Tourniquet and tranexamic acid use in total knee arthroplasty.

BACKGROUND: There is no consensus on how tourniquet and tranexamic acid (TXA) use in total knee arthroplasty (TKA) affect blood transfusion rates and total blood loss. We compared outcome measures and transfusion rates after TKA, with and without the use of tourniquet and TXA. METHODS: A retrospective study of 477 consecutive patients undergoing primary TKA between 2008 and 2013 was performed. There were 243 in the tourniquet-assisted (TA) and 234 in the tourniquet-unassisted (TU) group. Operative times, hemoglobin levels, blood transfusion rates, complications, and length of stay were assessed. Subanalysis was performed on those patients receiving and not receiving TXA within the TU group. RESULTS: Mean operative duration was 66.4 minutes in the TA group and 87.5 minutes in the TU group (P < .0001). Mean postoperative drop in hemoglobin was greater in TU group (3.1 g/dL vs 2.8 g/dL, P = .002). The transfusion rate was 9.5% in TA compared with 11.5% in TU patients (P = .46) with comparable mean units transfused (2.6 vs 2.2, P = .30). There was no difference in wound infection (P = .82) and total complication rates (P = .27) between groups. Those patients given TXA had a lower hemoglobin drop (2.6 g/dL vs 3.3 g/dL, P = .04) with similar transfusion (13.3% vs 11%, P = .61) and complication (P = .95) rates. CONCLUSIONS: TU TKA had a greater operative duration and postoperative drop in hemoglobin than TA TKA. However, transfusion rates were similar between groups. TXA use reduced the operative decrease in hemoglobin with no effect on complication or transfusion rates. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Independent assessment and outcomes of 196 short-tapered stems short-term follow-up and review of the literature.

BACKGROUND:: Longer term outcome data are now becoming available for short-tapered femoral stems for cementless total hip arthroplasty. The shorter stem has a metaphyseal fit, loading the bone in this area, leading to physiological bone remodelling. It is also bone preserving, as it is 35 mm shorter. It may be easier to insert through a smaller incision and potentially reduce complication rates. We present a retrospective single surgeon case series of 196 patients (>53% follow-up over 5 years). All patients had the cementless 'Microplasty Taperloc' (Biomet). Primary outcome measures were femoral component revision rates. Secondary outcome measures included complications, patient-reported functional outcome scores (Oxford hip) and radiographic evidence of loosening. METHODS:: Patients were identified using electronic software. All were routinely followed up and assessed in clinic since implant introduction in 2009. Oxford hip scores were routinely obtained. A surgeon who had not carried out the procedure independently assessed radiographs. RESULTS:: One hundred ninety-six patients were identified. The revision rate was 0.5% due to an intraoperative peri-prosthetic fracture of the femur identified on post-operative radiograph. The complication rate was 2%, attributable to: subsidence of the prosthesis (one hip), post-operative dislocation (two hips), one of which required acetabular revision. Oxford hip scores increased on average from 21 to 45 (pre- to post-operatively). There were no signs of radiographic loosening. CONCLUSION:: The results show that using the short-tapered stem is proving so far to be a reliable and safe alternative to its longer counterpart, with low complication rates in the short term.

Tightrope fixation of syndesmotic injuries in Weber C ankle fractures: a multicentre case series.

BACKGROUND: No general consensus has yet been established for the gold standard treatment of ankle syndesmotic complex injuries. Recent literature has documented the success of ankle tightrope fixation for heterogeneous ankle fracture patterns, resulting in syndesmotic complex injuries. We present a multicentre case series assessing the clinical, radiological and functional outcomes of patients with Weber C ankle fractures treated with the Arthrex TightRope® fixation system. METHOD: We performed a retrospective analysis of all adult patients with Weber C ankle fractures who were treated with the Arthrex TightRope® fixation system at four centres over a 3-year period. All patients were followed up for a mean of 14 months (range 12-26). Outcomes measures were assessed subjectively using functional scores (AOFAS and Olerud and Molander) and objectively using radiological measurements, complication rates and revision surgery rates. RESULTS: Thirty-six patients met our eligibility criteria. The mean age at operation was 31 years (range 18-65). There were 20 males and 16 females. No patients were lost to follow-up. The ankle tightrope maintained satisfactory reduction in the ankle mortise in 97% of cases. Of these 35 successfully treated cases, no evidence of re-displacement on follow-up radiographs of the syndesmotic complex was observed at an average of 10.8 months (range 6-12). Post-operative mean medial clear space was 3.1 mm, and mean tibio-fibular overlap was 10.1 mm. The mean American Orthopaedic Foot and Ankle Society (AOFAS) score was 88.8 (range 67-98) at a mean follow-up of 14 months (range 12-26). The overall complication rate was 6% (one failure requiring revision surgery and one medial sided skin irritation requiring removal of suture button). No infections or wound complications occurred. CONCLUSION: Tightrope fixation is a safe alternative to screw fixation for syndesmotic complex injuries in Weber C ankle fractures. We have shown that it has low complication rates and a high patient satisfaction.

A national survey of UK health libraries investigating the cost of interlibrary loan services and assessing the accessibility to key orthopaedic journals.

BACKGROUND: NHS Library Services are utilised by NHS staff and junior trainees to locate scientific papers that provide them with the evidence base required for modern medical practice. The cost of accessing articles can be considerable particularly for junior trainees. OBJECTIVES: This survey looks at variations in cost of journal article loans and investigates access to particular orthopaedic journals across the country. METHODS: A national survey of UK Health Libraries was performed. Access to and costs of journals and interlibrary loan services were assessed. Availability of five wide-reaching orthopaedic journals was investigated. RESULTS: Seven hundred and ten libraries were identified. One hundred and ten libraries completed the questionnaire (16.7%). Of these, 96.2% reported free access to scientific journals for users. 99.1% of libraries used interlibrary loan services with 38.2% passing costs on to the user at an average of £2.99 per article. 72.7% of libraries supported orthopaedic services. Journal of Bone and Joint Surgery (British) had greatest onsite availability. CONCLUSIONS: The study demonstrates fluctuations in cost of access to interlibrary loan services and variation in access to important orthopaedic journals. It provides a reflection of current policy of charging for the acquisition of medical evidence by libraries in the UK.

The effect of femoral stem length on duration of hospital stay.

Length of post-operative stay is an important factor in improving cost-effectiveness of total hip arthroplasty (THA). Short stem femoral components may reduce soft tissue and bone damage, permitting earlier mobilization and earlier safe discharge from hospital. This study compares the length of stay of patients undergoing THA using a short stem femoral component compared to an age matched group undergoing standard THA. The mean age in the standard stem group was 52.7 years and 50.4 years in the short femoral stem group (p=0.57). Total theatre time, blood loss and post-operative Oxford hip scores in the groups were not statistically different (p=0.11, p=0.91, p=0.16). Mean post-operative stay for the short stem group was shorter (3 vs 5 days, p=0.010), resulting in 10% cost saving per patient episode.

Approaching the ruptured anterior cruciate ligament.

Anterior cruciate ligament (ACL) disruptions are common injuries that currently hold a fearsome reputation among athletes of all abilities and disciplines. Indeed, if the diagnosis is missed at first presentation, it is difficult to attribute ongoing instability and recurrent injury to an ACL tear. Classically, patients then often improve shortly before repeatedly reinjuring their knee. At some point, the knee may lock, necessitating an arthroscopic meniscectomy. Tragically, this then hastens the progression of joint arthrosis and the decline of the joint function. While the burden of responsibility does not lie solely with the junior doctor or the general practitioner, it is often at the first consultation that the natural history of this devastating injury is decided. The ability to recognise, institute early management and reassure patients with ACL tears about the future is an invaluable asset to the non-specialist junior doctor. Once diagnosed, the responsibility of advising and further counselling of patients with ACL injuries is best left to the orthopaedic knee specialist. Family practitioners and emergency room doctors should not feel pressured to offer advice on specialist areas such as return to sports without reconstruction or indeed the need for reconstruction. Indeed, decisions to return to sports with ACL-deficient knees have all too often led to disastrous reinjury events to the articular cartilage and/or the menisci.