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 aspirin may represent an acceptable compromise in these patients

Using general practitioner records, hospital medical notes and through direct telephone conversation with patients, we investigated the accuracy of nine patient-reported complications after elective joint replacement surgery of the hip and knee. A total of 402 post-discharge complications were reported after 8546 elective operations that were undertaken within a three-year period. These were reported by 136 men and 240 women with an overall mean age of 71.8 years (34.3–93.2). A total of 319 (79.4%; 95% confidence interval, 75.4%–83.3%) reported complications were confirmed to be correct. Very high rates of correct reporting were demonstrated for infection (94.5%) and further surgery (100%), whereas the rates of reporting deep venous thrombosis (DVT), pulmonary embolism, myocardial infarct and stroke were lower (75%–84.2%). Dislocation, periprosthetic fractures and nerve palsy were associated with modest rates of correct reporting (36%–57.1%). More patients who had had knee surgery delivered incorrect reports of dislocation (p = 0.001) and DVT (p = 0.013). Despite these variations in accuracy, it appears that post-operative complications may form part of a larger patient-reported outcome programme for monitoring outcome after elective joint replacement surgery

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 mechanical prophylaxis and rapid rehabilitation the rate of symptomatic DVT and PE has reduced, isolation of pre-operative DVT, especially in patients with prior history of DVT remains a challenge. The aim of this study was to assess the utility of pre-operative dopplers as a tool to screen and reduce DVT/PE rate in patients undergoing total joint replacement. Methods. Between January 2014 and December 2014, 211 elective primary hip and knee arthroplasty were identified from our prospective institutional database as two consecutive cohorts (115 cases had pre-operative dopplers and 96 did not). All cases were performed by two adult reconstruction specialists. All primary total hip arthroplasties (THA) were non-cemented and all primary total knee arthroplasties (TKA) were cemented with similar implant and technique. In the first cohort, all cases underwent routine pre-operative doppler screening and in the control cohort, only patients with prior history of DVT or PE underwent pre-operative dopplers. All patients with clinical symptoms of calf pain underwent post-operative dopplers. Patients were followed for a minimum of 3 month post-operatively. All emergency room (ER) visits for role out DVT were identified. No patient was lost to follow. Results. In the cohort with pre-operative dopplers, none of the pre-operative dopplers were positive for DVT, including three patients that had a history of prior DVT. 34 patients in this group (29%) underwent post-operative dopplers, either during the hospital stay or in the ER within 3 month after index surgery. Only one patient (no prior history of DVT) developed symptomatic DVT/PE (0.8%) after total knee arthroplasty. In the control cohort, 3 of which (3%) had symptomatic DVT, one of which had PE (1%) during hospital stay, all after total knee arthroplasty. There was no statistical difference for rate of symptomatic DVT/PE between the two groups (p=0.3). There was no correlation between DVT and age, gender or BMI. Discussion and Conclusions. Utilization of routine pre-operative dopplers for all patients did not lower the rate of symptomatic DVT/PE and are not helpful in early detection and prevention in asymptomatic patients prior to routine total joint replacement. Pre-operative dopplers should be used in selected patients with high risk of DVT

Stable ankle fractures can be successfully treated non-operatively with a below knee plaster cast. In some European centres it is standard practice to administer thromboprophylaxis, in the form of low molecular weight heparin, to these patients in order to reduce the risk of deep venous thrombosis (DVT). The aim of our study was to assess the incidence of DVT in such patients in the absence of any thromboprophylaxis. We designed a prospective study, which was approved by the local ethics committee. We included 100 consecutive patients with ankle fractures treated in a below knee plaster cast. At the time of plaster removal (6 weeks), patients were examined for signs of DVT. A colour doppler duplex ultrasound scan was then performed by one of the two experienced musculoskeletal ultrasound technicians. We found that 5 patients developed a DVT. Two of these were above knee, involving the superficial femoral vein and popliteal vein respectively. The other three were below knee. None of the patients had any clinical symptoms or signs of DVT. None of the patients developed pulmonary embolism. Of these five patients, four had some predisposing factors for DVT. The annual incidence of DVT in the normal population is about 0.1%. This can increase to about 4.5% by the age of 75. DVT following hip and knee replacement can occur in 40-80% of cases. Routine thromboprophylaxis may be justified in these patients. However, with a low incidence of 5% following ankle fractures treated in a cast, we believe that routine thromboprophylaxis is not justified

Objectives. Tranexamic acid (TXA), an inhibitor of fibrinolysis blocking the lysine-binding site of plasminogen to fibrin, has been reported to reduce intraoperative and postoperative blood loss in patients undergoing primary total hip arthroplasty (PTHA) both with and without cement. Both intravenous (IV) and topical (TOP) administration of TXA can effectively reduce blood loss in THA without increasing risk of deep venous thrombosis (DVT). However, there have been few reports investigating the combination of intravenous and topical administration of TXA in bilateral cementless PTHA. We investigated the effects of combined intravenous and topical administration of TXA on postoperative blood loss, drainage volume, and perioperative complications in patients with bilateral simultaneous cementless PTHA for hip osteoarthritis. Patients and methods. We retrospectively reviewed the demographic and clinical data of 41 patients who underwent bilateral simultaneous cementless PTHA for hip osteoarthritis from May 2015 to January 2017, of which there were 29 male (70.7%) and 12 female (29.3%) patients. Patients in IV group (n= 11) received only TXA (15 mg/kg) 10 min prior to the incision of each side; and patients in IV + TOP group (n=13) received i.v. TXA (15 mg/kg) combined with topical adiministration (1.0 g) of TXA during the each THA procedure; patients in control group (n=17) received the same dosage of normal saline both i.v. and topically. Outcome measures were total blood loss, hemoglobin, hematocrit value (HCT) changes preoperatively, and on the 1st, 3rd postoperative day, the amount of drainage, and perioperative complications. Results. On the 1st, 3rd postoperative day, patients in group IV and group IV + TOP had significantly higher haematological parameters (haemoglobin, hematocrit value (HCT)) than patients in control group (P < 0.05 (group IV vs control group), P < 0.01 (group IV + TOP vs control group), respectively), while no significant differences found between patients in group IV and group IV + TOP (P > 0.05). The postoperative drainage volume of patients in group IV and group IV + TOP were significantly less than those in control group (P < 0.01, P < 0.01, respectively), while no significant differences found between those in group IV and group IV + TOP (P > 0.05). No significant differences were found in the perioperative complications (DVT or PE) among all three groups. Conclusion. The combined administration of intravenous and topical TXA resulted in a significantly reduction in postoperative blood loss, compared with placebo group. No adverse perioperative complications were observed. This study supports the combined intravenous and topical administration of TXA in bilateral cementless PTHA

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 mechanical prophylaxis and rapid rehabilitation the rate of symptomatic DVT and PE has reduced, isolation of pre-operative DVT, specially in patients with prior history of DVT remains a challenge. The aim of this study was to assess the use of pre-operative dopplers as a tool to detect and identify prior DVT in patients undergoing total joint replacement. Methods. Between January 2014 and December 2014, 211 elective primary and revision hip and knee arthroplasty were identified from our prospective institutional database. All cases were performed by two adult reconstruction specialists. All primary total hip arthroplasties (THA) were non-cemented and all primary total knee arthroplasties (TKA) were cemented with similar implant and technique. Prior to July 2014, only patients with prior history of DVT or PE underwent pre-operative dopplers. From July 2014, all cases underwent routine pre-operative doppler screening. All patients with clinical symptoms of calf pain underwent post-operative dopplers. Patients were followed for a minimum of 3 month post-operatively. All emergency room (ER) visits for role out DVT were identified. No patient was lost to follow. Results. 115 patients patient underwent pre-operative dopplers. Three patients had a history of prior popliteal DVT, none of which had post-operative DVT or PE. In the remaining 112 patients, none of the pre-operative dopplers were positive for DVT. 34 patients in this group (29%) underwent post-operative dopplers, either during the hospital stay or in the ER within 3 month after index surgery. Only one patient developed symptomatic PE (0.8%) after total knee arthroplasty. 96 patients did not have pre-operative dopplers, 3 of which (3%) had symptomatic DVT and PE during hospital stay, all after total knee arthroplasty. There was no statistical difference for rate of symptomatic DVT/PE between the two groups (p=0.3). There was no correlation between DVT and obesity, age, or revision versus primary cases. Discussion and Conclusions. Routine pre-operative dopplers do not significantly lower rate of symptomatic DVT/PE and are not helpful in early detection and prevention in asymptomatic patients prior to routine total joint replacement

Introduction. This is a retrospective review of the incidence of deep venous thrombosis (DVT) in 679 consecutive unilateral primary hip arthroplasty procedures performed between January 2007 and December 2010 managed with no anticoagulants. Mean age at operation was 58 years. Mean BMI was 26. The prophylaxis regimen included hypotensive epidural anesthesia, compression stockings, intermittent calf compression, early mobilization and an antiplatelet agent. Methods. 562 hybrid hip resurfacing procedures and 117 uncemented THRs, all performed through a posterior incision were included. Doppler ultrasound screening for DVT was performed in all patients between the fourth and sixth post-operative days. Patients were reviewed clinicoradiologically 6 to 10 weeks after operation and with a postal questionnaire at the end of 12 weeks to detect symptomatic VTE incidence following discharge. 14 patients with pre-existent VTE, coagulation disorders or cardiac problems requiring anticoagulant usage were excluded. Results. There were no symptomatic DVTs. Ten cases (1.5%) of asymptomatic below-knee DVT and 1 above-knee asymptomatic DVT (0.15%) were detected on USG. One patient had non-fatal pulmonary embolism but no evidence of lower limb DVT on repeated USG examinations. On investigation he was found to have Prothrombin 20210A mutation. The incidence of DVT was 1.6% (9 of 562) in the resurfacing group and 1.7% (2 of 117) in the THA group, an overall incidence of 1.6% (11/679) in the whole group. Fourteen patients (2.1%) needed a blood transfusion including 9 resurfacings (1.6%) and 5 THAs (4.3%). Discussion and Conclusion. This combination regimen which offers the prospect of low incidence of venous thromboembolism, without subjecting patients to the higher risks of bleeding associated with anticoagulant usage

Introduction. Total knee replacements (TKR) are among the commonest operations performed in orthopaedic practice. Literature review showed that 10-30% of patients who underwent TKR needed 1-3 units of blood. Tranexamic acid (TXA) has been popularised as an effective way to reduce blood loss and subsequent blood transfusion. Our aim was to investigate the value of TXA in reducing blood loss and blood transfusion after TKR and other clinical outcomes such as deep venous thrombosis (DVT), pulmonary embolism (PE), ischaemic heart diseases and mortality. Patients and Methods. A systematic review and meta-analysis of published randomised and quasi-randomised trials which used TXA to reduce blood loss in knee arthroplasty were conducted. Results. 18 clinical trials were considered suitable for detailed data extraction. There were no trials which utilised TXA in revision TKR. Blood loss. Fourteen studies (885 patients) were eligible for this outcome. Using TXA significantly reduced postoperative blood loss by an average of 203.64.65 ml (P-value <0.00001, 95% CI -177.44-229.84, I2 =89 %) and total blood loss by an average of 591.44 ml (P-value <0.00001, 95% CI -646.82-536.06, I2 =78 %). Blood transfusion. Sixteen studies (1085 patients) were eligible to measure the effect of TXA on blood transfusion after TKR. TXA led to a reduction in the proportion of patients who required blood transfusion (RD -0.34, P-value <0.00001, 95% CI -0.38-0.29, I2 =65). Other outcomes. There were no significant differences in the length of hospital stay, DVT, PE, mortality, wound haematoma or infections between the study groups. Conclusion. TXA appears effective and safe in reducing blood loss and allogeneic blood transfusion in primary TKR

Background. The National Institute for Health and Clinical Effectiveness recommends both low molecular weight heparin (LMWH) and Rivaroxaban for venous thromboembolic (VTE) prophylaxis following lower limb arthroplasty. Despite evidence in the literature that suggests Rivaroxaban reduces VTE events, there are emerging concerns from the orthopaedic community regarding an increase in wound complications following its use. Methods. Through the orthopaedic clinical directors forum, Trusts replacing LMWH with Rivaroxaban for lower limb arthroplasty thromboprophylaxis during 2009 were identified. Prospectively collected Hospital episode statistics (HES) data was then analysed for these units so as to determine rates of 90-day symptomatic deep venous thrombosis (DVT), pulmonary embolism (PE), major bleed (cerebrovascular accident or gastrointestinal haemorrhage), all-cause mortality, and 30-day wound infection and readmission rates before and after the change to Rivaroxaban. 2752 patients prescribed Rivaroxaban following TKR or THR were compared to 10358 patients prescribed LMWH. Data was analysed using odds ratios (OR). Results. There were significantly more wound infections in the Rivaroxaban group (3.85% vs. 2.81%, OR=0.72; 95% CI 0.58–0.90). There were no significant differences between the two groups for PE (OR=1.52; 0.77–2.97), major bleed (OR=0.73; 0.48–1.12), all-cause mortality (OR=0.93; 0.46–1.87) and re-admission rate (OR=1.21; 0.88–1.67). There were significantly fewer symptomatic DVTs in the Rivaroxaban group (0.91% vs. 0.36%, OR=2.51; 1.30–4.82). Discussion. This study is the first to describe the real impact of the use of Rivaroxaban in the NHS. When compared with LMWH in lower limb arthroplasty patients, there were fewer DVTs in the Rivaroxaban group. However, wound infection rates were significantly higher following Rivaroxaban use whilst providing no reduction in symptomatic PE or all-cause mortality

Introduction:. One of the complications occurring after total knee arthroplasty (TKA) is venous thromboembolism (VTE). The current screening techniques for VTE are venography, lower extremity vascular ultrasound, pulmonary scintigraphy, and contrast-enhanced computed tomography (CT). Although venography and lower extremity vascular ultrasound can detect deep venous thrombosis (DVT) in the lower extremities, pulmonary thrombosis poses a diagnostic problem. We performed contrast-enhanced CT screening for DVT and pulmonary embolism (PE) after TKA, and assessed the efficacy of the following prophylactics for VTE: fondaparinux, enoxaparin, and edoxaban. Materials and Methods:. Subjects included 219 patients (260 knees) undergoing TKA at our hospital between April 2007 and November 2012. The 260 subject knees were divided as follows: group C, 31 cases in which DVT prophylactics were not used (April 2007 to October 2008); group F, 107 cases receiving fondaparinux 2.5 mg/day (July 2007 to October 2009); group ENO, 87 cases receiving enoxaparin 2000–4000 IU/day (November 2009 to October 2011); and group EDO, 35 cases receiving edoxaban 15–30 mg/day (November 2011 to November 2012). Contrast-enhanced CT images were obtained from the pulmonary apex to the foot for diagnosis of VTE. Groups were compared for incidence of symptomatic PE, asymptomatic PE, DVT-negative asymptomatic PE, DVT-positive asymptomatic PE, and DVT. Results:. Incidence of symptomatic PE tended to be lower in group ENO than in group C (p = 0.067), but no statistically significant differences in asymptomatic PE were observed between any groups (Figure 1). DVT-negative asymptomatic PE (Figure 2) was present in 2 cases in group C (6.5%), 14 cases in group F (13.1%), 3 cases in group ENO (3.4%), and 2 cases in group EDO (5.7%) (Figure 1). Patients diagnosed with symptomatic PE presented only with mild clinical symptoms and physical findings. As a result, PE was not suspected from clinical findings alone. The diagnosis of symptomatic PE was confirmed by the presence of thrombosis in the pulmonary artery on contrast-enhanced CT (Figure 3). Conclusion:. Asymptomatic PE is not prevented by prophylaxis after TKA. Contrast-enhanced CT screening is effective for identifying asymptomatic VTE, especially asymptomatic PE

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

Background. The optimal strategy for postoperative deep venous thrombosis (DVT) prophylaxis remains among the most controversial topics in hip and knee arthroplasty. Warfarin, the most commonly used chemical anticoagulant, initially causes transient hypercoagulability; however the optimal timing of treatment with respect to surgery remains unclear. Our purpose was to evaluate the effects of pre- versus postoperative initiation of warfarin therapy with a primary endpoint of perioperative change in hemoglobin (pre- minus post-operative level), with secondary endpoints of postoperative International Normalized Ratio (INR), drain output, and bleeding/thrombotic events. Methods. A quasi-experimental study design was employed, under which patients were assigned to begin taking warfarin the night prior to surgery or the night following surgery based on day of the week seen in clinic. An a priori power analysis was conducted in order to ensure appropriate enrollment to detect a 0.5 g/dL difference in perioperative change in hemoglobin between groups, given an alpha level of 0.05 and beta of 0.80. Based on the results, the study included all primary, elective total hip and knee arthroplasties performed by a single surgeon over a 12 month period. Fifteen patients were excluded (7 chronic anticoagulation, 3 hip fractures, 2 medical contraindications, 3 simultaneous procedures), leaving 165 cases (108 hips, 57 knees) available for study. Of these, 73 received warfarin preoperatively (49 hips, 24 knees) and 92 postoperatively (59 hips, 33 knees). Warfarin was dosed according to a standard nomogram in both groups. INR (on postoperative days 1 and 2), perioperative decrease in hemoglobin (difference between level preoperatively and on postoperative days 1 and 2), and drain outputs were compared between groups using a student t test. Adverse events (transfusions, hematomas, epidural complications, and pulmonary embolus) were compared using two-tailed Fischer's exact test. Results. No statistically significant difference in perioperative hemoglobin change was observed between treatment groups on either postoperative day 1 (mean 3.279 versus 3.377, p=0.6824) or 2 (mean 4.0 versus 4.12, p=0.6831). As expected, the preoperative warfarin group demonstrated higher INRs on both postoperative days 1 (mean 1.18 versus 1.12, p=0.0023) and 2 (mean 1.46 versus 1.31, p=0.0006). Of note, preoperative warfarin dosing was also associated with significantly lower drain outputs (mean 185.4 versus 268.7, p=0.0025). 9 transfusions (4 preoperative dosing, 5 postoperative dosing), 3 hematomas (1 preoperative dosing, 2 postoperative dosing), and 1 pulmonary embolus (preoperative dosing) occurred, but no significant difference could be detected given the numbers available for study. Conclusions. Initiation of warfarin pre- rather than postoperatively was not associated with a significant difference in perioperative hemoglobin change, although a significant reduction in drain output was observed. Larger studies are needed to determine whether the risk of adverse events is increased with either dosing strategy

Background. Fifteen to twenty percent of patients presenting for total hip arthroplasty (THA) have bilateral disease. While simultaneous bilateral THA is of interest to patients and surgeons, debate persists regarding its merits. The majority of previous reports on simultaneous bilateral THA involve patients in the lateral decubitus position, which require repositioning, prepping and draping, and exposure of a fresh wound to pressure and manipulation for the contralateral THA. The purpose of this study was to compare complications, component position, and financial parameters for simultaneous versus staged bilateral THAs using the direct anterior approach (DAA). Methods. Medical records were reviewed for patient demographics, medical history, operative time, estimated blood loss (EBL), change in hemoglobin, transfusion, tranexamic acid (TXA) use, length of stay (LOS), discharge disposition, leg length discrepancy, acetabular cup position, and perioperative complications. Cost and reimbursement data were analyzed. Results. Forty-four patients were included in the sequential group and fifteen patients in the simultaneous group (Figure 1). Operative time was significantly longer for simultaneous DAA THA, with procedures lasting 260 +/− 48 minutes compared to 132 +/− 30 minutes for a single arthroplasty in the sequential group (p<0.001). Patients undergoing simultaneous bilateral DAA THA also had a significantly higher EBL (p<0.001), hemoglobin drop (p<0.001), and blood transfusion rate (p<0.01) compared to parameters for a single arthroplasty in the sequential group. This was despite TXA being used in a significantly higher proportion of simultaneous procedures compared to sequential procedures (p<0.01). The LOS was significantly longer in patients undergoing simultaneous bilateral DAA THA (2.9 +/− 1.0 days) compared to sequential (2.2 +/− 0.6 days) (p<0.001). No deep venous thrombosis (DVT) or pulmonary embolism (PE) was detected in either group during the observation period. No significant difference was detected regarding perioperative complications or whether patients were able to be discharged home instead of to a post-inpatient facility (Figure 2). There was no significant difference in component position, complications, or readmissions between groups. Total cost per hip was significantly less for the simultaneous ($15,565 +/− 1,470) compared to the sequential group ($19,602 +/− 3,094) (p<0.001). There was no significant difference in total payments between the simultaneous group ($25,717 +/− 4,404) and the sequential group ($24,926 +/− 8,203) (p=0.93). Thus, with lower cost and similar reimbursement, profit per hip was significantly higher for the simultaneous ($9,606 +/− 5,060) compared to the sequential group ($5,324 +/− 7,997) (p<0.05). (Figure 3). Conclusions. Significant data regarding simultaneous bilateral THA has been published but results are conflicting and different surgical approaches were used. To our knowledge only four previous reports have been published examining simultaneous bilateral THA performed via the DAA. While simultaneous DAA THA presents challenges, our results suggest that simultaneous DAA THA may add value to the healthcare system without resulting in increased complications compared to sequential hip arthroplasty

Introduction. Patients undergoing total hip arthroplasty (THA) stand in the danger, a particularly high risk for venous thromboembolism (VTE). Fondaparinux and edoxaban, which inhibit FXa, indirectly and directly, respectively, have been used for prevention of VTE after THA in Japan. The aim of this study was to compare the efficacy of fondaparinux and edoxaban for VTE after elective THA in Japanese patients. Materials and methods. We randomly assigned 320 patients underdoing elective cemented THA to receive postoperative 2.5 mg fondaparinux once daily for first postoperative 3 days and 1.5 mg once daily for the subsequent 7 days (FPX group) [1], postoperative 15 mg edoxaban once daily for postoperative 10 days (EDO15mg group), 30 mg edoxaban once daily for postoperative 10 days (EDO30mg group), and 30 mg edoxaban once daily for first postoperative 3 days and 15 mg once daily for the subsequent 7 days (EDOmix group). Deep venous thrombosis (DVT) was diagnosed by ultrasonography at postoperative day 3 and 14. Computed tomography to detect pulmonary thromboembolism was performed to all patients who had proximal DVTs. The χ. 2. test with Bonferroni correction was used to compare variables of the incidence of DVT between each group. The intention-to-treat analysis was performed for statistical analysis in each group. The EDO30 mg group and EDOmix group were regarded as one group in the assessment at the postoperative day 3, and named as the EDO30mg+mix group. Result. There was no fetal bleeding, bleeding in a critical organ, or bleeding leading to reoperation. One patient in the FPX group dropped out due to discontinuation of administration due to proximal DVT at postoperative day 3 and switch to fibrinolytic therapy therapy. One patient in the EDO15mg group dropped out due to stop of administration because of subconjunctival hemorrhage at postoperative day 9. All the patients took the ultrasonography at postoperative day 3. The incidence of DVT was 13.8% (11/80) in the FPX group, 20.0% (16/80) in the EDO15mg group, and 15.0% (24/160) in the EDO30mg+mix group. At the postoperative day 14, except for dropouts, the incidence of DVT was 5.1% (4/79) in the FPX group, 19.0% (15/79) in the EDO15mg group, 8.8% (7/80) in the EDO30mg group, 13.8% (11/80) in the EDOmix group. One proximal DVT was detected in the FPX group at the postoperative day 3, and in other three groups at the postoperative day 14, of which, asymptomatic PE was detected in one patient in each FPX group and EDO30mg group. There was no significance between other each group in the intention-to-treat analysis. The incidence of DVT in the FPX group had a tendency to be lower than that of DVT in the EDO15mg group (p = 0.06). Discussion and conclusions. The results suggest that fondaparinux and edoxaban have an equal effect to prevent DVT for Japanese patients undergoing elective cemented THR. From the point of view of the cost-effectiveness and safety, edoxaban may be worth considering as an alternative

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’

Over a 13-year period we studied all patients who underwent major hip and knee surgery and were diagnosed with objectively confirmed symptomatic venous thromboembolism, either deep venous thrombosis or non-fatal pulmonary embolism, within six months after surgery. Low-molecular-weight heparin had been given while the patients were in hospital.

There were 5607 patients. The cumulative incidence of symptomatic venous thromboembolism was 2.7% (150 of 5607), of which 1.1% had developed pulmonary embolism, 1.5% had deep venous thrombosis and 0.6% had both. Patients presented with deep venous thrombosis at a median of 24 days and pulmonary embolism at 17 days after surgery for hip fracture. After total hip replacement, deep venous thrombosis and pulmonary embolism occurred at a median of 21 and 34 days respectively. After total knee replacement, the median time to the presentation of deep venous thrombosis and pulmonary embolism was 20 and 12 days respectively. The cumulative risk of venous thromboembolism lasted for up to three months after hip surgery and for one month after total knee replacement. Venous thromboembolism was diagnosed after discharge from hospital in 70% of patients who developed this complication.

Despite hospital-based thromboprophylaxis, most cases of clinical venous thromboembolism occur after discharge and at different times according to the operation performed.

The risk of venous thromboembolism in patients following arthroplasty may be reduced by continuing chemical thromboprophylaxis for up to 35 days post-operatively. This prospective cohort study investigated the compliance of 40 consecutive consenting patients undergoing lower limb arthroplasty with self-administration of a recommended subcutaneous chemotherapeutic agent for six weeks after surgery. Compliance was assessed by examination of the patient for signs of injection, number of syringes used, and a self-report diary at the end of the six-week period. A total of 40 patients, 15 men and 25 women, were recruited. One woman was excluded because immediate post-operative complications prevented her participation. Self-administration was considered feasible in 87% of patients (95% confidence interval (CI) 76 to 98) at the time of discharge. Among this group of 34 patients, 29 (85%) were compliant (95% CI 73 to 97). Patients can learn to self-administer subcutaneous injections of thromboprophylaxis, and compliance with extended prophylaxis to six weeks is good.

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.