Background. Venous thromboembolism (VTE) is a common, costly, and morbid complication following TJA. Consequently, the current standard of care recommends that all TJA candidates receive some form of thromboprophylaxis postoperatively. Chemoprophylaxis, however, is not without its own risks and has been associated with greater risk of perioperative complications such as major bleeding, infection, stroke, and increased wound drainage. Mechanical compression devices serve as an alternative to chemoprophylaxis. Compression devices are thought to function by decreasing venous stasis and activating fibrinolysis. Intermittent pneumatic compression devices (IPCD) function by providing pressure at a constant cycle; whereas continuous enhanced circulation therapy (CECT) devices such as ActiveCare portable system (Medical Compression Systems, Or Akiva, Israel) function in a synchronized manner with the patient's own respiratory cycles. While both of these systems are widely utilized, there is scarce data comparing their effectiveness as thromboprophylatic agents following TJA. The purpose of this meta-analysis is to comparatively evaluate the efficacy of ActiveCare to IPCDs in the prevention of thromboembolic events following TJA. Methods. A literature search using PubMed, Cochrane, and EMBASE databases were used to identify all articles published between January 2000 and August 2016. Key words used to conduct the search were venous foot pump, intermittent pneumatic compression, total hip arthroplasty/replacement, total knee arthroplasty/replacement, deep vein thrombosis, thromboembolic disease and pulmonary emboli. Two independent investigators carried out the literature review using the PRISMA guidelines (Figure 1). Analysis of risk ratio was performed by evaluation of studies which compared IPCD with any control chemoprophylaxis regiment or ActiveCare with any control chemoprophlaxis regiment. Assessment of heterogeneity and analysis of data were operated by Review Manager 5.3. Results. Our primary search protocol yielded 968 individual studies by both reviewers of which 525 were duplicates. After screening the remaining 443 abstracts for relevancy 357 were excluded, leaving 86 for full text examination. After a thorough evaluation, 60 were further excluded, and a total of 24 studies, published between 2000 and 2014, were included for analysis, representing 9,134 patients. Of these, 13 were randomized controlled trials and 11 were retrospective studies. When compared to control chemoprophylactic groups, the risk ratio (RR) of DVT development was 0.51 (95% CI: 0.39 – 0.67; I. 2. =69%) with NSIPCDs and 0.47 (95% CI: 0.27 – 0.80; I. 2. =0%) with RSCDs. The RR for development of PE in these groups respectively were 0.24 (95% CI: 0.04 – 0.15) versus 0.55 (95% CI: 0.35 – 0.88) (Figure 3). Conclusion. When compared to chemoprophylaxis alone, compression devices appear to reduce the incidence of VTEs following TJA. The addition of mechanical prophylaxis to any chemoprophylactic regimen increased VTED prevention Following a comparative analysis of IPCDs and ActiveCare our study suggests that ActiveCare may be more effective at preventing VTE events, albeit not statistically significant. Thus, our results demonstrate that while both devices are effective thromboprophylactic modalities, more research is warranted to better elucidate the strengths and limitations of compression devices as thromboprophylatic agents. For any figures or tables, please contact the authors directly

Patients awaiting resolution of swelling and oedema prior to ankle surgery can represent a significant burden on hospital beds. Our study assessed whether external pneumatic intermittent compression (EPIC) can reduce delays to surgery. Our prospective randomised controlled trial (n= 20) compared outcomes of patients treated with EPIC vs control group managed with ice and elevation. Included were patients aged <18 years with isolated closed ankle fractures admitted for management of swelling prior to surgery. Excluded were open fractures, injuries to contralateral leg, diabetes, absent pulses, peripheral vascular disease, inability to consent, no requirement for admission. Eligible patients were randomised to active or control arms. All patients were managed initially with reduction and back slab application. Patients in active arm fitted with EPIC (Hydroven 3000) device over the back slab. Assessment by treating team determined the time at which patient is assessed ready for surgery. Patients in the treatment arm were assessed as ready for surgery sooner, (123 hrs vs 168hrs, T score = 1.925, P 0.035) and had a shorter time to surgery (167 hrs vs 216 hrs, T score = 1.748, P 0.047) Length of stay was reduced bud did not reach statistical significance. (259 hrs vs 269 hrs, T score 0.229, P 0.41). Our results showed a statistically and clinically significant reduction in time that patients were assessed ready for surgery and time to surgery in the treatment cohort. We conclude that although further data is needed to achieve an adequately powered study and assess the safety profile of the EPIC, incorporation of EPIC into routine clinical practice has the potential for significant cost savings

Introduction. Venous thromboembolism (VTE), defined as either pulmonary embolism (PE) or deep venous thrombosis (DVT), is a rare, but serious complication following total hip arthroplasty (THA). Current VTE guidelines recommend pharmacologic agents with or without intermittent pneumatic compression devices (IPCDs). At our institution, both 81mg aspirin (ASA) twice a day (BID) and portable IPCDs were prescribed to THA patients at standard risk for VTE. The aim of this study is to determine if discontinuing the use of portable outpatient IPCDs is safe and does not increase the rate of VTE in patients undergoing THA. Methods. A retrospective review of 1,825 consecutive THA cases was conducted identifying patients with a VTE 90-days postoperatively. Patients were divided into two separate consecutive cohorts. Cohort one consisted of THA patients who received outpatient IPCDs for a period of 14 days (control). Cohort two consisted of THA patients without outpatient IPCDs (experimental). Patients were non-randomized to 81mg ASA BID for 28 days for VTE chemoprophylaxis. An interim power analysis was performed to determine the proper sample size. Results. A total of 748 patients were discharged with outpatient IPCDs while 1,077 patients were discharged without IPCDs. There were no VTE events found in control group (0%). The total VTE rate of the experimental group was 0.2% (2 PE and 1 DVT). There was no statistical difference between these rates (p=0.24). A binary logistic regression did not detect any significant associations for any VTE outcomes even after accounting for demographic differences. Conclusion. Our findings suggest that discontinued use of outpatient portable IPCDs is safe and does not increase the rate of VTE in standard risk patients undergoing THA while using 81mg ASA BID as VTE prophylaxis

We report decreased clinical VTE rates following increased use of mechanical prophylaxis in elective kip and knee arthroplasty. Usage of intermittent pneumatic compression (IPC) increased due to the increased availability of pump machinery. Timing of IPC use also changed with IPC used intraoperatively on the unoperated limb and for a longer period postoperatively Clinical VTE rates are assessed for two years prior to the change in practice (1140 procedures) and two years afterwards (1285 procedures). There was no other change in practice (chemical thromboprophylaxis, anesthetic technique, use of compression stockings, usage of tourniquet or usage of cement) or in patient profile. Overall clinical VTE rates during admission dropped from 2.98% to 0.62% (p<0.0001). This decrease was seen in both hips 1.77% to 0.2% (p=0.029) and knees 3.97% to 0.89% (p=0.0002). There was a decrease in both pulmonary emboli 1.14% to 0.16% (p=0.0043) and symptomatic DVT 1.84% TO 0.47% (p=0.0023). There was no change in the rate of post discharge VTE events recorded 1.07% (p=0.57), either for DVT or PE (P=0.74 for each). We conclude that IPC with non-sequential calf compression is effective in reducing the rates of clinical in-hospital VTE after elective hip and knee arthroplasty

Although a number of agents have been shown to reduce the risk of thromboembolic disease, their use in total hip replacement (THR) remains controversial. Uncertainty exists regarding the safety of chemical prophylaxis as well as the choice of the most effective agent. Previous studies suggested that pneumatic compression with foot-pumps provide the best balance of safety and effectiveness, however too few patients were investigated in randomised clinical trials to draw evidence-based conclusions. The purpose of this randomized clinical trial was to compare the safety and efficacy of pneumatic compression with foot-pumps versus low-molecular-weight heparin (LMWH) for prophylaxis against DVT. Inclusion criteria were hip osteoarthritis and age less than 80 years. Exclusion criteria were history of thromboembolic disease, heart disease, and bleeding diatheses. 216 consecutive patients were considered for inclusion in the trial and were randomized either for management with LMWH (Fraxiparin, Sanofi-Synthelabo, France) or with the A-V Impulse foot-pump (Orthofix Vascular Novamedix, UK). Patients were monitored for DVT using serial duplex sonography and phlebography. DVT was detected in 3 of 100 patients managed with the foot-pump compared with 6 of 100 patients who received chemical prophylaxis (p< .05). Sixteen patients did not tolerate continuous use of the foot-pump and were excluded from the study. The average postoperative drainage was 259ml in the foot-pump group and 328ml in the LMWH group (p< .05). Patients with foot-pump had less swelling of the thigh (10mm compared with 15mm) (p< .05). The patients of the foot-pump group had less postoperative oozing and bruising than did those who had received LMWH. One patient developed heparin-induced thrombocytopenia. This study confirms the safety and efficacy of mechanical prophylaxis of DVT in THR. Some patients cannot tolerate the foot-pump

After decades of clinical experience and hundreds of studies, the ideal method of deep vein thrombosis (DVT) prophylaxis remains controversial. One of the most widely quoted publications on the subject in recent years has been the guidelines published by the American College of Chest Physicians (ACCP). The seventh and eighth ACCP Conference on Antithrombotic Therapy and Prevention of Thrombosis were published in Chest in 2004 and 2008 respectively. The highest level recommendation (1-A) was reserved for Warfarin at a relatively high dose (target international normalised ratio (INR) of 2–3), Low Molecular Weight Heparin (LMWH), or Fondaparinux for a minimum of 10 days for both total hip and total knee replacement. These agents were recommended for all patients, regardless of their relative risk of bleeding or risk of venous thromboembolism (VTE). These recommendations were found to be aggressive by the standards of most orthopaedic surgeons and a number of issues were identified with the methodology and resulting recommendations of the ACCP including: The emphasis on multicentre randomised clinical trials that are enormously expensive and strongly weighted towards pharmaceutical sponsored studies, methodology that prevented inclusion of studies of lower cost, lower tech options such as aspirin or lower dose Warfarin since randomised trials on a large scale are not available due to lack of funding or pharmaceutical company interest in generic low-cost options, lack of consideration of pneumatic compression options such as newly available mobile foot pumps with chips for monitoring compliance, financial conflict of interest of virtually all of the authors of the guidelines and the fundamental problem with utilising asymptomatic DVT as a study endpoint. The concerns with the aggressive nature of these recommendations were confirmed by studies from two academic centres which reported a high incidence of wound and bleeding complications when changing to a 1-A protocol. Recent studies indicate that readmissions following joint replacement are much more likely to be due to wound drainage and bleeding complications than DVT or pulmonary embolism (PE). In response to these concerns, the AAOS released guidelines in 2008 that were updated in 2011. The resulting recommendations represented a dramatic departure from the ACCP guidelines. Clinically crucial endpoints such as PE and death were utilized in the analysis rather than asymptomatic DVT, which was the criteria utilised by the Chest Physicians and the 2011 recommendations also considered symptomatic DVT. The AAOS guidelines consider patient risk category rather than making a uniform recommendation for all patients. Much more discretion is given to surgeons to utilise less aggressive prophylactic strategies including aspirin and foot pumps. In 2012, the ninth edition of the ACCP guidelines was published and many of the concerns previously expressed over prior editions were successfully addressed. Conflict of interest among the authors was much less of an issue, there was more attention placed on symptomatic events and clinically important complications, and a wider scope of literature was considered. The resulting guidelines represented a dramatic departure from previous recommendations. Aspirin and pneumatic compression were elevated to level 1 recommendation status along with potent drug regimens such as injectable drugs (LMWH and Xa inhibitor) as well as the new oral Xa inhibitors and antithrombin agents. When pneumatic compression devices are utilised, the use of a battery powered device capable of recording compliance was recommended. Patient risk status as well as patient preference were also considered. The new ACCP guidelines have successfully addressed many of the concerns previously addressed and are much more in line with the AAOS guidelines. It is anticipated that the federal Surgical Care Improvement Project (SCIP) guidelines for VTE prophylaxis will be released in 2013 and will also embrace the changes recommended by the ACCP. It is further likely that the AAOS and ACCP guidelines are close enough that they may well join forces in the near future and release a single unified document

Introduction. We studied the safety and efficacy of multimodal thromboprophylaxis (MMP) in patients with a history of venous thromboembolism (VTE) undergoing total hip arthroplasty (THA). MMP includes discontinuation of procoagulant medications, VTE risk stratification, regional anesthesia, an intravenous bolus of unfractionated heparin before femoral work, rapid mobilization, the use of pneumatic compression devices, and chemoprophylaxis tailored to the patient's risk. Material and methods. From 2004 to 2018, 257 patients (mean age: 67 years; range: 26–95) with a history of VTE underwent 277 primary, elective THAs procedures (128 right, 100 left, 9 single-stage bilateral, 20 staged bilateral) by two orthopaedic surgeons at a single institution. The patients had a history deep vein thrombosis (DVT) 186 (67%), pulmonary embolism (PE) 43 (15.5%), or both 48 (17.5%). Chemoprophylaxis included aspirin (38 patients) and anticoagulation (239 patients; Coumadin: 182, low-molecular-weight heparin: 3, clopidogrel: 1, rivaroxaban: 3, and a combination: 50). Forty eight patients (17.3%) had a vena cava filter at the time of surgery. Patients were followed for 120 days to detect complications, and for a year to detect mortality. Results. Postoperative VTE was diagnosed in seven patients (2.5%): DVT in five, and PE with and without DVT in one patient each. Bleeding complications occurred in 2 patients, one requiring surgical evacuation of a hematoma. Seven patients died during the first year (2.5%). One patient died 5 months postoperatively of a fatal PE during open thrombectomy, and one patient died of a hemorrhagic stroke while receiving Coumadin. PE or bleeding was not suspected in any of the remaining 5 fatalities. Conclusions. The result of this study spanning over 13 years, suggests that MMP is safe and effective. Postoperative anticoagulation should be prudent as very few patients developed postoperative VTE (2.5%) or died of suspected or confirmed PE. Mortality during the first year was mostly unrelated to VTE or bleeding. For any tables or figures, please contact the authors directly

Venous thromboembolic events (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), remain one of the most common complications following total joint arthroplasty. Reported rates of symptomatic VTE following THA and TKA range from 0.83% to 15% and 2% to 10%, respectively. Thus, VTE prophylaxis should be routinely administered following total joint arthroplasty. However, while orthopaedic surgeons have considerable flexibility regarding their VTE prophylaxis regimen, it remains unclear which is optimal. Patients at low risk of VTE may receive excessive anticoagulation and unnecessarily risk further perioperative morbidity (wound complications, bleeding) following total joint arthroplasty. With an evolving health care landscape, emphasis on complications and readmissions, and shorter inpatient hospitalizations, it is imperative that a VTE prophylaxis regimen is simple, effective, easy to monitor, and has high patient compliance. Mobile pneumatic compression devices (MCDs) have been used with greater frequency following total joint arthroplasty, with multiple reports demonstrating their effectiveness in VTE prevention with or without the addition of aspirin for chemical prophylaxis. The use of MCDs allows the avoidance of more aggressive anticoagulation in the majority of patients undergoing total joint arthroplasty, decreases the incidence of wound complications, and achieves a low overall incidence of symptomatic VTE. Future investigations are necessary to determine the necessity and impact of the addition of aspirin to the use of MCDs for VTE prophylaxis

Venous thromboembolism (VTE) prophylaxis following total joint arthroplasty (TJA) should be individualised in order to maximise the efficacy of prophylactic measures while avoiding the adverse events associated with the use of anticoagulants. At our institution, we have developed a scoring model using the Nationwide Inpatient Sample (NIS) database, which is validated against our institutional data, to stratify patients into low- and high-risk groups for VTE. Low-risk patients are placed on aspirin 81 mg twice daily for four weeks post-operatively, and high-risk patients are placed on either a Vitamin K antagonist (warfarin), low molecular weight heparin, or other oral anticoagulants for four weeks post-operatively. All patients receive sequential pneumatic compression devices post-operatively, and patients are mobilised with physical therapy on the day of surgery. Patients who have a history of peptic ulcer disease or allergy to aspirin are also considered for other types of anticoagulation following surgery. Risk Stratification Criteria. Major comorbid risk factors utilised in our risk stratification model include history of hypercoagulability or previous VTE, active cancer or history of non-cutaneous malignancy, history of stroke, and pulmonary hypertension. We consider patients with any of these risk factors at elevated risk of VTE and therefore candidates for formal anticoagulation. Other minor risk factors include older age, bilateral surgery compared with unilateral, inflammatory bowel disease, varicose veins, obstructive sleep apnea, and history of myocardial infarction, myeloproliferative disorders, and congestive heart failure. Each minor criterion is associated with a score. The cumulative score is compared with a defined threshold and the score that surpasses the threshold indicates that the patient should receive post-operative anticoagulation. To facilitate the use of this scoring system, an iOS mobile application (VTEstimator) has been developed and can be downloaded from the app store

Introduction. We investigated the incidence of venous thromboembolism (VTE) and pulmonary embolism (PE) after total knee arthroplasty (TKA) and assessed the efficacy and complications of three different chemical prophylactic regimens. Materials and Methods. From May, 2011 to November 2013, 268 patients, 330 knees were randomly allocated to three groups, low molecular weight heparin (LMWH) 5000IU for 2 days followed by aspirin 100mg for 5 days (Group HA, 110 knees), rivaroxaban 10mg for 7 days (Group X7, 110 knees), or for 10 days (Group X10, 110 knees) postoperatively. Intermittent pneumatic compression device was applied on all patients. The multidetector row computed tomography (MDCT) was done at postoperative 10 days to evaluate VTE (PE & DVT separately), and MDCT was rechecked to evaluate the changes of VTE at postoperative 3 months in VTE patients. Additionally, major and minor bleeding complications, amounts of bleeding, and bruise around wound were checked. Results. The incidence of VTE was 42 (38.2%) in Group HA, 22 (20.0%) in Group X7, 11 (10.0%) in Group X10. Deep vein thrombosis (DVT) was revealed 39 (35.5%) in Group HA, 17 (15.5%) in Group X7, 8 (7.3%) in Group X10. Group HA showed statistically higher prevalence in VTE and DVT than rivaroxavan groups. PE was detected 21 (19.1%) in Group HA, 11 (10.0%) in Group X7, 3 (2.7%) in Group X10. Group X10 was statistically significantly lower PE incidence than Group HA (p=0.0001) and Group X7 (p=0.027). Asymptomatic distal DVT was completely resolved in 88.8% with no specific treatment. There was no major or minor bleeding complications and bleeding amounts were not statistically different in 3 groups. Conclusion. Rivaroxaban has better prophylactic efficacy with no increasing bleeding complications than LMWH followed by aspirin. Ten days rivaroxaban was more effective for PE and VTE prevention than 7 days rivaroxavan. However, most of reduced VTEs were asymptomatic and distal DVTs

Our American Academy of Orthopaedic Surgeons (AAOS) and the American College of Chest Physicians (ACCP) have come to a consensus that the use of routine prophylaxis against venous thromboembolism (VTE) is indicated for our patients undergoing total joint arthroplasty. The new guidelines acknowledge differences in efficacy of the various agents and the variable risk of VTE among patients. Agents include warfarin, low molecular weight heparin, aspirin, oral Xa inhibitors, and direct thrombin inhibitors. The use of pneumatic compression devices have been found to be effective in decreasing risk of deep vein thrombosis (DVT) as a stand-alone strategy after total knee arthroplasty (TKA) and is given a level 1C recommendation by ACCP while the data is less strong for use following total hip arthroplasty (THA). Mechanical devices are not associated with an increased bleeding risk, and address the concerns of some surgeons with regard to post-operative bleeding. The availability of mobile compression devices has expanded the indications for use as a result of portability. While the use of mobile pump technology in DVT prophylaxis adds to the armamentarium of tools available for use in VTE risk mitigation, it does not eliminate the need for pharmacologic prophylaxis. While all arthroplasty patients are at elevated risk of VTE, the highest risk is associated with those having a prior history of DVT or pulmonary embolism (PE), having had prior surgery within the preceding three months, or requiring prolonged immobilization post-operatively for any reason. In these patients, thromboprophylaxis with any of a number of agents will play a valuable role in VTE risk reduction. Additionally, not all patients tolerate the use of the pump device. Those individuals with chronic peripheral arterial disease or arterial ulcers in the legs are also poor candidates for mechanical compression strategies which may exacerbate existing vascular compromise and perfusion of the limb. Assessment of the medical comorbidities of the patient may also stratify them to higher risk where the demonstrated benefits of pharmacologic prophylaxis outweigh the considerations of bleeding associated with their use (such as in the morbidly obese/high BMI patients). Mobile pump technology is a valuable adjunct to our VTE reduction strategies, but do not eliminate the need for pharmacologic agents. The judicious selection of DVT prophylaxis strategies based on the totality of the constellation of orthopaedic and medical factors unique to each patient allows us to make clinical decisions tailored to their needs, their risk of VTE, and their reliability in functioning as an active partner in their own post-operative care

Introduction. Pulmonary emboli (PE) after total hip and knee arthroplasties is an uncommon event. However, once it happens, it may results in sudden death. Thus, the prophylaxis of venous thromboembolism (VTE), including symptomatic deep vein thrombosis (DVT) and PE, is one of the challenging trials for Orthopaedic surgeons. Many procedures have been developed, e.g. early mobilization, compression stocking, intermittent pneumatic compression (IPC) devices, and anticoagulation agents. However, the most effective treatment for prophylaxis against VTE after the arthroplasties remains undecided. Recently, many low molecular weight heparin (LMWH) agents are developing, and these are strongly effective for anticoagulation. However, these agents sometimes lead to bleeding complications, and result in uncontrolled critical bleeding. We are introducing our protocol with conventional aspirin as VTE prophylaxis after the arithroplasties. Patients and methods. All patients prior to the surgeries are evaluated laboratory and duplex venous ultrasonography examinations to exclude thrombophilic or hemophilic conditions, and existence of DVT. Then, the thrombophilic, and also prolonged immobility, obesity, malignant tumors, cardiovascular dysfunction and DVT patients are regarded as high risk for VTE. These are offered a prophylaxis consisting of a removable inferior vena cava (IVC) filter, together with anticoagulant medication. Usually, the filter is removed three months after the surgery. In other patients, the arthroplasties are carried out under the spinal or epidural anesthesia with IPC on both feet. IPC is also applied, except for the periods of ambulation, usually two to three days of hospitalization after surgery. Full weight bearing ambulation with a walker is allowed on post-op day one. Patients receive aspirin (acetylsalicylic acid) 325 mg daily for six weeks starting the night of surgery. Pain is controlled with celecoxib (COX-2 selective nonsteroidal anti-inflammatory drug) 400 mg daily, and oral narcotics for break through pain. Before discharge, usually within three days post surgery, all patients are evaluated DVT by duplex venous ultrasonography. The incidence of blood loss, wound complications, and subcutaneous ecchymosis are recorded. Results and discussion. Although the incidence rate of all DVT (symptomatic and asymptomatic) after the arthroplasties was 2–3%, there was no patient readmitted or reoperated with critical bleeding, wound complications, nor fatal DVT/PE in this time period. The cost for the preoperative screening examinations, i.e. blood test and duplex venous ultrasonography, is approximately 200 US dollars. This is much less expensive than the cost associated with more aggressive anticoagulation agents and our procedures provided an acceptable level of outcomes with minimal risk of severe complications. Conclusions. The efficacy and safety of multimodal prophylaxis which employs aspirin against symptomatic PE in selected patients with hip and knee arthroplasties was demonstrated. Thus our protocol is recommended as a first choice for VTE prophylaxis

Mechanical prophylaxis with foot-pumps provides an interesting alternative to chemical agents in the prevention of thomboembolic disease following major orthopaedic surgery procedures. Recent studies have suggested that simultaneous use of graduated compression stockings (GCS) may hinder the pneumatic compression effect of foot pumps. The hypothesis of this prospective study was that the use of foot-pumps without GCS does not affect the efficacy of DVT prophylaxis, and improves patient compliance. 846 consecutive patients admitted at a single institution undergoing total hip (THR) or knee replacement (TKR) were included in the study. The A-V Impulse System. ®. foot-pump units (Orthofix Vascular Novamedix, Andover, UK) was used in all patients. Forty-six patients discontinued the use of foot-pumps, leaving 400 patients who received foot-pumps in combination with GCS and 400 patients with foot pumps alone. Eleven patients of the stocking group (2.7%) and 9 patients of the no-stockings group (2.3%) developed postoperative symptomatic DVT (p=0.07). DVT was more frequent in TKR (10 of 364; 2.7%) than in THR (10 of 436; 2.3%). Non-fatal pulmonary embolism occurred in 4 patients out of 20 with symptomatic DVT, 2 each of the stockings and no stockings groups. The foot pump discontinuation rate of patients treated with stockings was 7%, versus 4% of patients treated without stockings (p< 0.05). In conclusion, management of patients with foot-pumps without GCS does not reduce efficacy of DVT prophylaxis after THR and TKR, and improves patient compliance

Total knee arthroplasty (TKA) is one of the most successful surgeries to relieve pain and dysfunction caused by severe arthritis of the knee. Despite developments in prophylactic methods, deep venous thrombosis (DVT) and pulmonary embolism (PE) continue to be a serious complication following TKA. Otherwise DVT/PE is known to be a relatively low incidence in Asian patients, its accurate incidence is still controversial. Therefore, we prospectively investigated the incidence of DVT/PE after primary TKA by contrast enhanced computed tomography (CE-CT) and venous ultrasonography (US) in Japanese Patients. Methods. We prospectively investigated 51 patients who underwent primary TKA at the hospital from July 2013 to December 2013. All were of Japanese ethnicity. The mean age at the surgery was 74.9 years and average BMI was 26.0. There were 45 (88.2%) cases of osteoarthritis and 5 (9.8%) of rheumatoid arthritis. A single knee surgery team performed all operations with cemented type prostheses by utilizing pneumatic tourniquet. There were 21 cases of one-staged bilateral TKA and 30 of unilateral TKA. All patients were applied intermittent pneumatic compression (IPC) until 24 hours and graduated compression stockings for 3[高木1] weeks after the operation. Beginning from the day after the surgery, the patients were allowed walking with walker, along with the gradual range of motion exercise for physical thromboprophylaxis. Low-dose unfractionated heparin (LDUH) as a chemical thromboprophylaxis was administered subcutaneously for 3 days after the surgery. Informed consent was obtained regarding this thromboprophylaxis protocol. CE-CT and venous US were performed at the 4th day after surgery and images were read by a single senior radiologist team. The patients without DVT/PE by examination, they did not take additional chemical thromboprophylaxis. In cases of existence of DVT, continuous heparin administration and oral warfarin were applied and adjusted in appropriate dose for treatment. Warfarin was continued to be applied for at least three months until the patients had no symptoms and normal D-dimer level. In cases of PE, additional ultrasonic echocardiography (UCG) was performed, and then we consulted cardiologist to treat for PE. Results. CE-CT was performed in 42 patients (82.3%), otherwise nine patients (17.7%) could not take the examination because of exclusion criteria. There was no side-effect regard to contrast medium. The incidence of DVT and/or PE was 32 patients (62.7%), including two PE (3.9%), 21 DVT (41.1%) and nine both PE and DVT (17.6%). Six-teen patients were used LDUH routinely for 3 days after surgery. Five patients were used continuous heparin administration and oral warfarin instead of using LDUH because of medical co-morbidities. Additional continuous heparin administration and oral warfarin after LDUH use was needed in 26 patients. Three patients who had duodenal ulcer with chronic pancreatitis, massive PE with right heart strain and multiple DVT/PE with HIT antibody were needed another treatment. Conclusion. We prospectively investigated 51 patients for DVT/PE after primary TKA using CE-CT and venous US. The incidence of DVT/PE after primary TKA was 62.7%, including 21.5% of PE, as high frequency in Japanese patients

Introduction. Patients undergoing total knee arthroplasty (TKA) are at high risk of post operative venous thromboembolism (VTE). Edoxaban, the oral direct and selective factor Xa inhibitor, is available for preventing VTE after TKA. Recently, patients often take antiplatelet drugs including aspirin for their past illness. In our hospital, patients, in general, undergoing TKA receive edoxaban, but patients with aspirin for past illness receive only aspirin for preventing VTE. The aim of this study was to compare edoxaban and aspirin for preventing VTE in patients undergoing TKA. Materials and methods. From April 2012 to March 2014, 137 patients underwent primary TKA under general anesthesia with epidural anesthesia or femoral/ sciatic nerve block. Patients were excluded following; (1) renal dysfunction, (2) have taken anticoagulants such as warfarin for past illness. Finally, a total of 120 patients were enrolled. At the surgery, tourniquet was inflated and mid-vastus approach was used. After prosthesis implantation, tourniquet was deflated and drain tube was inserted. Intra and after operation, an intermittent pneumatic compression device was used. At postoperative day 2, edoxaban or aspirin started after removal of epidural anesthesia or drainage tube. Ninety-seven patients were assigned to receive edoxaban once daily (group E), and the rest of 23 received aspirin again same as before (group A). Edoxaban were scheduled to continue for 10 days. DVT diagnosis. At postoperative day 7, compression and colored Doppler imaging was taken for bilateral common femoral veins, superficial veins, popliteal veins and calf veins by skilled clinical technologist. Augmentation by calf squeezing and by dropped lower leg down were included. Diagnosing DVT criteria was loss of vein compressibility, presence of intraluminal echogenicity and absence of venous flow. D-dimer levels. At preoperative, postoperative days 7 and 14, plasma D-dimer levels were measured. Statistical analysis. Data were compared using independent t-test or the chi-square test. A significant difference was set at p<0.05. Results. Patients’ characteristics were shown in table 1. Age in the group A was significantly higher than in the group E. The total incidence of DVT was 40%. The incidence of DVT was significantly decreased in group E compared to group A at day 7 (group E: 34% versus group A: 65%, p<0.01) (table 2). The D-dimer level in group E was significantly decreased at postoperative day 7 (13.2 ± 6.8 (mean ± SD) vs 17.0 ± 9.1, p<0.05). At day 14, there were no significant differences (Figure 1). Discussion. In this study, edoxaban decreased the incidence of DVT after TKA compared to aspirin. The result of D-dimer supported the efficacy of edoxaban. Results showed that edoxaban is effective for preventing DVT following TKA. Recently, TKA patients often take antiplatelet drugs including aspirin for their past illness. It is still controversial to add an antithrombotic drug for preventing VTE. The incidence of DVT with aspirin was higher than that with edoxaban. Thus, patients received only aspirin might be needed not only to pay attention to VTE, but also to add anticoagulants as edoxaban for preventing VTE

Recently, the International Consensus Statement Group reported that mechanical prophylaxis with foot-pumps should be considered “Grade A” recommendation for prevention of deep-vein thrombosis after total hip replacement. Mechanical prophylaxis with foot-pumps provides an interesting alternative to chemical agents in the prevention of thomboembolic disease following major orthopaedic surgery procedures. Recent duplex ultrasound studies have suggested that simultaneous use of graduated compression stockings (GCS) may hinder the pneumatic compression effect of foot pumps. The hypothesis of this prospective study was that the use of foot-pumps without GCS does not affect the efficacy of DVT prophylaxis, and improves patient compliance. 846 consecutive patients admitted at a single institution undergoing total hip (THR) or knee replacement (TKR) were included in the study. The A-V Impulse System® foot-pump units (Orthofix Vascular Novame-dix, Andover, UK) was used in all patients. Forty-six patients discontinued the use of foot-pumps, leaving 400 patients who received foot-pumps in combination with GCS and 400 patients with foot pumps alone. Eleven patients of the stocking group (2.7%) and 9 patients of the no-stockings group (2.3%) developed postoperative symptomatic DVT (p=0.07). DVT was more frequent in TKR (10 of 364; 2.7%) than in THR (10 of 436; 2.3%). Non-fatal pulmonary embolism occurred in 4 patients out of 20 with symptomatic DVT, 2 each of the stockings and no stockings groups. The foot pump discontinuation rate of patients treated with stockings was 7%, versus 4% of patients treated without stockings (p< 0.05). In conclusion, management of patients with foot-pumps without GCS does not reduce efficacy of DVT prophylaxis after THR and TKR, and improves patient compliance

Background. Venous thromboembolisms are serious complications of arthroplasty of the lower extremities. Although early ambulation and active leg exercise is recommended, postoperative patients with surgical pain have difficulty in moving their legs. Therefore, we developed a novel leg exercise apparatus (LEX) to facilitate active leg movement even during the early postoperative period (Fig 1). LEX is a portable apparatus that allows patients to actively move their legs while in the supine position. LEX enables dorsiflexion, plantar flexion, combined eversion and inversion of the ankle, and multi-joint movement of the leg. Objectives. To describe how LEX facilitates active movement of the leg and thereby increases venous flow in the lower extremities. Participants and Methods. The venous flow volume of the femoral vein of 8 healthy volunteers; 5 men and 3 women, with a mean age of 22.4 (range, 22–26) years, were measured by duplex ultrasonography. The measurements were repeated at 1, 3, 5, and 10 minutes after the completion of one-minute active ankle exercise with LEX, and during the 10-minute use of an intermittent pneumatic compression (IPC) device. The same measurements were taken from 8 healthy volunteers; 5 men and 3 women, with a mean age of 21.6 (19–26) years, after three types of 1 minute LEX exercise: rapid dorsiflexion-plantar flexion (60 reps/min), slow dorsiflexion-plantar flexion (30 reps/min) and combined motion of the leg (30 reps/min). These measurements were repeated at 1, 10, 20, and 30 minutes after the 1 min-LEX exercise. Statistical methods. All data were analyzed in a two-way repeated measures analysis of variance. Post-hoc analyses were performed using the Bonferroni comparisons test. The probability level accepted for statistical significance was p < 0.05 (SPSS Statistics Version 21). Results. Whereas the flow volume of the femoral vein after the 1 min-LEX exercise increased 2.00-fold over the baseline level, the value at 1 minute after the start of IPC did 1.18-fold (p = 0.033). The flow volume at 10 minutes had increased 1.50-fold; the corresponding values during IPC use were the same as those during rest (Fig 2). The flow volume after the 1 min-LEX exercise had increased for 30 minutes. After 30 minutes of rapid dorsiflexion-plantar flexion, it increased 1.63-fold over the baseline level. While 1 minute after slow flexion, the flow volume increased 1.38-fold and remained on the same level, this value was 1.53-fold at 30 minutes after combined leg motion. The combined leg exercise made the flow volume higher than dorsiflexion-plantar flexion at equal speed (Fig 3). Discussion. Short periods of LEX use improved the venous flow volume of the femoral vein more than continuous use of IPC. The 1-min LEX exercise had improved the femoral venous flow volume for 30 minutes, and combined leg exercise was more effective than a single ankle exercise. These results suggest that LEX exercise can induce the lower-extremity venous flow greater than that achieved using IPC. Clinical Relevance: LEX might be effective for enabling postoperative patients to move their legs and to improve venous flow of the lower extremities

Near infrared light between the wavelengths of 700 and 950 nanometers has a relatively low absorption in tissue, and light of these wavelengths is able to penetrate several centimetres into tissue. Absorption of light is primarily due to hemoglobin. The absorption spectra for oxy-hemoglobin and deoxy-hemoglobin are different, and therefore comparison of light absorption at different wavelengths allows an assessment of the relative concentrations of these two chromophores. Light penetrates bone as well as soft-tissue, and near infrared spectroscopy (NIRS) is potentially a relatively simple, low-cost technique for assessing perfusion in bone. However, although absorption of light is low, scattering is high, and the spatial resolution of the measurement is poor. Application of the technique to the study of bone perfusion requires consideration of the potential confounding absorption arising from adjacent tissues that may have higher perfusion. A clinical problem of interest in our institute is that of vascular changes occurring in bone of patients with spinal cord injury (SCI), and the relationship of these changes to bone density changes. We have, therefore, concentrated on developing NIRS for measurement of the proximal tibia, which is a common site for fractures in these patients. In order to develop a probe for the measurement of bone, experiments were performed with phantoms containing infrared absorbing dyes. Numerical simulations were also performed using the Monte Carlo technique. One of the most important design considerations is the distance between the optode delivering light to the skin, and the collecting optode which detects light. It was found that a separation of 20 mm between the light source and detector was an optimum compromise for minimizing contributions from overlying skin and surrounding muscle, while still being able to detect light efficiently enough to measure dynamic changes in chromophore concentration. We have now started to apply this technique clinically. Relative changes of oxy- and deoxy-hemoglobin concentration have been measured in response to a range of interventions. Comparison has been made of the effect of different interventions designed to modify perfusion of bone (neuro-muscular stimulation of the calf, intermittent pneumatic compression, low amplitude high frequency vibration, and venous tourniquet). We are studying vascular reactivity in chronic SCI patients and controls and we have also started to investigate the effect of daily neuro-muscular stimulation in acute SCI patients. Preliminary results of these clinical studies will be presented

Introduction. Traumatized musculoskeletal tissue often exhibits prolonged time to healing, mostly due to low blood flow and innervation. Intermittent Pneumatic Compression (IPC) increases blood flow and decreases thromboembolic event after orthopedic surgery,[1] however little is known about healing effects.[2] We hypothesized that IPC could stimulate tissue repair: 1.) blood flow 2.) nerve ingrowth 3.) tissue proliferation and during immobilisation enhance 4.) biomechanical tissue properties. Methods. Study 1: In 104 male Sprague Dawley (SD) rats the right Achilles tendon was ruptured and the animals freely mobilized. Half the group received daily IPC-treatment, using a pump and cuff over the hindpaw that inflates/deflates cyclicly, 0–55mmHg (Biopress SystemTM, Flexcell Int.), and the other half received sham-treatment. Healing was assessed at 1,3,6 weeks by perfusion-analysis with laser doppler scanner (Perimed, Sweden), histology and biomechanical testing. Study 2: 48 male SD-rats were ruptured as above. Three groups of each 16 rats were either mobilized, immobilized or immobilized with IPC treatment. Immobilization was performed by plaster cast. Healing was assessed at 2 weeks with histology and biomechanical testing. Results. Study 1: At 3 and 6 weeks reperfusion increased by 21% and 23% (p< 0.05) after IPC-treatment, strengthened by the observation of elevated numbers of blood vessels and nerves. Fibroblast density was at all time points significantly increased in the IPC group. At three and six weeks the IPC treated tendons displayed an increased tissue organization confirmed by higher collagen I/III ratio in the IPC group. No differences (p = 0.10) were found regarding biomechanical strength. Study 2: Compared to mobilization, immobilization caused a downregulation (p<0.05) of all biomechanical and histological parameters, eg. maximum force decreased 80% and collagen III occurrence by 83%. However when immobilization was combined with IPC biomechanical and histological healing increased significantly compared to pure immobilization, eg. maximum force increased 63% and collagen III occurrence by 150%. Conclusion. This study demonstrated that IPC treatment can counteract biomechanical and morphological deficits caused by immobilization by enhancing proliferative soft tissue repair. Thus, IPC promotes tissue repair by stimulating tissue perfusion and nerve ingrowth as well as accelerating both fibroblast proliferation and collagen organization

We evaluated the safety and efficacy of a multimodal approach for prophylaxis of thromboembolism after THA, which includes preoperative autologous blood donation; hypotensive epidural anesthesia; intravenous administration of heparin during surgery, before femoral preparation when the thrombogenesis is maximally activated; expeditious surgery, minimizing femoral vein occlusion and blood loss; pneumatic compression; and early mobilization after surgery. 1946 consecutive, non-selected patients (2016 THAs) who received multimodal thromboembolic prophylaxis were followed prospectively for 3 months. Only patients with history of thrombocytopenia (platelet count < 100.000) or adverse reaction to heparin were excluded. The average age was 65 years (14 to 93), ASA classification was 1 in 14%, 2 in 48%, 3 in 37% and 4 in 1% of patients. There was a history of DVT in 86 patients and PE in 35. After surgery, the patients also received pharmacologic prophylaxis for 6 weeks (aspirin 83%; warfarin 17%). The incidence of asymptomatic DVT assessed by ultrasound in the first 198 consecutive patients was 7.1% (14 of 198). The incidence of clinical DVT in the subsequent 1748 patients was 1.8% (32 of 1748). Symptomatic PE occurred in 0.56% (11 of 1946), none of them fatal. The rate of PE in patients receiving aspirin was 0.49% (8 of 1615) and warfarin 0.9% (3 of 331). There was 1 PE among 95 patients with a prior history of PE or DVT (1%). One morbidly obese patient died of a cardiac arrhythmia confirmed by autopsy. There was only one major bleeding complication: one patient with a history of coagulopathy developed hematuria requiring a bladder flush and five units of blood, with an uneventful recovery. No patients developed epidural hematoma following administration of intraoperative heparin. A multimodal approach to prevent thromboembolic disease, showed results that compare favorably with the literature, and with our historic control of 2592 THRs without intraoperative heparin (PE rate of 1%; 0.04% fatal). This multimodal approach appears safe and efficacious as thromboembolic prophylaxis. Our low rate of PE does not support routine anticoagulation prophylaxis with drugs with a significant risk of bleeding