Knee disarticulation vs. transfemoral amputation after failed transtibial amputation: Surgical outcome and prosthetic fitting in patients with peripheral vascular disease.

OBJECTIVE: Our aim was to compare transfemoral amputation (TFA) to knee disarticulation (KD) as a reamputation level after failed transtibial amputation (TTA) in patients with peripheral vascular disease and/or diabetes. METHODS: We studied 152 patients undergoing reamputation, 86 TFA and 66 KD, after a failed TTA. The primary outcome was reamputation and reoperation, and secondary outcomes were prosthetic fitting and mortality. Logistic regression analyses were performed to identify factors associated with the outcome. RESULTS: The reamputation rate was 36% after KD and 15% after TFA ( p = 0.004). The multivariable analysis showed that TFA was associated with a significantly reduced risk of reamputation, odds ratio (OR) = 0.31 (95% confidence interval [95% CI], 0.1-0.7). The overall reoperation rate was 38% after KD and 22% after TFA ( p = 0.03). This reduction of risk for TFA was not significant in the multivariable analysis, OR = 0.49 (95% CI, 0.2-1.0). Prosthetic limb fitting was possible in 30% after KD and 19% after TFA ( p = 0.1). Previous amputation in the contralateral leg was the only factor associated with reduced ability for prosthetic fitting in the multivariable analysis, OR = 0.15 (95% CI, 0.03-0.7). Mortality at 30 d was 17% and 53% at 1 year. No independent factors affected 30-d mortality in the multivariable analysis. CONCLUSIONS: In this study, we found a significantly lower risk of reamputation after TFA compared with KD after a failed TTA. We consider TFA to be the reamputation level of choice, especially when there is a need of reducing risk of further reamputations.

Preoperative administration of local infiltration anaesthesia decreases perioperative blood loss during total knee arthroplasty - a randomised controlled trial.

PURPOSE: Local infiltration anaesthesia (LIA) consisting of ropivacaine, epinephrine and ketorolac administered at the end of surgery has become the gold standard for postoperative analgesia as it provides improved postoperative pain relief compared to other methods. The use of LIA has retrospectively been shown to be associated with decreased perioperative blood loss. However, no randomised controlled trials have examined the effect of of preoperative LIA on blood loss. This study aimed to compare pre- vs perioperative LIA during TKA surgery, with a primary outcome of perioperative blood loss. METHODS: The present study was performed as a prospective single-center randomised controlled trial. A total of 100 patients undergoing primary TKA between October 2016 and March 2018 were randomised to receive either pre- or perioperative LIA. Perioperative blood loss was measured, as well as pre- and postoperative haemoglobin levels. Postoperative pain was estimated at intervals approximately 24, 48 and 72 hours after surgery; analgesic drug consumption was recorded for each patient, as well as the total length of stay as an in-patient. RESULTS: Ninety six patients received either pre- or perioperative LIA as part of the intervention and control group respectively. Average blood loss was 39% lower in the intervention group at 130 ml vs 212 ml in the control group (p=0.002). No significant difference in haemoglobin drop, postoperative pain or length of hospital stay was found. CONCLUSIONS: Preoperative LIA resulted in a 39% decrease in perioperative blood loss during TKA surgery compared to perioperative administration while providing non-inferior postoperative pain relief.

Surgical repair of acute Achilles tendon ruptures: a follow-up of 639 consecutive cases.

BACKGROUND: Most studies on acute Achilles tendon rupture (AATR) and its treatment contain only a small number of patients, and due to selection criteria, older patients and those with comorbidities are typically excluded. Therefore, little is known about true complication rates in an unselected population reflecting the situation in an ordinary orthopedic department. METHOD: Patient files of 639 consecutive Achilles tendon repairs in 631 patients with AATR between February 1998 and December 2005 were reviewed, and all complications from the day of surgery until December 2011 were identified using the hospital's patient records and the Swedish national registry. RESULTS: Twenty-five (3.9%) re-operations were done, out of which 22 were due to a re-rupture. Fifty-one (8.6%) cases were of deep vein thrombosis (DVT), no difference between patients given versus patients not given thromboprophylaxis. Nineteen (3.0%) cases were of surgical site infection (SSI), all of which resolved upon oral antibiotics. CONCLUSIONS: Surgical repair of acute Achilles tendon rupture was associated with a low risk for re-operations, but the risk for deep vein thrombosis was considerable, despite the use of prophylaxis.

Postoperative Thromboprophylaxis With New Oral Anticoagulants is Superior to LMWH in Hip Arthroplasty Surgery: Findings from the Swedish Registry.

BACKGROUND: Although the use of thromboprophylaxis is well established, there is no consensus on the preferred thromboprophylaxis regimen after THA; large, population-based studies offer an opportunity to examine this problem in a robust way that can complement results from randomized trials. QUESTIONS/PURPOSES: Using data from a large national registry, we asked: (1) Is there any difference between low-molecular weight heparin (LMWH) and new oral anticoagulants in preventing symptomatic deep vein thrombosis (DVT) and pulmonary embolism (PE), after THA? (2) Are there any differences in safety parameters, such as bleeding, reoperations and mortality, between LMWH and new oral anticoagulants? METHODS: Between 2008 and 2012, 78,066 THAs were performed in Sweden. This study evaluated 32,663 (42%) of them, selected through the merger of several national registries. These patients underwent unilateral THA due to primary osteoarthritis. They had not experienced any venous thromboembolic events 5 years before the index operation and were not prescribed potent antithrombotic agents, of any type, in the 6 months before the index operation. Additionally, their postoperative thromboprophylaxis was confirmed in a national registry by purchase of prescribed medications. We divided the cohort into two groups: those patients who received new oral anticoagulants (5752, 18%) and those who received LMWH (26,881, 82%) as postoperative thromboprophylaxis. Our primary endpoints were the frequencies of symptomatic DVT and symptomatic PE within 3 months of surgery. Our secondary comparison was a between-group comparison of bleeding (by way of diagnostic coding), reoperation, and mortality within 3 months of surgery. Odds ratios (OR) are presented with 95% confidence intervals (CIs) as pooled results for the two groups after adjustment for duration of thromboprophylaxis (short or extended for at least 28 days), year of the index operation, Elixhauser comorbidity index, sex, age and previous treatment with platelet aggregation inhibitors. RESULTS: The risk of symptomatic DVT was lower in the group that received new oral anticoagulants than the group that received LMWH (0.3% versus 0.6%, OR, 0.47; 95% CI, 0.27-0.76; p = 0.026). The risk of symptomatic PE was lower in the group that received new oral anticoagulants than the group that received LMWH (0.1% versus 0.4%, OR, 0.36; 95% CI, 0.16-0.69; p = 0.005). There was no difference in the risk of bleeding (by way of diagnostic coding) (OR, 1.03; 95% CI, 0.82-1.28; p = 0.688), reoperation (OR, 1.02; 95% CI, 0.71-1.44; p = 0.860) or mortality (OR, 0.83; 95% CI, 0.31-1.88; p = 0.883) between groups. CONCLUSIONS: New oral anticoagulants were associated with a lower risk of symptomatic DVT and symptomatic PE in this large, registry study, and we observed no differences in the risk of bleeding, reoperation, or death between the groups. Although we were able to control for a number of potential confounding variables, we cannot ascertain the indications that drove the prescription decisions in this setting, and there were important between-group differences in terms of duration of thromboprophylaxis (new oral anticoagulants generally were used for a longer period of time after surgery). Future studies, preferably large randomized trials with pragmatic inclusion criteria, to analyze symptomatic DVT, symptomatic PE and death are needed to confirm or refute our findings. LEVEL OF EVIDENCE: Level III, therapeutic study.

Increased mortality among patients with diabetes following first-ever transfemoral amputation.

AIMS: Transfemoral amputation (TFA) is associated with a high postoperative mortality though it is unclear whether diabetes is associated with an increased mortality or not. The aim was to examine mortality at 1 week and 1 year after first-ever TFA with special reference to diabetes. METHODS: We included 162 first-ever TFAs from 1996 to 2012. Mortality data were collected with the use of the Swedish personal identification number. RESULTS: The median age was 85 years. Diabetes mellitus were present in 19% (n = 30) of the patients and 67% (n = 109) had cardiovascular disease. Mortality was significantly higher for patients with diabetes compared to patients without diabetes at 1 week (30% vs. 8%, p = 0.001) and at 1 year (80% vs. 57%, p = 0.02). This difference was significant in multivariable analysis. CONCLUSIONS: We conclude that postoperative mortality was high. The high mortality rate emphasizes the need for early and adequate evaluation of every patient́s overall condition and whether amputation is beneficial or not. Although further studies are needed to analyze the specific causes of early death in amputees and we suggest close monitoring of blood-sugar in patients with diabetes and early treatment of infections and cardiac events in all patients.

Is fast reversal and early surgery (within 24 h) in patients on warfarin medication with trochanteric hip fractures safe? A case-control study.

BACKGROUND: Hip fracture patients in general are elderly and they often have comorbidities that may necessitate anticoagulation treatment, such as warfarin. It has been emphasized that these patients benefit from surgery without delay to avoid complications and reduce mortality. This creates a challenge for patients on warfarin and especially for those with trochanteric or subtrochanteric hip fractures treated with intramedullary nailing, as this is associated with increased bleeding compared to other types of hip fractures and surgical methods. The aim of the study was to evaluate if early surgery (within 24 h) of trochanteric or subtrochanteric hip fractures using intramedullary nailing is safe in patients on warfarin treatment after fast reversal of the warfarin effect. METHODS: A retrospective case-control study including 198 patients: 99 warfarin patients and 99 patients without anticoagulants as a 1:1 ratio control group matched for age, gender and surgical implant. All patients were operated within 24 h with a cephalomedullary nail due to a trochanteric or subtrochanteric hip fracture. All patients on warfarin were reversed if necessary to INR ≤ 1.5 before surgery using vitamin K and/or four-factor prothrombin complex concentrate (PCC). Per- and postoperative data, transfusion rates, adverse events and mortality was compared. RESULTS: There were no significant differences in the calculated blood-loss, in-house adverse events or mortality (in-house, 30-day or 1-year) between the groups. There were no significant differences in the pre- or peroperative transfusions rates, but there was an increased rate of postoperative transfusions in the control group (p = 0.02). CONCLUSION: We found that surgical treatment with intramedullary nailing within 24 h of patients with trochanteric or subtrochanteric hip fractures on warfarin medication after reversing its effect to INR ≤ 1.5 using vitamin K and/or PCC is safe.

Patient claims in prosthetic hip infections: a comparison of nationwide incidence in Sweden and patient insurance data.

Background and purpose - Patients in Sweden are insured against avoidable patient injuries. Prosthetic joint infections (PJIs) resulting from intraoperative contamination are regarded as compensable by the Swedish public insurance system. According to the Patient Injury Act, healthcare personnel must inform patients about any injury resulting from treatment and the possibility of filing a claim. To analyze any under-reporting of claims and their outcome, we investigated patients' claims of PJI in a nationwide setting Patients and methods - The national cohort of PJI after primary total hip replacement, initially operated between 2005 and 2008, was established through cross-matching of registers and review of individual medical records. We analyzed 441 PJIs and the number of filed patients' claims, with regards to incidence, outcome, and any national, sex-linked or socioeconomic differences. Results - We identified 329/441 (75%) patients with PJIs as non-claimants. 96% of the filed claims were accepted. 64 (57%) of claimants sustained permanent disability. 2 factors were found to statistically significantly reduce the odds of filing claims: patient's age above 73 years and fracture as indication for surgery. There were no significant national, sex-linked, or socioeconomic differences. Interpretation - The incidence of patients' claims of PJI is low but claims are usually accepted when filed. Healthcare personnel should increase their knowledge of the Patient Injury Act to inform patients about possibilities of eligible compensation.

What Is the Influence of a Delay to Surgery >24 Hours on the Rate of Red Blood Cell Transfusion in Elderly Patients With Intertrochanteric or Subtrochanteric Hip Fractures Treated With Cephalomedullary Nails?

OBJECTIVES: To evaluate the influence of delay to surgery >24 hours on the rate of red blood cell transfusion in a selected population of hip fracture patients. DESIGN: Cohort study. SETTING: Tertiary care university hospital. PATIENTS: A consecutive series of 987 patients (714 females) with a mean age of 86.3 (range 50-106) years operated with an intramedullary nail due to an unstable intertrochanteric or subtrochanteric hip fracture. INTERVENTION: Patients operated with an intramedullary nail due to an unstable intertrochanteric or subtrochanteric hip fracture. MAIN OUTCOME MEASURES: Red blood cell transfusion rate, mortality, and postoperative length of stay were analyzed. Logistic regression analysis was used to adjust for anticoagulants, acetylsalicylic acid class, fracture type, preoperative hemoglobin (Hb) value, and time to surgery. Follow-up time was 1 year. RESULTS: There was an increased preoperative transfusion rate among patients delayed for more than 24 hours to surgery (22%), compared with those operated within 24 hours (6.1%) (P < 0.001). After adjusting for anticoagulants, acetylsalicylic acid class, fracture type, preoperative Hb value, and time to surgery, it was found that anticoagulants [relative risk (RR), 2.0; confidence interval (CI), 1.1-3.5] and surgery delayed for more than 24 hours (RR, 3.9; CI, 2.3-6.1) were significantly associated with an increased rate of preoperative transfusions, although an increasing preoperative Hb value was associated with a lower rate of transfusions (RR, 0.3; CI, 0.2-0.4). CONCLUSION: We found an increased rate of preoperative transfusions among patients with unstable intertrochanteric or subtrochanteric hip fractures operated with an intramedullary nail that were delayed for surgery more than 24 hours. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Prosthetic joint infection following hip fracture and degenerative hip disorder: a cohort study of three thousand, eight hundred and seven consecutive hip arthroplasties with a minimum follow-up of five years.

PURPOSE: Prosthetic joint infections (PJIs) occur on a regular basis and with an increasing incidence. Under reporting of complications to national registries and unreliable ICD-10 coding increases the risk of under estimating the true rate of PJIs after hip arthroplasty. Also, the microbiology and final outcome is less well described, especially for hip-fracture patients operated upon with primary and secondary fracture prostheses. Our aim was to analyse re-operation rate, outcome and microbiology of PJIs following hip arthroplasty in patients operated upon due to hip fractures and degenerative hip disorders. METHODS: This was a single-centre cohort study of 3807 consecutive hip arthroplasties performed between 1996 and 2005. The primary study outcome was to compare the incidence of PJIs. The secondary outcome was to analyse the microbiology and outcome of PJIs. RESULTS: We identified 62 PJIs: seven surgical-site PJIs were found in patients operated upon for a degenerative hip disorder, 22 [hazard ratio (HR) 4.3] were found in patients operated upon for a primary fracture and prosthesis and 25 (HR 6.1) in patients operated upon with a secondary fracture and prosthesis. Outcome treatment was unfavourable for hip fracture patients with a high rate of Girdlestone operation performed (22 of 27). Staphylococcal infections dominated in the fracture group, whereas polybacterial infections were more common in patients with degenerative hip disorder. CONCLUSIONS: Patients with a displaced femoral neck fracture treated primary or secondary with arthroplasties have a greater risk of PJIs and display worse outcomes compared with patients with a total hip replacement due to degenerative hip disorders.

Symptomatic venous thromboembolism and mortality in orthopaedic surgery - an observational study of 45 968 consecutive procedures.

BACKGROUND: Little information exists on the presentation of symptomatic venous thromboembolism (VTE) in orthopaedic surgery when a defined protocol for thromboprophylaxis is used. The objective with this study was to establish the VTE rate and mortality rate in orthopaedic surgery. METHODS: We performed a prospective, single centre observational cohort study of 45 968 consecutive procedures in 36 388 patients over a 10 year period. Follow-up was successful in 99.3%. The primary study outcome was the incidence of symptomatic deep vein thrombosis (DVT), symptomatic pulmonary embolism (PE) and mortality at 6 weeks, specified for different surgical procedures. The secondary outcome was to describe the DVT distribution in proximal and distal veins and the proportion of VTEs diagnosed after hospital discharge. For validation purposes, a retrospective review of VTEs diagnosed 7-12 weeks postoperatively was also performed. RESULTS: In total, 514 VTEs were diagnosed (1.1%; 95% CI: 1.10-1.14), the majority (84%) after hospital discharge (432 out of 514).With thromboprophylaxis, high incidence of VTE was found after internal fixation (IF) of pelvic fracture (12%; 95% CI: 5-26), knee replacement surgery (3.7%; 95% CI: 2.8-5.0), after internal fixation (IF) of proximal tibia fracture (3.8%; 95% CI: 2.3-6.3) and after IF of ankle fracture (3.6%; 95% CI: 2.9-4.4). Without thromboprophylaxis, high incidence of VTE was found after Achilles tendon repair (7.2%; 95% CI: 5.5-9.4). In total 1094 patients deceased (2.4%; 95% confidence interval (CI): 2.33- 2.44) within 6 weeks of surgery. Highest mortality was seen after lower limb amputation (16.3%, CI: 13.8-19.1) and after hip hemiarthroplasty due to hip fracture (9.6%, CI; 7.6-12.1). CONCLUSION: The overall incidence of VTE is low after orthopaedic surgery but our study highlights surgical procedures after which the risk for VTE remains high and improved thromboprophylaxis is needed.

Tourniquet time affects postoperative complications after knee arthroplasty.

PURPOSE: Pneumatic tourniquets are frequently used in knee arthroplasty surgery. However, there is a lack of evidence to define safe tourniquet time in lower limb surgery. The primary aim of this study was to investigate whether tourniquet time influences the risk of postoperative complications after primary and secondary knee arthroplasty. METHODS: This study was a prospective register study. Since we wanted dispersion in tourniquet time, we included a consecutive series of 577 primary knee arthroplasties, 46 revision knee arthroplasties, and 18 patellar supplementing knee arthroplasties from a clinical audit database over a period of five years. The following postoperative complications were recorded: superficial wound infections, deep wound infections, deep vein thrombosis, pulmonary embolism, nerve injuries, compartment syndrome, cuff pressure injuries, and bandage injuries. RESULTS: Tourniquet time over 100 minutes was associated with an increased risk of complications after knee arthroplasty surgery (OR 2.2, CI 1.5-3.1). This increase in risk remained after adjusting for cuff pressure, sex, age, American Society of Anesthesiologists (ASA) classification, smoking, diabetes, and surgery indication (OR 2.4, CI 1.6-3.6). CONCLUSIONS: Tourniquet time over 100 minutes increases the risk of complications after knee arthroplasty surgery and special attention is advocated to reduce the tourniquet time.

Internal fixation of garden I and II femoral neck fractures: posterior tilt did not influence the reoperation rate in 382 consecutive hips followed for a minimum of 5 years.

OBJECTIVE: To analyze factors influencing the reoperation rate due to fracture healing complications after internal fixation of Garden I and II femoral neck fractures with special reference to a new validated method assessing the preoperative posterior tilt on lateral radiographs. DESIGN: Prospective cohort study. SETTING: Level II trauma center. PATIENTS: A consecutive cohort of 382 hips in 379 patients who underwent internal fixation for a Garden I or II femoral neck fracture. INTERVENTION: The posterior tilt in preoperative radiographs was analyzed with a new validated method. A Cox regression analysis was used to evaluate factors associated with reoperation due to fracture healing complications. Age, gender, cognitive function, ASA classification, time to surgery, and the posterior tilt were tested as independent factors in the model. MAIN OUTCOME MEASURES: Reoperation rate due to fracture healing complications with a minimal follow-up of 5 years. Reoperation data were validated against the National Board of Health and Welfare's national registry using unique Swedish personal identification numbers. RESULTS: The overall reoperation rate was 19% (72 of 382 hips) and the reoperation rate due to fracture healing complications was 12% (45 of 382 hips). The posterior tilt had no influence on the risk for reoperation due to fracture healing complication, nor had the age, gender, cognitive function, ASA classification, or the time to surgery. CONCLUSIONS: Preoperative posterior tilt measurement on lateral radiographs cannot be used as a discriminator for fracture healing complications in Garden I and II femoral neck fractures. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

The vertical hip fracture - a treatment challenge. A cohort study with an up to 9 year follow-up of 137 consecutive hips treated with sliding hip screw and antirotation screw.

BACKGROUND: Femoral neck fractures with a vertical orientation have been associated with an increased risk for failure as they are both axial and rotational unstable and experience increased shear forces compared to the conventional and more horizontally oriented femoral neck fractures. The purpose of this study was to analyse outcome and risk factors for reoperation of these uncommon fractures. METHODS: A cohort study with a consecutive series of 137 hips suffering from a vertical hip fracture, treated with one method: a sliding hips screw with plate and an antirotation screw. Median follow-up time was 4.8 years. Reoperation data was validated against the National Board of Health and Welfare's national registry using the unique Swedish personal identification number. RESULTS: The total reoperation rate was 18%. After multivariable Logistic regression analysis adjusting for possible confounding factors there was an increased risk for reoperation for displaced fractures (22%) compared to undisplaced fractures (3%), and for fractures with poor implant position (38%) compared to fractures with adequate implant position (15%). CONCLUSIONS: The reoperation rate was high, and special attention should be given to achieve an appropriate position of the implant.

Hip arthroplasty after failed fixation of trochanteric and subtrochanteric fractures.

BACKGROUND AND PURPOSE: Hip arthroplasty is an option for elderly patients with osteoporosis for the treatment of failure after fixation of trochanteric and subtrochanteric fractures, either as a total hip arthroplasty (THA) or as a hemiarthroplasty (HA). We analyzed the reoperation rate and risk factors for reoperation in a consecutive series of patients. METHODS: All patients (n = 88) operated from 1999 to 2006 with a THA (n = 63) or an HA (n = 25) due to failure of fixation of a trochanteric fracture (n = 63) or subtrochanteric fracture (n = 25) were included. Background data were collected from the patient records. A search was performed in the national registry of the Swedish National Board of Health and Welfare in order to find information on all reoperations. The follow-up time was 5-11 years. RESULTS: The reoperation rate was 16% (14/88 hips). A periprosthetic fracture occurred in 6 patients, a deep prosthetic infection in 5 patients, and a dislocation of the prosthesis in 3 patients. Standard-length femoral stems had an increased risk of reoperation (11/47) compared to long stems (3/41) (HR = 4, 95% CI: 1.0-13; p = 0.06). INTERPRETATION: The high reoperation rate reflects the complexity of the surgery. Using long femoral stems that bridge previous holes and defects may be one way to reduce the risk for reoperation.

Medial Achilles tendon island flap--a novel technique to treat reruptures and neglected ruptures of the Achilles tendon.

PURPOSE: There is a strong consensus for surgical treatment of reruptures and neglected ruptures of the Achilles tendon. A number of different surgical techniques have been described and several of these methods include extensive surgical exposure to the calf and technically demanding tendon transfers. The overall risk of complications is high and in particular the risk for wound healing problems, which are triggered by an increased tension in the skin when inserting a bulky graft to cover the rupture. In order to reduce the risk for wound healing problems a new, less complicated surgical technique was developed, as described in this study. METHODS: Nine consecutive patients (including six chronic ruptures and three reruptures) with complicating co-morbidities and with a tendon defect between three and eight centimetres were operated upon using the described novel technique. Patient-reported functional outcome was reported after two to eight years. RESULTS: All tendon defects were successfully repaired. Neither early nor late surgical complications occurred. High patient satisfaction was reported for all patients. CONCLUSIONS: The new surgical technique with a medial Achilles tendon island flap seems to be safe and results in a good patient reported outcome.

Unipolar versus bipolar Exeter hip hemiarthroplasty: a prospective cohort study on 830 consecutive hips in patients with femoral neck fractures.

BACKGROUND: Hip replacement using a hemiarthroplasty (HA) is a common surgical procedure in elderly patients with fractures of the femoral neck. Data from the Swedish Hip Arthroplasty Register suggest that there is a higher risk for revision surgery with the bipolar HA compared with the unipolar HA. PURPOSE: In this study we analysed the reoperation and the dislocation rates for Exeter HAs in patients with a displaced femoral neck fracture, comparing the unipolar and bipolar prosthetic designs. Additionally, we compared the outcome for HAs performed as a primary intervention with those performed secondary to failed internal fixation. METHODS: We studied 830 consecutive Exeter HAs (427 unipolar and 403 bipolar) performed either as a primary operation for a displaced fracture of the femoral neck or as a secondary procedure after failed internal fixation of a fracture of the femoral neck. Cox regression analyses were performed to evaluate factors associated with reoperation and prosthetic dislocation. Age, gender, the surgeon's experience, indication for surgery (primary or secondary) and type of HA (unipolar or bipolar) were tested as independent variables in the model. RESULTS: The prosthetic design (uni- or bipolar) had no influence on the risk for reoperation or dislocation, nor had the age, gender or the surgeon's experience. The secondary HAs were associated with a significantly increased risk for reoperation (HR 2.6, CI 1.5-4.5) or dislocation (HR 3.3, CI 1.4-7.3) compared to the primary HAs. We found no difference in the risk for reoperation or dislocation when comparing Exeter unipolar and bipolar HAs, but special attention is called for to reduce the risk of prosthesis dislocation and reoperation after a secondary HA.

A follow-up study of the fate of small asymptomatic deep venous thromboses.

BACKGROUND: Postoperative asymptomatic deep venous thromboses (ADVT) can give rise to posttthrombotic syndrome (PTS), but there are still many unresolved issues in this context. For example, there is a lack of knowledge regarding the fate of small ADVT following minor orthopedic surgery. This follow-up study evaluates postthrombotic changes and clinical manifestations of PTS in a group of patients with asymptomatic calf vein DVT after surgery for Achilles tendon rupture. METHODS: Forty-six consecutive patients with distal ADVT were contacted and enrolled in a follow-up consisting of a single visit at the hospital at a mean time of 5 years postoperatively, including clinical examination and scoring, ultrasonography and venous plethysmography. All patients had participated in DVT-screening with colour duplex ultrasound (CDU) 3 and 6 weeks postoperatively and 80% of them were treated with anticoagulation. RESULTS: With CDU postthrombotic changes and deep venous reflux were detected at follow-up in more than 50% of the patients, more commonly in somewhat larger calf DVT:s initially affecting more than one vessel. However, only about 10% of the patients had significant venous reflux according to venous plethysmography. No patient had plethysmographic evidence of remaining outflow obstruction, but presence of postthrombotic changes shown with CDU negatively influenced venous outflow capacity measured with plethysmography. A clinical entity of PTS was rarely found and occurred only in two patients (4%) and then classified by Villalta scoring as of mild degree with few clinical signs of disease. Distal ADVT:s detected in the early postoperative period (3 weeks) showed DVT-progression in 75% of the limbs that were still immobilized and without anticoagulation. CONCLUSIONS: Asymptomatic postoperative distal DVT:s following surgery for Achilles tendon rupture have a good prognosis and a favourable clinical outcome. In our material of 46 patients the general appearance of the clinical entity of PTS at 5 years follow-up was low (<5%). Morphological and functional abnormalities were mainly seen in those patients that initially had somewhat larger distal DVT:s involving more than one deep calf vein segment.

Direction of hip arthroplasty dislocation in patients with femoral neck fractures.

In order to prevent hip arthroplasty dislocations, information regarding the direction of the dislocation is important for accurate implant positioning and for optimising the postoperative regimens in relation to the surgical approach used. The aim of this study was to analyse the influence of the surgical approach on the direction of the dislocation in patients treated by a hemiarthroplasty (HA) or total hip arthroplasty (THA) after a femoral neck fracture. Fracture patients have a high risk for dislocations, and this issue has not been previously studied in a selected group of patients with a femoral neck fracture. We analysed the radiographs of the primary dislocation in 74 patients who had sustained a dislocation of their HA (n = 42) or THA (n = 32). In 42 patients an anterolateral (AL) surgical approach was used and in 32 a posterolateral (PL). The surgical approach significantly influenced the direction of dislocation in patients treated with HA (p < 0.001), while no such correlation was found after THA (p = 0.388). For THA patients there was a correlation between the mean angle of anteversion of the acetabular component and the direction of dislocation when comparing patients with anterior and posterior dislocations (p = 0.027). These results suggest that the surgical approach of a HA has an influence on the direction of dislocation, in contrast to THA where the position of the acetabular component seems to be of importance for the direction of dislocation in patients with femoral neck fractures.

Dislocation of total hip replacement in patients with fractures of the femoral neck.

BACKGROUND: Total hip replacement is increasingly used in active, relatively healthy elderly patients with fractures of the femoral neck. Dislocation of the prosthesis is a severe complication, and there is still controversy regarding the optimal surgical approach and its influence on stability. We analyzed factors influencing the stability of the total hip replacement, paying special attention to the surgical approach. PATIENTS AND METHODS: We included 713 consecutive hips in a series of 698 patients (573 females) who had undergone a primary total hip replacement (n = 311) for a non-pathological, displaced femoral neck fracture (Garden III or IV) or a secondary total hip replacement (n = 402) due to a fracture-healing complication after a femoral neck fracture. We used Cox regression to evaluate factors associated with prosthetic dislocation after the operation. Age, sex, indication for surgery, the surgeon's experience, femoral head size, and surgical approach were tested as independent factors in the model. RESULTS: The overall dislocation rate was 6%. The anterolateral surgical approach was associated with a lower risk of dislocation than the posterolateral approach with or without posterior repair (2%, 12%, and 14%, respectively (p < 0.001)). The posterolateral approach was the only factor associated with a significantly increased risk of dislocation, with a hazards ratio (HR) of 6 (2-14) for the posterolateral approach with posterior repair and of 6 (2-16) without posterior repair. INTERPRETATION: In order to minimize the risk of dislocation, we recommend the use of the anterolateral approach for total hip replacement in patients with femoral neck fractures.