We describe our technique and rationale using
hybrid fixation for primary total hip arthroplasty (THA) at the Hospital
for Special Surgery. Modern uncemented acetabular components have
few screw holes, or no holes, polished inner surfaces, improved
locking mechanisms, and maximised thickness and shell-liner conformity. Uncemented
sockets can be combined with highly cross-linked polyethylene liners,
which have demonstrated very low wear and osteolysis rates after
ten to 15 years of implantation. The results of cement fixation
with a smooth or polished surface finished stem have been excellent,
virtually eliminating complications seen with cementless fixation
like peri-operative femoral fractures and thigh pain. Although mid-term
results of modern cementless stems are encouraging, the long-term
data do not show reduced revision rates for cementless stems compared
with cemented smooth stems. In this paper we review the conduct
of a hybrid THA, with emphasis on pre-operative planning, surgical
technique, hypotensive epidural anaesthesia, and intra-operative
physiology. Cite this article:
We performed a meta-analysis of modern total
joint replacement (TJR) to determine the post-operative mortality and
the cause of death using different thromboprophylactic regimens
as follows: 1) no routine chemothromboprophylaxis (NRC); 2) Potent
anticoagulation (PA) (unfractionated or low-molecular-weight heparin, ximelagatran,
fondaparinux or rivaroxaban); 3) Potent anticoagulation combined
(PAC) with regional anaesthesia and/or pneumatic compression devices
(PCDs); 4) Warfarin (W); 5) Warfarin combined (WAC) with regional anaesthesia
and/or PCD; and 6) Multimodal (MM) prophylaxis, including regional
anaesthesia, PCDs and aspirin in low-risk patients. Cause of death
was classified as autopsy proven, clinically certain or unknown.
Deaths were grouped into cardiopulmonary excluding pulmonary embolism
(PE), PE, bleeding-related, gastrointestinal, central nervous system,
and others (miscellaneous). Meta-analysis based on fixed effects
or random effects models was used for pooling incidence data. In all, 70 studies were included (99 441 patients; 373 deaths).
The mortality was lowest in the MM (0.2%) and WC (0.2%) groups.
The most frequent cause of death was cardiopulmonary (47.9%), followed
by PE (25.4%) and bleeding (8.9%). The proportion of deaths due
to PE was not significantly affected by the thromboprophylaxis regimen (PA, 35.5%;
PAC, 28%; MM, 23.2%; and NRC, 16.3%). Fatal bleeding was higher
in groups relying on the use of anticoagulation (W, 33.8%; PA, 9.4%;
PAC, 10.8%) but the differences were not statistically significant. Our study demonstrated that the routine use of PA does not reduce
the overall mortality or the proportion of deaths due to PE.
We evaluated the safety and efficacy of a multimodal approach for prophylaxis of thromboembolism after THA, which includes preoperative autologous blood donation; hypotensive epidural anesthesia; intravenous administration of heparin during surgery, before femoral preparation when the thrombogenesis is maximally activated; expeditious surgery, minimizing femoral vein occlusion and blood loss; pneumatic compression; and early mobilization after surgery. 1946 consecutive, non-selected patients (2016 THAs) who received multimodal thromboembolic prophylaxis were followed prospectively for 3 months. Only patients with history of thrombocytopenia (platelet count <
100.000) or adverse reaction to heparin were excluded. The average age was 65 years (14 to 93), ASA classification was 1 in 14%, 2 in 48%, 3 in 37% and 4 in 1% of patients. There was a history of DVT in 86 patients and PE in 35. After surgery, the patients also received pharmacologic prophylaxis for 6 weeks (aspirin 83%; warfarin 17%). The incidence of asymptomatic DVT assessed by ultrasound in the first 198 consecutive patients was 7.1% (14 of 198). The incidence of clinical DVT in the subsequent 1748 patients was 1.8% (32 of 1748). Symptomatic PE occurred in 0.56% (11 of 1946), none of them fatal. The rate of PE in patients receiving aspirin was 0.49% (8 of 1615) and warfarin 0.9% (3 of 331). There was 1 PE among 95 patients with a prior history of PE or DVT (1%). One morbidly obese patient died of a cardiac arrhythmia confirmed by autopsy. There was only one major bleeding complication: one patient with a history of coagulopathy developed hematuria requiring a bladder flush and five units of blood, with an uneventful recovery. No patients developed epidural hematoma following administration of intraoperative heparin. A multimodal approach to prevent thromboembolic disease, showed results that compare favorably with the literature, and with our historic control of 2592 THRs without intraoperative heparin (PE rate of 1%; 0.04% fatal). This multimodal approach appears safe and efficacious as thromboembolic prophylaxis. Our low rate of PE does not support routine anticoagulation prophylaxis with drugs with a significant risk of bleeding.
We selected 20 matched pairs of patients who had had total hip arthroplasty by the same surgeon using the same cemented technique. Matching was by age, sex, height, weight and diagnosis. One of each pair had received hypotensive epidural anaesthesia, with less than 300 ml blood loss: the other had normotensive general anaesthesia with more than 500 ml of blood loss. Early postoperative radiographs were evaluated independently by three blinded observers, using a scoring criteria which assessed the quality of the cement-bone interface. The results showed that patients who had received epidural anaesthesia had significantly better radiographic scores (p less than 0.02). Our findings suggest that hypotensive anaesthesia facilitates penetration of cement into bone.
