Topical tranexamic acid reduces transfusion rates in total hip and knee arthroplasty.

The efficaciousness of topical tranexamic acid use at the end of knee arthroplasty surgery to reduce blood loss and transfusion requirements has previously been shown. The aim of this study was to retrospectively assess the effectiveness of topical tranexamic acid use, comparing 155 patients undergoing hip and knee arthroplasty surgery in which tranexamic acid was routinely used, to a group of 149 patients from a similar time frame prior to the introduction of tranexamic acid use. The transfusion rate fell from 19.3% to 2.3% for hip arthroplasty patients and from 13.1% to 0% for knee arthroplasty patients; these differences were significant. We also found significant reductions in haemoglobin loss, blood loss and length of stay of 8 g/L, 244 mL and 1.0 days respectively for hip arthroplasties and 15 g/L, 527 mL and 1.2 days respectively for knee arthroplasties following the introduction of tranexamic acid.

A comparison of complications requiring return to theatre in hip and knee arthroplasty patients taking enoxaparin versus rivaroxaban for thromboprophylaxis.

BACKGROUND: There is no consensus on the optimal form of venous thromboembolic prophylaxis treatment in hip and knee arthroplasty patients, or on the safety and complication profile of the available chemical prophylaxis modalities. In this study we aimed to measure the return to theatre rate for any cause related to wound complications in patients undergoing total hip replacement and total knee replacement, and compare these rates between patients on oral Rivaroxaban 10mg OD and subcutaneous Enoxaparin 40mg OD in our department. MATERIAL AND METHODS: There were a total of 387 patients included in the study; 227 patients in group 1, who received Enoxaparin 40mg OD, and 160 patients in group 2, who received Rivaroxaban 10mg OD. RESULTS: The primary outcome measure was re-operation rate due to wound complications. Secondary outcome measures were infection rate, incidence of deep vein thrombosis, pulmonary emboli, duration of hospital stay, change in haemoglobin and haematocrit and blood transfusion rate. In this retrospective cohort study we found that patients who received Rivaroxaban were more than twice as likely to return to theatre for wound complications compared to patients receiving Enoxaparin. Although not statistically significant, this increase is in line with previous studies. Infection rates increased from 0.9% to 1.9% after the introduction of Rivaroxaban and microbiologically confirmed superficial infections rose from 1.3% to 3.1% after Rivaroxaban was introduced in our unit. These rises were not statistically significant. CONCLUSION: Our study highlights the need for large randomised controlled trials to assess post-operative complications following the introduction of Rivaroxaban for post-arthroplasty thromboprophylaxis.

The effect of 4 mm bicortical drill hole defect on bone strength in a pig femur model.

INTRODUCTION: In orthopaedic surgery, small bicortical circular bone defects are often produced as a result of internal fixation of fractures. The aim of this study was to determine the amount of torsional strength reduction in animal bone with a bicortical bone defect and how much residual strength remains if the bicortical bone defect was occluded. METHOD: Forty pig femurs were divided into four groups. Group 1 femurs were left intact. Group 2 femurs were given a 4 mm bicortical bone defect. Group 3 were prepared as in Group 2, but occluded with a 4.5 mm cortical screw. Group 4 were prepared as in Group 2, but occluded with plaster of paris. Measurements including the length of the bone, working length of the bone, mid-diaphyseal diameter and cortical thickness were recorded. All specimens were tested until failure under torsional loading. Peak torque at failure and angular deformation were recorded. One-way analysis of variance was used to test the sample groups, with a value of P < 0.05 considered to be statistically significant. RESULTS: When compared with Group 1, all of the other groups showed a reduction in peak torque at failure point. Only the difference in peak torque between Groups 1 and 2 was statistically significant (P = 0.007). Group 2 showed the most reduction with 23.11% reduction in peak torque and 38.19% reduction in total energy absorption. No significant difference was found comparing the bone length, bone diameter and the cortical thickness. CONCLUSION: The presence of the defect remains the major contributing factor in long bone strength reduction. It has been shown that a 10% bicortical defect was sufficient to produce a reduction in peak torque and energy absorption under torsional loading. By occluding this defect using a screw or plaster of paris, an improvement in bone strength was achieved. These results may translate clinically to an increased vulnerability to functional loads immediately following screw removal and prior to the residual screw holes healing.

Coeliac disease presenting with bilateral fibular stress fractures.

We present the case of an apparently healthy 22-year-old female who presented with atraumatic stress fractures of both fibulae. Further investigation demonstrated that she had osteopoenia secondary to occult coeliac disease. The fractures were successfully treated non-operatively. The awareness of the prevalence of occult coeliac disease is increasing due to simpler diagnostic tests, as is its significance as a cause of secondary osteoporosis. Knowing the relationship between these two conditions will help orthopaedic surgeons treating such patients to refer them promptly to appropriate specialists.

Acute versus gradual correction of idiopathic tibia vara in children: a systematic review.

BACKGROUND: Idiopathic tibia vara (Blount disease) is an acquired form of tibial deformity found mainly in children who are Afro-Caribbean and obese. It is uncommon. Several methods have been described for the surgical treatment of this condition, which can be categorized as either acute or gradual correction. The aim of this study is to review the evidence comparing the outcome of acute versus gradual correction of childhood tibia vara using accuracy of reduction as the primary outcome measure. METHODS: A systematic search was made of the literature across multiple databases to find all studies describing acute or gradual correction of this condition that reported radiographic correction as an outcome measure. RESULTS: One retrospective comparative series was found that provided weak evidence of an improvement in mechanical axis deviation using gradual correction with a Taylor Spatial Frame compared with acute correction. Seventeen other case series were found, from which, there was no evidence of an advantage for either form of treatment. CONCLUSIONS: There is very little evidence to recommend one form of correction over the other. LEVEL OF EVIDENCE: Systematic review of case series (level IV).

Lengthening of the first metatarsal through an arthrodesis site for treatment of brachymetatarsia: a case report.

Brachymetatarsia of the first metatarsal is an uncommon condition, but one that is amenable to treatment by lengthening via distraction osteogenesis, a process that employs 2 groups of pins of an appropriate external fixator inserted in the metatarsal to apply gradual distraction across an intervening osteotomy. We present the case of a female, aged 13 years, who presented with congenital bilateral first brachymetatarsia and left foot pain due to transfer metatarsalgia. The short and plantarflexed first ray could not accommodate both groups of fixator pins, even with the fixator set at its shortest length. An alternative strategy was devised that reduced the degree of plantarflexion using a tarsometatarsal arthrodesis, which effected subsequent lengthening through the healing fusion site. Lengthening commenced after 10 days and continued over a period of 52 days, at a rate of 0.5 mm to 1.0 mm per day. Consolidation occurred at 20 weeks with a final increase in length of 25 mm. The patient returned to vigorous sporting activity 1 year after removal of the fixator. To our knowledge, this is the first account of a metatarsal-lengthening arthrodesis at the tarsometatarsal level.