Introduction Venous thromboembolic disease is a serious complication of total hip replacement (THR). Use of low-molecular-weight heparin (LMWH) has been shown to reduce the occurrence of deep-vein thrombosis (DVT) significantly, but side effects such as bleeding and thrombocytopenia are frequent. Pneumatic compression with foot-pumps seems to provide the best balance of effectiveness and safety. However, a recent meta-analysis showed that the overall number of patients investigated in randomised clinical trials is too small to draw evidence-based conclusions regarding
Routine prophylaxis for venous thromboembolic disease after total hip replacement (THR) is recommended. Pneumatic compression with foot pumps seems to provide an alternative to chemical agents. However, the overall number of patients investigated in randomised clinical trials has been too small to draw evidence-based conclusions. This randomised clinical trial was carried out to compare the effectiveness and safety of mechanical versus chemical prophylaxis of DVT in patients after THR. Inclusion criteria were osteoarthritis of the hip and age less than 80 years. Exclusion criteria included a history of thromboembolic disease, heart disease, and bleeding diatheses. There were 216 consecutive patients considered for inclusion in the trial who were randomised either for management with the A-V Impulse System foot pump. We excluded 16 patients who did not tolerate continuous use of the foot pump or with low-molecular-weight heparin (LMWH). Patients were monitored for DVT using serial duplex sonography at 3, 10 and 45 days after surgery. DVT was detected in three of 100 patients in the foot-pump group and with six of 100 patients in the LMWH group (p <
0.05). The mean post-operative drainage was 259 ml in the foot-pump group and 328 ml in the LMWH group (p <
0.05). Patients in the foot-pump group had less swelling of the thigh (10 mm compared with 15 mm; p <
0.05). One patient developed heparin-induced thrombocytopenia. This study confirms the effectiveness and safety of
We aimed to examine the characteristics of deep venous flow in
the leg in a cast and the effects of a wearable neuromuscular stimulator
(geko; FirstKind Ltd) and also to explore the participants’ tolerance
of the stimulator. This is an open-label physiological study on ten healthy volunteers.
Duplex ultrasonography of the superficial femoral vein measured
normal flow and cross-sectional area in the standing and supine
positions (with the lower limb initially horizontal and then elevated).
Flow measurements were repeated during activation of the geko stimulator
placed over the peroneal nerve. The process was repeated after the
application of a below-knee cast. Participants evaluated discomfort
using a questionnaire (verbal rating score) and a scoring index
(visual analogue scale).Objectives
Methods
Prophylaxis against venous thromboembolism after elective total hip replacement is routinely recommended. Our preference has been to use
This study was undertaken to evaluate the safety and efficacy of retrievable inferior vena cava filters in high-risk orthopaedic patients. A total of 58 patients had a retrievable inferior vena cava filter placed as an adjunct to chemical and
Introduction A prospective cohort study was conducted to assess the incidence of venous thromboembolism (VTE) in 300 patients undergoing elective spinal surgery. Although this subject has been extensively studied in patients undergoing joint replacement surgery, the true incidence of VTE related to spinal surgery remains unknown. We also sought to assess the efficacy of various forms of VTE prophylaxis, another area which has not been adequately studied. Methods Bilateral lower extremity venous duplex scans were performed pre-operatively, within one week postoperatively and at 4 to 6 weeks post-operatively. Information was collected regarding age, gender, body mass index, type and duration of surgical procedure, intra-operative blood loss and blood transfusion, pre- and post-operative mobility and other risk factors for VTE. All patients received vigorous
Aims. To evaluate the incidence of primary venous thromboembolism (VTE),
epidural haematoma, surgical site infection (SSI), and 90-day mortality
after elective spinal surgery, and the effect of two protocols for
prophylaxis. Patients and Methods. A total of 2181 adults underwent 2366 elective spinal procedures
between January 2007 and January 2012. All patients wore anti-embolic
stockings, mobilised early and were kept adequately hydrated. In
addition, 29% (689) of these were given low molecular weight heparin
(LMWH) while in hospital. SSI surveillance was undertaken using the
Centers for Disease Control and Prevention criteria. Results. In patients who only received
Introduction. Guidelines from the North American Spine Society (2009 and 2013) are the best evidence-based instructions on venous thromboembolism (VTE) and antibiotic prophylaxis in spinal surgery. NICE guidelines exist for VTE prophylaxis but do not specifically address spinal surgery. In addition, the ruling of the UK Supreme Court in 2015 resulted in new guidance on consent being published by the Royal College of Surgeons of England (RCSEng). This study assesses our compliance in antibiotic, VTE prophylaxis and consent in spinal surgery against both US and UK standards. Methods. Retrospective review of spinal operations performed between August and December 2016. Case notes, consent forms and operation notes were analysed for consent, peri-operative antibiotic prescribing and post-operative VTE instructions. Results. Four Spinal surgeons performed 45 operations during this period. 31 patients (69%) received a copy of the signed consent with this process being formally documented in 22 (71%) of those cases. All patients were consented by a competent surgeon. 82% of cases consented prior to the date of procedure were countersigned on the day of operation. There was a mean time of 25.3 days between initial consent and operation (Range: 0–170). 37 (82%) cases had clear instructions for VTE and antibiotic prophylaxis. All prescribed post-operative antibiotics were administered. Discussion. The North American Guidelines state that prophylactic antibiotic is appropriate in all spinal surgery with prolonged cases requiring intraoperative re-dosing and only complex cases needing a postoperative regimen. Eight patients underwent a complex procedure and 7 appropriately received postoperative antibiotics. Of the 29 patients that underwent a simple procedure, 12 did not receive post-operative regimen, in line with the guidelines. However, the remainder 17 were over treated. The US Guidelines recommend
Venous Thromboembolism (VTE) is the most common complication following major joint surgery. While attention has focused on VTE following joint arthroplasty their exists a gap in the literature examining the incidence of VTE in spinal surgery; with a shortage of epidemiological data, guidelines for optimal prophylaxis are limited. This survey, undertaken at the 2009 BASS Annual Meeting, sought to examine prevailing trends in VTE thromboprophylaxis in spinal surgery and to compare selections made by Orthopaedic and Neurosurgeons. We developed a questionnaire based around eight clinical scenarios. Participants were asked to supply details on their speciality (orthopaedics or neurosurgery) and level of training (grade) and to select which method(s) of thromboprophylaxis they would employ for each scenario. Thirty-nine participants provided responses to the eight scenarios; complete details, including speciality and grade of those surveyed, were complied for 27 of the 39 questionnaires completed. LMWH was the preferred pharmacological method of thromboprophylaixs selected 31% and 72% of the time by orthopaedic and neurosurgeons respectively. For each of the eight clinical scenarios LMWH and BK TEDS were selected more frequently by neurosurgeons than orthopaedic surgeons who elected to employ early mobilisation and
Introduction. Reported incidence of DVT after spinal surgery ranges from 0-15% and PE 0.5-2.7%. Theoretically, manipulation of the vessels and venous stasis caused by retraction during anterior lumbar inter-body fusion may increase the propensity for thrombosis. The reported incidence of DVT and PE following major abdominal and pelvic surgery are high (up to 23%) and all these patients routinely receive chemical prophylaxis. Aim. Should patients undergoing ALIF surgery receive chemical prophylaxis routinely?. Materials and Methods. Retrospective review of ALIF procedures done between Jan 2007- Jan 2010. Review of case notes, radiology reports and telephone call to the patients to exclude DVT. Total of 76 patients underwent ALIF during this period. Forty six were female(60.5%) and 36 were 2 level fusions(47%). L5-S1 being commonly fused (76%) followed by L4-L5 (23%). Average surgical time from theatre records is 115 minutes(31-369 minutes). All patients received
Purpose of Study. To investigate current practice of thromboprophylaxis in major UK spinal centres for both trauma and elective surgery, and to asses compliance with NICE guidelines. Methods. A telephonic survey was carried out which comprised of questions relating to current practice of thromboprophylaxis in major spinal units across the UK. Questions probed practice with regard to trauma versus elective surgery, agents used, timing of prophylaxis, length of treatment and whether practice has changed since the introduction of NICE guidelines. Results. Thirty specialised centres were contacted. Twenty eight centres followed NICE recommendations, with 2 centres using their own protocol. Four centres made changes to their existing protocols after the emergence of NICE guidelines. GCS (Graduated compression stockings) were uniformly used by all, with most centres using flowtron boots and/or foot in addition. The practices are differing within centres for elective versus trauma surgery. Of note, in patients with an acute cord injury, 20 centres used combined pre operative prophylaxis whereas 10 centres used only
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
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
The optimal characteristics of pneumatic compression for
Recently, the International Consensus Statement Group reported that
The optimal regime of antithrombotic prophylaxis for patients undergoing total knee arthroplasty (TKA) has not been established. Many surgeons employ intermittent pneumatic compression while others use low-molecular-weight heparins (LMWH) which were primarily developed for total hip arthroplasty. We compared the efficacy and safety of these two techniques in a randomised study with blinded assessment of the endpoint by phlebography. We randomised 130 patients, scheduled for elective TKA, to receive one daily subcutaneous injection of nadroparin calcium (dosage adapted to body-weight) or continuous intermittent pneumatic compression of the foot by means of the arteriovenous impulse system. A total of 108 patients (60 in the LMWH group and 48 in the
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
Although patients with a history of venous thromboembolism
(VTE) who undergo lower limb joint replacement are thought to be
at high risk of further VTE, the actual rate of recurrence has not
been reported. The purpose of this study was to identify the recurrence rate
of VTE in patients who had undergone lower limb joint replacement,
and to compare it with that of patients who had undergone a joint
replacement without a history of VTE. . From a pool of 6646 arthroplasty procedures (3344 TKR, 2907 THR,
243 revision THR, 152 revision TKR) in 5967 patients (68% female,
mean age 67.7; 21 to 96) carried out between 2009 and 2011, we retrospectively
identified 118 consecutive treatment episodes in 106 patients (65%
female, mean age 70; 51 to 88,) who had suffered a previous VTE.
Despite
Venous Thromboembolism is a common complication following a hip replacement. Recently the pulmonary embolism prevention study was published. It reported that aspirin decreased the fatal pulmonary embolism rate in patients admitted with a fracture neck of femur. In addition new products (synthetic factor X inhibitor -Fondaparinux, and a direct thrombin inhibiter-Desirudin) have been reported to be more effective than low molecular weight heparin in preventing asymptomatic deep vein thrombosis. We felt it was important to repeat a survey, done in 1997, on the use thromboembolism prophylaxis among British Orthopaedic Surgeons. A single page questionnaire was sent out to all 1308 consultants Orthopaedic surgeons who were members of the British Orthopaedic Association. Those who did not respond were sent a reminder letter. We achieved a 72% response rate. All surgeons use some form of prophylaxis. Eighty five percent of surgeons use pharmacological prophylaxis. Low molecular weight heparin is used by 55% of surgeons. Twenty percent of surgeons use aspirin as their only form of pharmacological prophylaxis. Less than 1% (5 consultants) use early mobilisation alone and nearly 2% (13 consultants) use graded stockings and early mobilisation as their only form of prophylaxis. Seventy four percent of surgeons have a unit policy. Thirty percent have changed their regime in the last 3 years. The majority of British Orthopaedic surgeons still use pharmacological thromboprophylaxis. There has been a significant increase in the use of Aspirin from 5% to 30%. Aspirin is often combined with a
Aims. This phase II safety study aimed to investigate the bleeding side effect profile in patients treated with Rivaroxaban as a new agent for venous thromboembolism (VTE) prophylaxis following hip or knee arthroplasty. Methods. A retrospective study of complications was conducted in 88 consecutive patients undergoing hip and knee arthroplasty at one centre. Patients received chemical and/or
The purpose of the present study is to determine the incidence, location and rate of VTE following routine
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
Background. Post-operative deep venous thrombosis (DVT) and subsequent pulmonary embolism (PE) remain a serious complication after total joint replacement. Although with modern chemical and
Background. Post-operative deep venous thrombosis (DVT) and subsequent pulmonary embolism (PE) remain a serious complication after total joint replacement. Although with modern chemical and
Introduction. Recent UK national guidelines advocate using a combination of mechanical and pharmacological VTE prophylaxis in patients undergoing lower limb arthroplasty. We compared the results from our two series of patients: one treated with clexane and the other treated with rivaroxaban. Methods. Both groups received
Patients with a history of venous thromboembolism (VTE) are considered at very high risk for recurrence after lower limb arthroplasty (LLA). However, the chance of a new VTE episode after LLA has not been yet quantified. The aim of this study was to define the incidence of VTE recurrence following knee and hip arthroplasty. The case notes for all LLA patients treated at our hospital from 2009 to 2011 were reviewed. There were 5946 primary and revision LLA operations in total; 118 of these interventions were performed in 106 patients with a history of VTE. This group included 69 females and 37 males with a mean age of 69.9. Routine thromboprophylaxis for LLA patients included mechanical (footpumps & TED stockings) plus chemical prophylaxis using Aspirin 150 mg for 6 weeks. Patients with a VTE history had the same
Aim. To assess the incidence of fatal pulmonary embolism (PE) following elective total knee replacement (TKR) with a standardised multi-modal prophylaxis regime in a large teaching DGH over a 10 year period. Material and methods. Information was gathered from a prospective audit database, utilising clinical coding for TKR and those that had died within 42 and 90 days. The 10 years from April 2000 were analysed to establish both 42 and 90 day mortality rates. A multi-modal prophylaxis regime for all patients included regional anaesthesia (when possible),
We report decreased clinical VTE rates following increased use of
Background. This clinical study was performed to establish the prevalence of deep vein thrombosis and pulmonary embolism after shoulder surgery. The incidence of VTE complicating shoulder surgery is poorly described in literature. Methods. We reviewed retrospectively clinical records of all patients who had any surgical procedure performed on their shoulder between 2001 and 2009.‘Patients’ records were assessed for any admissions due to proven VTE; we looked for any radiological results suggestive of venous thromboembolism. Results. We identified 920 patients who had surgical procedure under GA on their shoulder; including 113 patients had shoulder arthroplasty. There was 1 fatal PE in this group – patient died within 48 hours following reverse shoulder replacement, post mortem revealed massive pulmonary embolism. There were 2 cases of symptomatic DVT of lower limb, both treated successfully with anticoagulation. No upper limb DVT was identified. There were 7 patients who had negative tests for suspected thrombosis. Discussion. Recent studies suggest that DVT incidence following arthroplasty is as high as 13%. In our study we examined occurrence of symptomatic VTE only. According to our results the incidence of symptomatic DVT following shoulder surgery is about 0.3% and symptomatic PE about 0.1 %. The prevalence of asymptomatic VTE is probably much higher and further research needs to be undertaken in that area. We would advice to think carefully about risk of thrombosis and use
We performed routine venography after operation in a consecutive series of 252 patients with total joint arthroplasties in whom no form of routine chemical or
Introduction. Recent UK national guidelines advocate using a combination of mechanical and pharmacological VTE prophylaxis in patients undergoing lower limb arthroplasty but do not recommend one particular pharmacotherapy over another. Objectives. We compared the results from our two series of patients: one treated with clexane and the other treated with rivaroxaban, with respect to average length of stay, postoperative wound leakage, readmission within 30 days of surgery and re-do surgery. Methods. Both groups were comparable in terms of age, sex and proportion of hip and knee patients. Both groups received
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
Introduction. Venous Thromboembolism is a well documented complication of Total hip and total knee replacement, and NICE guidelines recommend use of pharmacological prophylaxis routinely after these procedures. Current practice in our department is use of
Introduction. Air travel and total joint arthroplasty are both established risk factors for development of venous thromboembolism (VTE); accordingly patients are typically counseled against flying in the early postoperative period. The basis for this recommendation may be unfounded, as the risk of VTE associated with flying in the early postoperative period has not been investigated. Methods. This is a case-control study of 1465 consecutive unilateral total hip arthroplasties (THA) and total knee arthroplasties (TKA) performed by a single surgeon over an 18-month period. A multimodal regimen was used for VTE prophylaxis, consisting of early mobilization,
Background. Current UK NICE guidelines on the prevention of thromboembolism state that all patients undergoing elective Hip or Knee Replacement surgery should be offered combined mechanical and pharmacological VTE prophylaxis. Methods. The original audit was performed between October 1999 and January 2009, totaling 7,532 patients. Updated to the full 10 years, a total of 8,140 patients underwent hip or knee replacement surgery (revision and primary) in our unit. Using a targeted thromboprophylaxis policy 83% of patients received mechanical A-V foot pumps only until mobile. High risk patients (12%) received in addition LMWH or fondaparinux, with only very high risk patients continuing on chemical prophylaxis post-discharge. All data are collected and stored on our own joint registry database with patients being assessed pre-operatively to determine their level of VTE risk. Results. Overall DVT rate was 1%, PE rate 0.5% and fatal PE rate 0.06%. The rates were slightly higher in the targeted Chemical thromboprophylaxis group (DVT 1.6%, PE 0.95%, fatal PE 0.1%) as expected as these patients were identified as being high risk. 5% of patients failed to receive any prophylaxis and in these patients the rates were the lowest of all (DVT 0.8%, PE 0.3% and fatal PE 0%). All p-values were >0.05. These rates are similar to those published in recent trials involving the oral anticoagulants Dabigatran and Rivaroxaban, given to all patients, (RE-NOVATE, RECORD 1,2,3,4, RE-MOBILISE Trials) with all p values again > 0.05. Complications however were ten times less using a targeted approach. Conclusion. We recommend the use of a targeted approach, only chemically treating those patients who are at high risk for thromboembolism, along with a rapid recovery programme. This has not only been shown to be safe but cuts costs and has ten times fewer complications than treating all patients with both chemical and
Introduction: We undertook a questionnaire study to assess the compliance with DVT prophylaxis following lower limb arthroplasty surgery and evaluate reasons for non-compliance (if any). Method: Following joint replacement surgery, 50 patients (45 had THR, 5 had TKR) were asked to fill in anonymised questionnaire at 6 weeks. They were asked about awareness for DVT, information given, prevention methods, duration and type of prophylaxis given and their compliance with treatment. Results: Most of the patients (45) were aware of the risk of DVT while 2 were not aware and 3 were not sure. 37 patients were given information during their clinic visit while 7 did not receive any information and 6 can’t remember. 32 patients remembered discussing risk of developing DVT while 9 did not and 9 were not sure. 34 patients (68%) were aware of prophylactic methods. Except for 2 patients, the rest 48 patients (96%) confirmed receiving prophylaxis. 48 patients (96%) had
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
Introduction and Aims: Venous Thromboembolism is a common complication following a hip replacement. Recently the pulmonary embolism prevention study was published. It reported that aspirin decreased the fatal pulmonary embolism rate in patients admitted with a fracture neck of femur. In addition, new products (synthetic factor X inhibitor-Fondaparinux, and a direct thrombin inhibiter-Desirudin) have been reported to be more effective than low molecular weight heparin in preventing asymptomatic deep vein thrombosis. We felt it was important to repeat a survey, done in 1997, on the use of thromboembolism prophylaxis among British Orthopaedic Surgeons. Method: A single page questionnaire was sent out to all 1308 consultants – orthopaedic surgeons who were members of the British Orthopaedic Association. Those who did not respond were sent a reminder letter. Results: We achieved a 72% response rate. All surgeons use some form of prophylaxis. Eighty-five percent of surgeons use pharmacological prophylaxis. Low molecular weight heparin is used by 55% of surgeons. Twenty percent of surgeons use aspirin as their only form of pharmacological prophylaxis. Less than 1% (five consultants) use early mobilisation alone and nearly 2% (13 consultants) use graded stockings and early mobilisation as their only form of prophylaxis. Seventy-four percent of surgeons have a unit policy. Thirty percent have changed their regime in the last three years. Conclusion: The majority of British orthopaedic surgeons still use pharmacological thromboprophylaxis. There has been a significant increase in the use of Aspirin, from 5% to 30%. Aspirin is often combined with a
The selection of venous thromboembolism (VTE) prophylaxis after total joint arthroplasty (TJA) has been controversial. Although the aspirin controversy is presumably resolved, there is no medical evidence for the “optimal” VTE prophylaxis regime for individual patients. A risk-stratified multi-modal VTE prophylaxis protocol was developed and adopted by consensus. VTE risk factors and bleeding risk factors were categorised into six VTE/bleeding risk levels: (1) pre-operative vitamin K antagonists (VKA) use, (2) bleeding risk factors, (3) hypercoagulable state, (4) pre-operative anti-platelet therapy [clopidogrel use], (5) VTE risk factors, (6) no VTE or bleeding risk factors. The pharmacologic agents used for each risk level were: (1) resume VKA with low molecular weight heparin (LMWH) bridge, (2) pharmacologic agents contra-indicated and
Malignancy and surgery are risk factors for venous thromboembolism (VTE). We undertook a systematic review of the literature concerning the prophylactic management of VTE in orthopaedic oncology patients. MEDLINE (PubMed), EMBASE (Ovid), Cochrane, and CINAHL databases were searched focusing on VTE, deep vein thrombosis (DVT), pulmonary embolism (PE), bleeding, or wound complication rates.Aims
Methods
As the first wave of the COVID-19 pandemic began to dip, restarting elective orthopaedics became a challenge. Protocols including surgery at ‘green’ sites, self-isolation for 14 days, and COVID-19 testing were developed to minimize the risk of transmission. In this study, we look at risk effects of 14-day self-isolation on the incidence of venous thromboembolism (VTE) in our green site hospital among patients undergoing total joint replacement (TJR). This retrospective cohort study included 50 patients who underwent TJR. Basic demographic data was collected including, age, sex, American Society of Anesthesiologists (ASA) grade, body mass index (BMI), type of surgery, and complications at two and four weeks. Univariate and multivariate analysis were used to identify risk factors associated with an increased risk of VTE.Aims
Methods
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 aspirin, followed closely for development of symptoms, and scanned with ultrasound to determine resolution of IDVT. Among a cohort of 5,078 patients undergoing TKA, 532 patients (695 TKAs, 12.6%) developed an IDVT between 1 January 2014 to 31 December 2019 at a single institution, as diagnosed using Doppler ultrasound at the first postoperative visit. Of the entire cohort of 532 patients with IDVT, 91.4% (486/532) were treated with aspirin (325 mg twice daily) and followed closely. Repeat lower limb ultrasound was performed four weeks later to evaluate the status of IDVT.Aims
Methods
The consensus is that bipolar hemiarthroplasty (BHA) in allograft-prosthesis composite (APC) reconstruction of the proximal femur following primary tumour resection provides more stability than total hip arthroplasty (THA). However, no comparative study has been performed. In this study, we have compared the outcome and complication rates of these two methods. In a retrospective study, 57 patients who underwent APC reconstruction of proximal femur following the primary tumour resection, either using BHA (29) or THA (28), were included. Functional outcome was assessed using the Musculoskeletal Tumour Society (MSTS) scoring system and Harris Hip Score (HHS). Postoperative complications of the two techniques were also compared.Aims
Methods
Tranexamic acid (TXA) has been shown to significantly reduce transfusion rates in primary total hip arthroplasties (THAs), but high-quality evidence is limited in the revision setting. The purpose of the current study was to compare the rate of blood transfusions and symptomatic venous thromboembolic events (VTEs) in a large cohort of revision THAs treated with or without intravenous (IV) TXA. We performed a retrospective review of 3264 revision THAs (2645 patients) between 2005 and 2014, of which 1142 procedures received IV TXA (1 g at incision and 1 g at closure). The mean age in the revision group with TXA was 65 years (28 to 95), with 579 female patients (51%). The mean age in the revision group treated without TXA was 67 years (21 to 98), with 1160 female patients (55%). Outcomes analyzed included rates of transfusion and symptomatic VTEs between procedures undertaken with and without TXA. These comparisons were performed for the overall cohort, as well as within cases subcategorized for aseptic or septic aetiologies. A propensity score was developed to minimize bias between groups and utilized age at revision THA, sex, body mass index, American Society of Anesthesiologists (ASA) score, preoperative anticoagulation, and year of surgery.Aims
Patients and Methods
Antibiotic-loaded bone cements (ALBCs) may offer early protection against the formation of bacterial biofilm after joint arthroplasty. Use in hip arthroplasty is widely accepted, but there is a lack of evidence in total knee arthroplasty (TKA). The objective of this study was to evaluate the use of ALBC in a large population of TKA patients. Data from the National Joint Registry (NJR) of England and Wales were obtained for all primary cemented TKAs between March 2003 and July 2016. Patient, implant, and surgical variables were analyzed. Cox proportional hazards models were used to assess the influence of ALBC on risk of revision. Body mass index (BMI) data were available in a subset of patients.Aims
Materials and Methods
Total ankle arthroplasty (TAA) surgery is complex and attracts a wide variety of complications. The literature lacks consistency in reporting adverse events and complications. The aim of this article is to provide a comprehensive analysis of each of these complications from a literature review, and to compare them with rates from our Unit, to aid clinicians with the process of informed consent. A total of 278 consecutive total ankle arthroplasties (251 patients), performed by four surgeons over a six-year period in Wrightington Hospital (Wigan, United Kingdom) were prospectively reviewed. There were 143 men and 108 women with a mean age of 64 years (41 to 86). The data were recorded on each follow-up visit. Any complications either during initial hospital stay or subsequently reported on follow-ups were recorded, investigated, monitored, and treated as warranted. Literature search included the studies reporting the outcomes and complications of TAA implants.Aims
Patients and Methods
To investigate whether elective joint arthroplasty performed
at the weekend is associated with a different 30-day mortality We examined the 30-day cumulative mortality rate (Kaplan-Meier)
for all elective hip and knee arthroplasties performed in England
and Wales between 1st April 2003 and 31st December 2014, comprising
118 096 episodes undertaken at the weekend and 1 233 882 episodes
performed on a weekday. We used Cox proportional-hazards regression
models to assess for time-dependent variation and adjusted for identified
risk factors for mortality.Aims
Patients and Methods
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. 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.Aims
Materials and Methods
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 aspirin. In all, 36 159 patients (23.1%) were prescribed aspirin
and 120 639 patients (76.9%) were prescribed LMWH. We found no statistically
significant differences between the aspirin and LMWH groups in the
rate of pulmonary embolism (0.49% These results should be considered when the existing guidelines
for thromboprophylaxis after knee replacement are reviewed.
We investigated the incidence of and risk factors
for venous thromboembolism (VTE) following surgery of the shoulder
and elbow and assessed the role of thromboprophylaxis in upper limb
surgery. All papers describing VTE after shoulder and elbow surgery
published in the English language literature before 31 March 2012
were reviewed. A total of 14 papers were available for analysis,
most of which were retrospective studies and case series. The incidence
of VTE was 0.038% from 92 440 shoulder arthroscopic procedures,
0.52% from 42 261 shoulder replacements, and 0.64% from 4833 procedures
for fractures of the proximal humerus (open reduction and internal fixation
or hemiarthroplasty). The incidence following replacement of the
elbow was 0.26% from 2701 procedures. Diabetes mellitus, rheumatoid
arthritis and ischaemic heart disease were identified as the major
risk factors. The evidence that exists on thromboprophylaxis is based on level
III and IV studies, and we therefore cannot make any recommendations
on prophylaxis based on the current evidence. It seems reasonable
to adopt a multimodal approach that involves all patients receiving
mechanical prophylaxis, with chemical prophylaxis reserved for those
who are at high risk for VTE. Cite this article:
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. 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). Aims
Patients and Methods
The aim of this study was to define the incidence
of venous thromboembolism (VTE) and risk factors for the development
of deep-vein thrombosis (DVT) after the resection of a musculoskeletal
tumour. A total of 94 patients who underwent resection of a musculoskeletal
tumour between January 2003 and December 2005 were prospectively
studied. There were 42 men and 52 women with a mean age of 54.4
years (18 to 86). All patients wore intermittent pneumatic compression
devices and graduated compression stockings. Ultrasound examination
of the lower limbs was conducted to screen for DVT between the fifth
and ninth post-operative days. DVT was detected in 21 patients (22%). Of these, two were symptomatic
(2%). One patient (1%) had a fatal pulmonary embolism. Patients
aged ≥ 70 years had an increased risk of DVT (p = 0.004). The overall incidence of DVT (both symptomatic and asymptomatic)
after resection of a musculoskeletal tumour with mechanical prophylaxis
was high. It seems that both mechanical and anticoagulant prophylaxis
is needed to prevent VTE in patients who have undergone the resection
of a musculoskeletal tumour. Cite this article:
We studied 4253 patients undergoing primary joint replacement between November 2002 and November 2007, of whom 4060 received aspirin only as chemical prophylaxis; 46 were mistakenly given low molecular weight heparin initially, which was stopped and changed to aspirin; 136 received no chemoprophylaxis and 11 patients received warfarin because of a previous history of pulmonary embolism. We identified the rate of clinical thromboembolism before and after discharge, and the mortality from pulmonary embolism at 90 days. The overall death rate was 0.31% (13 of 4253) and the rate of fatal pulmonary embolism was 0.07% (3 of 4253). Our data suggest that fatal pulmonary embolism is not common following elective primary joint replacement, and with modern surgical practice elective hip and knee replacement should no longer be considered high-risk procedures.
Despite increasing scientific investigation, the best method for preventing post-operative deep-vein thrombosis remains unclear. In the wake of the publication of the Pulmonary Embolism Prevention trial and the Scottish Intercollegiate Guidelines Network (SIGN) on the prevention of thromboembolism, we felt that it was timely to survey current thromboprophylactic practices. Questionnaires were sent to all consultants on the register of the British Orthopaedic Association. The rate of response was 62%. The survey showed a dramatic change in practice towards the use of chemoprophylaxis since the review by Morris and Mitchell in 1976. We found that there was a greater uniformity of opinion and prescribing practices in Scotland, consistent with the SIGN guidelines, than in the rest of the UK. We argue in favour of the use of such documents which are based on a qualitative review of current scientific literature.
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 aspirin. In all, 21.1%
of patients were prescribed aspirin and 78.9% LMWH. Without adjustment, we
found no statistically significant differences. The rate of pulmonary
embolism was 0.68% in both groups and 90-day mortality was 0.65%
with aspirin and 0.61% with LMWH (OR 0.93; 95% CI 0.77 to 1.11).
With risk adjustment, the difference in mortality increased (OR
0.84; 95% CI 0.69 to 1.01). With propensity score matching the mortality difference
increased even further to 0.65% with aspirin and 0.51% with LMWH
(OR 0.77; 95% CI 0.61 to 0.98). These results should be considered
when the conflicting recommendations of existing guidelines for
thromboprophylaxis after hip replacement are being addressed.
Satisfactory primary wound healing following
total joint replacement is essential. Wound healing problems can
have devastating consequences for patients. Assessment of their healing
capacity is useful in predicting complications. Local factors that
influence wound healing include multiple previous incisions, extensive
scarring, lymphoedema, and poor vascular perfusion. Systemic factors
include diabetes mellitus, inflammatory arthropathy, renal or liver
disease, immune compromise, corticosteroid therapy, smoking, and
poor nutrition. Modifications in the surgical technique are necessary
in selected cases to minimise potential wound complications. Prompt
and systematic intervention is necessary to address any wound healing
problems to reduce the risks of infection and other potential complications. Cite this article:
Deep vein thrombosis is a common complication
of immobilising the lower limb after surgery. We hypothesised that
intermittent pneumatic compression (IPC) therapy in outpatients
who had undergone surgical repair of acute ruptures of the Achilles
tendon could reduce the incidence of this problem. A total of 150 patients who had undergone surgical repair of
the Achilles tendon were randomised to either treatment with IPC
for six hours per day (n = 74) under an orthosis or treatment as
usual (n = 74) in a plaster cast without IPC. At two weeks post-operatively,
the incidence of deep vein thrombosis was assessed using blinded, double-reported
compression duplex ultrasound. At this point, IPC was discontinued
and all patients were immobilised in an orthosis for a further four
weeks. At six weeks post-operatively, a second compression duplex ultrasound
scan was performed. At two weeks, the incidence of deep vein thrombosis was 21% in
the treated group and 37% in the control group (p = 0.042). Age
over 39 years was found to be a strong risk factor for deep vein
thrombosis (odds ratio (OR) = 4.84, 95% confidence interval (CI)
2.14 to 10.96). Treatment with IPC, corrected for age differences
between groups, reduced the risk of deep vein thrombosis at the
two-week point (OR = 2.60; 95% CI 1.15 to 5.91; p =0.022). At six weeks,
the incidence of deep vein thrombosis was 52% in the treated group
and 48% in the control group (OR 0.94, 95% CI 0.49 to 1.83). IPC
appears to be an effective method of reducing the risk of deep vein
thrombosis in the early stages of post-operative immobilisation
of outpatients. Further research is necessary to elucidate whether
it can confer similar benefits over longer periods of immobilisation
and in a more heterogeneous group of patients. Cite this article:
Fractures of the proximal femur are one of the
greatest challenges facing the medical community, constituting a
heavy socioeconomic burden worldwide. The National Hip Fracture
Audit currently provides a framework for service evaluation. This
evaluation is based upon the assessment of process rather than assessment
of patient-centred outcome and therefore it fails to provide meaningful
data regarding the clinical effectiveness of treatments. This study
aims to capture data from the cohort of patients who present with
a fracture of the proximal femur at a single United Kingdom Major
Trauma Centre. Patient-centred outcomes will be recorded and provide
a baseline cohort within which to test the clinical effectiveness
of experimental interventions.
We report the incidence and location of deep-vein thrombosis in 312 patients who had sustained high-energy, skeletal trauma. They were investigated using magnetic resonance venography and Duplex ultrasound. Despite thromboprophylaxis, 36 (11.5%) developed venous thromboembolic disease with an incidence of 10% in those with non-pelvic trauma and 12.2% in the group with pelvic trauma. Of patients who developed deep-vein thrombosis, 13 of 27 in the pelvic group (48%) and only one of nine in the non-pelvic group (11%) had a definite pelvic deep-vein thrombosis. When compared with magnetic resonance venography, ultrasound had a false-negative rate of 77% in diagnosing pelvic deep-vein thrombosis. Its value in the pelvis was limited, although it was more accurate than magnetic resonance venography in diagnosing clots in the lower limbs. Additional screening may be needed to detect pelvic deep-vein thrombosis in patients with pelvic or acetabular fractures.
We performed a systematic review and meta-analysis
to compare the efficacy of intermittent mechanical compression combined
with pharmacological thromboprophylaxis, against either mechanical
compression or pharmacological prophylaxis in preventing deep-vein
thrombosis (DVT) and pulmonary embolism in patients undergoing hip
or knee replacement. A total of six randomised controlled trials,
evaluating a total of 1399 patients, were identified. In knee arthroplasty,
the rate of DVT was reduced from 18.7% with anticoagulation alone
to 3.7% with combined modalities (risk ratio (RR) 0.27, p = 0.03;
number needed to treat: seven). There was moderate, albeit non-significant,
heterogeneity (I2 = 42%). In hip replacement, there was
a non-significant reduction in DVT from 8.7% with mechanical compression
alone to 7.2% with additional pharmacological prophylaxis (RR 0.84)
and a significant reduction in DVT from 9.7% with anticoagulation
alone to 0.9% with additional mechanical compression (RR 0.17, p
<
0.001; number needed to treat: 12), with no heterogeneity (I2 =
0%). The included studies had insufficient power to demonstrate
an effect on pulmonary embolism. We conclude that the addition of intermittent mechanical leg
compression augments the efficacy of anticoagulation in preventing
DVT in patients undergoing both knee and hip replacement. Further
research on the role of combined modalities in thromboprophylaxis
in joint replacement and in other high-risk situations, such as fracture
of the hip, is warranted.
This review considers the surgical treatment
of displaced fractures involving the knee in elderly, osteoporotic patients.
The goals of treatment include pain control, early mobilisation,
avoidance of complications and minimising the need for further surgery.
Open reduction and internal fixation (ORIF) frequently results in
loss of reduction, which can result in post-traumatic arthritis
and the occasional conversion to total knee replacement (TKR). TKR
after failed internal fixation is challenging, with modest functional
outcomes and high complication rates. TKR undertaken as treatment
of the initial fracture has better results to late TKR, but does
not match the outcome of primary TKR without complications. Given
the relatively infrequent need for late TKR following failed fixation,
ORIF is the preferred management for most cases. Early TKR can be
considered for those patients with pre-existing arthritis, bicondylar
femoral fractures, those who would be unable to comply with weight-bearing restrictions,
or where a single definitive procedure is required.
Following the publication in 2007 of the guidelines from the National Institute for Health and Clinical Excellence (NICE) for prophylaxis against venous thromboembolism (VTE) for patients undergoing surgery, concerns were raised by British orthopaedic surgeons as to the appropriateness of the recommendations for their clinical practice. In order to address these concerns NICE and the British Orthopaedic Association agreed to engage a representative panel of orthopaedic surgeons in the process of developing expanded VTE guidelines applicable to all patients admitted to hospital. The functions of this panel were to review the evidence and to consider the applicability and implications in orthopaedic practice in order to advise the main Guideline Development Group in framing recommendations. The panel considered both direct and indirect evidence of the safety and efficacy, the cost-effectiveness of prophylaxis and its implication in clinical practice for orthopaedic patients. We describe the process of selection of the orthopaedic panel, the evidence considered and the contribution of the panel to the latest guidelines from NICE on the prophylaxis against VTE, published in January 2010.
We report a systematic review and meta-analysis of published randomised controlled trials evaluating the efficacy of tranexamic acid (TXA) in reducing blood loss and transfusion in total hip replacement (THR). The data were evaluated using the generic evaluation tool designed by the Cochrane Bone, Joint and Muscle Trauma Group. We identified 11 clinical trials which were suitable for detailed extraction of data. There were no trials that used TXA in revision THR. A total of seven studies (comprising 350 patients) were eligible for the blood loss outcome data. The use of TXA reduced intra-operative blood loss by a mean of 104 ml (95% confidence interval (CI) −164 to −44, p = 0.0006, heterogeneity I2 0%), postoperative blood loss by a mean of 172 ml (95% CI −263 to −81, p = 0.0002, heterogeneity I2 63%) and total blood loss by a mean of 289 ml (95% CI −440 to −138, p <
0.0002, heterogeneity I2 54%). TXA led to a significant reduction in the proportion of patients requiring allogeneic blood transfusion (risk difference −0.20, 95% CI −0.29 to −0.11, p <
0.00001, I2 15%). There were no significant differences in deep-vein thrombosis, pulmonary embolism, infection rates or other complications among the study groups.
The National Institute for Clinical Excellence (NICE) produces recommendations on appropriate treatment within the National Health Service (NHS) in England and Wales. The NICE guidelines on prophylaxis for venous thromboembolism in orthopaedic surgery recommend that all patients be offered a low molecular weight heparin (LMWH). The linked hospital episode statistics of 219 602 patients were examined to determine the rates of complications following lower limb arthroplasty for the 12-month periods prior to and following the publication of these guidelines. These were compared with data from the National Joint Registry (England and Wales) regarding the use of LMWH during the same periods. There was a significant increase in the reported use of LMWH (59.5% to 67.6%, p <
0.001) following the publication of the guidelines. However, the 90-day venous thromboembolism events actually increased slightly following total hip replacement (THR, 1.69% to 1.84%, p = 0.06) and remained unchanged following total knee replacement (TKR, 1.99% to 2.04%). Return to theatre in the first 30 days for infection did not show significant changes. There was an increase in the number of patients diagnosed with thrombocytopenia, which was significant following THR (0.11% to 0.16%, p = 0.04). The recommendations from NICE are based on predicted reductions in venous thromboembolism events, reducing morbidity, mortality and costs to the NHS. The early results in orthopaedic patients do not support these predictions, but do show an increase in complications.
We investigated whether simultaneous bilateral sequential total hip replacement (THR) would increase the rate of mortality and complications compared with unilateral THR in both low- and high-risk groups of patients. We enrolled 978 patients with bilateral and 1666 with unilateral THR in the study. There were no significant pre-operative differences between the groups in regard to age, gender, body mass index, diagnosis, comorbidity as assessed by the grading of the American Society of Anesthesiologists (ASA), the type of prosthesis and the duration of follow-up. The mean follow-up was for 10.5 years (5 to 13) in the bilateral THR group and 9.8 years (5 to 14) in the unilateral group. The peri-operative mortality rate of patients who had simultaneous bilateral THR (0.31%, three of 978 patients) was similar to that of patients with unilateral THR (0.18%, three of 1666 patients). The peri-operative mortality rate of patients in the bilateral group was similar in high risk and low risk patients (0.70%, two of 285 patients vs 0.14%, one of 693 patients) and this was also true in the unilateral THR group (0.40%, two of 500 patients vs 0.09%, one of 1166 patients). Patients with bilateral THR required more blood transfusions and a longer hospital stay than those in the unilateral THR group. There was no significant difference (p = 0.32) in the overall number of complications between the groups. This was also true for the low-risk (p = 0.81) vs high-risk (p = 0.631) patients. Our findings confirm that simultaneous sequential bilateral THR is a safe option for patients who are considered to be either high or low risk according to the ASA classification.
Thromboprophylaxis remains a controversial subject. A vast amount of epidemiological and trial data about venous thromboembolism has been published over the past 40 years. These data have been distilled and synthesised into guidelines designed to help the practitioner translate this extensive research into ‘evidence-based’ advice. Guidelines should, in theory, benefit patient care by ensuring that every patient routinely receives the best prophylaxis; without guidelines, it is argued, patients may fail to receive treatment or be exposed to protocols which are ineffective, dangerous or expensive. Guidelines, however, have not been welcomed or applied universally. In the United States, orthopaedic surgeons have published their concerns about the thromboprophylaxis guidelines prepared by the American College of Chest Physicians. In Britain, controversy persists with many surgeons unconvinced of the risk/benefit, cost/benefit or practicality of thromboprophylaxis. The extended remit of the recent National Institute of Clinical Excellence thromboprophylaxis guidelines has been challenged. The reasons for this disquiet are addressed in this paper and particular emphasis is placed on how clinically-acceptable guidelines could be developed and applied.
We carried out an audit on the result of achieving early walking in total knee replacement after instituting a new rehabilitation protocol, and assessed its influence on the development of deep-vein thrombosis as determined by Doppler ultrasound scanning on the fifth post-operative day. Early mobilisation was defined as beginning to walk less than 24 hours after knee replacement. Between April 1997 and July 2002, 98 patients underwent a total of 125 total knee replacements. They began walking on the second post-operative day unless there was a medical contraindication. They formed a retrospective control group. A protocol which allowed patients to start walking at less than 24 hours after surgery was instituted in August 2002. Between August 2002 and November 2004, 97 patients underwent a total of 122 total knee replacements. They formed the early mobilisation group, in which data were prospectively gathered. The two groups were of similar age, gender and had similar medical comorbidities. The surgical technique and tourniquet times were similar and the same instrumentation was used in nearly all cases. All the patients received low-molecular-weight heparin thromboprophylaxis and wore compression stockings post-operatively. In the early mobilisation group 90 patients (92.8%) began walking successfully within 24 hours of their operation. The incidence of deep-vein thrombosis fell from 27.6% in the control group to 1.0% in the early mobilisation group (chi-squared test, p <
0.001). There was a difference in the incidence of risk factors for deep-vein thrombosis between the two groups. However, multiple logistic regression analysis showed that the institution of an early mobilisation protocol resulted in a 30-fold reduction in the risk of post-operative deep-vein thrombosis when we adjusted for other risk factors.
This population-based study investigated the incidence and trends in venous thromboembolic disease after total hip and knee arthroplasty over a ten-year period. Death or readmission for venous thromboembolic disease up to two years after surgery for all patients in Scotland was the primary outcome. The incidence of venous thromboembolic disease, including fatal pulmonary embolism, three months after surgery was 2.27% for primary hip arthroplasty and 1.79% for total knee arthroplasty. The incidence of fatal pulmonary embolism within three months was 0.22% for total hip arthroplasty and 0.15% for total knee arthroplasty. The majority of events occurred after hospital discharge, with no apparent trend over the period. The data support current advice that prophylaxis should be continued for at least six weeks following surgery. Despite the increased use of policies for prophylaxis and earlier mobilisation, there has been no change in the incidence of venous thromboembolic disease.
There is a high risk of venous thromboembolism when patients are immobilised following trauma. The combination of low-molecular-weight heparin (LMWH) with graduated compression stockings is frequently used in orthopaedic surgery to try and prevent this, but a relatively high incidence of thromboembolic events remains. Mechanical devices which perform continuous passive motion imitate contractions and increase the volume and velocity of venous flow. In this study 227 trauma patients were randomised to receive either treatment with the Arthroflow device and LMWH or only with the latter. The Arthroflow device passively extends and plantarflexes the feet. Patients were assessed initially by venous-occlusion plethysmography, compression ultrasonography and continuous wave Doppler, which were repeated weekly without knowledge of the category of randomisation. Those who showed evidence of deep-vein thrombosis underwent venography for confirmation. The incidence of deep-vein thrombosis was 25% in the LMWH group compared with 3.6% in those who had additional treatment with the Arthroflow device (p <
0.001). There were no substantial complications or problems of non-compliance with the Arthroflow device. Logistic regression analysis of the risk factors of deep-vein thrombosis showed high odds ratios for operation (4.1), immobilisation (4.3), older than 40 years of age (2.8) and obesity (2.2).