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Jørgensen CC, Llau J, Jenny JY, Albaladejo P. European guidelines on peri-operative venous thromboembolism prophylaxis: first update.: Chapter 3: Day surgery and fast-track surgery. Eur J Anaesthesiol 2024; 41:577-581. [PMID: 38957022 DOI: 10.1097/eja.0000000000002010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2024]
Affiliation(s)
- Christoffer Calov Jørgensen
- From the Department of Anaesthesia and Intensive Care, Hospital of Northern Zealand, Hillerød (CCJ); The Centre for Fast-track Hip and Knee Replacement, Copenhagen, Denmark (CCJ); Anesthesiology and Critical Care Department, Hospital Universitari Doctor Peset (JL); Universitat de València, València, Spain (JL); Clinique Sainte Odile, Haguenau, France, EHS (J-YJ); Department of Anaesthesia and Critical Care, Grenoble Alpes University Hospital, Grenoble, France; and ESAIC, Brussels, Belgium (JL, PA)
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Zhang Q, Zhao L, Riva N, Yu Z, Jiang M, Gatt A, Guo JJ. Incidence of deep venous thrombosis in patients with hemophilia undergoing bilateral simultaneous total knee arthroplasty: a retrospective cohort study. BMC Musculoskelet Disord 2024; 25:326. [PMID: 38658972 PMCID: PMC11041033 DOI: 10.1186/s12891-024-07404-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 04/01/2024] [Indexed: 04/26/2024] Open
Abstract
BACKGROUND Hemophilic arthropathy usually affects the knees bilaterally. In order to reduce costs and improve rehabilitation, bilateral simultaneous total knee arthroplasty (TKA) can be performed. However, pharmacological prophylaxis for deep venous thrombosis (DVT) remains controversial in patients with severe hemophilia. The purpose of this study was to establish the incidence of DVT in severe hemophilia A patients undergoing bilateral simultaneous TKA without pharmacological thromboprophylaxis. METHODS Consecutive patients with severe hemophilia A undergoing bilateral simultaneous TKA at a single center between January 2015 and December 2020 were retrospectively reviewed. All patients received a modified coagulation factor substitution regimen. Tranexamic acid (TXA) was used for hemostasis in all patients during surgery. All patients followed a standardized postoperative protocol with routine mechanical thromboprophylaxis, and none received anticoagulation. D-dimer was measured preoperatively, on the day of the operation and on postoperative days 1, 7 and 14. Ultrasound (US) of the lower extremities was performed before (within 3 days of hospitalization) and after surgery (days 3 and 14) to detect asymptomatic DVT. Patients were followed up until 2 years after surgery for the development of symptomatic DVT or pulmonary embolism (PE). RESULTS 38 male patients with severe hemophilia A underwent 76 simultaneous TKAs. Mean (± standard deviation) age at the time of operation was 41.7 (± 17.1) years. Overall, 47.3% of patients had D-dimer concentrations above the threshold 10 µg/mL on day 7 and 39.5% on day 14. However, none of the patients had DVT detected on postoperative US, nor developed symptomatic DVT or PE during the 2-year follow-up. CONCLUSIONS The risk of DVT in patients with severe hemophilia A after bilateral simultaneous TKA is relatively low, and routine pharmacological thromboprophylaxis may not be needed.
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Affiliation(s)
- Qian Zhang
- Department of Orthopedics and Sports Medicine, The First Affiliated Hospital of Soochow University, Suzhou, PR China
| | - Lingying Zhao
- Department of Hematology, National Clinical Research Center for Hematologic Disease, The First Affiliated Hospital of Soochow University, Suzhou, PR China
- Jiangsu Institute of Hematology, Key Laboratory of Thrombosis and Hemostasis of Ministry of Health of PR China, Suzhou, PR China
| | - Nicoletta Riva
- Department of Pathology, Faculty of Medicine and Surgery, University of Malta, Msida, Malta
| | - Ziqiang Yu
- Department of Hematology, National Clinical Research Center for Hematologic Disease, The First Affiliated Hospital of Soochow University, Suzhou, PR China
- Jiangsu Institute of Hematology, Key Laboratory of Thrombosis and Hemostasis of Ministry of Health of PR China, Suzhou, PR China
| | - Miao Jiang
- Department of Hematology, National Clinical Research Center for Hematologic Disease, The First Affiliated Hospital of Soochow University, Suzhou, PR China
- Jiangsu Institute of Hematology, Key Laboratory of Thrombosis and Hemostasis of Ministry of Health of PR China, Suzhou, PR China
| | - Alexander Gatt
- Department of Pathology, Faculty of Medicine and Surgery, University of Malta, Msida, Malta
- Department of Haematology, Mater Dei Hospital, Msida, Malta
| | - Jiong Jiong Guo
- Department of Orthopedics and Sports Medicine, The First Affiliated Hospital of Soochow University, Suzhou, PR China.
- Jiangsu Institute of Hematology, Key Laboratory of Thrombosis and Hemostasis of Ministry of Health of PR China, Suzhou, PR China.
- China-Europe Sports Medicine Belt-and-Road Joint Laboratory of Ministry of Education of PRC, Suzhou, PR China.
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Nemeth B, Smeets M, Pedersen AB, Kristiansen EB, Nelissen R, Whyte M, Roberts L, de Lusignan S, le Cessie S, Cannegieter S, Arya R. Development and validation of a clinical prediction model for 90-day venous thromboembolism risk following total hip and total knee arthroplasty: a multinational study. J Thromb Haemost 2024; 22:238-248. [PMID: 38030547 DOI: 10.1016/j.jtha.2023.09.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 09/07/2023] [Accepted: 09/07/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND The risk of venous thromboembolism (VTE) following total hip arthroplasty (THA) and total knee arthroplasty (TKA) is 1.0% to 1.5%, despite uniform thromboprophylaxis. OBJECTIVES To develop and validate a prediction model for 90-day VTE risk. METHODS A multinational cohort study was performed. For model development, records were used from the Oxford Royal College of General Practitioners Research and Surveillance Centre linked to Hospital Episode Statistics and Office of National Statistics UK routine data. For external validation, data were used from the Danish Hip and Knee Arthroplasty Registry, the National Patient Registry, and the National Prescription Registry. Binary multivariable logistic regression techniques were used for development. RESULTS In the UK data set, 64 032 THA/TKA procedures were performed and 1.4% developed VTE. The prediction model consisted of age, body mass index, sex, cystitis within 1 year before surgery, history of phlebitis, history of VTE, presence of varicose veins, presence of asthma, history of transient ischemic attack, history of myocardial infarction, presence of hypertension and THA or TKA. The area under the curve of the model was 0.65 (95% CI, 0.63-0.67). Furthermore, 36 169 procedures were performed in the Danish cohort, of whom 1.0% developed VTE. Here, the area under the curve was 0.64 (95% CI, 0.61-0.67). The calibration slope was 0.92 in the validation study and 1.00 in the development study. CONCLUSION This clinical prediction model for 90-day VTE risk following THA and TKA performed well in both development and validation data. This model can be used to estimate an individual's risk for VTE following THA/TKA.
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Affiliation(s)
- Banne Nemeth
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands; Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, The Netherlands.
| | - Mark Smeets
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands. https://twitter.com/MarkSmeets4
| | - Alma Becic Pedersen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark. https://twitter.com/AlmaBPedersen
| | - Eskild Bendix Kristiansen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Rob Nelissen
- Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Martin Whyte
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK. https://twitter.com/mbwhyte1
| | - Lara Roberts
- King's Thrombosis Centre, King's College Hospital NHS Foundation Trust, London UK. https://twitter.com/LaraNRoberts1
| | - Simon de Lusignan
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, UK; Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK. https://twitter.com/lusignan_s
| | - Saskia le Cessie
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands; Department of Medical Statistics, Leiden University Medical Center, Leiden, The Netherlands
| | - Suzanne Cannegieter
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands; Department of Internal Medicine, Leiden University Medical Center, Leiden, The Netherlands. https://twitter.com/s_cannegieter
| | - Roopen Arya
- King's Thrombosis Centre, King's College Hospital NHS Foundation Trust, London UK. https://twitter.com/AryaRoopen
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Thompson R, Cassidy R, Hill J, Bryce L, Napier R, Beverland D. Are Patients With Morbid Obesity at Increased Risk of Pulmonary Embolism or Proximal Deep Vein Thrombosis After Lower Limb Arthroplasty? A Large-database Study. Clin Orthop Relat Res 2024; 482:115-124. [PMID: 37404124 PMCID: PMC10723888 DOI: 10.1097/corr.0000000000002742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 04/24/2023] [Accepted: 05/26/2023] [Indexed: 07/06/2023]
Abstract
BACKGROUND Whether increased BMI is associated with an increased risk of venous thromboembolism (VTE) is controversial. Despite this, BMI > 40 kg/m 2 remains a common cutoff for lower limb arthroplasty eligibility. Current United Kingdom national guidelines list obesity as a risk factor for VTE, but these are based on evidence that has largely failed to differentiate between potentially minor (distal deep vein thrombosis [DVT]), and more harmful (pulmonary embolism [PE] and proximal DVT) diagnoses. Determining the association between BMI and the risk of clinically important VTE is needed to improve the utility of national risk stratification tools. QUESTIONS/PURPOSES (1) In patients undergoing lower limb arthroplasty, is BMI 40 kg/m 2 or higher (morbid obesity) associated with an increased risk of PE or proximal DVT within 90 days of surgery, compared with patients with BMI less than 40 kg/m 2 ? (2) What proportion of investigations ordered for PE and proximal DVT were positive in patients with morbid obesity who underwent lower limb arthroplasty compared with those with BMI less than 40 kg/m 2 ? METHODS Data were collected retrospectively from the Northern Ireland Electronic Care Record, a national database recording patient demographics, diagnoses, encounters, and clinical correspondence. Between January 2016 and December 2020, 10,217 primary joint arthroplasties were performed. Of those, 21% (2184 joints) were excluded; 2183 were in patients with multiple arthroplasties and one had no recorded BMI. All 8033 remaining joints were eligible for inclusion, 52% of which (4184) were THAs, 44% (3494) were TKAs, and 4% (355) were unicompartmental knee arthroplasties; all patients had 90 days of follow-up. The Wells score was used to guide the investigations. Indications for CT pulmonary angiography for suspected PE included pleuritic chest pain, reduced oxygen saturations, dyspnea, or hemoptysis. Indications for ultrasound scans for suspected proximal DVT included leg swelling, pain, warmth, or erythema. Distal DVTs were recorded as negative scans because we do not treat them with modified anticoagulation. The division of categories was set at BMI 40 kg/m 2 , a common clinical cutoff used in surgical eligibility algorithms. Patients were grouped according to WHO BMI categories to assess for the following confounding variables: sex, age, American Society of Anesthesiologists grade, joint replaced, VTE prophylaxis, grade of operative surgeon, and implant cement status. RESULTS We found no increase in the odds of PE or proximal DVT in any WHO BMI category. When comparing patients with BMI less than 40 kg/m 2 with those with a BMI of 40 kg/m 2 or higher, there was no difference in the odds of PE (0.8% [58 of 7506] versus 0.8% [four of 527]; OR 1.0 [95% CI 0.4 to 2.8]; p > 0.99) or proximal DVT (0.4% [33 of 7506] versus 0.2% [one of 527]; OR 2.3 [95% CI 0.3 to 17.0]; p = 0.72). Of those who received diagnostic imaging, 21% (59 of 276) of CT pulmonary angiograms and 4% (34 of 718) of ultrasounds were positive for patients with BMI less than 40 kg/m 2 compared with 14% (four of 29; OR 1.6 [95% CI 0.6 to 4.5]; p = 0.47) and 2% (one of 57; OR 2.7 [95% CI 0.4 to 18.6]; p = 0.51) for patients with BMI 40 kg/m 2 or higher. There was no difference in the percentage of CT pulmonary angiograms ordered (4% [276 of 7506] versus 5% [29 of 527]; OR 0.7 [95% CI 0.5 to 1.0]; p = 0.07) or ultrasounds ordered (10% [718 of 7506] versus 11% [57 of 527]; OR 0.9 [95% CI 0.7 to 1.2]; p = 0.49) for BMI less than 40 kg/m 2 and BMI 40 kg/m 2 or higher. CONCLUSION Increased BMI should not preclude individuals from lower limb arthroplasty based on suspected risk of clinically important VTE. National VTE risk stratification tools should be based on evidence assessing clinically relevant VTE (specifically, proximal DVT, PE, or death of thromboembolism) only. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
| | | | - Janet Hill
- Musgrave Park Hospital, Belfast, Northern Ireland, UK
| | - Leeann Bryce
- Musgrave Park Hospital, Belfast, Northern Ireland, UK
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Levent A, Kose O, Linke P, Gehrke T, Citak M. Tranexamic acid is safe and effective in patients with heterozygous factor V Leiden mutation during total joint arthroplasty. Arch Orthop Trauma Surg 2023; 143:613-620. [PMID: 34342666 DOI: 10.1007/s00402-021-04110-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 07/28/2021] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Patients with an inherent hypercoagulable state are at a higher risk of venous thromboembolism (VTE) following total joint arthroplasty (TJA). Further administration of tranexamic acid (TXA) during TJA may increase the risk of VTE in these high-risk patients. There is no study that specifically analyzes the safety and efficacy of TXA during TJA in patients with factor V Leiden (FVL) mutation; therefore, the purpose of this study was to evaluate the safety and efficacy of TXA use on the risk of VTE and bleeding in patients carrying FVL mutation. MATERIALS AND METHODS A total of 42 patients with FVL mutation (22 hips, 20 knees) and 40 control patients (20 hips, 20 knees) who underwent TJA were retrospectively reviewed. All patients received 1 g TXA intravenously 15 min before the skin incision and 2 g of TXA was administered locally at the surgical site as a periarticular injection. Pharmacological thromboprophylaxis (low-molecular-weight heparin) was administered to all patients. Estimated blood loss and in-hospital thromboembolic complications were compared between the groups. RESULTS In both total knee arthroplasty (TKA) and total hip arthroplasty (THA) patients, there was no significant difference in the amount of estimated blood loss among the groups (p = 0.980, and p = 0963, respectively). None of the patients in the THA group received a blood transfusion. The transfusion rate was similar in the TKA group (p = 0.756, one patient in each group). No VTE, myocardial infarction, or any other complications related to TXA use were observed in any of the patients. CONCLUSIONS The combined local and systemic administration of TXA could be safely used in patients with heterozygous FVL mutation receiving pharmacological thromboprophylaxis during TJA without increasing the risk of VTE.
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Affiliation(s)
- Ali Levent
- Department of Orthopedic Surgery, ENDO-Klinik Hamburg, Holstenstr. 2, 22767, Hamburg, Germany. .,Department of Orthopedics and Traumatology, Sanliurfa Mehmet Akif Inan Training and Research Hospital, Health Sciences University, Şanlıurfa, Turkey.
| | - Ozkan Kose
- Department of Orthopedics and Traumatology, Antalya Training and Research Hospital, Antalya, Turkey
| | - Philip Linke
- Department of Orthopedic Surgery, ENDO-Klinik Hamburg, Holstenstr. 2, 22767, Hamburg, Germany
| | - Thorsten Gehrke
- Department of Orthopedic Surgery, ENDO-Klinik Hamburg, Holstenstr. 2, 22767, Hamburg, Germany
| | - Mustafa Citak
- Department of Orthopedic Surgery, ENDO-Klinik Hamburg, Holstenstr. 2, 22767, Hamburg, Germany
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Chen Y, Liu J, Su Y, Zhao H, Zhao Y, Wen M, Lu S, Cao X, Zhang W, Liu L, Wu J. Annexin V - and tissue factor + microparticles as biomarkers for predicting deep vein thrombosis in patients after joint arthroplasty. Clin Chim Acta 2022; 536:169-179. [PMID: 36191610 DOI: 10.1016/j.cca.2022.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 08/29/2022] [Accepted: 09/08/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Venous thromboembolism (VTE) is a common and severe complication of joint arthroplasty. Microparticles (MPs) containing phosphatidylserine (PS) and tissue factor (TF) can trigger coagulation in VTE. This study aims to measure and compare MP levels in joint arthroplasty patients with and without VTE. METHODS This prospective cohort study enrolled 181 patients who underwent joint arthroplasty. Ultrasound examination was used to diagnose VTE on preoperative day 0 and postoperative day 6. MPs were analysed using transmission electron microscopy (TEM), nanoparticle tracking analysis (NTA), and flow cytometry. The levels of platelet-derived microparticles (PMPs), endothelial cell-derived microparticles (EMPs), granulocyte-derived microparticles (GMPs), red cell-derived microparticles (RMPs), monocyte-derived microparticles (MMPs), Annexin V+ MPs (AV+ MPs), and tissue factor+ MPs (TF+ MPs) derived from five kinds of MPs were measured on day 0 (before surgery), 1, 2, 3, 4, 5, and 6 after surgery. RESULTS The levels of AV-TF+ EMPs and AV-TF+ MMPs were significantly increased in patients with VTE on postoperative day 5 compared to those without VTE (P=0.031 and P=0.031, respectively). CONCLUSION AV-TF+ MPs may indicate the development of VTE and serve as predictive markers in joint arthroplasty patients.
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Affiliation(s)
- Yuying Chen
- Department of Clinical Laboratory, Peking University Fourth School of Clinical Medicine, Beijing, P.R.China
| | - Jian Liu
- Adult reconstruction department, Beijing Jishuitan Hospital, Beijing, P.R.China
| | - Yu Su
- Department of Clinical Laboratory, Beijing Jishuitan Hospital, Beijing, P.R.China
| | - Huiru Zhao
- Department of Clinical Laboratory, Beijing Jishuitan Hospital, Beijing, P.R.China
| | - Yujing Zhao
- Department of Clinical Laboratory, Beijing Jishuitan Hospital, Beijing, P.R.China
| | - Meng Wen
- Department of Clinical Laboratory, Beijing Jishuitan Hospital, Beijing, P.R.China
| | - Shan Lu
- Department of Clinical Laboratory, Beijing Jishuitan Hospital, Beijing, P.R.China
| | - Xiangyu Cao
- Department of Clinical Laboratory, Peking University Fourth School of Clinical Medicine, Beijing, P.R.China
| | - Wenjie Zhang
- Department of Clinical Laboratory, Peking University Fourth School of Clinical Medicine, Beijing, P.R.China
| | - Lei Liu
- Department of Clinical Laboratory, Liyuan Hospital of Tongji Medical College of Huazhong University of Science and Technology, Hubei, P.R.China
| | - Jun Wu
- Department of Clinical Laboratory, Peking University Fourth School of Clinical Medicine, Beijing, P.R.China; Department of Clinical Laboratory, Beijing Jishuitan Hospital, Beijing, P.R.China.
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Petersen PB, Lindberg-Larsen M, Jørgensen CC, Kehlet H. Venous thromboembolism after fast-track elective revision hip and knee arthroplasty - A multicentre cohort study of 2814 unselected consecutive procedures. Thromb Res 2021; 199:101-105. [PMID: 33485092 DOI: 10.1016/j.thromres.2021.01.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 12/07/2020] [Accepted: 01/06/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) prophylaxis is much debated within total hip and knee arthroplasty (THA/TKA). Revision hip and knee arthroplasty (rTHA/rTKA) are more extensive procedures, but data on the risk of postoperative VTE is conflicting and there are no specific guidelines for thromboprophylaxis. Furthermore, data on rTHA/rTKA within a fast-track protocol is sparse. Thus, we aimed at evaluating the incidence and time course of VTE in unselected elective rTHA/rTKA within our established multicentre fast-track collaboration with in-hospital only thromboprophylaxis if length of stay (LOS) ≤ 5 days. METHODS We used an observational study design of unselected consecutive fast-track elective major component rTHA/rTKA from 6 dedicated fast-track centres between 2010 and 2018. We obtained information on revisions through Danish hip and knee arthroplasty registers and complete (>99%) 90 days follow-up through the Danish National Patient Registry in combination with chart review. RESULTS We included 2814 procedures with median LOS 3 days [2-5] and 21% had LOS >5 days. The 90-day incidence of VTE was 0.42% (n = 12), with 8 (0.28%) DVT and 4 (0.14%) PE, after median 14 days [IQR: 11-23] with the latest on day 31. CONCLUSION The 90-day incidence of VTE after elective fast-track rTHA and rTKA was about 0.4% which is comparable to the 90-day VTE incidence after primary fast-track THA, TKA and unicompartmental knee arthroplasty. Future investigations should focus on identification of high-risk patients while the surgical trauma per se may be less important.
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Affiliation(s)
| | - Martin Lindberg-Larsen
- Orthopaedic Research Unit, Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Department of Clinical Research, University of Southern Denmark, Denmark; Lundbeck Foundation Centre for Fast-track Hip and Knee Arthroplasty, Copenhagen, Denmark
| | - Christoffer Calov Jørgensen
- Section for Surgical Pathophysiology, Rigshospitalet, Copenhagen, Denmark; Lundbeck Foundation Centre for Fast-track Hip and Knee Arthroplasty, Copenhagen, Denmark
| | - Henrik Kehlet
- Section for Surgical Pathophysiology, Rigshospitalet, Copenhagen, Denmark; Lundbeck Foundation Centre for Fast-track Hip and Knee Arthroplasty, Copenhagen, Denmark
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Gade IL, Kold S, Severinsen MT, Kragholm KH, Torp‐Pedersen C, Kristensen SR, Riddersholm SJ. Venous thromboembolism after lower extremity orthopedic surgery: A population-based nationwide cohort study. Res Pract Thromb Haemost 2021; 5:148-158. [PMID: 33537539 PMCID: PMC7845063 DOI: 10.1002/rth2.12449] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 10/07/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) causes morbidity and mortality in the general population. Several events occur after lower limb orthopedic surgery, but the contribution from various types of lower limb surgery is not well known. OBJECTIVE To investigate the postoperative incidence of VTE for all types of lower extremity orthopedic surgery compared with the background population. METHODS Individual-level linkage of Danish nationwide register data for all Danish residents with first-time orthopedic surgery of the lower limb (1996-2017) and, for each of these, four controls from the general population matched on age, sex, and history of VTE. Adjusted hazard ratios (HR) compared the postoperative risk of VTE to the matched controls. RESULTS In total 7203 of the 1 012 823 patients with a first orthopedic procedure had a VTE within 180 days after surgery, corresponding to a postoperative cumulative incidence of 0.71% (95% confidence interval [CI], 0.70-0.73). The cumulative incidence of VTE among controls was 0.11% (95% CI, 0.11-0.12). The HR of VTE within the first 30 days after surgery below knee level was 20.5 (95% CI, 17.9-23.5) compared with matched controls. The HRs of VTE after minor distal procedures (eg, meniscectomy and arthroscopies) were 2.9 (95% CI, 1.9-4.4) to 7.1 (95% CI, 6.4-8.0). CONCLUSION All types of lower limb orthopedic surgery including minor distal procedures were associated with higher rates of VTE compared with matched controls, in particular within the first 30 days after surgery.
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Affiliation(s)
- Inger Lise Gade
- Department of Hematology and Clinical Cancer Research CenterAalborg University HospitalAalborgDenmark
- Department of Clinical BiochemistryAalborg University HospitalAalborgDenmark
| | - Søren Kold
- Department of Clinical MedicineAalborg UniversityAalborgDenmark
- Department of Orthopedic SurgeryAalborg University HospitalAalborgDenmark
| | - Marianne T. Severinsen
- Department of Hematology and Clinical Cancer Research CenterAalborg University HospitalAalborgDenmark
- Department of Clinical MedicineAalborg UniversityAalborgDenmark
| | - Kristian H. Kragholm
- Department of CardiologyNorth Denmark Regional HospitalHjørringDenmark
- Unit of Clinical BiostatisticsAalborg University HospitalAalborgDenmark
| | - Christian Torp‐Pedersen
- Department of Clinical MedicineAalborg UniversityAalborgDenmark
- Unit of Clinical BiostatisticsAalborg University HospitalAalborgDenmark
- Department of Cardiology and Clinical InvestigationNorth Zealand HospitalHillerødDenmark
| | - Søren R. Kristensen
- Department of Clinical BiochemistryAalborg University HospitalAalborgDenmark
- Department of Clinical MedicineAalborg UniversityAalborgDenmark
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Nemeth B, Nelissen R, Arya R, Cannegieter S. Preventing VTE following total hip and knee arthroplasty: Is prediction the future? J Thromb Haemost 2021; 19:41-45. [PMID: 33043553 PMCID: PMC7839761 DOI: 10.1111/jth.15132] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 09/21/2020] [Accepted: 09/28/2020] [Indexed: 12/15/2022]
Abstract
Venous thromboembolism (VTE) is a common complication following total hip arthroplasty (THA) and total knee arthroplasty (TKA). Many guidelines advise on the ideal pharmacological thromboprophylaxis strategy; however, despite its use, approximately 1.5% of patients still develop symptomatic VTE. Considering the large number of THAs and TKAs performed worldwide (2.5 million in total), the impact of VTE following these interventions is enormous. This paper discusses a concept how to further lower rates of VTE and bleeding complications following surgery. By stratifying patients according to their risk, we can optimize the balance between VTE and bleeding for each individual. This way, low-risk patients may be safely withheld from treatment (and avoid unnecessary bleeding complications and costs), whereas high-risk patients should receive adequate therapy (for instance, an increased thromboprophylaxis dosage and duration). An individualized strategy requires a well-functioning VTE prediction model following THA and TKA to help physicians to decide on optimal thromboprophylaxis therapy.
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Affiliation(s)
- Banne Nemeth
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
- Department of Orthopaedic SurgeryLeiden University Medical CenterLeidenThe Netherlands
| | - Rob Nelissen
- Department of Orthopaedic SurgeryLeiden University Medical CenterLeidenThe Netherlands
| | - Roopen Arya
- King’s Thrombosis CentreKing’s College Hospital NHS Foundation TrustLondonUnited Kingdom
| | - Suzanne Cannegieter
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
- Division of Thrombosis and HaemostasisLeiden University Medical CenterLeidenThe Netherlands
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Keller K, Hobohm L, Barco S, Schmidtmann I, Münzel T, Engelhardt M, Eckhard L, Konstantinides SV, Drees P. Venous thromboembolism in patients hospitalized for knee joint replacement surgery. Sci Rep 2020; 10:22440. [PMID: 33384429 PMCID: PMC7775461 DOI: 10.1038/s41598-020-79490-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Accepted: 12/04/2020] [Indexed: 11/25/2022] Open
Abstract
Patients undergoing knee joint replacement (KJR) are at high risk of postoperative venous thromboembolism (VTE), but data on the time trends of VTE rate in this population are sparse. In this analysis of the German nationwide inpatient sample, we included all hospitalizations for elective primary KJR in Germany 2005-2016. Overall, 1,804,496 hospitalized patients with elective primary KJR (65.1% women, 70.0 years [IQR 63.0-76.0]) were included in the analysis. During hospitalization, VTE was documented in 23,297 (1.3%) patients. Total numbers of primary KJR increased from 129,832 in 2005 to 167,881 in 2016 (β-(slope)-estimate 1,978 [95% CI 1,951 to 2,004], P < 0.001). In-hospital VTE decreased from 2,429 (1.9% of all hospitalizations for KJR) to 1,548 (0.9%) cases (β-estimate - 0.77 [95% CI - 0.81 to - 0.72], P < 0.001), and in-hospital death rate from 0.14% (184 deaths) to 0.09% (146 deaths) (β-estimate - 0.44 deaths per year [95% CI - 0.59 to - 0.30], P < 0.001). Infections during hospitalization were associated with a higher VTE risk. VTE events were independently associated with in-hospital death (OR 20.86 [95% CI 18.78-23.15], P < 0.001). Annual number of KJR performed in Germany increased by almost 30% between 2005 and 2016. In parallel, in-hospital VTE rates decreased from 1.9 to 0.9%. Perioperative infections were associated with higher risk for VTE. Patients who developed VTE had a 21-fold increased risk of in-hospital death.
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Affiliation(s)
- Karsten Keller
- Department of Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Langenbeckstr. 1, 55131, Mainz, Germany.
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany.
| | - Lukas Hobohm
- Department of Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Langenbeckstr. 1, 55131, Mainz, Germany
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany
| | - Stefano Barco
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany
- Clinic for Angiology, University Hospital Zurich, Zurich, Switzerland
| | - Irene Schmidtmann
- Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany
| | - Thomas Münzel
- Department of Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Langenbeckstr. 1, 55131, Mainz, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Germany
| | - Martin Engelhardt
- Department for Orthopaedics, Trauma Surgery and Hand Surgery, Klinikum Osnabrück, Osnabrück, Germany
- Institute for Applied Training Science, Leipzig, Germany
| | - Lukas Eckhard
- Department of Orthopaedics and Traumatology, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany
- Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Philipp Drees
- Department of Orthopaedics and Traumatology, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany
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Wu L, Cheng B. Analysis of perioperative risk factors for deep vein thrombosis in patients with femoral and pelvic fractures. J Orthop Surg Res 2020; 15:597. [PMID: 33302974 PMCID: PMC7731763 DOI: 10.1186/s13018-020-02131-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 11/29/2020] [Indexed: 11/20/2022] Open
Abstract
Objective Clinical characteristics, anticoagulant protocols, and risk factors of deep vein thrombosis (DVT) in patients with femoral and pelvic fractures were analyzed throughout the perioperative period to provide references for early identification and optimization of risk factors. Methods This was a retrospective study. A total of 569 patients undergoing surgery of femoral and pelvic fractures from May 2018 to December 2019 were included. The clinical data including general conditions, trauma, surgery, anticoagulant protocols, and laboratory indexes were collected. According to the results of deep vein Doppler ultrasonography of the lower extremities, the patients were divided into non-DVT group and DVT group. Univariate analysis and multivariate logistic regression analysis were used to identify the independent risk factors of preoperative and postoperative DVT. Results The incidence of DVT was 40.25% and preoperative DVT was 26.71%, which was higher than the incidence of postoperative DVT of 17.22%. Most of them were thrombus on the affected side (60.26%) and distal thrombus (81.66%). The average time of DVT formation was 6.55 ± 0.47 days after trauma and 6.67 ± 0.48 days after surgery. Chronic obstructive pulmonary disease (COPD), anemia, hypoproteinemia, non-anticoagulation before surgery, delayed anticoagulation after trauma and admission, high-energy trauma, multiple injuries, drinking history, and advanced age were independent risk factors for perioperative DVT. The increased level of fibrinogen degradation products was an independent risk factor for preoperative DVT. These risk factors were identified to be independently associated with postoperative DVT, including intraoperative blood transfusion, postoperative blood transfusion, pulmonary infection, preoperative non-anticoagulation, postoperative delayed anticoagulation, preoperative waiting time > 7 days, operative time > 2 h, c-reactive protein, fibrinogen level, platelet count 1 day after surgery, c-reactive protein, fibrinogen, and hemoglobin levels 3 days after surgery, comminuted fracture. Conclusions At present, anticoagulation and other DVT prevention and treatment programs have not changed the current situation that the incidence of DVT is still high. Through the analysis of the risk factors of DVT throughout the perioperative period, optimizing the perioperative blood transfusion, preoperative lung disease, hypoproteinemia, anemia, inflammation, etc., and surgery as soon as possible after trauma may further reduce its incidence.
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Affiliation(s)
- Linqin Wu
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Yuzhong District, Chongqing, 400000, China
| | - Bo Cheng
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Yuzhong District, Chongqing, 400000, China.
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Petersen PB, Jørgensen CC, Gromov K, Kehlet H. Venous thromboembolism after fast-track unicompartmental knee arthroplasty – A prospective multicentre cohort study of 3927 procedures. Thromb Res 2020; 195:81-86. [DOI: 10.1016/j.thromres.2020.07.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Revised: 06/29/2020] [Accepted: 07/02/2020] [Indexed: 12/31/2022]
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Ono K, Takedani H. Risk of deep venous thrombosis after total knee arthroplasty in patients with haemophilia A. Haemophilia 2020; 26:867-872. [DOI: 10.1111/hae.14095] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 06/06/2020] [Accepted: 06/11/2020] [Indexed: 12/15/2022]
Affiliation(s)
- Kumiko Ono
- Department of Joint Surgery Research Hospital The Institute of Medical Science The University of Tokyo Tokyo Japan
| | - Hideyuki Takedani
- Department of Joint Surgery Research Hospital The Institute of Medical Science The University of Tokyo Tokyo Japan
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Lindberg-Larsen M, Petersen PB, Jørgensen CC, Overgaard S, Kehlet H. Postoperative 30-day complications after cemented/hybrid versus cementless total hip arthroplasty in osteoarthritis patients > 70 years. Acta Orthop 2020; 91:286-292. [PMID: 32285735 PMCID: PMC8023910 DOI: 10.1080/17453674.2020.1745420] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - The use of cementless total hip arthroplasty (THA) in elderly patients is debated because of increased risk of early periprosthetic femoral fractures. However, cemented femoral components carry a risk of bone cement implantation syndrome. Hence, we compared in-hospital complications, complications leading to readmission and mortality ≤ 30 days postoperatively between hybrid/cemented (cemented femoral component) vs. cementless THA in osteoarthritis patients > 70 years.Patients and methods - This is a prospective observational cohort study in 9 centers from January 2010 to August 2017. We used 30-day follow-up from the Danish National Patient Registry, patient records, and data from the Danish Hip Arthroplasty Register. Only THAs performed as a result of osteoarthritis were included.Results - 3,368 (42%) of the THAs were cemented/hybrid and 4,728 (58%) cementless. The in-hospital complication risk was 7.7% after cemented/hybrid vs. 5.3% after cementless THA (< 0.001), statistically not significant when adjusting for comorbidities (p = 0.1). There were similar risks of complications causing readmission (5.7% vs. 6.2%) and mortality ≤ 30 days (0.2% vs. 0.3%). 15 cases (0.4%) of pulmonary embolism (PE) were found after cemented/hybrid vs. 4 (0.1%) after cementless THA (p = 0.001); none occurred within 24 hours postoperatively. 2 of the PEs after cementless THA led to mortality. Cemented/hybrid THA remained significantly associated with risk of PE (RR 3.9, p = 0.02), when adjusting for comorbidities. BMI > 35 was associated with highest risk of PE (RR 5.7, p = 0.003). The risk of periprosthetic femoral fracture was 0.2% after cemented/hybrid vs. 1.5% after cementless THA (p < 0.001) and the risk of dislocations was 1.2% after cemented/hybrid THA vs. 1.8% after cementless THA (p = 0.04).Interpretation - The higher risk of PE after cemented/hybrid THA and higher risk of periprosthetic femoral fractures and dislocations after cementless THA highlights that both medically and surgically complications are related to fixation technique and have to be considered.
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Affiliation(s)
- Martin Lindberg-Larsen
- Lundbeck Foundation Centre for Fast-track Hip and Knee Arthroplasty
- Orthopaedic Research Unit, Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Department of Clinical Research, University of Southern Denmark
| | | | - Christoffer Calov Jørgensen
- Lundbeck Foundation Centre for Fast-track Hip and Knee Arthroplasty
- Section for Surgical Pathophysiology, Rigshospitalet, Copenhagen, Denmark
| | - Søren Overgaard
- Orthopaedic Research Unit, Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Department of Clinical Research, University of Southern Denmark
| | - Henrik Kehlet
- Lundbeck Foundation Centre for Fast-track Hip and Knee Arthroplasty
- Section for Surgical Pathophysiology, Rigshospitalet, Copenhagen, Denmark
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Keller K, Hobohm L, Barco S, Schmidtmann I, Münzel T, Engelhardt M, Goldhofer M, Konstantinides SV, Drees P. Venous thromboembolism in patients hospitalized for hip joint replacement surgery. Thromb Res 2020; 190:1-7. [PMID: 32247912 DOI: 10.1016/j.thromres.2020.03.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 03/24/2020] [Accepted: 03/26/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) is a potentially life-threatening disease. Major transient risk factors include trauma, surgery, and immobilization. Patients undergoing hip joint replacement (HJR) are characterized by a high risk of postoperative VTE, but data on the time trends of VTE rates in this population are sparse. METHODS In an analysis of the German nationwide inpatient sample, we included all hospitalizations for elective primary HJR in Germany from 2005 to 2016. Time trends of the surgical procedure, overall death rates, and VTE rates were analysed, and predictors of VTE identified. RESULTS Overall, 1,885,839 inpatients with elective primary HJR (59.1% women, 51.4% ≥70 years) were included in the analysis. During hospitalization, VTE was documented in 11,554 (0.6%) patients. While total numbers of primary HJR increased from 145,223 in 2005 to 171,421 in 2016 (β-(slope)-estimate 1818 [95%CI 1083 to 2553], P < 0.001), in-hospital VTE decreased from 1288 (0.9%) to 843 (0.5%) cases (β-estimate -0.71 [95%CI -0.77 to -0.65], P < 0.001), and in-hospital death rate from 0.33% (476 deaths) to 0.29% (498 deaths) (β-estimate -0.11 [95%CI -0.20 to -0.02], P = 0.018). Infections during hospitalization were associated with higher VTE risk than cancer and cardiovascular events. VTE events were independently associated with an increased death risk (OR 15.19 [95%CI 14.19-16.86], P < 0.001). CONCLUSIONS While total numbers of HJR increased significantly in Germany between 2005 and 2016, in-hospital rates of VTE decreased from 0.9% to 0.5%. Patients with perioperative VTE had a 15-fold increase of in-hospital death. Cancer, cardiovascular disease and perioperative infections were associated with higher risk for VTE.
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Affiliation(s)
- Karsten Keller
- Center for Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany; Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany.
| | - Lukas Hobohm
- Center for Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany; Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany
| | - Stefano Barco
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany; Clinic for Angiology, University Hospital Zurich, Zurich, Switzerland
| | - Irene Schmidtmann
- Institute of Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany
| | - Thomas Münzel
- Center for Cardiology, Cardiology I, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Rhine Main, Germany
| | - Martin Engelhardt
- Department for Orthopedics, Trauma Surgery and Hand Surgery, Klinikum Osnabrück, Osnabrück, Germany; Institute for Applied Training Science, Leipzig, Germany
| | - Markus Goldhofer
- Center for Orthopaedics and Trauma Surgery, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany
| | - Stavros V Konstantinides
- Center for Thrombosis and Hemostasis (CTH), University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany; Department of Cardiology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Philipp Drees
- Center for Orthopaedics and Trauma Surgery, University Medical Center Mainz (Johannes Gutenberg-University Mainz), Mainz, Germany
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