Objectives

Venous thromboembolism (VTE) is a major potential complication following orthopaedic surgery. Subcutaneously administered enoxaparin has been used as the benchmark to reduce the incidence of VTE. However, concerns have been raised regarding the long-term administration of enoxaparin and its possible negative effects on bone healing and bone density with an increase of the risk of osteoporotic fractures. New oral anticoagulants such as rivaroxaban have recently been introduced, however, there is a lack of information regarding how these drugs affect bone metabolism and post-operative bone healing.

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

We prospectively studied the outcome of a protocol of prophylaxis for deep vein thrombosis (DVT) in 103 consecutive patients undergoing surgical stabilisation of pelvic and acetabular fractures. Low-molecular-weight heparin (LMWH) was administered within 24 hours of injury or on achieving haemodynamic stability. Patients were screened for proximal DVT by duplex ultrasonography performed ten to 14 days after surgery. The incidence of proximal DVT was 10% and of pulmonary embolus 5%. Proximal DVT developed in two of 64 patients (3%) who had received LMWH within 24 hours of injury, but in eight of 36 patients (22%) who received LMWH more than 24 hours after the injury (p < 0.01). We conclude that LMWH, when begun without delay, is a safe and effective method of thromboprophylaxis in high-risk patients with major pelvic or acetabular fractures

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% vs 0.45%, AOR 0.88 (95% confidence interval (CI) 0.74 to 1.05); p = 0.16), 90-day mortality (0.39% vs 0.45%, AOR 1.13 (95% CI 0.94 to 1.37); p = 0.19) or major haemorrhage (0.37% vs 0.39%, AOR 1.01 (95% CI 0.83 to 1.22); p = 0.94). There was a significantly greater likelihood of needing to return to theatre in the aspirin group (0.26% vs 0.19%, AOR 0.73 (95% CI 0.58 to 0.94); p = 0.01). Between patients receiving LMWH or aspirin there was only a small difference in the risk of pulmonary embolism, 90-day mortality and major haemorrhage. These results should be considered when the existing guidelines for thromboprophylaxis after knee replacement are reviewed

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)

The number of arthroplasties being performed increases each year. Patients undergoing an arthroplasty are at risk of venous thromboembolism (VTE) and appropriate prophylaxis has been recommended. However, the optimal protocol and the best agent to minimise VTE under these circumstances are not known. Although many agents may be used, there is a difference in their efficacy and the risk of bleeding. Thus, the selection of a particular agent relies on the balance between the desire to minimise VTE and the attempt to reduce the risk of bleeding, with its undesirable, and occasionally fatal, consequences. Acetylsalicylic acid (aspirin) is an agent for VTE prophylaxis following arthroplasty. Many studies have shown its efficacy in minimising VTE under these circumstances. It is inexpensive and well-tolerated, and its use does not require routine blood tests. It is also a ‘milder’ agent and unlikely to result in haematoma formation, which may increase both the risk of infection and the need for further surgery. Aspirin is also unlikely to result in persistent wound drainage, which has been shown to be associated with the use of agents such as low-molecular-weight heparin (LMWH) and other more aggressive agents. The main objective of this review was to summarise the current evidence relating to the efficacy of aspirin as a VTE prophylaxis following arthroplasty, and to address some of the common questions about its use. . There is convincing evidence that, taking all factors into account, aspirin is an effective, inexpensive, and safe form of VTE following arthroplasty in patients without a major risk factor for VTE, such as previous VTE. Cite this article: Bone Joint J 2017;99-B:1420–30

After total hip (THR) or knee replacement (TKR), there is still an appreciable risk of developing deep-vein thrombosis despite prophylaxis with low-molecular-weight heparin (LMWH). In a prospective, randomised study we examined the efficacy of LMWH in combination with intermittent pneumatic compression in patients undergoing primary unilateral THR or TKR. We administered 40 mg of enoxaparin daily to 131 patients combined with either the use of intermittent pneumatic compression or the wearing of graduated compression stockings. Compression ultrasonography showed no evidence of thrombosis after LMWH and intermittent pneumatic compression. In the group with LMWH and compression stockings the prevalence of thrombosis was 28.6% (40% after TKR, 14% after THR). This difference was significant (p < 0.0001). In the early post-operative phase after THR and TKR, combined prophylaxis with LMWH and intermittent pneumatic compression is more effective than LMWH used with graduated compression stockings

Patients who undergo total knee replacement (TKR)are at high risk of venous thromboembolism. Low-molecular-weight heparins (LMWH) are the most suitable chemical prophylactic agents but there are some uncertainties about their safety and effectiveness. The foot pump offers an alternative. We randomised 229 patients undergoing primary, unilateral TKR to receive either the A-V Impulse foot pump or enoxaparin, a LMWH. Ascending venography was undertaken between the sixth and eighth postoperative day in 188 patients without knowledge of the randomisation category. The prevalence of venographic deep-vein thrombosis was 58% (57/99) in the foot-pump group and 54% (48/89) in the LMWH group which was not statistically significant. There were four cases of proximal thrombi and two of fatal pulmonary emboli in the foot-pump group and none in the LMWH group. There were fewer haemorrhagic complications and soft-tissue effects in the foot-pump group. We conclude that the neither method provides superior prophylaxis

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 mechanical prophylaxis group) had phlebography eight to 12 days after surgery. Of the 47 with deep-vein thrombosis, 16 had received LMWH (26.7%, 95% CI 16.1 to 39.7) and 31, mechanical prophylaxis (64.6%, 95% CI 49.5 to 77.8). The difference between the two groups was highly significant (p < 0.001). Only one patient in the LMWH group had severe bleeding. We conclude that one daily subcutaneous injection of calcium nadroparin in a fixed, weight-adjusted dosage scheme is superior to intermittent pneumatic compression of the foot for thromboprophylaxis after TKA. The LMWH scheme was also safe

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 mechanical prophylaxis of DVT in THR. Some patients cannot tolerate the foot pump

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

We performed a meta-analysis of the English literature to assess the efficacy of four common regimes for thromboembolic prophylaxis after total knee arthroplasty: aspirin, warfarin, low-molecular-weight heparin (LMWH) and pneumatic compression. We reviewed 136 articles and abstracts published between January 1980 and December 1997. Papers not using routine venography and a lung scan or angiography to detect deep-venous thrombosis (DVT) and pulmonary emboli (PE) respectively, were excluded. Of the 136 studies, 23 with 6001 patients were selected. The incidence of DVT was 53% (1701/3214) in the aspirin group, 45% (541/1203) in the warfarin group, 29% (311/1075) in the LMWH group, and 17% (86/509) in the pneumatic compression device group. Intermittent pneumatic compression devices and LMWH were significantly better than warfarin (p < 0.0001) or aspirin (p < 0.0001) in preventing DVT. The incidence of asymptomatic PE was 11.7% in the aspirin group (222/1901), 8.2% (101/1229) in the warfarin group and 6.3% (24/378) in the pneumatic compression group. No studies with LMWH used routine lung scans. Warfarin and pneumatic compression were significantly better than aspirin in preventing asymptomatic PE (p < 0.05). The incidence of symptomatic PE was 1.3% (23/1800) in the aspirin group, 0.4% (2/559) in the warfarin group, 0.5% (2/416) in the LMWH group and 0% (0/177) in the pneumatic compression group. No statistically significant difference was noted between the above prophylatic regimes due to the very small incidence of symptomatic PE. Prophylaxis for thromboembolic disease in TKA may have to include a combination of some of the above regimes to incorporate their advantages

Ximelagatran is an oral direct thrombin inhibitor intended for the prophylaxis and treatment of thrombo-embolic complications. Purpose: The efficacy and safety of ximelagatran, and its subcutaneous (sc) form melagatran, were evaluated in patients undergoing total hip or knee replacement (THR, TKR). Study 1 was a randomised, double-blind, controlled, dose–response study in which patients received 2-6 doses of sc melagatran (1, 1.5, 2.25, or 3 mg bid) followed by oral ximelagatran (8, 12, 18, or 24 mg bid), or sc dalteparin (5000 IU od). Melagatran treatment was initiated immediately before surgery. Study 2 was a randomized, double-blind, controlled study in which patients received 1–5 doses of sc melagatran (3 mg bid) initiated 4–12 h after surgery followed by oral ximelagatran (24 mg bid), or sc enoxaparin (40 mg od). In both studies, low-molecular-weight heparin (LMWH) was started the evening before surgery, and all treatment regimens were continued for 8–11 days. Bilateral venography was performed on the final day of treatment. Results: In Study 1, 1876 patients underwent THR (n=1270) or TKR (n=606). A significant dose-dependent reduction in venous thromboembolism (VTE) was seen with melagatran + ximelagatran for both THR (P< 0.0001) and TKR (P=0.0014). The rate of VTE was significantly lower with the highest dose of melagatran + ximelagatran (15.1%) when compared with dalteparin (28.2%) (P< 0.0001). In Study 2, 2788 patients underwent THR (n=1923) or TKR (n=865). The VTE rate was 31% in the melagatran + ximelagatran group and 27% in the enoxaparin group (P=0.053). Total bleeding volume was not significantly different between treatment groups. Conclusion: Fixed-dose sc melagatran followed by oral ximelagatran are efficacious and well tolerated for the prophylaxis of VTE following THR or TKR

Purpose: Is prevention of postoperative venous thrombosis using low-molecular-weight heparin (LMWH) sufficient in orthopaedic and traumatology units?. Material and methods: Between 1995 and 2000, all patients undergoing orthopaedic or traumatology procedures involving the lower limb underwent a venous control the sixth day after surgery: RPO with phlebography if positive until September 1996 then duplex Doppler of the lower limbs. In all 755 patients, mean age 68 years (34–90), undergoing planned orthopaedic procedures (341 THA, 135 TKA, 111 tibial osteotomies, 66 single compartment prostheses, cruciate surgery) or procedures for trauma (56 femoral neck, trochanter, bimalleolar, etc.) were included. Results: A total of 118 cases of deep vein thrombosis were discovered giving an incidence of 16%. The deep vein thrombosis was in the sural territory in 95 cases (posterior tibial, fibular, vastus and/or anterior tibial) but there were also 13 cases of proximal thrombosis in the iliofemoral or femoral localisations. The large majority of the cases were homolateral to the surgical side, eight were found in the other limb. In this series, the venous risk differed from one surgical procedure to another (for the same operator): 11% for THA, 22% for TKA (without tourniquet) and 17 to 12.5% for tibial osteotomies with tourniquet (valgisation and transposition of the anterior tuberosity), 13.5 % for single compartment prostheses with tourniquet. Our oldest patient was 90 years old and was treated by intermediary arthroplasty for a cervical fracture. The youngest were 34 years old for anterior cruciate ligament surgery or valgisation osteotomy and 38 and 39 years for THA subsequent to advanced necrosis. Finally, there was no statistical difference by sex. Conclusion: Systematic use of duplex Doppler examination of both limbs postoperatively revealed a large number of deep vein thrombosis patients despite systematic use of LMWH which certainly modified their clinical presentation. These patients were then given adapted treatment which led to regression of the complications: postphlebitis syndrome and pulmonary embolism with the risk of medicolegal complications

Introduction Recent changes in the management of hip fracture surgery patients may have resulted in changes in the epidemiology of venous thromboembolism (VTE). We aimed to determine the incidence of and predictive risk factors for symptomatic VTE and mortality, and the use of VTE prophylaxis, in hip fracture surgery patients. Methods Hip fracture surgery patients were enrolled in 525 hospitals in France between October 1 and November 30, 2002 in this prospective, multicenter, epidemiological study. VTE was assessed by a critical events committee at 3 months. Risk factors were identified using logistic regression. Results Data were from 6860 (97%) of 7019 enrolled patients. Median age was 82 years and 76% were women. 47% were femoral neck and 53% trochanteric or subtrochanteric fractures. All were operated on (osteosynthesis 57%, half prosthesis 35% and THR 8%). Prophylaxis with a low-molecular-weight heparin (LMWH) was administered perioperatively in 97.6% and for at least four weeks in 69.5% (median prophylaxis duration: 6 weeks). The rate of symptomatic VTE at 3 months was 1.34% (95% CI: 1.04– 1.64). There were 16 PE (rate 0.25%) and 3 were fatal. The rate of major bleeding was 1.2%. At 6 months, 1006 patients (14.7%) were dead. Significant risk factors for symptomatic VTE were: history of VTE (OR 2.9), induction of anesthesia until arrival in the recovery room > 2 hrs (OR 2.5), and varicose veins/post-thrombotic syndrome (OR 2.2). LMWH prophylaxis significantly reduced the risk of symptomatic VTE (OR 0.2). Significant predictive factors for mortality were: cancer (OR 2.3), surgical complications requiring re-intervention (OR 1.8), confusion before fracture (OR 1.8), ASA score ≥3 (OR 1.7), BMI ≤18 kg/m2 (OR 1.6), congestive heart failure (OR 1.6), atrial fibrillation (OR 1.6) and age > 80 years (OR 1.1). Conclusions Extended LMWH prophylaxis is applied widely after hip fracture surgery in France. The current rate of postoperative VTE is low. However, a major change in the care of these patients is needed because of the high mortality rate

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 mechanical prophylaxis of DVT. This trial is a contribution in comparing the effectiveness and safety of mechanical versus chemical prophylaxis of DVT in patients managed with THR. Methods Inclusion criteria were hip osteoarthritis, age less than 80 years, and uninterrupted use of a foot-pump. Exclusion criteria were a history of thromboembolic disease, heart disease, malignancy and bleeding diatheses. Two hundred and sixteen 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). All patients started mobilisation on crutches with partial weight-bearing on day two using compression stockings. The foot-pump was applied on both feet in the recovery room and was used until patient discharge. Management with the foot-pump was interrupted only during physiotherapy and toileting. A reverse Trendelenburg position (head-high, feet-low) was applied at rest to enhance the pneumatic effect of the pumps. Patients were monitored for DVT using serial duplex sonography (Sonoline Elegra, Siemens, Germany) at day three, 10 and 45 after surgery. Results DVT was detected in three of 100 patients managed with the foot-pump compared with six of 100 patients who received chemical prophylaxis. Sixteen patients did not tolerate continuous use of the foot-pump and were excluded from the study. The average post-operative drainage was 259 ml in the foot-pump group and 328 ml in the control group (p=0.05). Patients with foot-pump had less swelling of the thigh (10 mm compared with 15 mm) (p=0.05). One patient developed heparin-induced thrombocytopenia. Conclusions This study confirms the effectiveness and safety of mechanical prophylaxis of DVT in THR, confirming the outcomes of previous randomized clinical trials. Some patients cannot tolerate the foot-pump, mostly because of sleep disturbance. In relation to the conduct of this study, one or more of the authors is in receipt of a research grant from a non-commercial source

The October 2023 Knee Roundup³⁶⁰ looks at: Cementless total knee arthroplasty is associated with more revisions within a year; Kinematically and mechanically aligned total knee arthroplasties: long-term follow-up; Aspirin thromboprophylaxis following primary total knee arthroplasty is associated with a lower rate of early periprosthetic joint infection compared with other agents; The impact of a revision arthroplasty network on patient outcomes; Re-revision knee arthroplasty in a tertiary centre: how does infection impact on outcomes?; Does the knee joint have its own microbiome?; Revision knee surgery provision in Scotland; Aspirin is a safe and effective thromboembolic prophylaxis after total knee arthroplasty: a systematic review and meta-analysis; Patellar resurfacing and kneeling ability after total knee arthroplasty: a systematic review.

Aims

The aim of this study was to assess the clinical and radiological results of patients who were revised using a custom-made triflange acetabular component (CTAC) for component loosening and pelvic discontinuity (PD) after previous total hip arthroplasty (THA).

Aims

Venous thromboembolism (VTE) is a potential complication of foot and ankle surgery. There is a lack of agreement on contributing risk factors and chemical prophylaxis requirements. The primary outcome of this study was to analyze the 90-day incidence of symptomatic VTE and VTE-related mortality in patients undergoing foot and ankle surgery and Achilles tendon (TA) rupture. Secondary aims were to assess the variation in the provision of chemical prophylaxis and risk factors for VTE.

Aims

We investigated the efficacy and safety profile of commonly used venous thromboembolism (VTE) prophylaxis agents following hip and knee arthroplasty.