Purpose. This meta-analysis was designed to compare the effectiveness and safety of intravenous (IV) versus topical administration of tranexamic acid (TXA) in patients undergoing primary total knee arthroplasty (TKA) by evaluating the need for allogenic blood transfusion, incidence of postoperative complications, volume of postoperative blood loss, and change in hemoglobin levels. Materials and Methods. Studies were included in this meta-analysis if they assessed the allogenic blood transfusion rate, postoperative complications including pulmonary thromboembolism (PTE) or deep vein thrombosis (DVT), volume of postoperative blood loss via drainage, estimated blood loss, total blood loss, and change in hemoglobin before and after surgery in primary TKA with TXA administered through both the intravenous (IV) and topical routes.[Fig. 1]. Results. Ten studies were included in this meta-analysis.[Fig. 2] The proportion of patients requiring allogenic blood transfusion (OR 1.34, 95% CI: 0.63 to 2.81; P=0.45) [Fig. 3] and the proportion of patients who developed postoperative complications including PTE or DVT (OR 0.85, 95% CI: 0.41 to 1.77; P=0.66) did not significantly differ between the two groups. There was 52.3 mL less blood loss via drainage (95% CI: −50.74 to 185.66 ml; P=0.44),[Fig. 4] 21.5 mL greater estimated blood loss (95% CI: −98.05 to 55.12 ml; P=0.32), and 51.4 mL greater total blood loss (95% CI: −208.16 to 105.31 ml; P=0.52) [Fig. 5]in the topical TXA group as compared to the IV TXA group. The two groups were also similar in terms of the change in hemoglobin levels (0.02 g/dl, 95% CI: −0.36 to 0.39 g/dl; P=0.94). Conclusion. In primary TKA, there are no significant differences in the transfusion requirement, postoperative complications, blood loss, and change in hemoglobin levels between the intravenous and topical administration of TXA. For figures/tables, please contact authors directly.

Introduction. Unlike the NJR, no surgeon driven national database currently exists for ligament surgery in the UK and therefore information on outcome and adverse event is limited to case series. Methods. Prospectively collected Hospital episode statistics (HES) data for England was analysed so as to determine national rates of 90-day symptomatic deep venous thrombosis (DVT), pulmonary thromboembolism (PTE) rate, significant wound infection and 30-day readmission rates with cause following anterior cruciate ligament (ACL) reconstruction. This diagnostic and operative codes information is routinely collected on every patient admitted to hospital in England NHS. Results. All HES data between April 2008 and March 2010 was analysed for patients undergoing ACL reconstruction (13571 patients). 90-day DVT and PTE rates were 0.29% (40) and 0.20% (27) respectively. There were no deaths. 0.94% (127) had a wound complication recorded and 1.34% (182) were readmitted to an orthopaedic ward within 30 days. Conclusion. We are particularly interested in adverse event reporting from ACL surgery. Our knowledge of current UK ligament practice and outcome is based upon low uptake postal surveys and small number case series. We have been able to quantify the complication rate for thrombotic events, readmission rate and other adverse events following ACL surgery from a national database. Contrary to popular belief there is a real but small risk of PTE following ACL surgery. We believe this data strengthens the argument for a funded prospective UK ligament registry

Introduction: Traditionally conservative treatment has been used in fractures of more than 4 parts in patients over 65 years of age. Due to the increasing physical demands on the part of the patients and the increase in life expectancy we have had to reassess our attitude with respect to these fractures. Materials and methods: We carried out a prospective study in patients with 4-part proximal humeral fracture treated with shoulder arthroplasty in 33 patients. Mean age 65–90, 81% women. The choice of prosthesis depended on the surgeon. The decision to use an inverted prosthesis was due to the impossibility of repairing the rotator cuff. The assessment parameters used were: clinical assessment, pain-scale, Constant Test, DASH questionnaire and satisfaction survey. Results: The total complication rate was 45% (15 patients), 7 suffered a functional limitation of movement, 2 damaged their rotator cuff, 1 had a prosthesis dislocation, 2 had infections, 1 had pulmonary thromboembolism (PTE) and 2 were cases with previous neurological lesions. Twelve percent of all complications were independent of the technique used and in 42% there was no baseline pathological condition that justified their poor evolution. Good results were seen in 76% of functionally active patients. Conclusions: In spite of the failure rate and the demanding technical requirements of this technique, shoulder arthroplasty may be considered the procedure of choice in active patients over 65 years of age

Introduction. The National Institute for Health and Clinical Effectiveness recommends both low molecular weight heparin (LMWH) and Rivaroxaban for venous thromboembolic (VTE) prophylaxis following lower limb arthroplasty. Despite evidence in the literature that suggests Rivaroxaban reduces VTE events, there are emerging concerns from the orthopaedic community regarding an increase in wound complications following its use. Methods. Through the orthopaedic clinical directors forum, Trusts replacing LMWH with Rivaroxaban for lower limb arthroplasty thromboprophylaxis during 2009 were identified. Prospectively collected Hospital episode statistics (HES) data was then analysed for these units so as to determine rates of 90-day symptomatic deep venous thrombosis (DVT), pulmonary thromboembolism (PTE), major bleed (cerebrovascular accident or gastrointestinal haemorrhage), all-cause mortality, and 30-day wound infection and readmission rates before and after the change to Rivaroxaban. 2752 patients prescribed Rivaroxaban following TKR or THR were compared to 10358 patients prescribed LMWH. Data was analysed using odds ratios (OR). Results. There were significantly more wound infections in the Rivaroxaban group (3.85% vs. 2.81%, OR=0.72; 95% CI 0.58-0.90). There were no significant differences between the two groups for PTE (OR=1.52; 0.77-2.97), major bleed (OR=0.73; 0.48-1.12), all-cause mortality (OR=0.93; 0.46-1.87) and re-admission rate (OR=1.21; 0.88-1.67). There were significantly fewer symptomatic DVTs in the Rivaroxaban group (0.91% vs. 0.36%, OR=2.51; 1.30-4.82). Conclusion. This study is the first to describe the real impact of the use of Rivaroxaban in the NHS. When compared with LMWH in lower limb arthroplasty patients, wound infection rates were significantly higher following Rivaroxaban use whilst providing no reduction in symptomatic PTE or all-cause mortality

Introduction. Patients undergoing total hip arthroplasty (THA) stand in the danger, a particularly high risk for venous thromboembolism (VTE). Fondaparinux and edoxaban, which inhibit FXa, indirectly and directly, respectively, have been used for prevention of VTE after THA in Japan. The aim of this study was to compare the efficacy of fondaparinux and edoxaban for VTE after elective THA in Japanese patients. Materials and methods. We randomly assigned 320 patients underdoing elective cemented THA to receive postoperative 2.5 mg fondaparinux once daily for first postoperative 3 days and 1.5 mg once daily for the subsequent 7 days (FPX group) [1], postoperative 15 mg edoxaban once daily for postoperative 10 days (EDO15mg group), 30 mg edoxaban once daily for postoperative 10 days (EDO30mg group), and 30 mg edoxaban once daily for first postoperative 3 days and 15 mg once daily for the subsequent 7 days (EDOmix group). Deep venous thrombosis (DVT) was diagnosed by ultrasonography at postoperative day 3 and 14. Computed tomography to detect pulmonary thromboembolism was performed to all patients who had proximal DVTs. The χ. 2. test with Bonferroni correction was used to compare variables of the incidence of DVT between each group. The intention-to-treat analysis was performed for statistical analysis in each group. The EDO30 mg group and EDOmix group were regarded as one group in the assessment at the postoperative day 3, and named as the EDO30mg+mix group. Result. There was no fetal bleeding, bleeding in a critical organ, or bleeding leading to reoperation. One patient in the FPX group dropped out due to discontinuation of administration due to proximal DVT at postoperative day 3 and switch to fibrinolytic therapy therapy. One patient in the EDO15mg group dropped out due to stop of administration because of subconjunctival hemorrhage at postoperative day 9. All the patients took the ultrasonography at postoperative day 3. The incidence of DVT was 13.8% (11/80) in the FPX group, 20.0% (16/80) in the EDO15mg group, and 15.0% (24/160) in the EDO30mg+mix group. At the postoperative day 14, except for dropouts, the incidence of DVT was 5.1% (4/79) in the FPX group, 19.0% (15/79) in the EDO15mg group, 8.8% (7/80) in the EDO30mg group, 13.8% (11/80) in the EDOmix group. One proximal DVT was detected in the FPX group at the postoperative day 3, and in other three groups at the postoperative day 14, of which, asymptomatic PE was detected in one patient in each FPX group and EDO30mg group. There was no significance between other each group in the intention-to-treat analysis. The incidence of DVT in the FPX group had a tendency to be lower than that of DVT in the EDO15mg group (p = 0.06). Discussion and conclusions. The results suggest that fondaparinux and edoxaban have an equal effect to prevent DVT for Japanese patients undergoing elective cemented THR. From the point of view of the cost-effectiveness and safety, edoxaban may be worth considering as an alternative

Introduction and purpose: A large amount of studies discuss risk factors that lead to higher mortality and a worse functional recovery in patients who sustain a hip fracture, namely age, a previous pathology and gender. The purpose of this study is to determine what role is played by obesity in the evolution of this pathology. Materials and methods: This is a prospective study that includes all the patients older than 65 who were admitted to our hospital for a non-pathological hip fracture between 1999 and 2002. Of a total 1142 patients, 15.5% were obese (BMI> 30). No differences were detected as to the type of fracture, time to surgery or length of hospitalization. The group of obese patients required fewer postoperative blood transfusions since their postop hemoglobin levels were significantly higher than those of the other group. All patients were followed up for up to six months after having sustained the fracture or until exitus. Results: Mortality was 24% for the control group and 39.1% for obese patients. Significantly, this group also had a higher complications rate (pneumonias, deep venous thrombosis, pulmonary thromboembolism and digestive bleeding). Lastly, functional recovery took significantly less time. Conclusions: Vital and functional prognosis after sustaining a hip fracture is bleaker for obese patients. In our study we quantified it at a RR = 1.62 for mortality and at a RR=2.01 for poor functional recovery. The higher frequency of postop complications lead us to indicating more stringent prophylactic measures for these patients

Aim: We audited medical complications after revision hip arthroplasty, in elderly and young patients and correlated its occurrence to the preoperative medical status. Methods: 104 revision hip replacements in 100 patients (mean age 71.5 years) were followed up for a mean of 33.9 months. (9–67). 49 were above 75 years of age. The American Society of Anaesthetists grading system was used to assess preoperative medical fitness. 50% patients were in ASA grade III. Medical complications in the first 3 postoperative months were classified into major, moderate and minor (Phillips). There were pre-existing cardiac problems in 57, COPD in 13, vascular disease in 7, cerebro vascular disease in 7, previous DVT in 6 and renal/endocrine problems in 16. Results: Overall medical complication rate was 35% (7% major, 14% moderate and 14% minor). The rate in elderly patients was 21%. There was 1 postoperative death due to cardiac reasons at 2 months. There were cardiac complications in 23%, anaemia in 17%, respiratory problems in 10%, hematemesis in 7%, renal in 7%, circulatory in 7%, deep vein thrombosis in 5%, pulmonary thromboembolism in 5%. Mean hospital stay was 17.8 days. 83 patients had no pain, 88 were independent, and 7 had poor mobility. 85% were satisfied with the operation. The major medical complications were not significantly higher in elderly than in younger patients. Conclusion ASA grade correlated positively with frequency and severity of medical complications (Fisher exact test p < 0.001). The occurrence was independent of the age of the patient (p=0.106). Revision hip arthroplasty was well-tolerated in elderly patients and age alone is not a contra-indication. This compared favourably with other reported series. Good anaesthetic and medical support is vital

Introduction and Objectives: Acetabular bone defects in hip replacement therapy present difficulties in terms of achieving stable, long-lasting fixation of the implant. Various surgical techniques exist to correct this problem. In this study we analysed the clinical and radiographic progression of a series of patients treated with fragmented grafts using the X-Change acetabular revision method. Materials and Methods: From November 1988 to February 1998, 24 patients were treated, with an average age of 64.5 (±7) at the time of surgery. Patients were evaluated clinically preoperatively and were evaluated using the Harris scale at the end of the follow-up period. Defects were classified according to Paprosky’s classification of acetabular bone defects. Radiographic studies were used to evaluate upward and medial migration of the acetabular component and to look for signs of loosening. Follow-up time was a minimum of 12 months, with an average of 56.2 months. Results: Average score on the Harris scale went from 49.7 points (±12.9) preoperatively to 88.2 points (±14.1) on follow-up. There was no graft incorporation in 5 patients (20%). There were 3 infections, 2 prosthetic dislocations, and one case of pulmonary thromboembolism. Upward migration of the cup (from the upper obturator line) was 0.48 cm (±0.72) postoperatively and 0.48 cm (±0.84) at follow-up. Medial migration (measured from Kohler’s line) was −0.16 cm (±0.50) postoperatively and −0.09 cm (±0.56) on follow-up. Cup angle (measured at the anteroposterior plate of the pelvis) changed from 48.9° (±5°) to 56° (±7°) at the conclusion of the follow-up period. Discussion and Conclusions: This reconstructive technique provides stable, long-lasting fixation of the implant with complication rates similar to those described in the literature. We consider it a useful technique in the management of this type of defect, particularly in young patients who need to recover acetabular bone stock

We used the D-dimer level as a measure for the early diagnosis of deep vein thrombosis (DVT), which can cause fatal pulmonary thromboembolism (PTE), following total hip arthroplasty (THA). Recently, we have performed anticoagulation therapy, in addition to the use of elastic stocking and intermittent pneumatic compression, for the prevention of DVT. In the present study, we examined the effect of administration of anticoagulation drugs on the changes in the D-dimer level. Of 123 patients who had undergone THA between April 2003 and October 2007, 70 patients who were available for 3 or more measurements of the D-dimer level were included in this study. These 70 patients were divided into the following three groups: N group consisting of 30 patients who were not given anticoagulation drugs (4 males, 26 females; mean age 69 years (45–87 years); mean body mass index (BMI) 24.1 (15.8–28.5)), W group consisting of 23 patients who were administered dose-adjusted warfarin at a dose of 5 mg within 3 days after surgery and at 1–3 mg following 1-day rest (3 males, 20 females; mean age 62 years (48–83 years); mean BMI 24.1 (17.8–35.9)), and F group composed of 15 patients who were given fondaparinux (2.5 mg) between postoperative days 1 and 14 (6 males, 11 females; mean age 64 years (51–81 years); mean BMI 23.1 (18.2–31.6)). There was no significant difference in sex ratio and BMI between the three groups, while a significant difference in age was found between the N and F groups. The D-dimer level was measured on days 3, 7, 10, 14 and 21 and changes in the median D-dimer level were compared between groups. In the N group, the D-dimer level was around 8 μg/ml between postoperative days 3 and 10 and exceeded 10 μg/ml on postoperative day 14. In the W group, the D-dimer level was around 8 μg/ml between postoperative days 3 and 14 and decreased thereafter. In the F group, the D-dimer level was less than 3 μg/ ml on postoperative day 3, increased gradually thereafter until postoperative day 14, reaching the maximum level of approximately 8 μg/ml, and then decreased thereafter. The D-dimer level was significantly different between the N and F groups and between the W and F groups on day 3, between the N and F groups and between the W and F groups on day 7, and between the N and W groups on day 21. With regard to hemorrhagic adverse events, neither major nor minor bleeding event was observed in either the W or F group. The present study suggested that fondaparinux is effective for preventing DVT in an early postoperative period, with relatively low D-dimer levels observed between postoperative days 3 and 10. We expect that various types of anticoagulation drugs will be used in the future. Elucidating the effect of these drugs on the D-dimer level will help in the early diagnosis of DVT

The August 2012 Trauma Roundup³⁶⁰ looks at: pelvic fractures, thromboembolism and the Japanese; venous thromboembolism risk after pelvic and acetabular fractures; the displaced clavicular fracture; whether to use a nail or plate for the displaced fracture of the distal tibia; the dangers of snowboarding; how to predict the outcome of lower leg blast injuries; compressive external fixation for the displaced patellar fracture; broken hips in Morocco; and spinal trauma in mainland China.