Nonpharmacologic thromboembolic prophylaxis in total knee arthroplasty

The Role of Intraoperative Intermittent Pneumatic Compression Devices in Venous Thromboembolism Prophylaxis in Total Hip and Total Knee Arthroplasty

Venous thromboembolism (VTE) is a common complication after total hip arthroplasty (THA) and total knee arthroplasty (TKA), occurring in up to 85% of patients who are not treated with prophylaxis. The initiation of VTE development may occur intraoperatively. This study investigated whether this gap in VTE prophylaxis can be addressed by the use of intraoperative intermittent pneumatic compression devices (IPCDs) and if intraoperative IPCDs have a meaningful benefit in preventing symptomatic VTE. The authors defined symptomatic VTE as deep venous thrombosis in either lower extremity or a pulmonary embolism. The authors evaluated the medical records of 3379 patients who underwent THA or TKA at their institution in 2014 and 2015. Effects of various factors, including age, sex, body mass index, and smoking status, were compared between these 2 cohorts. Patients who experienced a symptomatic VTE were also matched by age, sex, and procedure type with randomly selected controls. In the patient sample, 47 patients (1.4%) developed VTE. Forty (1.2%) of these patients underwent TKA, whereas 7 (0.2%) underwent THA. Venous thromboembolism occurred less frequently in patients who received intraoperative IPCDs (0.8%) than in patients who did not receive them (1.5%); however, this difference did not reach statistical significance. Total knee arthroplasty was associated with increased odds of VTE compared with THA, as was female sex. These results did not show a statistically significant benefit to the intraoperative use of IPCDs. Pneumatic compression remains a fast, easy, low-cost, low-risk, intuitive intervention that can supplement the postoperative multimodal approach and is worthy of further study. Intraoperative IPCD use should be considered for patients with a higher risk of VTE. [Orthopedics. 2018; 41(1):e98-e103.].

Evaluation of venous return in lower limb by passive ankle exercise performed by PHARAD

This paper presents evaluation of venous return, i.e., blood flow volume of vein (BF), in the lower limb after passive exercise performed by our developed "parallel link type human ankle rehabilitation assistive device (PHARAD)". The PHARAD can perform complex passive exercises (plantar flexion/dorsiflexion, inversion/eversion, adduction/abduction, and combination of these motions) by reproducing input motions of a foot plate that is attached to a sole of foot. The passive exercise can be performed for not only rehabilitation but also prevention of deep vein thrombosis (DVT). In this study, we measured the concentration of Total hemoglobin (Total-Hb) using multi-channel near infra-red spectroscopy (NIRS)-based tissue oximeters and calculated a gradient of Total-Hb during a venous occlusion. We defined the gradient as BF and evaluated BF after 3 min passive exercise performed by the PHARAD comparing to BF of resting. Seven healthy young adult people were recruited for the experiment and we assessed passive exercise, active exercise, and walking. Experimental results show that BF after the passive exercises significantly increases compare to BF of resting and this indicates that passive exercises performed by the PHARAD increases BF and has a potential to prevent DVT.

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.

Mobile compression devices and aspirin for VTE prophylaxis following simultaneous bilateral total knee arthroplasty

Recently, Levy et al questioned the effectiveness of mobile compression devices (MCDs) as the sole method of thromboprophylaxis following simultaneous bilateral total knee arthroplasty (TKA). This study's purpose was to assess if the addition of aspirin to MCDs improves venous thromboembolism (VTE) prevention following simultaneous bilateral TKA. Ninety-six patients (192 TKAs) were retrospectively reviewed: 47 patients received MCDs for 10 days and aspirin for 6 weeks postoperatively based on a risk stratification protocol, while 49 patients received warfarin for 4 weeks postoperatively. One symptomatic VTE was noted in the warfarin cohort, while one patient in the MCD/aspirin cohort and three patients in the warfarin cohort were readmitted within 3 months of surgery. In appropriately selected patients, MCDs with aspirin shows promise in VTE prevention following simultaneous bilateral TKA.

Thrombosis incidence in unilateral vs. simultaneous bilateral total knee arthroplasty with compression device prophylaxis

This study compares the incidence of venous thromboembolic event (VTE) in 55 patients (110 knees) undergoing simultaneous bilateral TKA with 287 patients (287 knees) undergoing unilateral TKA using a mobile compression device as monotherapy prophylaxis in both groups. All patients were clinically evaluated 3months after surgery with symptomatic confirmed VTE as an endpoint. Deep venous thrombosis (DVT) was documented by duplex ultrasound and pulmonary embolism (PE) was documented by spiral CT. The simultaneous bilateral TKA group had 6 VTEs (10.9%) with 2 PEs (3.6%). The unilateral TKA group had 9 VTEs (3.1%), and 0 PE. Patients undergoing simultaneous bilateral TKA yielded more than twice the rate of VTE compared with patients undergoing unilateral TKA using a mobile compression device as sole thromboprophylactic modality.

Blood transfusion associated with shoulder arthroplasty

BACKGROUND

Studies have reported high rates of transfusion in shoulder arthroplasty. This study was conducted to evaluate the rate of transfusion at our institution, to confirm reported risk factors for transfusion, and to look for changes over time.We hypothesized that transfusion rates associated with shoulder arthroplasty at our institution are lower than those recently reported and that the incidence of transfusion is higher in individuals with low preoperative hemoglobin, with revision arthroplasty, and in older individuals.

MATERIALS AND METHODS

A retrospective review of 366 shoulder arthroplasties (323 patients) was performed. This included total shoulder arthroplasties, hemiarthroplasties, revision arthroplasties, and reverse total shoulder arthroplasties. Logistic regression analysis evaluated the association of clinical variables with transfusion. Early (1996-2005) and late (2006-2009) groups were compared to evaluate changes in demographics and transfusion rates over time.

RESULTS

The overall transfusion rate was 7.4% (27 of 339). Predictors of transfusion were higher intraoperative blood loss, low preoperative hemoglobin level, and humeral cement fixation. Procedure type was not predictive of transfusion. There was no difference in transfusion rates between the early and late groups, but the late group had an increased use of general anesthesia combined with a regional block, increased intraoperative blood loss, and increased use of sequential compression devices for venous thromboembolism prophylaxis.

CONCLUSIONS

Lower preoperative hemoglobin, higher intraoperative blood loss, and humeral cement fixation were predictors of transfusion, but not female sex, increasing age, type of procedure, or comorbidities.

Evaluation of deep venous thrombosis prophylaxis in low-risk patients undergoing total knee arthroplasty

Our objective of the study was to address the question: "What is the efficacy of a deep venous thrombosis (DVT) and pulmonary embolus prophylaxis protocol after total knee arthroplasty (TKA) in which low-risk patients had only aspirin and mechanical devices for prophylaxis?" A multimodal approach to DVT prophylaxis using aspirin as the primary mode of chemoprophylaxis was successful in preventing DVT-related morbidity and mortality in 312 consecutive TKAs performed in low-risk patients. There were no DVT-related deaths and no deaths in general at 90 days of follow-up coupled with a low rate of readmission for thromboembolic events and no readmissions or reoperations from bleeding in this group. This low-morbidity, low-cost prophylaxis should be considered an appropriate protocol for low-risk patients undergoing TKA. Of all TKAs performed during the time period of the study, 73% qualified for the low-risk group.

Decreasing the incidence of deep vein thrombosis through the use of prophylaxis

Every year, thousands of patients develop deep vein thrombosis (DVT) after undergoing surgery. Deep vein thromboses that result in pulmonary embolisms (PEs) are believed to be one of the most frequently occurring, preventable killers of hospitalized patients. Strategies for preventing a patient from developing DVT include implementing chemical or mechanical prophylaxis or a combination of the two. By instituting a DVT-assessment program, implementing mechanical DVT prophylaxis, and educating nurses and patients, the incidence of DVTs in orthopedic patients can be reduced, leading to fewer deaths from PEs.

Identifizierung von Risikofaktoren postoperativer Komplikationen in der primären Knieendoprothetik

AIM

Postoperative complications following primary total knee replacement performed between 2000 and 2002 were assessed to determine perioperative patient- and procedure-related risks associated with the procedure.

METHODS

For this analysis, the data collected during postoperative hospitalization for 17,644 total knee arthroplasties were assessed. The analysis included two steps. First, using logistic regression, we identified and quantified significant risk factors for the occurrence of general postoperative complications. Second, univariate analysis was utilized to qualitatively and quantitatively analyze the influence of these significant risk factors on the occurrence of major complications (hematoma, cardiovascular complication, deep venous thrombosis, pulmonary embolism, joint infection, and pneumonia).

RESULTS

General postoperative complications were reported in 11.3%. Major postoperative complications occurred in 7.2% with hematoma in 2.9%, cardiovascular complications in 1.8%, deep venous thrombosis in 1.2%, pulmonary embolism in 0.2%, joint infection in 0.8%, and pneumonia in 0.3%. Patient-related risk factors such as age, surgery time, gender, high ASA classification as well as procedure-related risk factors such as allogeneic blood transfusions and lateral release significantly increased the rate of postoperative complications. Males were more prone to hematoma, joint infection, and pneumonia in the immediate postoperative course than females, who were more in danger of developing deep venous thrombosis. Allogeneic blood transfusions increased the risk for postoperative hematoma, infection, and cardiovascular complication. Regional anesthesia was shown to decrease the risk for the occurrence of postoperative deep venous thrombosis and pulmonary embolism.

CONCLUSIONS

Postoperative complications in total knee replacement are increased in males and elder patients. Increased time of surgery and allogeneic blood transfusions also represent important risk factors for postoperative complications following primary total knee replacement.

Medicolegal aspects of hip and knee arthroplasty

Hip and knee arthroplasties usually are satisfying for the patient and the surgeon; however, these procedures also have considerable risks for generating a medical malpractice lawsuit. Strict adherence to the standard of care and recently implemented patient safety strategies should reduce the surgeon's liability. Expert technical execution of the surgery, timely evidence-based patient treatment, and detailed documentation in the medical record will not only improve the quality of patient care but also will serve as a strong legal defense should the need arise.

A single-centre prospective study of clinical and haemostatic risk factors for venous thromboembolism following lower limb arthroplasty

Previous studies report conflicting results concerning the potential significance of thrombophilic genotypes in postarthroplasty venous thromboembolism (VTE). This study assessed thrombophilic genotypes, haemostatic and clinical variables as independent risk factors for VTE postarthroplasty. A total number of 569 patients undergoing elective lower limb arthroplasty at a single centre were prospectively studied. All patients were interviewed and had blood samples collected preoperatively. Bilateral lower limb ultrasonography was performed at day 7 +/- 2 postoperatively in all patients (ventilation/perfusion lung scanning in symptomatic patients only). The incidence of inhospital postoperative VTE was 26%. In univariate analysis - increased age, knee arthroplasty, recent surgery, general anaesthesia, shorter operation time, non-receipt of blood transfusion and differences in surgical practice (including use of pneumatic calf compression, surgical drains and postoperative bandaging techniques) were significantly associated with VTE. Factor V Leiden, prothrombin G20210A and MTHFR C677T mutations were not significant risk factors for VTE, and of all haemostatic variables tested, only median activated partial thromboplastin time showed significant difference between VTE and non-VTE patients (34 s vs. 33 s). Multiple logistic regression analysis demonstrated that increased age, knee arthroplasty and individual surgeon's routine practices were the only significant independent risks for VTE; hence routine preoperative blood screening for a potential hypercoaguable state is not indicated in this surgical setting.

Managing thromboembolic risk in hip and knee arthroplasty: state of the art

Deep vein thrombosis and pulmonary embolism are major causes of morbidity and mortality after knee and hip arthroplasty in the United States. Although patients frequently receive prophylaxis for thromboembolism postarthroplasty, surgeons vary in their choice of modality and often use suboptimal strategies due to the possibility of provoking postoperative bleeding. This article discusses the rationale for the prevention of venous thromboembolism and offers an overview of clinical recommendations for prophylaxis in knee and hip replacement surgery. Supporting medical evidence for these recommendations is described. A summary of current prophylactic regimens and discussion of duration of therapy are also presented.