Patients with pelvic and acetabular fractures have a high risk of developing thromboembolic complications. Despite routine screening, the risk of PE remains high and may develop in patients with negative DVT screening. The search for a means to identify the patient ‘at risk’ has been elusive. 537 consecutive patients, referred to Royal Adelaide Hospital over a 20 year period for treatment of pelvic and acetabular fractures, were evaluated prospectively for pulmonary embolus (PE). 352 patients referred directly to the author were treated with variable dose heparin as prophylaxis to venous thromboembolic (VTE) disease. 184 patients primarily admitted under the general surgeons or to ITU, prior to referral to the author, were treated with fixed dose heparin or Enoxaparin. All patients were followed prospectively to determine the rate of pulmonary embolus. The heparin dosage requirements of those who developed pulmonary emboli were compared to those who did not. Patients were also identified for whom a clinical diagnosis of deep venous thrombosis (DVT) was made during the study and their heparin dosage requirements were determined. 7 of 352 patients treated with variable dose heparin developed PE (1.98%). 13 of 184 patients treated with fixed dose heparin, Enoxaparin, or combinations, developed PE (7.06%). An incidental finding of DVT was made in 36 patients. Of these, 10 patients (2.8%) were treated with variable dose heparin and 26 patients (14.1%) with fixed dose heparin or Enoxaparin. The average Injury Severity Score was higher in patients treated with variable dose heparin than those treated with fixed dose regimes. Patients treated with variable dose heparin who developed PE showed a progressively increasing heparin requirement. The majority of patients who did not develop PE (72%) showed a progressively decreasing heparin requirement (suggesting reversal of a prothrombotic state). 21% showed an initial increasing heparin requirement followed by a decreasing requirement (suggesting a prothrombotic state that was reversed, e.g. a DVT successfully treated by the increasing heparin dose provided by a variable dose regime). 4% manifested a static heparin requirement (suggesting maintenance of a prothrombotic state). 8 patients treated with variable dose heparin developed DVT. 6/8 patients manifested a phase of progressively increasing heparin requirement, followed by a decreased requirement, and 2/8 patients manifested a sustained level of heparin requirement. Patients with pelvic and acetabular fractures treated with variable dose heparin showed a rate of PE (1.98%). This is remarkably low compared with published rates of PE in such patients, and particularly compared with those patients treated only with chemoprophylaxis. The rate of PE was 3.5x higher and the rate of DVT was 5x higher in patients treated with fixed dose heparin or Enoxaparin. Patients who developed PE or DVT manifested an increasing heparin requirement. An increasing dosage of heparin may protect the ‘at risk’ patient from venous thromboembolism. Fixed dose unfractionated heparin/LMWH may be insufficient to treat the ‘at risk’ patient. An increasing heparin requirement may identify the patient ‘at risk’.
Abstract. Introduction. Neck of femur (NOF) fracture patients are at risk of developing venous thromboembolisms (VTE). VTE risks could be reduced by adhering to the National Institute for Health and Care Excellence (NICE) recommendation for 1 month of prophylaxis with low molecular weight heparin. This audit aimed to assess and improve local compliance to national guidelines on
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,
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”
The National Institute of Clinical Excellence (NICE) published guidance for reducing the risk of venous thromboembolism (VTE) in January 2010. This guidance has had a significant impact on the management of all inpatients. It is now mandatory to risk assess every inpatient and commence appropriate treatment if indicated. The guidelines specifically exclude outpatients although NICE recognises' that lower limb cast immobilisation is a risk factor for VTE. The purpose of our study was to establish the current practice for the management of outpatients treated with lower limb casts in England. The NHS Choices website lists 166 acute hospitals in England. A telephone audit was conducted in February 2011. A member of the on call orthopaedic team was asked: 1. Are you aware of the NICE guidelines for
Introduction. ‘VTE disease is the new MRSA’, with much attention received in the media and the political world. Following the 2010 NICE guidelines all patients admitted to hospital should have
Introduction. Rivaroxaban, an oral factor Xa inhibitor, has been approved by USFDA for prophylaxis of deep vein thrombosis (DVT) and pulmonary embolism (PE) in hip and knee arthroplasties. Its indication in hip fracture surgery has been recently recommended in Asian venous thromboembolism (VTE) guidelines. Phase II dose-ranging study demonstrated that 5 mg rivaroxaban is as effective as enoxaparin for
Purpose. The hip fracture has been increasing as the aging population continues to grow. Hip fracture patients are more susceptible to blood loss and venous thromboembolism (VTE). The objective of this study was to assess the efficacy and safety of tranexamic acid (TXA) in fracture patients undergoing fast-track hemiarthroplasty. Methods. 609 hip fracture patients undergoing hemiarthropalsty from January 2013 to September 2016 were prospectively selected. 289 patients received 15 mg/kg TXA prior to surgery, and the remaining 320 patients received no TXA. All the patients received a fast-track program including nutrition management, blood management, pain management,
Purpose. According to the National Institute for Clinical Excellence (NICE) a risk assessment for venous thromboembolism (VTE) should be conducted on all patients undergoing elective orthopaedic surgery. We looked at the patient outcome undergoing elective Ilizarov surgery in terms of symptomatic VTE occurring during or after frame management. Methods. We performed a retrospective chart review of all adult Ilizarov cases performed by a single surgeon between 2000–2011. Patient mortality was confirmed using the Demographics Batch Service. Results. There were 457 cases in 445 patients with a mean age of 42.6 years (range 16–84). There were 440 lower limb and 31 upper limb frames. 185 cases were for infection and 62 cases required flap coverage by plastic surgeons. There were 31 bone transports, 112 deformity corrections, 39 lengthening, 37 fusions, 48 stabilizations and 134 compression/distractions. The mean duration of frame treatment was 34 weeks (range 6–85). According to NICE guidelines all our cases had at least one risk factor for VTE; 243 had two, 200 had three and 28 had four or more. All cases received no pharmacological
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
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 mechanical
Recent recommendations by the National Institute
for Health and Care Excellence (NICE) suggest that all patients undergoing
elective orthopaedic surgery should be assessed for the risk of
venous thromboembolism (VTE). Little is known about the incidence of symptomatic VTE after
elective external fixation. We studied a consecutive series of adult
patients who had undergone elective Ilizarov surgery without routine
pharmacological prophylaxis to establish the incidence of symptomatic
VTE. . A review of a prospectively maintained database of consecutive
patients who were treated between October 1998 and February 2011
identified 457 frames in 442 adults whose mean age was 42.6 years
(16.0 to 84.6). There were 425 lower limb and 32 upper limb frames.
The mean duration of treatment was 25.7 weeks (1.6 to 85.3). According to NICE guidelines all the patients had at least one
risk factor for VTE, 246 had two, 172 had three and 31 had four
or more. . One patient (0.23%) developed a pulmonary embolus after surgery
and was later found to have an inherited thrombophilia. There were
27 deaths, all unrelated to VTE. The cost of providing
Venous thromboembolic (VTE) events including deep vein thrombosis (DVT) and pulmonary embolism (PE) remain a significant concern following total joint arthroplasty. The American Academy of Orthopaedic Surgeons (AAOS) guidelines for
Introduction. Venous thromboembolism (VTE), including pulmonary embolism (PE) resulting from deep vein thrombosis (DVT), remains a well-known serious complication after femoral fractures. The low molecular heparin is widely used to prevent VTE. This study compared the effectiveness of VTE prevention between dalteparin and enoxaparin. Materials and Methods. From 2013 to 2014, we retrospectively recruited 712 patients who had femoral fractures with operative treatment. All patients receiving VTE chemoprophylaxis with perioperative period using dalateparin in Group 1(N=395) and enoxaparin in Group 2(N=317). The prophylactic dosing was determined using individual product labeling and identified as enoxaparin 40 mg every 12 hours and dalteparin 2500 international unit (IU) once daily, based on clinical practice guidelines. The prophylaxis was started at admission, and maintained during average 8.43.5 days after operation. The outcome including the incidence of clinically significant deep vein thrombosis, pulmonary embolism, perioperative bleeding and cost of drugs were evaluated between two groups. Results. The two study groups did not differ significantly in fracture type, age, gender, ASA score. The overall incidence of VTE is similar between two groups. However, the incidence of fatal PE is significantly lower in patients with dalteparin (Group 1: 4/395(1.00%), Group 2: 10/317(3.15%), p<0.001). And the overall cost of each group is significantly different between two groups (Group 1: average KRW 89,426, Group 2: average KRW 32,188, p<0.001). Conclusion. Both dalteparin and enoxaparin could be safely used without notable complications in
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
Introduction. The issue regarding whether suction drainage should be used during TKA continues to be debated as both methods have disadvantages. The use of a drain may increase estimated blood loss and incidence of blood transfusion, while no drainage may be associated with ecchymosis formation surrounding the surgical site and wound problems. This prospective randomized study aimed to clarify the need for suction drainage in TKA by assessing the short-term postoperative outcome. Patients and Methods. We randomized 39 patients undergoing TKAs either with or without an intra-articular suction drain and divided to two groups. All the TKAs were performed by a single surgeon using cemented prostheses. As the perioperative blood management, air tourniquet was used during surgery, the knee arthrotomy was closed water-tightly, and all the patients were received both intra-articular and intra-venous administrations of tranexamic acid. After the surgery, a bulky compression dressing was applied to prevent the third space leakage of the blood for four days and rivaroxaban was used for venous thromboembolism prophylaxis for one week. The two groups were compared in terms of hemoglobin decrease, recovery of knee flexion, postoperative pain, and examined both the knee circumference and knee swelling. The incidence of short-term complications also evaluated. Results. TKAs were performed in 24 patients with (Group 1) and 15 patients without (Group 2) suction drain and there was no major complication in both groups. We found no significant differences in the mean postoperative blood loss, postoperative pain, and ROM during two weeks after TKA between the two groups. The amount of the intra-articular fluid measured with computed tomography as the postoperative knee swelling was similar between the two groups. Discussion and Conclusions. Recently, as the pharmacologic agents have been routinely used for venous thromboembolism prophylaxis after TKA for more than one week, perioperative bleeding should be managed more intensively. The administration of tranexamic acid has been widely reported to decrease the postoperative blood loss, and water-tightness of the arthrotomy closure can reduce hemarthrosis and arthrotomy leakage to the third space by a tamponade effect. The advantage of the bulky compression dressing reportedly is to reduce soft tissue edema and bleeding in an effort to promote venous drainage. Furthermore, this study did not demonstrate that intra-articular suction drain contributed to decrease the amount of intra-articular fluid at two weeks after the surgery. In conclusion, under the condition of routine pharmacologic
Objective. The purpose of this study was to evaluate the efficacy and safety of the drained-clamped method with intra-articular infusion of tranexamic acid (TA) for reducing blood loss in total knee arthroplasty (TKA). Material and Methods. From November 2011 to July 2014 inclusive, 72 patients with a diagnosis of osteoarthritis underwent unilateral primary TKA using a computed tomography (CT) free navigation system. Patients were randomly divided into two groups: group T (n=40) was given 2000 mg (40 ml) of TA and group W (n=32) was given 40 ml sterile saline only. All operations were performed under total anaesthesia through the medial mid-vastus approach. Cemented posterior stabilised or cruciate retaining prostheses were used. The patella was resurfaced. After tourniquet release and wound suture, TA or saline was infused into the knee joint in addition to the drained-clamped method for 2 hours. For
Introduction. Recent UK national guidelines advocate using a combination of mechanical and pharmacological
A national quality improvement initiative identified potentially avoidable complications, including venous thromboembolism (VTE) as “never events.” While the intent of this designation was to improve system-wide performance and to decrease medical costs, its value in total joint arthroplasty has not been defined. We performed this study to assess the relative incidence of VTE related admissions following TKA, the relative costs associated with care directed towards this complication, and compliance with SCIP
NICE technology appraisal guidance 157 suggests that the oral anticoagulation medication Dabigatran etexilate can be used for the primary prevention of venous thromboembolic events (VTE's) in adult patients who have undergone elective total hip or knee replacement surgery. The NICE guidance reports that 13.8% of patients receiving recommended doses of Dabigatran experienced adverse bleeding events. In the pivotal hip and knee VTE trial, wound secretion only accounted for 4.9% of patients treated with Dabigatran (cf 3.0% of patients treated with Enoxaparin). We report our wound secretion experience after Dabigatran use at Warwick Hospital from March 2009 to March 2010. Of the 788 lower-limb arthroplasties performed, 55 patients (6.9%) had oozing wounds after discharge (Mean=8 days, Range=1-39 days). This resulted in 226 extra home-visits by discharge nurses, 26 positive microbiology cultures and 5 confirmed wound infections needing antibiotic treatment and/or surgical intervention. Incidentally, there were also 2 known cases each of deep vein thrombosis and pulmonary embolus in this cohort. The number of complications was markedly increased from previous years when LMWH was the
