The necessity of pharmacological prophylaxis against venous thromboembolism in major joint arthroplasty

Purpose

Venous thromboembolism (VTE) is a recognised post-operative complication of major lower limb joint arthroplasty. Current National Institute for Health and Clinical Excellence (NICE) guidelines suggest the use of both mechanical and pharmacological prophylaxis following hip and knee replacement. Since the introduction of enhanced recovery programmes following hip and knee arthroplasty the requirement for routine pharmacological VTE prophylaxis has been questioned. The purpose of this study was to assess the efficacy of pharmacological prophylaxis against symptomatic VTE in patients undergoing hip and knee arthroplasty under an enhanced recovery programme.

Methods

Symptomatic VTE incidence was audited in 1,100 patients undergoing primary or revision total hip or knee arthroplasty at the same hospital with only mechanical prophylaxis from 2007 to 2009. Following addition of chemical prophylaxis (enoxaparin) symptomatic VTE incidence in 522 patients undergoing primary or revision total hip or knee arthroplasty from 2011 to 2012 was re-audited.

Results

In the mechanical prophylaxis group incidence of DVT was 0.73 % [95 % confidence interval (CI) 0.37–1.43 %] and incidence of pulmonary embolism (PE) 0.91 % (95 % CI 0.49–1.67 %). Following addition of pharmacological prophylaxis incidence of DVT was 0.57 % (95 % CI 0.20–1.68 %) and incidence of PE 1.15 % (95 % CI 0.53–2.48 %).

Conclusions

We found no statistically significant difference in symptomatic VTE incidence following the addition of enoxaparin. We question whether routine pharmacological prophylaxis still has a role following total hip and knee arthroplasty. Peri-operative optimisation, including post-operative analgesia and mobility, with current enhanced recovery programmes may be sufficient. As anticoagulants carry increased risk of post-operative bleeding and wound ooze, in addition to significant cost implications, their role remains controversial.     

Determinants of knee replacement in subjects with a history of arthroscopy: data from the osteoarthritis initiative

Objective

To investigate the risk and determinants of knee replacement (KR) in subjects with or at risk of osteoarthritis (OA) and a history of arthroscopy.

Methods

Data from the osteoarthritis initiative cohort were analyzed (n = 4796, up to the seventh year of follow-up). Cox proportional hazard analysis was used to determine the risk of KR according to the history of arthroscopy. A multivariable model was used to determine the risk factors for KR among subjects with a history of arthroscopy (n = 842), including age, gender, body mass index, history of knee injury, and baseline physical activity scale for the elderly, Western Ontario and McMaster (WOMAC) total score, and radiographic Kellgren and Lawrence (KL) score.

Results

History of arthroscopy was associated with risk of KR after adjustments for the mentioned determinants of OA (HR: 1.90 (1.49–2.44); P value <0.001). Female gender (HR: 1.86 (1.30–2.68); P value <0.001), higher WOMAC (HR: 1.02 (1.01–1.03); P value <0.001), and KL score (HR: 2.64 (2.08–3.35); P value <0.001) increased the risk of KR among subjects with a history of arthroscopy. Subjects with a history of knee injury had 50 % lower risk of KR (HR: 0.50 (0.35–0.72); P value <0.001) after arthroscopy.

Conclusion

Female gender, more clinical symptoms and radiographic signs of OA, was associated with higher risk of future KR in subjects with a history of arthroscopy. Subjects with arthroscopy in the setting of concomitant knee injury were 50 % less likely to undergo KR compared to subjects who underwent arthroscopy without a history of concomitant knee injury.

     

Elective hip and knee arthroplasty and the effect of rivaroxaban and enoxaparin thromboprophylaxis on wound healing

Introduction

Rivaroxaban is the first licensed oral direct inhibitor of factor Xa. Recent studies from the RECORD trials suggest rivaroxaban has superior efficacy compared to enoxaparin in preventing venous thromboembolism (VTE) with no significant increase in the major bleeding risk. Concerns remain regarding the incidence of minor bleeding, consequent delayed wound healing and subsequent risk of infection. The aim of this observational study was to assess the incidence of post-operative complications in patients receiving either rivaroxaban or enoxaparin thromboprophylaxis following elective hip and knee arthroplasty.

Methods

A total of 258 patients undergoing elective total hip or knee arthroplasty within one NHS Trust were included. A total of 202 subjects (mean age, 70.7 years ± 10.0, 43 % men) received a daily dose of 10 mg of oral rivaroxaban and 56 (mean age, 70.9 years ± 9.8, 39 % men) had a daily subcutaneous injection of 40 mg of enoxaparin as thromboprophylaxis. Endpoints included VTE (deep vein thrombosis and pulmonary embolism), haemorrhagic wound complications, hospital re-admission, requirement for blood transfusion, minor and major bleeding and death.

Results

There were no significant differences in the incidence of VTE, requirement for blood transfusion and readmission rate between rivaroxaban and enoxaparin-treated patients. The incidence of minor bleeding (2.0 vs. 0 %) and haemorrhagic wound complications (5.0 vs. 1.8 %) were non-significantly higher in the rivaroxaban-treated group. There were no cases of pulmonary embolism, major bleeding or death in either group.

Conclusion

Our experience with rivaroxaban in elective hip and knee arthroplasty showed no significant difference in the incidence of VTE or major bleeding. There was, however, a tendency to greater risk of minor bleeding and wound complications that were largely haemorrhagic in nature, which may have reached significance in a larger study.     

Usefulness of knee arthroscopy for diagnosis of knee pain in pediatric patients: comparison with preoperative clinical diagnosis

Purpose

To investigate the knee arthroscopic findings of pediatric patients with knee pain.

Subjects

Ninety-five knees of 94 patients (46 males and 48 females) aged 15 years or younger who underwent knee arthroscopy during a 4-year period from January 2007 were studied. The mean age at surgery was 13.5 (7–15) years. The mean interval from symptom onset to arthroscopic examination was 6.8 months (5 days to 2 years 10 months).

Results

The most common cause of knee pain was sports-related activities (64 knees). Other causes included falling from a moving bicycle (5 knees), while knee pain appeared with no defined reason in 14 knees. The most frequent final diagnosis based on knee arthroscopic findings was anterior cruciate ligament (ACL) injury (35 knees), followed by discoid lateral meniscus (16 knees), lateral meniscal tear (11 knees), and medial plica syndrome (9 knees), while no arthroscopic abnormality was observed in 8 of 95 knees. Among the 95 knees, the diagnosis based on preoperative physical tests and imaging findings was different from the arthroscopic diagnosis in 16 knees, 8 of which were diagnosed preoperatively as medial meniscal tear.

Conclusion

ACL injury and discoid lateral meniscus were the predominant conditions in pediatric patients who underwent knee arthroscopic surgery for knee pain. Knee arthroscopy is useful to provide a definitive diagnosis for knee pain in pediatric patients. Preoperative evaluations had a diagnostic accuracy of only 83.2 % and failed to diagnose conditions such as medial plica syndrome and chondral injury. Therefore, diagnosis before knee arthroscopy has to be interpreted with caution.     

Administration of enoxaparin 24 h after total knee arthroplasty: safer for bleeding and equally effective for deep venous thrombosis prevention

Background

The purpose of this study was to determine the safety and effectiveness, as assessed by risk of bleeding and incidence of deep venous thrombosis (DVT), of administering delayed low-molecular-weight heparin (LMWH) after total knee arthroplasty.

Methods

A prospective study of 210 consecutive patients undergoing primary unilateral total knee arthroplasty was undertaken. The patients were randomized into two groups: one of which was managed according to a standard LMWH program (LMWH-s group) and the other with delayed LMWH (LMWH-p). LMWH was initiated 12 h after wound closure in the LMWH-s group, and 24 h after wound closure in the LMWH-p group.

Results

The total blood loss in the first three postoperative days was calculated and all complications were recorded. The mean total blood loss was 435 and 387 mL in the LMWH-s group and LMWH-p group, respectively (p < 0.01). No significant difference in the incidence of symptomatic DVT was observed. The mean length of hospital stay was 7.29 days in the LMWH-s group and 6.56 days in the LMWH-p group (p < 0.05).

Conclusions

After total knee arthroplasty, LMWH-p is safer for bleeding than LMWH-s and equally effective concerning prevention of DVT.     

Diabetes mellitus increases the incidence of deep vein thrombosis after total knee arthroplasty

Introduction

Many patients undergoing total knee arthroplasty (TKA) have diabetes mellitus, which may increase the risk of deep vein thrombosis (DVT) after TKA. We therefore assessed whether diabetes mellitus increased the incidence of DVT within 14 days after TKA.

Materials and methods

The incidence of DVT within 14 days of surgery was compared in diabetic and non-diabetic patients undergoing TKA in our hospital between June 2011 and February 2013. The relationships between diabetes mellitus and DVT were analyzed.

Results

Of the 358 enrolled patients, 70 (19.6 %) had diabetes and 288 (80.4 %) did not. DVT occurred within 14 days in 198 patients, 52 of 70 (74.3 %) in the diabetes group and 146 of 288 (50.7 %) in the non-diabetes group (p = 0.012). DVT of the contralateral leg was observed in 16 and 50 patients, respectively (p = 0.452). Logistic regression analysis showed that the risk of DVT was 2.71-fold higher in patients with than without diabetes mellitus (95 % CI 1.183–6.212, p = 0.018). There were no significant differences in age, gender, hypertension, BMI, duration of surgery, intra-operative blood loss, and duration of tourniquet between the two groups.

Conclusions

The incidence of DVT 14 days after TKA was significantly higher in patients with than without diabetes.     

Incidence of postoperative deep vein thrombosis after robotic-assisted laparoscopic prostatectomy: a prospective study in Chinese patients

Objective

To investigate the incidence of deep vein thrombosis (DVT) in Chinese patients undergoing robotic-assisted laparoscopic radical prostatectomy (RALP) for prostate cancer and the need for prophylactic anticoagulation.

Methods

From August 2007 to September 2010, patients with prostate cancer undergoing RALP in our center were prospectively recruited for the study. Perioperative parameters, including patients’ age, disease stage and pathology, and intraoperative findings were collected. All patients underwent Doppler ultrasonographic evaluation of their bilateral lower limbs on postoperation day 3 for any evidence of DVT. The incidence of and possible predisposing factors for DVT were determined.

Results

One hundred and nine consecutive patients were recruited during the study period. The incidence rate of post-RALP DVT was 16.9 % (18 cases), with only one patient (1 %) developing above-knee DVT. No patient developed DVT-associated complications during follow-up. Patients with DVT were older (69.2 ± 4.4 vs. 65 ± 5.8 years old; p = 0.05), had greater intraoperative blood loss (775 vs. 264.7 ml; p = 0.001) and required lengthier hospitalization (8.1 vs. 6.0 days; p = 0.013). However, no difference in smoking history, body mass index, history of diabetes, lymph node dissection or disease stage was observed between patients with and without DVT.

Conclusions

The post-RALP incidence of DVT in Chinese populations is not low. However, the majority of DVT cases are below the knee level and asymptomatic.     

Quantitative index for deciding whether to administer preventive anticoagulant therapy in osteoarthritis patients undergoing total knee arthroplasty

Background

The 2008 American Academy of Orthopedic Surgeons recommended that surgeons assess the relative risks of venous thromboembolism and bleeding in patients undergoing total knee arthroplasty (TKA). In this situation, a quantitative index is required for deciding whether to administer preventive anticoagulant therapy for deep venous thrombosis (DVT). In this study, we investigated the risk factors for DVT after TKA.

Methods

We included 102 patients (122 knees) who underwent primary TKA for osteoarthritis of the knee between October 2007 and March 2010. DVT was evaluated using lower limb venous ultrasonography. Cutoff values for individual risk factors were determined using a receiver-operating characteristic analysis, and the patients were grouped according to the cutoff values; the odds ratios (95 % CI) were also investigated. The Wilcoxon signed-rank test and χ ² test were also used.

Results

DVT was positive in 25 knees (20.5 %). Three risk factors for DVT after TKA were identified: age 76 years or older, preoperative maximum soleus vein (MAX-SV) diameter of 6.0 mm or greater, and preoperative D-dimer value of 1.1 μg/dl or higher. The incidence of DVT was significantly higher in the group with two or more risk factors than in the group with one or no risk factors (p = 0.0001).

Conclusions

Development of postoperative DVT correlated significantly with the presence of the following risk factors: age 76 years or older, preoperative MAX-SV diameter of 6.0 mm or greater, and a preoperative D-dimer value of 1.1 μg/dl or higher. Considering the risk–benefit ratio, avoiding preventive anticoagulant therapy following TKA can be an option for patients with osteoarthritis with one or no risk factors.     

Correlation of clinical examination,ultrasound sonography,and magnetic resonance imaging findings with arthroscopic findings in relation to acute and chronic lateral meniscus injuries

Purpose

The aim of this study was to evaluate whether ultrasound sonography (USS) performed by orthopedic surgeons is a reliable method of investigating lateral meniscus (LM) knee lesions as compared to magnetic resonance imaging (MRI), and arthroscopy, which is the gold standard in clinical practice.

Methods

In total, 107 patients were involved in this study. They were hospitalized for arthroscopy due to LM injury of the knee. Clinical examination (McMurray’s, Apley’s, and joint line tenderness tests), USS, and MRI were performed prior to arthroscopy. We compared the results of clinical examination, USS, and MRI with the arthroscopic findings for the knee, which were considered the reference values.

Results

McMurray’s clinical test, which is the most sensitive method of detecting lateral meniscus lesions, gave the same sensitivity rate for both acute and chronic LM injuries: 65 %. USS was observed to be more sensitive and specific for chronic LM injuries (85 and 90 %, respectively) than for acute LM injuries (71 and 87 %). MRI also yielded higher values of sensitivity and specificity for chronic lateral meniscus injuries (75 and 95 %, respectively) than for acute LM injuries (68 and 87 %).

Conclusions

The accuracy of ultrasound examination is demonstrated by the high reliability of this method in the diagnosis of lateral meniscus lesions of the knee, and the evaluation performed in this study showed that ultrasound is a useful clinical tool for diagnosing knee pathology.     

Hydrocortisone reduces postoperative shivering following day care knee arthroscopy

Purpose

Postoperative shivering is commonly observed in patients after general anesthesia. A double-blind randomized controlled trial was conducted in patients undergoing day care knee arthroscopy to test the hypothesis that a single intraoperative dose of hydrocortisone would prevent or attenuate postoperative shivering.

Methods

One hundred and twenty patients were given a nitrous oxide-isoflurane-remifentanil anesthetic. Approximately ten minutes before the end of anesthesia, they were randomized to receive normal saline (Control group; n = 40); hydrocortisone 1 mg·kg^?1 iv (Hydrocortisone-1 group; n = 40), or hydrocortisone 2 mg·kg^?1 iv (Hydrocortisone-2 group; n = 40). Postoperative shivering was graded by a blinded observer using a five-point scale: Grade 0: none; Grade 1: one or more areas of piloerection but without visible muscular activity; Grade 2: visible muscular activity confined to one muscle group; Grade 3: same as Grade 2 but in more than one muscle group; and Grade 4: gross muscular activity involving the entire body.

Results

Shivering (Grades 1-4) was observed in 33 patients (82%) in the Control group, 13 patients (32%) in the Hydrocortisone-1 group (P < 0.001 compared with the Control group), and eight patients (20%) in the Hydrocortisone-2 group (P < 0.001 compared with the Control group). The overall incidence of shivering was similar in the Hydrocortisone-1 and Hydrocortisone-2 groups.

Conclusions

This study shows that hydrocortisone (1-2 mg·kg^?1 iv) provides effective prophylaxis against postoperative shivering in patients undergoing day care knee arthroscopy under general anesthesia.     

Is routine chemoprophylaxis necessary for prevention of venous thromboembolism following knee arthroplasty in a low incidence population?

Background

Standard thromboprophylaxis guidelines have not been applied universally in regions with low incidence of deep-vein thrombosis (DVT) considering risks of chemoprophylaxis and low incidence itself. We evaluated the prevalence of DVT, efficacy and safety of chemoprophylaxis, and necessity of pharmacological prevention in a low DVT incidence population.

Methods

One hundred and forty-eight patients undergoing unilateral total knee arthroplasty (TKA) were prospectively randomized to receive either a placebo or 2.5 mg of fondaparinux once daily for 5 days. Doppler ultrasonography was performed preoperatively and 7 days after surgery. The primary efficacy outcome was prevalence of DVT up to day 7. Secondary efficacy outcome was prevalence of symptomatic venous thromboembolism (VTE) up to day 90. Primary and secondary safety outcomes were incidence of major and minor bleeding, respectively.

Results

The prevalence of total DVT was 25.7 % in placebo group and 6.8 % in fondaparinux group (p = 0.002) and the prevalence of proximal DVT was lower in both groups with no statistical difference. There was no symptomatic VTE in either group up to day 90. Although no major bleeding was developed, fondaparinux group had a significant increase of minor bleeding events (p < 0.001).

Conclusions

There remains low incidence of VTE following TKA in East Asians even without chemoprophylaxis. Although short-term fondaparinux protocol could reduce the incidence of overall DVT, its routine use seems debatable due to extremely rare proximal DVT and symptomatic PE and drug-related bleeding complication. However, modified and selective use of chemoprophylaxis would be considerable in high risk patients.     

Incidence of symptomatic venous thrombo-embolism following shoulder surgery

Purpose

This clinical study was performed to establish the incidence of symptomatic deep vein thrombosis and pulmonary embolism after shoulder surgery as the incidence of venous thrombo-embolism complicating shoulder surgery is poorly described in literature.

Methods

We reviewed retrospectively clinical records of 920 consecutive patients who had any surgical procedure performed on their shoulder in Glan Clwyd Hospital, North Wales and a further 1,421 consecutive patients who had surgery in Morriston and Singleton Hospitals, South Wales. Patients’ records were assessed for any admissions due to proven VTE; we investigated for any radiological results suggestive of venous thrombo-embolism and for deaths in the post-operative period.

Results

We analyzed data of 2,341 patients. There was one fatal PE in this group, whereby the patient died within 48 hours following reverse shoulder replacement, and post mortem revealed massive pulmonary embolism. There were a further three cases of symptomatic, non-fatal PE. There were six cases of symptomatic DVT of lower limb. All these cases were treated successfully with anticoagulation. No upper limb DVT was identified.

Conclusion

Recent studies suggest that DVT prevalence following shoulder arthroplasty is as high as 13 %. In our study we examined occurrence of symptomatic VTE only. According to our results the prevalence of symptomatic DVT following shoulder surgery is 0.26 %, symptomatic PE 0.17 % and combined prevalence of VTE is 0.43 %. We would advise careful thought about the risk of thrombosis and use mechanical prophylaxis in shoulder surgery, especially for longer procedures. We would not recommend routine pharmacological prophylaxis unless there are additional risk factors.     

Stadiengerechte Therapie des Kniegelenkinfekts nach Arthroskopie

Objective

The goal is early diagnostic arthroscopy with irrigation and, if needed, debridement of all 6 recesses of the infected knee joint to quickly gain control of the infection and a satisfactory functional outcome.

Indications

Arthroscopic irrigation without delay is indicated even if a knee joint infection is only suspected.

Contraindications

No existing contraindications.

Surgical technique

Arthroscopic irrigation of the knee with stage-related debridement. Particularly irrigation and debridement of the two dorsal recesses. In stage IV according to Gächter, open synovectomy and radical debridement is recommended.

Postoperative management

In case of persistent infection, early revision. After removement of drainages mobilisation with continous passive motion. Antibiotic therapy is necessary even after the infection has been treated.

Results

Arthroscopic irrigation with stage-related debridment of all 6 recesses in combination with antibiotic therapy is the standard procedure for knee joint infections when there is no arthroplasty. Open surgery with debridement of infected bone tissue is indicated in patients with stage IV according to Gächter. Decisive for good results is an early intervention.     

Deep venous thrombosis following different isolated lower extremity fractures: what is known about prevalences, locations, risk factors and prophylaxis?

Introduction

Deep venous thrombosis (DVT) offers a high risk of morbidity and mortality, especially in case of pulmonary embolism. Precise data as to DVT after isolated lower extremity fractures (ILEFs) are rare. Even organizations like the American Academy of Orthopaedic Surgeons or the American College of Chest Physicians do not state exact recommendations as to optimal DVT prophylaxis (ppx) after ILEFs.

Prevalence

The incidence of DVT ranges from 5 to 86 % depending on the fracture whereas femur fractures offer the highest risk for clotting. The incidence seems to decrease in more distal fractures. Location: The risk to develop proximal clots is likely low, however, especially these are feared by surgeons. DVT can occur in both the injured and uninjured leg with a trend for higher incidences in the injured leg.

Risk factors

Risk factors for DVT after ILEF seem to be similar to risk factors for DVT development after orthopaedic surgery and in general. Risk factors caused by surgeons are the use of a tourniquet, prolonged operative time and a delay from injury to surgery.

Prophylaxis

Low molecular weight heparin is favoured by many authors, however, warfarin and acetylsalicylic acid are also used. Clear recommendations are still missing.

Conclusion

The rate of morbidity caused by DVT after ILEF is poorly understood so far. Exact data on prevalences are missing and optimal DVT prophylaxis still has to be defined.     

Nationwide practice patterns for the use of venous thromboembolism prophylaxis among men undergoing radical prostatectomy

Purpose

To examine the practice patterns and predictors of VTE prophylaxis following radical prostatectomy (RP).

Methods

This was a population-based observational study of 94,709 men with a diagnosis of prostate cancer (ICD-9 code 185) who underwent RP were identified from a hospital-based database from 2000 to 2010, including 68,244 (72.1 %) open RP (ORP) and 26,465 (27.9 %) robotic-assisted laparoscopic RP (RALP). VTE prophylaxis was classified as none, mechanical, pharmacologic, or combination.

Results

Following RP, 35,591 (52.2 %) received mechanical, 4,945 (7.2 %) pharmacologic, 7,720 (10.6 %) combination, and 20,438 (30.0 %) no VTE prophylaxis. A total of 245 VTE events (145 DVT, 114 PE) were identified, representing 0.25 % of all procedures. Men with >2 comorbidities (OR = 2.44; 95 % CI 1.78–3.35) and those who were black (OR = 1.44; 95 % CI 1.06–1.97) were more likely to have a VTE. Men who had RALP (OR = 0.61; 95 % CI 0.45–0.99), surgery at high-volume hospitals (OR = 0.45; 95 % CI 0.28–0.73), or received prophylaxis (OR = 0.67; 95 % CI 0.50–0.88) were less likely to develop a VTE.

Conclusion

Despite the observation that VTE prophylaxis reduces the risk of VTE by 40 %, VTE prophylaxis was not used in almost one-third of men who underwent radical prostatectomy.     

Retrospective comparison of three thromboprophylaxis agents,edoxaban, fondaparinux,and enoxaparin,for preventing venous thromboembolism in total knee arthroplasty

Purpose

Patients undergoing total knee arthroplasty (TKA) are at high risk of venous thromboembolism, manifesting as deep vein thrombosis (DVT) or pulmonary embolism. The purpose of this study is to evaluate the efficacy and safety of edoxaban 15 mg once daily (o.d.) for preventing DVT in patients undergoing TKA.

Methods

Three hundred patients undergoing primary TKA under general anaesthesia for osteoarthritis were enrolled in this study: 100 treated with enoxaparin 2,000 IU twice daily (b.i.d.), 100 treated with fondaparinux 1.5 mg o.d. and 100 treated with edoxaban 15 mg o.d.. All treatments were scheduled to continue for 14 days.

Results

The incidence of DVT in patients treated with edoxaban 15 mg o.d. was lower than in patients with enoxaparin 2,000 IU b.i.d. and fondaparinux 1.5 mg o.d.. D-dimer levels were significantly lower in patients with edoxaban than in patients with enoxaparin and fondaparinux 1.5 mg o.d. on the first postoperative day; ΔHb levels were lower in patients with edoxaban than in patients with enoxaparin and fondaparinux on postoperative days, However, the difference was not statistically significant. Finally, the incidence of hepatic dysfunction was lower in patients with edoxaban than in patients with enoxaparin and fondaparinux.

Conclusions

Edoxaban 15 mg o.d. was more efficient than enoxaparin 2,000 IU b.i.d. and fondaparinux 1.5 mg o.d.. Furthermore, edoxaban was safe compared with enoxaparin and fondaparinux. Edoxaban, an orally administered direct factor Xa (FXa) inhibitor, may offer a new option for preventing DVT, with a level of evidence III.     

Second-look arthroscopy after surgical treatment of Schatzker type II plateau fractures through the lateral submeniscal approach

Main problem

To evaluate cartilage healing using second-look arthroscopic examination in tibia plateau fracture patients who have undergone open reduction and internal fixation with a submeniscal approach technique.

Methods

Between January 2007 and January 2010, we used second-look arthroscopy during 18–24-month follow-up of 20 patients with Schatzkar type II tibial plateau fractures who had undergone open reduction and internal fixation with a submeniscal approach technique. We classified patients according to step-off, knee range of motion, and Knee Society Score, and compared the results with those obtained by arthroscopy.

Results

Radiologically, 16 cases (80 %) were reduced within 2 mm of step-off. In 11 of these cases, according to the Outerbridge classification, we checked for chondromalacia from grade II to III. We observed 2 mm of step-off in four cases, and each had chondromalacia of at least grade III. The Knee Society Score was associated with chondromalacia grade (p < 0.05).

Conclusion

Even in patients with normal joint range of motion and good clinical and radiological results, the actual condition of the articular cartilage varied significantly. Therefore, more long-term and regular follow-up is needed for proximal plateau fractures.     

Outpatients thromboprophylaxis following lower limb immobilisation: an institution’s experience

Background

Thromboembolism is a recognised preventable complication following lower limb immobilisation. This study evaluates an institution's experience of outpatient Venous Thromboembolism (VTE) prophylaxis using either Dalteparin administered subcutaneously or off-license Dabigatran orally in patients with lower limb injury requiring immobilisation.

Method

Group I consisted of 383 patients who were given either Dalteparin subcutaneously (239) or off-license Dabigatran (128) VTE prophylaxis orally following lower limb injury requiring immobilisation with 15 patients declined either option. Group II consisted of 679 patients that did not receive any thromboprophylaxis following lower limb injury requiring immobilisation. Clinical identifiable Pulmonary Embolism (PE) and Deep Vein Thrombosis (DVT) were extracted from the prospective VTE database and electronic patient records for Group I. While for Group II, this was information was obtained from patient’s records (retrospectively).

Results

There was no significant difference (Fisher's exact test) between Group I and Group II for DVT (0.168) and PE (0.284). The clinical PE and DVT incidence rate in Group I was 0.5 and 0 %, respectively, while in Group II, it was 0.1 and 0.7 %, respectively. One patient developed haemoptysis after Dabigatran was administered orally, and one patient had gastrointestinal bleeding after Dalteparin was given subcutaneously; no adverse medical harm came to either patient.

Conclusion

Although this study was unable to demonstrate, a statistically significant impact on VTE rates with prophylaxis, the protective role of prophylaxis is suggested by the low incidence of VTE in our study population, which is comparable to literature (20 %).

Level of Evidence: Therapeutic Level III

     

Is there a Valid and Reliable Assessment of Diagnostic Knee Arthroscopy Skill?

Background

The Basic Arthroscopic Knee Skill Scoring System (BAKSSS) has construct validity as an objective measure of arthroscopic proficiency when used to assess the task of performing arthroscopic meniscectomies on cadaver knees. The reliability of this instrument is unknown.

Questions/purpose

We asked whether (1) a simple modification of the BAKSSS would show construct validity similar to that in the initial BAKSSS study, (2) this assessment would be reliable, and (3) this assessment could be used as a high-stakes pass or fail test.

Methods

Twenty-three orthopaedic residents performed diagnostic knee arthroscopies on cadaveric knee specimens. Their competency was assessed by three live raters using the modified BAKSSS. Interrater reliability was assessed by comparing the scores given by each rater to each subject.

Results

The modified BAKSSS showed construct validity with junior residents achieving lower scores (mean score, 20) than senior residents (mean score, 33). The modified BAKSSS had an interrater reliability of kappa = 0.685–0.852. The modified BAKSSS had a kappa = 0.543 when used as a proficiency test for diagnostic arthroscopy.

Conclusions

The modified BAKSSS is useful for assessing diagnostic knee arthroscopy proficiency. Future scoring systems should be designed to be generalizable so they can be applied to multiple procedures without the need for modification, allow for video-based assessment, and must be rigorously tested for reliability and other types of validity (eg, face validity, content validity, and criterion-related validity).

Clinical Relevance

Having a valid and reliable assessment of basic arthroscopic procedures may allow educators to more adequately evaluate individual residents and the effectiveness of various training modalities.