Use of anticoagulants for thromboembolic prophylaxis is strongly supported by evidence. However, the use of these medications beyond the prophylactic period is poorly understood. We identified anticoagulant naïve patients that underwent hip or knee replacement between 2012 and 2019 from an arthroplasty registry and probabilistically linked 3,018 surgeries with nationwide pharmaceutical claims data. Rates of anticoagulation use were examined during the early (<= 60 days post-discharge), mid-term (61–180 days post-discharge) and long-term (181–360 days post-discharge) periods. Multivariable logistic regression analysis was performed to identify patient- and surgery-related factors associated with long-term anticoagulant use. Anticoagulants were supplied to 20% of arthroplasties within 60 days of discharge, 7% between 61–180 days, and 10% between 181–360 days. Older age, obesity, increased comorbidity burden, a longer length of stay, occurrence of a complication necessitating anticoagulation and dispensation of an anticoagulant within 60 days of discharge were all risk factors for long-term anticoagulant use. Given the risks associated with unnecessary use of these medications, certain patients who are prescribed anticoagulants beyond prophylactic period may benefit from specialist medication review in the months following surgery

Aims. Current guidelines recommend surgery within 48 hours among patients presenting with hip fractures; however, optimal surgical timing for patients on oral anticoagulants (OACs) remains unclear. Individual studies are limited by small sample sizes and heterogeneous outcomes. The aim of this study was to conduct a systematic review and meta-analysis to summarize the effect of pre-injury OACs on time-to-surgery (TTS) and all-cause mortality among older adults with hip fracture treated surgically. Methods. We searched MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials (CENTRAL) from inception to 14 October 2019 to identify studies directly comparing outcomes among hip fracture patients receiving direct oral anticoagulants (DOACs) or vitamin K antagonists (VKAs) prior to hospital admission to hip fracture patients not on OACs. Random effects meta-analyses were used to pool all outcomes (TTS, in-hospital mortality, and 30-day mortality). Results. A total of 34 studies (involving 39,446 patients) were included in our systematic review. TTS was 13.7 hours longer (95% confidence interval (CI) 9.8 to 17.5; p < 0.001) among hip fracture patients on OACs compared to those not on OACs. This translated to a three-fold higher odds of having surgery beyond the recommended 48 hours from admission (odds ratio (OR) 3.0 (95% CI 2.1 to 4.3); p = 0.001). In-hospital mortality was higher (OR 1.4 (95% CI 1.0 to 1.8); p < 0.03) among anticoagulated patients. Among studies comparing anticoagulants, there was no statistically significant difference in time-to-surgery between patients taking a DOAC compared to a VKA. Conclusion. Patients presenting with a hip fracture who were taking OACs prior to injury experience a delay in time-to-surgery and higher mortality than non-anticoagulated patients. Patients on DOACs may be at risk of further delays. Evaluating expedited surgical protocols in hip fracture patients on OACs is an urgent priority, with the potential to decrease morbidity and mortality in this group of high-risk patients. Cite this article: Bone Joint J 2021;103-B(2):222–233

Direct oral anticoagulant (DOAC) use is becoming more widespread in the geriatric population. Depending on the type of DOAC, several days are required for its anticoagulant effects to resorb, which may lead to surgical delays. This can have an important impact on hip fracture patients who require surgery. The goal of the current study is to compare surgical delays, mortality and complications for hip fracture patients who were on a DOAC to those who were not. A retrospective cohort study was conducted at a university hospital in Sherbrooke. All hip fracture patients between 2012 and 2018 who were on a DOAC prior to their surgery were included. These patients were matched with similar patients who were not on an anticoagulant (non-DOAC) for age, sex, type of fracture and date of operation. Demographic and clinical data were collected for all patients. Surgical delay was defined as time of admission to time of surgery. Mortality and complications up to one year postoperative were also noted. Each cohort comprised of 74 patients. There were no statistically signification differences in Charleson Comorbidty Index and American Society of Anesthesiologists scores between cohorts. Surgical delay was significantly longer for DOAC patients (36.3±22.2 hours vs. 18.6±18.9 hours, p < 0 .001). Mortality (6.1%) and overall complication (33.8%) rates were similar between the two cohorts. However, there were more surgical reinterventions in DOAC patients than non-DOAC ones (16.2% vs. 0.0%, p < 0 .001). Among DOAC patients, mortality was greater for those operated after 48 hours (23.1% vs. 3.3%, p < 0 .05) and complications were more frequent for those operated after 24 hours (52.0% vs. 37.5%, p < 0 .05). Direct oral anticoagulant (DOAC) use in hip fracture patients is associated with longer surgical delays. Longer delays to surgery are associated with higher mortality and complication rates in hip fracture patients taking a DOAC. Hip fracture patients should have their surgery performed as soon as medically possible, regardless of anticoagulant use

Direct oral anticoagulant (DOAC) use is becoming more widespread in the geriatric population. Depending on the type of DOAC, several days are required for its anticoagulant effects to resorb, which may lead to surgical delays. This can have an important impact on hip fracture patients who require surgery. The goal of the current study is to compare surgical delays, mortality and complications for hip fracture patients who were on a DOAC to those who were not. A retrospective cohort study was conducted at a university hospital in Sherbrooke. All hip fracture patients between 2012 and 2018 who were on a DOAC prior to their surgery were included. These patients were matched with similar patients who were not on an anticoagulant (non-DOAC) for age, sex, type of fracture and date of operation. Demographic and clinical data were collected for all patients. Surgical delay was defined as time of admission to time of surgery. Mortality and complications up to one year postoperative were also noted. Each cohort comprised of 74 patients. There were no statistically signification differences in Charleson Comorbidty Index and American Society of Anesthesiologists scores between cohorts. Surgical delay was significantly longer for DOAC patients (36.3±22.2 hours vs. 18.6±18.9 hours, p < 0 .001). Mortality (6.1%) and overall complication (33.8%) rates were similar between the two cohorts. However, there were more surgical reinterventions in DOAC patients than non-DOAC ones (16.2% vs. 0.0%, p < 0 .001). Among DOAC patients, mortality was greater for those operated after 48 hours (23.1% vs. 3.3%, p < 0 .05) and complications were more frequent for those operated after 24 hours (52.0% vs. 37.5%, p < 0 .05). Direct oral anticoagulant (DOAC) use in hip fracture patients is associated with longer surgical delays. Longer delays to surgery are associated with higher mortality and complication rates in hip fracture patients taking a DOAC. Hip fracture patients should have their surgery performed as soon as medically possible, regardless of anticoagulant use

Aims. The Peri-Implant and PeriProsthetic Survival AnalysiS (PIPPAS) study aimed to investigate the risk factors for one-year mortality of femoral peri-implant fractures (FPIFs). Methods. This prospective, multicentre, observational study involved 440 FPIF patients with a minimum one-year follow-up. Data on demographics, clinical features, fracture characteristics, management, and mortality rates were collected and analyzed using both univariate and multivariate analyses. FPIF patients were elderly (median age 87 years (IQR 81 to 92)), mostly female (82.5%, n = 363), and frail: median clinical frailty scale 6 (IQR 4 to 7), median Pfeiffer 4 (1 to 7), median age-adjusted Charlson Comorbidity Index (CCI) 6 (IQR 5 to 7), and 58.9% (n = 250) were American Society of Anesthesiologists grade III. Results. Overall, 90.5% (n = 398) of the patients were treated surgically, 57.0% (n = 227) retained the implant, and 88.7% (n = 353) managed with fixation. Mortality rates were 8.2% (n = 3.6) in-hospital, 11.4% (n = 50) at 30 days, 21.1% (n = 93) at six months, and 21.6% (n = 95) at 12 months. Medical complications, mainly delirium, were common in the acute setting (52.7%, n = 215). The nonunion rate was 4.1% (n = 18). Mortality risk factors in the univariate analysis were age, living at a nursing home, no walking outdoors, frailty variables, fractures in the distal epiphysis, fractures around a proximal nail, discharge to a healthcare facility, and no osteoporotic treatment at discharge. Protective factors against mortality in the univariate analysis were surgical treatment by an experienced surgeon, management without an arthroplasty, allowing full weightbearing, mobilization in the first 48 hours postoperatively, and geriatric involvement. Risk factors for mortality in the multivariate analysis were cognitive impairment (Pfeiffer’s questionnaire) (hazard ratio (HR) 1.14 (95% CI 1.05 to 1.23), p = 0.002), age-adjusted CCI (HR 1.18 (95% CI 1.07 to 1.30), p = 0.001), and antiaggregant or anticoagulant medication at admission (HR 2.00 (95% CI 1.19 to 3.38), p = 0.009). Haemoglobin level at admission was protective against mortality (HR 0.85 (95% CI 0.74 to 0.97), p = 0.018). Conclusion. Mortality in FPIFs occurs mainly within the first six months of follow-up. Early co-management and clinical optimization, particularly targeting frail older patients, is crucial in reducing mortality following these fractures. Cite this article: Bone Jt Open 2024;6(1):43–52

Most of current literatures advise on thromboprophylaxis with injectable LMWH for trauma patients. Injectable anticoagulants have got inherent problems of pain, bruising and difficulty in administering the drug, which leads to low compliance. Clexane is derived from a pig's intestinal mucosa, hence could be objectionable to certain proportion of patients because of their religious beliefs. Oral anticoagulants have been used as thromboprophylactic agents in hip and knee arthroplasty. However there is not enough literature supporting their use as thromboprophylactic agent in ambulatory trauma patients with ankle fracture being managed non-operatively as out-patient. This study looks into the efficacy of oral anticoagulant in preventing VTE in ambulatory trauma patients requiring temporary lower limb immobilisation for management of ankle fracture. The end point of this study was symptomatic deep vein thrombosis (either proximal or distal) and pulmonary embolism. Routine assessment with a VTE assessment risk proforma for all patients with temporary lower limb immobilisation following lower limb injury requiring plaster cast is done in the fracture clinic at this university hospital. These patients are categorised as low or high risk for a venous thromboembolic event depending on their risk factor and accordingly started on prophylactic dose of oral anticoagulant (Rivaroxaban - Factor Xa inhibitor). Before the therapy is started these patients have a routing blood check, which includes a full blood count and urea and electrolyte. Therapy is continued for the duration of immobilisation. Bleeding risk assessment is done using a proforma based on NICE guideline CG92. If there is any concern specialist haematologist advice is sought. A total of 200 consecutive patients who presented to the fracture clinic with ankle fracture, which was managed in plaster cast non-operatively, were included in this study. They were followed up for three months following injury. This was done by checking these patients’ radiology report including ultrasound and CT pulmonary scan (CTPA) test on hospital's electronic system. Fracture of the lateral malleolus which include Weber-A, Weber-B and Weber-C fractures were included in the study. Also included were bimalleolar fractures and isolated medial malleolus fractures. Complex pilon fractures, polytrauma and paediatric patients were excluded from the study. Only one case of plaster associated isolated distal deep vein (soleal vein) thrombosis was reported in this patient subgroup. There was no incidence of proximal deep vein thrombosis or pulmonary embolism. No significant bleeding event was reported. Injectable low molecular weight heparin (LMWH) rather than oral anticoagulant has been recommended by most of the studies and guidelines as main thromboprophylactic agent for lower limb trauma patients

Background. Thromboembolic disease is a common complication of total hip replacement (THR). The administration of postoperative anticoagulants is therefore highly recommended. The purpose of this study was to compare rivaroxaban with fondaparinux with regards to their safety and effectiveness for the prevention of venous thromboembolic events (VTE) after THR. Methods. We conducted an independent prospective study comparing VTE prevention strategies in two successive series of patients (Groups A and B) undergoing elective unilateral THR. Group A (n=253) received fondaparinux daily 2.5 mg for 10 days, followed by tinzaparin 4500 IU daily for one month. Group B (n=229) received 10 mg rivaroxaban daily for 40 days without platelet monitoring. All surgeries were performed by a single surgeon under general anesthesia using an active blood transfusion-sparing plan. In the absence of contraindications, patients received intra-operative administration of tranexamic acid to reduce postoperative bleeding. Preoperative and postoperative hemoglobin levels were recorded at regular intervals. Bleeding events were documented. The bleeding index was calculated by adding the number of red blood cell units and the difference in the hemoglobin level (in g/dL) between the first morning after the day of surgery and the seventh postoperative day (POD 7). After 5 to 10 days, all patients underwent bilateral lower-extremity duplex ultrasonography to screen for deep venous thrombi. Any clinical symptoms of pulmonary embolism were evaluated with spiral computed tomography lung scans. Clinical evaluation to look for evidence of deep venous thrombi and pulmonary emboli was performed at eight weeks postoperatively. Results. Baseline characteristics between the two groups were comparable. The rate of major bleeding events, proximal deep venous thrombi, and pulmonary emboli was nil in each group. The incidence of blood transfusion was 0.8% in Group A (2 of 253 hips) and 0.4% (1 of 229 hips) in Group B (p=1.0). The bleeding index analysis excluded 8 hips for which the hemoglobin value at POD 7 was not measured. The bleeding index was 1.03 (standard deviation, 0.88) in Group A and 0.8 (standard deviation, 0.80) in Group B (p<0.001). The incidence of bleeding index >2 was 10.5% (27 of 247 hips) in Group A and 3% (7 of 227 hips) in Group B (p<0.001). Discussion. We compared two series of patients treated with THR undertaken with postoperative anticoagulation to prevent VTE. The high level of success these anticoagulant treatments had at preventing VTE in our series could be attributed at least partially to the combination of an active blood-sparing transfusion plan with the use of anticoagulant molecules reported in the literature to be quite potent. Conclusions. This prospective study comparing two anticoagulant regimens in patients treated with THR did not detect any difference with regards to the efficacy of the treatments, although there was significantly less bleeding index in patients who received rivaroxaban

Financial impact and patient satisfaction with four different anticoagulants for hip and knee arthroplasty in patients with a previous history of VTE- A prospective randomised trial. Introduction. New generation oral anticoagulants (dabigatran/rivaroxaban) have recently become available for the prevention of venous thromboembolism (VTE) following hip and knee arthroplasty. Traditional therapies (warfarin/low molecular weight heparins) are less costly, but have several limitations. The aim of this study was to evaluate the financial impact of substituting enoxaparin and warfarin with newer therapies dabigatran and rivaroxaban. A secondary objective was to investigate patient satisfaction with these treatments. Methods. A randomised prospective study was conducted over a 12 month period. Patients with a history of VTE undergoing hip or knee replacement were randomised to receive one of four anticoagulants for five weeks post surgery. Information was gathered during the hospital stay and then post discharge, by telephone, for five weeks(35 days)to determine costs. The costs included cost of drug, nursing time, blood monitoring and transport costs. The patients were also asked to complete the Duke Anticoagulation Satisfaction Scale (DASS). The DASS is a 26 item questionnaire which has 7 responses for each question. Results. Although dabigatran and rivaroxaban had higher drug acquisition costs, warfarin and enoxaparin were financially more costly overall. These additional costs were mainly due to increased blood monitoring and time for training and administration which is not required for newer therapies. DASS scores were significantly better with dabigatran (38.5±5.1) and rivaroxaban (38.6±8.3) compared to warfarin (71.8±16.2) and enoxaparin (68.5±14.2) (p< 0.001). This indicates more satisfaction for patients prescribed dabigatran or rivaroxaban compared to traditional therapies. Conclusion. The use of new generation oral anticoagulants has the potential to significantly reduce the financial burden of thromboprophylaxis on the NHS with an additional benefit of better patient satisfaction when compared to traditional therapies

Abstract

In his classic monograph entitled Low Friction Arthroplasty of the Hip, which was published in 1979, John Charnley dedicated a chapter to thromboembolic complications. The overall incidence of pulmonary embolism (PE) was approximately 8% and the incidence of death from PE approximately 1%. Surveys of orthopaedic surgeons who undertake total joint replacement conducted by The American Association of Hip and Knee Surgeons (AAHKS), 30 years later, showed that there was still no consensus as to the best form of prophylaxis with a wide variation of methods being used.

In the past 3 years, for the first time there is uniformity in the recommendations of the American Academy of Orthopaedic Surgeons (AAOS) and the American College of Chest Physicians (ACCP). Both groups have reached an agreement that the rate of DVT formation is not the ideal endpoint to use when assessing the efficacy of thromboprophylaxis after joint replacement, as had been done in previous drug trials. Most of these DVTs are asymptomatic and of questionable clinical significance. At least one recent study brings into question the association between the rate of DVT formation and that of subsequent symptomatic events. Both groups also focus on minimizing iatrogenic bleeding complications, which can lead to compromised clinical results, including limited movement and pain in the case of knee replacement and increased risk of infection in both knee and hip replacement. To further complete the uniformity of approach in the United States, the Center for Medicare and Medicaid Services (CMS), which administers the Surgical Care Improvement Program (SCIP) that monitors hospital compliance with VTE prophylaxis of hospitalised patients, has also changed their policy. Beginning January 2014, either aspirin or a compression device has been considered as acceptable measures for THR, TKR and hip fracture. The remarkable success reported from many centers with the use of aspirin and/or the use of a mobile compression device in patients without major risk factors, such as a prior history of symptomatic VTE, clearly indicate that aggressive pharmacoprophylaxis is not necessary for the vast majority of patients who undergo joint replacement.

Rivaroxaban was introduced for thromboprophylaxis at the Royal Cornwall Hospital for hip and knee arthroplasty surgery in October 2009. We identified 140 patients from theatre logbooks who underwent elective joint replacement between October 2009 and March 2010. Patient notes, computer and DVT clinic records and WebPacs data were collected to determine the uptake of the new drug and the incidence of wound problems, DVTs and any other post-operative complications. In our sample 55.7% [78/140] patients received rivaroxaban. 10.3% [8/78] of patients on rivaroxaban suffered wound complications compared with 6.6% [4/62] of patients on alternative anticoagulation. Three patients suffered DVT's, 1 of whom was taking rivaroxaban. There were a further 6 patients, 4 on rivaroxaban, with leg swelling severe enough to merit investigation, all of whom had negative doppler scans. Bleeding events included 4 patients with postoperative haematemesis of which 2 were taking rivaroxaban. Five patients, all under different surgical operators of which 3 had taken rivaroxaban, developed stiff total knee replacements and were offered MUA or physiotherapy.

Aim: Evaluate the incidence of complications related to timing (time between admission ad operation) and oral antiplatelet/anticoagulant therapy in patients treated for a hip fracture.

Materials and Methods: We prospectively evaluated 5 groups of 30 patients each, selected out of 875 consecutive patients admitted at the First Aid Unit of our Hospital with a proximal femoral fracture: group A – patients on Warfarin therapy, treated more than 5 days after admission (in order to allow the wash-out of Warfarin, as advised by many Anaesthesiologist Associations); B – patients treated more than 5 days after admission, not on Warfarin therapy; C – patients treated less than 48 hours after admission, not on Warfarin therapy; D – patients on Aspirin/NSAIDS therapy, treated more than 5 days after admission; E – patients on Ticlopidine/Clopidogrel therapy, treated more than 5 days after admission. The groups were comparable regarding age, gender, pre-trauma walking ability, mental state, fracture type and treatment. Blood loss, number of RBC transfusions, complications during hospitalization and up to 6 months after discharge, duration of hospitalization, degree of functional recovery and 2 years mortality were recorded. Statistical analysis included Kruskall-Wallis, U-Mann-Whitney and Logistic Regression Tests (SPSS 13.0 software).

Results: Group A showed higher preoperative blood loss (p=0.002), and longer hospitalization (p< 0.001), compared to all other groups. Groups D and E showed no higher complication and mortality rate in comparison to group B and C, while group A showed higher complication and mortality rate. Standing alone, timing and Warfarin appear not to be significant risk factors, while taken together they represent a high risk factor for complications ad mortality (p=0.009).

Conclusion: Patients on Warfarin therapy, affected by hip fracture, are at high risk of complications and mortality, if the recommendation of postponing treatment until drug wash-out is accepted. Reversal of anticoagulation using vitamin K and straight-forward treatment should be considered. Antiplatelet therapy appears not to have the same adverse effect as anticoagulant therapy.

BACKGROUND: Oral DVT prophylaxis not requiring monitoring is an advantage in orthopaedic patients. Dabigatran etexilate is an oral direct thrombin inhibitor undergoing evaluation for the prevention of venous thromboembolic events (VTE) following orthopaedic surgery.

METHODS: In a phase III, multicenter, non-inferiority, double-blind study, patients undergoing total knee replacement were randomized to 3 treatments. The patients received 8±2 days of oral dabigatran etexilate, 150 or 220 mg once daily starting with a half dose (i.e.75 or 110 mg) 1–4 hours after surgery, or subcutaneous enoxaparin 40 mg once daily starting 12 hours prior to surgery. The primary efficacy outcome was the composite of total VTE and all causes of mortality during the treatment period. All efficacy and safety outcome events were adjudicated by blinded independent committees.

RESULTS: Efficacy could be evaluated for 1541 (75%) treated and operated patients. Total VTE and death occurred in 40.5%, 36.4% and 37.7% of patients assigned to dabigatran etexilate 150 or 220mg once daily or enoxaparin, respectively. Proximal DVT and/ or PE occurred in 3.8%, 2.6% and 3.5% of patients receiving dabigatran 150 or 220mg or enoxaparin, respectively. Three deaths occurred during the treatment period, one in each of the treatment groups. Safety was evaluated for all 2076 patients receiving study treatment. The rate of major bleeding was 1.3%, 1.5% and 1.3% of patients receiving dabigatran 150 or 220mg or enoxaparin. Elevated LFTs (ALT > 3xULN) occurred in 3.7%, 2.8% and 4.0% of the patients treated with 150 and 220 mg dabigatran or enoxaparin during the study. A temporary rise in LFTs was observed during the follow-up period in 0.5% of the patients who had received dabigatran and in 0.4% of the patients who had received enoxaparin.

CONCLUSIONS: Non-inferiority for the primary efficacy endpoint was met for both doses of dabigatran etexilate compared to enoxaparin. There was no difference in bleeding rates between the treatment groups. Oral administration of dabigatran etexilate once daily, given early in the postoperative period, was effective and safe for the prevention of total VTE in patients undergoing total knee replacement surgery.

To determine whether pre-operative cessation of anticoagulant or antiplatelet medication is necessary for patients undergoing total shoulder arthroplasty (TSA) or reverse total shoulder arthroplasty (RTSA). A prospectively maintained database was used to identify 213 consecutive patients treated with TSA or RTSA performed by a single surgeon across 3 centres. This cohort included 24 patients on an anticoagulant agent (warfarin, apixaban, rivaroxaban, dabigatran), 52 patients on an antiplatelet agent (aspirin, clopidogrel), and a control group of 137 patients not on anticoagulant or antiplatelet medication. Patients on anticoagulant or antiplatelet medications continued these agents peri-operatively. Outcomes included haemoglobin drop, intra-operative blood loss, operative time, transfusion requirements and post-operative complications. The mean age of the cohort was 74.3 years (range 47 – 93) and 75 (35.2%) of the patients were male. TSA was performed in 63 cases and RTSA in 150 cases. The mean haemoglobin drop in the control group was 17.3 g/L, compared to 19.3 g/L in the anticoagulant group (p = 0.20) and 15.6 g/L in the anti-platelet group (p = 0.14). The mean intra-operative blood loss in the control group was 107.8 mL, compared to 143.0 mL in the anticoagulant group (p = 0.03) and 134.3 mL in the anti-platelet group (0.02). The mean operative time in the control group was 49.3 minutes, compared to 47.1 minutes in the anticoagulant group (p = 0.56) and 50.3 minutes in the anti-platelet group (p = 0.78). Post-operatively no patients developed a wound infection or haematoma requiring intervention. Three patients not on anticoagulant or antiplatelet medication developed pulmonary embolism. Continuing anticoagulant or antiplatelet medication was associated with higher intra-operative blood loss, but produced no statistically significant differences in haemoglobin drop, operative time, transfusion requirements or post-operative complications. We now do not routinely stop any anticoagulant or antiplatelet medication for patients undergoing total shoulder arthroplasty

Aim. Prosthetic joint replacement is more commonly done in the elderly group of patients due to an increase pathology related to joint degeneration that comes with age. In this age group is also more frequent having underling condition that may predispose to a prosthetic joint infection. Also, the pharmacological intervention in those patients may play an important role as a risk factor for infection after joint replacement surgery. The use of oral anticoagulants seems to be particularly increased in elderly patients but there aren't enough data published to support an association between prosthetic joint infection and the use of oral anticoagulants. Identifying risk factors in elderly patients age >75 years old with a special focus on the oral anticoagulation therapy is the aim of the study. Methods. In a retrospective study from 2011 till 2018 all the patients >75 years old with knee and hip replacement surgery have been review looking for acute prosthetic infection and risk factors that may be predispose to it. Patients with previous surgery or any other mechanical complication that needed intervention on the same area have been excluded. Results. A total of 1220 patients have been included (801 knee replacement surgery and 419 hip replacement surgery). The mean age was 79.5 ± 3.44 years and most of the patients were women (72,6%). The infection rate was 2,5%. Several factors have been identified to be associated with acute infection. (Table.1.). The patients receiving oral anticoagulants had an increased risk of infection (OR 3.63 (1.60–7.74), p=0.002). Conclusions. Even all the risk factors associated with risk infection have been described previously, the relevant aspect is the increased risk of prosthetic joint infection in patients receiving oral anticoagulants

The December 2023 Hip & Pelvis Roundup. 360. looks at: Early hip fracture surgery is safe for patients on direct oral anticoagulants; Time to return to work by occupational class after total hip or knee arthroplasty; Is there a consensus on air travel following hip and knee arthroplasty?; Predicting whether patients will achieve minimal clinically important differences following hip or knee arthroplasty; High-dose dual-antibiotic-loaded cement for hip hemiarthroplasty in the UK (WHiTE 8): a randomized controlled trial; Vitamin E – a positive thing in your poly?; Hydroxapatite-coated femoral stems: is there a difference in fixation?

The April 2024 Trauma Roundup. 360. looks at: The infra-acetabular screw in acetabular fracture surgery; Is skin traction helpful in patients with intertrochanteric hip fractures?; Reducing pain and improving function following hip fracture surgery; Are postoperative splints helpful following ankle fracture fixation?; Biomechanics of internal fixation in Hoffa fractures: a comparison of four different constructs; Dual-plate fixation of periprosthetic distal femur fractures; Do direct oral anticoagulants necessarily mean a delay to hip fracture surgery?; Plate or retrograde nail for low distal femur fractures?

The December 2024 Wrist & Hand Roundup. 360. looks at: Variability in thumb ulnar collateral ligament rupture management across the UK: survey insights; Identifying five distinct hand osteoarthritis pain phenotypes highlights the impact of biopsychosocial factors; Long-term outcomes of MAÏA TMC joint prosthesis for osteoarthritis: a possible alternative to trapeziectomy; Diagnostic and management strategies for malignant melanoma of the hand; Early versus delayed surgery for distal radius fractures: comparable outcomes but higher complications in delayed treatment; Perioperative anticoagulant and antiplatelet use does not increase complications in wide-awake hand surgery; Variability in treatment of metacarpal shaft fractures highlights need for standardized care; Low-intensity pulsed ultrasound ineffective in reducing time to union for scaphoid nonunion post-surgery

Abstract. Extended Trochanteric Osteotomy (ETO) improves surgical exposure and aids femoral stem and bone cement removal in Revision Total Hip Replacement (RTHR) surgery. The aim of this study was to identify healing rates and complications of ETO in RTHR. Methods. From 2012 to 2019 we identified patients who underwent ETO for RTHR. Data collected demographics, BMI, diabetes, anticoagulants, indication for ETO, surgical approach, length of ETO and complications. Descriptive analysis of patient demographics, multiple linear regression analysis was performed to assess ETO complications. Results. There were 63 patients with an average age of 69 years. Indications for ETO were aseptic loosening (30), infection (15), periprosthetic fracture (9), recurrent dislocation (5), broken implant (4). There were 44 cemented and 19 uncemented femoral stem that underwent ETO. Average time from index surgery was 12 years (less than a year to 38 years). All procedures were through posterolateral approach and all ETO were stabilised with cables. Average length of ETO was 12.5cm. BMI varied from 18 to 37. There were 5 diabetics and 16 on anticoagulants. All but one ETO went on to unite. Other complications included infection, dislocations, lateral thigh pain and significant limp. Discussion. Fixation of ETO can be with either wires or cables or plate with cables/screws. Advantages of cables are no irritation over greater trochanter, no disruption of gluteus medius/vastus lateralis continuity, reproducible tension in cables and use of torque limiter minimises loss of tension in cables

Aims. This work aimed at answering the following research questions: 1) What is the rate of mechanical complications, nonunion and infection for head/neck femoral fractures, intertrochanteric fractures, and subtrochanteric fractures in the elderly USA population? and 2) Which factors influence adverse outcomes?. Methods. Proximal femoral fractures occurred between 1 January 2009 and 31 December 2019 were identified from the Medicare Physician Service Records Data Base. The Kaplan-Meier method with Fine and Gray sub-distribution adaptation was used to determine rates for nonunion, infection, and mechanical complications. Semiparametric Cox regression model was applied incorporating 23 measures as covariates to identify risk factors. Results. Union failure occured in 0.89% (95% confidence interval (CI) 0.83 to 0.95) after head/neck fracturs, in 0.92% (95% CI 0.84 to 1.01) after intertrochanteric fracture and in 1.99% (95% CI 1.69 to 2.33) after subtrochanteric fractures within 24 months. A fracture-related infection was more likely to occur after subtrochanteric fractures than after head/neck fractures (1.64% vs 1.59%, hazard ratio (HR) 1.01 (95% CI 0.87 to 1.17); p < 0.001) as well as after intertrochanteric fractures (1.64% vs 1.13%, HR 1.31 (95% CI 1.12 to 1.52); p < 0.001). Anticoagulant use, cerebrovascular disease, a concomitant fracture, diabetes mellitus, hypertension, obesity, open fracture, and rheumatoid disease was identified as risk factors. Mechanical complications after 24 months were most common after head/neck fractures with 3.52% (95% CI 3.41 to 3.64; currently at risk: 48,282). Conclusion. The determination of complication rates for each fracture type can be useful for informed patient-clinician communication. Risk factors for complications could be identified for distinct proximal femur fractures in elderly patients, which are accessible for therapeutical treatment in the management. Cite this article: Bone Jt Open 2023;4(10):801–807