Joint Procedures Research Articles

Security Enhancement of Joint Procedure Based on Improved Elliptic Curve Cryptography in LoRaWAN

Security Enhancement of Joint Procedure Based on Improved Elliptic Curve Cryptography in LoRaWAN

Video atlas of each uniportal robotic-assisted thoracic surgery lobectomy and lymphadenectomy.

It is important when evaluating new techniques that a surgeon can see and assess all the differences and similarities between their usual technique and the novel technique. Thus, we have collated a comprehensive atlas of videos of uniportal robotic lobectomies for every lobe. Surgeons who are considering embarking on a program of uniportal robotic lobectomies can accordingly see the different views and techniques that will be required for when they perform their first procedure. We have fully narrated the videos, so that you will be taken through each procedure. Whilst these five videos are fifty-five minutes in total, our intention is not necessarily for you to watch them all from start to finish, but rather, come to this video, select the lobe that you will shortly embark on, and watch it prior to your case so that you can visualise, as closely as possible, the procedure that you will be performing. We recommend that you watch the videos with your bedside assistant as the uniportal robotic lobectomy is a joint procedure between two surgeons, rather than a single surgeon's operation with an assistant. Though we have not provided videos on segmentectomies, the uniportal robotic lobectomy is an advanced technique and we are confident that advanced surgeons will be able to gain key insights with what has been included, even if they are proceeding to a segmentectomy for their first cases. We feel for an advanced surgeon, a segmentectomy will be just as suitable an operation as a lobectomy in the initial learning phase.

The role of proximal tibial osteotomy in joint preservation

IntroductionTibial osteotomy has a role in various aspects of joint preservation. Proper diagnosis and addressing all aspects of alignment both for focal cartilage lesions to support restorative repair procedures as well as in treatment of earlier phases of knee osteoarthritis in well selected patients. Malalignment of the leg axis is known to result in chronic overloading and thus contributing to the development of focal lesions as well as osteoarthritis. ObjectivesTo provide a comprehensive summary of the current state of utilization of tibial osteotomies in conjunction with other joint preserving procedures and to synthesize the current scientific evidence for the use of osteotomies in the setting of cartilage injuries. MethodsPubMed, Medline, Cochrane Systematic Reviews, and Clinical Keys were searched by the first author (M.H.) to validate that all papers of relevance to the area studied were included. Databases were searched comprehensively, and original research, systematic reviews, and meta-analysis were included at the authors’ discretion. References of selected articles were analyzed manually. Data from selected publications focused on tibial osteotomy were summarized. ResultsLeg axis and patellofemoral alignment must be considered as important risk factors for failure of restorative cartilage procedures in the knee joint. Alignment-correcting osteotomies play a crucial role in enhancing clinical results of cartilage repair surgeries especially in the long-term. Through the redistribution of load, the biomechanical environment of the joint is optimized, and the induced or transplanted repair tissue is protected against overloading, facilitating enhanced tissue maturation. Recent evidence suggests that even small deviations from a neutral axis (<5°) should be corrected by osteotomy. Preoperative investigation of potential malalignment would therefore be beneficial in every patient who is considered for cartilage repair and joint preservation. ConclusionJoint preservation procedures profit from addressing alignment by proximal tibial osteotomy. Unloading osteotomies are of utmost importance to facilitate a joint environment in which these procedures can be carried out successfully, reliably contributing to the long-term durability of cartilage restoration.

Use of multidisciplinary positive deviance seminars to improve efficiency in a high-volume arthroplasty practice: a pilot study.

Positive deviance (PD) seminars, which have shown excellent results in improving the quality of surgical practices, use individual performance feedback to identify team members who outperform their peers; the strategies from those with exemplary performance are used to improve team members' practices. Our study aimed to use the PD approach with arthroplasty surgeons and nurses to identify multidisciplinary strategies and recommendations to improve operating room (OR) efficiency. We recruited 5 surgeons who performed high-volume primary arthroplasty and had participated in 4-joint rooms since 2012, and 29 nurses who had participated in 4-joint rooms and in at least 16 cases in our data set. Three 1-hour PD sessions were held in February and March 2021: 1 with surgeons, 1 with nurses, and 1 with both surgeons and nurses to select recommendations for implementation. The sessions were led by a member of the nonorthopedic surgical faculty who was familiar with the subjects discussed and with PD seminars. To determine the success of the recommendations, we compared OR efficiency before and after implementation. We defined success as performance of 4 joint procedures within 8 hours. Eleven recommendations were recorded from the session with nurses and 7 from the session with surgeons, of which 11 were selected for implementation. During the month after implementation, there were great improvements across all time intervals of surgical procedures, with the greatest improvements seen in mean anesthesia preparation time in the room (4.51 min [26.3%]), mean procedure duration (9.75 min [14.0%]) and mean anesthesia finish time (5.78 min [44.0%]) (all p < 0.001). The total time saved per day was 49.84 minutes; this led to a success rate of 69.0%, a relative increase of 73.8% from our 2012-2020 success rate of 39.7% (p < 0.001). The recommendations and increased motivation owing to the individualized feedback reduced time spent per case, allowing more days to finish on time. Positive deviance seminars offer an inexpensive, efficient and collegial means for process improvement in the OR.

Secondary surgeries after replantation

Although digit replantation techniques and indications have evolved over time, resulting in improved overall outcomes, achieving ideal functional recovery remains a challenge. Secondary surgeries for replanted digits can be divided temporally into early- (weeks to months) and late-stage (months to years) procedures, with skin-coverage procedures being the most common in the early period and tenolysis being the most common procedures in the late postoperative stage. This article reviews the most common procedures, including available literature on secondary replant procedures involving nerve, tendon, bone, joint, and skin procedures. However, further larger-scale studies are necessary to establish clear guidelines regarding both postoperative protocols and indications for secondary surgery.

Advancement in total hip implant: a comprehensive review of mechanics and performance parameters across diverse novelties.

The UK's National Joint Registry (NJR) and the American Joint Replacement Registry (AJRR) of 2022 revealed that total hip replacement (THR) is the most common orthopaedic joint procedure. The NJR also noted that 10-20% of hip implants require revision within 1 to 10 years. Most of these revisions are a result of aseptic loosening, dislocation, implant wear, implant fracture, and joint incompatibility, which are all caused by implant geometry disparity. The primary purpose of this review article is to analyze and evaluate the mechanics and performance factors of advancement in hip implants with novel geometries. The existing hip implants can be categorized based on two parts: the hip stem and the joint of the implant. Insufficient stress distribution from implants to the femur can cause stress shielding, bone loss, excessive micromotion, and ultimately, implant aseptic loosening due to inflammation. Researchers are designing hip implants with a porous lattice and functionally graded material (FGM) stems, femur resurfacing, short-stem, and collared stems, all aimed at achieving uniform stress distribution and promoting adequate bone remodeling. Designing hip implants with a porous lattice FGM structure requires maintaining stiffness, strength, isotropy, and bone development potential. Mechanical stability is still an issue with hip implants, femur resurfacing, collared stems, and short stems. Hip implants are being developed with a variety of joint geometries to decrease wear, improve an angular range of motion, and strengthen mechanical stability at the joint interface. Dual mobility and reverse femoral head-liner hip implants reduce the hip joint's dislocation limits. In addition, researchers reveal that femoral headliner joints with unidirectional motion have a lower wear rate than traditional ball-and-socket joints. Based on research findings and gaps, a hypothesis is formulated by the authors proposing a hip implant with a collared stem and porous lattice FGM structure to address stress shielding and micromotion issues. A hypothesis is also formulated by the authors suggesting that the utilization of a spiral or gear-shaped thread with a matched contact point at the tapered joint of a hip implant could be a viable option for reducing wear and enhancing stability. The literature analysis underscores substantial research opportunities in developing a hip implant joint that addresses both dislocation and increased wear rates. Finally, this review explores potential solutions to existing obstacles in developing a better hip implant system.

Decision to Preserving Ankle Joint Function in Neglected Neck Talus Fracture with Type 2 Diabetic Mellitus Patient : A Case Report

Talus fractures are rare injuries to the hindfoot that still challenging in treatment. The anastomotic ring is likely to be damaged in neck talus fractures, which disrupt the blood flow and cause significant problems affecting fracture healing. Poor fracture healing and an increased risk of surgical complications were also associated with complex diabetes mellitus. We follow the progress of the illness from a 47 year old female complaint pain on her left ankle after falling down 6 months before outpatient. Physical examination shows swelling and varus deformed on affected ankle. Ankle x-ray and CT scan were done. Patient diagnosed as neglected close fracture left neck talus Hawkins type IV with type 2 diabetes mellitus. Then patient undergo an ankle arthroscopy to evaluate ankle joint and preserving ankle joint procedure by subtalar arthrodesis and iliac bone graft. This procedure achieved an excellent result in preserve ankle aligment, stability and soft tissue management. After 2 weeks wound heals without signs of infection and 3 weeks of followup VAS score mention from 0 to 1, with good compliance of the patient. Arthroscopy is safe procedure obtaining anatomical joint surface and reduce tissue damage. While arthrodesis enhance blood supply to encourage bone union, though loss of its ankle motion also has significant effect on ambulation.

Surgical Treatment of Catamenial Chest Pain: Excision of diaphragmatic endometriosis during robot-assisted laparoscopic surgery.

10% of women of reproductive age are affected by endometriosis, and diaphragmatic endometriosis represents 1-1.5% of these cases. Diaphragmatic endometriotic lesions often require surgical treatment. This video aims to demonstrate the appearance of diaphragmatic endometriosis and describe our experience with robot-assisted laparoscopic excision of full thickness diaphragmatic endometriosis. The patient was a 37-year-old female with the complaint of cyclical right shoulder pain (for 1 year). She previously had caesarean section scar and umbilical endometriosis excision procedures. The magnetic resonance imaging (MRI) of the abdomen highlighted three endometriotic nodules, one of which was described as full thickness on the right hemi-diaphragm. The patient underwent a robot-assisted laparoscopic endometriosis surgery as a joint procedure between the gynaecology and general surgery teams. The falciform ligament was completely divided to obtain full views of the endometriotic lesions on the diaphragm. Superficial diaphragmatic lesions were first excised. The larger deep nodule, which was described on the MRI, was then excised with the full thickness of diaphragm. Pleural cavity was entered intentionally to achieve complete excision of the nodule. Laparoscopic assessment of the right lower pleural cavity through this opening did not show any endometriotic lesions. After the excision, the diaphragm was repaired with a barbed suture. Negative pressure suction of the pleural cavity was performed at the end of this repair instead of using a chest tube. The patient was discharged on the 3rd day with no complications encountered. Histopathological examination confirmed endometriosis. The patient was asymptomatic three months after surgery. Robotic-assisted surgery is an easy and safe choice especially in such challenging dual compartment surgeries by providing a 3D view that abolishes sensory loss and increases depth perception, providing better manoeuvrability with tremor absence.

Flexor Carpi Radialis Tendon Insertion Onto the Trapezial Ridge: An Anatomic Description

The flexor carpi radialis (FCR) tendon is often involved in surgical procedures of the hand and wrist. The FCR tendon may be mobilized from the trapezium during distal radius fracture fixation, for tendon transfer, and during carpometacarpal joint procedures. There is a paucity of literature describing the anatomy of the FCR insertion onto the trapezial ridge. We analyzed the insertional characteristics of the FCR onto the trapezium. Forty-two fresh-frozen cadaveric wrists were dissected using the extended FCR approach through the FCR tendon sheath. The length of the fibrous portion of the FCR insertion onto the trapezial ridge was measured from proximal to distal using a digital caliper. FCR insertion onto the trapezium was present in all specimens. The mean length of the FCR insertion was 11.8 ± 4.14 mm. The character of the tissue quality varied across specimens. These results demonstrate the commonality of the FCR fibers that insert onto the trapezium. The length and tissue quality of this insertion varied across specimens. Understanding the complex anatomy of the hand and wrist facilitates surgical planning and intraoperative techniques. The FCR tendon insertion onto the trapezium is an important component of exposure for the volar approach to the distal radius and surgical management of thumb carpometacarpal joint arthritis.

Evaluation of the effectiveness and efficiency of the East African community joint assessment procedure by pharmaceutical companies: Opportunities for improvement.

Background: A 2021 study to determine the viewpoints among the seven member countries regarding the effectiveness (i.e., achieving the intended outcomes) and efficiency (i.e., achieving the intended outcomes in timely manner with the resources available) of the East African Community Medicine Regulatory Harmonisation (EAC-MRH) Joint Assessment Procedure recommended the conduct of a similar study among pharmaceutical company applicants. The aim of this study then was to evaluate the effectiveness and efficiency of the current EAC-MRH operating model from the applicants' perspective, including the challenges and opportunities for improvement. Methods: Using the Process Effectiveness and Efficiency Rating for Industry questionnaire developed by the authors, data were collected from company representatives responsible for EAC joint procedure submissions. Results: Responses from 14 study participants underlined the support of pharmaceutical companies for the EAC-MRH initiative, which has facilitated the harmonisation of registration requirements across the EAC region leading to one registration for all countries and a reduction of the workload for both applicants and assessors. In addition, it is expected that shorter timelines for approval will lead to improved access to quality-assured essential medicines in the region. Access to various markets at the same time was also noted as an important benefit to pharmaceutical companies. Noted challenges include a lack of process information, a lack of centralised submission and tracking process and a lack of mandated central registration. A key strategy proposed by participants is the establishment of a regional administrative body to centrally receive and track EAC applications and the eventual establishment of a Regional EAC Medicines Authority. Conclusion: This is the first study evaluating the performance of the EAC work-sharing initiative from the point of view of the applicants. In general, the applicants believe that the system performs efficiently and fulfils its promise. However, some participants indicated that in some countries an EAC positive recommendation does not directly result in an individual country approvals. Following the recommendations listed in this report may mitigate identified areas for improvement and facilitate the overall goal of the EAC-MRH initiative to expedite the availability of needed quality-assured medicines to patients in the region.

Design considerations for rectangular bolted full face flanged joints for surface condensers

Rectangular bolted full face flanged joints are widely used in surface condensers within the power generation industry including the nuclear one. In order to design these components, it is necessary to analyze the flanged joint from the point of view of structural strength and tightness. This work presents an analytical procedure applied to a rectangular bolted flange to determine the thickness of the flange, the bolt stresses and tightness conditions. First, the proposed analytical procedure is validated by comparing results from finite element analysis (FEA) using non-linear approach considering the behavior of the gasket and contacts. In addition, the results of proposed procedure applied to the design of a rectangular flanged joint of a steam surface condenser were compared for two different gaskets: compressed non-asbestos fiber gasket and NBR elastomer gasket. The results show a better performance of the NBR elastomer gasket in comparison with compressed fiber gasket: better sealing conditions, reduction of thicknesses of flange and reduction of bolt stresses. It is important to highlight there are practically no references of procedures for design non-circular full face flanged joints.

Procedure Cost Comparison of Outpatient and Inpatient Shoulder Arthroplasty and Lower-Extremity Arthroplasty Within a Managed-Care Organization.

Introduction The authors sought to evaluate cost differences between shoulder arthroplasties and lower-extremity joint replacements in the outpatient and inpatient setting within a large health-maintenance organization. Methods A cross-sectional study of 100 total hip arthroplasties (THA), 100 total knee arthroplasties (TKA), and 100 shoulder arthroplasties (50 anatomical total shoulder arthroplasties and 50 reverse shoulder arthroplasties [RTSA]) was performed at a single regional health care center within an integrated health care maintenance organization. A time-driven activity-based costing methodology was used to obtain total cost of each episode for outpatient (vs) inpatient surgery. Results are presented by procedure type. Results Compared to their respective inpatient procedure, outpatient surgery was less expensive by 20% for RTSA, 22% for total shoulder arthroplasties, 29% for THA, and 30% for TKA. The cost of implants was the highest proportion of cost for all joint procedures across inpatient and outpatient settings, ranging from 28% of the total cost for inpatient THA to 63% of the cost for outpatient RTSA. Discussion Although many factors influence the total cost for arthroplasty surgery, including rate of hospitalization, duration of stay, operative time, complexity of cases, patient factors, equipment, and resource utilization, the implant cost remains the most expensive factor, with hospital bed admission status being the second costliest contribution. Conclusion Outpatient total arthroplasty substantially reduced procedure expenses in a managed-care setting by 20%-30%, although savings for outpatient shoulder arthroplasty was lower than savings for THA or TKA. Implant costs remain the largest portion of shoulder arthroplasty procedure expenses.

Evaluation of the joint procedure pathway: Are we coding our activity?

Evaluation of the joint procedure pathway: Are we coding our activity?

MRI-guided sacroiliac joint injections in children and adults: current practice and future developments.

Common etiologies of low back pain include degenerative arthrosis and inflammatory arthropathy of the sacroiliac joints. The diagnostic workup revolves around identifying and confirming the sacroiliac joints as a pain generator. Diagnostic sacroiliac joint injections often serve as functional additions to the diagnostic workup through eliciting a pain response that tests the hypothesis that the sacroiliac joints do or do not contribute to the patient's pain syndrome. Therapeutic sacroiliac joint injections aim to provide medium- to long-term relief of symptoms and reduce inflammatory activity and, ultimately, irreversible structural damage. Ultrasonography, fluoroscopy, computed tomography, and magnetic resonance imaging (MRI) may be used to guide sacroiliac joint injections. The populations that may benefit most from MRI-guided sacroiliac joint procedures include children, adolescents, adults of childbearing age, and patients receiving serial injections due to the ability of interventional MRI to avoid radiation exposure. Most clinical wide-bore MRI systems can be used for MRI-guided sacroiliac joint injections. Turbo spin echo pulse sequences optimized for interventional needle display visualize the needle tip with an error margin of < 1mm or less. Published success rates of intra-articular sacroiliac joint drug delivery with MRI guidance range between 87 and 100%. The time required for MR-guided sacroiliac joint injections in adults range between 23-35min and 40min in children. In this article, we describe techniques for MRI-guided sacroiliac joint injections, share our practice of incorporating interventional MRI in the care of patients with sacroiliac joint mediated pain, discuss the rationales, benefits, and limitations of interventional MRI, and conclude with future developments.

Shoulder Arthrodesis.

Shoulder arthrodesis is an end-stage, salvage procedure for the glenohumeral joint and can provide a pain-free, stable shoulder with varying levels of function. Common indications include brachial plexus injury, chronic instability with rotator cuff and deltoid dysfunction, and failed shoulder arthroplasty. Multiple techniques are described, including intra-articular and extra-articular arthrodeses. Fusion can be accomplished with screw fixation, plate fixation, external fixation, and arthroscopic-assisted techniques. The optimal position of the arm is heavily debated in the literature, but the ideal position is thought to be 30° of flexion, 30° of abduction, and 30° of internal rotation. After successful fusion, the patient should be able to bring their hand to their mouth, reach their back pocket, and cross the midline for hygiene. Complications are not uncommon and include nonunion, malunion, fracture, and infection. With the increasing incidence of shoulder arthroplasty, failed arthroplasties are more commonly encountered. In a salvage situation, shoulder arthrodesis may be considered.

Surgical outcomes in people with hemophilia A taking emicizumab prophylaxis: experience from the HAVEN 1-4 studies

AbstractMany people with hemophilia A (PwHA) undergo surgery in their lifetime, often because of complications of their disease. Emicizumab is the first bispecific monoclonal antibody prophylactic therapy for PwHA, and its efficacy and safety have been previously demonstrated; however, there is a need to build an evidence base on the management of PwHA on emicizumab undergoing surgery. Data from the HAVEN 1-4 phase 3 clinical trials were pooled to provide a summary of all minor and major surgeries in PwHA with or without factor VIII (FVIII) inhibitors who were receiving emicizumab prophylaxis. Overall, 233 surgeries were carried out during the HAVEN 1-4 trials: 215 minor surgeries (including minor dental and joint procedures, central venous access device placement or removal, and endoscopies) in 115 PwHA (64 with FVIII inhibitors) and 18 major surgeries (including arthroplasty and synovectomy) in 18 PwHA (10 with FVIII inhibitors). Perioperative hemostatic support was at the discretion of the treating physician. Overall, the median (interquartile range [IQR]) age was 33.5 (13.0-49.0) years and the median (IQR) emicizumab exposure time before surgery was 278.0 (177.0-431.0) days. Among the 215 minor surgeries, 141 (65.6%) were managed without additional prophylactic factor concentrate, and of those, 121 (85.8%) were not associated with a postoperative bleed. The majority (15 of 18 [83.3%]) of major surgeries were managed with additional prophylactic factor concentrate. Twelve (80.0%) of these 15 surgeries were associated with no intraoperative or postoperative bleeds. The data demonstrate that minor and major surgeries can be performed safely in PwHA receiving emicizumab prophylaxis. These trials are registered at www.clinicaltrials.gov as #NCT02622321, #NCT02795767, #NCT02847637, and #NCT03020160.

Factors associated with concurrent vs. sequentially combined surgery for patients undergoing risk-reducing bilateral salpingo- oophorectomy (434)

Factors associated with concurrent vs. sequentially combined surgery for patients undergoing risk-reducing bilateral salpingo- oophorectomy (434)

Orthopaedic Surgery Pediatric Sports Medicine: Characterizing Practice Patterns and Subspecialization.

Pediatric sports medicine is a new and rapidly growing subspecialty within orthopaedic surgery. However, there is very limited literature on the practice of pediatric sports medicine in North America. Therefore, the purpose of this study was to evaluate and describe the current practice patterns of orthopaedic surgeons specializing in pediatric sports medicine. An online survey was distributed to orthopaedic surgeons specializing in pediatric sports medicine through the Pediatric Research in Sports Medicine Society. The purpose of the survey was to characterize (1) surgeon demographics, (2) the breakdown of different joint specialization, and (3) the specific procedures for joints that the surgeons specialize in. Responses from 55 orthopaedic surgeons were collected and analyzed. Most respondents considered pediatric sports medicine as the primary focus of their practice (89.1%, n=49/55). The number of fellowships completed was almost evenly split between either a single fellowship (52.7%, n=29/55) or 2 or more (47.3%, n=26/55). The most common combination of fellowships was pediatric orthopaedics and adult sports medicine (32.7%, n=18/55). Most survey respondents had been in practice for <10 years (69.0%, n=38/55) and were affiliated with an academic center (61.8%, n=34/55). On average, 77.5% of the patients treated were <18 years old. The knee joint was the most specialized joint, with 98.2% (n=54/55) respondents reporting that the knee joint constituted ≥25% of their practice. The knee joint constituted a mean of 52.1% of the respondents' overall practice, followed by the shoulder (15.2%), hip (13.9%), ankle (7.5%), elbow (7.1%), and wrist (4.2%). Pediatric sports medicine practices are variable and have distinct practice patterns in pediatric, orthopaedic, and adult sports practices. In the current study, most surgeons are less than 10 years into practice, affiliated with academic centers, and have typically completed either 1 or 2 fellowships after residency. Surgeons were most commonly specialized in the knee joint and cared for patients <18 years old. Level of evidence IV.

Новый метод хирургического лечения пациентов с привычным вывихом надколенника: анализ первичных результатов

Introduction Surgical options used to treat recurrent patellar dislocations (RPD) in different countries include release of the lateral tendon retinaculum, tibia medialization, fixation of an autologous graft to the hip, transplantation of the ipsilateral gracilis tendon and medial patellofemoral ligament reconstruction. The methods may not completely eliminate the dislocation to ensure patellar stability and we undertook to develop a new surgical technique. The objective was to identify advantages and disadvantages of the new methodology for the treatment of RPD through comparative analysis. Material and methods 28 patients with RPD of varying degrees treated in the Department of Sports Trauma, State Institution "RSNPMCTO" the Ministry of Health of the Republic of Uzbekistan between 2015 and 2018 were reviewed. Dislocations were graded as average (grade 2; n = 3, 10.7 %) and grade 3 (n = 25; 89.3 %). Five (17.8%) of 28 patients had impaired m. vastus medialis and 23 (82.2 %) were diagnosed with impairment and defect of the retinaculum patella mediale. The patients underwent physical, laboratory, radiological and instrumentation (ultrasound, magnetic resonance imaging, diagnostic arthroscopy) examinations. Results Arthroscopic procedure of the knee joint with autoplasty patellar stabilization using the m. gracilis tendon and a biodegradable screw resulted in good outcomes (n = 27; 96.4 %) and a fair result in a patient (3.6 %) with grade 3 RPD due to synovitis, bursitis and pain in the knee joint; no poor results reported. Conclusion The patients could completely regain the limb functions through arthroscopic procedure of the knee joint with autoplasty patellar stabilization using the m. gracilis tendon and a biodegradable screw, optimization of surgical treatment strategy with regard to severity of displacement and injury to the soft tissues at the medial aspect of the patella.

The Safety of Continued Oral Anticoagulation Therapy in Joint Injections and Aspirations: A Qualitative Review of the Current Evidence.

Performing joint aspirations and injections on patients taking long-term oral anticoagulants poses a clinical conundrum. This review aimed to quantify the safety of performing joint procedures in these patients in terms of bleeding risk. In addition, it aimed to identify, in those receiving vitamin K antagonists, what level of international normalized ratio (INR) is the safest.A review of the medical literature was performed (electronic searches in Ovid [MEDLINE], EMBASE, and the Cochrane Library). English language original reports of patients undergoing joint injections or aspirations performed on anticoagulant therapy, published within the last 10 years, were included.Seven studies met the inclusion criteria. Patients were taking a variety of anticoagulants: warfarin, acenocoumarol, and direct oral anticoagulants. Four cases of hemorrhage were reported after 5427 procedures, over a pooled 32-year period, across 9 centers. The INR values were available for 3 cases with bleeding complications: values were 1.9, 2.3, and 3.4.Authors of all studies concluded that joint injection is safe in patients on anticoagulants. A variety of joints and approaches, reversal, or withholding of anticoagulation and bridging with low molecular weight heparin did not seem to alter bleeding risk. Bleeding complications remained low even in those with renal or hepatic impairment or those taking concomitant antiplatelets.In conclusion, joint aspiration and injection are safe in patients taking anticoagulants. Anticoagulation should not be routinely discontinued in these patients; decisions should be made on a case-by-case basis. Because of low event numbers, a recommended safe maximum INR value for joint procedures cannot be determined.