Tranexamic acid (TEA), an inhibitor of fibrinolysis,
reduces blood loss after routine total knee replacement (TKR). However,
controversy persists regarding the dosage and timing of administration
of this drug during surgery. We performed a prospective randomised
controlled study to examine the optimum blood-saving effect of TEA
in minimally invasive TKR. We randomly assigned 151 patients who underwent unilateral minimally
invasive TKR to three groups: 1) a placebo group (50 patients);
2) a one-dose TEA group (52 patients), who received one injection
of TEA (10 mg/kg) intra-operatively on deflation of the tourniquet;
and 3) a two-dose TEA group (49 patients), who received two injections
of TEA (10 mg/kg) given pre-operatively and intra-operatively. Total
blood loss was calculated from the maximum loss of haemoglobin.
All patients were followed clinically for the presence of venous
thromboembolism (VTE). The mean total blood loss was significantly higher in the placebo
group than in the other two groups (1222 ml (845 to 2043) Our prospective randomised controlled study showed that one intra-operative
injection of TEA is effective for blood conservation after minimally
invasive TKR.
We have previously described the mid- to long-term
results of conventional simple varus intertrochanteric osteotomy
for osteonecrosis of the femoral head, showing that 19 of the 26
hips had good or excellent results. We extended the follow-up to
a mean of 18.1 years (10.5 to 26) including a total of 34 hips in
28 patients, with a mean age at surgery of 33 years (19 to 53).
There were 18 men and ten women and 25 hips (74%) had a satisfactory
result with a Harris hip score ≥ 80. In all, six hips needed total
hip replacement (THR) or hemiarthroplasty. The collapse of the femoral
head or narrowing of the joint space was found to have progressed
in nine hips (26%). Leg shortening after osteotomy was a mean of
19 mm (8 to 36). With conversion to THR or hemiarthroplasty as the
endpoint, the ten-year survival rate was 88.2% (95% confidence interval
(CI) 82.7 to 93.7) and the 20-year survival rate was 79.7% (95%
CI 72.1 to 87.3); four hips were converted at ten years and other
two hips were converted at 20 years. Shortening of the leg after osteotomy remains a concern; however,
the conventional varus half-wedge osteotomy provides favourable
long-term results in hips with less than two-thirds of the medial
part of the femoral head affected by necrotic bone and with normal
bone superolaterally.
Symptomatic and asymptomatic deep-vein thrombosis
(DVT) is a common complication of knee replacement, with an incidence
of up to 85% in the absence of prophylaxis. National guidelines
for thromboprophylaxis in knee replacement are derived from total
knee replacement (TKR) data. No guidelines exist specific to unicompartmental knee
replacement (UKR). We investigated whether the type of knee arthroplasty
(TKR or UKR) was related to the incidence of DVT and discuss the
applicability of existing national guidelines for prophylaxis following
UKR. Data were collected prospectively on 3449 knee replacements,
including procedure type, tourniquet time, surgeon, patient age,
use of drains and gender. These variables were related to the incidence
of symptomatic DVT. The overall DVT rate was 1.6%. The only variable that had an
association with DVT was operation type, with TKR having a higher
incidence than UKR (2.2% TKR and UKR patients have different risk profiles for symptomatic
DVT. The risk-benefit ratio for TKR that has been used to produce
national guidelines may not be applicable to UKR. Further research
is required to establish the most appropriate form of prophylaxis
for UKR.
Controversy surrounds the most appropriate treatment
method for patients with a rupture of the tendo Achillis. The aim
of this study was to assess the long term rate of re-rupture following
management with a non-operative functional protocol. We report the outcome of 945 consecutive patients (949 tendons)
diagnosed with a rupture of the tendo Achillis managed between 1996
and 2008. There were 255 female and 690 male patients with a mean
age of 48.97 years (12 to 86). Delayed presentation was defined
as establishing the diagnosis and commencing treatment more than
two weeks after injury. The overall rate of re-rupture was 2.8%
(27 re-ruptures), with a rate of 2.9%
(25 re-ruptures) for those with an acute presentation and 2.7% (two
re-ruptures) for those with delayed presentation. This study of non-operative functional management of rupture
of the tendo Achillis is the largest of its kind in the literature. Our
rates of re-rupture are similar to, or better than, those published
for operative treatment. We recommend our regime for patients of
all ages and sporting demands, but it is essential that they adhere
to the protocol.
The incidence of deep-vein thrombosis (DVT) and
pulmonary embolism (PE) is thought to be low following foot and ankle
surgery, but the routine use of chemoprophylaxis remains controversial.
This retrospective study assessed the incidence of symptomatic venous
thromboembolic (VTE) complications following a consecutive series
of 2654 patients undergoing elective foot and ankle surgery. A total
of 1078 patients received 75 mg aspirin as routine thromboprophylaxis
between 2003 and 2006 and 1576 patients received no form of chemical
thromboprophylaxis between 2007 and 2010. The overall incidence
of VTE was 0.42% (DVT, 0.27%; PE, 0.15%) with 27 patients lost to follow-up.
If these were included to create a worst case scenario, the overall
VTE rate was 1.43%. There was no apparent protective effect against
VTE by using aspirin. We conclude that the incidence of VTE following foot and ankle
surgery is very low and routine use of chemoprophylaxis does not
appear necessary for patients who are not in the high risk group
for VTE.
Isolated fractures of the anterior column and anterior wall are a relatively rare subgroup of acetabular fractures. We report our experience of 30 consecutive cases treated over ten years. Open reduction and internal fixation through an ilioinguinal approach was performed for most of these cases (76.7%) and percutaneous techniques were used for the remainder. At a mean follow-up of four years (2 to 6), 26 were available for review. The radiological and functional outcomes were good or excellent in 23 of 30 patients (76.7%) and 22 of 26 patients (84.6%) according to Matta’s radiological criteria and the modified Merlé d’Aubigné score, respectively. Complications of minor to moderate severity were seen in six of the 30 cases (20%) and none of the patients underwent secondary surgery or replacement of the hip.
We reviewed the seven- to ten-year results of our previously reported prospective randomised controlled trial comparing total hip replacement and hemiarthroplasty for the treatment of displaced intracapsular fracture of the femoral neck. Of our original study group of 81 patients, 47 were still alive. After a mean follow up of nine years (7 to 10) overall mortality was 32.5% and 51.2% after total hip replacement and hemiarthroplasty, respectively (p = 0.09). At 100 months postoperatively a significantly greater proportion of hemiarthroplasty patients had died (p = 0.026). Three hips dislocated following total hip replacement and none after hemiarthroplasty. In both the total hip replacement and hemiarthroplasty groups a deterioration had occurred in walking distance (p = 0.02 and p <
0.001, respectively). One total hip replacement required revision compared with four hemiarthroplasties which were revised to total hip replacements. All surviving patients with a total hip replacement demonstrated wear of the cemented polyethylene component and all hemiarthroplasties had produced acetabular erosion. There was lower mortality (p = 0.013) and a trend towards superior function in patients with a total hip replacement in the medium term.
Vertebral compression fractures are the most prevalent complication of osteoporosis and percutaneous vertebroplasty (PVP) has emerged as a promising addition to the methods of treating the debilitating pain they may cause. Since PVP was first reported in the literature in 1987, more than 600 clinical papers have been published on the subject. Most report excellent improvements in pain relief and quality of life. However, these papers have been based mostly on uncontrolled cohort studies with a wide variety of inclusion and exclusion criteria. In 2009, two high-profile randomised controlled trials were published in the
The most common injury in rugby resulting in
spinal cord injury (SCI) is cervical facet dislocation. We report
on the outcome of a series of 57 patients with acute SCI and facet
dislocation sustained when playing rugby and treated by reduction
between 1988 and 2000 in Conradie Hospital, Cape Town. A total of
32 patients were completely paralysed at the time of reduction.
Of these 32, eight were reduced within four hours of injury and
five of them made a full recovery. Of the remaining 24 who were
reduced after four hours of injury, none made a full recovery and only
one made a partial recovery that was useful. Our results suggest
that low-velocity trauma causing SCI, such as might occur in a rugby
accident, presents an opportunity for secondary prevention of permanent
SCI. In these cases the permanent damage appears to result from
secondary injury, rather than primary mechanical spinal cord damage.
In common with other central nervous system injuries where ischaemia
determines the outcome, the time from injury to reduction, and hence
reperfusion, is probably important. In order to prevent permanent neurological damage after rugby
injuries, cervical facet dislocations should probably be reduced
within four hours of injury.
We investigated the safety and efficacy of treating osteoporotic vertebral compression fractures with an intravertebral cleft by balloon kyphoplasty. Our study included 27 patients who were treated in this way. The mean follow-up was 38.2 months (24 to 54). The anterior and middle heights of the vertebral body and the kyphotic angle were measured on standing lateral radiographs before surgery, one day after surgery, and at final follow-up. Leakage of cement was determined by CT scans. A visual analogue scale and the Oswestry disability index were chosen to evaluate pain and functional activity. Statistically significant improvements were found between the pre- and post-operative assessments (p <
0.05) but not between the post-operative and final follow-up assessments (p >
0.05). Asymptomatic leakage of cement into the paravertebral vein occurred in one patient, as did leakage into the intervertebral disc in another patient. We suggest that balloon kyphoplasty is a safe and effective minimally invasive procedure for the treatment of osteoporotic vertebral compression fractures with an intravertebral cleft.
Between January 2000 and December 2007, 31 patients 90 years of age or older underwent total hip replacement at our hospital. Their data were collected prospectively. The rate of major medical complications was 9%. The surgical re-operation rate was 3%. The requirement for blood transfusion was 71% which was much higher than for younger patients. The 30-day, one-year and current mortality figures were 6.4% (2 of 31), 9.6% (3 of 31) and 55% (17 of 31), respectively, with a mean follow-up for the 14 surviving patients of six years. Cox’s regression analysis revealed no significant independent predictors of mortality. Only 52% of patients returned immediately to their normal abode, with 45% requiring a prolonged period of rehabilitation. This is the first series to assess survival five years after total hip replacement for patients in their 90th year and beyond. Hip replacement in the extreme elderly should not be discounted on the grounds of age alone, although the complication rate exceeds that for younger patients. It can be anticipated that almost half of the patients will survive five years after surgery.
We report the outcome of the flangeless, cemented all-polyethylene Exeter acetabular component at a mean of 14.6 years (10 to 17) after operation. Of the 263 hips in 243 patients, 122 prostheses are still The cemented all-polyethylene Exeter acetabular component has an excellent long-term survivorship.
Arthroscopy of the knee is one of the most commonly
performed orthopaedic procedures worldwide. Large-volume outcome
data have not previously been available for English NHS patients.
Prospectively collected admissions data, routinely collected on
every English NHS patient, were analysed to determine the rates
of complications within 30 days (including re-operation and re-admission),
90-day symptomatic venous thromboembolism and all-cause mortality.
There were 301 701 operations performed between 2005 and 2010 –
an annual incidence of 9.9 per 10 000 English population. Of these,
16 552 (6%) underwent ligament reconstruction and 106 793 (35%)
underwent meniscal surgery. The 30-day re-admission rate was 0.64%
(1662) and 30-day wound complication rate was 0.26% (677). The overall
30-day re-operation rate was 0.40% (1033) and the 90-day pulmonary embolism
rate was 0.08% (230), of which six patients died. 90-day mortality
was 0.02% (47). Age <
40 years, male gender and ligament reconstruction
were significantly associated with an increased rate of 30-day re-admission
and unplanned re-operation. In addition, a significant increase
in 30-day admission rates were seen with Charlson comorbidity scores
of 1 (p = 0.037) and ≥ 2 (p <
0.001) compared with scores of
0, and medium volume units compared with high volume units (p <
0.001). Complications following arthroscopy of the knee are rare. It
is a safe procedure, which in the majority of cases is performed
as day case surgery. These data can be used for quality benchmarking,
in terms of consent, consultant re-validation and individual unit
performance.
Rivaroxaban has been recommended for routine use as a thromboprophylactic agent in patients undergoing lower-limb arthroplasty. However, trials supporting its use have not fully evaluated the risks of wound complications. This study of 1048 total hip/knee replacements records the rates of return to theatre and infection before and after the change from a low molecular weight heparin (tinzaparin) to rivaroxaban as the agent of chemical thromboprophylaxis in patients undergoing lower-limb arthroplasty. During a period of 13 months, 489 consecutive patients undergoing lower-limb arthroplasty received tinzaparin and the next 559 consecutive patients received rivaroxaban as thromboprophylaxis. Nine patients in the control (tinzaparin) group (1.8%, 95% confidence interval 0.9 to 3.5) returned to theatre with wound complications within 30 days, compared with 22 patients in the rivaroxaban group (3.94%, 95% confidence interval 2.6 to 5.9). This increase was statistically significant (p = 0.046). The proportion of patients who returned to theatre and became infected remained similar (p = 0.10). Our study demonstrates the need for further randomised controlled clinical trials to be conducted to assess the safety and efficacy of rivaroxaban in clinical practice, focusing on the surgical complications as well as the potential prevention of venous thromboembolism.
We report the mid- to long-term (mean 20.3 years, 10 to 32.5) results of the Chiari pelvic osteotomy in patients with pre- to advanced stage osteoarthritis in dysplastic hips. We followed 163 Japanese patients (173 hips) with a mean age at surgery of 20 years (9 to 54). Overall, 124 hips (72%) had satisfactory results, with Harris hip scores ≥ 80. Satisfactory results were seen in 105 of 134 hips with pre- or early osteoarthritis (78%) and 19 of 39 hips with advanced osteoarthritis (49%). A total of 15 hips (9%) underwent a total hip replacement (THR) with a mean interval between osteotomy and THR of 16.4 years. With conversion to THR as the endpoint, the 30-year survival rate was 85.9% (95% confidence interval 82.3 to 89.5). It was 91.8% for patients with pre- or early osteoarthritis and 43.6% for those with advanced osteoarthritis (p < 0.001). We now perform the Chiari osteotomy for patients with dysplastic hips showing poor joint congruency and who prefer a joint-conserving procedure to THR.
We conducted a retrospective study to investigate the effect of femoral bowing on the placement of components in total knee replacement (TKR), with regard to its effect on reestablishing the correct mechanical axis, as we hypothesised that computer-assisted total knee replacement (CAS-TKR) would produce more accurate alignment than conventional TKR. Between January 2006 and December 2009, 212 patients (306 knees) underwent TKR. The conventional TKR was compared with CAS-TKR for accuracy of placement of the components and post-operative alignment, as determined by five radiological measurements. There were significant differences in the reconstructed mechanical axes between the bowed and the non-bowed group after conventional TKR (176.2° ( For patients with significant femoral bowing, the reconstructed mechanical axes were significantly closer to normal in the CAS group than in the conventional group (179.2° (
In Africa the amount of joint replacement surgery is increasing, but the indications for operation and the age of the patients are considerably different from those in the developed world. New centres with variable standards of care and training of the surgeons are performing these procedures and it is important that a proper audit of this work is undertaken. In Malawi, we have pioneered a Registry which includes all joint replacements that have been carried out in the country. The data gathered include the age, gender, indication for operation, the prosthesis used, the surgical approach, the use of bone graft, the type of cement, pressurising systems and the thromboprophylaxis used. All patients have their clinical scores recorded pre-operatively and then after three and six months and at one year. Before operation all patients are counselled and on consent their HIV status is established allowing analysis of the effect of HIV on successful joint replacement. To date, 73 total hip replacements (THRs) have been carried out in 58 patients by four surgeons in four different hospitals. The most common indications for THR were avascular necrosis (35 hips) and osteoarthritis (22 hips). The information concerning 20 total knee replacements has also been added to the Registry.