative anticoagulation remains the surgeon's responsibility. The duration of prophylaxis will depend on when the patient is fully mobile

Introduction. Active patients may benefit from surgical repair of the achilles tendon with the aim of preserving functional length and optimising push-off power. A mini-open device assisted technique has the potential to reduce wound complications, but risks nerve injury. We present the largest published series of midsubstance achilles tendon repairs using the Achillon® device. Methods. A prospective cohort study was run at the Princess Royal Devon & Exeter Hospital between 2008 and 2015. We included all patients who presented with a midsubstance Achilles tendon rupture within 2 weeks of injury, and device assisted mini-open repair was offered to a young active adult population. All patients in the conservative and surgical treatment pathway had the same functional rehabilitation protocol with a plaster for 2 weeks, and a VACOped boot in reducing equinus for a further 8 weeks. Results. 354 patients presented with a midsubstance achilles tendon rupture over a 7-year period, of which 204 had conservative treatment and 150 patients had surgical repair with the Achillon device. Patients were assessed clinically for a minimum of 10 weeks, with long-term notes surveillance for late complications. The rerupture rate for conservative treatment was 1.5%, with no reruptures in the Achillon group. Infections in the surgical group were superficial in 2 cases (1.3%) and deep in 3 cases (2%). Pulmonary embolus occurred in 2 Achillon cases (1.3%), and 1 conservatively managed case (0.5%). There was 1 case of temporary sural nerve irritation in each group. Discussion. Our series show encouraging results for the Achillon® repair with no reruptures and a low complication profile. Functional rehabilitation is likely to have contributed to the low rerupture rate. Studies are emerging that show earlier and improved calf muscle strength in those having surgical repair, suggesting a role for device assisted mini open repair in a selected population

British national guidelines recommend agents which antagonise factor Xa or warfarin as prophylaxis of venous thromboembolism (VTE) in lower limb arthroplasty. However, they discourage the use of aspirin prophylaxis. We conducted a prospective, multi-centre audit between two national centres, Ninewells Hospital in Dundee and the Royal Infirmary in Edinburgh to compare bleeding and VTE risk. Only Edinburgh routinely uses aspirin as VTE prophylaxis. The study comprises a number of cycles from 2013 to 2015. Consecutive groups of patients were identified prospectively using elective theatre data and information extracted from their case-notes on type of VTE prophylaxis, VTE occurrence, wound complications and length of hospital stay for a period of nine weeks post-operatively. 262 Edinburgh patients and 92 Dundee patients were included. Most Edinburgh patients were prescribed aspirin in hospital and on discharge (188/262, 71.8%), in line with local protocol. In Dundee, dalteparin was most commonly prescribed in hospital (68/92, 73.9%) and rivaroxaban on discharge (57/92, 62.0%). The Edinburgh group had a 1.5% incidence of pulmonary embolus (PE) and a 1% rate of deep venous thrombosis (DVT), 2% had problems with wound haematoma and one patient (0.4%) required a transfusion; no wound washouts were required. In Dundee there was 0% PE, 2% DVT, 5% had problems with haematoma, 3% required transfusion and 2% required washout. There was no difference in length of hospital stay, with a mode of 4 days for both centres. Non-fatal PE was prevented in Dundee patients but possibly at the cost of greater incidence of wound complications

Background. This retrospective analysis was prompted by the authors' observation of the relatively high incidence of venous thromboembolism (VTE) in the surgical repair of acute Achilles tendon ruptures. Method. 88 patients were treated surgically for an acute Achilles tendon rupture. No prophylactic anticoagulation was given to any patients. The incidence of VTE was then reviewed retrospectively. Results. Five patients developed symptomatic deep vein thrombosis (5.7%) and one a near-fatal pulmonary embolus (1.1%). There were no major bleeding or cardiovascular adverse events. One patient developed a thrombus of the the lesser saphenous vein (1.1%) and there was one superficial sepsis (1.1%). A temporary peroneal nerve palsy occurred in one patient (1.1%). There were two re-ruptures (2.3%). Conclusion. There is no doubt that thromboprophylaxis must be given to the high risk patient and is also recommended for major orthopaedic surgery. Limited data is available for the use of thromboprophylaxis in foot and ankle surgery. In light of the unacceptably high incidence of venous thromboembolism in this study, the authors suggest that routine venous thromboembolism prophylaxis should be considered for these patients. MULTIPLE DISCLOSURES

Severe deformity and bone loss in patients with degenerative changes of the knee present a challenging surgical dilemma to the knee surgeon. We present the outcome following complex primary total knee replacements at our unit over 12 years undertaken by a single surgeon. Method:. 65 patients were followed up prospectively with regards to their pre- and post-operative Oxford knee scores, diagnoses, preoperative deformity, bone loss, surgical technique, type of implant used, bone substitutes, and perioperative, or long term complications. These patients were followed up annually. Result:. 70 complex primary total knee replacements were performed in 65 patients. The mean age was 70.5 years and the mean follow up was 62.4 months. Sleeve/wedge augmentation, and stemmed implant (Sigma®TC3- DePuy) were used in general. Bone grafting was utilized for contained bone defects. All except 4 patients were allowed to fully weight bear immediately postoperatively. The mean range of flexion was 112.5 degrees at their last follow up. The mean preoperative Oxford Knee Score was 12.8, and 41.5 postoperatively. 89.4% of patients had either an excellent or good, and the rest a fair outcome. Radiological appearance has been satisfactory in all patients at subsequent follow up, with no evidence of implant loosening. None required revision surgery. 6 patients required blood transfusion postoperatively. 2 patents developed symptomatic deep vein thrombosis and a further 2 had pulmonary embolus. Conclusion:. Our experience with complex primary total knee replacements has been promising with a good outcome

Hip fractures are among the most common orthopaedic injuries and represent a growing burden on healthcare as our population ages. Despite improvements in preoperative optimisation, surgical technique and postoperative care, complication rates remain high. Time to surgery is one of the few variables that may be influenced by the medical team. The aim of the present study was to evaluate the impact of time to surgery on mortality and major complications following surgical fixation of hip fractures. Utilising the American College of Surgeons' National Quality Improvement Program (NSQIP) database, we analysed all hip fractures (femoral neck, inter-trochanteric, and sub-trochanteric) treated from 2011 to 2013 inclusively. We divided patients into three groups based on time to surgery: less than one day (<24h), one to two days (24–48h), and two to five days (48–120h). Baseline characteristics were compared between groups and a multivariate analysis performed to compare 30-day mortality and major complications (return to surgery, deep wound infection, pneumonia, pulmonary embolus, acute renal failure, cerebrovascular accident, cardiac arrest, myocardial infarction, or coma) between groups. A total of 14,730 patients underwent surgical fixation of a hip fracture and were included in our analysis. There were 3,475 (24%) treated <24h, 9,960 (67%) treated 24–48h, and 1,295 (9%) treated 48–120h. Thirty-day mortality and major complication rates were 5.0% and 6.2% for the <24h group, 5.3% and 7.0% for the 24–48h group, 7.9% and 9.7% for the 48–120h group respectively. After controlling for baseline demographic differences between groups (age, sex, race) as well as pertinent comorbidities (diabetes, dyspnea, chronic obstructive pulmonary disease, chronic steroid use, hypertension, cancer, bleeding disorders, and renal failure), time to surgery beyond 48h resulted in greater odds of both mortality (1.45, 95%CI 1.10–1.91) and major complications (1.45, 95%CI 1.12–1.84). Time to surgery is one of the few variables that can be influenced by timely medical assessment and access to the operation room. Expediting surgery within 48h of hip fracture is of paramount importance as it may significantly reduce the risk of mortality as well as major complications

Aim. To assess the incidence of fatal pulmonary embolism (PE) following elective total knee replacement (TKR) with a standardised multi-modal prophylaxis regime in a large teaching DGH over a 10 year period. Material and methods. Information was gathered from a prospective audit database, utilising clinical coding for TKR and those that had died within 42 and 90 days. The 10 years from April 2000 were analysed to establish both 42 and 90 day mortality rates. A multi-modal prophylaxis regime for all patients included regional anaesthesia (when possible), mechanical prophylaxis (Flo-tron calf garment per-operatively, AV impulse boots until mobile and anti-embolism stockings for 6 weeks), mobilisation within 24 hours and 75mg aspirin for 4 weeks. A case note review was performed to ascertain the causes of death. Where a patient had been referred to the coroner, the coroner's office was contacted for PM results. Results. There were 6,584 cases; the mortality rates at 42 and 90 days were 0.36 and 0.52%. There were no fatal PE's within 42 days of surgery. 2 fatal PE's occurred subsequently at 48 and 57 days (0.03%) The leading causes of death were myocardial infarction and cerebro-vascular accident. Conclusion. Fatal pulmonary embolus following elective TKR with a multi-modal prophylaxis regime is not a significant cause of mortality

We have performed 466 metal-on-metal total hip replacements (THR) in our hospital, since November 1993. Forty-seven of these have been the TPP (Thrust plate prosthesis - Sulzer Medica). We present here the results of our experience with this prosthesis when used for the “younger” patient. Forty-two patients received 47 THRs The age was 40 years (range: 21 – 53 years) There were 25 female patients. At the latest review: one patient (with two THRs) had died from a pulmonary embolus one patient had a revision for an aseptic loosening (one hip) one patient was lost to follow-up (one hip). The remainder were satisfactory although two hips had subsided into a varus position. The early results were satisfactory in this high-demand group of patients

NICE technology appraisal guidance 157 suggests that the oral anticoagulation medication Dabigatran etexilate can be used for the primary prevention of venous thromboembolic events (VTE's) in adult patients who have undergone elective total hip or knee replacement surgery. The NICE guidance reports that 13.8% of patients receiving recommended doses of Dabigatran experienced adverse bleeding events. In the pivotal hip and knee VTE trial, wound secretion only accounted for 4.9% of patients treated with Dabigatran (cf 3.0% of patients treated with Enoxaparin). We report our wound secretion experience after Dabigatran use at Warwick Hospital from March 2009 to March 2010. Of the 788 lower-limb arthroplasties performed, 55 patients (6.9%) had oozing wounds after discharge (Mean=8 days, Range=1-39 days). This resulted in 226 extra home-visits by discharge nurses, 26 positive microbiology cultures and 5 confirmed wound infections needing antibiotic treatment and/or surgical intervention. Incidentally, there were also 2 known cases each of deep vein thrombosis and pulmonary embolus in this cohort. The number of complications was markedly increased from previous years when LMWH was the VTE prophylaxis used. This data suggests that the use of Dabigatran in Warwick Hospital may significantly increase surgical site morbidity and resource output after lower limb arthroplasty

Introduction and Aims: Single-stage bilateral total knee arthroplasty is an uncommon and often controversial procedure. Recent reports have refined the data relative to bilateral total knee arthroplasty and complications, which include myocardial infarction, deep vein thrombosis, pulmonary embolus and death. Method: A retrospective study of the cases of total knee arthroplasty performed by the senior authors in the last 10 years examines details of surgery and anaesthesia, pre- and post-operative management to identify the occurrence of complications. Patients also completed an Oxford Knee Score and a questionnaire relating to their experience of having a bilateral procedure. Results: While the outcomes and cost benefits of single-stage bilateral replacement are established, the risk of complications remains. This study establishes the low complication rate associated with this procedure in the senior author’s hands and documents the high patient satisfaction from it. Conclusion: The study demonstrates that, in selected patients, simultaneous bilateral knee replacement surgery can be performed with good outcomes without a definite increase in peri-operative risk

Purpose of the study:. The purpose of the study was to evaluate the possible causes or risk factors for the occurrence of venous thrombotic events (VTE) after shoulder arthroscopy. Methods:. Two cases that occurred in the practice were evaluated for the study. Evaluation of their medical history, procedures and post-operative care was made. The information was evaluated for possible risk factors that could have led to the VTE. Literature reports were also evaluated. All the relevant data (personal and literature) was used to determine risk factors that could help identify high risk patients undergoing arthroscopic shoulder surgery. Results:. Results revealed no intra operative risk factors for the VTE to occur. An underlying genetic predisposition in the one case and a previous history of VTE in the other were indentified as the major risk factors/causes. Literature review revealed that underlying mechanical causes should also be considered as possible risk factors. The rate of VTE occurring after a shoulder arthroscopy (0.6/1000 procedures) is much lower than when compared to knee, hip or spinal surgery. It should be noted however that upper limb VTE's have the highest risk of a pulmonary embolus developing as compared to a lower limb VTE. Conclusion:. Surgeons performing arthroscopic shoulder surgery also run the risk of their patients developing a VTE (upper or lower limb). The attending surgeon should assess and examine their patients preoperatively with as much scrutiny as they would their patients with upcoming knee, hip or spine surgery. Surgeons should have protocols in place to identify high risk patients. These should assess extrinsic as well as intrinsic risk factors. A high index of suspicion should also be maintained in the post-operative period