Clinical efficacy of mechanical thromboprophylaxis without anticoagulant drugs for elective hip surgery in an Asian population

Passive ankle motion and calf massage without anticoagulation therapy after total hip arthroplasty: A retrospective study

BACKGROUND

It has been previously reported that manual calf massage and passive ankle motion after total hip arthroplasty could reduce the incidence of venous thromboembolism. However, a combination of chemical and mechanical prophylaxes was employed. In this study, we aimed to examine the effect of mechanical prevention without pharmacological antithrombotic intervention.

METHODS

Of the 313 patients who underwent unilateral primary total hip arthroplasty and received passive ankle motion and calf massage postoperatively at our hospital between January 2015 and December 2019, 261 (58 men, 203 women; mean age 62.1 years) were included in this retrospective study. Pharmacological anticoagulation therapy was administered in 176 patients (combination group); 137 patients only underwent calf massage and passive ankle motion without anticoagulation therapy (single group). The study outcomes were operation time, the incidence of deep vein thrombosis, pulmonary thromboembolism, intraoperative bleeding, estimated actual blood loss, blood transfusion, and major bleeding.

RESULTS

No significant differences were found in sex, age, side, platelet counts, activated partial thromboplastin time, prothrombin time, prothrombin time - International Normalized Ratio, intraoperative blood loss, estimated blood loss, and operation time. Moreover, the incidence of deep vein thrombosis, pulmonary thromboembolism, and intraoperative bleeding was not significantly different between the groups (deep vein thrombosis 4.0% vs. 6.3%, p = 0.244; pulmonary thromboembolism 0.7% vs. 0%, p = 0.548; and intraoperative bleeding 394 ± 173.6 ml vs. 365.4 ± 168.5 ml, p = 0.550). However, estimated actual blood loss and postoperative bleeding differed between the groups (eABL 996.6 ± 348.3 ml vs. 858.5 ± 269.6 ml, p = 0.003; postoperative bleeding 601.8 ± 330.0 ml vs. 492.1 ± 277.1 ml, p = 0.016), and both increased in the combination group. No major bleeding was noted in the two groups.

CONCLUSION

Postoperative anticoagulant therapy does not have to be routinely used if mechanical prophylaxis is performed in patients without deep vein thrombosis before total hip arthroplasty.

Incidences of deep vein thrombosis and major bleeding under the administration of fondaparinux for thromboprophylaxis after periacetabular osteotomy: a retrospective observational study

Periacetabular osteotomy (PAO) is an effective joint-preserving procedure for patients with developmental dysplasia of the hip. Although deep vein thrombosis (DVT) is considered a serious complication of orthopaedic surgery, there is no consensus regarding a thromboprophylaxis strategy after PAO. We have routinely administered fondaparinux for DVT prophylaxis in adult patients undergoing PAO. The aim of this study was to investigate the incidences of DVT and major bleeding under the administration of fondaparinux for thromboprophylaxis after PAO. A total of 95 patients (100 hips) who underwent PAO with post-operative administration of fondaparinux for thromboprophylaxis were retrospectively enrolled. The incidences of DVT on ultrasound, major bleeding, and administration cessation were evaluated. Asymptomatic DVT occurred in one patient, major bleeding occurred in 14 hips and the administration of fondaparinux was stopped in 17 hips. Given the observed incidence of major bleeding, safer DVT prophylaxis modalities should be considered during PAO.

Portable compression devices in total joint arthroplasty: poor outpatient compliance

Background

Aspirin and mechanical compression devices are approved means of venous thromboembolism (VTE) prophylaxis after total joint arthroplasty. Prior studies of mechanical compression pumps after joint arthroplasty have been limited to the inpatient setting. The purpose of this study was to evaluate outpatient compliance and utilization factors in a rural population after elective hip or knee arthroplasty.

Methods

Utilization for portable pneumatic compression pumps after joint arthroplasty was prospectively recorded (hours). Compliance was defined as the recommended 20 hours per day. A questionnaire 2 weeks postoperatively assessed factors that may contribute to noncompliance. Patients were followed up for 90 days postoperatively to record VTE events.

Results

Data were collected for 115 joint arthroplasty patients (50 hips, 65 knees). Postdischarge day one had the highest average usage at 13.2 hours/day (66.0%, range 0%-100%), but this number fell to 4.8 hours/day (24.0, range 0%-100%) by day 14. Patient compliance (>20 hours use/day) was highest on postdischarge day one at 40 patients (34.7%). By postdischarge day 14, patient compliance fell to 17 patients (14.8%). Difficulty using the pumps (P = .027) and pump-associated heat (P = .009) were significantly associated with patient compliance. A deep vein thrombosis and nonfatal pulmonary embolism were recorded in 2 separate patients.

Conclusions

This study demonstrated poor outpatient compliance with portable pneumatic compression devices. Poor compliance was related to pump heat and difficulty with pump use. Even with poor compliance, a low incidence of VTE events was observed.

Asymptomatic Deep Venous Thrombosis After Elective Hip Surgery Could Be Allowed to Remain in Place Without Thromboprophylaxis After a Minimum 2-Year Follow-Up

BACKGROUND

It is not clear how to treat asymptomatic deep venous thromboses (DVTs) following elective hip arthroplasty because the natural course of DVTs is unclear. It is therefore valuable to understand the natural course of DVTs and their relation to thromboprophylactic methods.

METHODS

We followed 742 consecutive patients who underwent elective hip arthroplasty followed by mechanical or chemical prophylaxis of a DVT. All patients underwent preoperative and postoperative duplex ultrasonography of both limbs. Patients who developed postoperative DVT in the popliteal or calf vein were followed without thromboprophylaxis. DVT-positive patients were prospectively followed up with duplex ultrasonography at 3, 6, 12, and 24 months postoperatively.

RESULTS

Incidences of preoperative and postoperative DVTs were 3.9% and 33.0%, respectively. Nonfatal pulmonary embolism (PE) occurred in 1 patient after negative echography. All DVTs that developed in the calf vein postoperatively and without anticoagulation remained benign, and 93% of the DVTs ultimately disappeared.

CONCLUSION

These results confirmed that the natural course of asymptomatic distal DVTs is benign, with no risk of leading to PE. Thus, distal DVTs could be allowed to remain untreated without chemical prophylaxis to prevent PE in Asian populations.

Clinical efficacy of risk-stratified prophylaxis with low-dose aspirin for the management of symptomatic venous thromboembolism after total hip arthroplasty

BACKGROUND

Pulmonary thromboembolism (PTE) and deep vein thrombosis (DVT) are serious complications after total hip arthroplasty (THA). Aspirin has been considered a safe and cost-effective prophylaxis for venous thromboembolism (VTE), and there have been some reports about the incidence of PTE (0%-0.57%) and DVT (0.1%-0.35%) with low-dose aspirin for prophylaxis after THA. The aim of this study was to investigate the incidence of postoperative symptomatic VTE in our hospital and to evaluate the clinical efficacy of our prophylactic regimen.

PATIENT AND METHODS

We retrospectively reviewed the medical records of consecutive patients who underwent THA in our hospital between 2011 and 2016. A total of 3295 hips (male: 337 patients, 365 hips; female: 2527 patients, 2930 hips) were enrolled in this study. Patients were divided into low-risk and high-risk groups. Low-risk patients were administered aspirin (100 mg/day) for 28 days postoperatively. High-risk patients, such as those diagnosed with obesity and/or with a history of VTE, received anticoagulants (enoxaparin or edoxaban) for 5 days postoperatively, followed by a dose of aspirin for 28 days. Based on our criteria, 218 of 3295 hips were considered high risk.

RESULTS

No VTE-related mortality was observed. One patient developed symptomatic PTE, and one patient developed symptomatic DVT. Both were successfully treated. Postoperative fatal bleeding or bleeding from any organ such as gastrointestinal and cerebral hemorrhage were not observed. A low incidence (0.03%) was observed for symptomatic DVT and PTE.

CONCLUSIONS

This study demonstrated that the hospital's risk-stratified protocol using low-dose aspirin or anticoagulants was clinically effective in preventing symptomatic VTE. These results were considerably better than those reported from Western countries. However, all patients in this study were the Japanese. It was unclear whether similar results were given to non-Japanese patients. Therefore, this protocol needs severe carefulness to be applied to non-Japanese populations.

Anticoagulation in Revision Total Joint Arthroplasty: A Retrospective Review of 1917 Cases

Although several studies now support the use of aspirin for venous thromboembolism (VTE) prophylaxis in primary total hip arthroplasty (THA) and total knee arthroplasty (TKA), the optimal chemoprophylactic agent in revision THA and TKA is not clear. The purpose of this study was to determine if the type of chemoprophylaxis has an effect on the VTE rate in patients undergoing revision total joint arthroplasty (TJA). The second aim was to compare differences in rates of wound drainage in primary and revision TJA stratified by the postoperative chemoprophylaxis used. The authors retrospectively reviewed 1917 consecutive patients undergoing primary and revision TJA. Individual records were reviewed for patient demographics, medical comorbidities, type of chemoprophylaxis, VTE risk factors, intraoperative data, and postoperative complications. Outcomes, including VTE rate and wound complications, were compared between types of anticoagulant therapy used postoperatively. Of the 1917 patients, there were 742 (38.7%) primary TKAs, 326 (17%) revision TKAs, 608 (31.7%) primary THAs, and 241 (12.6%) revision THAs. The most common prophylactic agent used was rivaroxaban (40.6%), followed by warfarin (28.5%) and aspirin (27.6%). Type of chemoprophylaxis was not associated with postoperative VTE or wound drainage (P>.05). Although revision surgery was an independent risk factor for wound drainage (odds ratio, 3.201; 95% confidence interval, 1.594-6.426; P=.001), it was not a risk factor for VTE (odds ratio, 1.847; 95% confidence interval, 0.423-8.053; P=.414). Revision arthroplasty alone was not associated with an increased rate of VTE. Aspirin is as effective as other chemoprophylactic agents without the increased risk of bleeding in low-risk patients. [Orthopedics. 2019; 42(6):323-329.].

Venous thromboembolism prophylaxis after hip preservation surgery: a review and presentation of institutional experience

Venous thromboembolism (VTE) is a serious complication after major orthopedic procedures. The best options for prevention of the VTE are still debated. The most popular evidence-based guidelines for prevention and treatment of VTE in orthopedic surgery addressed the total hip or knee arthroplasty and hip fractures as the major orthopedic surgeries. Majority of studies have evaluated the different modalities of the VTE prophylaxis in patients undergiong hip or knee arthroplasty. Hip preservation surgeries (HPS) including mini-open femoroacetabular osteoplasty, surgical dislocation of the hip, arthroscopic procedures, and periacetabular osteotomy (PAO) are gained popularity in recent two decades. The majority of these patients are young, healthy and active and may not be considered at high risk for VTE. The frequency of VTE in patients undergoing PAO seems to be low between 0 and 5%. There is a paucity of data regarding rates of VTE in young healthy patients undergoing HPS as well as the optimal prevention methods for VTE. Hence current VTE prevention guidelines do not cover HPS adequately. We aimed to review the available literature regarding VTE events and VTE prophylaxis options after HPS. We discussed the available and potential options for prophylaxis of VTE events in these procedures along with our experience in a large cohort of hip preservation surgery.

Incidence of deep venous thrombosis following periacetabular and derotational femoral osteotomy: a case for mechanical prophylaxis

There are currently no established guidelines for appropriate antithrombotic prophylaxis following periacetabular osteotomy (PAO) or derotational femoral osteotomy (DFO). The purpose of this study was to determine the incidence of clinical deep venous thrombosis (DVT) following PAO and/or DFO wherein a portable, mechanical device and low-dose aspirin were used postoperatively for DVT prophylaxis. Patients who had undergone staged hip arthroscopy and primary PAO and/or DFO were prospectively reviewed. Following PAO/DFO, patients were prophylactically treated for thromboembolic disease with a portable, mechanical compression device for 3 weeks and low-dose aspirin for 4 weeks. Patients were followed in clinic until 24 months postoperatively. During the study period, 145 hips (124 patients) underwent surgery (PAO: 109, DFO: 24, PAO + DFO: 12). Overall, the incidence of clinically apparent DVT was 0% in the study cohort. Average estimated blood loss during surgery was 601 mL and five cases required blood transfusions of 1 or 2 units. Ten patients were seen in the emergency room 10–20 days after surgery presenting with calf tenderness and DVT was ruled out in all cases with ultrasound. There were no postoperative bleeding or wound complications. A portable, mechanical compression device and low-dose aspirin effectively lessens the risk of DVT following staged hip arthroscopy and PAO/DFO without an increased risk of bleeding complications.

Manual calf massage and passive ankle motion reduce the incidence of deep vein thromboembolism after total hip arthroplasty

BACKGROUND

Venous thromboembolism is one of the general complications following total hip arthroplasty, wherein various preventive treatments have been recommended. Several studies reported that venous thromboembolism incidence after total hip arthroplasty was similar in patients who were administered prophylaxis with a conventional mechanical procedure alone, and those who were administered pharmacological anticoagulation therapy. Therefore, the optimum methods of prophylaxis are still controversial. The purpose of this study was to investigate whether manual calf massage and passive ankle motion could lower the risk for venous thromboembolism after total hip arthroplasty.

METHODS

We retrospectively reviewed the data of 126 consecutive patients undergoing elective primary unilateral total hip arthroplasty wherein manual calf massage and passive ankle motion were performed after the surgery at our hospitals between January and October 2014. The 138 patients of the control group underwent total hip arthroplasty using the same surgical approach and pre- and postoperative protocols without this mechanical prophylaxis between January and December 2013. This mechanical prophylaxis was performed simultaneously 30 times during approximately 10 s; these procedures were repeated thrice immediately after total hip arthroplasty. Duplex ultrasonography was performed to observe the veins of both legs in all the patients on postoperative day 7.

RESULTS

The incidence of deep vein thrombosis was 6.52% and 0.79% in the control and manual calf massage and passive ankle motion groups, respectively. The odds ratio for the manual calf massage and passive ankle motion groups was 8.72. Performing this mechanical prophylaxis reduced the incidence of venous thromboembolism after total hip arthroplasty. This mechanical prophylaxis is not only simple and easy, but is also safe and inexpensive.

CONCLUSIONS

We therefore recommend that manual calf massage and passive ankle motion be performed in patients who will undergo total hip arthroplasty, if deep vein thrombosis does not exist before the surgery.

Intermittent Pneumatic Compression for the Prevention of Venous Thromboembolism after Total Hip Arthroplasty

BACKGROUND

Venous thromboembolism (VTE) is a relatively common and potentially life threatening complication after major hip surgery. There are two main types of prophylaxis: chemical and mechanical. Chemical prophylaxis is very effective but causes bleeding complications in surgical wounds and remote organs. On the other hand, mechanical methods are free of hemorrhagic complications but are less effective. We hypothesized that mechanical prophylaxis is effective enough for Asians in whom VTE occurs less frequently. This study evaluated the effect of intermittent pneumatic compression (IPC) in the prevention of VTE after major hip surgery.

METHODS

Incidences of symptomatic VTE after primary total hip arthroplasty with and without application of IPC were compared. A total of 379 patients were included in the final analysis. The IPC group included 233 patients (106 men and 127 women) with a mean age of 54 years. The control group included 146 patients (80 men and 66 women) with a mean age of 53 years. All patients took low-dose aspirin for 6 weeks after surgery. IPC was applied to both legs just after surgery and maintained all day until discharge. When a symptom or a sign suspicious of VTE, such as swelling or redness of the foot and ankle, Homans' sign, and dyspnea was detected, computed tomography (CT) angiogram or duplex ultrasonogram was performed.

RESULTS

Until 3 months after surgery, symptomatic VTE occurred in three patients in the IPC group and in 6 patients in the control group. The incidence of VTE was much lower in the IPC group (1.3%) than in the control group (4.1%), but the difference was not statistically significant. Complications associated with the application of IPC were not detected in any patient. Patients affected by VTE were older and hospitalized longer than the unaffected patients.

CONCLUSIONS

The results of this study suggest that IPC might be an effective and safe method for the prevention of postoperative VTE.

Impact of Active Ankle Movement Frequency on Velocity of Lower Limb Venous Flow following Total Hip Arthroplasty

Background. Although active ankle movement plays a predominant role in mechanical thromboprophylaxis following total hip arthroplasty (THA), the most effective frequency of movement remains unclear. Materials and Methods. In 29 consecutive patients undergoing THA, the velocity of blood flow in the profunda femoris was measured after various frequencies of ankle movement two days after THA using a pulse wave Doppler ultrasound system. To test the interobserver reliabilities for the velocity measured with Doppler ultrasound system, the intraclass correlation coefficient was calculated based on the measurement in 10 limbs of healthy volunteers. Results. At 0, 1, and 2 minutes after ankle movement, the velocity after movement at 60 contractions per minute was significantly faster than that after movement at 40 or 80 contractions per minute (p = 0.0007, repeated-measures analysis of variance). The intraclass correlation coefficient score in two investigators was 0.849 (95% confidence interval, 0.428 to 0.962). Conclusions. Active ankle movement at 60 contractions per minute is recommended in patients receiving THA to obtain optimal venous blood flow.

The incidence of deep vein thrombosis (DVT) during hip arthroscopic surgery

INTRODUCTION

The use of hip arthroscopy has been widely increasing. Although deep vein thrombosis (DVT) is thought to be a serious complication of orthopaedic surgery, there were few reports discussing DVT related to hip arthroscopic surgery. This study aimed to investigate the incidence and risk factors of DVT related to hip arthroscopic surgery.

MATERIALS AND METHODS

This retrospective study included 72 patients. Clinical diagnosis of DVT was confirmed through ultrasonography performed preoperatively and 3 days postoperatively. Additionally, D-dimer levels were measured preoperatively and on postoperative days 1, 3, and 7. Age, body mass index, operation time, procedure type, and D-dimer levels were statistically compared between the two groups (identified DVT vs. no identified DVT).

RESULTS

Five patients (6.94 %) were diagnosed with DVT clinically, although all cases were asymptomatic. The mean age of the patients with identified DVT was 62.0 ± 6.1 years; significantly higher than the mean age of the patients without DVT (45.1 ± 1.7 years; P = 0.0188).

CONCLUSION

The incidence of DVT during hip arthroscopy, investigated by ultrasound, was 6.94 %. From our results, we recommend screening for and treatment of asymptomatic DVT, especially in older patients, during hip arthroscopic surgery.

Preventing Venous Thromboembolism with Use of Intermittent Pneumatic Compression after Total Hip Arthroplasty in Korean Patients

Intermittent Pneumatic Compression (IPC) device has been used to prevent venous thromboembolism (VTE). This study investigated the effectiveness of IPC device. We evaluated incidences of deep vein thrombosis (DVT) and pulmonary embolism (PE) in total hip arthroplasty (THA) patients after use of IPC device, and compared with historical incidences from our institution. We applied IPC device in 741 patients who underwent 870 elective primary THAs from January 2010 to December 2013, DVT was detected in 3 patients (0.3%) by sonography, and one (0.1%) of them was symptomatic. Symptomatic PE occurred in 1 patient (0.1%) and there were no cases of fatal PE. The incidence of symptomatic DVT was significantly lower than the historical control (P = 0.042). The IPC is a safe and effective prophylaxis of VTE after primary THA in Korea.

A Current Review of Mechanical Compression and Its Role in Venous Thromboembolic Prophylaxis in Total Knee and Total Hip Arthroplasty

Interest in mechanical compression for venous thromboembolic disease prophylaxis has increased over the last several years because of concerns related to bleeding complications associated with chemoprophylaxis. However, the research evaluating compression is clearly not definitive. Therefore, this review aims to: (1) summarize methods of compression; (2) compare AAOS, ACCP, and SCIP guidelines; and (3) make recommendations regarding usage. Below-the-knee devices have demonstrated the most efficacy with multiple guidelines recommending usage. Efficacy and compliance may be improved with the use of mobile devices.

Screening for deep vein thrombosis after periacetabular osteotomy in adult patients: is it necessary?

BACKGROUND

The periacetabular osteotomy has become a common procedure for treating symptomatic acetabular dysplasia. Like other major hip procedures, there is concern regarding the risk of associated venous thromboembolic disease. Nevertheless, there is limited information regarding the need for screening, and optimal prophylactic measures have not been established.

QUESTIONS/PURPOSES

We sought to determine the frequency of thromboembolic events (deep vein thrombosis [DVT] and symptomatic pulmonary embolism [PE]) associated with the periacetabular osteotomy in in patients receiving aspirin and mechanical compression prophylaxis.

METHODS

We performed a retrospective review of 134 adult patients (149 hips) treated with the periacetabular osteotomy during an 8-year period. During this period, 136 (91%) of the hips treated with a periacetabular osteotomy were screened within 1 week for DVT, whereas 13 (9%) could not be evaluated for various reasons. The mean age of the patients at the time of surgery was 30 years (range, 18-60 years), and no patients were lost to followup during the 4 to 6 months after surgery. The same thromboembolic prophylactic regimen was used for all patients. This consisted of 325 mg aspirin twice a day and compression stockings for 6 weeks and lower extremity pneumatic compression devices while hospitalized. Screening bilateral lower extremity ultrasonography was performed within 1 week (mean, 4 days) of the procedure to detect asymptomatic DVTs.

RESULTS

Of the 134 patients, two patients (two hips) with negative postoperative screening ultrasounds presented at 14 and 38 days postoperatively with clinical symptoms of DVT. Repeat ultrasound confirmed this diagnosis in both cases. There were no symptoms of PE. Screening venous ultrasonography did not identify any DVTs during the early postoperative period before discharge. These two patients were treated with 3 to 6 months of warfarin anticoagulation. Neither patient had persistent symptoms related to the DVT.

CONCLUSIONS

These data indicate that the risk of symptomatic DVT associated with periacetabular osteotomy is low (1%) with use of aspirin and mechanical compression prophylaxis. Furthermore, routine postoperative screening did not detect any patients with an asymptomatic DVT.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

Quantitative index for deciding whether to administer preventive anticoagulant therapy in osteoarthritis patients undergoing total knee arthroplasty

BACKGROUND

The 2008 American Academy of Orthopedic Surgeons recommended that surgeons assess the relative risks of venous thromboembolism and bleeding in patients undergoing total knee arthroplasty (TKA). In this situation, a quantitative index is required for deciding whether to administer preventive anticoagulant therapy for deep venous thrombosis (DVT). In this study, we investigated the risk factors for DVT after TKA.

METHODS

We included 102 patients (122 knees) who underwent primary TKA for osteoarthritis of the knee between October 2007 and March 2010. DVT was evaluated using lower limb venous ultrasonography. Cutoff values for individual risk factors were determined using a receiver-operating characteristic analysis, and the patients were grouped according to the cutoff values; the odds ratios (95% CI) were also investigated. The Wilcoxon signed-rank test and χ² test were also used.

RESULTS

DVT was positive in 25 knees (20.5%). Three risk factors for DVT after TKA were identified: age 76 years or older, preoperative maximum soleus vein (MAX-SV) diameter of 6.0 mm or greater, and preoperative D-dimer value of 1.1 μg/dl or higher. The incidence of DVT was significantly higher in the group with two or more risk factors than in the group with one or no risk factors (p = 0.0001).

CONCLUSIONS

Development of postoperative DVT correlated significantly with the presence of the following risk factors: age 76 years or older, preoperative MAX-SV diameter of 6.0 mm or greater, and a preoperative D-dimer value of 1.1 μg/dl or higher. Considering the risk-benefit ratio, avoiding preventive anticoagulant therapy following TKA can be an option for patients with osteoarthritis with one or no risk factors.

DVT prophylaxis after TKA: routine anticoagulation vs risk screening approach - a randomized study

The American College of Chest Physicians (ACCP) recommended routine anticoagulation for thromboprophylaxis in patients undergoing lower limb arthroplasty. We compared results of routine anticoagulation Vs risk stratified approach for Deep Venous Thrombosis (DVT) prophylaxis after TKA in terms of symptomatic DVT and wound complications. Nine hundred TKAs done in 673 patients were randomized after DVT risk screening to routine anticoagulation (n = 450) or to risk stratification (n = 450) and selective anticoagulation. 194 patients in the risk screening group received only Aspirin. Primary outcome was symptomatic DVT and wound complication. This randomized study showed that the symptomatic DVT rates after TKA were similar whether patients were routinely anticoagulated or selectively anticoagulated after risk screening. However there was a significantly higher incidence of wound complications (P < 0.014) after routine anticoagulation.

Review article: Venous thromboembolism after total joint replacement

Venous thromboembolism can occur in up to 84% of cases following total joint replacement. It can result in pain, swelling, chronic post-thrombotic syndrome, and pulmonary embolism. Its prevention is vital to the success of the surgery. To achieve a safe and effective prophylaxis, a combination of mechanical and pharmacologic agents should be used. New generation of thromboprophylactic agents target different factors of the coagulation pathway.

Continuous femoral versus epidural block for attainment of 120° knee flexion after total knee arthroplasty: a randomized controlled trial

We conducted the prospective randomized controlled trial to test that continuous femoral nerve block (CFNB) improves attainment of 120° knee flexion compared to continuous epidural analgesia (CEA). Sixty-six patients scheduled for unilateral total knee arthroplasty were randomized into two groups; infusion of ropivacaine 0.15% into CEA or CFNB to third postoperative days. We studied the time required to attain 120° knee flexion, variations in thigh and calf circumferences around the treated knee, pain scores, rehabilitation milestones, the need for adjuvant analgesics, and side effects. CFNB patients attained earlier knee flexion to 120°, lower variations in thigh and calf circumferences, less pain during rehabilitation, and less need for adjuvant analgesics. CFNB is a better pain management strategy that accelerates knee flexion rehabilitation.

Economic Impact of Venous Thromboembolism Following Major Orthopaedic Surgery in Japan

OBJECTIVES

Venous thromboembolism (VTE) is the most frequent complication following major orthopaedic surgery (MOS). Although studies in Western populations have demonstrated significantly higher costs for patients with VTE versus those without VTE after MOS, there is a paucity of such data in Japan. This study was conducted to understand the costs and VTE rates in Japanese patients.

METHODS

Data were extracted from a hospital claims database. MOS was defined as total hip replacement, total knee replacement, or hip fracture repair. Subjects who underwent more than one MOS during the same admission were excluded. Identified VTE cases were matched on a 1:2 matching scheme on the basis of surgery type, hospital, and date of surgery (±6 months). The primary outcome was the difference in 90-day costs. Secondary outcomes included differences in total 6-month costs postsurgery and average length and cost of initial hospital stay.

RESULTS

The 90-day cumulative VTE incidence was 0.774%, with 94% of the cases occurring within 30 days postsurgery. Total 90-day costs were significantly higher in patients with VTE (difference of 864,153 Japanese yen [US $10,538]). Average length of stay was longer for patients with VTE (66 days vs. 42 days). Costs incurred by patients with VTE were on average much higher than those incurred by patients without VTE throughout 5 months postsurgery.

CONCLUSIONS

The development of a VTE in patients undergoing MOS results in a 1.5-fold increase in the length of stay and a 1.7-fold increase in 90-day costs. Findings indicate that the avoidance of VTEs through more effective prophylaxis will help to reduce the economic burden associated with MOS.

Inpatient enoxaparin and outpatient aspirin chemoprophylaxis regimen after primary hip and knee arthroplasty: a preliminary study

Our institution has used a thromboprophylaxis regimen consisting of inpatient enoxaparin and outpatient aspirin for patients at standard risk for venous thrombosis after hip and knee arthroplasty. We reviewed 500 cases using this protocol. Inpatient treatment with enoxaparin averaged 2.75 days, followed by a 28-day course of aspirin. The overall thrombosis rate was 0.6% (1 deep venous thrombosis and 2 pulmonary emboli). Bleeding requiring transfusion of 3 or more units of packed red blood cells occurred in 1.8% of the cases. Fifteen infections were noted, 14 superficial and 1 deep. This compared favorably with a control group of 500 patients using a 14-day course of enoxaparin followed by 14 days of aspirin. We believe that a brief course of inpatient enoxaparin and outpatient aspirin is a safe and effective form of thromboprophylaxis.

Chinese orthopedic surgeons' practice regarding postoperative thromboembolic prophylaxis after major orthopedic surgery

OBJECTIVE

To assess Chinese surgeon practice of thromboprophylaxis following major orthopedic surgery.

METHODS

A questionnaire survey was conducted amongst Chinese orthopedic surgeons. A total of 293 surgeons were surveyed concerning five key aspects of thromboembolic prophylaxis after major orthopedic surgery at the proseminar of Chinese guidelines for prevention of venous thromboembolism (VTE) after major orthopedic surgery in January of 2009.

RESULTS

Totally, 208 surgeons (71.0%) responded, successfully completing the questionnaire. Of them, 57.6% respondents selected combined basic, mechanical, and pharmacologic methods for thromboprophylaxis; 51.0% respondents prefer starting prophylaxis 12-24 hours after surgery; 60.3% surgeons would use chemoprophylaxis for 7-10 days; 47.6% respondents prefer VTE prevention based on patients' special conditions and needs upon discharge."Safety" was the most repeated and emphasized factor during VTE prophylaxis.

CONCLUSIONS

Multimodal thromboprophylaxis is frequently used after major orthopedic surgery. Half surgeons prefer to start chemoprophylaxis 12-24 hours after surgery. Thromboprophylaxis regimen varies for discharged patients.

Association between venous thromboembolism and plasma levels of both soluble fibrin and plasminogen-activator inhibitor 1 in 170 patients undergoing total hip arthroplasty

BACKGROUND AND PURPOSE

Markers of coagulation and fibrinolysis, such as soluble fibrin (SF), D-dimer, and plasminogen activator inhibitor 1 (PAI-1), have been developed in order to determine thrombotic tendency. We investigated whether these markers could be used to diagnose venous thromboembolism (VTE) in the early phase after primary total hip arthroplasty (THA).

METHODS

This prospective study involved 2 groups: an intermittent pneumatic compression (IPC) group (67 patients who underwent IPC only as prophylaxis for VTE) and a fondaparinux (FPX) group (103 patients who received IPC and FPX postoperatively). Plasma levels of SF and PAI-1 were measured on postoperative day 1. To diagnose postoperative VTE, multi-detector row computed tomography (MDCT) and duplex ultrasonography (US) were performed on postoperative day 7.

RESULTS

VTE was detected postoperatively in 17 cases in the IPC group (25%) and in 8 cases in the FPX group (6%). In the IPC group, plasma levels of SF and PAI-1 were higher in patients with VTE (p < 0.01) than in those without VTE. On the other hand, in the FPX group there were no differences in the levels of SF or PAI-1 measured before administration of FPX on postoperative day 1. The diagnostic criterion of an increase in SF or PAI-1 above the cutoff level (19.8 µg/mL and 53.5 ng/mL, respectively) provided a sensitivity of 100% and a specificity of 67% in the IPC group. In addition, when this criterion was applied to FPX patients, 7 of the 8 patients with VTE met the criterion, and there was a negative agreement rate of 48/49.

INTERPRETATION

Screening using the cutoff levels of SF and PAI-1 may be useful and shows high sensitivity in predicting postoperative VTE in the early phase after THA.

Risk factors and distribution of symptomatic venous thromboembolism in total hip and knee replacements: prospective study

PURPOSE

Venous thromboembolism (VTE) is a common complication of orthopaedic surgery in the industrialised world; though there may be variability between population groups. This study aims to define the incidence and risk factors for symptomatic VTE following primary elective total hip and knee arthoplasty surgery in a single centre in Eastern Europe.

METHODS

This prospective study included 499 adult patients undergoing total hip and knee arthroplasty for symptomatic osteoarthritis over a two-year period at the Clinic of Orthopaedic Surgery and Traumatology, Belgrade.

RESULTS

The overall rate of confirmed symptomatic VTE during hospitalisation was 2.6%. According to the univariate logistic regression, an age greater than 75 years (OR = 3.08; 95%CI = 1.01-9.65), a family history of VTE (OR = 6.61; 95% CI = 1.33-32.90), varicose veins (OR = 3.13; 95% CI = 1.03-9.48), and ischemic heart disease (OR = 4.93; 95% CI = 1.61-15.09) were significant risk factors for in-hospital VTE. A family history of VTE and ischemic heart disease were independent risk factors according to multivariate regression analysis. Preoperative initiation of pharmacological thromboprophylaxis (p = 0.03) and a longer duration of thromboprophylaxis (p = 0.001) were protective for postoperative DVT. Though thromboprophylaxis was safe, with very few patients suffering major haemorrhage or heparin-induced thrombocytopenia, there was a general reluctance by our local surgeons to use prolonged thromboprophylaxis.

CONCLUSION

VTE is common following hip and knee arthroplasty surgery. Orthopaedic patients with a family history of VTE, heart failure and coronary heart disease are at a considerable risk of thromboembolic complications in the postoperative period. There may be a role for preoperative thromboprophylaxis in addition to prolonged postoperative treatment.

Problems with measuring compression device performance in preventing deep vein thrombosis

The purpose of this article is to discuss issues related to the use and performance of mechanical compression devices in preventing deep vein thrombosis (DVT), such as graduated compression stockings (GCSs) and pneumatic compression devices (PCDs). While various studies have shown mechanical compression to be effective against DVT, the adequacy of the performance of these devices has not been conclusively determined. One reason for this inconclusiveness is small sample bias in which the results of many studies are open to a considerable chance of error. Another problem is that the studies may not be appropriate designed to measure device effectiveness and be free of bias. In addition, new methods of DVT prophylaxis are forcing a reexamination of what it means for a device to be "effective." Finally, the prevention of DVT is not likely to occur if the patient declines to comply with a prescribed treatment. Compliance is particularly bad with GCSs and some compliance comparisons on PCDs have suffered from failing to control for potentially confounding factors. As such, more and better studies need to be performed on these devices.

Incidence of deep vein thrombosis and pulmonary embolus following periacetabular osteotomy

BACKGROUND

Venous thromboembolism, a known complication of orthopaedic procedures, is thought to be more prevalent following hip surgery. Venous thromboembolism risk assessment and appropriate prophylaxis according to the American College of Chest Physicians guidelines has become the standard of care. However, it is accepted that venous thromboembolism prophylaxis is associated with potential adverse sequelae including hematoma, wound drainage, and infection. Little is known regarding the incidence of venous thromboembolism following periacetabular osteotomy and the necessity for and method of routine prophylaxis.

METHODS

A total of 1067 periacetabular osteotomies performed at six North American centers utilizing different methods of prophylaxis against venous thromboembolism were analyzed for type of prophylaxis and incidence of clinically symptomatic venous thromboembolism.

RESULTS

There were four cases of pulmonary embolus and seven cases of deep vein thrombosis. There were no reported deaths. The crude incidence of clinically symptomatic venous thromboembolism was 9.4 per 1000 procedures.

CONCLUSIONS

The risk from chemoprophylaxis and the development of hematoma may be greater than the risk of clinically important venous thromboembolism in patients undergoing periacetabular osteotomy.

Is routine chemical thromboprophylaxis after total hip replacement really necessary in a Japanese population?

Prophylaxis against venous thromboembolism after elective total hip replacement is routinely recommended. Our preference has been to use mechanical prophylaxis without anticoagulant drugs. A randomised controlled trial was performed to evaluate whether the incidence of post-operative venous thromboembolism was reduced by using pharmacological anticoagulation with either fondaparinux or enoxaparin in addition to our prophylactic mechanical regimen. A total of 255 Japanese patients who underwent primary unilateral cementless total hip replacement were randomly assigned to one of three postoperative regimens, namely injection of placebo (saline), fondaparinux or enoxaparin. There were 85 patients in each group. All also received the same mechanical prophylaxis during and after the operation, regardless of their assigned group. The primary measurement of efficacy was the presence of a venous thromboembolic event by day 11, defined as deep-vein thrombosis detected by ultrasonography, documented symptomatic deep-vein thrombosis or documented symptomatic pulmonary embolism. The duration of follow-up was 12 weeks.

The rate of venous thromboembolism was 7.2% with the placebo, 7.1% with fondaparinux and 6.0% with enoxaparin (p = 0.95 for the comparison of all three groups). Our study confirmed the effectiveness and safety of mechanical thromboprophylaxis without the use of anticoagulant drugs after total hip replacement in Japanese patients.

Natural course of asymptomatic deep venous thrombosis in hip surgery without pharmacologic thromboprophylaxis in an Asian population

BACKGROUND

The clinical importance of asymptomatic deep venous thrombosis in elective hip surgery is not clearly known.

QUESTIONS/PURPOSES

We determined the preoperative and postoperative incidences of asymptomatic deep venous thrombosis, identified preoperative factors associated with postoperative deep venous thrombosis or pulmonary embolism, and established its natural course in patients who underwent elective hip surgery without receiving pharmacologic thromboprophylaxis.

PATIENTS AND METHODS

We reviewed 184 patients who underwent consecutive elective hip surgeries with a mechanical thromboprophylaxis regimen including combined general and epidural anesthesia, intraoperative calf bandaging, early mobilization, and postoperative intermittent pneumatic compression with additional use of elastic stockings. Duplex ultrasonography was performed routinely to diagnose deep venous thrombosis in all patients before surgery and on Postoperative Days 3 and 21. All patients with postoperative deep venous thrombosis underwent additional ultrasonography at 3-month intervals, and all patients were followed postoperatively for 6 months or more.

RESULTS

Preoperatively, we found asymptomatic deep venous thrombosis in two patients (1%); both thromboses had completely and spontaneously resolved by Postoperative Day 21. Postoperatively, no patients had a fatal or symptomatic pulmonary embolism or proximal deep venous thrombosis, but nine patients (5%) had asymptomatic distal deep venous thrombosis develop, with no preoperative associated factors. These nine patients were followed closely without anticoagulant drugs, and all thromboses had disappeared without pulmonary embolism or thrombophlebitis by 6 months.

CONCLUSIONS

The incidence of preoperative and postoperative deep venous thrombosis was low in an Asian population having elective hip surgery and a nonpharmacologic thromboprophylaxis regimen. There were no preoperative factors associated with postoperative deep venous thrombosis, and all asymptomatic deep venous thromboses resolved spontaneously without associated pulmonary embolism or thrombophlebitis.

LEVEL OF EVIDENCE

Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.