Synovial Calprotectin is Superior to Synovial Leukocyte Count in Excluding Chronic Periprosthetic Joint Infections, a Retrospective Cohort Study.

BACKGROUND: Synovial calprotectin is a promising biomarker for diagnosing chronic periprosthetic joint infections (PJIs), but its diagnostic value has not been directly compared to synovial leukocyte count and polymorphonuclear neutrophils. This study aimed to: (1) evaluate and compare the diagnostic accuracy between these markers in patients undergoing revision arthroplasty for chronic PJI or aseptic reasons; and (2) determine the best rule-out and rule-in test for PJI. METHODS: Synovial fluid samples from patients undergoing revision arthroplasty in hip and knee joints were collected and analyzed. Patients diagnosed with an acute PJI, patients treated with antibiotics 2 weeks prior to revision surgery, and/or patients who had active inflammatory joint disease were excluded. Periprosthetic joint infections were diagnosed based on the presence of a sinus tract and/or positive intraoperative cultures according to the European Bone and Joint Infection Society microbiological criteria. RESULTS: A total of 137 patients were included, of whom 19 (14%) were diagnosed with a PJI. Overall, synovial calprotectin had the highest diagnostic accuracy of all studied markers (area under the curve 96%). Synovial calprotectin, with a cutoff of 50 mg/L, had the highest negative predictive value of 100%. However, PMNs (> 80%) combined with a leukocyte count (> 3,000 cells/µL) showed the highest positive likelihood ratio of an infection (PLR 17). CONCLUSIONS: Synovial calprotectin is the most accurate biomarker for ruling out a chronic PJI, while the combination of synovial leukocyte count and PMN is most reliable for ruling in a chronic PJI.

Positive Intraoperative Cultures in Cup Revisions of THA: What Happens to the Stem?

BACKGROUND: Positive intraoperative cultures (PICs) are encountered in some patients undergoing revision of the acetabular cup after a previous THA. It is unknown whether PIC of the cup indicates whether the stem is infected as well and what happens to the stem during follow-up. QUESTIONS/PURPOSES: (1) What proportion of patients undergoing THA who undergo cup revision have PICs? (2) What is the survival of the stem during follow-up in cup revisions with PICs versus that of those with negative cultures? (3) Does antibiotic treatment of PIC of the cup prevent revision THA during follow-up? METHODS: In this retrospective, comparative multicenter study, five surgeons at four centers performed 338 acetabular cup revisions between January 2015 and December 2017. After evaluating the data, we excluded one patient because of an incomplete dataset and 77 patients because fewer than three intraoperative cultures were obtained during surgery, leaving 260 patients for analysis. Follow-up was 2 years. Patients were stratified into three cohorts: no PIC, one PIC, and two or more PICs. RESULTS: The proportion of patients with one or more PIC was 15% (39 of 260). A total of 8% (21 of 260) had one and 7% (18 of 260) had two or more PICs. Stem survival was lower in patients with two or more PICs, but stem revision for periprosthetic joint infection was similar between groups. Two-year survival, which was defined as freedom from revision for any cause or infection, was 97% (95% confidence interval 95% to 99%) in the group without PICs, 100% (95% CI 95% to 100%) in the group with one PIC, and 86% (95% CI 68% to 100%; p = 0.08) in the group with two or more PICs. None of the patients in the no PIC and one PIC groups were treated with antibiotics. In the two or more PICs cohort, 12 of 18 patients were treated. The stem survived in one of 12 patients treated with antibiotics versus two of six patients who were not treated with antibiotics. CONCLUSION: When treated with antibiotics, more than two PICs isolated during cup revision surgery do not have a major impact on survival of the stem during follow-up. A larger cohort of patients with PICs during cup revision might confirm these findings. LEVEL OF EVIDENCE: Level III, therapeutic study.

Revision risk by using the direct superior approach (DSA) for total hip arthroplasty compared with postero-lateral approach: early nationwide results from the Dutch Arthroplasty Register (LROI).

BACKGROUND AND PURPOSE: The direct superior approach (DSA) is a modification of the classic posterolateral approach (PLA) for total hip arthroplasty (THA), in which the iliotibial band and short external rotators are spared. The revision rate of the DSA has not been investigated previously using arthroplasty registry data. We examined the reasons and risk of revision of the DSA, compared with the direct anterior approach (DAA) and PLA. PATIENTS AND METHODS: In this population-based cohort study we included 175,543 primary THAs performed between 2014 and 2020 (PLA, n = 117,576; DAA, n = 56,626; DSA, n = 1,341). Competing risk survival analysis and multivariable Cox proportional hazard analyses, adjusted for potential confounders, were performed. RESULTS: After 3 years, crude revision rates due to any reason were 2.1% (95% confidence interval [CI] 1.3-3.3) for DSA, and 2.9% (CI 2.8-3.0) for PLA. Crude dislocation revision rates were 0.3% (CI 0.1-0.8) for DSA, versus 1.0% (CI 0.9-1.0) for PLA. Dislocation revision rate for DSA did not differ from DAA (0.3% [CI 0.2-0.3]). Multivariable Cox regression analysis demonstrated no overall difference in revision rates for the DSA (HR 0.6 [CI 0.4-1.09) compared with the PLA. Lower risk of revision due to dislocation was found in patients operated on through the DSA (HR 0.3 [0.1-0.9]) compared with the PLA. CONCLUSION: Early nationwide results suggest that the DSA for total hip arthroplasty seems to show a tendency towards a lower risk of revision for dislocation but no overall reduced revision risk compared with the PLA.

No clinically relevant difference in patient-reported outcomes between the direct superior approach and the posterolateral or anterior approach for primary total hip arthroplasty: analysis of 37,976 primary hip arthroplasties in the Dutch Arthroplasty Registry.

BACKGROUND AND PURPOSE: The direct superior approach (DSA) is a modification of the posterolateral approach (PLA) for total hip arthroplasty (THA). Patient-reported outcome measures (PROMs) of the DSA have not been investigated previously using nationwide data. Our aim was to assess PROMs after THA using the DSA compared with the PLA and, secondarily, with the anterior approach (DAA). PATIENTS AND METHODS: In this population-based cohort study we included 37,976 primary THAs performed between 2014 and 2020 (PLA: n = 22,616; DAA: n = 15,017; DSA: n = 343) using Dutch Arthroplasty Registry data. PROMs (NRS pain, EQ-5D, HOOS-PS, and OHS) were measured preoperatively, and at 3 and 12 months postoperatively. Repeated measurements were analyzed using mixed-effects models, adjusted for confounders, to investigate the association between surgical approach and PROMs over time. RESULTS: From baseline to 3 and 12 months, improvements for NRS pain scores, EQ-5D, and OHS were comparable for the DSA compared with the PLA or DAA. No difference was found in HOOS-PS improvement 3 months postoperatively between DSA and PLA (-0.2, 95% confidence interval [CI] -2.4 to 1.9) and between DSA and DAA (-1.7, CI -3.9 to 0.5). At 12 months postoperatively, patients in the DSA group had improved -2.8 points (CI -4.9 to -0.6) more in HOOS-PS compared with the DAA, but not with the PLA group (-1.0, CI -3.2 to 1.1). CONCLUSION: Our study showed no clinically meaningful differences between the DSA and either PLA or DAA.

Symptomatic venous thromboembolism after trauma surgery : a study on 56.884 procedures.

Patients undergoing trauma surgery are at significant risk for developing thromboembolism. Venous thromboembolism rates, especially after less common surgical procedures are unknown. The purpose of this study is to establish data on the incidence of venous thromboembolism in trauma practice following a surgical procedure. All surgical trauma procedures between 2006 and 2011 were identified within the Achmea Health Database. This database records medical care to persons insured at the Achmea health insurance company. This is the largest health insurance company in the Netherlands. In the year following the surgical procedure we analyzed if a claim was filed concerning a deep venous thrombosis or pulmonary embolism. 56.884 surgical trauma procedures were included in the analysis and followed for one year thereafter. Venous thromboembolism development was raised most markedly until 100 days after the surgical procedure. Relatively high incidences of venous thromboembolism were found after surgical lower extremity and pelvic procedures. The present large database study provides a comprehensive view on the epidemiology of venous thromboembolism after different traumatic injuries requiring a surgical procedure.

CT radiation dose reduction in patients with total hip arthroplasties using model-based iterative reconstruction and orthopaedic metal artefact reduction.

OBJECTIVE: To evaluate the impact of radiation dose reduction on image quality in patients with metal-on-metal total hip arthroplasties (THAs) using model-based iterative reconstruction (MBIR) combined with orthopaedic metal artefact reduction (O-MAR). MATERIALS AND METHODS: Patients with metal-on-metal THAs received a pelvic CT with a full (FD) and a reduced radiation dose (RD) with -20%, -40%, -57%, or -80% CT radiation dose respectively, when assigned to group 1, 2, 3, or 4 respectively. FD acquisitions were reconstructed with iterative reconstruction, iDose4. RD acquisitions were additionally reconstructed with iterative model-based reconstruction (IMR) levels 1-3 with different levels of noise suppression. CT numbers, noise and contrast-to-noise ratios were measured in muscle, fat and bladder. Subjective image quality was evaluated on seven aspects including artefacts, osseous structures, prosthetic components and soft tissues. RESULTS: Seventy-six patients were randomly assigned to one of the four groups. While reducing radiation dose by 20%, 40%, 57%, or 80% in combination with IMR, CT numbers remained constant. Compared with iDose4, the noise decreased (p < 0.001) and contrast-to-noise ratios increased (p < 0.001) with IMR. O-MAR improved CT number accuracy in the bladder and reduced noise in the bladder, muscle and fat (p < 0.01). Subjective image quality was rated lower on RD IMR images than FD iDose4 images on all seven aspects (p < 0.05) and was not related to the applied radiation dose reduction. CONCLUSION: In RD IMR with O-MAR images, CT numbers remained constant, noise decreased and contrast-to-noise ratios between muscle and fat increased compared with FD iDose4 with O-MAR images in patients with metal-on-metal THAs. Subjective image quality reduced, regardless of the degree of radiation dose reduction.

Similar Superior Patient-Reported Outcome Measures for Anterior and Posterolateral Approaches After Total Hip Arthroplasty: Postoperative Patient-Reported Outcome Measure Improvement After 3 months in 12,774 Primary Total Hip Arthroplasties Using the Anterior, Anterolateral, Straight Lateral, or Posterolateral Approach.

BACKGROUND: Patient-reported outcome measures (PROMs) are used to evaluate the outcome of total hip arthroplasty (THA). We determined the effect of surgical approach on PROMs after primary THA. METHODS: All primary THAs, with registered preoperative and 3 months postoperative PROMs were selected from the Dutch Arthroplasty Register. Based on surgical approach, 4 groups were discerned: (direct) anterior, anterolateral, direct lateral, and posterolateral approaches. The following PROMs were recorded: Hip disability and Osteoarthritis Outcome Score Physical function Short form (HOOS-PS); Oxford Hip Score; EQ-5D index score; EQ-5D thermometer; and Numeric Rating Scale measuring pain, both active and in rest. The difference between preoperative and postoperative scores was calculated (delta-PROM) and used as primary outcome measure. Multivariable linear regression analysis was performed for comparisons. Cohen's d was calculated as measure of effect size. RESULTS: All examined 4 approaches resulted in a significant increase of PROMs after primary THA in the Netherlands (n = 12,274). The anterior and posterolateral approaches were associated with significantly more improvement in HOOS-PS scores compared with the anterolateral and direct lateral approaches. Furthermore, the posterolateral and anterior approaches showed greater improvement on Numeric Rating Scale pain scores compared with the anterolateral approach. No relevant differences in delta-PROM were seen between the anterior and posterolateral surgical approaches. CONCLUSION: Anterior and posterolateral surgical approaches showed more improvement in self-reported physical functioning (HOOS-PS) compared with anterolateral and direct lateral approaches in patients receiving a primary THA. However, clinical differences were only small.

Skin depigmentation along lymph vessels of the lower leg following local corticosteroid injection for interdigital neuroma.

Steroid injection is frequently used in the treatment of interdigital neuroma and has a high rate of success. We report the case of a patient who develops skin depigmentation at the injection site and linear streaks of depigmentation over the foot, the ankle and half way up to the knee after a steroid injection for interdigital neuroma. Minor disadvantages such as subcutaneous fat atrophy and depigmentation of the skin at the injection site are well known problems following steroid injection. Depigmentation of the skin with a lymphatic distribution in the foot after steroid injection for interdigital neuroma however, has not yet been reported before. This complication is a serious aesthetic problem and clinicians should be aware of this complication when treating patients with steroid injections for interdigital neuroma.

Development and first validation of a simplified CT-based classification system of soft tissue changes in large-head metal-on-metal total hip replacement: intra- and interrater reliability and association with revision rates in a uniform cohort of 664 arthroplasties.

OBJECTIVE: After implantation of a metal-on-metal total hip arthroplasty (MoM THA), a large incidence of pseudotumor formation has been described recently. Several centers have invited patients for follow-up in order to screen for pseudotumor formation. The spectrum of abnormalities found by CT in MoM THA patients can be unfamiliar to radiologists and orthopedic surgeons. Previously, a CT five-point grading scale has been published. In this paper, a simplification into a three-point classification system gives insight in the morphological distinction of abnormalities of the postoperative hip capsule in MoM implants in relation to the decision for revision. The reliability of this simplified classification regarding intra- and interrater reliability and its association with revision rate is investigated and discussed. MATERIALS AND METHODS: All patients who underwent MoM THA in our hospital were invited for screening. Various clinical measures and CT scan were obtained in a cross-sectional fashion. A decision on revision surgery was made shortly after screening. CT scans were read in 582 patients, of which 82 patients were treated bilaterally. CT scans were independently single read by two board-certified radiologists and classified into categories I-V. In a second meeting, consensus was obtained. Categories were subsequently rubricated in class A (categories I and II), B (category III), and C (categories IV and V). Intra- and inter-radiologist agreement on MoM pathology was assessed by means of the weighted Cohen's kappa. Categorical data were presented as n (%), and tested by means of Fisher's exact test. Continuous data were presented as median (min-max) and tested by means of Mann-Whitney U test (two group comparison) or Kruskal-Wallis test (three group comparison). Logistic regression analysis was performed in order to study independence of CT class for association with revision surgery. Univariate statistically significant variables were entered in a multiple model. All statistical analysis was performed two-tailed using alpha 5% as the significance level. RESULTS: In total, 664 scores from 664 MoM hips obtained by two observers were available for analyses. Interobserver reliability for the non-simplified version (I-V) was κw = 0.71 (95% CI: 0.62-0.79), which indicates good agreement between the two musculoskeletal radiologists. Intra- and interobserver reliability for the simplified version (A-C) were respectively κw 0.78 (95% CI: 0.68-0.87), and κw = 0.71 (95% CI: 0.65-0.76). This indicates good agreement within and between the two observers. The simplified A-C version is significantly associated with revision exclusively due to MoM pathology, in both patients with unilateral MoM THA (p < 0.001) and patients with bilateral MoM THA (p < 0.044). The simplified A-C version is associated with several clinical measures. In patients with unilateral MoM THA, with or without contralateral THA, in situ time (p < 0.008), cobalt and chromium (p < 0.001) were statistically significant. In patients with bilateral MoM, cobalt (p < 0.001) and chromium (p < 0.027) were statistically significant. Revision is significantly associated with cup size (p < 0.001), anteversion of the cup (p < 0.004), serum ion levels of cobalt and chromium (p < 0.001) and the adapted classification system (p < 0.001). In univariate logistic regression analysis on revision, cup, anteversion of the cup, cobalt-chromium ion serum levels, and the simplified (A-C) CT category system were statistically significant. The simplified (A-C) CT category system was an independent associate of revision, in several multiple logistic regression models. CONCLUSIONS: The presented simplified CT grading system (A-C) in its first clinical validation on 48- and 64-multislice systems is reliable, showing good intra- and interrater reliability and is independently associated with revision surgery.

Excellent results with the cemented Lubinus SP II 130-mm femoral stem at 10 years of follow-up: 932 hips followed for 5-15 years.

BACKGROUND AND PURPOSE: The Lubinus SP II stem is well documented in both orthopedic registries and clinical studies. Worldwide, the most commonly used stem lengths are 150 mm and 170 mm. In 1995, the 130-mm stem was introduced, but no outcome data have been published. We assessed the long-term survival of the Lubinus SP II 130-mm stem in primary total hip arthroplasty. PATIENTS AND METHODS: In a retrospective cohort study, we evaluated 829 patients with a Lubinus SP II primary total hip arthroplasty (932 hips). The hips were implanted between 1996 and 2001. The primary endpoint was revision for any reason. The mean follow-up period was 10 (5-15) years. RESULTS: Survival analysis showed an all-cause 10-year survival rate of the stem of 98.7% (95% CI: 99.7-97.7), and all-cause 10-year survival of the total hip arthroplasty was 98.3% (95% CI: 99.3-97.3). INTERPRETATION: Excellent long-term results can be achieved with the cemented Lubinus SP II with the relatively short 130-mm stem. This stem has potential advantages over its 150-mm and 170-mm siblings such as bone preservation distal to the stem, better proximal filling around the prosthesis, and easier removal.

Mid-term results of cemented hip arthroplasties through the direct anterior approach in the lateral decubitus position: a retrospective cohort study.

BACKGROUND: Reports show a high complication rate when starting with the Direct Anterior Approach (DAA) in a supine position for hip arthroplasty. The DAA with the patient in lateral decubitus position may avoid this problem because it supposedly provides better visibility, especially on the femoral side. However, this approach did show a rather high complication rate during the adoption of the approach at 1 year follow up in our previous report. We were interested what the overall 7 year survival estimate would be and whether improvement could be seen with growing experience. METHODS: A cohort of patients undergoing total hip arthroplasty right from the start of applying the DAA in lateral decubitus position was analysed. RESULTS: In total 175 hip prostheses (162 patients) were evaluated. The 7-year survival estimate was 95.1%, 95 CI: 91.8-98.4%. In 6 of 8 revisions there was aseptic loosening of the stem. By dividing the cohort into 3 consecutive groups in time we did not see a significantly improving revision rate. CONCLUSIONS: In our experience, the adoption of the direct anterior approach in lateral decubitus position caused a relatively low 7-year survival estimate without an apparent decrease with growing experience, however given the low number of cases further research is needed to investigate the long-term risk of adopting a new approach.

Comparison of osteolysis around 3 different cement restrictors in total hip arthroplasty.

BACKGROUND AND AIM: Several studies reported osteolysis around polyethylene glycol/polybutylene terephthalate (PEG/PBT) based femoral cement restrictors. Our goal was to evaluate and compare osteolysis around 3 different plug designs: the slow biodegradable PEG/PBT cement restrictor; the fast biodegradable gelatin cement restrictor; and the non-biodegradable polyethylene plug. PATIENTS AND METHODS: In a retrospective multicentre cohort study chart data were extracted of patients who received a total hip arthroplasty between 2008 and 2012. A total of 961 hips were included. Cortical ratio between inner and outer cortices at the centre of the plug was measured on routine postoperative follow-up moments. Median follow up of all 3 hospitals was 3.5 years (1.4-7.3). The primary outcome was evidence of osteolysis (i.e. the difference in cortical ratio [CR]) on anteroposterior (AP) radiographs at final follow-up. RESULTS: Progressive osteolysis was found around the PEG/PBT cement restrictor represented by a significantly increasing cortical ratio (ΔCR 0.067 (95% CI, 0.063-0.071). Distance from tip prosthesis to plug and size of the plug were found to be independent factors in predicting increased cortical ratio. CONCLUSIONS: Our multicentre cohort shows increase of cortical ratio around the PEG/PBT cement restrictor which progresses over time. Physicians should be aware of this fact and are advised to intensify follow-up of patients who received this cement restrictor.

Low revision rate throughout the adoption of the direct superior approach in primary total hip arthroplasty: an analysis based on 1551 total hip arthroplasties from the Dutch Arthroplasty Register.

BACKGROUND: Recently, surgeons introduced a minimally invasive modification on the classic posterolateral approach (PLA) in total hip arthroplasty (THA): the direct superior approach (DSA). We investigated the association between surgeon's experience and the risk of early revision of the DSA in primary THA, using data from the Dutch Arthroplasty Register (LROI). METHODS: We retrieved all primary THAs performed using the DSA in 4 hospitals between 2016 and 2022 (n = 1551). Procedures were sorted in 5 groups using the date of operation and number of previous procedures per surgeon: 1-25; 26-50; 51-75; 76-100; >100. Subsequently, data from different surgeons were pooled together and the risk of revision was calculated via a multilevel time-to-event analysis. RESULTS: The overall revision rate was 1.5% after a mean follow-up of 2 years. Patients from the 1-25 group had comparable risks of revision compared to patients in the >100 group (hazard ratio [HR] 1.0 [CI, 0.3-3.2]). The risk for patients in groups 26-50, 51-75 and 75-100 was also not statistically different from the >100 group (resp. HR 1.5 [CI, 0.5-5.0], 1.8 [CI, 0.5-6.4] and 0.5 [CI, 0.1-4.0]). Main reasons of revision were dislocation (0.5%) and infection (0.4%). CONCLUSIONS: We did not identify an association between the surgeon's experience and the early risk of revision for the DSA in primary THA in the Netherlands. The DSA seems safe in the early adoption phases with a low risk of revision due to dislocation and revision for all other causes.

Deep vein thrombosis after arthroscopic anterior cruciate ligament reconstruction: a prospective cohort study of 100 patients.

PURPOSE: To establish the incidence of venous thromboembolic complications as detected by bilateral complete compression ultrasonography (CCUS) after arthroscopic anterior cruciate ligament (ACL) reconstruction without thromboprophylaxis. METHODS: We performed a prospective cohort study to establish the incidence of venous thromboembolic complications after arthroscopic ACL reconstruction, as detected by bilateral CCUS at 14 days (range, 11 to 17 days) postoperatively. One hundred consecutive patients underwent bilateral extended ultrasonography. RESULTS: One hundred predominantly European patients with a mean age of 30 ± 10 years and mean body mass index of 25 ± 4 underwent ACL reconstruction with a mean operative duration of 68 ± 23 minutes and a tourniquet time of 76 ± 23 minutes. In 84% of patients an autologous hamstring graft was used, in 14% a bone-patellar tendon-bone graft was used, and 2 patients received an allograft. Of 100 patients, 9 (incidence, 9%; 95% confidence interval, 4.2 to 16.4) showed asymptomatic proximal or distal deep vein thrombosis on CCUS, of whom 4 (incidence, 4%; 95% confidence interval, 1.1 to 9.9) were symptomatic. A nonfatal pulmonary embolus developed in 1 patient during the 8-week follow-up period. CONCLUSIONS: This study shows that the incidence of venous thromboembolism after arthroscopic ACL reconstruction is relatively high; a 9% incidence of asymptomatic proximal or distal deep vein thrombosis was found, whereas 4% of patients were symptomatic. Further research is recommended to assess the need for thromboprophylaxis in patients undergoing ACL reconstruction, especially when risk factors are present. LEVEL OF EVIDENCE: Level IV, case series.

Ten-year results of a prospective cohort of large-head metal-on-metal total hip arthroplasty : a concise follow-up of a previous report.

AIMS: Large-diameter metal-on-metal (MoM) total hip arthroplasty (THA) has demonstrated unexpected high failure rates and pseudotumour formation. The purpose of this prospective cohort study is to report ten-year results in order to establish revision rate, prevalence of pseudotumour formation, and relation with whole blood cobalt levels. METHODS: All patients were recalled according to the guidelines of the Dutch Orthopaedic Association. They underwent clinical and radiographical assessments (x-ray and CT scan) of the hip prosthesis and whole blood cobalt ion measurements. Overall, 94 patients (95 hips) fulfilled our requirements for a minimum ten-year follow-up. RESULTS: Mean follow-up was 10.9 years (10 to 12), with a cumulative survival rate of 82.4%. Reason for revision was predominantly pseudotumour formation (68%), apart from loosening, pain, infection, and osteolysis. The prevalence of pseudotumour formation around the prostheses was 41%, while our previous report of this cohort (with a mean follow-up of 3.6 years) revealed a 39% prevalence. The ten-year revision-free survival with pseudotumour was 66.7% and without pseudotumour 92.4% (p < 0.05). There was poor discriminatory ability for cobalt for pseudotumour formation. CONCLUSION: This prospective study reports a minimum ten-year follow-up of large-head MoM THA. Revision rates are high, with the main reason being the sequelae of pseudotumour formation, which were rarely observed after five years of implantation. Blood ion measurements show limited discriminatory capacity in diagnosing pseudotumour formation. Our results evidence that an early comprehensive follow-up strategy is essential for MoM THA to promptly identify and manage early complications and revise on time. After ten years follow-up, we do not recommend continuing routine CT scanning or whole cobalt blood measurements, but instead enrolling these patients in routine follow-up protocols for THA. Cite this article: Bone Jt Open 2022;3(1):61-67.

Dutch orthopedic blood management surveys 2002 and 2007: an increasing use of blood-saving measures.

BACKGROUND: Hip and knee arthroplasties are frequently complicated by the need for allogeneic blood transfusions. The surveys were developed to assess the use of blood-saving measures in orthopedic surgery in the Netherlands in 2002 and 2007. STUDY DESIGN AND METHODS: In 2002 and 2007, a questionnaire on blood management measures after several orthopedic procedures was sent to all Dutch orthopedic departments (110 and 96, respectively). RESULTS: The response was 79% in 2002 and 84% in 2007. The use of preoperative autologous blood donation remained virtually unchanged in 2002 versus 2007 for both hip (10.9 and 10.5%) and knee (5.7 and 8.2%) arthroplasty. In 2007, there was a substantial increase in departments using erythropoietine for hip (31.6­66.1%) as well as knee (24.0­55.5%) arthroplasty. There was an increase of the use of autologous retransfusion of intraoperatively suctioned washed blood in hip (20.3­28.4%) as well as knee arthroplasty (8.9­16.1%) over the 5-year period, but it was predominantly used in revision hip arthroplasty (54.3%). The use of postoperative autologous retransfusion of filtered drained wound blood increased dramatically in 5 years time in hip (11.5­51.0%) and knee arthroplasty (15.9­59.3%). CONCLUSION: There is an evident increase in the preoperative use of erythropoietin and the postoperative use of autologous retransfusion of drained blood among Dutch orthopedic departments. There appears to be an increasing awareness and positive attitude among Dutch orthopedic surgeons to implement perioperative blood-saving measures.

Dutch orthopedic thromboprophylaxis: a 5-year follow-up survey.

BACKGROUND AND PURPOSE: Previous surveys in the Netherlands have revealed that guidelines regarding orthopedic thromboprophylaxis were not followed and that a wide variation in protocols exists. This survey was performed to assess the current use of thromboprophylactic modalities and to compare it with the results of a previous survey. METHODS: All departments of orthopedic surgery in the Netherlands were sent a follow-up survey on venous thromboprophylaxis, and the data obtained were compared to the results of a survey performed 5 years earlier. RESULTS: All departments used pharmacological thromboprophylaxis following arthroplasties of the hip and knee. Low-molecular-weight heparin (LMWH) was used most frequently (79%) of the departments, followed by fondaparinux (13%). 5 years earlier, coumarin treatment was the predominant prophylaxis (79%). All departments prescribed pharmacological prophylaxis after femoral and tibial fractures; 78% used LMWH. Prophylaxis was continued for 6 weeks in 85% of cases. LMWH treatment was initiated on the day before surgery in 31% of cases (65% in the previous survey), perioperatively in 55%, and in the evening following surgery in 24%. In general, for daycare surgery and arthroscopies either no prophylaxis was given or a LMWH was given for 1 day. After anterior cruciate ligament reconstruction, 94% of departments prescribed some form of pharmacological prophylaxis. INTERPRETATION: The use of pharmacological prophylaxis after arthroplasty of the hip and knee and also after fracture surgery around the hip and knee is common practice in the Netherlands. In 5 years, the widely used coumarin derivates have been largely replaced with LMWH.