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.

The purpose of this study was to highlight uncommon and confusing clinical problem of unilateral prolapsed intervertebral disc (PIVD) producing contralateral symptoms based on case reports and literature review.

Four cases of patients with disc prolapse contralateral to the symptomatic limb are presented. Two patients had cervical disc herniations, and one patient had a lumbar disc prolapse. All three patients had resolution of their contralateral radicular pain following discectomy.

Few reports have been published of patients with unilateral sciatica following contralateral lumbar disc herniation. The authors described the unique features of their patients’ anatomy and related this to their respective pathology. Coexistence of lumbar spondylosis and lateral recess stenosis, as well as the unique features of the attachments of the dural sac and nerve root sleeves to the surrounding osseous structures serve to provide an explanation for contralateral symptoms.

The cervical spine is quite different from the lumbar spine. Here the spinal cord rather than the more flexible cauda equina fills most of the spinal canal. A number of reports can be found describing Brown-Sequard syndrome as a consequence of cervical disc herniation. The two cases presented are in our opinion also the consequence of direct pressure on the spinal cord. We suggest that pressure on the ascending spinothalamic tracts leads to contralateral pain without other neurological symptoms.

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.

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.