GEOMETRY OF THE HIP JOINT: METHODOLOGY AND GUIDELINES

Prijelom zgloba kuka značajan je osobni, obiteljski i zdravstveni problem osoba starijih od 65 godina. U prvoj godini nakon prijeloma umire i do 30% ozlijeđenih, a oko 50% ih više ne postiže prijašnji stupanj neovisnosti u obavljanju svakodnevnih aktivnosti. Procjenjuje se da će kroz idućih 30 godina u svijetu biti oko 6 milijuna prijeloma zgloba kuka na godišnjoj razini, što je oko četiri puta više od današnjeg broja. Dosadašnja istraživanja koja su za cilj imala predviđanje prijeloma zgloba kuka na temelju njegove geometrije pokazala su da je ona neovisna varijabla od mineralne gustoće kostiju. U tom smislu geometrija kuka također je kao mjera predviđanja rezistentnija od različitih drugih čimbenika koji utječu na mineralnu gustoću kostiju, a njene promjene tijekom životnog vijeka mnogo su sporije. Specifičnost i osjetljivost geometrije kuka u predviđanju prijeloma visoka je i prihvatljiva u rezultatima istraživanja većine autora. U ovom preglednom članku prikazujemo dosadašnja relevantna saznanja o mjerama te čimbenicima koji određuju geometriju kuka kao i opće prihvaćene načine slikovnih metoda prikaza zgloba kuka. Usporedili smo i metodologiju jedanaest nasumično odabranih radova predviđanja prijeloma kuka na temelju njegove geometrije. Ukazujemo na potrebu daljnjeg usavršavanja metodologije i ujednačenijeg odabira pacijenata radi veće konzistentnosti u budućim istraživanjima. Geometrija zgloba kuka do sada se pokazala korisnim dijagnostičkim instrumentom, ali na ovom području ima i dalje prostora za poboljšanje.An hip fracture is an significant personal, family and health issue of people older than 65 years. In the first year of the fracture up to 30% of the injured die and about 50% of them never regain their formal degree of independence in fulfilling day-to-day activities. Estimations are that throughout 30 years in the world there will be around 6 million hip fractures per year which is about four times the todays amount. Todays predictions of hip fractures based on the hip geometry have shown us that the hip geometry is an independent variable of the bone mineral density. The hip geometry is more resistant to the effect of various factors than the bone mineral density and the changes throu life are a lot slower. The uniqueness and the sensitivity of the hip geometry in predicting a fracture is high and acceptable in research results of most authors. In this review we present the previous relevant knowledge about the measures and factors which determines the hip geometry and the accepted amount of pictorial methods of hip display. We have compared the methodology and the patients of eleven randomly picked writings on predicting hip fracture based on the hip geometry. We highlight the need of further refinement of the methodology and the more balanced selection of patients for a greater conformity in future writings.The hip geometry has shown it self as an useful diagnostical instrument but there is still more room for its improvement

New insights about suprapatellar cyst

Suprapatellar bursa is located between the quadriceps tendon and femur, and it develops before the birth as a separate synovial compartment proximal to the knee joint. By the fifth month of fetal life there is a suprapatellar septum between the knee joint cavity and suprapatellar bursa which later perforates and involutes in a way that a normal communication between the cavity of bursa and knee is established. A small portion of the embrionic septum can later lag as more or less expressed suprapatellar plica. In case when suprapatellar plica has a small communication with valve mechanism or in case of complete septum, bursa becomes a separate compartment and potential location for the suprapatellar cyst development. Magnetic resonance imaging is recognised as the gold standard in diagnosis of knee cysts because of its ability to show cystic nature of the lesion, its relationship with other anatomic structures, as well as to establish whether other knee pathologies are present. Considering treatment possibilities, majority of cysts around the knee resolve spontaneously and should be treated by aspiration and application of corticosteroids. Suprapatellar cyst is a very rare knee pathology and it can in some occasions be treated using open or arthroscopic surgery

A Validity of Ultrasound Subdivision of Risser Grade 4 in Assessment of Skeletal Maturity

In the treatment of adolescent idiopathic scoliosis, one of the most frequently used technique to determine skeletal ma- turity is the method described by Risser. The ossification of iliac apophysis progresses from ventral to caudal through the four zones and the fusion of the iliac apophysis to the iliac crest (Risser grade 5) indicated vertebral growth completion, therefore the termination of scoliotic deformity progression. The main disadvantages of Risser method are exposure to radiation and the questionable reliability, so there are efforts to examine iliac apohysis by ultrasound. There is also no resolute recommendation when to discontinue brace treatment of scoliosis. Using ultrasound, in this study, we subdi- vided Risser grade 4 to grade 4a and 4b, according to the amount of cartilage left unossified, in order to make clear when is safe to end brace treatment. We measured increase in height, during six month period, for 92 healthy children, who were classified by ultrasound in Risser 4a or 4b group. There was significantly larger increase in height for group 4a (p<0.001). For girls, we also noted time past from menarche as sign of biological maturity. Girls from group Risser 4b got menarche 2.74 years before they were examined while group Risser 4a got menarche only 1.57 years before (p<0.001). Subdvision of Risser 4 grade by ultrasound is promising method in determining end of brace treatment for scoliosis

Carpal tunnel syndrome - modern diagnostic and therapy

Sindrom karpalnog tunela najcešca je kompresivna neuropatija na ljudskom tijelu koja se manifestira ispadima u inervacijskom podrucju živca medianusa s ucestalošcu izmedu 50 i 150 slucajeva na 100.000 stanovnika. Simptomatika ovisi o trajanju i jacini kompresije živca. Smetnje senzibilnosti prvi su i najstalniji simptom, dok motoricke smetnje nastaju u bolesnika s dugotrajnom kompresijom živca. Elektroneurofiziološka dijagnostika "zlatni je standard” u postavljanju dijagnoze, a potrebno ju je uciniti kod svake klinicke sumnje na sindrom karpalnog tunela. Kao dodatna dijagnosticka sredstva u atipicnim slucajevima mogu poslužiti ultrazvuk i magnetska rezonancija karpalnog tunela. Neoperacijsko lijecenje rezervirano je za lakše oblike kompresije živca, te kod pojave sindroma u tranzitornim stanjima, kao što su trudnoca, laktacija, korištenje oralnih kontracepcijskih sredstava i sl. Metoda izbora za perzistentne i progresivne oblike sindroma karpalnog tunela, kao i za one koji ne reagiraju na konzervativnu terapiju, operacijsko je lijecenje. Dekompresija živca medianusa efikasan je i siguran zahvat koji u najvecem broju slucajeva oslobada pacijenta od tegoba. Sam zahvat može se izvršiti metodom "otvorenog polja” ili endoskopski, iako za sada nema pokazatelja o prednosti endoskopske tehnike u odnosu na klasicnu tehniku "otvorenog polja”, a jatrogena oštecenja živca medianusa daleko su cešca pri endoskopskoj tehnici. U svakodnevnoj praksi najvece znacenje ima rano prepoznavanje sindroma karpalnog tunela, te njegovo pravodobno i adekvatno lijecenje. U suprotnom dolazi do nepotrebno dugog trajanja smetnji za pacijenta i težeg oštecenja živca, što smanjuje izglede uspješnog lijecenja, te dovodi do nepotrebnih ekonomskih gubitaka.Carpal tunnel syndrome is the most common compressive neuropathy in the human body, which is expressed by a deficit in the median nerve innervation area, with prevalence of 50 to 150 cases per 100.000 inhabitants. Symptoms depend on nerve compression duration and intensity. Sensibility disorders are the first and one of the most persistent symptoms, while motoric disorders arise in patients with prolonged nerve compression. Electroneurophysiological diagnostics is a "golden standard” in diagnosis setting, and it is necessary to be done in every patient with a clinical doubt on carpal tunnel syndrome. Additional diagnostics means in atypical cases can be performed by ultrasound and magnetic resonance of the carpal tunnel. Non-surgical treatment is reserved for mild forms of nerve compression, and in cases of syndrome in temporary conditions like pregnancy, lactation, taking oral contraceptives etc. The method of choice for persistent and progressive forms of carpal tunnel syndrome, as well for those who don\u27t respond to the conservative treatment, is surgery. Decompression of median nerve is an efficient and secure procedure, which, in most cases, releases the patient from its symptoms. Procedure can be performed by an "open field” method or via endoscopy, although, for now, no indicators on advantages of endoscopic technique vs. classical technique of an "open field” have been found, and iatrogenous damage of the median nerve are much more frequent in surgery via endoscopy. In everyday practice, the most important is early recognition of the carpal tunnel syndrome, and its timely and adequate treatment. On the contrary, unnecessaryprolongation of the condition leads to much more severe nerve damage, which diminishes chances for a successful treatment and causes necessary economy losses

Croatian rotatory oblique three-dimensional osteotomy (CROTO) - a modified Wilson's osteotomy for adult hallux valgus intended to prevent dorsal displacement of the distal fragment and to reduce shortening of the first metatarsal bone

Aim: To evaluate biomechanical and clinical outcomes of a newly developed modification of the Wilson's osteotomy for hallux valgus: a three-dimensional subcaptial correction of the metatarsal head position with a simultaneous lateral and plantar shift with derotation intended to reduce displacement of the distal fragment and shortening of the first metatarsal bone. ----- Methods: Thirty four feet (28 female patients) underwent the new procedure and were evaluated before and 12 to 84 months (median=25.5) after the surgery. ----- Results: Plantar shift of the distal fragment was achieved in all feet. Shortening of the first metatarsal was moderate: ≤6 mm in 32/34 feet, 7 and 10 mm in the remaining two. Median difference in metatarsal index post- vs. pretreatment was -4.0. The hallux valgus angle, intermetatarsal and distal metatarsal articular angles were reduced in all feet. The American Orthopaedic Foot and Ankle Society score improved in all feet (median increase= 51.5). ----- Conclusion: The method allows for a lateral and plantar shift with derotation of the distal fragment and a mild/moderate shortening of the first metatarsal bone

Suprapatellar cyst: diagnostic and therapeutic possibillities

Suprapatelarna burza nalazi se između tetive m. kvadricepsa i distalnoga dijela natkoljenične kosti, a razvija se prije rođenja kao zasebni sinovijalni prostor proksimalno od zgloba koljena. Unatoč tome što anatomija dobro opisuje i definira supratatelarnu burzu i njezinu komunikaciju sa zglobnom šupljinom koljena, činjenica je da se u praksi ta zglobna šupljina i sinovijalna burza ipak smatraju jednim sinovijalnim prostorom, a granica između njih najčešće je više ili manje izražen sinovijalni nabor poznat kao suprapatelarna sinovijalna plika. Do petoga mjeseca fetalnog života između šupljine koljenskoga zgloba i suprapatelarne burze postoji poprečni suprapatelarni septum koji kasnije perforira i involuira, tako da se uspostavlja normalna komunikacija između šupljine burze i koljena. Jedan manji dio embrionalnog septuma kasnije može zaostati kao više ili manje izražena suprapatelarna plika. U slučaju kada suprapatelarna plika ima mali otvor s ventilnim mehanizmom ili u slučaju kompletnoga septuma, burza postaje odvojeni prostor, te potencijalno mjesto za razvoj cistične formacije, odnosno suprapatelarne ciste. U stručnoj literaturi za ovu rijetku patologiju spominju se i sinonomi kao što su suprapatelarna sinovijalna cista, suprapatelarni burzitis ili antefemoralna cista. U dijagnostici, pojedini autori koristili su ultrazvuk, artrografiju, scintigrafiju i kompjuteriziranu tomografiju. Međutim, magnetska rezonancija je u literaturi prepoznata kao “zlatni standard“ u dijagnostici cista oko koljena, upravo radi mogućnosti prikaza cistične prirode lezije, njezinoga odnosa prema drugim anatomskim strukturama, te radi utvrđivanja ostale patologije koljena. U pogledu liječenja, većina cisti oko koljena u djece nestaje spontano, te bi one općenito trebale biti liječene konzervativnim tretmanom koji obuhvaća aspiraciju i aplikaciju kortikosteroida. Operacijsko liječenje rezervirano je za velike suprapatelarne ciste koje ne reagiraju na konzervativno liječenje, odnosno one s nespecifičnim sinovitisom ili hemoragijom unutar ciste, s boli i ograničenim opsegom pokreta ili s udruženom intraartikularnom patologijom. Iako se po dostupnoj literaturi suprapatelarna cista kao iznimno rijetka patologija koljena može liječiti i otvorenom ekstirpacijom, možemo istaknuti da se može učinkovito i sigurno liječiti i artroskopskom dekompresijom uz ranu fizikalnu terapiju, bez recidiva i uz brzi funkcionalni oporavak pacijenta.The suprapatellar bursa is located between the quadriceps tendon and femur, and it develops before birth as a separate synovial compartment proximal to the knee joint. Even though the anatomy describes and defines the suprapatellar bursa and its communication with the knee joint cavity very well, the fact is that in practice joint cavity and suprapatellar bursa are still considered as one synovial area, and the border between them is a more or less expressed synovial fold also known as the suprapatellar plica. By the fifth month of fetal life, there is a suprapatellar septum between the knee joint cavity and suprapatellar bursa which later perforates and involutes in a way that a normal communication between the cavity of bursa and knee is established. A small portion of the embryonic septum can later lag as more or less expressed suprapatellar plica. In the case when the suprapatellar plica has a small communication with the valve mechanism or in the case of complete septum, the bursa becomes a separate compartment and potential place for suprapatellar cyst development. In literature, thereare synonyms for this kind of pathology such as suprapatellar synovial cyst, suprapatellar bursitis or antefemoral cyst. In diagnosis, some authors have used ultrasound, arthrography, scintigraphy and computed tomography. However, in literature, the MRI is recognized as the “gold standard” in diagnosis of knee cysts because of its ability to show the cystic nature of the lesion, its relationship with other anatomic structures, as well as to establish whether other knee pathologies are present. Considering treatment possibilities, the majority of cysts around the knee in children resolve spontaneously and should be treated conservatively covering aspiration and the application of corticosteroids. Surgical treatment is reserved for large cysts with unspecific synovitis, or with hemorrhage inside the cyst, with pain and limited range of motion, or with associated intra-articular pathology. Although, according to the available literature, the suprapatellar cyst as a very rare knee pathology is treated by an open excision. In conclusion, we can point out that it can also be effectively and safely treated by arthroscopic decompression without recurrence and followed by a fast and functional recovery of the patient

Suprapatellar cyst: diagnostic and therapeutic possibillities

Suprapatelarna burza nalazi se između tetive m. kvadricepsa i distalnoga dijela natkoljenične kosti, a razvija se prije rođenja kao zasebni sinovijalni prostor proksimalno od zgloba koljena. Unatoč tome što anatomija dobro opisuje i definira supratatelarnu burzu i njezinu komunikaciju sa zglobnom šupljinom koljena, činjenica je da se u praksi ta zglobna šupljina i sinovijalna burza ipak smatraju jednim sinovijalnim prostorom, a granica između njih najčešće je više ili manje izražen sinovijalni nabor poznat kao suprapatelarna sinovijalna plika. Do petoga mjeseca fetalnog života između šupljine koljenskoga zgloba i suprapatelarne burze postoji poprečni suprapatelarni septum koji kasnije perforira i involuira, tako da se uspostavlja normalna komunikacija između šupljine burze i koljena. Jedan manji dio embrionalnog septuma kasnije može zaostati kao više ili manje izražena suprapatelarna plika. U slučaju kada suprapatelarna plika ima mali otvor s ventilnim mehanizmom ili u slučaju kompletnoga septuma, burza postaje odvojeni prostor, te potencijalno mjesto za razvoj cistične formacije, odnosno suprapatelarne ciste. U stručnoj literaturi za ovu rijetku patologiju spominju se i sinonomi kao što su suprapatelarna sinovijalna cista, suprapatelarni burzitis ili antefemoralna cista. U dijagnostici, pojedini autori koristili su ultrazvuk, artrografiju, scintigrafiju i kompjuteriziranu tomografiju. Međutim, magnetska rezonancija je u literaturi prepoznata kao “zlatni standard“ u dijagnostici cista oko koljena, upravo radi mogućnosti prikaza cistične prirode lezije, njezinoga odnosa prema drugim anatomskim strukturama, te radi utvrđivanja ostale patologije koljena. U pogledu liječenja, većina cisti oko koljena u djece nestaje spontano, te bi one općenito trebale biti liječene konzervativnim tretmanom koji obuhvaća aspiraciju i aplikaciju kortikosteroida. Operacijsko liječenje rezervirano je za velike suprapatelarne ciste koje ne reagiraju na konzervativno liječenje, odnosno one s nespecifičnim sinovitisom ili hemoragijom unutar ciste, s boli i ograničenim opsegom pokreta ili s udruženom intraartikularnom patologijom. Iako se po dostupnoj literaturi suprapatelarna cista kao iznimno rijetka patologija koljena može liječiti i otvorenom ekstirpacijom, možemo istaknuti da se može učinkovito i sigurno liječiti i artroskopskom dekompresijom uz ranu fizikalnu terapiju, bez recidiva i uz brzi funkcionalni oporavak pacijenta.The suprapatellar bursa is located between the quadriceps tendon and femur, and it develops before birth as a separate synovial compartment proximal to the knee joint. Even though the anatomy describes and defines the suprapatellar bursa and its communication with the knee joint cavity very well, the fact is that in practice joint cavity and suprapatellar bursa are still considered as one synovial area, and the border between them is a more or less expressed synovial fold also known as the suprapatellar plica. By the fifth month of fetal life, there is a suprapatellar septum between the knee joint cavity and suprapatellar bursa which later perforates and involutes in a way that a normal communication between the cavity of bursa and knee is established. A small portion of the embryonic septum can later lag as more or less expressed suprapatellar plica. In the case when the suprapatellar plica has a small communication with the valve mechanism or in the case of complete septum, the bursa becomes a separate compartment and potential place for suprapatellar cyst development. In literature, thereare synonyms for this kind of pathology such as suprapatellar synovial cyst, suprapatellar bursitis or antefemoral cyst. In diagnosis, some authors have used ultrasound, arthrography, scintigraphy and computed tomography. However, in literature, the MRI is recognized as the “gold standard” in diagnosis of knee cysts because of its ability to show the cystic nature of the lesion, its relationship with other anatomic structures, as well as to establish whether other knee pathologies are present. Considering treatment possibilities, the majority of cysts around the knee in children resolve spontaneously and should be treated conservatively covering aspiration and the application of corticosteroids. Surgical treatment is reserved for large cysts with unspecific synovitis, or with hemorrhage inside the cyst, with pain and limited range of motion, or with associated intra-articular pathology. Although, according to the available literature, the suprapatellar cyst as a very rare knee pathology is treated by an open excision. In conclusion, we can point out that it can also be effectively and safely treated by arthroscopic decompression without recurrence and followed by a fast and functional recovery of the patient

Reliability of the AO group and Garden\u27s classification system of femoral neck fractures in the assessment of fracture with of without displacements

Cilj: odrediti stupanj kliničke pouzdanosti i ponovljivosti klasifikacijskih sistema za prijelom vrata bedrene kosti prema AO i Gardenovoj podjeli prijeloma na prijelome sa i bez koštanog pomaka određivanjem kapa koeficijenata neophodnih za izbor načina liječenja. Metode: Pet ispitivača klasificirali su nasumice odabranih 70 predoperativnih radiograma prijeloma vrata bedrene kosti prema AO i Gardenovom klasifikacijskom sistemu. Istovjetna procedura na istim radiogramima ponovljena je nakon tri mjeseca. Prvi postupak klasificiranja korišten je za izračun kapa vrijednosti između ispitivača, dok je prvi i drugi klasifikacijski postupak korišten sporazumno između ispitivača za izračun kapa vrijednosti za svakog pojedinačnog ispitivača.U prijelome bez koštanog pomaka svrstali smo, prema AO grupi B1, a po Gardenu I i II stupanj, a u skupinu prijeloma s koštanim pomakom prema AO grupi B2 i B3, a prema Gardenu III i IV. Jednakom statističkom metodom odredili smo kapa koeficijent sporazumno između ispitivača za tako umanjeni oblik klasifikacijskog sustava prijeloma vrata bedrene kosti. Rezultati: Srednja prosječna vrijednost za klasifikacijske sisteme za sporazum između ispitivača jesu: AO К = 0,48, Garden К = 0,42. Srednja vrijednost za sporazumne pojedinačne ispitivače je za AO grupu К = 0.55, Garden К = 0,50 koeficijent kapa vrijednosti. Srednja prosječna vrijednost za reducirane oblike klasifikacijskih sistema između ispitivača jesu: reducirani oblik AO grupe К = 0,69, a za reducirani oblik Gardena je К = 0,57. Srednja vrijednost za pojedinačne ispitivače je za reducirani oblik AO grupe К = 0,68, a reducirani oblik Gardena je 0,74 koeficijenta kapa vrijednosti (p < 0,05). Zaključak: Garden i AO grupa jedino su korisni za podjelu prijeloma vrata bedrene kosti na prijelome bez ili sa koštanim prijelomom. Za određivanje metode liječenja prijeloma vrata bedrene kosti, reducirani oblik Gardenove klasifikacije ili reducirani oblik AO grupe, pouzdaniji su od Gardenove ili AO klasifikacije.Aim: To determine the degree of clinical reliability and repeatability of the classification systems for neck femoral fractures according to the AO group and Garden estimate of fracture on the fractures with or without displacement according to the coefficient kappa value indispensable in the choice of treatment methods. Methods: Five observers classified 70 randomly selected anterior-posterior (AP) and lateral view preoperative radiographs of femoral neck fractures according to the AO group and Garden\u27s classification systems. The procedure was repeated on the same radiographs after three months. The first classification was used to calculate the inter observer agreement by kappa value between observers, while the first and second classification served to calculate the kappa value for each examiner. Then we set fractures without displacement by AO group B1 and by Garden I+II and fractures with displacement to the AO group B2 + B3 and Garden III+IV. With the same statistical method we have determined the kappa coefficient value for inter observer and intra observer agreement for such as a reduced form classification system of femoral neck fractures. Results: The overall mean value for the classification system for inter observer agreement is: AO К = 0.48, Garden К = 0.42 Mean intra observer agreement for AO group К = 0.55, Garden К = 0.50 coefficient kappa value. The overall mean for reduced form classification system for inter observer agreement is: reduced form of AO К = 0.69, reduced form of Garden К = 0.57 Mean intra observer agreement for reduced form AO group К = 0.68, reduced form Garden 0.74 coefficient kappa value (К) (p < 0.05). Conclusion: The Garden and AO group are the only ones useful for the division of femoral neck fractures without displacement and with displacement. To determine the methods of femoral neck fracture treatment, a reduced form of Garden´s classification system or reduced form of AO group is more reliable than the Garden or AO group classification system

Synchronous caecal small-cell neuroendocrine carcinoma and adenocarcinoma of the rectum

Neuroendokrini karcinom malih stanica debeloga crijeva rijedak je entitet s najčešće lošom prognozom. Osamdesetogodišnja žena podvrgnuta je operaciji debeloga crijeva zbog sinkronog tumora rektuma i cekuma. Patohistološka analiza tumora cekuma pokazala je trabekularne i čvrste nakupine, relativno uniformne male do srednje velike epitelne stanice, oskudne citoplazme, a u vezivnom tkivu bilo je dosta mitoza s većim područjima nekroze. Imunohistokemija je bila pozitivna na kromogranin A. Tumor je dijagnosticiran kao neuroendokrini karcinom malih stanica cekuma. Osim toga, tumor rektuma pokazao je mikroskopske nalaze u skladu s IIA stadijem adenokarcinoma. Imunohistokemijski panel pokazao je da je tumor bio negativan na neuroendokrine markere. Nije bilo kliničkoga nalaza koji ukazuje na pojačanu sekreciju hormona. Metastaze karcinoma nisu nađene. Provedena je postoperativna kemoterapija. Pacijentica je i dalje živa, dobrog općega stanja, bez znakova progresije tumora.Small-cell neuroendocrine colon carcinoma is a rare entity with a usually poor prognosis. An 80-year-old female had colon cancer surgery due to synchronous tumour of the rectum and caecum. Pathohystological analysis of the caecal tumour showed trabecular and solid clusters, relatively uniformed small to middle sized epithelial cells, deficient cytoplasm and there were a great number of mitosis with larger areas of necrosis in the connective tissue. The immunohistochemistry was positive for chromogranin A. The caecal tumour was diagnosed as a small-cell neuroendocrine carcinoma. In addition, the rectal tumour showed microscopic findings consistent with stage IIA adenocarcinoma. The immunohistochemical panel showed that the tumour was negative for neuroendocrine markers. There were no clinical findings suggestive of hormone hypersecretion. Cancer metastases were not found. Postoperative chemotherapy was applied. The patient is still alive, in good general condition and with no signs of tumour progression

Warfarin should not be used for thromboprohylaxis in elective major orthopaedic surgery: a Croatian perspective

Aim: To identify modes of venous thromboembolism (VTE) prophylaxis in patients undergoing elective major orthopaedic surgery (total hip or knee arthroplasty, THA/TKA) at a single university-associated hospital in Croatia. ----- Methods: A retrospective analysis of consecutive patients subjected to THA or TKA over a two-year period (2014-2015) with a focus on anticoagulation during the first 15 post-surgical days (period of highest VTE risk). ----- Results: Of 603 identified patients three (0.5%) were not anticoagulated (haemophilia) and others received perioperative doses of low molecular weight heparins (LMWH). Overall, 228 (37.8%) patients received prophylaxis not involving warfarin, and 372 continued with short-term LMWH with switching to warfarin. They contributed a total of 1218 international normalized ratio (INR) values (median=3, range=1-8). These were consistently below the target INR range across the observed period. Between post-surgical days 6 and 15 (after the initial titration), 438 values were taken in patients treated with LMWH+warfarin and 92.7% were below, and only 6.8% within the target range; 580 values were taken in patients already switched to warfarin, 74% were below and only 25% within the range. ----- Conclusion: The prevailing mode of VTE prophylaxis was in a clear contrast to (then) actual professional guidelines, with inadequate monitoring and poor anticoagulation. There is no reason to expect a substantially different situation at other institutions across the country. The prevailing practice of VTE prophylaxis in major orthopaedic surgery in Croatia should be promptly abandoned and up-dated in agreement with the current state of the art