Major Orthopedic Procedures Research Articles

Современные пероральные препараты для профилактики тромбоэмболических осложнений – критический обзор доказательной базы в контексте соотношения риск/польза

Modern oral medications used to prevent venous thromboembolism (VTE) have gained widespread use with major orthopaedic and trauma procedures. There are no accurate multicenter data on the frequency of usage of different prophylactic medications in our country but discussions of the colleagues at specialized web forums make us suspect that factor Xa and dabigatran etexilate inhibitors are in the top three next to low molecular weight heparins. Marketing and promotion strategies of pharmaceutical companies are likely to be of immense importance in that with the contribution of clinical research studies for pharmaceutical drugs. However, preferences of European and American orthopaedic surgeons for the choice of drugs are completely different from those of Russian surgeons. Vitamin K antagonists, acetylsalicylic acid, low molecular weight heparins are commonly used for antithrombotic therapy abroad. Different approaches of Russian and foreign orthopaedic surgeons to the choice of drugs can be explained by a different use of a high-quality evidence base. In our opinion, a collision component can be involved in the endpoints of clinical trials that will be discussed in the present critical review.

Effects of tranexamic acid in major orthopedic surgical procedures: a randomized comparative study

<p class="abstract"><strong>Background:</strong> Despite modern healthcare system, major surgeries always cause economical constraints. Complications due to blood loss, long hospital stay are most common in major surgical procedures. Tranexamic acid (TXA), a synthetic derivative of lysine is used instead of blood transfusion to control bleeding peri and post operatively.<strong> </strong>Hence this study was planned to assess the effects of tranexamic acid on various orthopedic surgical procedures, in terms of blood loss, duration of surgical procedure and hospital stay.</p><p class="abstract"><strong>Methods:</strong> Prospective randomized comparative study, among patients undergoing elective and emergency orthopedic surgery. Patients with multiple fractures, organ injury and CKD were excluded from this study. Patients were randomized to tranexamic acid (TXA) group and colloids, blood transfusion group based on computer generated random numbers. Thirty two patients were randomized to tranexamic acid group and thirty two in control group. Statistical analysis was done using SPSS V 20.<strong></strong></p><p class="abstract"><strong>Results:</strong> The mean age group was 38.41±11.4 and 36.83±13.5 in TXA group and control group respectively. The mean SD for blood loss in TXA group was 321.5±124.7 and control group 482.7±189.6, the difference was found to be highly statistically significant with p=0.0002. Likewise the difference in postoperative Hb was found to be statistically significant with p<0.01. The p value for surgical site infection and hematoma was not statistically significant.</p><p class="abstract"><strong>Conclusions:</strong> TXA significantly reduces blood loss and blood transfusion requirements in patients undergoing orthopedic surgery.</p>

Occurrence of never events after total joint arthroplasty in the United States.

Total joint arthroplasty (TJA) is a major orthopedic procedure associated with substantial morbidity and mortality. Never events (NEs) are harmful hospital-acquired conditions (HACs) that are preventable. Information on hospital admissions with TJA was collected from the National Inpatient Sample (NIS) from 2003 to 2012. NIS was queried to identify NE applicable to TJA patients based on the HAC definition listed by the Centers for Medicare and Medicaid Services (CMS). NEs were further compared before and after 2008 to evaluate the effect of the new CMS non-reimbursement policy on their incidence. A total of 8,176,774 patients were admitted with TJA from 2003 to 2012. 108,668 patients of these (1.33%) had ≥ 1 NE. The most prevalent NE was fall and trauma (0.7%). Significant multivariable predictors with higher odds of developing at least one NE included weekend admission [odds ratio (99.9% CI), 4.3 (3.1, 5.8), p < 0.001] and weight loss [odds ratio (99.9% CI), 2.8 (2.2, 3.5), p < 0.001]. A temporal comparison of NE before and after 2008 revealed a decrease in total NE occurrence after 2008 when the CMS announced discontinuing payment for NE (1.39% vs. 1.25%, p < 0.001). After adjustment for potential confounding risk factors, NE after TJA was significantly associated with an increased mortality (p < 0.001), a longer hospital stay (p < 0.001), and higher total hospitalization charges (p < 0.001). These data demonstrated that NE in TJA patients was predictive of an increased mortality, length of hospital stay, and hospitalization costs. This study established baseline NE rates in the TJA patient population to use as benchmarks and identified target areas for quality improvement in US.

Hospitalization, surgery, and incident dementia

IntroductionWe evaluated whether hospitalization with or without surgery increases risk for dementia or Alzheimer's disease. MethodsA clinical sample (843 clinically diagnosed dementia cases; 1686 matched nondemented individuals) was identified from Swedish Twin Registry studies. A register-based sample (4293 cases; 21,465 matched controls) was identified by linkage of Swedish Twin Registry to Swedish Patient Registry records. Apolipoprotein E (APOE) status and within-pair comparisons of dementia discordant twins indicated genetic susceptibility. ResultsNonsurgical hospitalization is associated with greater dementia risk than hospitalization with surgical intervention. In the register sample, thoracic, abdominal, and major orthopedic procedures entailed dementia risk; in the clinical sample, orthopedic alone. Within-pair analyses indicate that associations in part reflect genetic susceptibility in common to hospitalization and dementia. Potential gene-environment interactions were indicated by greater risk due to hospitalization among APOE ε4 noncarriers. DiscussionWe confirm hospitalization as a risk factor for dementia, with repeated hospitalizations a more important risk factor than surgery.

Venous thromboembolism prophylaxis after hip preservation surgery: a review and presentation of institutional experience.

ABSTRACTVenous thromboembolism (VTE) is a serious complication after major orthopedic procedures. The best options for prevention of the VTE are still debated. The most popular evidence-based guidelines for prevention and treatment of VTE in orthopedic surgery addressed the total hip or knee arthroplasty and hip fractures as the major orthopedic surgeries. Majority of studies have evaluated the different modalities of the VTE prophylaxis in patients undergiong hip or knee arthroplasty. Hip preservation surgeries (HPS) including mini-open femoroacetabular osteoplasty, surgical dislocation of the hip, arthroscopic procedures, and periacetabular osteotomy (PAO) are gained popularity in recent two decades. The majority of these patients are young, healthy and active and may not be considered at high risk for VTE. The frequency of VTE in patients undergoing PAO seems to be low between 0 and 5%. There is a paucity of data regarding rates of VTE in young healthy patients undergoing HPS as well as the optimal prevention methods for VTE. Hence current VTE prevention guidelines do not cover HPS adequately. We aimed to review the available literature regarding VTE events and VTE prophylaxis options after HPS. We discussed the available and potential options for prophylaxis of VTE events in these procedures along with our experience in a large cohort of hip preservation surgery.

Diagnostic heterogeneity in orthopaedic oncology makes standardized recommendations regarding anticoagulation difficult

Patients with cancer have a high incidence of venous thromboembolism (VTE). It is estimated that fifteen percent of patients with carcinoma develop VTE (1). Sarcoma patients have a similar incidence of VTE (2). Patients undergoing major orthopedic procedures are also at increased risk for developing VTE.

Aspirin provides adequate VTE prophylaxis for patients undergoing hip preservation surgery, including periacetabular osteotomy.

There are no clear guidelines regarding optimal venous thromboembolism (VTE) prophylaxis for patients undergoing hip preservation surgery (HPS), in particular pelvic osteotomy, which is considered to be a major orthopaedic procedure. The aim of this study was to determine the efficacy of aspirin for VTE prophylaxis in a large cohort of patients undergoing femoroacetabular osteoplasty (FAO) and periacetabular osteotomy (PAO). This was a retrospective study of prospectively collected data on patients undergoing HPS. A total of 603 patients (643 cases) underwent FAO and 80 patients (87 cases) underwent PAO between 2003 and 2016. The mean age of patients was 34.3 years (range 14.3–68.1 years). The type of VTE prophylaxis administered changed over time with earlier patients receiving warfarin (44 cases), followed by aspirin at 325 mg twice daily (448 cases), and most recently aspirin 81 mg twice daily (238 cases). The complications of symptomatic pulmonary embolism (PE), deep venous thrombosis (DVT) and major bleeding events within 90 days of surgery were documented. There were zero patients that developed major bleeding events or required evacuation of a hematoma. One patient who underwent FAO and received aspirin 325 mg, developed post-operative symptomatic DVT. One patient who underwent PAO and received aspirin 325 mg developed DVT and PE. This study demonstrates that the incidence of VTE following joint preservation procedure is acceptably low. Administration of aspirin to patients undergoing FAO or PAO appears to be adequate in reducing the risk of VTE. Only two patients in this cohort developed VTE following HPS.

The Role of Tranexamic Acid in Plastic Surgery: Review and Technical Considerations.

Minimizing blood loss during surgery is critical, and many modalities have been used to decrease unwanted surgical bleeding. Among many methods, use of pharmacologic agents such as antifibrinolytic drugs has been shown to significantly reduce blood loss and the rates of postoperative blood transfusion in many articles. Tranexamic acid is an antifibrinolytic agent that has been widely used in other surgical specialties, especially in cardiac, orthopedic, and trauma surgery. Despite its known benefits, the use of tranexamic acid in plastic surgery is extremely limited, primarily because most plastic surgery procedures do not involve the extent of blood loss that can lead to anemia and the need for blood transfusion, as is common in major orthopedic and cardiac surgery procedures. Nevertheless, there are significant benefits to be gained from the use of antifibrinolytic drugs in the full range of plastic surgery. In this article, the authors introduce the benefits, dosages, and technical considerations of using tranexamic acid in plastic surgery procedures.

Accuracy and trending of non-invasive hemoglobin measurement during different volume and perfusion statuses.

The evolution of non-invasive hemoglobin measuring technology would save time and improve transfusion practice. The validity of pulse co-oximetry hemoglobin (SpHb) measurement in the perioperative setting was previously evaluated; however, the accuracy of SpHb in different volume statuses as well as in different perfusion states was not well investigated. The aim of this work is to evaluate the accuracy and trending of SpHb in comparison to laboratory hemoglobin (Lab-Hb) during acute bleeding and after resuscitation. Seventy patients scheduled for major orthopedic procedures with anticipated major blood loss were included. Radical-7 device was used for continuous assessment of SpHb, volume status [via pleth variability index (PVI)] and perfusion status [via perfusion index (PI)]. Lab-Hb and SpHb were measured at three time-points, a baseline reading, after major bleeding, and after resuscitation. Samples were divided into fluid-responsive and fluid non-responsive samples, and were also divided into high-PI and low-PI samples. Accuracy of SpHb was determined using Bland-Altman analysis. Trending of SpHb was evaluated using polar plot analysis. We obtained 210 time-matched readings. Fluid non-responsive samples were 106 (50.5%) whereas fluid responsive samples were 104 (49.5%). Excellent correlation was reported between Lab-Hb and SpHb (r = 0.938). Excellent accuracy with moderate levels of agreement was also reported between both measures among all samples, fluid non-responsive samples, fluid-responsive samples, high-PI samples, and low-PI samples [Mean bias (limits of agreement): 0.01 (- 1.33 and 1.34) g/dL, - 0.08 (- 1.27 and 1.11) g/dL, 0.09 (- 1.36 and 1.54) g/dL, 0.01 (- 1.34 to 1.31) g/dL, and 0.04 (- 1.31 to 1.39) g/dL respectively]. Polar plot analysis showed good trending ability for SpHb as a follow up monitor. In conclusion, SpHb showed excellent correlation with Lab-Hb in fluid responders, fluid non-responders, low-PI, and high PI states. Despite a favorable mean bias of 0.01g/dL for SpHb, the relatively wide levels of agreement (- 1.3 to 1.3g/dL) might limit its accuracy. SpHb showed good performance as a trend monitor.

Sham surgery: justified but practical? A systematic review of sham surgery trials in orthopaedics

Background: An increasing trend for sham surgery trials in minor orthopaedic procedures has beenobserved. Trial outcomes have changed the practice landscape of these procedures. However, there has been no sham surgery trial in a major orthopaedic procedure. The aims of this systematic review were to consider the ethics of sham surgery trials; to describe orthopaedic sham surgery trials conducted to date; and to consider the challenges that will need to be overcome in order to conduct sham surgery trials for major orthopaedic procedures in the future. Methods: A systematic review of the literature and clinical trial registries was undertaken. Trials with a published main findings paper underwent a risk of bias assessment using the Cochrane Collaboration risk of bias tool, in addition to an ethical assessment based on the work of Horng and Miller. Results: We identified 22 sham surgery trials for minor orthopaedic procedures that have been completed, terminated, or are currently in process. Among the ten trials with a published main findings paper, only one was free from risk of bias; all others were at risk of bias. According to the ethical assessment, the benefits of a sham control were outweighed by the risks in all but two of the ten trials. Across the 22 trials with published and unpublished main findings, participant recruitment within reasonable timeframes, as well as the low threshold for crossover from the sham were recurring challenges. Conclusions: Researchers are obliged to carefully consider the feasibility of conducting a sham surgery trial in a major orthopaedic procedure, before drawing on limited research funds. Exploring the conditions under which patients and surgeons would find participation in a sham surgery trial acceptable, and simulating trial costs based on patient and surgeon preferences may assist funders, assessors and ethics boards to determine whether to support the conducting of future sham surgery trials in major orthopaedic procedures. Level of evidence: Level 1

Concurrent one-stage total knee and hip arthroplasty due to sequel of juvenile rheumatoid arthritis

Rationale:Rheumatoid arthritis is a chronic systemic connective tissue disease. Total hip and knee arthroplasties are common major orthopaedic procedures worldwide.Patient concerns:To date, no studies have presented 1-stage concurrent total hip arthroplasty (THA) and total knee arthroplasty (TKA) in patients with rheumatoid arthritis (RA). We reported a case which is, to our knowledge, the first description of both THA and TKA in a patient with RA simultaneously.Diagnoses:History of juvenile rheumatoid arthritis (JRA), deterioration of signs and symptoms in history and physical examinations and radiography were lead to making decision for her surgery.Interventions:Concurrent total hip replacement and total knee arthroplasty were performed for patient.Outcomes:After more than a 2-year follow-up time, the patient showed excellent clinical function and remained satisfied with the surgical outcome. Multiple simultaneous total joint arthroplasty (TJA) is reviewed in this article.Lessons:Joint arthroplasty surgeries can be performed in a simultaneous procedure to shorten disability and rehabilitation time with one anesthesia.

Efficacy of preoperative autologous blood donation and tranexamic acid in revision total hip arthroplasty: a randomized controlled trial

Background Revision total hip arthroplasty (RTHA) is known to entail some risk of hemorrhage during the intraoperative period. Preoperative autologous blood donation (PAD) is one of the most popular alternatives to allogeneic blood transfusion (ABT) in elderly patients undergoing major orthopedic procedures in which a substantial blood loss is expected. The aim of this study was to evaluate the effectiveness of a combination of PAD and intravenous tranexamic acid (TXA) in reducing the need for ABT following RTHA. Patients and methods A total of 60 patients were included in this randomized study that were divided into a study group of 30 patients, who had been transfused autologous blood and a control group of 30 patients who had been transfused only allogeneic blood. Parenteral iron preparation was given to all patients of the study group after each donation. Intraoperatively all patients of the study group received 2 g of intravenous TXA. This study was conducted through laboratory analysis of hemoglobin and hematocrit values during blood donation and for both groups in the preoperative and the postoperative period and the assessment of the amount of transfused blood units in both groups. Results The average values of hemoglobin and hematocrit in the first and the second donation were 11.9±1.2 g/dl, 36.1±3.8%, and 11.9±1.0 g/dl, 35.6±3.5%, respectively. During operative and postoperative periods, the statistical data processing showed that there was a nonsignificant difference between the study and control groups regarding the number of transfused blood units (both autologous and allogeneic) (P=0.578 and 0.089), respectively, and only 10% of patients in the study group needed allogeneic blood. Conclusion PAD combined with intraoperative intravenous TXA administration reduced the number of ABTs in patients who underwent RTHA.

Current Concepts of Prolotherapy in Orthopedic Surgery

Context Prolotherapy is a popular injection-based complementary treatment, which has shown promising results in the treatment of sprained and degenerated ligaments, and damaged dense connective tissues structures. More research was conducted in this area and many authors declared successful results for different indications. Evidence Acquisition The purpose of this study was to present a literature review regarding the current concepts of prolotherapy injections and improvements in the orthopedic clinical care practice. The Medline and PubMed databases were searched for the articles related to prolotherapy injections in the field of orthopedic surgery and additionally the reference list of each article was also included to provide a comprehensive evaluation. Results Numerous studies have been conducted on prolotherapy injections for different indications for orthopedics clinical care practice. Prolotherapy injections have successfully used for major orthopedic procedures in terms of rotator cuff lesions, knee ligamentous lesions, osteoarthritis-cartilage defects, and ligament-tendon injuries. Most of the studies showed that prolotherapy provided faster and better healing of tissues. Conclusions There is a great interest to prolotherapy in orthopedic clinics, especially to manage musculoskeletal lesions. More research conducted in this area and many authors declared successful results in their studies. In spite of this increasing trend for prolotherapy injections, there were only one or two clinical studies investigated prolotherapy injections for different indications and most of them have limited participants, short-term follow-up or poor quality studies. There is still need for further high-quality studies investigated optimal strategy of the injections of prolotherapy.

Survival rate and perioperative data of patients who have undergone hemipelvectomy: a retrospective case series.

BackgroundHemipelvectomy is a major orthopedic surgical procedure indicated in specific situations. Although many studies discuss surgical techniques for hemipelvectomy, few studies have presented survival data, especially in underdeveloped countries. Additionally, there is limited information on anesthesia for orthopedic oncologic surgeries. The primary aim of this study was to determine the survival rate after hemipelvectomy, and the secondary aims were to evaluate anesthesia and perioperative care associated with hemipelvectomy and determine the influence of the surgical technique (external hemipelvectomy [amputation] or internal hemipelvectomy [limb sparing surgery]) on anesthesia and perioperative care in Brazil.MethodsThis retrospective case series collected data from 35 adult patients who underwent hemipelvectomy between 2000 and 2013. Survival rates after surgery were determined, and group comparisons were performed using the Kaplan–Meier method and the log-rank test. Mantel–Cox test and multiple linear regression analysis with stepwise forward selection were performed for univariate and multivariate analyses, respectively.ResultsMean survival time was 32.8 ± 4.6 months and 5-year survival rate was 27 %. Of the 35 patients, 23 patients (65.7 %) underwent external hemipelvectomy and 12 patients (34.3 %) underwent internal hemipelvectomy. The survival rate was significantly higher in patients with bone tumors than in those with soft tissue sarcomas (P = 0.024). The 5-year cumulative probability of survival was significantly lower in patients who underwent external hemipelvectomy than in those who underwent internal hemipelvectomy (P = 0.043). In the univariate and multivariate analyses, only advanced disease stage (3 and 4) was identified as a significant independent predictor of reduced survival (P = 0.0003). Balanced general anesthesia combined with epidural block was the most frequent anesthesia technique. Median intraoperative crystalloid volume and red blood cell transfusions were 3500 mL and 2 units, respectively.ConclusionsOverall mean survival time after hemipelvectomy was 32.8 months. Advanced disease stage might be independently associated with reduced survival. Smaller amounts of fluids and transfusions were administered and time to discharge was shorter. Acute and chronic pain as well as wound complications are still important challenges in hemipelvectomy.

Successful implementation of thirty five major orthopaedic procedures under poor conditions after the two thousand and fifteen Nepal earthquake.

After receiving the 25 April 2015 Nepal earthquake relief mission, a fully self-sufficient Rescue Center of Trauma set up quickly in downtown Kathmandu by Chengdu Military Medical Team of PLA P. R. China. The medical team consisted of 68 members and 40 tons of supplies, which was equivalent to a small hospital. The medical area and living area were constructed with tents. Operating areas were converted from eight simple bungalows. The main purpose of the Rescue Center of Trauma was to save those earthquake survivors who needed surgery. From 30 April to 10 May, 35 cases of orthopaedic internal fixation and external fixation operations were completed in the Rescue Center of Trauma. Surgery involved a total of 27 patients. All of the 27 orthopaedic surgery patients received treatment without any serious complications, including internal fixation failure, infection, amputation, limb deformities, limb dysfunction, or skin necrosis. Trauma infection rates are usually higher after an earthquake. Due to poor conditions, implementation of orthopaedic surgery at a field hospital is limited due to a lack of blood, equipment, and drugs. Infection control remains a key determinant of the success of surgery. Effective measures to control infection include strict environmental disinfection, extending the sterilizing time of fixation devices and supplies, doubling the number and time of washing and disinfection, and rational use of antibiotics based on past experience.

The Current Perspectives of Stem Cell Therapy in Orthopedic Surgery.

ContextMusculoskeletal injuries may be painful, troublesome, life limiting and also one of the global health problems. There has been considerable amount of interest during the past two decades to stem cells and tissue engineering techniques in orthopedic surgery, especially to manage special and compulsive injuries within the musculoskeletal system.Evidence AcquisitionThe aim of this study was to present a literature review regarding the most recent progress in stem cell procedures and current indications in orthopedics clinical care practice. The Medline and PubMed library databases were searched for the articles related with stem cell procedures in the field of orthopedic surgery and additionally the reference list of each article was also included to provide a comprehensive evaluation.ResultsVarious sources of stem cells have been studied for orthopedics clinical care practice. Stem cell therapy has successfully used for major orthopedic procedures in terms of bone-joint injuries (fractures-bone defects, nonunion, and spinal injuries), osteoarthritis-cartilage defects, ligament-tendon injuries, femoral head osteonecrosis and osteogenesis imperfecta. Stem cells have also used in bone tissue engineering in combining with the scaffolds and provided faster and better healing of tissues.ConclusionsLarge amounts of preclinical studies have been made of stem cells and there is an increasing interest to perform these studies within the human population but preclinical studies are insufficient; therefore, much more and efficient studies should be conducted to evaluate the efficacy and safety of stem cells.

The Prevalence of Diabetes Mellitus and Routine Hemoglobin A1c Screening in Elective Total Joint Arthroplasty Patients

BackgroundDiabetes mellitus has been associated with significant perioperative complications in joint arthroplasty. In addition, many patients are unaware of their dysglycemic status, and the prevalence of undiagnosed dysglycemia in joint arthroplasty patients is unknown. MethodsSeveral years ago, we began routine hemoglobin A1c (HbA1c) level screening in all our patients planning to undergo elective total hip and total knee arthroplasties. We retrospectively reviewed the HbA1c levels in our initial 663 patients. ResultsForty-eight percent of these patients were found to be nondiabetic; 19% percent had a previous history of some level of dysglycemia. Most significantly, over one third, 33.6% of these patients were previously undiagnosed dysglycemic patients; 31% were diagnosed as prediabetic and 2.6% as diabetic. ConclusionOwing to the high prevalence of prediabetic patients who go on to develop diabetes and to the high correlation of poor glucose control with perioperative complications, we feel that it is imperative to identify this large number of previously undiagnosed dysglycemic patients. We recommend the routine screening of all patients planning to undergo major orthopedic procedures. Likewise, we recommend that identified patients be referred for diabetic counseling. We also recommend that patients with markedly elevated HbA1c levels have their elective surgery postponed until better glycemic control can be achieved.

Evaluating patient safety indicators in orthopedic surgery between Italy and the USA

To compare patient safety in major orthopedic procedures between an orthopedic hospital in Italy, and 26 US hospitals of similar size. Retrospective analysis of administrative data from hospital discharge records in Italy and Florida, USA, 2011-13. Patient Safety Indicators (PSIs) developed by the Agency for Healthcare Quality and Research were used to identify inpatient adverse events (AEs). We examined the factors associated with the development of each different PSI, taking into account known confounders, using logistic regression. One Italian orthopedic hospital and 26 hospitals in Florida with ≥1000 major orthopedic procedures per year. Patients ≥18 years who underwent 1 of the 17 major orthopedic procedures, and with a length of stay (LOS) >1 day. Patient Safety management between Italy and the USA. Patient Safety Indicators. A total of 14393 patients in Italy (mean age=59.8 years) and 131371 in the USA (mean age=65.4 years) were included. US patients had lower adjusted odds of developing a PSI compared to Italy for pressure ulcers (odds ratio [OR]: 0.21; 95% confidence interval [CI]: 0.10-0.45), hemorrhage or hematoma (OR: 0.42; CI 0.23-0.78), physiologic and metabolic derangement (OR: 0.08; CI 0.02-0.37). Italian patients had lower odds of pulmonary embolism/deep vein thrombosis (OR: 3.17; CI 2.16-4.67) compared to US patients. Important differences in patient safety events were identified across countries using US developed PSIs. Though caution about potential coding differences is wise when comparing PSIs internationally, other differences may explain AEs, and offer opportunities for cross-country learning about safe practices.

Low thrombin generation during major orthopaedic surgery fails to predict the bleeding risk in inhibitor patients treated with bypassing agents.

In the presence of high-titre inhibitors, haemostatic bypassing agents are used to control bleeding and perform surgery. In this setting, no specific laboratory test is yet available to guide drug choice, monitor treatment efficacy and predict the risk of bleeding. The aims of this study, carried out in patients candidate to orthopaedic surgery, were to assess the dose-dependent increase in thrombin generation (TG) after infusion of bypassing agents and to evaluate whether or not a correlation existed between the haemostatic efficacy of bypassing therapies and perioperative TG values. TG was measured in 16 inhibitor patients, 10 of whom underwent 11 major orthopaedic procedures. In the non-bleeding state, TG significantly improved 30 min after whichever dose (P < 0.01), with no dose-response relationship when values obtained after different rFVIIa doses were compared. TG significantly improved 30 min after the preoperative bolus (P < 0.05), while during the postoperative period TG values measured before and after dosing did not differ. Moreover, postoperative TG values were similar or even more impaired (P ≤ 0.05) than those measured before preoperative dosing. No difference was found by comparing procedures with and without bleeding complications and yet no bleeding occurred in spite of persistently low TG values in one-third of procedures. This study fails to support a definite role for the TG assay as a reliable laboratory tool to monitor the haemostatic efficacy of bypassing therapies and as a predictor of the risk of bleeding in inhibitor patients using these agents during orthopaedic surgery.

Effect of preoperative Staphylococcus aureus screening / decolonization on surgical site infection following major othopaedic operations: a prospective study

Background: Carriers of Staphylococcus aureus (S. aureus) have a higher likelihood of having surgical site infection (SSI). Aim: evaluate the impact of preoperative S. aureus screening and decolonization on the rate of SSI after major orthopaedic surgical operations. Methods: A prospective observational study was conducted on 400 patients scheduled for major orthopaedic surgical procedures at our institution between December 2013 to December 2014. The enrolled patients were divided into: intervention group (250 patients) who underwent the screening / decolonization protocol, and a control group (150 patients) with no implementation of the protocol. All patients were followed up for 3 months for postoperative S. aureus SSI. Findings: Of the 250 patients screened, 70 (28%) had positive nasal swabs for S. aureus. Among screened patients, 58 (23.2%) were identified as MSSA carriers, and 12 (4.8%) were identified as MRSA carriers. On post operative follow up, there were a total of 5 S. aureus SSI in the control group (3.3%, 95% CI 1.1-7.6%) and 3 in the intervention group (1.2%, 95% CI 0.25- 3.5% ). There was 2 MRSA infection in the control group (1.3%, 95% CI 0.2-4.7%), one MRSA infection in the intervention group (0.4%, 95% CI 0.01-2.2). Screening and decolonization lowered, the S. aureus SSI rate to 1.2% in screened/decolonized (intervention) versus 3.3% in those unscreened (control) patients. Conclusion: preoperative screening / decolonization of MRSA and MSSA carriers among patients undergoing major orthopaedic surgical operations using a combination of mupirocin and chlorhexidine is a safe protocol for reducing S. aureus SSI.