Aims. The aim of this study was to evaluate the healthcare costs and benefits of enoxaparin compared to
Aims. The optimal management of an infrapopliteal deep venous thrombosis (IDVT) following total knee arthroplasty (TKA) remains unknown. The risk of DVT propagation and symptom progression must be balanced against potential haemorrhagic complications associated with administration of anticoagulation therapy. The current study reports on a cohort of patients diagnosed with IDVT following TKA who were treated with
Aims. There is uncertainty regarding the optimal means of thromboprophylaxis
following total hip and knee arthroplasty (THA, TKA). This systematic
review presents the evidence for acetylsalicylic acid (aspirin)
as a thromboprophylactic agent in THA and TKA and compares it with
other chemoprophylactic agents. Materials and Methods. A search of literature published between 2004 and 2014 was performed
in accordance with Preferred Reporting Items for Systematic Reviews
and Meta-Analyses guidelines. A total of 13 studies were eligible
for inclusion. Results. Evidence from one good quality randomised controlled trial (RCT)
showed no difference in rates of venous thrombo-embolism (VTE) in
patients given
The number of arthroplasties being performed
increases each year. Patients undergoing an arthroplasty are at
risk of venous thromboembolism (VTE) and appropriate prophylaxis
has been recommended. However, the optimal protocol and the best
agent to minimise VTE under these circumstances are not known. Although
many agents may be used, there is a difference in their efficacy
and the risk of bleeding. Thus, the selection of a particular agent relies
on the balance between the desire to minimise VTE and the attempt
to reduce the risk of bleeding, with its undesirable, and occasionally
fatal, consequences. Acetylsalicylic acid (aspirin) is an agent for VTE prophylaxis
following arthroplasty. Many studies have shown its efficacy in
minimising VTE under these circumstances. It is inexpensive and
well-tolerated, and its use does not require routine blood tests.
It is also a ‘milder’ agent and unlikely to result in haematoma
formation, which may increase both the risk of infection and the
need for further surgery.
We compared thromboembolic events, major haemorrhage
and death after total hip replacement in patients receiving either
aspirin or low-molecular-weight heparin (LMWH). We analysed data from
the National Joint Registry for England and Wales linked to an administrative
database of hospital admissions in the English National Health Service.
A total of 108 584 patients operated on between April 2003 and September 2008
were included and followed up for 90 days. Multivariable risk modelling
and propensity score matching were used to estimate odds ratios
(OR) adjusted for baseline risk factors. An OR <
1 indicates
that rates are lower with LMWH than with
We compared thromboembolic events, major haemorrhage
and death after knee replacement in patients receiving either aspirin
or low-molecular-weight heparin (LMWH). Data from the National Joint
Registry for England and Wales were linked to an administrative
database of hospital admissions in the English National Health Service.
A total of 156 798 patients between April 2003 and September 2008
were included and followed for 90 days. Multivariable risk modelling
was used to estimate odds ratios adjusted for baseline risk factors
(AOR). An AOR <
1 indicates that risk rates are lower with LMWH
than with
Aims. The aim of this study was to present data on 11 459 patients
who underwent total hip (THA), total knee (TKA) or unicompartmental
knee arthroplasty (UKA) between November 2002 and April 2014 with
aspirin as the primary agent for pharmacological thromboprophylaxis. . Patients and Methods. We analysed the incidence of deep vein thrombosis (DVT) and pulmonary
embolism (PE) then compared the 90-day all-cause mortality with
the corresponding data in the National Joint Registry for England
and Wales (NJR). . Results. The incidence of PE was 0.6% after THA, 1.47% after TKA and 1.2%
after UKA. The 90-day mortality was 0.39% after THA and 0.44% after
TKA. No deaths occurred after UKA. The main causes of death were
ischaemic heart disease and respiratory failure. PE was responsible
for only 18% of deaths. There was a decline in 90-day mortality,
from 0.64% between 2002 and 2007, to 0.21% between 2008 and 2013
after THA, and from 0.47% to 0.39% after TKA for the corresponding
period. The standardised mortality ratio (SMR) declined from 86.5
(confidence interval (CI) 63.0 to 137.7) to 39.7 (CI 31.2 to 54.3)
p = 0.024. The incidence of proximal DVT was 0.3%. . Take home message: With individualised risk assessment and as
part of a multimodal approach,
The incidence of deep-vein thrombosis (DVT) and
pulmonary embolism (PE) is thought to be low following foot and ankle
surgery, but the routine use of chemoprophylaxis remains controversial.
This retrospective study assessed the incidence of symptomatic venous
thromboembolic (VTE) complications following a consecutive series
of 2654 patients undergoing elective foot and ankle surgery. A total
of 1078 patients received 75 mg
Venous thromboembolism (VTE) is a preventable cause of morbidity and mortality in patients undergoing elective hip arthroplasty surgery. The balance of post-operative VTE prophylaxis and risk of post-operative haemorrhage remains at the forefront of surgeon's mind. The National Institute for Clinical Excellence (NICE) has altered their prophylaxis guidance in the setting of total hip arthroplasty (THA). The aim of this study was to present the VTE incidence in 8,890 patients who underwent total hip arthroplasty between January 1997 and March 2018 with
Aims. We investigated the efficacy and safety profile of commonly used venous thromboembolism (VTE) prophylaxis agents following hip and knee arthroplasty. Methods. A systematic search of PubMed, Embase, Cochrane Library, Web of Science, and OrthoSearch was performed. Prophylaxis agents investigated were
Purpose: The objective of this study was to examine the relationship between
Background. Few studies have compared
Aims. Thromboprophylaxis following Total Hip Replacement (THR) surgery remains controversial, balancing VTE prevention against wound leakage and subsequent deep infection. We analysed the 90 day cause of death post THR in our institution after the implementation of new thromboprophylactic policy of low dose
The October 2023 Knee Roundup. 360. looks at: Cementless total knee arthroplasty is associated with more revisions within a year; Kinematically and mechanically aligned total knee arthroplasties: long-term follow-up;
Venous thromboembolism (VTE) is a serious complication after total hip and knee arthroplasty. There is still no consensus regarding the best mode of thromboprophylaxis after lower limb arthroplasty. The aim of this study was to ascertain the efficacy, safety profile and rate of adverse thromboembolic events of
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
The National Institute for Health and Clinical
Excellence (NICE) has thus far relied on historical data and predominantly
industry-sponsored trials to provide evidence for venous thromboembolic
(VTE) prophylaxis in joint replacement patients. We argue that the
NICE guidelines may be reliant on assumptions that are in need of
revision. Following the publication of large scale, independent
observational studies showing little difference between low-molecular-weight
heparins and
Thromboembolic disease is associated with a high degree of morbidity and mortality. There is increasing pressure for elective orthopaedic patients, including those undergoing foot and ankle surgery, to be prescribed chemical thromboprophylaxis post-operatively in order to reduce the risk of a thromboembolic event. The risks of chemical thromboprophylaxis in terms of increased bleeding, wound problems and HIT are well documented. The aim of this study was to determine the incidence of clinically significant thromboembolic events in patients undergoing elective foot and ankle surgery with and without the use of
Introduction: The recent BOA blue book on blood conservation in elective orthopaedic surgery highlighted the need for blood saving strategies to be implemented. Perioperative management guidelines of oral anti-coagulation and anti-thrombosis medication have to date concentrated on warfarin use. Information and guidelines on
Introduction: Venous thromboembolism is a major cause of morbidity and mortality in hospitalised patients and patients undergoing major orthopaedic surgery are at high risk from venous thromboembolism. Thromboprophylaxis, both mechanical and chemical, is commonly administrated to reduce fatality from thromboembolism after surgery. However, there is no convincing evidence in the literature demonstrating that routine chemothromboprophylaxis reduces death rates from pulmonary embolus. Furthermore, it is unclear from the literature which thromboprophylactic agent, if any, should be used. Recent NICE guidelines have recommended that heparin should be routinely administered to patients under-going THR to prevent thromboembolism, although it is unclear from the existing evidence if heparin is the most effective. However, research has suggested that
The June 2023 Trauma Roundup. 360. looks at:
The August 2024 Knee Roundup. 360. looks at: Calcification’s role in knee osteoarthritis: implications for surgical decision-making; Lower complication rates and shorter lengths of hospital stay with technology-assisted total knee arthroplasty; Revision surgery: the hidden burden on surgeons; Are preoperative weight loss interventions worthwhile?; Total knee arthroplasty with or without prior bariatric surgery: a systematic review and meta-analysis;
Background: Percutaneous compression plating (PCCP) is used for the fixation of intertrochanteric hip fractures by a minimally invasive technique. While offering several advantages compared to classic open reduction and internal fixation, the technique does not allow direct hemostasis. We aimed to assess the effect of regular
The Pulmonary Embolism Prevention (PEP) Trial was designed to assess the effects of a 35 day course of
Background. The most appropriate form of chemical thromboprophylaxis following knee replacement is a contentious issue. Most national guidelines recommend the use of low molecular weight Heparin (LMWH) whilst opposing the use of
Aims. The aims of this study were to compare the efficacy of two agents,
aspirin and warfarin, for the prevention of venous thromboembolism
(VTE) after simultaneous bilateral total knee arthroplasty (SBTKA),
and to elucidate the risk of VTE conferred by this procedure compared
with unilateral TKA (UTKA). Patients and Methods. A retrospective, multi-institutional study was conducted on 18
951 patients, 3685 who underwent SBTKA and 15 266 who underwent
UTKA, using
In a randomised trial we compared the effects of two different antithrombotic regimens on the incidence of venographically established deep venous thrombosis (DVT) in 83 patients undergoing surgery for fracture of the femoral neck. Group A received dextran 40 peroperatively plus 0.5 g
Current orthopedic practice requires consideration of apparently contradictory recommendations regarding VTE prevention among THR/TKR patients. American College of Chest Physicians (ACCP) 8th Clinical Practice Guidelines for the Prevention of Venous Thromboembolism recommend against
Aims. The place of thromboprophylaxis in arthroplasty surgery remains
controversial, with a challenging requirement to balance prevention
of potentially fatal venous thrombo-embolism with minimising wound-related
complications leading to deep infection. We compared the incidence
of fatal pulmonary embolism in patients undergoing elective primary
total hip arthroplasty (THA) between those receiving
Following the outcomes of the RECORD trials the protocol of extended thromboprophylaxis in patients undergoing elective primary total hip or knee arthroplasty has been changed in our institution. Between June 2008 and May 2009 patients were offered extended thromboprophylaxis with 150mg of
Upper gastrointestinal (GI) bleeding in patients who undergo hip and knee arthroplasty tends to be associated with NSAID use, steroid intake, pre-existing peptic ulcers and smoking. The use of
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
The aims of this study were to determine the indications and
frequency of ordering a CT pulmonary angiography (CTPA) following
primary arthroplasty of the hip and knee, and to determine the number
of positive scans in these patients, the location of emboli and
the outcome for patients undergoing CTPA. We analyzed the use of CTPA, as an inpatient and up to 90 days
as an outpatient, in a cohort of patients and reviewed the medical
records and imaging for each patient undergoing CTPA.Aims
Patients and Methods
Dabigatran etexilate (Pradaxa®) is an oral direct thrombin inhibitor that was recently approved in Europe and Canada for the prevention of venous thromboembolism (VTE) in patients undergoing total knee arthroplasty (TKA) or total hip arthroplasty (THA) surgery. In the phase III studies, concomitant administration of selective nonsteroidal anti-inflammatory drugs (NSAIDs with t½≤12 hours) and acetylsalicylic acid (ASA; <
160 mg/day) was allowed during treatment with dabigatran etexilate or enoxaparin. Due to the potential additional anticoagulant activity of these concomitant therapies a separate post hoc analysis was conducted to investigate the bleeding risk in these patients. We analysed the pooled study population (8,135 patients) from the three phase III trials in THA and TKA surgery (RE-MOBILIZE, RE-MODEL and RE-NOVATE) for major bleeding events (MBE). All MBE, which included surgical site bleeds, were assessed by an independent, expert adjudication committee. We report the rates of MBE and odds ratios (with 95% confidence intervals [CI]) for comparison of the subgroup concomitantly treated with NSAID (or ASA) versus the subgroup of patients without concomitant antithrombotically active medication. The overall rate of MBE (with and without NSAIDs and ASA) was 1.4% [CI 1.0–1.9], 1.1% [0.7–1.5] and 1.4% [1.0–2.0] with dabigatran etexilate 220 mg, 150 mg, and enoxaparin, respectively. Of the total population, 57.4% of patients received concomitant antithrombotic treatment: 54.1% received NSAID and 4.7% received ASA. The MBE rate in patients receiving dabigatran etexilate or enoxaparin plus NSAIDs was similar to the rate in patients taking only dabigatran etexilate or enoxaparin; 1.5% vs. 1.4% [OR 1.05; 0.55–2.01] for dabigatran etexilate 220 mg, 1.1% vs. 1.0% [OR 1.19; 0.55–2.55] for dabigatran etexilate 150 mg, and 1.6% vs. 1.2% [OR 1.32; 0.67–2.57] for enoxaparin. A similar pattern was seen in patients concomitantly receiving ASA; in this small group only a few patients with MBE were observed: 2 (1.6%) in the dabigatran etexilate 220 mg group, 2 (1.6%) in the 150 mg group, and 4 (3.0%) in the enoxaparin group. No relevant differences in risk for MBE were detected between treatments by co-medication subgroup or within treatment groups when comparing patients receiving dabigatran etexilate or enoxaparin only versus those concomitantly receiving NSAIDs or ASA. In conclusion, patients concomitantly receiving dabigatran etexilate and NSAIDs (with t½ ≤12 hours) or ASA (<
160 mg/day) have a similar risk of MBE to patients taking only dabigatran etexilate. These data support the use of dabigatran etexilate for the prevention of VTE in patients after THA or TKA, when concomitant use of NSAIDs or ASA (<
160 mg/day) is required.
Aims. It is common practice for patients to have postoperative blood tests after total joint replacement (TJR). However, there have been significant improvements in perioperative care with arthroplasty surgery, and a drive to reduce the length of stay (LOS) and move towards day-case TJR. We should reconsider whether this intervention is necessary for all patients. Methods. This retrospective study included all patients who underwent a primary unilateral TJR at a single tertiary arthroplasty centre during a one-year period. Electronic medical records of 1,402 patients were reviewed for patient demographics, LOS, and American Society of Anesthesiologists (ASA) grade. Blood tests were examined to investigate the incidence of postoperative anaemia, electrolyte abnormalities, and incidence of acute kidney injury (AKI). Results. For total knee arthroplasties, preoperative (R = −0.22) and postoperative haemoglobin (R = 0.2) levels were both negatively correlated with LOS (p < 0.001). For all patients who had undergone a TJR, 19 patients (0.014%) required a blood transfusion postoperatively due to symptomatic anaemia. Risk factors identified were age, preoperative anaemia, and long-term
Considerable debate exists regarding which agent(s) should be preferred for venous thromboembolism (VTE) chemical prophylaxis following joint replacement. We assessed the practice of surgeons regarding VTE chemical prophylaxis for primary THR and TKR, pre and post issuing of updated NICE guidance in 2018. A survey, circulated through the British Hip Society and regional trainee networks/collaboratives, was completed by 306 UK surgeons at 187 units. VTE chemical prophylaxis prescribing patterns for surgeons carrying out primary THR (n=258) and TKR (n=253) in low-risk patients were assessed post publication of 2018 NICE recommendations. Prescribing patterns before and after the NICE publication were subsequently explored. Questions were also asked about surgeon equipoise for participation in future RCTs. Following the new guidance, 34% (n=87) used low-molecular weight heparin (LMWH) alone, 33% (n=85)
Aims. We studied the safety and efficacy of multimodal thromboprophylaxis in patients with a history of venous thromboembolism (VTE) who undergo total hip arthroplasty (THA) within the first 120 postoperative days, and the mortality during the first year. Multimodal prophylaxis includes discontinuation of procoagulant medications, VTE risk stratification, regional anaesthesia, an intravenous bolus of unfractionated heparin prior to femoral preparation, rapid mobilization, the use of pneumatic compression devices, and chemoprophylaxis tailored to the patient’s risk of VTE. Methods. Between 2004 to 2018, 257 patients with a proven history of VTE underwent 277 primary elective THA procedures by two surgeons at a single institution. The patients had a history of deep vein thrombosis (DVT) (186, 67%), pulmonary embolism (PE) (43, 15.5%), or both (48, 17.5%). Chemoprophylaxis included
Thromboprophylaxis after elective orthopaedic surgery remains controversial. Recent guidelines from the National Institute for Clinical Excellence (NICE) have suggested that low molecular weight heparin should be given to all patients undergoing total hip replacement. The British Orthopaedic Association is currently debating this guideline with NICE, as it is not clear whether published evidence supports this view. We present the early mortality in our unit after total hip replacement using
Patients who sustain hip fractures should be operated on within 24 hours of admission according to the Royal College Of Physician Guidelines. A delay to theatre of more than 4 days is associated with an increase in inpatient mortality. A high proportion of patients with hip fractures are elderly and take
We studied 4253 patients undergoing primary joint replacement between November 2002 and November 2007, of whom 4060 received
Background: Aetiology of venous thromboembolism is multifactorial and thromboprophylaxis includes mechanical and chemical agents. There is no clear consensus on the choice of chemical agent in elective total hip arthroplasty (THA), although National Institute of Clinical Excellence (NICE) recommends low molecular weight heparin or fondaparinux to all patients. Aim: The aim of our study was to define the efficacy and safety of various chemical agents currently used for venous throboprophylaxis – namely
Thromboprophylaxis is of particular interest to the NHS due to the number of deaths from preventable hospital-acquired venous thrombo-embolism, considerable treatment cost and related long-term morbidities. In compliance with current NICE guidelines, our departmental protocol for chemical thromboprophylaxis changed from
Objective: To examine the impact of
Immobilisation is known to be a risk factor for thromboembolic events and the management of ankle fractures often involves immobilisation of the fracture in a below knee cast. Recent literature has found a 5% rate of subclinical deep vein thrombosis (DVT) and suggested thromboembolic prophylaxis is not required. This study involved all adult patients with isolated ankle fractures presenting to a district general hospital orthopaedic department over a 6 month period. This included patients undergoing internal fixation as well as non-operative management. A 3 to 7 month follow-up was performed to assess the incidence of clinical DVT or pulmonary embolism (PE) proven using Doppler imaging, venogram, and computed tomography pulmonary angiography. 119 patients met the entry criteria and, of these, 3 patients developed DVT and 2 patients presented with pulmonary embolus. 15 patients in the study were taking
Background. Hip fracture in the elderly has high morbidity and mortality. National guidelines have recommended low molecular weight (LMW) heparin or
Aim:. This prospective cohort study investigated whether the use of preoperative anticoagulants is an independent risk factor for the outcomes of surgical treatment of patients with a neck of femur fracture. Methods:. Data was obtained from a prospectively collected database. All patients admitted for a neck of femur fracture between Nov 2010 and Oct 2011 were included. This resulted in three hundred twenty-eight patients with 330 neck of femur fractures. Four groups were defined; patients preoperatively (i) on
Aims. We studied the impact of direct anterior (DA) versus non-anterior (NA) surgical approaches on prosthetic joint infection (PJI), and examined the impact of new perioperative protocols on PJI rates following all surgical approaches at a single institution. Patients and Methods. A total of 6086 consecutive patients undergoing primary total hip arthroplasty (THA) at a single institution between 2013 and 2016 were retrospectively evaluated. Data obtained from electronic patient medical records included age, sex, body mass index (BMI), medical comorbidities, surgical approach, and presence of deep PJI. There were 3053 male patients (50.1%) and 3033 female patients (49.9%). The mean age and BMI of the entire cohort was 62.7 years (18 to 102, . sd. 12.3) and 28.8 kg/m. 2. (13.3 to 57.6, . sd. 6.1), respectively. Infection rates were calculated yearly for the DA and NA approach groups. Covariates were assessed and used in multivariate analysis to calculate adjusted odds ratios (ORs) for risk of development of PJI with DA compared with NA approaches. In order to determine the effect of adopting a set of infection prevention protocols on PJI, we calculated ORs for PJI comparing patients undergoing THA for two distinct time periods: 2013 to 2014 and 2015 to 2016. These periods corresponded to before and after we implemented a set of perioperative infection protocols. Results. There were 1985 patients in the DA group and 4101 patients in the NA group. The overall rate of PJI at our institution during the study period was 0.82% (50/6086) and decreased from 0.96% (12/1245) in 2013 to 0.53% (10/1870) in 2016. There were 24 deep PJIs in the DA group (1.22%) and 26 deep PJIs in the NA group (0.63%; p = 0.023). After multivariate analysis, the DA approach was 2.2 times more likely to result in PJI than the NA approach (OR 2.2 (95% confidence interval 1.1 to 3.9); p = 0.006) for the overall study period. Conclusion. We found a higher rate of PJI in DA versus NA approaches. Infection prevention protocols such as use of
We performed a meta-analysis of the English literature to assess the efficacy of four common regimes for thromboembolic prophylaxis after total knee arthroplasty:
British national guidelines recommend agents which antagonise factor Xa or warfarin as prophylaxis of venous thromboembolism (VTE) in lower limb arthroplasty. However, they discourage the use of
Venous Thromboembolism is a common complication following a hip replacement. Recently the pulmonary embolism prevention study was published. It reported that
Aims. The purpose of this article was to review the current literature
pertaining to the use of mobile compression devices (MCDs) for venous
thromboembolism (VTE) following total joint arthroplasty (TJA),
and to discuss the results of data from our institution. Patients and Methods. Previous studies have illustrated higher rates of post-operative
wound complications, re-operation and re-admission with the use
of more aggressive anticoagulation regimens, such as warfarin and
factor Xa inhibitors. This highlights the importance of the safety,
as well as efficacy, of the chemoprophylactic regimen. Results. Studies have shown a symptomatic VTE rate of 0.92% with use of
MCDs for prophylaxis, which is comparable with rates seen with more
aggressive anticoagulation protocols. A prior prospective study
found that use of a pre-operative risk stratification protocol based on
personal history of deep vein thrombosis, family history of VTE,
active cancer, or a hypercoaguable state allowed for the avoidance
of aggressive prophylactic anticoagulation in over 70% of patients
while maintaining a low incidence of symptomatic VTE. Conclusion. Further investigation is needed into the role of
The selection of venous thromboembolism (VTE) prophylaxis after total joint arthroplasty (TJA) has been controversial. Although the
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
Venous thrombo-embolism is a common complication following hip replacement. The recently-published pulmonary embolism prevention study reported that
The August 2014 Research Roundup. 360 . looks at: Antibiotic loaded ceramic of use in osteomyelitis; fibronectin implicated in cartilage degeneration; Zinc Chloride accelerates fracture healing in rats; advertisements and false claims; Net Promoter Score: substance or rhetoric?;
Introduction: Approximately 60000 patients are admitted each year in the UK with neck of femur fractures, the vast majority of whom are elderly presenting with multiple medical comorbidities, including a history of ischaemic heart disease and stroke. They are often on a number of regular medications which may include
Introduction and Aims: Venous Thromboembolism is a common complication following a hip replacement. Recently the pulmonary embolism prevention study was published. It reported that
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
Background. Revision total knee arthroplasty (rTKA) is a complex procedure with increased risk of blood loss and transfusions. The Musculoskeletal Infection Society has included D-dimer as a serology marker for peri-prosthetic infection. The study's intent is to understand the impact of preoperative D-dimer levels on blood loss and venous thromboembolism in revision TKA. Methods. Following IRB approval, rTKA performed by a single surgeon between January 1, 2017 and December 31, 2019 were reviewed. Inclusion criteria consisted of pre-operative D-Dimer, cemented revision TKA of one or both components under tourniquet control. 89 patients met the criteria including 37 males (41.6%) and 52 females (58.4%). Mean ages were 65 for males and 67 for females. The data revealed 54 patients (61%) had an elevated D-dimer (group 1) and 35 patients (39%) had a normal D-dimer (group 2). Sex stratification showed 21 males (57.8%) and 33 females (63.5%) with elevated D-dimer. TXA protocol included 2 grams intravenous (82 patients) or 2 grams intra-articular application (7 patients). Post-operative anticoagulation included Lovenox 40mg daily for 2 weeks followed by
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
Introduction. Deep vein thrombosis(DVT) and pulmonary embolism(PE) are well-recognised complications following lower limb arthroplasty (Cohen et al, 2001). The National Institute for Clinical Excellence and British Orthopaedic Association recommend the use of both mechanical and chemical prophylaxis. At our institute regimens have changed reflecting new developments in the use of thombo-prophylaxis. Our aim was to assess the efficacy of these methods in preventing complications. Methods. Since moving from
Since the introduction of the National Institute
for Health and Care Excellence (NICE) guidelines on thromboprophylaxis
and the use of extended thromboprophylaxis with new oral agents,
there have been reports of complications arising as a result of
their use. We have looked at the incidence of wound complications
after the introduction of dabigatran for thromboprophylaxis in our
unit. We investigated the rate of venous thromboembolism and wound
leakage in 1728 patients undergoing primary joint replacement, both
before and after the introduction of dabigatran, and following its
subsequent withdrawal from our unit. We found that the use of dabigatran led to a significant increase
in post-operative wound leakage (20% with dabigatran, 5% with a
multimodal regimen; p <
0.001), which also resulted in an increased
duration of hospital stay. The rate of thromboembolism in patients
receiving dabigatran was higher (1.3%) than in those receiving the multimodal
thromboprophylaxis regimen, including low molecular weight heparin
as an inpatient and the extended use of
The October 2013 Hip &
Pelvis Roundup. 360 . looks at: Young and impinging; Clothes, weather and femoral heads?; Go long, go cemented; Surgical repair of the abductors?;
In his classic monograph entitled Low Friction Arthroplasty of the Hip, which was published in 1979, John Charnley dedicated a chapter to thromboembolic complications. The overall incidence of pulmonary embolism (PE) was approximately 8% and the incidence of death from PE approximately 1%. Surveys of orthopaedic surgeons who undertake total joint replacement conducted by The American Association of Hip and Knee Surgeons (AAHKS), 30 years later, showed that there was still no consensus as to the best form of prophylaxis with a wide variation of methods being used. In the past 3 years, for the first time there is uniformity in the recommendations of the American Academy of Orthopaedic Surgeons (AAOS) and the American College of Chest Physicians (ACCP). Both groups have reached an agreement that the rate of DVT formation is not the ideal endpoint to use when assessing the efficacy of thromboprophylaxis after joint replacement, as had been done in previous drug trials. Most of these DVTs are asymptomatic and of questionable clinical significance. At least one recent study brings into question the association between the rate of DVT formation and that of subsequent symptomatic events. Both groups also focus on minimizing iatrogenic bleeding complications, which can lead to compromised clinical results, including limited movement and pain in the case of knee replacement and increased risk of infection in both knee and hip replacement. To further complete the uniformity of approach in the United States, the Center for Medicare and Medicaid Services (CMS), which administers the Surgical Care Improvement Program (SCIP) that monitors hospital compliance with VTE prophylaxis of hospitalised patients, has also changed their policy. Beginning January 2014, either
Antiplatelet agents are widely prescribed for the primary and secondary prevention of cardiovascular events. A common clinical problem facing orthopaedic and trauma surgeons is how to manage patients receiving these agents who require surgery, either electively or following trauma. The dilemma is to balance the risk of increased blood loss if the antiplatelet agents are continued peri-operatively against the risk of coronary artery/stent thrombosis and/or other vascular event if the drugs are stopped. The traditional approach of stopping these medications up to two weeks before surgery appears to pose significant danger to patients and may require review. This paper covers the important aspects regarding the two most commonly prescribed antiplatelet agents,
Thromboembolism following total hip arthroplasty is a common complication that may result in significant morbidity and mortality. Despite this, optimal prophylactic regimen is controversial. According to the literature, the prevalence of deep venous thrombosis during the early post-operative period ranges from 13% in patients utilizing low molecular weight heparin to 18% in patients treated with sequential compression devices alone. We investigated the efficacy of a comprehensive approach encompassing the use of
The National Institute for Clinical Excellence, UK published guidelines in 2007 encouraging the use of low molecular weight heparin (LMWH) joint replacement surgery. Subsequently, our hospital adopted these guidelines in the treatment of total hip replacements. This study is based on our prospective database of total hip replacements between 2005 and 2009 and compares the complication and mortality rates pre- and post institution of the NICE guidelines. We analysed prospectively collected data on 686 patients who underwent a primary total hip replacement done by a single surgeon between January 2005 and April 2009. We compared the incidence of mortality, pulmonary embolism, myocardial infarction and intracranial bleeding between the two groups. Prior to the guidelines, all patients were treated for the duration of their admission with 75mg
Venous thromboembolic events, either deep vein thromboses or pulmonary emboli, are important complications in patients undergoing knee or hip arthroplasty. The purpose of this study was to evaluate the effectiveness of a mobile compression device (ActiveCare+S.F.T.®; Medical Compression Systems, Inc., Or Akiva, Israel) with or without
Since the establishment of our department a multi-modal approach to thromboprophylaxis that uses
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
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
Introduction. Deep venous thrombosis (DVT) is a potentially serious complication after total hip (THA) and knee (TKA) arthroplasty, traditionally justifying aggressive prophylaxis with low molecular weight heparin (LMWH) or direct oral anticoagulants (DOA) at the cost of an increased risk of bleeding. However, fast-track procedures might reduce the DVT risk and decrease the cost-benefit ratio of the current recommendations. The objective of this study was to compare thrombotic and bleeding risk in an unselected population of elective THA and TKA with a fast-track procedure. MATERIAL - METHODS. A series of 1,949 patients were analyzed prospectively. There were 1,136 women and 813 men, with a mean age of 70 years. In particular, 16% were previously treated by antiplatelet agents and 8% by anticoagulants. All patients followed a fast-track procedure including early walking within 24 hours of surgery, and 80% of patients returned home after surgery, with a mean length of stay of 3 days (THA) or 4 days (TKA). The occurrence of a thromboembolic event or hemorrhagic complication has been identified. Results. Out of the 1,110 THAs, 5 thromboembolic events were identified (0.4%): 2 non-fatal pulmonary embolism and 3 DVTs. There was no impact of these complications on the final result. 19 hemorrhagic complications were identified (1.7%): 10 significant haematomas (3 of which were complicated by infection), 9 anemias (with 4 transfusions). Out of the 839 TKAs, 9 thromboembolic events were identified (1.0%): 4 non-fatal pulmonary embolism and 5 DVTs. There was no impact of these complications on the final result. 14 hemorrhagic complications were identified (1.7%): 8 haematomas including 4 reoperations, 6 anemias (with 5 transfusions). Discussion. Thromboembolic complications after elective THA and TKA have virtually disappeared, with a rate of 0.7%. On the other hand, bleeding complications are now more frequent, with a rate of 1.7%. This suggests that the cost-benefit ratio of preventive treatments with LMWH or DOA should be reassessed. Prescribing LMWH or DOA after elective THA and TKA with fast-track procedures exposes the patient to a much higher risk of bleeding than thrombotic risk. The use of
Venous thromboembolic events, either deep vein thromboses or pulmonary emboli, are important complications in patients undergoing knee or hip arthroplasty. The purpose of this study was to evaluate the effectiveness of a mobile compression device (ActiveCare+S.F.T.®; Medical Compression Systems, Inc., Or Akiva, Israel) with or without
We report an audit of 208 patients with a mean age of 39 years (16 to 65) attending the Orthopaedic Assessment Unit at the Wellington Hospital between January 2006 and December 2007 with an injury of the tendo Achillis requiring immobilisation in a cast. Information on assessment of venous thromboembolism (VTE) risk, prophylactic measures and VTE events for all patients was obtained from the medical records. A VTE risk factor was documented in the records of three (1%) patients. One of the 208 patients received
We performed a meta-analysis of modern total
joint replacement (TJR) to determine the post-operative mortality and
the cause of death using different thromboprophylactic regimens
as follows: 1) no routine chemothromboprophylaxis (NRC); 2) Potent
anticoagulation (PA) (unfractionated or low-molecular-weight heparin, ximelagatran,
fondaparinux or rivaroxaban); 3) Potent anticoagulation combined
(PAC) with regional anaesthesia and/or pneumatic compression devices
(PCDs); 4) Warfarin (W); 5) Warfarin combined (WAC) with regional anaesthesia
and/or PCD; and 6) Multimodal (MM) prophylaxis, including regional
anaesthesia, PCDs and
Venous thromboembolic events, either deep vein thromboses or pulmonary emboli, are important complications in patients undergoing knee or hip arthroplasty. The purpose of this study was to evaluate the effectiveness of a mobile compression device (ActiveCare+S.F.T.®; Medical Compression Systems, Inc., Or Akiva, Israel) with or without
Study design: In order to evaluate a new CECT (Continuous Enhanced Circulation Therapy) based on protocol for DVT prevention a prospective, randomize, single-blind study was designed to compare the effect of the new protocol to the current standard of care in DCT prophylaxis (LMWH). Objectives: To evaluate and compare the incidence and severity of DVT between the two groups. Background: Total hip and knee replacements are operations particularly prone to thromboembolic complications. Recommendations regarding prophylaxis have changed over the years. A treatment protocol was proposed, based upon the CECT system as the primary DVT prophylaxis method with the addition of low dose
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
Venous thromboembolic events, either deep vein thromboses or pulmonary emboli, are important complications in patients undergoing knee or hip arthroplasty. The purpose of this study was to evaluate the effectiveness of a mobile compression device (ActiveCare+S.F.T.®; Medical Compression Systems, Inc., Or Akiva, Israel) with or without
Introduction:. The incidence of heterotrophic ossification after primary total hip arthoplasty (THA) has been reported to be between 8 to 90%. The incidence is higher in lateral approach because of extensive muscular trauma associated with it. There exists limited data on the incidence of heterotrophic ossification after direct anterior approach (DAA) THA. The purpose of this study was to assess the incidence of heterotrophic ossification after THA via the direct anterior approach and the influence of surgical technique and chemoprophylaxis. Method:. A consecutive series of four hundred two primary uncemented direct anterior approach total hip arthoplasties in 378 patients were reviewed for incidence of heterotrophic ossification. In the first 200 total hip arthoplasties an anterior capsulectomy (Group 1) was done for exposure while in the subsequent 202 total hip arthoplasties a capsulotomy (Group 2) followed by complete release of supero-lateral flap of from its attachement to the gluteus minimus muscle and trochanter was performed (Figure 1). Group 1 received warfarin for thromboprophylaxis; while
Blood loss following total hip replacement is a major contributor to increase morbidity and length of stay. Various techniques have been described to reduce its occurrence. We now follow a set protocol, combining rivaroxaban for thrombo-prophylaxis and tranexamic acid to reduce immediate postoperative bleeding. Patients and methods:. Using data collected prospectively we looked at 2 groups of consecutive patients undergoing THR. The protocol was the only factor changed during the period studied. Initially we used subcutaneous dalteparin injections and continued use of
Our aim was to determine the total blood loss associated with surgery for fracture of the hip and to identify risk factors for increased blood loss. We prospectively studied 546 patients with hip fracture. The total blood loss was calculated on the basis of the haemoglobin difference, the number of transfusions and the estimated blood volume. The hidden blood loss, in excess of that observed during surgery, varied from 547 ml (screws/ pins) to 1473 ml (intramedullary hip nail and screw) and was significantly associated with medical complications and increased hospital stay. The type of surgery, treatment with
We report a retrospective review of the incidence of venous thromboembolism in 463 consecutive patients who underwent primary total hip arthroplasty (487 procedures). Treatment included both total hip replacement and hip resurfacing, and the patients were managed without anticoagulants. The thromboprophylaxis regimen included an antiplatelet agent, generally
Rivaroxaban has been recommended for routine use as a thromboprophylactic agent in patients undergoing lower-limb arthroplasty. Starting January 2011, our unit has converted from
Despite increasing scientific investigation, the best method for preventing post-operative deep vein thrombosis remains unclear in patients undergoing a total hip replacement. In the wake of the recent controversial National Institute for Health and Clinical Excellence Clinical Guidelines on the prevention of thrombo-embolism, we felt it was timely to survey current Scottish Surgeons thrombo-prophylactic practice when performing total hip replacements. E-mail questionnaires were sent to all Scottish Orthopaedic consultants. They were asked about routine pharmacological and mechanical prophylaxis in patients undergoing total hip replacement. Comparison was made with a previous survey done in 2003. The response rate was 75%. The survey showed an increased use of pharmacological prophylaxis from 93% to 100%. This was due to the increased use of
The August 2024 Research Roundup360 looks at: Effect of vitamin D deficiency on periprosthetic joint infection and complications after primary total joint replacement; Postoperative angiotensin receptor blocker use associated with decreased rates of manipulation under anaesthesia in patients undergoing total knee arthroplasty; Central sensitization: the missing link between psychological distress and poor outcome following primary total knee arthroplasty; Thromboprophylaxis for the trauma and orthopaedic surgeon; Life expectancy after treatment of metastatic bone disease: an international trend analysis.
In response to the recent publication in April 2007 of NICE guidelines on venous thromboembolism, we report our practice and experience of VTE in adult hip and knee arthroplasty. It is generally agreed that the 2 major complications of VTE are sudden death as a result of pulmonary embolism and post thrombotic syndrome. NICE guidelines make 2 assumptions:. That chemical and mechanical prophylaxis can reduce these complications. That Orthopaedic surgery, in particular elective Primary Joint Replacements are particularly high risk procedures with respect to these 2 complications. We have studied a large cohort of patients who had
In response to the recent publication in April 2007 of NICE guidelines on venous thromboembolism, we report our practice and experience of VTE in adult hip and knee arthroplasty. It is generally agreed that the 2 major complications of VTE are sudden death as a result of pulmonary embolism and post thrombotic syndrome. NICE guidelines make 2 assumptions:. That chemical and mechanical prophylaxis can reduce these complications. That Orthopaedic surgery, in particular elective Primary Joint Replacements are particularly high risk procedures with respect to these 2 complications. We have studied a large cohort of patients who had
Following the recent publication in April 2007 of NICE guidelines on venous thromboembolism, we report our practice and experience of VTE in adult hip and knee arthroplasty. It is generally agreed that the 2 major complications of VTE are sudden death as a result of pulmonary embolism and post thrombotic syndrome. NICE guide-lines make 2 assumptions:. That chemical and mechanical prophylaxis can reduce these complications. That Orthopaedic surgery, in particular elective Primary Joint Replacements are particularly high risk procedures with respect to these 2 complications. Methods and Results: We have studied a large cohort of patients who had
Introduction. Flexor Hallucis Longus (FHL) tendon transfer is a well-recognised salvage operation for irreparable tendon Achilles (TA) ruptures and intractable Achilles tenonopathy. Several case series describes the technique and results of arthroscopic FHL tendon transfers. We present a comparative case series of open and arthroscopic FHL tendon transfers from Southmead Hospital, Bristol, UK. Methods. For the arthroscopic FHL transfers in most cases the patients were positioned semi prone with a tourniquet. A 2 or 3 posterior portal technique was used and the tendon was secured using an RCI screw. The rehabilitation was similar in both groups with 2 weeks in an equinus backslab followed by gradual dorsiflexion in a boot over the following 6 weeks. Anticoagulation with oral