Aspirin as a thromboprophylaxis agent after revision knee arthroplasty: A retrospective analysis.

Introduction: Total knee arthroplasty is a common and effective procedure. Although complication rates are low, certain complications such as venous thromboembolism are potentially serious. The optimal prophylactic agent and dosage after revision knee arthroplasty remains unclear. The main objective of this work was to study the efficacy and safety of aspirin as a thromboprophylaxis agent following revision knee arthroplasties. Patients and methods: A retrospective review of patients undergoing revision knee arthroplasty between 2013 and 2020at a University Teaching Hospital was undertaken. The primary outcome was the development of a symptomatic thromboembolic event requiring treatment within 90 days post-surgery. The secondary outcomes were adverse events associated with aspirin therapy: surgical site infection rate; incidence of major bleeding; readmission rate and mortality within 90 days post-surgery. Results: 490 patients were included. 374 (76.3%) received prophylactic aspirin (150 mg once daily for 28 days) and 75 (15.3%) patients received dalteparin for 28 days due to contraindication to aspirin use. Those already receiving other thromboprophylaxis agents for pre-existing comorbidities continued these after relevant medical consultation. The overall rates of venous thromboembolism and symptomatic DVT after aspirin prophylaxis were 0.6% (3/490) and 0.8% (3/374), respectively. VTE incidence did not significantly differ between those administered aspirin and other agents. No patient experienced major bleeding within 90 postoperative days. Only 2 of 490 (0.4%) patients had wound infection requiring readmission; neither received prophylactic aspirin. Conclusion: Extended out-of-hospital thromboembolic prophylaxis with aspirin may be at least as effective as other agents in patients undergoing revision knee arthroplasty. Aspirin is safe, effective, and cheap compared with other agents.

The effect of the COVID-19 pandemic on hip fracture care: our experience at the University Hospitals of Leicester (UHL).

The United Kingdom (UK) Covid-19 pandemic has led to unique changes in the operation of the National Health Service (NHS) including within trauma and orthopaedics. This has led to a significant impact on the NHS ability to provide hip fracture care and sustain emergency surgery. This has led to local hip fracture services changing operations to provide more sustainable care and significant impacts on best practice tariffs. Data was collected using the National Hip Fracture Database data submitted by UHL and split into two cohorts - Pre Covid-19 and Post Covid-19. Data has been collected for 67 consecutive patients in April 2019 (Pre Covid-19) and 87 consecutive patients in April 2020 (Post Covid-19) as of 4th May after the introduction of the Covid-19 measures locally. Data has been collected on demographics- age and sex, ASA, admission time, time of operation, 30 day mortality and length of stay. The average time to theatre in the pre Covid-19 cohort was 27.3 hours and in the post Covid-19 cohort was 45.1 hours. This is an increase of 65.2%. All patients in the pre Covid-19 cohort were operated on and 4 in the post Covid-19 were conservatively managed. However, there were no significant effects on 30 day mortality or length of stay. In conclusion, the measures taken due to the Covid-19 pandemic had a profound impact on the care of hip fracture patients with significant delays in time to theatre. As a result, it is clear that the measures influenced practice at UHL and the best practice tariffs were not met.

Early Total Enteral Feeding in Stable Very Low Birth Weight Infants: A Before and After Study.

Background: Fear of necrotizing enterocolitis (NEC) has perpetuated delayed initiation and slow advancement of enteral feeding in very low birth weight (VLBW) infants with inherent risks of parenteral alimentation. The objective of this study was to assess effect of early total enteral feeding (ETEF) on day of achievement of full enteral feeds, feed intolerance, NEC and sepsis. Methods: In total, 208 stable VLBW neonates (28-34 weeks) admitted during 6 month periods of three consecutive years were enrolled. First phase (n = 73) constituted the 'before' phase with standard practice of initial intravenous fluid therapy and slow enteral feeding. The second prospective phase (n = 51) consisted of implementation of ETEF with infants receiving full enteral feeds as per day's fluid requirement since Day 1 of life. The third phase (n = 84) was chosen to assess the sustainability of change in practice. Results: Day of achievement of full feeds was significantly earlier in Phases 2 and 3 compared with Phase 1 (8.97 and 5.47 vs. 14.44 days, respectively, p = 0.0001). Incidence of feed intolerance was comparable between Phases 1 and 2 (22 vs. 14%, p = 0.28), with marked reduction in incidence of NEC (14 vs. 4%, p = 0.028). There was a significant decrease in sepsis, duration of parenteral fluid and antibiotic therapy as well as hospital stay with comparable mortality. Conclusion: In stable preterm VLBW infants, ETEF is safe and has the benefit of optimizing nutrition with decrease in sepsis, NEC and hospital stay.

Thromboprophylaxis in Ambulatory Trauma Patients With Foot and Ankle Fractures: Prospective Study Using a Risk Scoring System.

UNLABELLED: Lower-limb immobilization has been implicated as an etiological factor for venous thromboembolic events (VTEs). However, there is no patient-centered scoring system available for risk assessment in ambulatory trauma patients with temporary lower-limb immobilization. A patient questionnaire scoring system has been developed for ambulatory patients with foot and ankle fracture being managed nonoperatively as outpatients by temporary lower-limb immobilization. Patients are classed as either high or low risk for developing a VTE and offered low-molecular-weight heparin (LMWH) accordingly. This is a prospective study of 150 patients with a follow-up of 6 months. Only 3 patients developed VTEs: one was noncompliant with medicine, one was started on LMWH 2 days after getting a plaster cast, and the third was not started on LMWH in spite of family history of VTEs. This study showed that using this scoring system, LMWH can be used safely and effectively as a thromboprophylactic agent for ambulatory trauma patients requiring temporary lower-limb immobilization to manage foot and ankle fractures. It is a step toward developing a validated clinical prediction score to enable risk assessment in ambulatory trauma patients who are managed non-operatively with temporary lower limb immobilization. LEVELS OF EVIDENCE: Prognostic, Level IV: Case series.

Is ultrasound diagnosis reliable in acute extensor tendon injuries of the knee?

Ruptures of the patellar and quadriceps tendon are rare injuries requiring immediate repair to re-establish knee extensor continuity and allow early motion. Ultrasound is extensively used as a diagnostic tool before surgery on acute traumatic tears of the patellar tendon and quadriceps tendons. The aim of our study was to evaluate the role of sonography in diagnosing quadriceps and patellar tendon rupture and in differentiating partial from complete tears. We conducted a retrospective review of 51 consecutive patients who had a surgical intervention for suspected acute quadriceps and patellar tendon rupture over a 5-year period. Intra-operative findings were compared with pre-operative clinical examination. Radiographs, ultrasound and MRI reports were reviewed. On clinical examination, 22 patients had a suspected patellar tendon rupture and 29 patients had a suspected quadriceps tendon rupture. Diagnosis was confirmed by clinical examination and plain radiographs alone in 13 patients, with additional ultrasound performed in 24 patients and MRI scan performed in 14 patients. There were 8 false positives out of 24 [33.3%] in the ultrasound proven group and 1 false positive out of 13 [7.69%] in the clinical examination and radiographs only group. MRI was 100% accurate. We conclude that ultrasonography is not a reliable method in establishing the diagnosis of acute injuries to the extensor mechanism of the knee, particularly the quadriceps tendon ruptures in the obese and the very muscular patients. If there is clinical ambiguity, MRI scan is a better investigation tool before undertaking surgical treatment.

Non-traumatic anterior mediastinal abscess in childhood.

Anterior mediastinal abscesses (MAs) due to a non-traumatic etiology are extremely rare in childhood and only 13 such cases have been reported in the literature. We report a 5-year-old male child with disseminated staphylococcal infection and a large non-traumatic anterior MA, who had a successful recovery after surgical drainage of the abscess.

Metachronous occurrence of multifocal phaeochromocytoma.

The authors report an 8-yr-old boy who presented with hypertension, psychosis, and visual disturbances due to a left adrenal phaeochromocytoma which was excised. After 4 years, the child developed multifocal phaeochromocytomas in the left suprarenal area, right adrenal gland, and left para-aortic region. The tumors were excised along with re-implantation of normal adrenal tissue from the right adrenal into the omentum. The course of the disease and the family history were suggestive of von Hippel-Lindau (VHL) disease.