Objectives. The length of the tourniquet time during total knee arthroplasty (TKA) is related to the incidence of post-operative deep vein thrombosis (DVT). Our aim in this study was to investigate the effect of the early release of the tourniquet on the incidence of DVT in patients undergoing TKA. Methods. A total of 200 patients who underwent TKA between November 2015 and November 2016 were prospectively enrolled. The tourniquet was inflated before surgery and released immediately after the introduction of the components (early release group). This group was compared with a retrospective cohort of 200 primary TKAs, in which the tourniquet was released after the dressings had been applied (late release group). The presence of a DVT was detected using bilateral lower limb ultrasonography. Peri-operative clinical and follow-up data were collected for analysis. Results. The incidence of DVT in the early release group (9 of 196, 4.6%) was significantly lower compared with the late release group (24 of 200, 12%; odds ratio (OR) 0.35, 95% confidence interval (CI) 0.16 to 0.78, p = 0.008). The incidence of proximal DVT in the early release group (1 of 196 (0.5%)) was significantly lower than in the late release group (8 of 196, 4%; OR 0.12, 95% CI 0.02 to 0.99, p = 0.020). Although the mean intra-operative blood loss was higher in the early release group, the mean post-operative drainage, total blood loss, transfusion requirements and complications were not significantly different in the two groups. Conclusion. In patients who undergo TKA, releasing the tourniquet early is associated with a decreased incidence of DVT, without increasing the rate of complications. Cite this article: Bone Joint Res 2017;6:535–541

Deep vein thrombosis is uncommon in children but can occur given certain circumstances. Protein C deficiency has recently been described in a child with deep vein thrombosis complicating septic arthritis. We present four case reports of children who developed deep vein thrombosis in association with musculoskeletal sepsis. All had evidence of musculoskeletal sepsis and thrombosis. One child died. Prothrombotic screens were performed demonstrating normal haematological parameters in the three surviving children. The high mortality of deep vein thrombosis complicating musculoskeletal sepsis is emphasised, particularly the potential for septic embolic complications. Deep vein thrombosis should be considered in any child with musculoskeletal sepsis and generalised limb swelling. Early recognition and treatment can lead to favourable outcomes

Deep vein thrombosis remains a significant and common complication following joint replacement and debate exists over which contributing factors are important. This study investigates the effect of a number of variables on the incidence of symptomatic deep vein thrombosis in knee arthroplasty surgery. Data was collected prospectively on 3449 knee replacements including procedure type, tourniquet time, surgeon, patient age, and gender. These variables were assessed by the use of generalised linear modelling against the presence or absence of symptomatic deep vein thrombosis demonstrated on duplex ultrasonography. The overall deep vein thrombosis rate was 1.6%. The only variable which had an association with confirmed symptomatic DVT was operation type with total knee replacements having a higher incidence than unicompartmental knee replacements (2.2% vs 0.3% p=0.0003). Tourniquet time did not exhibit a statistically significant effect (p=0.63) These data show that the DVT rate in unicompartmental knee replacement is statistically significantly lower than that of total knee replacement. They do not support the notion that increased tourniquet time is associated with an increased risk of DVT

INTRODUCTION. Venous thromboembolism (VTE), especially, deep vein thrombosis (DVT) in lower extremities, often seriously combined with pulmonary embolism (PE), is a major and critical complication after total hip arthroplasty (THA). For better disgonsis of VTEs, D-dimer test is one of the useful methods. The aim of this study was to evaluate the efficacy of D-dimer levels before THA. MATERIALS AND METHODS. Medical records of patients with osteoarthritis who received THA between April 2009 and March 2010 were reviewed. Value of D-dimer at preoperative day 1, postoperative day 3 and 14 was examined in those patients. D-dimer levels were examined by Latex Immunity Nephelometry Measurement Method and the Kit (Sysmex Corporation, Kobe, Japan). A total of 327 patients with D-dimer values were examined. The values D-dimer of the available patients were under 1.0 μg/ml. Ninety-nine patients (30%) had a high D-dimer level. DVT was diagnosed by doppler ultrasonography at preoperative day 1, postoperative day 3 and 14. The sensitivity and specificity of D-dimer in different cutoffs were verified by Receiver Operating Characteristic (ROC) curve. The ROC curve was constructed to describe the relationship between the sensitivity and the false positive rate for different values of D-dimer to patients suspected of VTEs. The study protocol was approved by the institutional ethics committee. RESULTS. Eighty-two patients (83%) were females and 17 (18%) were males. Mean age was 67.3 (51–88) years. Mean value of D-dimer was 2.6 (1.1–10.3) μg/mL. DVT was detected in 21 patients (21%) at the preoperative day 1 (DVT positive group). Average of age of this (or DVT positive) group was 71.9 (52–88) years. There was significant difference in D-dimer level between DVT negative group, DVT was not detected at the preoperative day 1, and DVT positive group (p<0.05). The areas under the receiver operating characteristic curve of D-dimer were larger than those of other parameters in the ROC curve (p=0.76). The cutoff value from the Youden index was 1.95 μg/mL, and the sensitivity and specificity values were 84.2% and 62.7%, respectively. The incidence of DVT in the positive group was 19% and 16%, respectively. DISCUSSION AND CONCLUSION. Even DVT in the calf has the potential to propagate proximally, which led to a risk of PE. Therefore, screening for detection of DVT is important, even if the DVT was asymptomatic distal DVT. In some countries, it is thought that if the value of D-dimer is less than 0.5 μg/mL, VTEs are excluded in patients without surgeries, but some D-dimer kits, frequently used in Japan, have different cutoff values for the exclusion of DVT. Assessment of D-dimer is simple and reliable, as to be one of the beneficial methods to detect high-risk patients of VT and/or occult DVT before THA. In conclusion, it is important to evaluate preoperative screening of VTE before THA, as the existence of pre-operative DVT has high risk of postoperative DVT occurrences. The D-dimer test is one of useful methods to evaluate the perioperative state of the patients with VTE risk

Objectives: Post-operative deep vein thrombosis (DVT) is considered uncommon in Japanese. Numerous reports of pulmonary embolism (PE) have been reported in the last few decades, and although thrombo-embolic diseases appear to be increasing, the incidence of DVT and PE in Japan have not been investigated thoroughly. We studied the incidence of proximal DVT and PE in Japanese patients who had total hip arthroplasty (THA) and total knee arthroplasty (TKA). Patients and Methods: Between October 1996 and November 2000, we performed THA on 99 patients and TKA on 75 patients at Mie University Hospital. All were included in this study. They were routinely examined for proximal DVT by ultrasonography before and after their operation. Those patients who had ultrasonographic findings of DVT were also investigated for PE by ventilation-perfusion lung scan. Results and Discussion: No patient had a DVT before surgery. Fourteen patients had post-operative DVT, detected by ultrasonography, and confirmed by venography. 12 cases were females and 2 cases were males. There were 5 cases of PE among the fourteen cases of DVT, The symptomayic PE were 2 cases, and non-incidence of PE were 3 cases. The incidence of DVT was 5.2% on the left side and 4.0% on the right side.The incidence of DVT was 11.2% in THA, and 4.0% in TKA, while that of PE was 5.0% in THA and 0% in TKA. These results suggest that DVT and PE in Japan are lower than those of white races

Purpose: Metabolic syndrome (MS) is defined as central adiposity, elevated fasting glucose, hypertension, and dyslipidemia defined as high triglyceride and low high-density lipoprotein (HDL) cholesterol. MS is associated with a systemic proinflammatory and prothrombotic state. We asked if patients with MS undergoing total knee arthroplasty (TKA) have an increased risk for symptomatic deep vein thrombosis at 3 months follow-up (DVT). Method: 1,460 consecutive patients were reviewed from our joint registry undergoing primary, unilateral TKA between the years of 1998–2006. Demographic variables of age, gender, comorbidity, and education were retrieved. Metabolic syndrome (MS) was defined as body mass index above 30 kg/m2, diabetes, hypertension, and hypercholesterolemia. Logistic regression was used to examine the relationship of MS on the incidence of DVT. Results: The overall incidence of symptomatic DVT was 4.4% (65/1460). Patients with MS had an increased incidence of DVT as compared to those without MS(15.5% vs 3.4%). Adjusted analysis showed that MS increased the risk of symptomatic DVT by 3.2(95% CI [1.0,15.4], p=0.04) times compared to those without MS. Conclusion: Hospital protocols developed for prophylactic anti-coagulation following TKR should give special consideration to patients with MS

Deep vein thrombosis (DVT) in shoulder operations is rare although a few case reports exist. No definite guidelines exist and therefore it is difficult for the surgeon to decide on thromboprophylaxis. We prospectively evaluated the incidence of DVT following arthroscopic shoulder sub acromial decompression in 72 patients after obtaining local ethics committee approval. Patients with previous history of DVT and those on anticoagulants were excluded from the study. Pre and post-operative Doppler scans on 4 limbs were performed by a single consultant radiologist at an average of 3 weeks. All operations were performed by a single surgeon under GA in beach chair position as a day case procedure on standard lines. Postoperatively the shoulder was immobilised in a sling for comfort and physiotherapy was supervised by a qualified therapist. No patient received any DVT prophylaxis. The average age of 54.6 years, 47 were classified as ASA 1, 15 as ASA 2 and 10 ASA 3.58 patients had additional interscalene nerve blocks for pain relief. The average operating time was 43 mins. Additional procedures included excision of lateral clavicle in 32, glenoid labral and rotator cuff debridement in 12 and 14 patients. There were no DVTs on Doppler scans. Shoulder arthroscopic sub acromial decompression procedures do not carry a risk of DVT and routine thromboprohylaxis is not required even in higher anaesthetic risk patients

Purpose. To investigate the incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE) with external fixator use and to help establish whether current guidelines are appropriate. Methods. Case notes of individuals undergoing external fixator application by the senior author (PC) from March 2005 to June 2011 were examined. In this period 207 individuals underwent 255 primary applications of Ilizarov, Taylor Spatial Frame (TSF) or monolateral fixator. Fixators applied were 173 tibial, 63 femoral and 19 to other bones. Records were obtained for 182 individuals (88%), representing 214 operations (84%). Results. Two cases of DVT were found (1%). In both cases mechanical and chemical prophylaxis had been used, as guided by risk assessment. One of these individuals also experienced a PE. This person was of notably high risk, surgery involving excision of tibial adamantinoma and a high body mass index (45). He had also recently travelled from overseas (a travel time of over 3 hours). Other than surgical time there was one additional risk factor in 39 cases, two additional risk factors in four and three additional risk factors in four. Conclusions. Little evidence exists about the incidence of DVT and PE with the use of external fixators. The National Institute of Health and Clinical Excellence (NICE) provide guidance for thromboprophylaxis in orthopaedic surgery with specific recommendations for hip and knee arthroplasty and hip fracture. For orthopaedic surgery other than lower limb arthroplasty NICE recommends thromboprophylaxis is guided by risk factors on a case by case basis. Our findings raise the question of whether extended course chemical thromboprophylaxis, as for lower limb arthroplasty, should be employed for high risk individuals undergoing application of external fixator

Introduction. No published work exists regarding deep vein thrombosis (DVT) and pulmonary embolism (PE) incidence with the elective use of external fixators. The aim of this work was to establish the rate of DVT and PE in such cases to help inform whether thromboprophylaxis guided by risk factors is adequate or if a more aggressive approach is required. Patients and methods. Information from a prospectively maintained electronic database and case notes were examined for consecutive patients from March 2005 to June 2011. Occurrence of DVT and PE, detected by ultrasound or CT angiogram, were recorded. Risk factors for thromboembolism, age, weight, height, surgical indications, type of surgery and operative time were recorded. As recommended by the National Institute for Health and Clinical Excellence (NICE) thromboprophylaxis use is guided by risks of thromboembolism and bleeding. For adults and older adolescent patients contralateral leg compression stockings and an intraoperative calf pump were used. Mobilisation began the morning after surgery and the majority of cases permitted to bear weight fully. Results. Two hundred and seven (207) individuals underwent 255 primary applications of Ilizarov, Taylor Spatial Frame (TSF) or monolateral fixator, 173 tibial, 63 femoral and 19 to other bones. Case notes were obtained for 182 individuals (88%), representing 214 operations (84%). One DVT and one PE were recorded, an overall incidence of 2/214 (0.9%) (excluding those under 16 years old 2/143 (1.4%)). In both cases mechanical and chemical prophylaxis had been used as guided by risk assessment. The PE was sustained by a person of notably high risk, surgery involving excision of tibial adamantinoma and a high body mass index (45). He had also recently travelled from overseas (a travel time of over 3 hours). Conclusions. The rate of DVT/PE for elective application of external fixators is low with risk assessment guiding prophylaxis

Combined multi-detector row CT (MD-CT) pulmonary angiography (CTPA) and lower extremity venography (CTV) is an effective method for detection of pulmonary embolism (PE) and deep vein thrombosis (DVT). However, the usefulness of this method after total knee arthroplasty (TKA) has not been reported. The aim of this study is to evaluate our screening program in the management of thromboembolism. Over a 1.5-year period, 30 patients with primary TKA were examined using an MD-CT (Lightspeed ultra 16.GE) before and 7th day after operation. 25 seconds after intravenous administration of 320ml of contrast material, CTPA was performed with 1.25-mm collimation and CTV from the iliac crest to the ankles was done with 0.625-mm collimation 165 seconds after contrastmaterial injection. The mean age of the patients was 72.2 (53–80). Twenty patients had osteoarthritis, nine had rheumatoid arthritis and one osteonecrosis. All patients were received 4 weeks of warfarin therapy and prophylaxis. PE was observed in A1+2, A3, A6, A9, A10 area. PE was most frequently detected in A10 area of pulmonary artery (6/30). While, DVT was detected in only popliteal vein (6/30). The incidence of PE was 30% (9/30)and DVT 20% (6/30). Both PE and DVT were observed in 3 patients, the incidence was 10% (3/30). Combined CTPA and CTV is a safe and accurate diagnotic method for detecting PE and DVT after TKA, and the ability to directly visualize emboli of this system is effective as therapeutic tool

We obtained approval from the local research and ethics committee and prospectively evaluated the incidence of Deep vein thrombosis (DVT) in arthroscopic shoulder sub acromial decompression in 72 patients. All patients were assessed clinically for DVT risks as per the established guidelines. Patients with previous history of DVT, those on anticoagulants and those positive for DVT on pre op scans were excluded from the study. All patients had doppler scans on 4 limbs performed by a single consultant radiologist at an average of 4 weeks pre and post operative period. All operations were performed by a single surgeon under GA in beach chair position with routine precautions for DVT, as a day case procedure. Arthroscopy and additional procedures were performed on standard lines. Postoperatively the shoulder was immobilised in a sling for comfort and physiotherapy was supervised by a qualified therapist. Demographic data, co-morbidities, patient position, ASA risk, nerve blocks, surgery duration, medications, intra operative findings, were documented. No patient received any DVT prophylaxis. All patients were available for followup and clinical and doppler findings were documented at an average 4 week period. 3 patients had bilateral procedures. There were 38 female and 34 male patients with an average age of 54.6 years. 47 were classified as ASA1, 15 as ASA2 and 10 ASA 3. Common co morbidities included hypertension, diabetes, acid peptic disease in 34 patients. 37 patients had additional interscalene nerve blocks for pain relief. The average operating time was 52 mins. Additional procedures included excision of lateral clavicle in 32, glenoid labral and rotator cuff debridement in 12 and 14 patients. There were no DVT's on all doppler scans. Shoulder arthroscopic sub acromial decompression procedures do not carry a risk of DVT and routine thromboprohylaxis is not required even in higher anaesthetic risk patients

Introduction. There is insufficient data on the trends of anticoagulation after total knee arthroplasty (TKA) in the USA, and the efficacy and safety of rivaroxaban, beyond randomized clinical trials and small cohort studies. Patients and Methods. Using the Truven Health MarketScan database, we retrospectively evaluated new anticoagulation prescriptions after elective TKA from 2010 to 2015. The frequency of deep vein thrombosis (DVT), pulmonary embolism (PE), and adverse events, within 90 days, were then evaluated in 24,856 new users of warfarin and 21,398 new users of rivaroxaban in commercially insured patients (COM), and 15,483 new users of warfarin and 8,997 new users of rivaroxaban in Medicare supplement patients (MED). Data was analyzed by odds ratios using logistic regression models with stabilized inverse probability treatment weighting. Results. Warfarin use decreased from approximately 50% to 17% in COM patients and 60% to 25% in MED patients. Rivaroxaban use increased from 0 to 35% in COM patients and from 0 to 39% in MED patients. Older patients, females, a history of DVT, renal impairment, use of antiplatelet agents or surgery performed as an outpatient had lower odds of getting rivaroxaban. Patients in Western region and having surgery in 2015 had higher odds of getting rivaroxaban. COM patients with capitated insurance plans and a history of PE had lower odds of rivaroxaban initiation. MED patients with atrial fibrillation, cardiovascular disease or hyperlipidemia had lower odds of rivaroxaban initiation. Warfarin users had significantly higher odds ratio of DVT (OR 2.06 in COM patients and OR 2.21 in MED patients) and PE (OR 2.03 in COM patients and OR 2.16 in MED patients) than rivaroxaban users. There were no statistically significant differences in the bleeding risk between the two agents, but warfarin users had a significantly higher odds ratio of periprosthetic infection in both COM (1.57) and MED (1.79) patients. Conclusions. There has been an increase in prophylaxis with rivaroxaban, and a decrease in both warfarin and LMWH use after elective TKA over four years. Rivaroxaban had lower odds ratio of both DVT and PE than warfarin, and bleeding risks were similar. For figures, tables, or references, please contact authors directly

Surgery for pelvic or acetabular fractures carries a high risk of deep-vein thrombosis (DVT). Reports indicate that fondaparinux is a more effective thromboprophylactic agent than low molecular weight heparin (LMWH) after major orthopaedic surgery. We prospectively evaluated a new protocol for DVT prophylaxis using fondaparinux. Patients and methods. One hundred and eight patients with pelvic or acetabular fractures were randomised to receive either fondaparinux or enoxaparin. Specific review points included the primary end-point of clinical deep vein thrombosis (DVT) or pulmonary embolism (PE) and any evidence of adverse effects such as bleeding or allergic reactions. Results. Two patients that received enoxaparin were found to have a DVT (3%) and one patient died from a PE (1%). There was no documented DVT or PE in patients that received fondaparinux. The mean number of units of blood transfused was significantly higher in the enoxaparin group and this was significant post-operatively (p<0.05). The current study supports that post-operative fondaparinux, in patients with pelvic and acetabular fractures, is more effective and equally safe to enoxaparin

Knee arthroscopy is the most commonly performed orthopaedic operation world wide. There is however little data on the incidence of DVT and consequently there is no consensus regarding the need for periopeartive thromboprophylaxia. Hoppener et al,2003 reported a high incidence of 11% DVT without the use of thromboprophylaxis. The aim of our study was to establish the incidence of venous thromboembolic complications in day case knee arthroscopy without any thromboprophylaxis. A retrospective review of 458 consecutive knee arthroscopies done in our unit between Feb 1998 to May 2007 were carried out. They were all day cases and did not receive any chemical thromboprophylaxis. All the case notes were carefully scrutinized for any readmissions for symptoms of venous thromboembolism(VTE). The clinical signs documented were pain, tenderness, swelling or redness of the legs, dyspnoea, chest pain and haemoptysis leg pains or redness following the surgery. There were 278 males and 180 females. The age group ranged from 15 to 88 years. The average age group was 57.7years. The primary out come of the study was the incidence of symptomatic and asymptomatic venous thromboembolic complications after the knee arthroscopy during the 2 week and 8 week followup period. Our study showed there were no cases of symptomatic deep vein thrombosis in any of the patients. The pooled overall estimate of the incidence of all VTE, without the use of thromboprophylaxis was 7.4%, symptomatic 2% and asymptomatic 5.4%. This is not in agreement with our study. The limitation of our study, it is a retrospective analysis and no investigative tools were used. We conclude that until more extensive studies have been performed, it seems justified to withhold thromboprophylaxis in patients undergoing uncomplicated knee arthroscopic procedures in a daycare setting

Introduction. Corrosion at the modular junction of the femoral component in total hip arthroplasty (THA) was considered as a cause of adverse local tissue reaction in recent years. We reported three adverse local tissue reaction cases after total hip arthroplasty using the same modular neck stem in this study. Materials and Methods. We have been essentially using the same titanium modular neck stem system and the same combination bearing surface of 26mm cobalt chromium (CoCr) head and highly cross linked polyethylene line for primary total hip arthroplasty since November 2009. Three female showed adverse local tissue reaction and had additional surgical treatment after the THA. Results. Two patients showed asymptomatic focal osteolysis on X-ray at the Gruen zone 1 around three years after the THA (one case also showing pseudo tumor around lessor trochanter). One patient presented symptomatic deep vein thrombosis (DVT) suddenly four years after the surgery and was detected massive pseudo tumor around the hip in MRI. High serum cobalt level was detected in two pseud tumor cases (9.3 ng/ml in DVT case, 5.0 ng/ml in an osteolysis case). The patients had debridement of pseudo tumor and osteolysis. The 26mm CoCr head was replaced a delta ceramic head with a new neck and liner. Two osteolysis cases were grafted allogenic bone chips. Pathology specimens showed tissue necrosis. All retrieved head and neck component showed some corrosion only at the modular of head neck junction. High level of cobalt (2.43 mg/100g) and chromium (4.60 mg/100g) were detected in necrotic tissue of DVT case by ICP-MS (Inductively Coupled Plasma-Mass Spectrometry) analysis. Discussion and Conclusion. This study showed adverse local tissue reaction could occur in spite of using small metal head and polyethylene bearing secondary to corrosion at the taper. It is thought that head neck junction corroded due to mechanically assisted crevice corrosion. An incidence of adverse local tissue reaction of this titanium modular stem might be lesser 0.2% (3/2600 over) in our institute. However, we began to stat new combination of bearing surfaces, ceramic head and polyethylene liner, even so extremely low incidence of adverse local tissue reaction derived from cobalt chromium alloy

Introduction: We undertook a questionnaire study to assess the compliance with DVT prophylaxis following lower limb arthroplasty surgery and evaluate reasons for non-compliance (if any).

Method: Following joint replacement surgery, 50 patients (45 had THR, 5 had TKR) were asked to fill in anonymised questionnaire at 6 weeks. They were asked about awareness for DVT, information given, prevention methods, duration and type of prophylaxis given and their compliance with treatment.

Results: Most of the patients (45) were aware of the risk of DVT while 2 were not aware and 3 were not sure. 37 patients were given information during their clinic visit while 7 did not receive any information and 6 can’t remember. 32 patients remembered discussing risk of developing DVT while 9 did not and 9 were not sure. 34 patients (68%) were aware of prophylactic methods. Except for 2 patients, the rest 48 patients (96%) confirmed receiving prophylaxis. 48 patients (96%) had mechanical prophylaxis in the ward while 6 continued at home as well. 46 patients (92%)remembered receiving chemical prophylaxis both in the ward and at home thereafter.

36 patients received chemical prophylaxis (injections) for 10 days, 5 for 7 days, 8 for a few days and 1 patient for 6 weeks post-op. 38 patients (76%) self administrated the injections while 6 had family members help and 3 had district nurse visit. 47 patients (94%) received injections for the complete duration. 3 patients did not receive injections regularly at home (missed nurse visit – 1, not advised – 1, forgot to inject – 1).

Discussion: DVT compliance is still an issue in surgery especially when patients were asked to self-administer the injections. We achieved 94 % compliance with our protocol. This study shows that greater emphasis on patient education, awareness and motivation may help improve compliance.

Background: Both chemical and mechanical methods of prophylaxis have reduced the the incidence of thromboembolic complications following Total Knee Replacement (TKR). Only a few studies have shown that mobilisation on the first post operative day further reduces the incidence of thromboembolic phenomena.

Aims: We conducted a prospective study to verify not only if early mobilisation but also whether the distance mobilised on the first post-operative day after TKR reduced the incidence of thromboembolic complications.

Methodology: The incidence of deep venous thrombosis and pulmonary embolism were compared in 50 consecutive patients who underwent TKR from July 2006 following a change in the mobilisation protocol with 50 consecutive patients who underwent TKR before the protocol was instigated. The mobilisation protocol changed from strict bed rest the first post operative day to mobilisation on the first post operative day. Mobilisation was defined as sitting out of bed or walking for at least 15–30 minutes twice a day. The distance mobilised was accurately recorded by the physiotherapists. All patients underwent duplex scans of both lower limbs on the fourth post operative day.

Results: There was a Significant reduction in the incidence of thromboembolic complications in the mobilisation group (7 in total) compared to the control group (16 in total) (p=0.03). Furthermore in the mobilisation group the odds of developing a thromboemobloic complication was Significantly reduced the greater the distance the patient mobilised, (Chi squared linear trend=8.009, p =0.0047).

Early mobilisation in the first 24 hours post TKR is a cheap and effective way to reduce the incidence of post-operative DVT.

Deep venous thrombosis (DVT) and clinical outcome measurements in a series of 610 patients who did not receive routine chemical thromboprophylaxis for lower limb arthroplasty were studied. Patients who had undergone primary total hip or knee replacement under the care of two orthopaedic consultants were identified from the Trent Arthroplasty Database. Surgery was performed between 1992 and 1999 in one hospital only. Venography was undertaken on the seventh to tenth postoperative day. Patients with proximal thrombosis were anti-coagulated with warfarin as per protocol. Venogram reports were available for 81% of cases.

One year following surgery a standard postal questionnaire was sent to all patients. A response rate of 88% was achieved. Data was captured with respect to residual pain, ability to walk and the overall satisfaction with joint replacement.

DVT following total hip (THR) or knee replacement (TKR) in patients who did not receive routine chemical thromboprophylaxis was common (46. 4%) in line with other studies.

Knee surgery was associated with a high prevalence of thrombosis (57. 6%) compared to hip replacement although only one fifth of DVTs were found to extend into a proximal vein. Approximately half (44. 2%) of all THR associated thrombus was above knee DVT. Questionnaire responses evaluating clinical outcome and satisfaction were correlated to venographic results and analysed using an SPSS statistical package. Using Chi-squared analysis no statistically significant differences were found between deep venous thrombosis and patient-perceived pain (p=0. 12), mobility (p=0. 07) or overall satisfaction (p=0. 23). It is generally assumed that chemical thromboprophylaxis will diminish DVT related complications such as post-phlebitic limb syndrome. Despite a high prevalence of thrombosis in patients who did not receive pharmacological agents for prophylaxis, this study did not demonstrate an adverse outcome on pain, function or patient satisfaction. Morbidity as a result of DVT needs to be studied further before the role of chemical thromboprophylaxis can be determined.

The incidence of DVT and need for thrombo-prophylaxis following isolated distal lower extremity fractures is unknown. The purpose of this study was to determine whether or not thrombo-prophylaxis with low molecular weight heparin was needed in this trauma population.

A Multicentered Prospective Randomised Double Blind Placebo Controlled Trial was designed to define the incidence of DVT and need for thrombo-prophylaxis in this population. A sample size of two hundred and ninety-nine patients ensured a one tailed type one error of alpha = 0.05 and power of 80% as confirmed from previous studies. Males and female patients between the ages of eighteen and seventy-five years with isolated distal lower extremity fractures (excluding the foot) were eligible. All patients had surgery within forty-eight hours after injury. Patients excluded from the trial were polytrauma patients, those medically unfit for the operating room, patients with foot fractures, those receiving anticoagulation, inability to provide consent, platelets 200 umol /L. Randomization was carried out via computer generation to receive either placebo or Fragmin for fourteen days. At fourteen days, all patients underwent bilateral venograms interpreted by three independent radiologists. Equivocal venograms were interpreted by consensus. Routine follow-up was carried out for all patients at two, six, eight and twelve weeks.

A total of two hundred and ninety-nine patients were enrolled in the study. One hundred thirty-six patients in the Fragmin group and one hundred and twentyfive in the placebo group completed the intervention. There were one hundred and twenty-five males and one hundred and thirty-six females in total. There was no statistically significant difference in DVT incidence between those patients treated with Fragmin or Placebo (p = 0.41). Gender, medical issues, pre-operative level of activity and body mass index had no effect on the incidence of DVT.

The incidence of DVT in fragmin treated and placebo treated patients is 8.1% and 11.2%, respectively (p = 0.41). This study suggests that DVT thrombo-prophylaxis is not indicated in this patient population. To our knowledge, this is the first Randomised Controlled Trial utilizing venograms (gold standard) for DVT identification.

The Pulmonary Embolism Prevention (PEP) Trial was designed to assess the effects of a 35 day course of aspirin (160 mg daily) on the risks of thromboembolic events, other cardiovascular outcomes and bleeding among individuals undergoing surgery for hip fracture or joint replacement. From 1992 to 1998, 148 hospitals in Australia, New Zealand, South Africa, Sweden and the United Kingdom randomised 13,356 hip fracture patients, and 22 hospitals in New Zealand randomised 4,088 elective arthroplasty patients. Among hip fracture patients, aspirin produced proportional reductions in PE of 43% (95% confidence interval [CI] 18% to 60%; 2P=0.002) and symptomatic DVT of 29% (95% CI 3% to 48%; 2P=0.03). PE or DVT was confirmed in 105 (1.6%) of 6679 patients allocated aspirin versus 165 (2.5%) of 6677 allocated placebo, representing an absolute reduction of 9±2 per 1000 and a proportional reduction of 36% (95% CI 19% to 50%; 2P=0.0003). Aspirin prevented 4±1 fatal pulmonary emboli per 1000 treated (18 aspirin vs 43 placebo deaths), representing a proportional reduction of 58% (95% CI 27% to 76%; 2P=0.002), with no apparent effect on deaths from other vascular (hazard ratio 1.04; 95% CI 0.86 to 1.26) or non-vascular cause (1.01; 95% CI 0.84 to 1.23). Deaths due to bleeding were rare (13 aspirin vs 15 placebo), but there was an excess of 6±3 post-operative transfused bleeds per 1000 allocated aspirin (2P=0.04). Among elective arthroplasty patients, venous thromboembolism rates were lower but the proportional effects of aspirin appeared similar to those among hip fracture patients.