The administration of heparin during operation has been reported to enhance the efficacy of thromboprophylaxis in patients undergoing total hip replacement. We have performed a small pilot study in which intraoperative doses of heparin were given in addition to the usual postoperative thromboprophylaxis with enoxaparin in 32 patients undergoing total knee replacement. The primary endpoint was deep-vein thrombosis (DVT) as demonstrated by bilateral venography on 6 ± 2 days after operation. Sixteen patients developed DVT; in two the thrombosis was proximal as well as distal and in one the occurrence was bilateral. There was one major haemorrhage. These results are similar to those obtained with the use of postoperative thromboprophylaxis with enoxaparin alone. They do not provide support for the initiation of a larger randomised trial of this approach to management

Patients who undergo total knee replacement (TKR)are at high risk of venous thromboembolism. Low-molecular-weight heparins (LMWH) are the most suitable chemical prophylactic agents but there are some uncertainties about their safety and effectiveness. The foot pump offers an alternative. We randomised 229 patients undergoing primary, unilateral TKR to receive either the A-V Impulse foot pump or enoxaparin, a LMWH. Ascending venography was undertaken between the sixth and eighth postoperative day in 188 patients without knowledge of the randomisation category. The prevalence of venographic deep-vein thrombosis was 58% (57/99) in the foot-pump group and 54% (48/89) in the LMWH group which was not statistically significant. There were four cases of proximal thrombi and two of fatal pulmonary emboli in the foot-pump group and none in the LMWH group. There were fewer haemorrhagic complications and soft-tissue effects in the foot-pump group. We conclude that the neither method provides superior prophylaxis

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

Purpose. This study investigates the effect of early tourniquet release on range of flexion following total knee replacement, and the influence of anticoagulation with Rivaroxaban and Clexane (Enoxaparin). Method. 78 patients were included in the study, who underwent unilateral primary total knee replacement (TKR) in our department under the care of two specialist knee surgeons over a 12 month period. 27 patients underwent TKR with early release of the tourniquet and haemostasis, prior to closure of quadriceps layer: 22 were anticoagulated with Rivaroxaban (GROUP ER), 15 with the low molecular weight heparin Clexane (GROUP EC). Over the same time period, 41 patients TKR with late release of the tourniquet, following closure and bandaging: 13 were anticoagulated with Rivaroxaban (GROUP LR), 28 with Clexane (GROUP LC). A standardised operative technique was employed, and all patients received an AGC (Biomet) PCL-retaining prostheses. Outcome was assessed with range of flexion at 12 weeks postoperatively. Results. The mean range of flexion at 12 weeks was 106.8° in Group ER, 96.54° in Group LR, 108.33° in Group EC and 101.11° in LC. The mean difference in flexion at 12 weeks between Group EC and LC was 7.2°, and between ER and LR was 10.2°. Conclusion. Our study supports the theory that early tourniquet release and haemostasis has a beneficial effect on the early range of flexion following TKR. This affect appears to be increased when the oral anticoagulant Rivaroxaban is used, when compared with low molecular weight heparin

We compared thromboembolic events, major haemorrhage and death after knee replacement in patients receiving either aspirin or low-molecular-weight heparin (LMWH). Data from the National Joint Registry for England and Wales were linked to an administrative database of hospital admissions in the English National Health Service. A total of 156 798 patients between April 2003 and September 2008 were included and followed for 90 days. Multivariable risk modelling was used to estimate odds ratios adjusted for baseline risk factors (AOR). An AOR < 1 indicates that risk rates are lower with LMWH than with aspirin. In all, 36 159 patients (23.1%) were prescribed aspirin and 120 639 patients (76.9%) were prescribed LMWH. We found no statistically significant differences between the aspirin and LMWH groups in the rate of pulmonary embolism (0.49% vs 0.45%, AOR 0.88 (95% confidence interval (CI) 0.74 to 1.05); p = 0.16), 90-day mortality (0.39% vs 0.45%, AOR 1.13 (95% CI 0.94 to 1.37); p = 0.19) or major haemorrhage (0.37% vs 0.39%, AOR 1.01 (95% CI 0.83 to 1.22); p = 0.94). There was a significantly greater likelihood of needing to return to theatre in the aspirin group (0.26% vs 0.19%, AOR 0.73 (95% CI 0.58 to 0.94); p = 0.01). Between patients receiving LMWH or aspirin there was only a small difference in the risk of pulmonary embolism, 90-day mortality and major haemorrhage. These results should be considered when the existing guidelines for thromboprophylaxis after knee replacement are reviewed

Aims

This study compared patient-reported outcomes of three total knee arthroplasty (TKA) designs from one manufacturer: one cruciate-retaining (CR) design, and two cruciate-sacrificing designs, anterior-stabilized (AS) and posterior-stabilized (PS).

We carried out an audit on the result of achieving early walking in total knee replacement after instituting a new rehabilitation protocol, and assessed its influence on the development of deep-vein thrombosis as determined by Doppler ultrasound scanning on the fifth post-operative day. Early mobilisation was defined as beginning to walk less than 24 hours after knee replacement. Between April 1997 and July 2002, 98 patients underwent a total of 125 total knee replacements. They began walking on the second post-operative day unless there was a medical contraindication. They formed a retrospective control group. A protocol which allowed patients to start walking at less than 24 hours after surgery was instituted in August 2002. Between August 2002 and November 2004, 97 patients underwent a total of 122 total knee replacements. They formed the early mobilisation group, in which data were prospectively gathered. The two groups were of similar age, gender and had similar medical comorbidities. The surgical technique and tourniquet times were similar and the same instrumentation was used in nearly all cases. All the patients received low-molecular-weight heparin thromboprophylaxis and wore compression stockings post-operatively. In the early mobilisation group 90 patients (92.8%) began walking successfully within 24 hours of their operation. The incidence of deep-vein thrombosis fell from 27.6% in the control group to 1.0% in the early mobilisation group (chi-squared test, p < 0.001). There was a difference in the incidence of risk factors for deep-vein thrombosis between the two groups. However, multiple logistic regression analysis showed that the institution of an early mobilisation protocol resulted in a 30-fold reduction in the risk of post-operative deep-vein thrombosis when we adjusted for other risk factors

Aims

Periprosthetic joint infection (PJI) occurs in approximately 1% to 2% of total knee arthroplasties (TKA) presenting multiple challenges, such as difficulty in diagnosis, technical complexity, and financial costs. Two-stage exchange is the gold standard for treating PJI but emerging evidence suggests 'two-in-one' single-stage revision as an alternative, delivering comparable outcomes, reduced morbidity, and cost-effectiveness. This study investigates five-year results of modified single-stage revision for treatment of PJI following TKA with bone loss.

INTRODUCTION. We examined whether the introduction of an oral factor Xa inhibitor, increased total blood loss in patients undergoing primary total knee arthroplasty surgery. METHODS. Two groups were studied. The intervention group were prescribed a factor Xa inhibitor 6-10 hours post-surgery, and the control group were prescribed low molecular weight heparin (LMWH) 6-10 hours post-surgery. All other factors were kept constant. Pre- and post-operative haemoglobin levels (post-operative on day 2) were recorded. Any requirement for transfusion was also documented. Actual drop in haemoglobin levels was compared between the two groups. RESULTS. 43 patients were prescribed a factor Xa inhibitor and 37 patients LMWH thromboprophylaxis. Baseline pre-operative haemoglobin were comparable (p=0.91; 13.2 vs 13.2g/dL), however, post-operative blood loss was significantly increased in the factor Xa inhibitor group (p=<0.0001; 3.4 vs 2.6g/dL). More patients required transfusion in the factor Xa inhibitor group (0.07% vs 0.03%). Blood loss was significantly increased in the intervention group in patients who were not on anti-platelet medication, when compared with those on concurrent anti-platelet therapy (p=<0.001). CONCLUSIONS. Oral factor Xa inhibitors significantly increase post-operative blood loss in total knee arthroplasty surgery when compared with LMWH. There is a subsequent increased requirement for blood transfusion and the potential complications related to bleeding and transfusion. These factors must be considered and balanced with the ease of oral anticoagulation when introducing these newer agents in total knee arthroplasty patients. The anticoagulatory effects of oral factor Xa inhibitors are most pronounced in patients not on concurrent anti-platelet therapy

The optimal regime of antithrombotic prophylaxis for patients undergoing total knee arthroplasty (TKA) has not been established. Many surgeons employ intermittent pneumatic compression while others use low-molecular-weight heparins (LMWH) which were primarily developed for total hip arthroplasty. We compared the efficacy and safety of these two techniques in a randomised study with blinded assessment of the endpoint by phlebography. We randomised 130 patients, scheduled for elective TKA, to receive one daily subcutaneous injection of nadroparin calcium (dosage adapted to body-weight) or continuous intermittent pneumatic compression of the foot by means of the arteriovenous impulse system. A total of 108 patients (60 in the LMWH group and 48 in the mechanical prophylaxis group) had phlebography eight to 12 days after surgery. Of the 47 with deep-vein thrombosis, 16 had received LMWH (26.7%, 95% CI 16.1 to 39.7) and 31, mechanical prophylaxis (64.6%, 95% CI 49.5 to 77.8). The difference between the two groups was highly significant (p < 0.001). Only one patient in the LMWH group had severe bleeding. We conclude that one daily subcutaneous injection of calcium nadroparin in a fixed, weight-adjusted dosage scheme is superior to intermittent pneumatic compression of the foot for thromboprophylaxis after TKA. The LMWH scheme was also safe

We performed a meta-analysis of the English literature to assess the efficacy of four common regimes for thromboembolic prophylaxis after total knee arthroplasty: aspirin, warfarin, low-molecular-weight heparin (LMWH) and pneumatic compression. We reviewed 136 articles and abstracts published between January 1980 and December 1997. Papers not using routine venography and a lung scan or angiography to detect deep-venous thrombosis (DVT) and pulmonary emboli (PE) respectively, were excluded. Of the 136 studies, 23 with 6001 patients were selected. The incidence of DVT was 53% (1701/3214) in the aspirin group, 45% (541/1203) in the warfarin group, 29% (311/1075) in the LMWH group, and 17% (86/509) in the pneumatic compression device group. Intermittent pneumatic compression devices and LMWH were significantly better than warfarin (p < 0.0001) or aspirin (p < 0.0001) in preventing DVT. The incidence of asymptomatic PE was 11.7% in the aspirin group (222/1901), 8.2% (101/1229) in the warfarin group and 6.3% (24/378) in the pneumatic compression group. No studies with LMWH used routine lung scans. Warfarin and pneumatic compression were significantly better than aspirin in preventing asymptomatic PE (p < 0.05). The incidence of symptomatic PE was 1.3% (23/1800) in the aspirin group, 0.4% (2/559) in the warfarin group, 0.5% (2/416) in the LMWH group and 0% (0/177) in the pneumatic compression group. No statistically significant difference was noted between the above prophylatic regimes due to the very small incidence of symptomatic PE. Prophylaxis for thromboembolic disease in TKA may have to include a combination of some of the above regimes to incorporate their advantages

Aims

The optimal management of an infrapopliteal deep venous thrombosis (IDVT) following total knee arthroplasty (TKA) remains unknown. The risk of DVT propagation and symptom progression must be balanced against potential haemorrhagic complications associated with administration of anticoagulation therapy. The current study reports on a cohort of patients diagnosed with IDVT following TKA who were treated with aspirin, followed closely for development of symptoms, and scanned with ultrasound to determine resolution of IDVT.

Aims

While patients with psychological distress have poorer short-term outcomes after total knee arthroplasty (TKA), their longer-term function is unknown. We aimed to 1) assess the influence of preoperative mental health status on long-term functional outcomes, quality of life, and patient satisfaction; and 2) analyze the change in mental health after TKA, in a cohort of patients with no history of mental health disorder, with a minimum of ten years’ follow-up.

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To compare time dependent functional improvement for patients with medial, respectively lateral knee osteoarthritis (OA) after treatment with opening wedge osteotomy relieving the pressure on the osteoarthritic part of the knee.

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Antibiotic-loaded bone cements (ALBCs) may offer early protection against the formation of bacterial biofilm after joint arthroplasty. Use in hip arthroplasty is widely accepted, but there is a lack of evidence in total knee arthroplasty (TKA). The objective of this study was to evaluate the use of ALBC in a large population of TKA patients.

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We report the natural course of Baker’s cysts following total knee arthroplasty (TKA) at short- and mid-term follow-up.

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The aim of this study was to investigate the incidence, risk factors, and outcome of venous thromboembolism (VTE) following anterior cruciate ligament (ACL) reconstruction in a nationwide cohort.

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The aim of this study was to identify the most effective regimen of multiple doses of oral tranexamic acid (TXA) in achieving maximum reduction of blood loss in total knee arthroplasty (TKA).

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The aims of this study were to compare the efficacy of two agents, aspirin and warfarin, for the prevention of venous thromboembolism (VTE) after simultaneous bilateral total knee arthroplasty (SBTKA), and to elucidate the risk of VTE conferred by this procedure compared with unilateral TKA (UTKA).

Aims

The optimal method of tibial component fixation remains uncertain in total knee arthroplasty (TKA). Hydroxyapatite coatings have been applied to improve bone ingrowth in uncemented designs, but may only coat the directly accessible surface. As peri-apatite (PA) is solution deposited, this may increase the coverage of the implant surface and thereby fixation. We assessed the tibial component fixation of uncemented PA-coated TKAs versus cemented TKAs.