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Andronic D, Andronic O, Ammann E, Pravin E, Cubberley R. Outcomes of different perioperative management strategies of patients on chronic anticoagulation in elective total hip and knee arthroplasty: a systematic review. Fam Pract 2024:cmae020. [PMID: 38641558 DOI: 10.1093/fampra/cmae020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/21/2024] Open
Abstract
INTRODUCTION There are currently different management guidelines for patients undergoing elective total hip arthroplasty (THA) or total knee arthroplasty (TKA) that are on long-term anticoagulation. The timing of discontinuation and restarting the anticoagulation is challenging during the postoperative care, which often involves general practitioners and physiotherapists. METHODS The systematic review followed the PRISMA guidelines and included 3 databases: PubMed/MEDLINE, EMBASE, and Web of Science Core Collection. It was registered in the International Prospective Register for Systematic Reviews and Meta-analysis (PROSPERO) under the registration number: CRD42023408906. The risk of bias assessment was performed using the Methodological index for non-randomized studies (MINORS) criteria. RESULTS Six retrospective studies involving 727 patients with therapeutic anticoagulation (1,540 controls) for elective THA, TKA and revision arthroplasty have been included. The follow-up ranged from 30 days to 1 year postoperatively. All studies evaluated outcomes of warfarin therapeutic anticoagulation versus prophylactic dosages of one or more of the following: warfarin, aspirin, low-molecular-weight heparin (LMWH) and unfractionated low-dose heparin (UFH). One study did not discontinue therapeutic anticoagulation. Two studies reported no significant differences in complications between groups, whilst 3 studies had significantly higher rates of superficial wound infections, revision surgeries, postoperative haematomas, and prosthetic joint infections (PJI). CONCLUSION Different anticoagulation-related perioperative management strategies achieve different outcomes following elective arthroplasty in patients with therapeutic chronic anticoagulation. There is contradictory evidence regarding the need for the discontinuation of therapeutic warfarin. Retrospective data showed that individual risk stratification with multi-modal prophylaxis resulted in minimal complications. LEVEL OF EVIDENCE Systematic Review of Level III studies.
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Affiliation(s)
- Diana Andronic
- School of Allied Health, Faculty of Health, Education, Medicine & Social Care ARU, Cambridge, United Kingdom
| | - Octavian Andronic
- Department of Trauma and Orthopaedics, Balgrist University Hospital, Zürich, Switzerland
| | - Elias Ammann
- Department of Trauma and Orthopaedics, Perth Orthopaedics and Sports Medicine Centre, Perth, Australia
| | - Edward Pravin
- Faculty of Medicine, Curtin University, Perth, Australia
| | - Rachael Cubberley
- School of Allied Health, Faculty of Health, Education, Medicine & Social Care ARU, Cambridge, United Kingdom
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Diaz-Dilernia F, Lucero C, Slullitel PA, Zanotti G, Comba F, Piccaluga F, Buttaro M. Medium-term outcomes of conventional versus short uncemented femoral stems for primary total hip arthroplasty in patients younger than 55 years. Hip Int 2024; 34:82-91. [PMID: 37293776 DOI: 10.1177/11207000231177588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND Short stems are designed with a bone preservation philosophy in mind. This study aims to compare the outcomes/complications and survival of a collarless fully hydroxyapatite (HA)-coated conventional tapered stem and a HA-coated partial neck-retaining uncemented short stem in patients ⩽55 years old at medium-term follow-up. METHODS We retrospectively studied 247 uncemented THAs operated between 2010 and 2014, comparing 146 patients treated with the fully HA-coated collarless stem (Group A) with 101 patients treated with a partial neck preserving, HA-coated short stem (Group B). 87 and 62 males were in groups A and B, respectively (p = 0.11). The mean age of the series was 46 years (17-55) (p =0.16). The mean follow-up of groups A and B were 9.9 (7-12) years and 9.7 (7-12) years, respectively (p =0.21). RESULTS Mean Harris Hip Score improved from 55 to 92 in group A (p <0.001) and from 54 to 95 in group B (p <0.001), without differences between groups. Mean femoral neck length preservation in groups A and B was 13.6 (0-28) mm and 26 (11-38) mm, respectively (p =0.001). 13 (8.9%) and 1 (1%) patients in groups A and B presented postoperative complications, respectively (p =0.008). The conventional stem group had more aseptic loosening (Group A 3.4% vs. Group B 0%, p =0.06) along with more Symptomatic radiolucent lines (Group A 3.4% vs. Group B 0%, p =0.06). CONCLUSIONS Both conventional and short stems showed excellent implant survival rates and functional outcomes at a mean follow-up of 9.8 years. However, complications and radiolucent lines were more frequent with a collarless conventional-length stem. Bone preservation of the femoral neck and diaphysis may be preferred in active young patients.
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Affiliation(s)
- Fernando Diaz-Dilernia
- Sunnybrook Health Sciences Centre/Holland Orthopaedic & Arthritic Centre, Division of Orthopaedic Surgery, Department of Surgery, Faculty of Medicine, University of Toronto, ON, Canada
- Hip Surgery Unit, Institute of Orthopaedics "Carlos E. Ottolenghi", Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Carlos Lucero
- Hip Surgery Unit, Institute of Orthopaedics "Carlos E. Ottolenghi", Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Pablo A Slullitel
- Hip Surgery Unit, Institute of Orthopaedics "Carlos E. Ottolenghi", Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Gerardo Zanotti
- Hip Surgery Unit, Institute of Orthopaedics "Carlos E. Ottolenghi", Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Fernando Comba
- Hip Surgery Unit, Institute of Orthopaedics "Carlos E. Ottolenghi", Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Francisco Piccaluga
- Hip Surgery Unit, Institute of Orthopaedics "Carlos E. Ottolenghi", Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Martin Buttaro
- Hip Surgery Unit, Institute of Orthopaedics "Carlos E. Ottolenghi", Italian Hospital of Buenos Aires, Buenos Aires, Argentina
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Lucero CM, García-Mansilla A, Albani-Forneris A, Holc F, Slullitel PA, Zanotti G, Comba F, Piccaluga F, Buttaro MA. Do nonagenarians have more complications and unplanned readmissions than octogenarians following primary THA? A retrospective cohort study. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:2981-2986. [PMID: 36930268 DOI: 10.1007/s00590-023-03502-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 02/26/2023] [Indexed: 03/18/2023]
Abstract
INTRODUCTION The performance of total hip arthroplasty in elderly patients, especially nonagenarians, is challenging due to higher patient frailty and medical comorbidities. We compared 90-day postoperative complications and unplanned readmissions between nonagenarians and octogenarians undergoing elective THA. METHODS One hundred and eleven patients undergoing elective, unilateral THA were retrospectively analyzed. Forty-four patients were nonagenarians (Group A), and 67 patients were octogenarians (Group B). Demographic data included age, gender, body mass index (BMI), ASA score and Charlson Comorbidity Index (CCI). Frailty was defined according to the Rockwood Frailty Index. All patients underwent a thorough preoperative assessment through a specific institutional clinical pathway created for this matter. Postoperative adverse events were grouped into major or minor. A regression model was used to evaluate independent risk factors for the development of complications. RESULTS There were no differences in the ASA score (65.9% vs. 53.7% ASA III-IV), prevalence of frailty (1% vs. 9%) and comorbidities between both groups (p > .05). The CCI was higher in nonagenarians (p = 0.007). Nonagenarians had more in-hospital complications, although most were minor (p = 0.002), none of which resulted in mortality. Ninety-day unplanned readmissions were similar between groups, with 4 (9.1%) and 6 (9%) in groups A and B, respectively (p = 1). Although age was a factor associated with the development of postoperative complications in the univariate regression model (OR 3.81, 95% CI 1.31 to 11.11, p = 0.014), it lost significance after performing the multivariate analysis (OR 2.48, 95% CI 0.78 to 7.90, p = 0.125). CONCLUSION The age of 90 years old was not a barrier to perform elective THA safely. Nonagenarians had higher in-hospital minor complications when compared to the younger cohort. However, age over 90 years was not an independent risk factor for unplanned readmissions or mortality. Multimodal protocols of perioperative care are paramount for improving outcomes after THA in very old patients.
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Affiliation(s)
- Carlos M Lucero
- 'Sir John Charnley' Hip Surgery Unit, Institute of Orthopaedics 'Carlos E. Ottolenghi', Italian Hospital of Buenos Aires, 4190 Peron St., C1199ABH, Buenos Aires, Argentina.
| | - Agustín García-Mansilla
- 'Sir John Charnley' Hip Surgery Unit, Institute of Orthopaedics 'Carlos E. Ottolenghi', Italian Hospital of Buenos Aires, 4190 Peron St., C1199ABH, Buenos Aires, Argentina
| | - Agustín Albani-Forneris
- 'Sir John Charnley' Hip Surgery Unit, Institute of Orthopaedics 'Carlos E. Ottolenghi', Italian Hospital of Buenos Aires, 4190 Peron St., C1199ABH, Buenos Aires, Argentina
| | - Fernando Holc
- 'Sir John Charnley' Hip Surgery Unit, Institute of Orthopaedics 'Carlos E. Ottolenghi', Italian Hospital of Buenos Aires, 4190 Peron St., C1199ABH, Buenos Aires, Argentina
| | - Pablo A Slullitel
- 'Sir John Charnley' Hip Surgery Unit, Institute of Orthopaedics 'Carlos E. Ottolenghi', Italian Hospital of Buenos Aires, 4190 Peron St., C1199ABH, Buenos Aires, Argentina
| | - Gerardo Zanotti
- 'Sir John Charnley' Hip Surgery Unit, Institute of Orthopaedics 'Carlos E. Ottolenghi', Italian Hospital of Buenos Aires, 4190 Peron St., C1199ABH, Buenos Aires, Argentina
| | - Fernando Comba
- 'Sir John Charnley' Hip Surgery Unit, Institute of Orthopaedics 'Carlos E. Ottolenghi', Italian Hospital of Buenos Aires, 4190 Peron St., C1199ABH, Buenos Aires, Argentina
| | - Francisco Piccaluga
- 'Sir John Charnley' Hip Surgery Unit, Institute of Orthopaedics 'Carlos E. Ottolenghi', Italian Hospital of Buenos Aires, 4190 Peron St., C1199ABH, Buenos Aires, Argentina
| | - Martin A Buttaro
- 'Sir John Charnley' Hip Surgery Unit, Institute of Orthopaedics 'Carlos E. Ottolenghi', Italian Hospital of Buenos Aires, 4190 Peron St., C1199ABH, Buenos Aires, Argentina
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Kheir MM, Dilley JE, Speybroeck J, Kuyl EV, Ochenjele G, McLawhorn AS, Meneghini RM. The Influence of Dorr Type and Femoral Fixation on Outcomes Following Total Hip Arthroplasty for Acute Femoral Neck Fractures: A Multicenter Study. J Arthroplasty 2023; 38:719-725. [PMID: 36283515 DOI: 10.1016/j.arth.2022.10.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 10/16/2022] [Accepted: 10/17/2022] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND The American Academy of Orthopaedic Surgeons guidelines report moderate evidence for cementing femoral stems for hip fractures, mainly derived from hemiarthroplasty literature. This is the first large, nonregistry study examining the influence of femoral fixation, implant type, patient characteristics, and radiographic factors on outcomes after total hip arthroplasty (THA) for acute femoral neck fractures. METHODS A multicenter retrospective study was performed of 709 THA cases (199 cemented, 510 cementless) for femoral neck fractures from 2006 to 2020 at three large academic institutions. Demographics, perioperative characteristics, and radiographs were reviewed. Kaplan-Meier survivorship curves were generated for multiple outcomes. Univariate and multivariate analyses were performed with P ≤ .05 denoting significance. RESULTS Cementless stems had a higher all-cause aseptic femoral revision rate (5.1 versus 0.5%, P = .002) and periprosthetic femoral fracture rate (4.3 versus 0%, P = .001). Each successive Dorr type had a higher fracture rate with cementless implants: 2.3%, 3.7%, and 15.9% in Dorr A, B, and C, respectively (P < .001). Logistic regression analyses confirmed that cementless stems (P = .02) and Dorr C bone (P = .001) are associated with periprosthetic fractures; collared implants and prophylactic cables did not protect against fractures. There was no difference in rates of dislocation, septic revision, or mortality between groups. CONCLUSION Cementless stems during THA for femoral neck fractures have a higher aseptic femoral revision rate, specifically for periprosthetic fractures. Dorr C bone was particularly prone with an alarmingly high fracture rate. All fractures occurred in cementless cases, suggesting that cemented stems may minimize this complication. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Michael M Kheir
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Julian E Dilley
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jacob Speybroeck
- Department of Orthopaedic Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Emile-Victor Kuyl
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - George Ochenjele
- Department of Orthopaedic Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | | | - R Michael Meneghini
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
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Intraoperative unfractionated heparin before femoral component cementation should be avoided in femoral neck fracture treated with hybrid total hip arthroplasty. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023:10.1007/s00590-023-03472-7. [PMID: 36645495 DOI: 10.1007/s00590-023-03472-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Accepted: 01/09/2023] [Indexed: 01/17/2023]
Abstract
PURPOSE To compare the incidence of perioperative thromboembolic events in femoral neck fracture (FNF) patients treated with hybrid total hip arthroplasty (THA) with intraoperative unfractionated heparin (UFH) versus a control group without intraoperative UFH before femoral component cementation. METHODS We compared 139 cases without UFH (group A) versus 134 who received 10 UI/kg UFH (group B). Indication of UFH before cementation depended on the preferences of the anaesthesiologists in each case. We assessed intraoperative bone cement implantation syndrome (BCIS) and 30-day thromboembolic events, and 90-day and 1-year mortality. BCIS was classified as per Donaldson et al.'s classification according to the degree of hypotension, arterial desaturation or loss of consciousness. RESULTS BCIS was observed in 51 (18%) cases, including 37 (13%) grade 1 and 14 (5%) grade 2. Forty-seven BCISs (35%) were observed in group B and 4 (3%) in group A (p < 0.001). Multivariate regression showed that intraoperative UFH (OR = 18, CI 95% 6-52) and consumption of oral anticoagulants (OR = 3.3, CI 95% 1-10) increased the risk of BCIS. Five patients further developed a 30-day pulmonary embolism in group B, while 2 presented this complication in group A (p = 0.231). No association between BCIS and 30-day thromboembolic events was found (p = 0.62). 90-day (1% each, p = 0.98) and 1-year (2% vs. 3%, p = 0.38) mortality were similar. CONCLUSIONS BCIS was a frequent finding in FNF patients treated with hybrid THA. We found a paradoxically significant increase in BCIS with the use of UFH. Heparin did not seem to prevent BCIS, other thromboembolic events and mortality in this group of patients.
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Total Joint Arthroplasty in Patients With Atrial Septal Defects: What Are the 90-Day Complications? Arthroplast Today 2022; 17:43-46. [PMID: 36032792 PMCID: PMC9399375 DOI: 10.1016/j.artd.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Accepted: 07/08/2022] [Indexed: 11/23/2022] Open
Abstract
Background Methods Results Conclusions Level of evidence
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The Effect of Femoral Fixation on Revision and Mortality Following Elective Total Hip Arthroplasty in Patients Over the Age of 65 years. An Analysis of the American Joint Replacement Registry. J Arthroplasty 2022; 37:1105-1110. [PMID: 35131391 DOI: 10.1016/j.arth.2022.01.088] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2021] [Revised: 01/22/2022] [Accepted: 01/30/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND With the overwhelming use of cementless femoral fixation for primary total hip arthroplasty in the United States, the associations of stem fixation on the risk of revision and mortality are poorly understood. We evaluated the relationship between femoral fixation and risk of revision and mortality in patients included in the American Joint Replacement Registry. METHODS Elective, primary, unilateral total hip arthroplasties in the American Joint Replacement Registry, in patients over the age of 65 years were considered. In total, 9,612 patients with a cemented stem were exact matched 1:1 with patients who received a cementless stem based on age, gender, and the Charlson Comorbidity Index. Outcomes compared between the groups included need and reason for revision at 90 days and 1 year; in-hospital, 90-day, and 1-year mortality; and mortality after early revision. Covariates were used in linear regression analyses. RESULTS Cemented fixation was associated with a 37% reduction in the risk of 90-day revision, and a reduction in the risk of revision for periprosthetic fracture of 87% at 90 days and 81% at 1 year. Cemented fixation was associated with increased 90-day and 1-year mortality (odds ratio [OR] 3.15, confidence interval [CI] 2.24-4.43 and OR 2.36, CI 1.86-3.01, respectively). Patients who underwent subsequent revision surgery within the first year exhibited the highest mortality risk (OR 3.23, CI 1.05-9.97). CONCLUSION In this representative sample of the United States, 90-day revision for any reason and for periprosthetic fracture was significantly reduced in patients with a cemented stem. This benefit must be weighed against the association with increased mortality and with the high risk of mortality associated with early revision, which was more prevalent with cementless fixation.
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LeBrun DG, Salvati EA, Gonzalez Della Valle A. Multimodal Thromboprophylaxis in Patients With a History of Venous Thromboembolism Undergoing Primary and Revision Knee Arthroplasty. HSS J 2022; 18:212-218. [PMID: 35645638 PMCID: PMC9097001 DOI: 10.1177/15563316211055465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 10/03/2021] [Indexed: 02/07/2023]
Abstract
Background: Patients with a history of venous thromboembolism (VTE) undergoing total knee arthroplasty (TKA) are at a high risk of postoperative VTE. Purpose: In this high-risk population, we sought to evaluate the safety and efficacy of multimodal thromboprophylaxis. The regimen consisted of discontinuation of procoagulant medications, VTE risk stratification, regional anesthesia, rapid mobilization, perioperative use of pneumatic compression devices, vigorous ankle dorsiflexion during the recovery period, and chemoprophylaxis tailored to the patient's risk of VTE. Methods: We conducted a retrospective chart review of 141 consecutive patients with a history of VTE who underwent 177 elective TKA procedures between 2005 and 2019 by 2 arthroplasty surgeons at a single institution. The patients had a history of deep venous thrombosis (DVT) (n = 127; 72%), pulmonary embolism (PE) (n = 20; 11%), or both (n = 30; 17%). Postoperative chemoprophylaxis included aspirin (n = 20; 11%), anticoagulation (n = 135; 77%), or a combination of aspirin and anticoagulation (n = 21; 12%). Complications within 120 days, including VTE events, wound complications, bleeding, and unplanned readmissions, were recorded, as was 1-year mortality. Results: Five patients (2.8%) developed symptomatic DVT (3 distal, 2 proximal), and 4 patients (2.3%) developed symptomatic PE. The most common postdischarge complications were wound infection (n = 6; 3.4%) and stiffness requiring manipulation under anesthesia (n = 5; 2.8%). There was 1 emergency room visit and 13 unplanned readmissions; 3 patients developed intra-articular hematomas or prolonged wound drainage and recovered uneventfully. All patients were alive 1 year after surgery. Conclusion: The findings of this retrospective study suggest that multimodal prophylaxis may be safe and effective in patients with a history of VTE undergoing primary and revision TKA. More rigorous study is warranted.
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Affiliation(s)
- Drake G. LeBrun
- Hospital for Special Surgery, New York,
NY, USA,Drake G. LeBrun, MD, MPH, Hospital for
Special Surgery, 535 E 70th Street, New York, NY 10021, USA.
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Preliminary outcomes of the cementless UNITED hip system for primary total hip arthroplasty at a minimum 2-year follow-up. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 32:745-752. [PMID: 34117920 DOI: 10.1007/s00590-021-03038-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 04/18/2021] [Indexed: 12/27/2022]
Abstract
INTRODUCTION This study aimed to report the initial results of the cementless UNITED hip system in primary total hip arthroplasty (THA) with a minimum follow-up of 2 years. METHODS We retrospectively studied a consecutive series of 203 cementless THAs in 180 patients operated between 2015-2017. We included 89 female and 91 male patients with a mean age of 67 (28 to 89) years. The mean follow-up was 40 (29 to 62) months. Clinical outcome scores and radiographs were measured. Survival was calculated defining failure as the need for any further femoral or acetabular revision, irrespective of the reason. RESULTS No femoral component loosening was detected. One patient had a Vancouver-B1 intraoperative periprosthetic femoral fracture treated with implant retention and cerclage wires. Two acetabular components were revised for aseptic loosening. Three patients suffered an acute infection treated with debridement, antibiotics, and implant retention. The mean Merle d'Aubigné et Postel scores improved from 13 (4 to 16) points preoperatively to 17 (12 to 18) points at the latest follow-up (p < 0.001). At a mean time of 40 months of follow-up, the survival was 99% and 100% for the acetabular and the femoral components, respectively. CONCLUSION This cementless design showed excellent preliminary outcomes in terms of fixation and patient satisfaction, comparable to that of other well-known similar systems.
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Muscatelli SR, Zheng H, Hughes RE, Cowen ME, Hallstrom BR. Non-Inferiority of Aspirin for Venous Thromboembolism Prophylaxis After Hip Arthroplasty in a Statewide Registry. J Arthroplasty 2021; 36:2068-2075.e2. [PMID: 33589277 DOI: 10.1016/j.arth.2021.01.025] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 01/05/2021] [Accepted: 01/11/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Uncertainty remains surrounding the use of aspirin as a sole chemoprophylactic agent to reduce the risk of venous thromboembolism (deep vein thrombosis or pulmonary embolism) and bleeding after primary total hip arthroplasty. METHODS We performed a non-inferiority analysis of a retrospective cohort of patients undergoing total hip arthroplasty from April 1, 2013 to December 31, 2018. Cases were retrieved from the Michigan Arthroplasty Registry Collaborative Quality Initiative database and performed by 355 surgeons at 61 hospitals throughout Michigan. Surgical setting ranged from small community hospitals to large academic and non-academic centers. The primary outcomes were post-operative venous thromboembolism event or death and bleeding event. RESULTS Of the 59,747 patients included, 32,878 (55.03%) were female, and the mean age was 64.5. A total of 462 (0.77%) composite venous thromboembolism events occurred. There were 221 (0.71%) and 129 (0.80%) venous thromboembolism events in patients receiving aspirin only and anticoagulants only, respectively. Aspirin was non-inferior to anticoagulants for composite venous thromboembolism events (odds ratio 0.99, 95% confidence interval 0.79-1.26, P < .001). Bleeding events occurred in 767 (1.28%) patients, with 304 (0.97%) and 281 (1.74%) bleeding events in patients receiving aspirin only and anticoagulants only, respectively. Aspirin was non-inferior to anticoagulants for bleeding events (odds ratio 0.62, 95% confidence interval 0.52-0.74, P < .001). CONCLUSION Aspirin is not inferior to other anticoagulants as pharmacologic venous thromboembolism prophylaxis with regards to post-operative risk of venous thromboembolism or bleeding. Sole use of aspirin for venous thromboembolism prophylaxis after total hip arthroplasty should be considered in the appropriate patient.
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Affiliation(s)
- Stefano R Muscatelli
- Department of Orthopaedic Surgery, University of Michigan Health System, Ann Arbor, MI
| | - Huiyong Zheng
- Department of Orthopaedic Surgery, University of Michigan Health System, Ann Arbor, MI
| | - Richard E Hughes
- Department of Orthopaedic Surgery, University of Michigan Health System, Ann Arbor, MI
| | - Mark E Cowen
- Quality Insitute, St. Joseph Mercy Hospital, Ann Arbor, MI
| | - Brian R Hallstrom
- Department of Orthopaedic Surgery, University of Michigan Health System, Ann Arbor, MI
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Gonzalez Della Valle A, Shanaghan KA, Nguyen J, Liu J, Memtsoudis S, Sharrock NE, Salvati EA. Multimodal prophylaxis in patients with a history of venous thromboembolism undergoing primary elective hip arthroplasty. Bone Joint J 2020; 102-B:71-77. [DOI: 10.1302/0301-620x.102b7.bjj-2019-1559.r1] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aims We studied the safety and efficacy of multimodal thromboprophylaxis in patients with a history of venous thromboembolism (VTE) who undergo total hip arthroplasty (THA) within the first 120 postoperative days, and the mortality during the first year. Multimodal prophylaxis includes discontinuation of procoagulant medications, VTE risk stratification, regional anaesthesia, an intravenous bolus of unfractionated heparin prior to femoral preparation, rapid mobilization, the use of pneumatic compression devices, and chemoprophylaxis tailored to the patient’s risk of VTE. Methods Between 2004 to 2018, 257 patients with a proven history of VTE underwent 277 primary elective THA procedures by two surgeons at a single institution. The patients had a history of deep vein thrombosis (DVT) (186, 67%), pulmonary embolism (PE) (43, 15.5%), or both (48, 17.5%). Chemoprophylaxis included aspirin (38 patients), anticoagulation (215 patients), or a combination of aspirin and anticoagulation (24 patients). A total of 50 patients (18%) had a vena cava filter in situ at the time of surgery. Patients were followed for 120 days to record complications, and for one year to record mortality. Results Postoperative VTE was diagnosed in seven patients (2.5%): DVT in five, and PE with and without DVT in one patient each. After hospitalization, three patients required readmiss-ion for evacuation of a haematoma, one for wound drainage, and one for monitoring of an elevated international normalized ratio (INR). Seven patients died (2.5%). One patient died five months postoperatively of a PE during open thrombectomy. She had discontinued anticoagulation. One patient died of a haemorrhagic stroke while receiving Coumadin. PE or bleeding was not suspected in the remaining five fatalities. Conclusion Multimodal prophylaxis is safe and effective in patients with a history of VTE. Postoperative anticoagulation should be prudent as very few patients developed VTE (2.5%) or died of suspected or confirmed PE. Mortality during the first year was mostly unrelated to either VTE or bleeding. Cite this article: Bone Joint J 2020;102-B(7 Supple B):71–77.
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Affiliation(s)
- Alejandro Gonzalez Della Valle
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medical College of Cornell University, New York, New York, USA
| | - Kate A. Shanaghan
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medical College of Cornell University, New York, New York, USA
| | - Joseph Nguyen
- Department of Biomechanics, Hospital for Special Surgery, Weill Cornell Medical College of Cornell University, New York, New York, USA
| | - Jiabin Liu
- Department of Anesthesiology, Hospital for Special Surgery, Weill Cornell Medical College of Cornell University, New York, New York, USA
| | - Stavros Memtsoudis
- Department of Anesthesiology, Hospital for Special Surgery, Weill Cornell Medical College of Cornell University, New York, New York, USA
| | - Nigel E. Sharrock
- Department of Anesthesiology, Hospital for Special Surgery, Weill Cornell Medical College of Cornell University, New York, New York, USA
| | - Eduardo A. Salvati
- Department of Orthopaedic Surgery, Hospital for Special Surgery, Weill Cornell Medical College of Cornell University, New York, New York, USA
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Mihara M, Tamaki Y, Nakura N, Takayanagi S, Saito A, Ochiai S, Hirakawa K. Clinical efficacy of risk-stratified prophylaxis with low-dose aspirin for the management of symptomatic venous thromboembolism after total hip arthroplasty. J Orthop Sci 2020; 25:156-160. [PMID: 30902536 DOI: 10.1016/j.jos.2019.02.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Revised: 02/07/2019] [Accepted: 02/12/2019] [Indexed: 11/20/2022]
Abstract
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.
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Affiliation(s)
- Masahiko Mihara
- Shonan Kamakura Joint Reconstruction Center, 5-4-17 Dai, Kamakura, Kanagawa, 247-0061, Japan.
| | - Yasunobu Tamaki
- Shonan Kamakura Joint Reconstruction Center, 5-4-17 Dai, Kamakura, Kanagawa, 247-0061, Japan
| | - Nariaki Nakura
- Shonan Kamakura Joint Reconstruction Center, 5-4-17 Dai, Kamakura, Kanagawa, 247-0061, Japan; Kitakyushu General Hospital, 1-1 Higashijono-machi, Kokurakita-ku, Kita-Kyushu, Fukuoka, 802-8517, Japan
| | - Satoshi Takayanagi
- Shonan Kamakura Joint Reconstruction Center, 5-4-17 Dai, Kamakura, Kanagawa, 247-0061, Japan
| | - Akira Saito
- Shonan Kamakura Joint Reconstruction Center, 5-4-17 Dai, Kamakura, Kanagawa, 247-0061, Japan
| | - Shunsuke Ochiai
- Shonan Kamakura Joint Reconstruction Center, 5-4-17 Dai, Kamakura, Kanagawa, 247-0061, Japan
| | - Kazuo Hirakawa
- Shonan Kamakura Joint Reconstruction Center, 5-4-17 Dai, Kamakura, Kanagawa, 247-0061, Japan
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Lung BE, Kanjiya S, Bisogno M, Komatsu DE, Wang ED. Risk factors for venous thromboembolism in total shoulder arthroplasty. JSES OPEN ACCESS 2019; 3:183-188. [PMID: 31709360 PMCID: PMC6834973 DOI: 10.1016/j.jses.2019.07.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Background Although venous thromboembolism (VTE) has been studied in lower-extremity arthroplasty, there are few guidelines regarding established risk factors for VTE in total shoulder arthroplasty (TSA). With literature suggesting the VTE rate may be as high as 13%, VTE prevention and risk factors should be considered in preoperative planning. Methods All TSAs from 2011 through 2016 were queried from the National Surgical Quality Improvement Program database. Age, sex, body mass index, American Society of Anesthesiologists class, ethnicity, functional status, comorbidities, discharge destination, surgical indication, length of stay, and operative time were compared between patients with and without 30-day postoperative VTE. Pearson χ2 and t tests were used to assess baseline categorical and continuous variables, respectively. Multivariate logistic regression analysis was conducted to determine associated independent risk factors for VTE. Results The analysis included 13,299 patients; VTE developed in 83 patients (0.62%). Patients with VTE were older (72 years vs. 69 years) and had a longer hospital stay (3.5 days vs. 1.9 days). Compared with patients with no VTE, patients with VTE were more likely to undergo TSA for proximal humeral fractures, to be discharged to a rehabilitative center, to have a preoperative albumin level lower than 3.5 g/dL, to undergo non-elective surgery, to have an American Society of Anesthesiologists class of 3 or greater, to have a surgical-site infection develop, and ultimately to need a shoulder reoperation (all P < .05). Multivariate logistic regression analysis revealed that hypoalbuminemia (albumin level < 3.5 g/dL), an increased length of stay, and African American ethnicity were independent risk factors for VTE development. Conclusion Patients with hypoalbuminemia, an increased length of stay, and African American ethnicity are at an increased risk of VTE after shoulder arthroplasty. A high index of suspicion is warranted for elderly patients with fractures who may need preoperative medical optimization.
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Affiliation(s)
- Brandon E Lung
- School of Medicine, Stony Brook University, Stony Brook, NY, USA
| | - Shrey Kanjiya
- Department of Orthopaedics, Stony Brook University, Stony Brook, NY, USA
| | - Michael Bisogno
- Department of Orthopaedics, Stony Brook University, Stony Brook, NY, USA
| | - David E Komatsu
- Department of Orthopaedics, Stony Brook University, Stony Brook, NY, USA
| | - Edward D Wang
- Department of Orthopaedics, Stony Brook University, Stony Brook, NY, USA
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Diaz-Dilernia F, Slullitel PA, Oñativia JI, Comba FM, Piccaluga F, Buttaro MA. Impaction Bone Grafting or Uncemented Modular Stems for the Treatment of Type B3 Periprosthetic Femoral Fractures? A Complication Rate Analysis. J Arthroplasty 2019; 34:2051-2057. [PMID: 31160153 DOI: 10.1016/j.arth.2019.04.047] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 04/14/2019] [Accepted: 04/22/2019] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Because the gold standard for the treatment of Vancouver type-B3 periprosthetic femoral fractures (PFFs) is yet to be defined, we sought to analyze the complication rate between the impaction bone grafting (IBG) technique with a cemented stem and reconstruction with an uncemented distally-fixed modular stem (DFMS). METHODS We retrospectively studied 54 B3 PFFs operated between 2000 and 2016, comparing the complication rate of 33 patients treated with the IBG technique (group A) with 21 patients treated with a DFMS (group B). Median follow-up of groups A and B were 75 months (interquartile range [IQR], 36-111 months) and 55 months (IQR, 32-73 months), respectively (P = .008). Median age of groups A and B were 78 years (IQR, 74-83 years) and 81 years (IQR, 74-86 years), respectively (P = .30). Median grade of Endo-Klink femoral bone defect was 3 (IQR, 3-3) for both groups (P = .11). We performed a multiple regression analysis to determine risk factors for complications including the following variables: age, initial diagnosis, and surgical technique. RESULTS As for infection outcomes, 2-stage revision surgery was more frequent in group A than in group B (4 vs 0, P = .003). Group A presented more implant failures than group B (5 vs 1, P = .195). We found 4 dislocations in group B and 2 in group A (P = .192). Multiple regression analysis showed a significant association between surgical technique and complication rate (P = .01). The IBG technique presented an odds risk for complications of 4.77 (P = .016; IQR, 1.33-17.21). CONCLUSION Femoral reconstruction with the IBG technique evidenced an ostensibly higher complication rate than that of DFMS for the treatment of B3 PFF.
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Affiliation(s)
- Fernando Diaz-Dilernia
- Hip centre "Sir John Charnley", Institute of Orthopaedics "Carlos E. Ottolenghi" Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Pablo Ariel Slullitel
- Hip centre "Sir John Charnley", Institute of Orthopaedics "Carlos E. Ottolenghi" Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Jose Ignacio Oñativia
- Hip centre "Sir John Charnley", Institute of Orthopaedics "Carlos E. Ottolenghi" Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Fernando Martin Comba
- Hip centre "Sir John Charnley", Institute of Orthopaedics "Carlos E. Ottolenghi" Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Francisco Piccaluga
- Hip centre "Sir John Charnley", Institute of Orthopaedics "Carlos E. Ottolenghi" Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Martin Alejandro Buttaro
- Hip centre "Sir John Charnley", Institute of Orthopaedics "Carlos E. Ottolenghi" Italian Hospital of Buenos Aires, Buenos Aires, Argentina
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Krauss ES, Segal A, Cronin M, Dengler N, Lesser ML, Ahn S, Caprini JA. Implementation and Validation of the 2013 Caprini Score for Risk Stratification of Arthroplasty Patients in the Prevention of Venous Thrombosis. Clin Appl Thromb Hemost 2019; 25:1076029619838066. [PMID: 30939898 PMCID: PMC6714918 DOI: 10.1177/1076029619838066] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Appropriate chemoprophylaxis choice following arthroplasty requires accurate patient risk
assessment. We compared the results of our prospective department protocol to the Caprini
risk assessment model (RAM) retrospectively in this study group. Our goal was to determine
whether the department protocol or the Caprini score would identify venous thromboembolism
(VTE) events after total joint replacement. A secondary purpose was to validate the 2013
Caprini RAM in joint arthroplasty and determine whether patients with VTE would be
accurately identified using the Caprini score. A total of 1078 patients met inclusion
criteria. A Caprini score of 10 or greater is considered high risk and a score of 9 or
less is considered low risk. The 2013 version of the Caprini RAM retrospectively
stratified 7 of the 8 VTE events correctly, while only 1 VTE was identified with the
prospective department protocol. This tool provided a consistent, accurate, and
efficacious method for risk stratification and selection of chemoprophylaxis.
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Affiliation(s)
- Eugene S Krauss
- 1 Department of Orthopaedic Surgery, Northwell Health, Syosset Hospital, Syosset, NY, USA
| | - Ayal Segal
- 1 Department of Orthopaedic Surgery, Northwell Health, Syosset Hospital, Syosset, NY, USA
| | - MaryAnne Cronin
- 3 Emeritus, NorthShore University Health System, Evanston, IL, USA
| | - Nancy Dengler
- 1 Department of Orthopaedic Surgery, Northwell Health, Syosset Hospital, Syosset, NY, USA
| | - Martin L Lesser
- 2 Biostatistics Unit, Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - Seungjun Ahn
- 2 Biostatistics Unit, Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - Joseph A Caprini
- 3 Emeritus, NorthShore University Health System, Evanston, IL, USA.,4 University of Chicago Pritzker School of Medicine, Chicago, IL, USA
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Borgen PO, Pripp AH, Dybvik E, Leistad L, Dahl OE, Reikerås O. Similar Clinical Outcomes with Preoperative and Postoperative Start of Thromboprophylaxis in THA: A Register-based Study. Clin Orthop Relat Res 2017; 475. [PMID: 28643079 PMCID: PMC5539041 DOI: 10.1007/s11999-017-5419-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Elective THA is associated with a high risk of thromboembolic events. Although these events may be less common now than they were in the past, they can be serious, and most patients undergoing the procedure therefore still receive thromboprophylaxis. However, controversy remains regarding whether to begin thromboprophylaxis before THA or after to best balance the risks of clotting and bleeding. QUESTIONS/PURPOSES We asked the following questions: (1) Is there a difference in bleeding events with pre- versus postoperative thromboprophylaxis? (2) Is there a difference in thromboembolic episodes after THA between the two regimens? (3) How do the two approaches of thromboprophylaxis influence mortality, readmissions, and other complications? METHODS We used a population-based followup design with predefined data based on international health codification to assess clinical effects of LMWH prophylaxis initiated before or after THA. We took data limited to primary THAs done in Norway between January 1, 2008, and December 31, 2011, from the Norwegian Arthroplasty Register and the National Patient Register to have necessary data elements to complete the study. The two registers were merged after identifying patients with their 11-digit personal identification number (Social Security number). We obtained data regarding demographics, administrative and surgical details, and episode histories for prophylaxis-related events within 180 days of surgery. A total of 25,163 patients undergoing THA were included for analysis, and 9977(40%) versus 15,186 (60%) patients received pre- and postoperative LMWH, respectively. We performed statistical adjustment for differences in baseline characteristics using multivariate logistic regression. RESULTS After adjustment for age, sex, operation time, year of surgery, and American Society of Anesthesiologists class, we could not show major differences in bleeding events; (odds ratio [OR], 1.04; 95% CI, 0.88-1.22; p = 0.660), thromboembolic episodes; (OR, 1.03; 95% CI, 0.84-1.27; p = 0.786), or other postoperative clinical complications; (OR, 0.86; 95% CI, 0.76-0.99; p = 0.034), with the two regimens. Six-month mortality was similar, (OR, 0.76; 95% CI, 0.56-1.05; p = 0.093), and the readmission rate was higher in the preoperative group; (OR, 0.92; 95% CI, 0.85-0.97; p = 0.016). CONCLUSIONS The risk for postoperative complications seems to be comparable whether LMWH prophylaxis is initiated before or after THA. The postoperative approach reduces costs, decreases risks related to neuraxial anesthesia, and facilitates same-day admissions. Methods for individual risk assessment including laboratory tests would be feasible. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Pål O. Borgen
- Department of Orthopaedics, Martina Hansens Hospital, Dønskiveien 8, 1346 Gjettum, Norway
| | - Are H. Pripp
- Oslo Centre of Biostatistics and Epidemiology, Research Support Services, Oslo University Hospital, Oslo, Norway
| | - Eva Dybvik
- Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Lilian Leistad
- The Norwegian Patient Register, The Norwegian Directorate of Health, Trondheim, Norway
| | - Ola E. Dahl
- Centre of Medical Science, Education and Innovation, Innlandet Hospital Trust, Elverum, Norway ,Thrombosis Research Institute, London, UK
| | - Olav Reikerås
- Department of Orthopaedics, Oslo University Clinic, Rikshospitalet, Norway
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19
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Gonzalez Della Valle A, Blanes Perez A, Lee YY, Saboeiro GR, Konin GP, Endo Y, Sharrock NE, Salvati EA. The Clinical Severity of Patients Diagnosed With an In-Hospital Pulmonary Embolism Following Modern, Elective Joint Arthroplasty Is Unrelated to the Location of Emboli in the Pulmonary Vasculature. J Arthroplasty 2017; 32:1304-1309. [PMID: 28012721 DOI: 10.1016/j.arth.2016.11.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Revised: 11/07/2016] [Accepted: 11/13/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND In the event of a postoperative pulmonary embolism (PE), it is generally believed that patients with centrally located emboli will have worse clinical symptoms than those with segmental or subsegmental ones. We studied if a relationship exists between the clinical severity at the time of PE diagnosis and the location of the emboli within the pulmonary vasculature. METHODS All 269 patients who developed an in-hospital, computed tomography pulmonary angiography-proved, PE following elective total hip arthroplasty or total knee arthroplasty in our institution were studied. The clinical severity of the PE was calculated using the Pulmonary Embolism Severity Index (PESI) that classifies patients in 5 classes (class 5: most severe). All computed tomography pulmonary angiographies were re-reviewed to determine the location of the emboli within the pulmonary vasculature (central, segmental, or subsegmental-unilateral or bilateral). The association between PESI and the PE location was examined. RESULTS The most proximal location of the emboli was central in 62, segmental in 139, and subsegmental in 68. There were 180 unilateral and 89 bilateral PE patients. There was no association between the PESI and the location of the emboli within the pulmonary vasculature (P = .32). Patients with bilateral or unilateral lung involvement had similar PESI (P = .78). CONCLUSION The PESI, a recognized, validated predictor of mortality after PE was similar in patients with central, segmental, or subsegmental PE; and in patients with unilateral or bilateral lung involvement. The present study may aid clinicians while assessing and discussing the severity of PE symptoms with patients at the time of diagnosis.
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Affiliation(s)
| | - Alvaro Blanes Perez
- Hospital for Special Surgery, Weill Medical College of Cornell University, New York, New York
| | - Yuo-Yu Lee
- Hospital for Special Surgery, Weill Medical College of Cornell University, New York, New York
| | - Gregory R Saboeiro
- Hospital for Special Surgery, Weill Medical College of Cornell University, New York, New York
| | - Gabrielle P Konin
- Hospital for Special Surgery, Weill Medical College of Cornell University, New York, New York
| | - Yoshimi Endo
- Hospital for Special Surgery, Weill Medical College of Cornell University, New York, New York
| | - Nigel E Sharrock
- Hospital for Special Surgery, Weill Medical College of Cornell University, New York, New York
| | - Eduardo A Salvati
- Hospital for Special Surgery, Weill Medical College of Cornell University, New York, New York
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Skin staples versus intradermal wound closure following primary hip arthroplasty: a prospective, randomised trial including 231 cases. Hip Int 2016; 25:563-7. [PMID: 26165360 DOI: 10.5301/hipint.5000278] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/19/2015] [Indexed: 02/04/2023]
Abstract
Intradermal wound closure is controversial in primary total hip arthroplasty. Randomised, controlled trials in wound closure following a total hip arthroplasty (THA) are scarce. Our hypothesis was that skin staples closure would be related to a similar complication rate and operative time as intradermal closure with polypropylene. From September 2011 to May 2012, 231 THAs in 219 patients with an average age of 62 years old (range: 21-91) were performed. No differences were observed in both groups according to sex, age, BMI and comorbidities (p = 0,82). Cases were divided into 3 groups according to medical factors that influence wound healing: group 1 (no medical history, 70.5%), group 2 (diabetes, tobacco smokers, obesity, corticosteroids, rheumatoid disease, 25%) and group 3 (organ transplantation, neoplastic patients or 2 or factors of group 2, 4.5%). Once randomised using a computer-generated method, all patients remained within the group to which they were allocated to wound closure with skin staples (Leukosan® SkinStapler PTW-35, BSN, Germany) that were used in 112 THAs in 105 patients (48%), or continuous 3.0 intradermal non-absorbable polypropylene suture (Prolene™ 0, Ethicon Inc. Somerville, New Jersey, USA) in 119 THA´s in 115 patients (52%). A 3.8% wound complication rate was observed in this series, with a 2.1% complication rate for the group that was closed with skin staples and a 1.7% rate for the group with intradermal suture (p = 0.7). All the complications were treated conservatively except for one acute deep infection (0.4%) that was successfully treated with debridement, component retention and intravenous antibiotics. There were no differences in both groups related to operative time or wound length.In these series of primary elective THAs, skin staples were associated with a similar complication rate to an intradermal closure technique.
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González Della Valle A, Sharrock N, Barlow M, Caceres L, Go G, Salvati EA. The modern, hybrid total hip arthroplasty for primary osteoarthritis at the Hospital for Special Surgery. Bone Joint J 2016; 98-B:54-9. [PMID: 26733642 DOI: 10.1302/0301-620x.98b1.36409] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We describe our technique and rationale using hybrid fixation for primary total hip arthroplasty (THA) at the Hospital for Special Surgery. Modern uncemented acetabular components have few screw holes, or no holes, polished inner surfaces, improved locking mechanisms, and maximised thickness and shell-liner conformity. Uncemented sockets can be combined with highly cross-linked polyethylene liners, which have demonstrated very low wear and osteolysis rates after ten to 15 years of implantation. The results of cement fixation with a smooth or polished surface finished stem have been excellent, virtually eliminating complications seen with cementless fixation like peri-operative femoral fractures and thigh pain. Although mid-term results of modern cementless stems are encouraging, the long-term data do not show reduced revision rates for cementless stems compared with cemented smooth stems. In this paper we review the conduct of a hybrid THA, with emphasis on pre-operative planning, surgical technique, hypotensive epidural anaesthesia, and intra-operative physiology.
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Affiliation(s)
| | - N Sharrock
- Hospital for Special Surgery, 535 East 70th Street, New York, 20012, USA
| | - M Barlow
- Hospital for Special Surgery, 535 East 70th Street, New York, 20012, USA
| | - L Caceres
- Hospital for Special Surgery, 535 East 70th Street, New York, 20012, USA
| | - G Go
- Hospital for Special Surgery, 535 East 70th Street, New York, 20012, USA
| | - E A Salvati
- Hospital for Special Surgery, 535 East 70th Street, New York, 20012, USA
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One-Year All-Cause Mortality of Patients Diagnosed as Having In-Hospital Pulmonary Embolism After Modern Elective Joint Arthroplasty Is Low And Unaffected By Radiologic Severity. J Arthroplasty 2016; 31:473-9. [PMID: 26461488 DOI: 10.1016/j.arth.2015.09.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Revised: 09/01/2015] [Accepted: 09/09/2015] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND We studied the 1-year complication rate of patients diagnosed as having a pulmonary embolism (PE) after elective total hip arthroplasty (THA) and total knee arthroplasty (TKA) surgery and the distribution of emboli in the pulmonary circulation, and determined if a relationship exists between the location of the PE and age, gender, body mass index, preoperative predisposing factors, American Society of Anesthesiology classification, type of surgery, prophylaxis, hospital stay, transfer to a higher level of care, and mortality. METHODS Two hundred sixty-nine patients who developed an in-hospital PE proved by computed tomography pulmonary angiography after elective THA or TKA between 2005 and 2012 were studied. RESULTS The most proximal location of the emboli was central in 62, segmental in 139, and subsegmental in 68. Nineteen patients (7%) developed a bleeding complication during PE treatment. Twenty-nine patients (11%) were readmitted during the first year. Two patients (0.74%) died: one had a segmental PE after TKA. He died 11 months after surgery due to an autopsy-proven sepsis. The second patient developed a segmental PE after THA. She was anticoagulated, developed an intracranial bleed, and died 8 months after surgery. Multivariate analysis showed that demographic variables, American Society of Anesthesiology class, preoperative comorbidities (with the exception of arrhythmia), and the presence of preoperative predisposing factors had no effect in the location of the PE. CONCLUSION The 1-year mortality rate of these patients is low. Death can be caused by bleeding complications secondary to anticoagulation or by unrelated conditions. This information may aid clinicians while counseling patients who developed a PE after surgery, particularly those with small subsegmental emboli.
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Loures EDA, Simoni LF, Leite ICG, Loures DN, Loures CN. Análise preliminar do componente acetabular de titânio plasma‐spray MD‐4®. Rev Bras Ortop 2015. [DOI: 10.1016/j.rbo.2014.02.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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de Araújo Loures E, Simoni LF, Leite ICG, Loures DN, Loures CN. Preliminary analysis on the MD-4® plasma-sprayed titanium acetabular component. REVISTA BRASILEIRA DE ORTOPEDIA (ENGLISH EDITION) 2015; 50:206-13. [PMID: 26229918 PMCID: PMC4519615 DOI: 10.1016/j.rboe.2015.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Accepted: 02/24/2014] [Indexed: 11/22/2022]
Abstract
Objectives To evaluate the short-term performance of a type of implant manufactured in Brazil. Methods This study analyzed a cohort of 60 patients who underwent implantation of MD-4® acetabular components during primary hip arthroplasty procedures performed between January 1, 2010, and August 1, 2012. The patients were studied retrospectively with regard to clinical behavior, stability and radiological osseointegration. The patients were followed up for a minimum of 12 months and a maximum of 42 months (mean: 27) and were evaluated by means of the Harris Hip Score, SF-36 questionnaire and serial conventional radiographs. Results All the components were radiologically stable, without evidence of migration or progressive radiolucency lines. On average, the Harris Hip Score evolved from 36.1 to 92.1 (p < 0.001) and the SF-36 showed significant increases in all its domains (p < 0.001). No differences were observed among patients with osteoarthrosis, osteonecrosis, hip dysplasia or other conditions. Conclusions The short-term results showed clinical and radiological signs of stability and osseointegration of the implants, which may represent a predictive factor regarding medium-term survival of this acetabular component.
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Mont MA, Hozack WJ, Callaghan JJ, Krebs V, Parvizi J, Mason JB. Venous thromboemboli following total joint arthroplasty: SCIP measures move us closer to an agreement. J Arthroplasty 2014; 29:651-2. [PMID: 24655607 DOI: 10.1016/j.arth.2014.02.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Accepted: 02/19/2014] [Indexed: 02/01/2023] Open
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Bloch BV, Patel V, Best AJ. Thromboprophylaxis with dabigatran leads to an increased incidence of wound leakage and an increased length of stay after total joint replacement. Bone Joint J 2014; 96-B:122-6. [DOI: 10.1302/0301-620x.96b1.31569] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Since the introduction of the National Institute for Health and Care Excellence (NICE) guidelines on thromboprophylaxis and the use of extended thromboprophylaxis with new oral agents, there have been reports of complications arising as a result of their use. We have looked at the incidence of wound complications after the introduction of dabigatran for thromboprophylaxis in our unit. We investigated the rate of venous thromboembolism and wound leakage in 1728 patients undergoing primary joint replacement, both before and after the introduction of dabigatran, and following its subsequent withdrawal from our unit. We found that the use of dabigatran led to a significant increase in post-operative wound leakage (20% with dabigatran, 5% with a multimodal regimen; p < 0.001), which also resulted in an increased duration of hospital stay. The rate of thromboembolism in patients receiving dabigatran was higher (1.3%) than in those receiving the multimodal thromboprophylaxis regimen, including low molecular weight heparin as an inpatient and the extended use of aspirin (0.3%, p = 0.047). We have ceased the use of dabigatran for thromboprophylaxis in these patients. Cite this article: Bone Joint J 2014;96-B:122–6.
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Affiliation(s)
- B. V. Bloch
- Leicester General Hospital, University
Hospitals of Leicester NHS Trust, Gwendolen Road, Leicester
LE5 4PW, UK
| | - V. Patel
- Leicester General Hospital, University
Hospitals of Leicester NHS Trust, Gwendolen Road, Leicester
LE5 4PW, UK
| | - A. J. Best
- Leicester General Hospital, University
Hospitals of Leicester NHS Trust, Gwendolen Road, Leicester
LE5 4PW, UK
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Economic Impact of Venous Thromboembolism Following Major Orthopaedic Surgery in Japan. Value Health Reg Issues 2013; 2:81-86. [PMID: 29702857 DOI: 10.1016/j.vhri.2013.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
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.
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Safety and efficacy of multimodal thromboprophylaxis following total knee arthroplasty: a comparative study of preferential aspirin vs. routine coumadin chemoprophylaxis. J Arthroplasty 2013; 28:575-9. [PMID: 23142450 DOI: 10.1016/j.arth.2012.08.004] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Revised: 06/05/2012] [Accepted: 08/05/2012] [Indexed: 02/01/2023] Open
Abstract
Multimodal thromboprophylaxis encompasses preoperative VTE risk stratification, regional anesthesia, mechanical prophylaxis, and early mobilization. We determined if aspirin can be safely used for adjuvant chemoprophylaxis in patients who have a low thromboembolic risk. 1016 consecutive patients undergoing TKA received multimodal thromboprophylaxis. Aspirin was used in 67% of patients and Coumadin 33% (high risk patients, or who were on Coumadin before surgery). This study group was compared to 1001 consecutive patients who received multimodal thromboprophylaxis and routine Coumadin chemoprophylaxis. There was no significant difference in rates of VTE, PE, bleeding, complications, readmission and 90-day mortality between the two groups. There was a significantly higher rate of wound related complications in the control group (p=0.03). Multimodal thromboprophylaxis with aspirin given to the majority of patients at a low VTE risk is safe and effective in patients undergoing primary TKA.
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Abstract
We investigated the incidence of and risk factors for venous thromboembolism (VTE) following surgery of the shoulder and elbow and assessed the role of thromboprophylaxis in upper limb surgery. All papers describing VTE after shoulder and elbow surgery published in the English language literature before 31 March 2012 were reviewed. A total of 14 papers were available for analysis, most of which were retrospective studies and case series. The incidence of VTE was 0.038% from 92 440 shoulder arthroscopic procedures, 0.52% from 42 261 shoulder replacements, and 0.64% from 4833 procedures for fractures of the proximal humerus (open reduction and internal fixation or hemiarthroplasty). The incidence following replacement of the elbow was 0.26% from 2701 procedures. Diabetes mellitus, rheumatoid arthritis and ischaemic heart disease were identified as the major risk factors. The evidence that exists on thromboprophylaxis is based on level III and IV studies, and we therefore cannot make any recommendations on prophylaxis based on the current evidence. It seems reasonable to adopt a multimodal approach that involves all patients receiving mechanical prophylaxis, with chemical prophylaxis reserved for those who are at high risk for VTE. Cite this article: Bone Joint J 2013;95-B:70–4.
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Affiliation(s)
- R. Dattani
- Cambridge University Hospitals NHS Foundation
Trust, Biomedical Campus, Hills Road, Cambridge
CB2 0QQ, UK
| | - C. D. Smith
- Royal Devon And Exeter Hospital, Princess
Elizabeth Orthopaedic Centre, Barrack Road, Exeter
EX2 5DW, UK
| | - V. R. Patel
- South West London Elective Orthopaedic
Centre, Dorking Road, Epsom, Surrey
KT18 7EG, UK
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Buttaro MA, de la Rosa DM, Comba F, Piccaluga F. High failure rate with the GAP II ring and impacted allograft bone in severe acetabular defects. Clin Orthop Relat Res 2012; 470:3148-55. [PMID: 22644424 PMCID: PMC3462861 DOI: 10.1007/s11999-012-2402-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Reconstruction rings and bone allografts have been proposed to manage severe acetabular bone loss. However, a high early failure rate of the Graft Augmentation Prosthesis (GAP) II reinforcement ring (Stryker Orthopaedics, Mahwah, NJ, USA) has been reported in one small series. QUESTIONS/PURPOSES We therefore determined (1) the survival of this device in combination with impacted morselized allograft bone in patients with severe defects and (2) the complication rate. METHODS We retrospectively reviewed 24 patients (21 aseptic and three septic) with severe acetabular bone loss (10 hips with Type III defects and 14 with Type IV defects according to the American Academy of Orthopaedic Surgeons classification). We determined function and numbers of failures. The minimum followup was 24 months (mean, 34 months; range, 24-72 months). RESULTS At latest followup, the reconstruction had failed in nine of the 24 patients: six with aseptic loosening, three with infection. The average postoperative Merle d'Aubigné-Postel score of the patients whose reconstructions had not failed was 16.6 points; at latest followup, these patients had radiographic evidence of incorporation and consolidation of bone allografts. Seven of the nine patients whose reconstructions had failed underwent reoperation. Fatigue fracture of the ring at the plate-cup union occurred in five patients at an average of 45 months postoperatively. All patients with failed reconstructions who underwent reoperation were treated with Trabecular Metal(™) (Zimmer Inc, Warsaw, IN, USA) cups and were functioning well at latest followup. CONCLUSIONS We observed a high rate (37%) of early catastrophic failures of the GAP II reconstruction ring, particularly in patients with Type IV defects. Due to this high failure rate, we have abandoned its use. LEVEL OF EVIDENCE Level IV, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Martin A. Buttaro
- Hip Surgery Unit, Institute of Orthopaedics “Carlos E. Ottolenghi”, Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Diego Muñoz de la Rosa
- Hip Surgery Unit, Institute of Orthopaedics “Carlos E. Ottolenghi”, Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Fernando Comba
- Hip Surgery Unit, Institute of Orthopaedics “Carlos E. Ottolenghi”, Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Francisco Piccaluga
- Hip Surgery Unit, Institute of Orthopaedics “Carlos E. Ottolenghi”, Italian Hospital of Buenos Aires, Buenos Aires, Argentina
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Zhi-Jian S, Gui-Xing Q, Xi-Sheng W, Yu Z, Jin J. Chinese orthopedic surgeons' practice regarding postoperative thromboembolic prophylaxis after major orthopedic surgery. CHINESE MEDICAL SCIENCES JOURNAL = CHUNG-KUO I HSUEH K'O HSUEH TSA CHIH 2012; 27:141-146. [PMID: 23062635 DOI: 10.1016/s1001-9294(14)60046-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
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.
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Affiliation(s)
- Sun Zhi-Jian
- Department of Orthopedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
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Comba F, Alonso Hidalgo I, Buttaro M, Piccaluga F. Risk Factor Analysis for 30-Day Mortality After Primary THA in a Single Institution. HSS J 2012; 8:111-5. [PMID: 23874248 PMCID: PMC3715626 DOI: 10.1007/s11420-012-9279-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2011] [Accepted: 04/16/2012] [Indexed: 02/07/2023]
Abstract
The purpose of this study was to determine the prevalence of, and associated risk factors for, 30-day perioperative death following primary total hip arthroplasty (THA). Data of all the patients were compiled from the computerized total joint registry at a single institution. Between May 1993 and May 2006, 3,232 consecutive primary THA (2,453 elective and 779 nonelective) were performed. Eleven deaths occurred during the first month after surgery (0.34 %). Thirty-day mortality rate after elective THA was 0.08 % (two of 2,453 IC 95 %(0-0.4)). The 30-day mortality rate after nonelective THA was 1.15 % (nine of 779 IC 95 %(0.7-2.4). To analyze the factors that could have contributed with death, we conducted a 4-to-1 nested case-control study. Control cases were strictly matched by sex, age, surgeon, prosthesis fixation mode, and date of surgery. Conditional logistic regression was used to evaluate the association of risk factors with mortality. Elective surgery was associated with a lower risk of mortality with an odds ratio (OR) of 0.07 (95 % CI 0.008-0.6);p = 0.015. American Society of Anesthesiologists (ASA) score III-IV increased the mortality risk 13 times (OR 13.7; 95 % CI 1.6-114.8). Cardiovascular disease increased the risk for mortality eight times (OR 8.83 (95 % CI 1.78-43.6). Time delay before surgery showed a trend towards significance (p = 0.06). Aggressive vs. nonaggressive thromboembolism prophylaxis and the amount of blood transfusions required were not associated with a higher risk of death. Patients undergoing a THA due to fractures, patients with high ASA score, and those with cardiovascular disease were the highest risk factors for 30-day mortality after primary THA.
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Affiliation(s)
- Fernando Comba
- Institute of Orthopaedics “Carlos E. Ottolenghi”, Hospital Italiano de Buenos Aires, Potosí 4215 (1199ACK) Buenos Aires, Argentina
| | - Ignacio Alonso Hidalgo
- Institute of Orthopaedics “Carlos E. Ottolenghi”, Hospital Italiano de Buenos Aires, Potosí 4215 (1199ACK) Buenos Aires, Argentina
| | - Martín Buttaro
- Institute of Orthopaedics “Carlos E. Ottolenghi”, Hospital Italiano de Buenos Aires, Potosí 4215 (1199ACK) Buenos Aires, Argentina
| | - Francisco Piccaluga
- Institute of Orthopaedics “Carlos E. Ottolenghi”, Hospital Italiano de Buenos Aires, Potosí 4215 (1199ACK) Buenos Aires, Argentina
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Aspirin for elective hip and knee arthroplasty: a multimodal thromboprophylaxis protocol. INTERNATIONAL ORTHOPAEDICS 2012; 36:1995-2002. [PMID: 22684546 DOI: 10.1007/s00264-012-1588-4] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2012] [Accepted: 05/21/2012] [Indexed: 10/28/2022]
Abstract
PURPOSE Multimodal thromboprophylaxis includes preoperative thromboembolic risk stratification and autologous blood donation, surgery performed under regional anaesthesia, postoperative rapid mobilisation, use of pneumatic compression devices and chemoprophylaxis tailored to the patient's individual risk. We determined the 90-day rate of venous thromboembolism (VTE), other complications and mortality in patients who underwent primary elective hip and knee replacement surgery with multimodal thromboprophylaxis. METHODS A total of 1,568 consecutive patients undergoing hip and knee replacement surgery received multimodal thromboprophylaxis: 1,115 received aspirin, 426 received warfarin and 27 patients received low molecular weight heparin and warfarin with or without a vena cava filter. RESULTS The rate of VTE, pulmonary embolism, proximal deep vein thrombosis (DVT) and distal DVT was 1.2, 0.36, 0.45 and 0.36 %, respectively, in patients who received aspirin. The rates in those who received warfarin were 1.4, 0.9, 0.47 and 0.47 %, respectively. The overall 90-day mortality rate was 0.2 %. CONCLUSIONS Multimodal thromboprophylaxis in which aspirin is administered to low-risk patients is safe and effective following primary total joint replacement.
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Poultsides LA, Gonzalez Della Valle A, Memtsoudis SG, Ma Y, Roberts T, Sharrock N, Salvati E. Meta-analysis of cause of death following total joint replacement using different thromboprophylaxis regimens. ACTA ACUST UNITED AC 2012; 94:113-21. [PMID: 22219258 DOI: 10.1302/0301-620x.94b1.27301] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
We performed a meta-analysis of modern total joint replacement (TJR) to determine the post-operative mortality and the cause of death using different thromboprophylactic regimens as follows: 1) no routine chemothromboprophylaxis (NRC); 2) Potent anticoagulation (PA) (unfractionated or low-molecular-weight heparin, ximelagatran, fondaparinux or rivaroxaban); 3) Potent anticoagulation combined (PAC) with regional anaesthesia and/or pneumatic compression devices (PCDs); 4) Warfarin (W); 5) Warfarin combined (WAC) with regional anaesthesia and/or PCD; and 6) Multimodal (MM) prophylaxis, including regional anaesthesia, PCDs and aspirin in low-risk patients. Cause of death was classified as autopsy proven, clinically certain or unknown. Deaths were grouped into cardiopulmonary excluding pulmonary embolism (PE), PE, bleeding-related, gastrointestinal, central nervous system, and others (miscellaneous). Meta-analysis based on fixed effects or random effects models was used for pooling incidence data. In all, 70 studies were included (99 441 patients; 373 deaths). The mortality was lowest in the MM (0.2%) and WC (0.2%) groups. The most frequent cause of death was cardiopulmonary (47.9%), followed by PE (25.4%) and bleeding (8.9%). The proportion of deaths due to PE was not significantly affected by the thromboprophylaxis regimen (PA, 35.5%; PAC, 28%; MM, 23.2%; and NRC, 16.3%). Fatal bleeding was higher in groups relying on the use of anticoagulation (W, 33.8%; PA, 9.4%; PAC, 10.8%) but the differences were not statistically significant. Our study demonstrated that the routine use of PA does not reduce the overall mortality or the proportion of deaths due to PE.
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Affiliation(s)
- L A Poultsides
- Hospital for Special Surgery, 535 East 70th Street, New York, New York 10021, USA
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35
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Buttaro MA, Costantini J, Comba F, Piccaluga F. The use of femoral struts and impacted cancellous bone allograft in patients with severe femoral bone loss who undergo revision total hip replacement. ACTA ACUST UNITED AC 2012; 94:167-72. [DOI: 10.1302/0301-620x.94b2.27296] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We determined the midterm survival, incidence of peri-prosthetic fracture and the enhancement of the width of the femur when combining struts and impacted bone allografts in 24 patients (25 hips) with severe femoral bone loss who underwent revision hip surgery. The pre-operative diagnosis was aseptic loosening in 16 hips, second-stage reconstruction in seven, peri-prosthetic fracture in one and stem fracture in one hip. A total of 14 hips presented with an Endoklinik grade 4 defect and 11 hips a grade 3 defect. The mean pre-operative Merle D’Aubigné and Postel score was 5.5 points (1 to 8). The survivorship was 96% (95% confidence interval 72 to 98) at a mean of 54.5 months (36 to 109). The mean functional score was 17.3 points (16 to 18). One patient in which the strut did not completely bypass the femoral defect was further revised using a long cemented stem due to peri-prosthetic fracture at six months post-operatively. The mean subsidence of the stem was 1.6 mm (1 to 3). There was no evidence of osteolysis, resorption or radiolucencies during follow-up in any hip. Femoral width was enhanced by a mean of 41% (19% to 82%). A total of 24 hips had partial or complete bridging of the strut allografts. This combined biological method was associated with a favourable survivorship, a low incidence of peri-prosthetic fracture and enhancement of the width of the femur in revision total hip replacement in patients with severe proximal femoral bone loss.
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Affiliation(s)
- M. A. Buttaro
- Italian Hospital of Buenos Aires, The
Hip Surgery Unit, Institute of Orthopaedics ‘Carlos
E. Ottolenghi’, Potosi 4247, Buenos
Aires, 1199, Argentina
| | - J. Costantini
- Italian Hospital of Buenos Aires, The
Hip Surgery Unit, Institute of Orthopaedics ‘Carlos
E. Ottolenghi’, Potosi 4247, Buenos
Aires, 1199, Argentina
| | - F. Comba
- Italian Hospital of Buenos Aires, The
Hip Surgery Unit, Institute of Orthopaedics ‘Carlos
E. Ottolenghi’, Potosi 4247, Buenos
Aires, 1199, Argentina
| | - F. Piccaluga
- Italian Hospital of Buenos Aires, The
Hip Surgery Unit, Institute of Orthopaedics ‘Carlos
E. Ottolenghi’, Potosi 4247, Buenos
Aires, 1199, Argentina
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Tsuda K, Kawasaki T, Nakamura N, Yoshikawa H, Sugano N. Natural course of asymptomatic deep venous thrombosis in hip surgery without pharmacologic thromboprophylaxis in an Asian population. Clin Orthop Relat Res 2010; 468:2430-6. [PMID: 20058109 PMCID: PMC2919892 DOI: 10.1007/s11999-009-1220-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2009] [Accepted: 12/22/2009] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Kosuke Tsuda
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Tomio Kawasaki
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Suita, Osaka Japan
| | - Nobuo Nakamura
- Center of Arthroplasty, Kyowakai Hospital, Suita, Osaka Japan
| | - Hideki Yoshikawa
- Department of Orthopaedic Surgery, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
| | - Nobuhiko Sugano
- Department of Orthopaedic Medical Engineering, Osaka University Graduate School of Medicine, 2-2 Yamadaoka, Suita, Osaka Japan
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Campbell D, Smith P, Lewis P, Bruce W. Controversies of thrombophylaxis following knee arthroplasty surgery. ANZ J Surg 2010; 80:391-5. [DOI: 10.1111/j.1445-2197.2010.05306.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Memtsoudis SG, Della Valle AG, Besculides MC, Esposito M, Koulouvaris P, Salvati EA. Risk factors for perioperative mortality after lower extremity arthroplasty: a population-based study of 6,901,324 patient discharges. J Arthroplasty 2010; 25:19-26. [PMID: 19106028 DOI: 10.1016/j.arth.2008.11.010] [Citation(s) in RCA: 84] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2008] [Accepted: 11/15/2008] [Indexed: 02/01/2023] Open
Abstract
The goal of this study was to provide nationally representative data on characteristics of patients who died after hip and knee arthroplasty and to determine risk factors for such outcome. Using national in-patient data collected between 1990 and 2004, we identified a cumulative in-hospital mortality rate of 0.35% among an estimated 6,901,324 procedures. The strongest independent risk factors for in-hospital mortality were pulmonary embolism and cerebrovascular complications, which increased the odds for a fatal outcome by approximately 40-fold. Preoperative risk factors for in-hospital mortality were revision total hip arthroplasty, advanced age, and the presence of a number of comorbid diseases, predominantly dementia, renal, and cerebrovascular disease. Our results can be used to identify patients at risk for fatal outcome and implement interventions to reduce such risk.
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Affiliation(s)
- Stavros G Memtsoudis
- Department of Anesthesiology, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, New York 10021, USA
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High incidence of complications from enoxaparin treatment after arthroplasty. Clin Orthop Relat Res 2010; 468:115-9. [PMID: 19669848 PMCID: PMC2795811 DOI: 10.1007/s11999-009-1020-6] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2008] [Accepted: 07/22/2009] [Indexed: 01/31/2023]
Abstract
UNLABELLED Pulmonary embolism (PE) complicates 1% to 10% of total joint arthroplasties and generally requires immediate anticoagulation. Low-molecular-weight heparins have supplanted unfractionated heparin as the treatment of choice for PE and hold a 1A recommendation from the American College of Chest Physicians for this indication. However, the complications of enoxaparin treatment begun in close proximity to arthroplasty surgery are not well described. We examined the records of 135 patients who underwent total joint arthroplasty, experienced an in-hospital PE, and received treatment with enoxaparin at therapeutic doses (1 mg/kg body weight). The type and frequency of complications were determined and classified as major or minor. Twenty-seven percent of patients experienced minor complications and 10% experienced major complications. The incidence of major bleeding was substantially higher than rates reported for nonsurgical patients. The overall complication rate of enoxaparin treatment is similar to the rate of complications reported for unfractionated heparin treatment in this setting, but the complications are less severe. LEVEL OF EVIDENCE Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
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Sugano N, Miki H, Nakamura N, Aihara M, Yamamoto K, Ohzono K. Clinical efficacy of mechanical thromboprophylaxis without anticoagulant drugs for elective hip surgery in an Asian population. J Arthroplasty 2009; 24:1254-7. [PMID: 19577898 DOI: 10.1016/j.arth.2009.05.015] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2008] [Accepted: 05/11/2009] [Indexed: 02/01/2023] Open
Abstract
To evaluate the clinical efficacy of mechanical thromboprophylaxis after elective hip surgery, we reviewed 3016 patients who underwent hip surgery at 5 centers. Primary total hip arthroplasty (THA), revision THA, and pelvic or femoral osteotomies were performed in 2648, 298, and 70 patients, respectively. Epidural anesthesia, intraoperative calf bandage, early mobilization, and intermittent pneumatic compression postoperatively with additional use of elastic stockings were the basic regimen for thromboprophylaxis. Postoperatively, no cases of fatal pulmonary embolism (PE) were encountered. One symptomatic PE and 4 symptomatic deep vein thrombosis cases were identified, all of which were successfully treated using heparin and warfarin. By 6 months, no deaths had occurred. We conclude that mechanical thromboprophylaxis without anticoagulant drugs is safe and effective for elective hip surgeries in our patient population.
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Affiliation(s)
- Nobuhiko Sugano
- Department of Orthopedic Medical Engineering, Osaka University Graduate School of Medicine, Suita, Osaka, Japan
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Buttaro MA, Comba F, Piccaluga F. Proximal femoral reconstructions with bone impaction grafting and metal mesh. Clin Orthop Relat Res 2009; 467:2325-34. [PMID: 19294476 PMCID: PMC2866911 DOI: 10.1007/s11999-009-0777-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2008] [Accepted: 02/23/2009] [Indexed: 01/31/2023]
Abstract
Extensive circumferential proximal cortical bone loss is considered by some a contraindication for impaction bone grafting in the femur. We asked whether reconstruction with a circumferential metal mesh, impacted bone allografts, and a cemented stem would lead to acceptable survival in these patients. We retrospectively reviewed 14 patients (15 hips) with severe proximal femoral bone defects (average, 12 cm long; 14 type IV and one type IIIB using the classification of Della Valle and Paprosky) reconstructed with this method. The minimum followup was 20 months (average, 43.2 months; range, 20-72 months). Preoperative Merle D'Aubigné and Postel score averaged 4.8 points. With revision of the stem as the end point, the survivorship of the implant was 100% at one year and 86.6% at 72 months. The mean functional score at last followup was 14.4 points. We observed two fractures of the metal mesh at 31 and 48 months in cases reconstructed with a stem that did not bypass the mesh. Dislocation (3 cases) and acute deep infection (3 cases) were the most frequent complications. Patients with complete absence of the proximal femur may be candidates for biological proximal femoral reconstructions using this salvage procedure. Bone impaction grafting must be a routine technique if this method is selected.
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Affiliation(s)
- Martín A. Buttaro
- Hip Surgery Unit, Institute of Orthopaedics “Carlos E. Ottolenghi,” Italian Hospital of Buenos Aires, Potosí 4215 (C1199ACK), Buenos Aires, Argentina
| | - Fernando Comba
- Hip Surgery Unit, Institute of Orthopaedics “Carlos E. Ottolenghi,” Italian Hospital of Buenos Aires, Potosí 4215 (C1199ACK), Buenos Aires, Argentina
| | - Francisco Piccaluga
- Hip Surgery Unit, Institute of Orthopaedics “Carlos E. Ottolenghi,” Italian Hospital of Buenos Aires, Potosí 4215 (C1199ACK), Buenos Aires, Argentina
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Assessment of thrombotic risk factors predisposing to thromboembolic complications in prosthetic orthopedic surgery. J Orthop Sci 2009; 14:484-90. [PMID: 19802658 DOI: 10.1007/s00776-009-1368-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2009] [Accepted: 05/08/2009] [Indexed: 02/09/2023]
Abstract
BACKGROUND Congenital thrombophilia is responsible for thromboembolic complications despite prolonged low-molecular-weight heparin (LMWH) prophylaxis following hip and knee endoprosthesis surgery. METHODS A series of 86 patients with hip or knee endoprosthesis surgery were assessed 1 year after operation. Antithrombin III, protein C, and protein S were determined, and the activated protein C sensitivity ratio was measured. We screened for the presence of lupus anticoagulant, factor V Leiden mutation, and polymorphism of prothrombin G20210A. The lower limb venous circulation was monitored by color Doppler ultrasonography. Pulmonary embolism (PE) was diagnosed using ventilation and perfusion scintigraphy. RESULTS In all, 33 patients had thromboembolic complications, 18 with thrombophilia (7 with combined form). Of the 53 patients without complications 12 had thrombophilia (2 with combined form). The differences were statistically significant. The risk score, the prevalence of FV Leiden and prothrombin G20210A mutations, and lupus anticoagulant were also significantly higher in the symptomatic group. Deep vein thrombosis (DVT) developed preoperatively in 15 patients; DVT and PE in 4 patients; thrombophilia was diagnosed in 53% and 75% of these cases. In all, 17 patients had postoperative thromboembolic complications: DVT developed in nine and PE in one patient (all with thrombophilia); DVT + PE developed in seven patients (all but one had thrombophilia). CONCLUSIONS Significant differences were found in the incidence (P < or = 0.01) of thrombophilia and the risk score (P < or = 0.02) between symptomatic and asymptomatic patients. We recommend preoperative thrombophilia screening for patients with a history or familial prevalence of thromboembolism and/or with a high risk score (> or =15). In cases of thrombophilia, the form and duration of anticoagulant treatment must be decided individually.
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González Della Valle A, Khakharia S, Glueck CJ, Taveras N, Wang P, Fontaine RN, Salvati EA. VKORC1 variant genotypes influence warfarin response in patients undergoing total joint arthroplasty: a pilot study. Clin Orthop Relat Res 2009; 467:1773-80. [PMID: 19034590 PMCID: PMC2690741 DOI: 10.1007/s11999-008-0641-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2008] [Accepted: 11/11/2008] [Indexed: 01/31/2023]
Abstract
UNLABELLED Warfarin dosing algorithms do not account for genetic mutations that can affect anticoagulation response. We retrospectively assessed to what extent the VKORC1 variant genotype would alter the likelihood of being a hyperresponder or hyporesponder to warfarin in patients undergoing total joint arthroplasty. We used the international normalized ratio (INR) on the third postoperative day of 3.0 or greater to define warfarin hyperresponders and 1.07 or less to define hyporesponders. A control group of normal responders was identified. From a cohort of 1125 patients receiving warfarin thromboprophylaxis, we identified 30 free of predisposing factors that could affect warfarin response: 10 hyperresponders, eight hyporesponders, and 12 normal responders. Homozygous carriers of the VKORC1 mutant AA genotype were more likely (compared with carriers of GA or GG genotypes) to be hyperresponders (odds ratio, 7.5; 95% confidence interval, 1.04-54.1). Homozygous carriers of the GG (normal) genotype were more likely (compared with carriers of AA or GA genotypes) to be hyporesponders (odds ratio, 9; 95% confidence interval, 1.14-71). Preoperative screening for the VKORC-1 genotype could identify patients with a greater potential for being a hyperresponder or hyporesponder to warfarin. This may allow an adjusted pharmacogenetic-based warfarin dose to optimize anticoagulation, reducing postoperative risks of bleeding and thrombosis or embolism. LEVEL OF EVIDENCE Level III, diagnostic study.
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Novicoff WM, Brown TE, Cui Q, Mihalko WM, Slone HS, Saleh KJ. Mandated venous thromboembolism prophylaxis: possible adverse outcomes. J Arthroplasty 2008; 23:15-9. [PMID: 18555656 DOI: 10.1016/j.arth.2008.04.014] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2007] [Accepted: 04/06/2008] [Indexed: 02/01/2023] Open
Abstract
The purpose of this study was to assess the prevalence and seriousness of adverse outcomes owing to mandatory venous thromboembolism (VTE) prophylaxis. A retrospective study of administrative claims data was conducted to look at the rate of VTEs and other complications in patients undergoing hip and knee arthroplasty. Additional analysis was done to determine whether patient characteristics could explain findings. Although rates of VTE remain unchanged from 2003 to 2007, the rate of immediate postprocedure hematoma, seroma, and hemorrhage went from 1.4% in 2003 to 9.6% in 2006. Return to a more conservative prophylaxis approach resulted in a marked decrease in rates of significant bleeding events. Although preventing VTEs is an important quality concern, mandating prophylaxis for all patients could have unintended adverse outcomes. These guidelines might need to be reevaluated for hip and knee arthroplasty patients.
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Affiliation(s)
- Wendy M Novicoff
- Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, Virginia 22908, USA
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Geerts WH, Bergqvist D, Pineo GF, Heit JA, Samama CM, Lassen MR, Colwell CW. Prevention of Venous Thromboembolism. Chest 2008; 133:381S-453S. [PMID: 18574271 DOI: 10.1378/chest.08-0656] [Citation(s) in RCA: 2862] [Impact Index Per Article: 178.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- William H Geerts
- From Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | | | - Graham F Pineo
- Foothills Hospital, University of Calgary, Calgary, AB, Canada
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Sharrock NE, Gonzalez Della Valle A, Go G, Lyman S, Salvati EA. Potent anticoagulants are associated with a higher all-cause mortality rate after hip and knee arthroplasty. Clin Orthop Relat Res 2008; 466:714-21. [PMID: 18264861 PMCID: PMC2505231 DOI: 10.1007/s11999-007-0092-4] [Citation(s) in RCA: 139] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2007] [Accepted: 11/29/2007] [Indexed: 01/31/2023]
Abstract
Anticoagulation for thromboprophylaxis after THA and TKA has not been confirmed to diminish all-cause mortality. We determined whether the incidence of all-cause mortality and pulmonary embolism in patients undergoing total joint arthroplasty differs with currently used thromboprophylaxis protocols. We reviewed articles published from 1998 to 2007 that included 6-week or 3-month incidence of all-cause mortality and symptomatic, nonfatal pulmonary embolism. Twenty studies included reported 15,839 patients receiving low-molecular-weight heparin, ximelagatran, fondaparinux, or rivaroxaban (Group A); 7193 receiving regional anesthesia, pneumatic compression, and aspirin (Group B); and 5006 receiving warfarin (Group C). All-cause mortality was higher in Group A than in Group B (0.41% versus 0.19%) and the incidence of clinical nonfatal pulmonary embolus was higher in Group A than in Group B (0.60% versus 0.35%). The incidences of all-cause mortality and nonfatal pulmonary embolism in Group C were similar to those in Group A (0.4 and 0.52, respectively). Clinical pulmonary embolus occurs despite the use of anticoagulants. Group A anticoagulants were associated with the highest all-cause mortality of the three modalities studied.
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MESH Headings
- Anesthesia, Conduction/adverse effects
- Anticoagulants/adverse effects
- Arthroplasty, Replacement, Hip/adverse effects
- Arthroplasty, Replacement, Hip/mortality
- Arthroplasty, Replacement, Knee/adverse effects
- Arthroplasty, Replacement, Knee/mortality
- Aspirin/adverse effects
- Azetidines/adverse effects
- Benzylamines/adverse effects
- Fondaparinux
- Heparin, Low-Molecular-Weight/adverse effects
- Humans
- Intermittent Pneumatic Compression Devices/adverse effects
- Morpholines/adverse effects
- Platelet Aggregation Inhibitors/adverse effects
- Polysaccharides/adverse effects
- Pulmonary Embolism/etiology
- Pulmonary Embolism/mortality
- Pulmonary Embolism/prevention & control
- Risk Assessment
- Risk Factors
- Rivaroxaban
- Thiophenes/adverse effects
- Treatment Outcome
- Warfarin/adverse effects
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Affiliation(s)
- Nigel E Sharrock
- Department of Anesthesiology, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA.
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Mayle RE, DiGiovanni CW, Lin SS, Tabrizi P, Chou LB. Current concepts review: venous thromboembolic disease in foot and ankle surgery. Foot Ankle Int 2007; 28:1207-16. [PMID: 18021595 DOI: 10.3113/fai.2007.1207] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Robert E Mayle
- Orthopaedic Surgery, Stanford University, Stanford, CA, USA
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