Aims. The aims of this study were to assess the pre- and postoperative incidence of deep vein thrombosis (DVT) using routine duplex Doppler ultrasound (DUS), to assess the incidence of pulmonary embolism (PE) using CT angiography, and to identify the factors that predict postoperative DVT in patients with a pelvic and/or acetabular fracture. Methods. All patients treated surgically for a pelvic and/or acetabular fracture between October 2016 and January 2020 were enrolled into this prospective single-centre study. The demographic, medical, and surgical details of the patients were recorded. DVT screening of the lower limbs was routinely performed using DUS before and at six to ten days after surgery. CT angiography was used in patients who were suspected of having PE. Age-adjusted univariate and stepwise multiple logistic regression analysis were used to determine the association between explanatory variables and postoperative DVT. Results. A total of 191 patients were included. A DVT was found preoperatively in 12 patients (6.3%), of which six were proximal. A postoperative DVT was found in 42 patients (22%), of which 27 were proximal. Eight patients (4.2%) had a PE, which was secondary to a DVT in three. None of the 12 patients in whom a vena cava filter was implanted prophylactically had a PE. Multivariate logistic regression analysis indicated that the association with the need for spinal surgery (odds ratio (OR) 19.78 (95% confidence interval (CI) 1.12 to 348.08); p = 0.041), intramedullary nailing of a long bone fracture (OR 4.44 (95% CI 1.05 to 18.86); p = 0.043), an operating time > two hours (OR 3.28 (95% CI 1.09 to 9.88); p = 0.035), and additional trauma surgery (OR 3.1 (95% CI 1.03 to 9.45); p = 0.045) were statistically the most relevant independent predictors of a postoperative DVT. Conclusion. The acknowledgement of the risk factors for the development of a DVT and their weight is crucial to set a threshold for the index of suspicion for this diagnosis by medical staff. We suggest the routine use of the DUS screening for DVT in patients with a pelvic and/or acetabular fracture before and six to ten days after surgery. Cite this article: Bone Joint J 2022;104-B(2):283–289

Stable fractures of the ankle can be successfully treated non-operatively by a below-knee plaster cast. In some centres, patients with this injury are routinely administered low-molecular-weight heparin, to reduce the risk of deep-vein thrombosis (DVT). We have assessed the incidence of DVT in 100 patients in the absence of any thromboprophylaxis. A colour Doppler duplex ultrasound scan was done at the time of the removal of the cast. Five patients did develop DVT, though none had clinical signs suggestive of it. One case involved the femoral and another the popliteal vein. No patient developed pulmonary embolism. As the incidence of DVT after ankle fractures is low, we do not recommend routine thromboprophylaxis

We prospectively studied the outcome of a protocol of prophylaxis for deep vein thrombosis (DVT) in 103 consecutive patients undergoing surgical stabilisation of pelvic and acetabular fractures. Low-molecular-weight heparin (LMWH) was administered within 24 hours of injury or on achieving haemodynamic stability. Patients were screened for proximal DVT by duplex ultrasonography performed ten to 14 days after surgery. The incidence of proximal DVT was 10% and of pulmonary embolus 5%. Proximal DVT developed in two of 64 patients (3%) who had received LMWH within 24 hours of injury, but in eight of 36 patients (22%) who received LMWH more than 24 hours after the injury (p < 0.01). We conclude that LMWH, when begun without delay, is a safe and effective method of thromboprophylaxis in high-risk patients with major pelvic or acetabular fractures

INTRODUCTION. Tranexamic Acid (TA) has been shown to decrease peri-operative bleeding in primary Total Knee Replacement (TKR) surgery. There are still concerns with regards to the increased risk of thromboembolic events with the use of TA. The aim of this study was to assess whether the use of pre-operative TA increased the incidence of Deep Vein Thrombosis (DVT) and Pulmonary Embolism (PE) in TKR. METHODS. Patients who underwent primary TKR between August 2007 and August 2009 were identified from the databases of three surgeons within the lower limb arthroplasty unit. A retrospective case notes analysis was performed. DVT was diagnosed on Duplex Ultrasound Scan and PE on CT Pulmonary Angiogram. A positive result was a diagnosis of DVT or PE within 3 months of surgery. RESULTS. 322 patients underwent primary TKR over the 2 year period. 131 patients received TA pre-operatively. 191 patients did not receive TA prior to surgery. A total of 4 (3.1%) patients who received TA were diagnosed with either a DVT (2) or PE (2) post operatively. In those patients not receiving TA, 6 had a DVT and 2 had a PE, a total of 8 (4.2%). CONCLUSION. Pre-operative use of Tranexamic Acid in primary Total Knee Replacement does not increase the incidence of DVT and PE

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The use of multimodal non-opioid analgesia in hip fractures, specifically acetaminophen combined with non-steroidal anti-inflammatory drugs (NSAIDs), has been increasing. However, the effectiveness and safety of this approach remain unclear. This study aimed to compare postoperative outcomes among patients with hip fractures who preoperatively received either acetaminophen combined with NSAIDs, NSAIDs alone, or acetaminophen alone.

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The aim of this study was to assess the safety and clinical outcome of patients with a femoral shaft fracture and a previous complex post-traumatic femoral malunion who were treated with a clamshell osteotomy and fixation with an intramedullary nail (IMN).

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To assess the feasibility of a randomized controlled trial (RCT) that compares three treatments for acetabular fractures in older patients: surgical fixation, surgical fixation and hip arthroplasty (fix-and-replace), and non-surgical treatment.

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The aim of this study was to compare the early postoperative mortality and morbidity in older patients with a fracture of the femoral neck, between those who underwent total hip arthroplasty (THA) and those who underwent hemiarthroplasty.

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For displaced femoral neck fractures (FNFs) in geriatric patients, there remains uncertainty regarding the effect of total hip arthroplasty (THA) compared with hemiarthroplasty (HA) in the guidelines. We aimed to compare 90-day surgical readmission, in-hospital complications, and charges between THA and HA in these patients.

There are concerns regarding the rates and significance of DVT and PE following ankle fracture with published rates of VTEs varying widely. This study aimed to identify the incidence of VTEs in patients with ankle fractures and to compare this to the background risk of VTEs in these patients and the population. 1,283 consecutive patients with ankle fractures presenting to our trauma centre over a twenty-month period were studied prospectively. Patients with conservatively-managed ankle fractures were encouraged to mobilise weight-bearing but not provided with chemical thromboprophylaxis, whilst operatively-managed fractures were only prescribed chemical thromboprophylaxis during their inpatient stay. Both hospital and national episode data were searched to identify VTEs between 1981 and 2014. Over this 33-year period there were 17 PEs and 5 DVTs. Of these, 50percnt; occurred prior to the ankle fracture, 23percnt; greater than one year after the fracture and only 27percnt; in the 90 days following injury, with no fatal PEs in this cohort. The incidence of VTEs among conservatively-managed ankle fractures within 30 and 90 days was 1.1 and 3.3 per thousand patients respectively. Operatively-managed fractures were at greater risk, with 5.2 per thousand patients at 30 days and 7.8 at 90 days. We have found that the incidence of VTEs is very low after ankle fracture: approximately five times lower than after major joint arthroplasty. The efficacy of chemical thromboprophylaxis remains controversial, and given that the rate of major haemorrhagic complications is 2percnt;, it remains to be determined whether this is appropriate after ankle fracture

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

Aims. The best time for definitive orthopaedic care is often unclear in patients with multiple injuries. The objective of this study was make a prospective assessment of the safety of our early appropriate care (EAC) strategy and to evaluate the potential benefit of additional laboratory data to determine readiness for surgery. Patients and Methods. A cohort of 335 patients with fractures of the pelvis, acetabulum, femur, or spine were included. Patients underwent definitive fixation within 36 hours if one of the following three parameters were met: lactate < 4.0 mmol/L; pH ≥ 7.25; or base excess (BE) ≥ -5.5 mmol/L. If all three parameters were met, resuscitation was designated full protocol resuscitation (FPR). If less than all three parameters were met, it was designated an incomplete protocol resuscitation (IPR). Complications were assessed by an independent adjudication committee and included infection; sepsis; PE/DVT; organ failure; pneumonia, and acute respiratory distress syndrome (ARDS). . Results. In total, 66 patients (19.7%) developed 90 complications. An historical cohort of 1441 patients had a complication rate of 22.1%. The complication rate for patients with only one EAC parameter at the point of protocol was 34.3%, which was higher than other groups (p = 0.041). Patients who had IPR did not have significantly more complications (31.8%) than those who had FPR (22.6%; p = 0.078). Regression analysis showed male gender and injury severity score to be independent predictors of complications. Conclusions. This study highlights important trends in the IPR and FPR groups, suggesting that differences in resuscitation parameters may guide care in certain patients; further study is, however, required. We advocate the use of the existing protocol, while research is continued for high-risk subgroups. . Cite this article: Bone Joint J 2017;99-B:122–7

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

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The primary aim of this study was to identify independent predictors associated with nonunion and delayed union of tibial diaphyseal fractures treated with intramedullary nailing. The secondary aim was to assess the Radiological Union Scale for Tibial fractures (RUST) score as an early predictor of tibial fracture nonunion.

Background:. The aim of this study was to review the surgical complications and clinical outcomes of patients with Pilon fractures treated with Ilizarov frames. Methods:. Data collected included surgical complications, grade of initial injury using the Ruedi-Allgower classification and quality of reduction according to the Teeny and Wiss criteria. Outcome scores were collected retrospectively using the Foot and Ankle Disability Index (FADI). Results:. A total of 97 consecutive patients were identified. All patients were treated with indirect reduction by capsuloligamentotaxis and stabilisation using an ankle-spanning Ilizarov external fixator. The mean time to union was 6 months. Data was available for 70 patients. 35 patients developed a pin site infection. There were no cases of osteomyelitis. 4 patients developed a DVT and 1 patient a PE, 4 patients required ankle fusions. Quality of reduction according to the criteria of Teeny and Wiss was anatomic in 40 patients, good in 23 patients, fair in 6 patients, poor in 3 patients. Conclusion:. This is one of the larger series of Pilon factures on literature review. Ilizarov frame fixation achieves stable reduction of the fractured fragments without additional trauma to soft tissues with minimal complications and good functional results

Patients with a history of venous thromboembolism (VTE) are considered at very high risk for recurrence after lower limb arthroplasty (LLA). However, the chance of a new VTE episode after LLA has not been yet quantified. The aim of this study was to define the incidence of VTE recurrence following knee and hip arthroplasty. The case notes for all LLA patients treated at our hospital from 2009 to 2011 were reviewed. There were 5946 primary and revision LLA operations in total; 118 of these interventions were performed in 106 patients with a history of VTE. This group included 69 females and 37 males with a mean age of 69.9. Routine thromboprophylaxis for LLA patients included mechanical (footpumps & TED stockings) plus chemical prophylaxis using Aspirin 150 mg for 6 weeks. Patients with a VTE history had the same mechanical prophylaxis but received warfarin for 3 months. There were no fatal VTEs within 90 days of surgery. There were 5 episodes (4.2%) of VTE recurrence and specifically 4 PE and one DVT (femoral vein) at 4 months after the operation. Two of the PEs were asymptomatic, diagnosed on CTPA scans being requested for low O2 saturations on routine monitoring. In the group of patients without a VTE history there were 35 VTE episodes (0.6%), indicating a significantly lower rate of VTE (p=0.001) in comparison with the study group. Patients with a history of VTE had a 4.2% chance of having a further VTE. This is seven times greater than the rate among all other patients despite using more aggressive chemoprophylaxis

Post operative warfarinisation of elective arthroplasty patients delays their discharge. We retrospectively analysed all patients who required warfarinisation post surgery from April to September 2011. We identified the number of extra days stayed for the sole purpose of warfarinisation (i.e. after discharge by Physiotherapy and Occupational Therapy) and estimated the cost implications of this extended stay. 76 patients were warfarinised post operation, mean age 70.6 years (50–87) with 42 females and 34 males, 37 THR and 33 TKR. The mean extra days stayed was 3.1 (range 0 to 9). Atrial fibrillation and previous venous thromboembolism (DVT/PE) were the most common indication, 78%, followed by a current episode of DVT/PE, 11%. The nature of joint replacement made no difference to the extra days stayed (3.1 for THR and 2.9 for TKR) or the INR (2.27 in both groups) at discharge. Random loading dose instead of the recommended 5 mg of warfarin resulted in prolonged stay, 4.5 days compared to 3 days otherwise. The approximate cost per inpatient day is £500 (£137 nursing, £163 medical and £200 for facilities). From our results this amounts to £1500 per patient and £228,000 a year. In addition, there is a loss of income as the bed occupancy means not being able to undertake another arthroplasty surgery (£3,600 per patient) and possible failure to achieve waiting time targets. We conclude that substantial financial and resource savings can be made if warfarinisation is undertaken at the community level

Rivaroxiban is a factor Xa inhibitor and is a newer oral alternative for thromboprophylaxis after joint replacements. Its major advantage is its oral administration and hence better patient compliance. However there are some doubts about its efficacy compared to dalteparin/heparin. We have recently changed over from using dalteparin injections to rivaroxiban tablets for thromboprophylaxis after hip replacements. We assessed our results to find efficacy and specificity of its action in patients undergoing THR. 504 patients underwent hip replacement in last 2 years. 316 were treated with dalteparin injections (fragmin) for thromboprophylaxis while 189 patients were treated with oral rivaroxiban for 35 days after their hip replacement. Average haemoglobin drop at 24 hours postop was 2.79 in Rivaroxiban group compared to 3. 10 in dalteparin group. 19 patients (of 189 i.e. 10.05%) required postop blood transfusion in rivaroxiban group as against 60 (of 315 i.e. 19.04%) in Dalteparin group. This difference was statistically significant. Incidence of DVT was no different in either groups, but the number of patients was too small to compare this. Rivaroxiban appears to be more specific in its action and our results suggest a significant reduction in postop blood transfusion following hip replacements without any increase in rate of Deep Vein Thrombosis. We would like to present our findings and discuss role of oral thromboprophylaxis after joint replacements

The CALEDonian Technique™, promoting enhanced recovery after surgery, is a multimodal multidisciplinary technique. This has demonstrated excellent analgesic control allowing early mobilisation and discharge following TKA, whilst maintaining patient safety. All patients follow a planned programme beginning with pre-operative out-patient education at the pre-assessment visit. An anaesthetic regimen consisting of pre-emptive analgesia is combined with a spinal/epidural with propofol sedation. Intra-articular local anaesthetic soft tissue wound infiltration by the surgeon under direct vision is supplemented by post-operative high volume intermittent boluses via an intra-articular catheter. Early active mobilisation is positively encouraged. A prospective audit of over 1000 patients demonstrated 35% of patients mobilised on day 0 and 95% by day 1, with rescue analgesia required in only 5% of cases. 79% of patients experienced no nausea or vomiting helping reduce length of stay from six to four postoperative days. A catheterisation rate of 7%, a DVT rate of 0.6% and a PE rate of 0.5% remained within or below previously published levels. Laboratory studies examining the performance of the epidural filter and injection technique used for the post-operative intra-articular injections demonstrated this to be robust and effective at preventing bacterial ingress. This in-vitro data is supported by clinical results demonstrating no increase in the deep infection rate of 0.7% since the implementation of the technique at our institution. We conclude that the CALEDonian Technique™ effectively and safely improves patient post-operative recovery following TKA

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Complex joint fractures of the lower extremity are often accompanied by soft-tissue swelling and are associated with prolonged hospitalization and soft-tissue complications. The aim of the study was to evaluate the effect of vascular impulse technology (VIT) on soft-tissue conditioning in comparison with conventional elevation.