Background of study. There has been an exponential increase in the use of direct thrombin (DT) and factor Xa inhibitors (FXI) in patients with cardiovascular problems. Premature cessation of DT/FXI in patients with cardiac conditions can increase the risk of coronary events. Our aim was to ascertain whether it is necessary to stop DT and FXI preoperatively to avoid postoperative complications following hip fracture surgery. Materials and Methods. Prospective data was collected from 189 patients with ongoing DT/FXI therapy and patients not on DT/FXI who underwent hip fracture surgery. Statistical comparison on pre- and postoperative haemoglobin (Hb), ASA grades, comorbidities, operative times, transfusion requirements, hospital length of stay (LOS), wound infection, haematoma and reoperation rates between the two groups was undertaken. Results. There were 91 patients in the DT/FXI group (DTX) and 88 in the non-DTX group (NDTX). Mean age was 81.9 years. There was no difference in ASA grade, number of comorbidities (except cardiac comorbidities), age, gender and operation times between the groups. Mean preoperative Hb was 12.9 g/dl and 13.5 g/dl respectively in the DTX and NDTX. 4 and 2 patients respectively required transfusions postoperatively in the DTX and NDTX (p= 0.17). We found no difference with respect to LOS, wound infection, haematoma and reoperation rates between the two groups postoperatively. Conclusions. Our study suggests that maintaining DT and FXI therapy throughout the perioperative period in high risk patients with femoral neck fractures is not associated with an increased risk of bleeding or complications following hip fracture surgery

Aims. Bacterial infection activates neutrophils to release neutrophil extracellular traps (NETs) in bacterial biofilms of periprosthetic joint infections (PJIs). The aim of this study was to evaluate the increase in NET activation and release (NETosis) and haemostasis markers in the plasma of patients with PJI, to evaluate whether such plasma induces the activation of neutrophils, to ascertain whether increased NETosis is also mediated by reduced DNaseI activity, to explore novel therapeutic interventions for NETosis in PJI in vitro, and to evaluate the potential diagnostic use of these markers. Methods. We prospectively recruited 107 patients in the preoperative period of prosthetic surgery, 71 with a suspicion of PJI and 36 who underwent arthroplasty for non-septic indications as controls, and obtained citrated plasma. PJI was confirmed in 50 patients. We measured NET markers, inflammation markers, DNaseI activity, haemostatic markers, and the thrombin generation test (TGT). We analyzed the ability of plasma from confirmed PJI and controls to induce NETosis and to degrade in vitro-generated NETs, and explored the therapeutic restoration of the impairment to degrade NETs of PJI plasma with recombinant human DNaseI. Finally, we assessed the contribution of these markers to the diagnosis of PJI. Results. Patients with confirmed PJI had significantly increased levels of NET markers (cfDNA (p < 0.001), calprotectin (p < 0.001), and neutrophil elastase (p = 0.022)) and inflammation markers (IL-6; p < 0.001) in plasma. Moreover, the plasma of patients with PJI induced significantly more neutrophil activation than the plasma of the controls (p < 0.001) independently of tumour necrosis factor alpha. Patients with PJI also had a reduced DNaseI activity in plasma (p < 0.001), leading to a significantly impaired degradation of NETs (p < 0.001). This could be therapeutically restored with recombinant human DNaseI to the level in the controls. We developed a model to improve the diagnosis of PJI with cfDNA, calprotectin, and the start tail of TGT as predictors, though cfDNA alone achieved a good prediction and is simpler to measure. Conclusion. We confirmed that patients with PJI have an increased level of NETosis in plasma. Their plasma both induced NET release and had an impaired ability to degrade NETs mediated by a reduced DNaseI activity. This can be therapeutically restored in vitro with the approved Dornase alfa, Pulmozyme, which may allow novel methods of treatment. A combination of NETs and haemostatic biomarkers could improve the diagnosis of PJI, especially those patients in whom this diagnosis is uncertain. Cite this article: Bone Joint J 2024;106-B(9):1021–1030

The introduction of direct thrombin inhibitors in arthroplasty surgery has reignited the debate on the risk of wound complications when using chemical thromboprophylaxis. It has been suggested that direct thrombin inhibitors might lead to an increased risk of systemic and operative site bleeding and wound sepsis when compared to low molecular weight heparin. In July 2009, departmental thromboprophylaxis policy for patients undergoing hip and knee replacement surgery (including revision) was changed from subcutaneous enoxaparin for the duration of inpatient stay to dabigatran for 10 days (knees) or 28 days (hips) unless contraindicated. In the 2 years prior to policy change, 1091 patients underwent hip or knee arthroplasty (Group A), with 1150 patients undergoing the same procedures in the 2 years following July 2009 (Group B). A minority of patients were already on warfarin (2% in group 1, 3% in group 2). This study presents a retrospective analysis of all patients who returned to theatre within 30 days of joint replacement surgery to assess whether the change in unit policy caused any discernible increase in bleeding-related complications. In group A, 20 / 1091 patients (1.8%) returned to theatre within 30 days. 9 were for reasons unrelated to thromboprophylaxis (mainly dislocated hips), 4 for gastrointestinal bleeding and 7 for wound complications (haematoma, wound breakdown, or infection). In group B, 22 / 1150 patients (1.9%) returned to theatre within 30 days. 13 were for unrelated reasons, 4 for gastrointestinal bleeding, and 5 for wound complications. One patient with a wound complication was on warfarin and therefore did not receive dabigatran. The lower wound complication rate in group B was not statistically different. This study, in a large heterogeneous group of patients, suggests that a change from enoxaparin to dabigatran does not increase the incidence of early infection, or the risk of bleeding at the operative site or the gastrointestinal tract

The introduction of direct thrombin inhibitors in arthroplasty surgery has reignited the debate on the risk of wound complications when using chemical thromboprophylaxis. It has been suggested that direct thrombin inhibitors might lead to an increased risk of systemic and operative site bleeding and wound sepsis when compared to low molecular weight heparin. In July 2009, departmental thromboprophylaxis policy for patients undergoing hip and knee replacement surgery (including revision) was changed from subcutaneous enoxaparin for the duration of inpatient stay to dabigatran for 10 days (knees) or 28 days (hips) unless contraindicated. In the 2 years prior to policy change, 1091 patients underwent hip or knee arthroplasty (Group A), with1150 patients undergoing the same procedures in the 2 years following July 2009 (Group B). A minority of patients were already on warfarin (2% in group 1, 3% in group 2). This study presents a retrospective analysis of all patients who returned to theatre within 30 days of joint replacement surgery to assess whether the change in unit policy caused any discernible increase in bleeding-related complications. In group A, 20/1091 patients (1.8%) returned to theatre within 30 days. 9 were for reasons unrelated to thromboprophylaxis (mainly dislocated hips), 4 for gastrointestinal bleeding and 7 for wound complications (haematoma, wound breakdown, or infection). In group B, 22/1150 patients (1.9%) returned to theatre within 30 days. 13 were for unrelated reasons, 4 for gastrointestinal bleeding, and 5 for wound complications. One patient with a wound complication was on warfarin and therefore did not receive dabigatran. The lower wound complication rate in group B was not statistically different. This study, in a large heterogeneous group of patients, suggests that a change from enoxaparin to dabigatran does not increase the incidence of local or systemic complications of sufficient severity to warrant return to theatre

The introduction of direct thrombin inhibitors in arthroplasty surgery has reignited the debate on the risk of wound complications when using chemical thromboprophylaxis. It has been suggested that direct thrombin inhibitors might lead to an increased risk of systemic and operative site bleeding and wound sepsis when compared to low molecular weight heparin. In July 2009, departmental thromboprophylaxis policy for patients undergoing hip and knee replacement surgery (including revision) was changed from subcutaneous enoxaparin for the duration of inpatient stay to dabigatran for 10 days (knees) or 28 days (hips) unless contraindidated. In the 2 years prior to policy change, 1091 patients underwent hip or knee arthroplasty (Group 1), with1150 patients undergoing the same procedures in the 2 years following July 2009 (Group 2). A minority of patients were already on warfarin (2% in group 1, 3% in group 2). This study presents a retrospective analysis of all patients who returned to theatre within 30 days of joint replacement surgery to assess whether the change in unit policy caused any discernible increase in bleeding-related complications. In group 1, 23/1091 patients (2.1%) returned to theatre within 30 days. 8 were for reasons unrelated to thromboprophylaxis (mainly dislocated hips), 5 for gastrointestinal bleeding (mainly upper GI endoscopy) and 10 for wound complications (haematoma, wound breakdown, or washout of early infection). In group 2, 22 / 1150 patients (1.9%) returned to theatre within 30 days. 12 were for unrelated reasons, 5 for GI bleeding, and 5 for wound complications. The lower return to theatre rate in the second group was not statistically different. This study, in a large heterogeneous group of patients, suggests that a change from enoxaparin to dabigatran does not increase the incidence of early infection, or the risk of bleeding at the operative site or the gastrointestinal tract

Despite improvements in surgical technique, blood loss continues to be an issue following TJR in 2013. Peri-operative blood loss averages between 1000 and 1500 cc during THR and TKR. Multiple methods have been employed in attempts to minimise this loss. Concepts such as hypotensive anesthesia, tourniquet use, intraoperative blood salvage and autologous pre-donation and postoperative re-infusion drains as well as the use of bipolar sealants, fibrin sprays and thrombin agents have been tried with varying degrees of success. Recently there has been a surge of interest in the use of antifibrinolytics such as Tranexamic Acid (TXA), Aprotinin and Aminocaproic Acid. These medications have a long history of use in other fields such as cardiac and oral surgery but are just recently being utilised following TJR. Of these medications, TXA has been by far the best studied. TXA is a synthetic amino acid that inhibits fibrinolysis by competitively and reversibly blocking the Lysine binding sites on plasminogen. This inhibits its activation and slows the conversion from plasminogen to plasmin and this prohibits the binding of plasmin to fibrin and the subsequent dissolving of clot formation. TXA can be used either topically or intravenously and there are more than 50 clinical papers that have evaluated the effectiveness of TXA in TJR. There is abundant scientific data to support its safety with minimal increased risk of thrombosis and its use should be considered as a safe, effective and economical means of reducing blood loss in TJR in 2013

Our American Academy of Orthopaedic Surgeons (AAOS) and the American College of Chest Physicians (ACCP) have come to a consensus that the use of routine prophylaxis against venous thromboembolism (VTE) is indicated for our patients undergoing total joint arthroplasty. The new guidelines acknowledge differences in efficacy of the various agents and the variable risk of VTE among patients. Agents include warfarin, low molecular weight heparin, aspirin, oral Xa inhibitors, and direct thrombin inhibitors. The use of pneumatic compression devices have been found to be effective in decreasing risk of deep vein thrombosis (DVT) as a stand-alone strategy after total knee arthroplasty (TKA) and is given a level 1C recommendation by ACCP while the data is less strong for use following total hip arthroplasty (THA). Mechanical devices are not associated with an increased bleeding risk, and address the concerns of some surgeons with regard to post-operative bleeding. The availability of mobile compression devices has expanded the indications for use as a result of portability. While the use of mobile pump technology in DVT prophylaxis adds to the armamentarium of tools available for use in VTE risk mitigation, it does not eliminate the need for pharmacologic prophylaxis. While all arthroplasty patients are at elevated risk of VTE, the highest risk is associated with those having a prior history of DVT or pulmonary embolism (PE), having had prior surgery within the preceding three months, or requiring prolonged immobilization post-operatively for any reason. In these patients, thromboprophylaxis with any of a number of agents will play a valuable role in VTE risk reduction. Additionally, not all patients tolerate the use of the pump device. Those individuals with chronic peripheral arterial disease or arterial ulcers in the legs are also poor candidates for mechanical compression strategies which may exacerbate existing vascular compromise and perfusion of the limb. Assessment of the medical comorbidities of the patient may also stratify them to higher risk where the demonstrated benefits of pharmacologic prophylaxis outweigh the considerations of bleeding associated with their use (such as in the morbidly obese/high BMI patients). Mobile pump technology is a valuable adjunct to our VTE reduction strategies, but do not eliminate the need for pharmacologic agents. The judicious selection of DVT prophylaxis strategies based on the totality of the constellation of orthopaedic and medical factors unique to each patient allows us to make clinical decisions tailored to their needs, their risk of VTE, and their reliability in functioning as an active partner in their own post-operative care

Drug therapy forms an integral part of the management of many orthopaedic conditions. However, many medicines can produce serious adverse reactions if prescribed inappropriately, either alone or in combination with other drugs. Often these hazards are not appreciated. In response to this, the European Union recently issued legislation regarding safety measures which member states must adopt to minimise the risk of errors of medication.

In March 2014 the Medicines and Healthcare products Regulatory Agency and NHS England released a Patient Safety Alert initiative focussed on errors of medication. There have been similar initiatives in the United States under the auspices of The National Coordinating Council for Medication Error and The Joint Commission on the Accreditation of Healthcare Organizations. These initiatives have highlighted the importance of informing and educating clinicians.

Here, we discuss common drug interactions and contra-indications in orthopaedic practice. This is germane to safe and effective clinical care.

Cite this article: Bone Joint J 2015;97-B:434–41.

We performed a systematic review and meta-analysis to compare the efficacy of intermittent mechanical compression combined with pharmacological thromboprophylaxis, against either mechanical compression or pharmacological prophylaxis in preventing deep-vein thrombosis (DVT) and pulmonary embolism in patients undergoing hip or knee replacement. A total of six randomised controlled trials, evaluating a total of 1399 patients, were identified. In knee arthroplasty, the rate of DVT was reduced from 18.7% with anticoagulation alone to 3.7% with combined modalities (risk ratio (RR) 0.27, p = 0.03; number needed to treat: seven). There was moderate, albeit non-significant, heterogeneity (I² = 42%). In hip replacement, there was a non-significant reduction in DVT from 8.7% with mechanical compression alone to 7.2% with additional pharmacological prophylaxis (RR 0.84) and a significant reduction in DVT from 9.7% with anticoagulation alone to 0.9% with additional mechanical compression (RR 0.17, p < 0.001; number needed to treat: 12), with no heterogeneity (I² = 0%). The included studies had insufficient power to demonstrate an effect on pulmonary embolism.

We conclude that the addition of intermittent mechanical leg compression augments the efficacy of anticoagulation in preventing DVT in patients undergoing both knee and hip replacement. Further research on the role of combined modalities in thromboprophylaxis in joint replacement and in other high-risk situations, such as fracture of the hip, is warranted.