Review article: Venous thromboembolism after total joint replacement

Safety and Blood Loss Associated With Tourniquets in Total Knee Arthroplasty

Objective

To measure total blood loss and safety of tourniquets, tourniquets during cementation, or no tourniquets during total knee arthroplasty (TKA).

Methods

This retrospective cohort study included 75 patients from King Khalid University Hospital in Riyadh, Saudi Arabia. Patients were equally divided into three groups: tourniquets, no-tourniquets, and tourniquets during cementation. Recorded data included: baseline characteristics (age, sex, weight, height, body mass index (BMI), anesthesia type, and comorbidities), blood loss parameters (total blood loss, preoperative and postoperative hematocrit (Hct) and hemoglobin (Hgb), and blood transfusion units), duration of surgery, hospital stay, and thromboembolic events during 3-months postoperatively. Statistical significance was reported by using a P-value < 0.05, and 95% confidence intervals.

Results

The tourniquet group had significantly lower mean total blood loss (544.67 mL ± 418.86; P = 0.001), higher mean postoperative hemoglobin values (115.44 g/dL ± 10.97; P = 0.004) and hematocrit (34.25 % ± 3.35; P = 0.005), and lower median intra-operative loss (100 cc, 10-300; P < 0.001), than the other groups. Tourniquets during cementation required significantly more mean surgery time (131.84 minutes ± 22.12; P = 0.003), and longer median hospital stay (8 days, 5-13) than the other groups.

Conclusion

Tourniquet use during TKA significantly decreased total and intraoperative blood loss, but it did not have any significant effect on the transfusion rate or the incidence of thromboembolic events.

Complications and outcome after periacetabular osteotomy - influence of surgical approach

BACKGROUND

Bernese periacetabular osteotomy (PAO) was introduced by Ganz as a novel surgical technique for hip dysplasia with a congruent hip to reorient the acetabulum in skeletally mature patients. The PAO through a modified Smith-Petersen (Iliofemoral) approach, has been subject to many modifications in order to avoid complications and to minimise risks for failure.

AIM

The aim of this review was to report on the complication rates, functional and radiological outcomes in relation to surgical approaches.

METHODS

A search of NICE healthcare database advanced search, was conducted from the year of inception to May 2018. We included studies that reported complications of PAO. Data extracted from case series was analysed to detect the incidence of complications, relation to surgical approach and temporal trend of complications.

RESULTS

40 studies including 4070 hips with a mean age of 29 years and a mean follow-up of 52.8 month, were analysed. Outcome measures demonstrated good to excellent outcome in 82%. Higher rates of LFCN and sciatic nerve injuries were found to be associated with the ilioinguinal and the 2-incision approach. Minimally invasive (MIS) modified Smith-Petersen (MSP), minimally invasive trans-sartorial and trans-trochanteric approaches were not reported to be associated with any major wound complications. Radiological correction achieved with a mean improvement in acetabular inclination of 17.90 (range 4.5-40), anterior centre-edge correction 25.40 (range 10-51), lateral centre-edge correction 23.30 (range 15-44.6) and medial translation of 6 mm (range 3.2-10).

CONCLUSIONS

The complication rates seem to be lower in this current review (7%) as compared to the previous review performed by Clohisy et al. (6-37%). The MIS trans-sartorial/MIS MSP and intertrochanteric approaches are associated with an even reduced complications rates. This review enables favouring the minimally invasive approaches with regard to reducing nerve injury and wound complications.

How Do Previous Solid Organ Transplant Recipients Fare After Primary Total Knee Arthroplasty?

INTRODUCTION

Total knee arthroplasty (TKA) has been proven to increase knee outcome scores after solid organ transplantation (SOT), but many authors are concerned about a higher complication rate. The purpose of this study is to evaluate the complication profile of TKA after previous SOT.

METHODS

A search of the entire Medicare database from 2005 to 2011 was performed using International Classification of Disease, version 9, codes to identify 3339 patients who underwent TKA after 1 or more solid organ transplants including the kidney (2321), liver (772), lung (129), heart (412), and pancreas (167). A cohort of 1,685,295 patients served as a control with minimum 2-year follow-up. Postoperative complications at 30-day, 90-day, and overall time points were compared between the 2 cohorts.

RESULTS

Patients with any SOT were younger (age: <65, odds ratio [OR]: 6.58, P < .001), male (OR: 1.88, P < .001), and medically complex (significant increase in 28 of 29 Elixhauser comorbidities, P < .05). There was a significant increase (P < .05) in 11 of 13 (84.6%) recorded postoperative medical complications rates at 90 days. There was a significant increase overall in periprosthetic infection (OR: 2.11, P < .001), periprosthetic fracture (OR: 1.78, P < .001), and TKA revision (OR: 1.36, P < .001). When analyzed by individual organ, heart and lung transplants carried the fewest medical and surgical complications.

CONCLUSION

The results of this study demonstrate that patients with previous SOT who undergo elective primary TKA have more postoperative complications in the global period and at short-term follow-up. Yet, complication profiles by individual organ varied significantly.