Comparison of Surgical Site Infection Risk Between Warfarin, LMWH, and Aspirin for Venous Thromboprophylaxis in TKA or THA: A Systematic Review and Meta-Analysis.

BACKGROUND: Infection following arthroplasty can have devastating effects for the patient and necessitate further surgery. Venous thromboembolism (VTE) prophylaxis is required to minimize the risk of deep venous thrombosis and pulmonary embolism. Anticoagulation has been demonstrated to interfere with wound-healing and increase the risk of infection. We hypothesized that different anticoagulation regimes will have differing effects on rates of periprosthetic joint infection. The aim of this study was to compare the surgical site infection risk between the use of warfarin, low-molecular-weight heparin (LMWH), and aspirin for VTE prophylaxis following total knee or hip arthroplasty. METHODS: A systematic literature search was conducted in November 2018 using the PubMed, CINAHL, and Cochrane Central Register of Controlled Trials (CENTRAL) databases to identify studies that compared warfarin, LMWH, and/or aspirin with regard to surgical site infection rates following hip or knee arthroplasty. Meta-analyses were performed to compare the infection and VTE risks between groups. RESULTS: Nine articles involving 184,037 patients met the inclusion criteria. Meta-analysis showed that warfarin prophylaxis was associated with a higher risk of deep infection (or infection requiring reoperation) (odds ratio [OR] = 1.929, 95% confidence interval [CI] = 1.197 to 3.109, p = 0.007) and surgical site infection overall (OR = 1.610, 95% CI = 1.028 to 2.522, p = 0.038) compared with aspirin in primary total joint arthroplasty, with similar findings also seen when primary and revision procedures were combined. There was no significant difference in infection risk between warfarin and LMWH and between LMWH and aspirin. There was a nonsignificant trend for VTE risk to be higher with warfarin compared with aspirin therapy for primary procedures (OR = 1.600, 95% CI = 0.875 to 2.926, p = 0.127), and this was significant when both primary and revision cases were included (OR = 2.674, 95% CI = 1.143 to 6.255, p = 0.023). CONCLUSIONS: These findings caution against the use of warfarin for VTE prophylaxis for hip and knee arthroplasty. Further randomized head-to-head trials and mechanistic studies are warranted to determine how specific anticoagulants impact infection risk. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Interobserver and intraobserver variations in radial head fracture classification-assessment of two classification systems.

OBJECTIVE: The aim of this study was to evaluate the intra- and interobserver variation of two classification systems for radial head fractures (Mason and Charalambous classifications) using plain radiographs. MATERIAL AND METHODS: Five observers classified 30 radial head fractures as per the two classifications using anteroposterior and lateral elbow radiographs. Assessments were done on two occasions, at least 6 weeks apart. RESULTS: The interobserver and intraobserver variation of the Mason classification showed fair (mean kappa = 0.33) and moderate agreement (mean kappa = 0.43) respectively. The interobserver and intraobserver variation of the Charalambous classification showed moderate agreement for both (mean kappa = 0.42 and 0.49 respectively). A greater proportion of radial head fractures could be classified using the Charalambous classification compared with the Mason classification (P < 0.001). With the Charalambous classification, the inter-observer variation was better when assessing fracture morphology (4 morphology groups) versus fracture displacement (2 displaced/un-displaced groups) (p = 0.010). CONCLUSIONS: The Mason and Charalambous classifications for radial head fractures confer similar reliability when using plain radiographs, but the latter allows a greater proportion of fractures to be classified. Raters may agree more on fracture morphology as compared to fracture displacement. Our findings also demonstrate the limitations of using plain radiographs in classifying radial head fractures for clinical or research purposes, and suggest that evaluation with more sensitive modalities such as Computed Tomography may be preferable.

Quality of life after amputation in patients with advanced complex regional pain syndrome: a systematic review.

The majority of included studies (8 out of 11, n = 54) supported the concept of considering amputation for selected, unresponsive cases of complex regional pain syndrome (CRPS) as a justifiable alternative to an unsuccessful multimodality nonoperative option.Of patients who underwent amputation, 66% experienced improvement in quality of life (QOL) and 37% were able to use a prosthesis, 16% had an obvious decline in QOL and for 12% of patients, no clear details were given, although it was suggested by authors that these patients also encountered deterioration after amputation.Complications of phantom limb pain, recurrence of CRPS and stump pain were predominant risks and were noticed in 65%, 45% and 30% of cases after amputation, respectively and two-thirds of patients were satisfied.Amputation can be considered by clinicians and patients as an option to improve QOL and to relieve agonizing, excruciating pain of severe, resistant CRPS at a specialized centre after multidisclipinary involvement but it must be acknowledged that evidence is limited, and the there are risks of aggravating or recurrence of CRPS, phantom pain and unpredictable consequences of rehabilitation.Amputation, if considered for resistant CRPS, should be carried out at specialist centres and after MDT involvement before and after surgery. It should only be considered if requested by patients with poor quality of life who have failed to improve after multiple treatment modalities.Further high quality and comprehensive research is needed to understand the severe form of CRPS which behaves differently form less severe stages. Cite this article: EFORT Open Rev 2019;4:533-540. DOI: 10.1302/2058-5241.4.190008.

Diabetes mellitus does not increase the risk of knee stiffness after total knee arthroplasty: a meta-analysis of 7 studies including 246 053 cases.

PURPOSE: The association of diabetes mellitus with knee stiffness after total knee arthroplasty is still being debated. The aim of this study was to assess through meta-analysis the impact of diabetes mellitus on the prevalence of postoperative knee stiffness after total knee arthroplasty. METHODS: We conducted a literature search for terms regarding postoperative knee stiffness and diabetes mellitus on Embase, CINAHL, and PubMed NCBI. RESULTS: Of 1142 articles, seven were suitable for analysis. Meta-analysis showed that diabetes mellitus does not confer an increased risk of primary or revision total knee arthroplasty-induced postoperative knee stiffness when compared to nondiabetic patients (primary total knee arthroplasty, estimated odds ratio [OR] 1.474 and 95% confidence interval [CI] 0.97-2.23; primary and revision total knee arthroplasty, OR 1.340 and 95% CI 0.97-1.83). CONCLUSION: There is no strong evidence that diabetes mellitus increases the risk of knee stiffness after total knee arthroplasty. The decision to proceed with total knee arthroplasty, discussion as part of the consent process, and subsequent rehabilitation should not differ between patients with and without diabetes mellitus with regards to risk of stiffness. LEVEL OF EVIDENCE: Level III (meta-analysis).