Aims. The aim of this study was to examine perioperative blood transfusion practice, and associations with clinical outcomes, in a national cohort of hip fracture patients. Methods. A retrospective cohort study was undertaken using linked data from the Scottish Hip Fracture Audit and the Scottish National Blood Transfusion Service between May 2016 and December 2020. All patients aged ≥ 50 years admitted to a Scottish hospital with a hip fracture were included. Assessment of the factors independently associated with red blood cell transfusion (RBCT) during admission was performed, alongside determination of the association between RBCT and hip fracture outcomes. Results. A total of 23,266 individual patient records from 18 hospitals were included. The overall rate of blood transfusion during admission was 28.7% (n = 6,685). There was inter-hospital variation in transfusion rate, ranging from 16.6% to 37.4%. Independent perioperative factors significantly associated with RBCT included older age (90 to 94 years, odds ratio (OR) 3.04 (95% confidence interval (CI) 2.28 to 4.04); p < 0.001), intramedullary fixation (OR 7.15 (95% CI 6.50 to 7.86); p < 0.001), and sliding hip screw constructs (OR 2.34 (95% CI 2.19 to 2.50); p < 0.001). Blood transfusion during admission was significantly associated with higher rates of 30-day mortality (OR 1.35 (95% CI 1.19 to 1.53); p < 0.001) and 60-day mortality (OR 1.54 (95% CI 1.43 to 1.67); p < 0.001), as well as delays to postoperative mobilization, higher likelihood of not returning to their home, and longer length of stay. Conclusion. Blood transfusion after hip fracture was common, although practice varied nationally. RBCT is associated with adverse outcomes, which is most likely a reflection of perioperative anaemia, rather than any causal effect. Use of RBCT does not appear to reverse this effect, highlighting the importance of perioperative blood loss reduction. Cite this article: Bone Joint J 2022;104-B(11):1266–1272

Aims. Currently, there is little information about the need for peri-operative blood transfusion in patients undergoing shoulder arthroplasty. . The purpose of this study was to identify the rate of transfusion and its predisposing factors, and to establish a blood conservation strategy. . Methods. We identified all patients who had undergone shoulder arthroplasty at our hospital between 1 January 2011 and 31 December 2013. The rate of transfusion was determined from the patient’s records. While there were exceptions, patients typically underwent transfusion if they had a level of haemoglobin of < 7.5 g/dl if asymptomatic, < 9.0 g/dl if they had a significant cardiac history or symptoms of dizziness or light headedness. . Multivariable regression analysis was undertaken to identify predictors of transfusion. High- and low-risk cohorts for transfusion were identified from a receiver operating characteristic (ROC) curve. Results. Of 1174 shoulder arthroplasties performed on 1081 patients, 53 cases (4.5%) required transfusion post-operatively. Predictors of blood transfusion were a lower pre-operative haematocrit (p < 0.001) and shoulder arthroplasty undertaken for post-traumatic arthritis (p < 0.001). ROC analysis identified pre-operative haematocrit of 39.6% as a 90% sensitivity cut-off for transfusion. In total 48 of the 436 (11%) shoulder arthroplasties with a pre-operative haematocrit < 39.6% needed transfusion compared with five of the 738 (0.70%) shoulder arthroplasties with a haematocrit above this level. . Discussion . We found that transfusion was needed less frequently than previously described for shoulder arthroplasty. Patients with a pre-operative haematocrit < 39.6% should be advised that there is an increased risk for blood transfusion, while those with a haematocrit above this level are unlikely to require transfusion. . Take home message: The rate of transfusion after shoulder arthroplasty is under 5%, and those with a pre-operative haematocrit greater than or equal to 39.6% have a very low likelihood (< 1%) of requiring a transfusion. Cite this article: Bone Joint J 2016;98-B:224–8

We have investigated the effect of using tranexamic acid (TXA) during peri-acetabular osteotomy (PAO) on peri-operative blood loss and blood transfusion requirements. In addition we analysed whether the use of TXA was associated with an increased risk of venous thromboembolism (VTE) following this procedure. A consecutive series of 96 PAOs, performed by a single surgeon, were reviewed. A total of 48 patients received TXA and 48 did not. The TXA group received a continuous infusion of TXA at a rate of 10 mg/kg/h. The primary outcome measure was the requirement for blood transfusion. Secondary outcomes included total blood loss, the decrease in the level of haemoglobin in the blood, the length of hospital stay, and the complications of this treatment. The mean rate of transfusion was significantly lower in the TXA group (62.5% vs 12.5%, p < 0.001). The mean blood loss was also significantly reduced in the TXA group (1.9 L (standard deviation (. sd. ) 0.9) vs 1.5 L (. sd. 0.7), p < 0.01). No post-operative episodes of VTE were identified in either group. . The use of TXA reduced the blood loss and the rate of transfusion after PAO significantly, without adverse effects such as an increased rate of VTE. Cite this article: Bone Joint J 2015;97-B:1604–7

Aims. Transfusion after primary total hip arthroplasty (THA) has become rare, and identification of causative factors allows preventive measures. The aim of this study was to determine patient-specific factors that increase the risk of needing a blood transfusion. Methods. All patients who underwent elective THA were analyzed retrospectively in this single-centre study from 2020 to 2021. A total of 2,892 patients were included. Transfusion-related parameters were evaluated. A multiple logistic regression was performed to determine whether age, BMI, American Society of Anesthesiologists (ASA) grade, sex, or preoperative haemoglobin (Hb) could predict the need for transfusion within the examined patient population. Results. The overall transfusion rate was 1.2%. Compared to the group of patients without blood transfusion, the transfused group was on average older (aged 73.8 years (SD 9.7) vs 68.6 years (SD 10.1); p = 0.020) and was mostly female (p = 0.003), but showed no significant differences in terms of BMI (28.3 kg/m. 2. (SD 5.9) vs 28.7 kg/m. 2. (SD 5.2); p = 0.720) or ASA grade (2.2 (SD 0.5) vs 2.1 (SD 0.4); p = 0.378). The regression model identified a cutoff Hb level of < 7.6 mmol/l (< 12.2 g/dl), aged > 73 years, and a BMI of 35.4 kg/m² or higher as the three most reliable predictors associated with postoperative transfusion in THA. Conclusion. The possibility of transfusion is predictable based on preoperatively available parameters. The proposed thresholds for preoperative Hb level, age, and BMI can help identify patients and take preventive measures if necessary. Cite this article: Bone Jt Open 2024;5(7):560–564

Aims. Blood transfusion and postoperative anaemia are complications of total knee arthroplasty (TKA) that are associated with substantial healthcare costs, morbidity, and mortality. There are few data from large datasets on the risk factors for these complications. Methods. We retrospectively reviewed the records of TKA patients from a single tertiary care institution from February 2016 to December 2020. There were a total of 14,901 patients in this cohort with a mean age of 67.9 years (SD 9.2), and 5,575 patients (37.4%) were male. Outcomes included perioperative blood transfusion and postoperative anaemia, defined a priori as haemoglobin level < 10 g/dl measured on the first day postoperatively. In order to establish a preoperative haemoglobin cutoff, we investigated a preoperative haemoglobin level that would limit transfusion likelihood to ≤ 1% (13 g/dl) and postoperative anaemia likelihood to 4.1%. Risk factors were assessed through multivariable Poisson regression modelling with robust error variance. Results. In multivariable analyses, each gram of tranexamic acid reduced transfusion likelihood by 39% (adjusted risk ratio (ARR) 0.61 (95% confidence interval (CI) 0.47 to 0.78)). Risk factors associated with an increased risk of transfusion included operating time (ARR 2.07 (95% CI 1.54 to 2.77)) and drain use (ARR 1.73 (95% CI 1.34 to 2.24)). Conclusion. In this study, we found that increased tranexamic acid dosing, decreased operating time, and decreased drain use may reduce transfusions following TKA. We also established a single preoperative haemoglobin cutoff of 13 g/dl that could help minimize transfusions and reduce postoperative complete blood counts. Cite this article: Bone Joint J 2023;105-B(10):1086–1093

We studied 70 consecutive patients with adolescent idiopathic scoliosis who underwent corrective surgery. They were divided into two groups. In the study group of 38 patients one or more modern blood-conservation measures was used peri-operatively. The 32 patients in the control group did not have these measures. Both groups were similar in regard to age, body-weight, the number of levels fused and the type of surgery. Only two patients in the study group were transfused with homologous blood and these transfusions were ‘off-protocol’. Wastage of autologous pre-donated units was minimal (6 of 83 units). By contrast, all patients in the control group were transfused with homologous blood. In the study group there was a significant decrease (p = 0.005) in the estimated blood loss when all the blood-conservation methods were used. The use of blood-conservation measures, the lowering of the haemoglobin trigger for transfusion and the education of the entire team involved in the care of the patient can prevent the need for homologous blood transfusion in patients undergoing surgery for adolescent idiopathic scoliosis

We carried out a retrospective case-control study in 80 patients who underwent a revision total hip replacement. Group A (40 patients) received tranexamic acid and intra-operative cell salvage. Group B (40 patients) was a matched control group and did not receive this management. Each group was divided into four subgroups: revision of both components, revision of both components with bone grafting, revision of the acetabular component with or without bone graft, and revision of the femoral component with or without bone graft. In group A the total number of units transfused was 52, compared with 139 in group B, representing a reduction in blood usage of 62.5%. The mean amount of blood transfused from cell salvage in each group was 858 ml (113 to 2100), 477 ml (0 to 2680), 228 ml (75 to 315) and 464 ml (120 to 1125), respectively. There was a significant difference in the amount of blood returned between the groups (p < 0.0001). In group A, 22 patients needed transfusion and in group B, 37 (p < 0.0001). A cost analysis calculation showed a total revenue saving of £70 000 and a potential saving throughout our facility of £318 288 per year. Our results show that a significant reduction in blood transfusion can be made using combined cell salvage and tranexamic acid in revision surgery of the hip

We hypothesised there was no clinical value in using an autologous blood transfusion (ABT) drain in either primary total hip (THR) or total knee replacement (TKR) in terms of limiting allogeneic blood transfusions when a modern restrictive blood management regime was followed. A total of 575 patients (65.2% men), with a mean age of 68.9 years (36 to 94) were randomised in this three-arm study to no drainage (group A), or to wound drainage with an ABT drain for either six hours (group B) or 24 hours (group C). The primary outcome was the number of patients receiving allogeneic blood transfusion. Secondary outcomes were post-operative haemoglobin (Hb) levels, length of hospital stay and adverse events. This study identified only 41 transfused patients, with no significant difference in distribution between the three groups (p = 0.857). The mean pre-operative haemoglobin (Hb) value in the transfused group was 12.8 g/dL (9.8 to 15.5) versus 14.3 g/dL (10.6 to 18.0) in the non-transfused group (p < 0.001, 95% confidence interval: 1.08 to 1.86). Post-operatively, the median of re-transfused shed blood in patients with a THR was 280 mL (Interquartile range (IQR) 150 to 400) and in TKR patients 500 mL (IQR 350 to 650) (p <  0.001). ABT drains had no effect on the proportion of transfused patients in primary THR and TKR. The secondary outcomes were also comparable between groups. Cite this article: Bone Joint J 2014;96-B:765–71

We have reviewed prospective data on 1016 patients who underwent unilateral total hip replacement to establish the pre-operative risk factors associated with peri-operative blood transfusion. Most patients who required transfusion were older and were of lower weight, height, pre-operative haemoglobin level and body mass index than patients who were not transfused. Multivariate analysis revealed that only the pre-operative haemoglobin level and the patients weight were identified as significant independent factors increasing the need for transfusion (p < 0.001). A haemoglobin level below 12 g/dl was associated with a threefold increase in transfusion requirement

Aims. Femoral periprosthetic fractures are rising in incidence. Their management is complex and carries a high associated mortality. Unlike native hip fractures, there are no guidelines advising on time to theatre in this group. We aim to determine whether delaying surgical intervention influences morbidity or mortality in femoral periprosthetic fractures. Methods. We identified all periprosthetic fractures around a hip or knee arthroplasty from our prospectively collated database between 2012 and 2021. Patients were categorized into early or delayed intervention based on time from admission to surgery (early = ≤ 36 hours, delayed > 36 hours). Patient demographics, existing implants, Unified Classification System fracture subtype, acute medical issues on admission, preoperative haemoglobin, blood transfusion requirement, and length of hospital stay were identified for all patients. Complication and mortality rates were compared between groups. Results. A total of 365 patients were identified: 140 in the early and 225 in the delayed intervention group. Mortality rate was 4.1% at 30 days and 19.2% at one year. There was some indication that those who had surgery within 36 hours had a higher mortality rate, but this did not reach statistical significance at 30 days (p = 0.078) or one year (p = 0.051). Univariate analysis demonstrated that age, preoperative haemoglobin, acute medical issue on admission, and the presence of postoperative complications influenced 30-day and one-year mortality. Using a multivariate model, age and preoperative haemoglobin were independently predictive factors for one-year mortality (odds ratio (OR) 1.071; p < 0.001 and OR 0.980; p = 0.020). There was no association between timing of surgery and postoperative complications. Postoperative complications were more likely with increasing age (OR 1.032; p = 0.001) and revision arthroplasty compared to internal fixation (OR 0.481; p = 0.001). Conclusion. While early intervention may be preferable to reduce prolonged immobilization, there is no evidence that delaying surgery beyond 36 hours increases mortality or complications in patients with a femoral periprosthetic fracture. Cite this article: Bone Jt Open 2024;5(6):452–456

Aims. The sacroiliac joint (SIJ) is the only mechanical connection between the axial skeleton and lower limbs. Following iliosacral resection, there is debate on whether reconstruction of the joint is necessary. There is a paucity of data comparing the outcomes of patients undergoing reconstruction and those who are not formally reconstructed. Methods. A total of 60 patients (25 females, 35 males; mean age 39 years (SD 18)) undergoing iliosacral resection were reviewed. Most resections were performed for primary malignant tumours (n = 54; 90%). The mean follow-up for surviving patients was nine years (2 to 19). Results. Overall, 27 patients (45%) were reconstructed, while 33 (55%) had no formal reconstruction. There was no difference in the use of chemotherapy (p = 1.000) or radiotherapy (p = 0.292) between the groups. Patients with no reconstruction had a mean larger tumour (11 cm (SD 5) vs 8 cm (SD 4); p = 0.014), mean shorter operating times (664 mins (SD 195) vs 1,324 mins (SD 381); p = 0.012), and required fewer blood units (8 (SD 7) vs 14 (SD 11); p = 0.012). Patients undergoing a reconstruction were more likely to have a deep infection (48% vs 12%; p = 0.003). Nine reconstructed patients had a hardware failure, with five requiring revision. Postoperatively 55 (92%) patients were ambulatory, with no difference in the proportion of ambulatory patients (89% vs 94%; p = 0.649) or mean Musculoskeletal Tumor Society Score (59% vs 65%; p = 0.349) score between patients who did or did not have a reconstruction. The ten-year disease-specific survival was 69%, with no difference between patients who were reconstructed and those who were not (78% vs 45%; p = 0.316). There was no difference in the rate of metastasis between the two groups (hazard ratio (HR) 2.78; p = 0.102). Conclusion. Our results demonstrate that SIJ reconstruction is associated with longer operating times, greater need for blood transfusion, and more postoperative infections, without any improvement in functional outcomes when compared to patients who did not have formal SIJ reconstruction. Cite this article: Bone Joint J 2024;106-B(1):93–98

Aims. To evaluate if, for orthopaedic trainees, additional cadaveric simulation training or standard training alone yields superior radiological and clinical outcomes in patients undergoing dynamic hip screw (DHS) fixation or hemiarthroplasty for hip fracture. Methods. This was a preliminary, pragmatic, multicentre, parallel group randomized controlled trial in nine secondary and tertiary NHS hospitals in England. Researchers were blinded to group allocation. Overall, 40 trainees in the West Midlands were eligible: 33 agreed to take part and were randomized, five withdrew after randomization, 13 were allocated cadaveric training, and 15 were allocated standard training. The intervention was an additional two-day cadaveric simulation course. The control group received standard on-the-job training. Primary outcome was implant position on the postoperative radiograph: tip-apex distance (mm) (DHS) and leg length discrepancy (mm) (hemiarthroplasty). Secondary clinical outcomes were procedure time, length of hospital stay, acute postoperative complication rate, and 12-month mortality. Procedure-specific secondary outcomes were intraoperative radiation dose (for DHS) and postoperative blood transfusion requirement (hemiarthroplasty). Results. Eight female (29%) and 20 male trainees (71%), mean age 29.4 years, performed 317 DHS operations and 243 hemiarthroplasties during ten months of follow-up. Primary analysis was a random effect model with surgeon-level fixed effects of patient condition, patient age, and surgeon experience, with a random intercept for surgeon. Under the intention-to-treat principle, for hemiarthroplasty there was better implant position in favour of cadaveric training, measured by leg length discrepancy ≤ 10 mm (odds ratio (OR) 4.08 (95% confidence interval (CI) 1.17 to 14.22); p = 0.027). There were significantly fewer postoperative blood transfusions required in patients undergoing hemiarthroplasty by cadaveric-trained compared to standard-trained surgeons (OR 6.00 (95% CI 1.83 to 19.69); p = 0.003). For DHS, there was no significant between-group difference in implant position as measured by tip-apex distance ≤ 25 mm (OR 6.47 (95% CI 0.97 to 43.05); p = 0.053). No between-group differences were observed for any secondary clinical outcomes. Conclusion. Trainees randomized to additional cadaveric training performed hip fracture fixation with better implant positioning and fewer postoperative blood transfusions in hemiarthroplasty. This effect, which was previously unknown, may be a consequence of the intervention. Further study is required. Cite this article: Bone Jt Open 2023;4(8):602–611

Aims. Recent improvements in surgical technique and perioperative blood management after total joint replacement (TJR) have decreased rates of transfusion. However, as many surgeons transition to outpatient TJR, obtaining routine postoperative blood tests becomes more challenging. Therefore, we sought to determine if a preoperative outpatient assessment tool that stratifies patients based on numerous medical comorbidities could predict who required postoperative haemoglobin (Hb) measurement. Methods. We performed a prospective study of consecutive unilateral primary total knee arthroplasties (TKAs) and total hip arthroplasties (THAs) performed at a single institution. Prospectively collected data included preoperative and postoperative Hb levels, need for blood transfusion, length of hospital stay, and Outpatient Arthroplasty Risk Assessment (OARA) score. Results. A total of 504 patients met inclusion criteria. Mean age at time of arthroplasty was 65.3 years (SD 10.2). Of the patients, 216 (42.9%) were THAs and 288 (57.1%) were TKAs. Six patients required a blood transfusion postoperatively (1.19%). Transfusion after surgery was associated with lower postoperative day 1 Hb (median of 8.5 (interquartile range (IQR) 7.9 to 8.6) vs 11.3 (IQR 10.4 to 12.2); p < 0.001), longer length of stay (1 day (IQR 1 to 1) vs 2 days (IQR 2 to 3); p < 0.001), higher OARA score (median of 60.0 (IQR 40 to 75) vs 5.0 (IQR 0-35); p = 0.001), and total hip arthroplasty (p < 0.001). All patients who received a transfusion had an OARA score > 34; however, this did not reach statistical significance as a screening threshold. Conclusion. Risk of blood transfusion after primary TJR was uncommon in our series, with an incidence of 1.19%. Transfusion was associated with OARA scores > 60. The OARA score, not American Society of Anesthesiologists grade, reliably identified patients at risk for postoperative blood transfusion. Selective Hb monitoring may result in substantial cost savings in the era of cost containment. Cite this article: Bone Joint J 2021;103-B(1):65–70

Aims. The aim of this study was to perform a systematic review of the evidence for the use of intraoperative cell salvage in patients undergoing revision hip arthroplasty, and specifically to analyze the available data in order to quantify any associated reduction in the use of allogenic blood transfusion, and the volume which is used. Methods. An electronic search of MEDLINE (PubMed), Embase, Scopus, and the Cochrane Library was completed from the date of their inception to 24 February 2022, using a search strategy and protocol created in conjunction with the PRISMA statement. Inclusion criteria were patients aged > 18 years who underwent revision hip arthroplasty when cell salvage was used. Studies in which pre-donated red blood cells were used were excluded. A meta-analysis was also performed using a random effects model with significance set at p = 0.05. Results. Of the 283 studies which were identified, 11 were included in the systematic review, and nine in the meta-analysis. There was a significant difference (p < 0.001) in the proportion of patients requiring allogenic transfusion between groups, with an odds ratio of 0.331 (95% confidence interval (CI) 0.165 to 0.663) associated with the use of cell salvage. For a total of 561 patients undergoing revision hip arthroplasty who were treated with cell salvage, 247 (44.0%) required allogenic transfusion compared with 418 of 643 patients (65.0%) who were treated without cell salvage. For those treated with cell salvage, the mean volume of allogenic blood which was required was 1.95 units (390 ml) per patient (0.7 to 4.5 units), compared with 3.25 units (650 ml) per patient (1.2 to 7.0 units) in those treated without cell salvage. The mean difference of -1.91 units (95% CI -4.0 to 0.2) in the meta-analysis was also significant (p = 0.003). Conclusion. We found a a significant reduction in the need for allogenic blood transfusion when cell salvage was used in patients undergoing revision hip arthroplasty, supporting its routine use in these patients. Further research is required to determine whether this effect is associated with types of revision arthroplasty of differing complexity. Cite this article: Bone Joint J 2023;105-B(10):1038–1044

Aims. Despite declining frequency of blood transfusion and electrolyte supplementation following total joint arthroplasty, postoperative blood analyses are still routinely ordered for these patients. This study aimed to determine the rate of blood transfusion and electrolyte restoration in arthroplasty patients treated with a perioperative blood conservation protocol and to identify risk factors that would predict the need for transfusion and electrolyte supplementation. Patients and Methods. Patients undergoing primary total joint arthroplasty of the hip or knee between July 2016 and February 2017 at a single institution were included in the study. Standard preoperative and postoperative laboratory data were collected and reviewed retrospectively. A uniform blood conservation programme was implemented for all patients. Need for blood transfusion or potassium supplementation was determined through a coordinated decision by the care team. Rates of transfusion and supplementation were observed, and patient risk factors were noted. Results. The overall rate of blood transfusion was 1.06% in the study population of 1132 total joint arthroplasties performed in 1023 patients. Of the 12 patients requiring transfusion, 11 were female, ten occurred in patients undergoing total hip arthroplasty, and all 12 patients had a preoperative haemoglobin level less than 130 g/l. Operative duration and surgical blood loss were significantly greater in those patients requiring blood transfusion. Nearly all patients requiring transfusion had a history of, or risk factors for, cardiovascular disease. Potassium supplementation was required in 15.5% of the study cohort; 72% of these patients receiving potassium presented with a potassium level less than 4 mmol/l during preoperative testing, while the remaining 28% had a past medical history of either significant anaemia, cardiopulmonary, cardiovascular, or renal diseases that had required substantial medical management. Conclusion. A consistent blood-conserving perioperative strategy effectively minimized need for blood transfusion in total joint arthroplasty patients below previously reported rates in the literature. We suggest that postoperative full blood counts and basic metabolic panels should not routinely be ordered in these patients unless their preoperative haemoglobin and potassium is below 130 g/dl or 4 mmol/l respectively, and they have medical comorbidities

Aims. The aim of this study was to determine whether fixation, as opposed to revision arthroplasty, can be safely used to treat reducible Vancouver B type fractures in association with a cemented collarless polished tapered femoral stem (the Exeter). Methods. This retrospective cohort study assessed 152 operatively managed consecutive unilateral Vancouver B fractures involving Exeter stems; 130 were managed with open reduction and internal fixation (ORIF) and 22 with revision arthroplasty. Mean follow-up was 6.5 years (SD 2.6; 3.2 to 12.1). The primary outcome measure was revision of at least one component. Kaplan–Meier survival analysis was performed. Regression analysis was used to identify risk factors for revision following ORIF. Secondary outcomes included any reoperation, complications, blood transfusion, length of hospital stay, and mortality. Results. Fractures (B1 n = 74 (49%); B2 n = 50 (33%); and B3 n = 28 (18%)) occurred at median of 4.2 years (interquartile range (IQR) 1.2 to 9.2) after primary total hip arthroplasty (THA) (n = 138) or hemiarthroplasty (n = 14). Rates of revision and reoperation were significantly higher following revision arthroplasty compared to ORIF for B2 (p = 0.001) and B3 fractures (p = 0.050). Five-year survival was significantly better following ORIF: 92% (95% confidence interval (CI) 86.4% to 97.4%) versus 63% (95% CI 41.7% to 83.3%), p < 0.001. ORIF was associated with reduced blood transfusion requirement and reoperations, but there were no differences in medical complications, hospital stay, or mortality between surgical groups. No independent predictors of revision following ORIF were identified: where the bone-cement interface was intact, fixation of B2 or B3 fractures was not associated with an increased risk of revision. Conclusion. When the bone-cement interface was intact and the fracture was anatomically reducible, all Vancouver B fractures around Exeter stems could be managed with fixation as opposed to revision arthroplasty. Fixation was associated with reduced need for blood transfusion and lower risk of revision surgery compared with revision arthroplasty. Cite this article: Bone Joint J 2021;103-B(2):309–320

Aims. This study aims to determine difference in annual rate of early-onset (≤ 90 days) deep surgical site infection (SSI) following primary total knee arthroplasty (TKA) for osteoarthritis, and to identify risk factors that may be associated with infection. Methods. This is a retrospective population-based cohort study using prospectively collected patient-level data between 1 January 2013 and 1 March 2020. The diagnosis of deep SSI was defined as per the Centers for Disease Control/National Healthcare Safety Network criteria. The Mann-Kendall Trend test was used to detect monotonic trends in annual rates of early-onset deep SSI over time. Multiple logistic regression was used to analyze the effect of different patient, surgical, and healthcare setting factors on the risk of developing a deep SSI within 90 days from surgery for patients with complete data. We also report 90-day mortality. Results. A total of 39,038 patients underwent primary TKA for osteoarthritis during the study period. Of these, 275 patients developed a deep SSI within 90 days of surgery, representing a cumulative incidence of 0.7%. The annual infection rate did not significantly decrease over the seven-year study period (p = 0.162). Overall, 13,885 (35.5%) cases were excluded from the risk analysis due to missing data. Risk factors associated with early-onset deep SSI included male sex, American Society of Anesthesiologists grade ≥ 3, blood transfusion, acute length of stay, and surgeon volume < 30 TKAs/year. Early-onset deep SSI was not associated with increased 90-day mortality. Conclusion. This study establishes a reliable baseline infection rate for early-onset deep SSI after TKA for osteoarthritis using robust Infection Prevention and Control surveillance data, and identifies several potentially modifiable risk factors. Cite this article: Bone Joint J 2023;105-B(9):971–976

Aims. It is common practice for patients to have postoperative blood tests after total joint replacement (TJR). However, there have been significant improvements in perioperative care with arthroplasty surgery, and a drive to reduce the length of stay (LOS) and move towards day-case TJR. We should reconsider whether this intervention is necessary for all patients. Methods. This retrospective study included all patients who underwent a primary unilateral TJR at a single tertiary arthroplasty centre during a one-year period. Electronic medical records of 1,402 patients were reviewed for patient demographics, LOS, and American Society of Anesthesiologists (ASA) grade. Blood tests were examined to investigate the incidence of postoperative anaemia, electrolyte abnormalities, and incidence of acute kidney injury (AKI). Results. For total knee arthroplasties, preoperative (R = −0.22) and postoperative haemoglobin (R = 0.2) levels were both negatively correlated with LOS (p < 0.001). For all patients who had undergone a TJR, 19 patients (0.014%) required a blood transfusion postoperatively due to symptomatic anaemia. Risk factors identified were age, preoperative anaemia, and long-term aspirin use. Significant abnormal sodium levels were found in123 patients (8.7%). However, only 36 patients (2.6%) required intervening treatment. Risk factors identified were age, preoperative abnormal sodium level, and long-term use of non-steroidal anti-inflammatory drugs, angiotensin receptor blockers, and corticosteroids. Similarly, abnormal potassium levels were evident in 53 patients (3.8%), and only 18 patients (1.3%) required intervening treatment. Risk factors identified were preoperative abnormal potassium level, and long-term use of angiotensin-converting enzyme inhibitors and diuretics. The incidence of AKI was 4.4% (61 patients). Risk factors identified were age, increased ASA grade, preoperative abnormal sodium, and creatinine level. Conclusion. Routine blood tests after primary TJR is unnecessary for most patients. Blood tests should only be performed on those with identifiable risk factors such as preoperative anaemia and electrolyte abnormalities, haematological conditions, long-term aspirin use, and electrolyte-altering medications. Cite this article: Bone Jt Open 2023;4(5):357–362

Aims. Tranexamic acid (TXA) is now commonly used in major surgical operations including orthopaedics. The TRAC-24 randomized control trial (RCT) aimed to assess if an additional 24 hours of TXA postoperatively in primary total hip (THA) and total knee arthroplasty (TKA) reduced blood loss. Contrary to other orthopaedic studies to date, this trial included high-risk patients. This paper presents the results of a cost analysis undertaken alongside this RCT. Methods. TRAC-24 was a prospective RCT on patients undergoing TKA and THA. Three groups were included: Group 1 received 1 g intravenous (IV) TXA perioperatively and an additional 24-hour postoperative oral regime, Group 2 received only the perioperative dose, and Group 3 did not receive TXA. Cost analysis was performed out to day 90. Results. Group 1 was associated with the lowest mean total costs, followed by Group 2 and then Group 3. The differences between Groups 1 and 3 (-£797.77 (95% confidence interval -1,478.22 to -117.32) were statistically significant. Extended oral dosing reduced costs for patients undergoing THA but not TKA. The reduced costs in Groups 1 and 2 resulted from reduced length of stay, readmission rates, emergency department attendances, and blood transfusions. Conclusion. This study demonstrated significant cost savings when using TXA in primary THA or TKA. Extended oral dosing reduced costs further in THA but not TKA. Cite this article: Bone Jt Open 2022;3(7):536–542

This prospective randomised clinical trial evaluated the effect of alternatives for allogeneic blood transfusions after total hip replacement and total knee replacement in patients with pre-operative haemoglobin levels between 10.0 g/dl and 13.0 g/dl. A total of 100 patients were randomly allocated to the Eprex (pre-operative injections of epoetin) or Bellovac groups (post-operative retransfusion of shed blood). Allogeneic blood transfusions were administered according to hospital policy. In the Eprex group, 4% of the patients (two patients) received at least one allogeneic blood transfusion. In the Bellovac group, where a mean 216 ml (0 to 700) shed blood was retransfused, 28% (14 patients) required the allogeneic transfusion (p = 0.002). When comparing Eprex with Bellovac in total hip replacement, the percentages were 7% (two of 30 patients) and 30% (nine of 30 patients) (p = 0.047) respectively, whereas in total knee replacement, the percentages were 0% (0 of 20 patients) and 25% (five of 20 patients) respectively (p = 0.042). Pre-operative epoetin injections are more effective but more costly in reducing the need for allogeneic blood transfusions in mildly anaemic patients than post-operative retransfusion of autologous blood