Introduction:. Hallux surgery is the most commonly performed elective surgery in the foot and ankle. As with all surgery, there are many potential complications quoted in the literature. Venous thromboembolism (deep vein thrombosis and pulmonary embolism) incidence and prophylaxis, however, is not adequately addressed and remains controversial. Material and Method:. This prospective study includes one hundred patients who underwent hallux surgery. Risk factors implicated to increase the risk of developing venous thromboembolic disease as well as anaesthetic time, thigh tourniquet time and regional anaesthetic blocks were documented. Compressive ultrasonography was performed in all the patients postoperatively to assess for deep vein thrombosis. Results:. There was one incident of calf deep vein thrombosis (DVT). No patient developed a pulmonary embolus. The one patient who developed a DVT was not at any higher risk than the average patient in the study. Conclusion:. As a result of the low incidence of venous thromboembolic disease in this study, the authors do not recommend the routine use of chemical venous thrombo-prophylaxis in patients undergoing hallux surgery. The decision to give postoperative anticoagulation remains the surgeon's responsibility. The duration of prophylaxis will depend on when the patient is fully mobile

Thromboembolic complications following lower limb arthroplasty are reported to be high. The aim of this of this study is to ascertain the incidence of symptomatic venous thromboembolic disease following lower limb arthroplasty without Pharmacological thrombo prophylaxis. Retrospective review was undertaken of 752 patients following total hip or total knee replacement between January 1. st. 2002 and June 30. th. 2005. Fifty one patients were considered high risk and received thrombopharmacologal prophylaxis with Clexane and Warfarin. Information on all patients was obtained from medical records, computerised information system, general practitioners and patients themselves to produce a complete picture of the three months immediately following the index arthroplasty. All patients who presented with calf symptoms suggestive of venous thrombosis, respiratory distress or died in that three months were investigated. Two patients were lost to follow up. All others had full documentation. Twenty-nine patients presented with calf related symptoms and after ultrasound investigation nine (five THR, four TKR) were confirmed to have venous thrombosis and were treated. One of these patients developed tense haemarthrosis while on treatment. Twelve other patients presented with respiratory symptoms. Eight (six THR two TKR) were confirmed to have pulmonary embolism on either VQ scan or spiral CT. Four of these on VQ scan were low probability. All patients were treated for thromboembolic disease and while on treatment one patient developed persistent wound discharge and infection. Of the 51 patients treated with pharmacological prophylaxis one developed a DVT and five developed wound problems, one of which was major. Two patients died during the three month period, but neither was related to thromboembolic disease. From the 699 patients the symptomatic DVT rate was 1.1%. Symptomatic pulmonary embolism rate was 1.5% including the low probability of VQ scans. There was no mortality from thromboembolism in this study. These results compare favourably with the recent literature. Our department has a policy to select patients for thromboembolic prophylaxis based on high risk factors. All other patients are fully informed of this risk and are treated with elevation, avoidance of swelling, early supervised and regular mobilisation. Our result from this study substantiate our policy for selection of patients for thromboembolic prophylaxis

Thromboembolic disease is associated with a high degree of morbidity and mortality. There is increasing pressure for elective orthopaedic patients, including those undergoing foot and ankle surgery, to be prescribed chemical thromboprophylaxis post-operatively in order to reduce the risk of a thromboembolic event. The risks of chemical thromboprophylaxis in terms of increased bleeding, wound problems and HIT are well documented. The aim of this study was to determine the incidence of clinically significant thromboembolic events in patients undergoing elective foot and ankle surgery with and without the use of aspirin. We audited a consecutive series of 1625 patients undergoing elective foot and ankle surgery between 2003 and 2010. Between 2003 and 2006 inclusive, aspirin was used post operatively as chemical thromboprohylaxsis. Between 2007 and 2010, no chemical thromboprohylaxsis was used. The follow-up period for all patients was at least three months post-operatively. Most patients were reviewed at 3 months by the senior surgeon. Those who were reviewed less than 3 months (patients undergoing minor procedures) were contacted via telephone to confirm whether a thromboembolic event had been diagnosed. There was no loss to follow up. Of the 1625 patients, 555 patients received aspirin and 1070 patients received no chemical thromboprohylaxsis. 5 of 1625 (0.31%) patients developed a clinically significant thromboembolic event. 3 patients developed a DVT at an average time of 5 weeks post operatively. 2 patients developed non-fatal PE at an average time of 7 weeks post operatively. 3 of the 5 thromboembolic events occurred in the aspirin group (all DVT's) whereas 2 of the 5 (all PE) developed in the non aspirin group. The incidence of clinically significant thromboembolic events is low in elective orthopaedic foot and ankle surgery. We suggest that the benefit of chemical thromboprophylaxis does not outweigh its potential risks in foot and ankle surgery

Background. Thromboembolic disease is a common complication of total hip replacement (THR). The administration of postoperative anticoagulants is therefore highly recommended. The purpose of this study was to compare rivaroxaban with fondaparinux with regards to their safety and effectiveness for the prevention of venous thromboembolic events (VTE) after THR. Methods. We conducted an independent prospective study comparing VTE prevention strategies in two successive series of patients (Groups A and B) undergoing elective unilateral THR. Group A (n=253) received fondaparinux daily 2.5 mg for 10 days, followed by tinzaparin 4500 IU daily for one month. Group B (n=229) received 10 mg rivaroxaban daily for 40 days without platelet monitoring. All surgeries were performed by a single surgeon under general anesthesia using an active blood transfusion-sparing plan. In the absence of contraindications, patients received intra-operative administration of tranexamic acid to reduce postoperative bleeding. Preoperative and postoperative hemoglobin levels were recorded at regular intervals. Bleeding events were documented. The bleeding index was calculated by adding the number of red blood cell units and the difference in the hemoglobin level (in g/dL) between the first morning after the day of surgery and the seventh postoperative day (POD 7). After 5 to 10 days, all patients underwent bilateral lower-extremity duplex ultrasonography to screen for deep venous thrombi. Any clinical symptoms of pulmonary embolism were evaluated with spiral computed tomography lung scans. Clinical evaluation to look for evidence of deep venous thrombi and pulmonary emboli was performed at eight weeks postoperatively. Results. Baseline characteristics between the two groups were comparable. The rate of major bleeding events, proximal deep venous thrombi, and pulmonary emboli was nil in each group. The incidence of blood transfusion was 0.8% in Group A (2 of 253 hips) and 0.4% (1 of 229 hips) in Group B (p=1.0). The bleeding index analysis excluded 8 hips for which the hemoglobin value at POD 7 was not measured. The bleeding index was 1.03 (standard deviation, 0.88) in Group A and 0.8 (standard deviation, 0.80) in Group B (p<0.001). The incidence of bleeding index >2 was 10.5% (27 of 247 hips) in Group A and 3% (7 of 227 hips) in Group B (p<0.001). Discussion. We compared two series of patients treated with THR undertaken with postoperative anticoagulation to prevent VTE. The high level of success these anticoagulant treatments had at preventing VTE in our series could be attributed at least partially to the combination of an active blood-sparing transfusion plan with the use of anticoagulant molecules reported in the literature to be quite potent. Conclusions. This prospective study comparing two anticoagulant regimens in patients treated with THR did not detect any difference with regards to the efficacy of the treatments, although there was significantly less bleeding index in patients who received rivaroxaban

Purpose

The frequency of venous thrombo-embolism (VTE) after total hip arthroplasty(THA) is 20–30% and it is serious complication under THA. Therefore it is necessary to detect and prevent VTE. The purpose of this study were examined the frequency of VTE and the factor of incidence of VTE in our hospital.

Aim

To investigate the incidence, types and trends in diagnosis of venous thromboembolic events (VTE) in patients undergoing total knee arthroplasty (TKA) over a ten-year period.

We studied 1162 consecutive total hip replacements (THR) to establish the incidence of fatal pulmonary embolism (PE), clinical non-fatal PE and deep-vein thrombosis (DVT) in the six months after surgery. Chemical thromboprophylaxis had not been routinely used. We used a validated questionnaire supplemented by post-mortem records and a review of the clinical notes. Follow-up was 100%. The death rate from PE was 0.34% (95% CI 0.09 to 0.88), with one fatal PE after discharge 40 days after operation. The clinical PE rate confirmed by imaging was 1.20% (CI 0.65 to 2.02), with 0.7% of patients readmitted. The venographically-confirmed clinical DVT rate was 1.89% (CI 1.11 to 2.76), with 1.13% readmitted. The total thromboembolic morbidity was 3.4% (95% CI 2.5% to 4.7%); prophylaxis to reduce this would be justifiable if the complications of such prophylaxis did not produce an alternative morbidity. The fatal PE rate after THR without routine chemical prophylaxis was low; a very large randomised clinical trial would be required to demonstrate directly whether any prophylactic measure could reduce this. There is a large discrepancy between the high DVT rate reported in clinical trials using universal screening venography and the symptomatic DVT rate shown in this study. We found insufficient evidence to recommend continuing thromboprophylaxis after discharge from hospital.

Cite this article: Bone Joint J 2023;105-B(6):590–592.

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

To compare the efficacy of intra-articular and intravenous modes of administration of tranexamic acid in primary total knee arthroplasty in terms of blood loss and fall in haemoglobin level. Study Design: Randomized controlled trial. Duration of Study: Six months, from May 2019 to Nov 2019. Seventy-eight patients were included in the study. All patients undergoing unilateral primary total knee replacement were included in the study. Exclusion criteria were patients with hepatitis B and C, history of previous knee replacement, bilateral total knee replacement, allergy to TXA, Hb less than 11g/dl in males and less than 10g/dl in females, renal dysfunction, use of anticoagulants for 7 days prior to surgery and history of thromboembolic diseases. Patients were randomly divided into group A and B. Group A patients undergoing unilateral primary total knee replacement (TKR) were given intravenous tranexamic acid (TXA) while group B were infiltrated with intra-articular TXA. Volume of drain output, fall in haemoglobin (Hb) level and need for blood transfusion were measured immediately after surgery and at 12 and 24 hours post operatively in both groups. The study included 35 (44.87%) male and 43 (55.13%) female patients. Mean age of patients was 61 ± 6.59 years. The mean drain output calculated immediately after surgery in group A was 45.38 ± 20.75 ml compared with 47.95 ± 23.86 ml in group B (p=0.73). At 24 hours post operatively, mean drain output was 263.21 ± 38.50 ml in intravenous group versus 243.59 ± 70.73 ml in intra-articular group (p=0.46). Regarding fall in Hb level, both groups showed no significant difference (p>0.05). About 12.82% (n=5) patients in group A compared to 10.26% (n=4) patients required blood transfusion post operatively (p=0.72). Intra-articular and intravenous TXA are equally effective in patients undergoing primary total knee arthroplasty in reducing post-operative blood loss

Aims. A typical pattern of blood loss associated with total hip arthroplasty (THA) is 200 ml intraoperatively and 1.3 l in the first 48 postoperative hours. Tranexamic acid (TXA) is most commonly given as a single preoperative dose only and is often withheld from patients with a history of thromboembolic disease as they are perceived to be “high-risk” with respect to postoperative venous thromboembolism (VTE). The TRanexamic ACid for 24 hours trial (TRAC-24) aimed to identify if an additional 24-hour postoperative TXA regime could further reduce blood loss beyond a once-only dose at the time of surgery, without excluding these high-risk patients. Methods. TRAC-24 was a prospective, phase IV, single centre, open label, parallel group, randomized controlled trial (RCT) involving patients undergoing primary unilateral elective THA. The primary outcome measure was the indirect calculated blood loss (IBL) at 48 hours. The patients were randomized into three groups. Group 1 received 1 g intravenous (IV) TXA at the time of surgery and an additional oral regime for 24 hours postoperatively, group 2 only received the intraoperative dose, and group 3 did not receive any TXA. Results. A total of 534 patients were randomized, with 233 in group 1, 235 in group 2, and 66 in group 3; 92 patients (17.2%) were considered high-risk. The mean IBL did not differ significantly between the two intervention groups (848.4 ml (SD 463.8) for group 1, and 843.7 ml (SD 478.7) for group 2; mean difference -4.7 ml (95% confidence interval -82.9 to 92.3); p = 0.916). No differences in mortality or incidence of VTE were observed between any group. Conclusion. The addition of oral TXA for 24 hours postoperatively does not reduce blood loss beyond that achieved with a single 1 g IV perioperative dose alone. There may be a clinically relevant difference in patients with a normal BMI, which warrants further investigation. Critically, there were no safety issues in patients with a history of thromboembolic, cardiovascular, or cerebrovascular disease. Cite this article: Bone Joint J 2021;103-B(7):1197–1205

The October 2014 Research Roundup. 360 . looks at: unpicking syndesmotic injuries: CT scans evaluated; surgical scrub suits and sterility in theatre; continuous passive motion and knee injuries; whether pain at night is melatonin related;venous thromboembolic disease following spinal surgery; clots in lower limb plasters; immune-competent cells in Achilles tendinopathy; and infection in orthopaedics

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

Background. There remains a paucity of clinical studies on the effects of coronavirus on perioperative outcomes, with no existing trials reporting on risk factors associated with increased risk of postoperative mortality in these patients. The objectives of this study were to assess perioperative complications and identify risk factors for increased mortality in patients with coronavirus undergoing surgery. Methods. This multicentre cohort study included 340 coronavirus negative patients versus 82 coronavirus positive patients undergoing surgical treatment for neck of femur fractures across nine NHS hospitals within Greater London, United Kingdom. Predefined study outcomes relating to patient demographics, fracture configuration, operative treatment, perioperative complications and mortality were recorded by observers using a standardised data collection proforma. Univariate and multivariate analysis were used to identify risk factors associated with increased risk of mortality. Findings. Coronavirus positive patients had increased risk of postoperative complications (89.0% vs 35.0%, p<0.001), higher rates of admission to high dependency and intensive care units (61.0% vs 18.2%, p<0.001), and increased length of hospital stay (13.8 ± 4.6 days vs 6.7 ± 2.5 days, p<0.001) compared to coronavirus negative patients. Postoperative complications in coronavirus positive patients included respiratory infections (13.4%), thromboembolic disease (13.4%), acute kidney injury (12.2%), and multi-organ dysfunction (12.2%). Coronavirus positive patients had increased risk of postoperative mortality (30.5% vs 10.3%, p<0.001) compared to coronavirus negative patients, with positive smoking status (Hazard ratio: 15.4 (95% CI: 4.55–52.2, p<0.001) and greater than three comorbidities (Hazard ratio: 13.5 (95% CI: 2.82–66.0, p<0.001) associated with increased risk of mortality. Interpretation. Surgery in coronavirus positive patients was associated with increased length of hospital stay, more admissions to the critical care unit, higher risk of perioperative complications and increased mortality compared to coronavirus negative patients. Multivariate analysis revealed that smoking and multiple pre-existing comorbidities were associated with increased risk of postoperative mortality

We performed a meta-analysis to evaluate the relative efficacy of regional and general anaesthesia in patients undergoing total hip or knee replacement. A comprehensive search for relevant studies was performed in PubMed (1966 to April 2008), EMBASE (1969 to April 2008) and the Cochrane Library. Only randomised studies comparing regional and general anaesthesia for total hip or knee replacement were included. We identified 21 independent, randomised clinical trials. A random-effects model was used to calculate all effect sizes. Pooled results from these trials showed that regional anaesthesia reduces the operating time (odds ratio (OR) −0.19; 95% confidence interval (CI) −0.33 to −0.05), the need for transfusion (OR 0.45; 95% CI 0.22 to 0.94) and the incidence of thromboembolic disease (deep-vein thrombosis OR 0.45, 95% CI 0.24 to 0.84; pulmonary embolism OR 0.46, 95% CI 0.29 to 0.80). Regional anaesthesia therefore seems to improve the outcome of patients undergoing total hip or knee replacement

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

Tranexamic acid (TXA) has been used to reduce blood loss during total hip arthroplasty (THA), but its use could increase the risk of venous thromboembolic disease (VTE). Several studies have reported that TXA does not increase the prevalence of deep vein thrombosis (DVT), but most of those used routine chemical thromboprophylaxis, thereby masking the potential increased risk of TXA on VTE. We wished to ascertain whether TXA increases the prevalence of VTE in patients undergoing THA without routine chemical thromboprophylaxis. We carried out a retrospective case-control study in 254 patients who underwent a primary THA, 127 of whom received TXA (1 g given pre-operatively) and a control group of 127 who did not. All patients had mechanical but no chemical thomboprophylaxis. Each patient was examined for DVT by bilateral ultrasonography pre-operatively and on post-operative days 1 and 7. TXA was found to statistically significantly increase the incidence of total DVT on post-operative day 7 compared with the control group (24 (18.9%) and 12 (9.4%), respectively; p < 0.05) but most cases of DVT were isolated distal DVT, with the exception of one patient with proximal DVT in each group. One patient in the control group developed a non-fatal symptomatic pulmonary embolism (PE). The use of TXA did not appear to affect the prevalence of either proximal DVT or PE. Cite this article: Bone Joint J 2015; 97-B:458–62