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PubMed2003

Risk factors for clinically relevant pulmonary embolism and deep venous thrombosis in patients undergoing primary hip or knee arthroplasty.

BACKGROUND: Prevention of thromboembolic complications after elective lower extremity arthroplasty has increasingly relied on routine thromboprophylaxis in all patients. Not all patients are at equal risk, however, and prophylaxis is not devoid of complications. The aim of this study was to examine the risk factors for clinically relevant pulmonary embolism and deep venous thrombosis after elective primary hip or knee arthroplasty in a large patient population. METHODS: During the 10-yr study period, 116 of 9,791 patients undergoing primary hip or knee arthroplasty at the authors' institution who experienced pulmonary embolism or deep venous thrombosis within 30 days of surgery were matched at a 1:1 ratio with patients undergoing the same surgery with the same surgeon who did not experience an adverse event. Medical records were reviewed, with data abstracted using a standardized data collection form. RESULTS: Increased body mass index (P = 0.031; odds ratio = 1.5 for each 5-kg/m2 increase) and American Society of Anesthesiologists physical status classification of 3 or greater (P = 0.005; odds ratio = 2.6) were found to independently increase the likelihood of pulmonary embolism or deep venous thrombosis. In addition, use of antithrombotic prophylaxis was found to decrease the likelihood of these thromboembolic events (P = 0.050; odds ratio = 0.2 for aspirin or subcutaneous heparin, and odds ratio = 0.4 for warfarin or low-molecular-weight heparin). CONCLUSIONS: In patients undergoing primary elective lower extremity arthroplasty, obesity, poor American Society of Anesthesiologists physical status classification, and lack of thromboprophylaxis are independent risk factors for clinically relevant thromboembolic events.

Aged↗
PubMed2001

Dalteparin vs. enoxaparin as prophylaxis for deep-vein thrombosis after total hip or knee arthroplasty: a retrospective analysis.

OBJECTIVE: To assess the clinical and economic consequences of a formulary switch from enoxaparin to dalteparin as first-line prophylaxis for deep-vein thrombosis in patients undergoing inpatient rehabilitation after total hip arthroplasty or total knee arthroplasty. DESIGN: Retrospective cohort study. RESULTS: There were 461 patients eligible for the study. The age-adjusted risk of a deep-vein thrombosis event confirmed by duplex ultrasonography among patients treated with dalteparin was substantially lower than among patients treated with enoxaparin, whereas the age-adjusted risk of a bleeding event in the dalteparin group was also lower than that in the enoxaparin group. Adjusted per capita costs of deep-vein thrombosis prophylaxis during the rehabilitation stay were $129 lower among subjects treated with dalteparin. CONCLUSION: The switch to dalteparin as a first-line therapy for deep-vein thrombosis prophylaxis in the rehabilitation period after total hip arthroplasty or total knee arthroplasty has led to substantial cost savings for Kessler Institute without compromising patient care.

Aged↗
PubMed2002

Osteoconductive coatings for total joint arthroplasty.

Osteoconductive calcium phosphate coatings for total joint arthroplasty have been in clinical use since the mid1980s. The basic principles involved and basic science evidence for the efficacy of osteoconductive coatings were examined. Hydroxyapatite coatings provide consistent and better filling with bone of the gaps and spaces around cementless joint components after surgery as compared with porous-coated implant surfaces, resulting in better implant stability. Of all the calcium phosphate coatings, hydroxyapatite coatings have had the most widespread application in hip arthroplasty. Their clinical advantages over more conventional implant surfaces are evident in primary and revision hip arthroplasties. A clinical survival rate in the author's series of 97% at a minimum of 11 years followup for the femoral component in a young active patient population (average age, 53 years) was obtained with no mechanical failures. The average polyethylene wear rate in this group was 0.129 mm/year. In a similar group of young patients with revision arthroplasty using hydroxyapatite-coated femoral components, an 11-year survival rate of 93% was obtained. Histologic analysis of specimens retrieved at autopsy confirmed the excellent bony fixation of components. Advantages of the more recent biomimetic hydroxyapatite coatings were examined.

Arthroplasty, Replacement↗
PubMed2004

Long-term results of total joint arthroplasty in elderly patients who are frail.

Many studies of joint replacement in the aged population include a wide spectrum of geriatric patients ranging from relative healthy and otherwise vigorous younger-elderly to small numbers of much older patients with many comorbid problems. To clarify the latter patient subset we assessed the results of total hip and knee arthroplasties done on a group of frail elderly patients. We retrospectively reviewed the preoperative and postoperative charts and radiographs of 130 patients who were at least 80 years when they had a total joint arthroplasty. One hundred arthroplasties (70 hips, 30 knees) were done. On a subjective grading scale, 95% of the patients were very satisfied, 5% reported satisfactory outcomes and no patients considered their results poor. After surgery, 90% of the patients became community walkers without assistance. The level of independent living was maintained in 97% of patients at long-term followup. Causes of morbidity included two infections, one dislocation, and one leg-length discrepancy. This study specifically addresses the outcomes of total joint replacement in elderly patients who are frail. We show that satisfactory and cost-effective health outcomes can be anticipated after total joint arthroplasties in this age group.

Aged↗
PubMed2001

Occurrence of pulmonary thromboembolism immediately after arthroplasty.

INTRODUCTION: Respiratory complications are common after arthroplasty, with pulmonary thromboembolic disease (PTE) and fat emboli being the most serious. A scintigraphic study was designed to assess the occurrence of both diseases. A prospective tomographic study of perfusion was performed within 24 h of arthroplasty. Details of the detection of fat embolism will be presented elsewhere. METHODS: Patients with previous PTE were excluded. Tomographic lung studies were acquired after 99mTc-macroaggregated albumin injection. Pre- and post-operative arterial blood gases (ABGs) and relevant chest radiography/computed tomography scans were obtained. ABGs were analysed as the difference in alveolar-arterial oxygen gradients, pre- and post-operatively (DA-a). RESULTS: Forty patients were studied (16F, 24M) with a mean age of 71 years (range 36-88 years). Of these, 16 were hip and 24 knee arthroplasties. PTE was detected in 25 of 38 (66%) patients evaluated. The value of DA-a was significantly different between patients with PTE and without PTE (P>0.05). Administration of prophylactic pre-operative low molecular weight heparin makes no difference to the early onset of PTE. CONCLUSION: There is a high incidence of PTE immediately after arthroplasty.

Arthroplasty, Replacement, Hip↗
PubMedDate not supplied

Revision total hip and total knee arthroplasty.

For thousands of patients with advanced degenerative joint disease, total joint arthroplasty provides improved function, decreased pain, and the opportunity to resume a more active lifestyle (Drake, Ace, & Maale, 2002). Although hip and knee replacements are both successful interventions for degenerative joint conditions, complications may arise that require revision of the original surgery. In 1999, approximately 25,000 revisions of knee replacements (ICD Code 81.22) and 30,000 revisions of hip replacements (ICD Code 81.53) were performed in the United States (American Academy of Orthopaedic Surgeons [AAOS], 2002). Approximately 10,000 revision total hip arthroplasty procedures were performed on Medicare patients in 2000. The total cost of revision surgery, including the 10,000 total knee revision procedures performed on this same patient population during that year, exceeds USD 3 billion (Bourne, Maloney, & Wright, 2004). Descriptions of the risk factors and indications for revision total hip and total knee arthroplasty are included in this article. Nursing interventions and patient education specific to these patient populations are outlined, and a discussion of complications following revision total joint arthroplasty is included.

Activities of Daily Living↗
PubMed2006

Low complication rate of LISS for femur fractures adjacent to stable hip or knee arthroplasty.

UNLABELLED: Fractures of the femur after a knee or hip arthroplasty historically have been plagued with high complication rates. The Less Invasive Stabilization System (LISS) has theoretical advantages of improved biomechanics and limited insult to the bone's vascular supply. We theorized that the LISS would have a lower complication rate than historical controls for these fractures. Patients who were treated with a LISS at two Level I trauma centers from July 2001 to July 2003 were prospectively followed up. The inclusion criteria were an acute fracture of the femur treated with a LISS in a patient with a stable ipsilateral total knee prosthesis and/or hip pros- thesis. There were 24 patients in the study group. The injury mechanism was a low-energy fall for all patients. All patients were females with an average age of 79.5 years (range. 64-93 years). Ten patients had ipsilateral hip arthroplasties, nine patients had ipsilateral total knee arthroplasties, and five patients had knee and hip arthroplasties. Followup was at an average of 48 weeks (range, 17-101 weeks). Eighteen of the 19 fractures in the surviving patients with followup healed uneventfully for a complication rate of 5.2%. One fracture was complicated by hardware pullout and was revised to a longer LISS that healed uneventfully. We think our data show that our patients had a low complication rate compared with that of historical controls, and we suggest that the LISS may be an appropriate treatment alternative for femur fractures associated with stable hip or knee prostheses. LEVEL OF EVIDENCE: Therapeutic, Level IV.

Accidental Falls↗
PubMed2003

Disability in adults with hip and knee arthroplasty: a French national community based survey.

OBJECTIVES: To compare levels of disability of people with and without hip and knee arthroplasty in a random national sample. METHODS: In 1999 a screening questionnaire to classify people into groups of increasing probabilities of disability was sent to 417 500 people; response rate 86%. The study population was obtained by a stratified randomisation, with a high sampling rate for the most severely disabled group and a minimum sampling rate for people without daily living restrictions. A computer assisted interview to assess levels of disability, dependence, and handicap was given to 21 760 people; response rate 78%. A weighting factor was applied to obtain estimates representative of the French population. The presence of chronic conditions, impairments, and disability was ascertained from the subjects' reports. RESULTS: The hip and knee arthroplasty group comprised 815 subjects in the sample, indicating an estimated 691 000 subjects (95% confidence interval (CI) 597 000 to 785 000) in the French non-institutionalised population. The prevalence of arthroplasty is estimated at 1.2%. After adjustments for confounding factors, activity limitations were greater among subjects with arthroplasty for the following activities: climbing stairs (odds ratio (OR)=4.0, 95% CI 2.8 to 5.8); walking distance (OR=3.4, 95% CI 2.5 to 4.6 for a walking distance less than 500 m); bending forward (OR=3.2, 95% CI 2.2 to 4.7); cutting toenails (OR=2.8, 95% CI 1.9 to 3.9); carrying (OR=2.6, 95% CI= 1.8 to 3.8); shopping (OR=2.1, 95% CI 1.5 to 2.9). CONCLUSIONS: This study would be useful to policy-makers considering population strategies for managing disabling arthritis.

Activities of Daily Living↗
PubMed2002

The reliability of diagnosis of infection during revision arthroplasties.

BACKGROUND: Follow up studies have shown that 0.5 to 4% of the total joint arthroplasties will be complicated by infection. Distinction between aseptic loosening and infection is important for prediction of the final outcome after revision arhtroplasty but also for the choice of operative treatment. However, diagnosis of low grade chronic infection is extremely demanding. MATERIALS AND METHODS: 68 hip and knee revision arthroplasties were reviewed retrospectively in order to evaluate the reliability of pre- and perioperative analysis of infection during total joint revision arthroplasties. The sensitivity and specificity for clinical signs, blood white-cell count, C-reactive protein level, radiographic analysis, bone and leukocyte scans, joint aspirations, and gram staining were determined. Tissue sample were harvested and cultured in all cases. Positive cultures were regarded as a true infection. RESULTS: We were not able to characterize the infection by clinical signs. Also no single test was able to show the presence of infection in all cases. The best results were obtained from pre- and perioperative joint aspirations. Joint aspiration showed 1.0 specificity and 0.75 sensitivity. CONCLUSION: It is clear from this study that no single test is able to show the presence of infection in every case. Classical clinical signs, laboratory tests, special imaging studies and joint aspirations have all yielded a notable rate of false negative results. Therefore, we recommend that, if arthroplasty patients have pain in prosthetic joint without clear radiological evidence of loosening, bone scans and preoperative joint aspirations should be undertaken. Also, if radiological evidence of loosening is accompanied with one or more of following criteria; C-reactive protein level elevated, radiologic evidence of infection, loosening within the first five years after implantation. In case of infection a delayed two-stage reconstruction should be managed.

Aged↗
PubMed2003

The incidence of deep vein thrombosis after hip and knee arthroplasties in Japanese patients: a prospective study.

PURPOSE: To document the incidence of proximal deep vein thrombosis and pulmonary embolism in 58 consecutive Japanese patients undergoing total hip arthroplasty or total knee arthroplasty. METHODS: Patients were routinely examined for proximal deep vein thrombosis by B-mode ultrasonography before and after surgery. Those patients who had ultrasonographic findings of deep vein thrombosis were also investigated for pulmonary embolism by ventilation-perfusion lung scan. RESULTS: The incidence of deep vein thrombosis after total hip arthroplasty and total knee arthroplasty were 9.1% and 4.0% respectively, and the incidence of pulmonary embolism were 3.0% and 0%, respectively. There were no cases of fatal pulmonary embolism. CONCLUSION: The incidence of deep vein thrombosis and pulmonary embolism in Japanese patients may have increased over the last few decades.

Aged↗
PubMed2005

Post-thrombotic syndrome after total hip or knee arthroplasty: incidence in patients with asymptomatic deep venous thrombosis.

PURPOSE: To measure the risk of developing signs of post-thrombotic syndrome 15 to 24 months after total hip or knee arthroplasty in patients with asymptomatic deep venous thrombosis (DVT). METHODS: A total of 85 total knee arthroplasty patients and 47 total hip arthroplasty patients were postoperatively screened for asymptomatic DVT using colour duplex ultrasound. RESULTS: The rate of asymptomatic DVT was 37.6% (n = 32) in knee patients and 34.0% (n = 16) in hip patients. All 32 DVT cases in the knee group had thrombi located below the knee, whereas 6 of the 16 DVT cases in the hip group had thrombi located above the knee, the remaining 10 were below the knee. Patients with proximal thrombi were treated with warfarin for 3 months, whereas patients with distal DVT received 300 mg aspirin daily for the same period. All DVT cases were monitored for up to 12 weeks using repeated colour duplex scans. Signs of thrombus resolution were present at around 6 weeks (range, 4-12 weeks). Clot propagation was observed in 3 cases. In a mean of postoperative 18 months (range, 15-24 months), 28 of the 32 knee patients with asymptomatic DVT were available for follow-up: 11 had transient calf and ankle swelling, 6 had persistent oedema, and the remaining 11 were symptom free. 14 of the 16 hip patients with asymptomatic DVT were available for follow-up: 6 had transient calf and ankle swelling, 4 had persistent oedema, and 4 remained symptom free. 17 patients reported ongoing problems and were re-examined. Signs of mild-to-moderate post-thrombotic syndrome were recorded in 4 knee patients and 3 hip patients. CONCLUSIONS: Patients with above-knee DVT were much more likely to have post-thrombotic syndrome. Despite thromboprophylaxis with low-molecular-weight heparin, asymptomatic DVT is common after total joint arthroplasty and is responsible for the development of post-thrombotic venous insufficiency and post-thrombotic syndrome in a considerable proportion of patients. Once symptomatic or asymptomatic DVT is established, treatment appears incapable of preventing the occurrence of post-thrombotic syndrome, especially in cases of above-knee DVT. Efforts should hence concentrate on combating DVT propagation and improving DVT prevention.

Age Distribution↗
PubMed2006

Modeling early recovery of physical function following hip and knee arthroplasty.

BACKGROUND: Information on early recovery after arthroplasty is needed to help benchmark progress and make appropriate decisions concerning patient rehabilitation needs. The purpose of this study was to model early recovery of physical function in patients undergoing total hip (THA) and knee (TKA) arthroplasty, using physical performance and self-report measures. METHODS: A sample of convenience of 152 subjects completed testing, of which 69 (mean age: 66.77 +/- 8.23 years) underwent THA and 83 (mean age: 60.25 +/- 11.19 years) TKA. Postoperatively, patients were treated using standardized care pathways and rehabilitation protocols. Using a repeated measures design, patients were assessed at multiple time points over the first four postoperative months. Outcome measures included the Lower Extremity Function Scale (LEFS), the physical function subscale of the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC PF), the 6 minute walk test (6 MWT), timed up and go test (TUG) and a timed stair test (ST). Average recovery curves for each of the measures were characterized using hierarchical linear modeling. Predictors of recovery were sequentially modeled after validation of the basic developmental models. RESULTS: Slopes of recovery were greater in the first 6 to 9 weeks with a second-degree polynomial growth term (weeks squared) providing a reasonable fit for the data over the study interval. Different patterns of recovery were observed between the self-report measures of physical function and the performance measures. In contrast to the models for the WOMAC PF and the LEFS, site of arthroplasty was a significant predictor (p = 0.001) in all of the physical performance measure models with the patients post TKA initially demonstrating higher function. Site of arthroplasty (p = 0.025) also predicted the rate of change for patients post THA and between 9 to 11 weeks after surgery, the THA group surpassed the function of the patients post TKA. CONCLUSION: Knowledge about the predicted growth curves will assist clinicians in referencing patient progress, and determining the critical time points for measuring change. The study has contributed further evidence to highlight the benefit of using physical performance measures to learn about the patients' actual level of disability.

Aged↗
PubMed2005

Safety of one-stage bilateral hip and knee arthroplasties under regional anaesthesia and routine anaesthetic monitoring.

Using a computer-based quality assurance program, we analysed peri-operative data on 160 patients undergoing one-stage bilateral hip or knee arthroplasties under regional anaesthesia with routine anaesthetic monitoring and only using peripheral intravenous access for peri-operative safety. We monitored defined intra-operative adverse events such as hypotension, myocardial ischaemia, arrhythmias, hypovolaemia, hypertension and early post-operative complications. We also determined post-operative hip and knee function, and patient satisfaction with different aspects of the anaesthetic management. Those patients undergoing one-stage bilateral arthroplasties were matched according to a cross-stratification which used three variables (American Society of Anesthesiologists' physical status scoring system, age and joint replaced) to patients undergoing unilateral hip or knee arthroplasties. Serious intra-operative adverse events were, with the exception of intra-operative hypotension, very infrequent in patients undergoing bilateral (nine adverse events) as well as unilateral arthroplasties (five adverse events). Early post-operative complications were also infrequent in both groups. However, the risks of receiving a heterologous blood transfusion (odds ratio 2.5; 95% confidence interval (CI) 1.3 to 5.0, estimated by exact conditional logistic regression) or vasoactive drugs (odds ratio 3.9; 95% CI 2.0 to 7.8) were significantly greater for patients undergoing bilateral operations. Patient satisfaction with anaesthesia was high; all patients who underwent the one-stage bilateral operation would choose the same anaesthetic technique again.

Aged↗
PubMed1999

An analysis of blood management in patients having a total hip or knee arthroplasty.

Three hundred and thirty orthopaedic surgeons in the United States participated in a study of transfusion requirements associated with total joint arthroplasty. A total of 9482 patients (3920 patients who had a total hip replacement and 5562 patients who had a total knee replacement) were evaluated prospectively from September 1996 through June 1997. Of those patients, 4409 (46 percent [57 percent of the patients who had a hip replacement and 39 percent of the patients who had a knee replacement]) had a blood transfusion. Two thousand eight hundred and ninety patients (66 percent) received autologous blood, and 1519 patients (34 percent) received allogenic blood. Ordered logistic regression analysis showed the most important predictors of the transfusion of allogenic blood to be a low baseline hemoglobin level and a lack of predonated autologous blood. Preoperative donation of autologous blood decreases the risk of transfusion of allogenic blood; however, inefficiencies in the procedures for obtaining autologous blood were identified. Sixty-one percent (5741) of the patients had predonated blood for autologous transfusion, but 4464 (45 percent) of the 9920 units of the predonated autologous blood were not used. Primary procedures and revision total knee arthroplasty were associated with the greatest number of wasted autologous units. Of the 5741 patients who had predonated blood, 503 (9 percent) needed a transfusion of allogenic blood. The frequency of allogenic blood transfusion varied with respect to the type of operative procedure (revision total hip arthroplasty and bilateral total knee arthroplasty were associated with the highest prevalence of such transfusions) and with a baseline hemoglobin level of 130 grams per liter or less. Transfusion of allogenic blood was also associated with infection (p < or = 0.001), fluid overload (p < or = 0.001), and increased duration of hospitalization (p < or = 0.01). These latter findings warrant further evaluation in controlled studies.

Aged↗
PubMed2000

Preoperative autologous donation for total joint arthroplasty. An analysis of risk factors for allogenic transfusion.

BACKGROUND: While autologous blood is commonly predonated to provide replacement of blood lost in orthopaedic procedures, few studies of patients managed with total joint replacement have addressed the problem of which patients are likely to benefit from an autologous blood-donation program. METHODS: A retrospective analysis of 489 consecutive patients who had had a total joint arthroplasty was performed to identify the risk factors for allogenic transfusion and to further define the indications for preoperative autologous blood donation. The operations included 247 total knee replacements (157 unilateral primary, thirty-two revision, and twenty-nine one-stage bilateral primary procedures) and 271 total hip replacements (163 primary and 108 revision procedures). Fifty-four percent (264) of the 489 patients donated a total of 527 units of blood (average, 2.0 units per patient) preoperatively. RESULTS: One hundred and ninety-one patients (39 percent) required a transfusion of autologous blood or allogenic blood, or both. One hundred and thirty-one patients (27 percent) received autologous blood, and eighty-two patients (17 percent) received a transfusion of allogenic blood; twenty-two patients (4 percent) received both autologous and allogenic blood. Neither form of transfusion caused serious complications. Fifty-six percent (295) of the 527 units of autologous blood were discarded. Autologous donation significantly decreased the requirements for allogenic transfusion (relative risk, 0.1; p<0.0001). It also caused the level of hemoglobin to decrease an average of 12.2 grams per liter from the time before donation to the time before the operation (p<0.0001). Factors that increased the risk for allogenic transfusion were a revision knee or hip procedure or a one-stage bilateral primary knee replacement (relative risk, 5.7; p<0.0001), an initial hemoglobin level of less than 130 grams per liter (relative risk, 5.6; p<0.0001), and an age of sixty-five years or older (relative risk, 2.8; p = 0.02). None of the sixty-seven patients who had a primary knee or hip arthroplasty and an initial hemoglobin level of 150 grams per liter or more required an allogenic transfusion. In addition, none of the sixty-three patients who had a primary arthroplasty, an initial hemoglobin level of between 130 and less than 150 grams per liter, and an age of less than sixty-five years required an allogenic transfusion. Eighty-three percent (115) of the 138 autologous units donated by the seventy patients in these two groups were discarded. These wasted units accounted for 39 percent of the 295 discarded units for the entire study sample. CONCLUSIONS: The efficiency of collection of autologous blood can be improved by identifying patients who have a very low risk of transfusion according to the type of arthroplasty, the initial level of hemoglobin, and age. Patients who have an initial hemoglobin level of at least 150 grams per liter or an initial hemoglobin level of between 130 and 150 grams per liter and an age of less than sixty-five years have a minimal risk of needing a transfusion during or after a primary total joint replacement. These patients should be apprised of their low risk so that they can make an informed decision regarding preoperative autologous donation.

Aged↗
PubMed2000

Anticoagulant treatment of thromboembolism with intravenous heparin therapy in the early postoperative period following total joint arthroplasty.

BACKGROUND: Treatment of thromboembolism with intravenous heparin therapy in the early postoperative period after total joint arthroplasty has been associated with a high rate of complications. The purpose of the present study was to compare the rate of bleeding complications in a group of patients who required intravenous heparin therapy for the treatment of thromboembolism after total hip or knee arthroplasty with the rate in a control group of patients who received only prophylactic anticoagulation. METHODS: The postoperative courses of forty-four consecutive patients who were managed with intravenous administration of heparin and oral administration of warfarin for the treatment of a thromboembolic event following unilateral total hip or knee arthroplasty were compared with those of a control group of 376 consecutive patients who had these same procedures but did not have a thromboembolic complication. The patients in the control group were managed with prophylactic anticoagulation with use of enoxaparin. Sixty-eight percent (thirty) of the forty-four patients in the heparin group received the initial dose of heparin on or before the fourth postoperative day, and 82 percent (thirty-six) received an initial bolus of 5000 units of heparin at the initiation of therapy. RESULTS: The rate of bleeding complications was 9 percent (four of forty-four) in the heparin group, compared with 6 percent (twenty-three of 376) in the control group (p = 0.44). The mean transfusion requirement in the heparin group (1.8 units of packed red blood cells) was significantly greater than that in the control group (0.8 unit) (p < 0.0001). Three of the four patients who had a bleeding complication while receiving heparin and warfarin had coagulation parameters that were substantially higher than recommended levels. The mean duration of hospitalization in the heparin group (fifteen days) was significantly longer than that in the control group (seven days) (p < 0.0001). CONCLUSIONS: The results of the present study suggest that the use of intravenous heparin therapy for the treatment of thromboembolism in the early postoperative period after total joint arthroplasty is associated with a rate of bleeding complications that is similar to that associated with the use of prophylactic anticoagulation with use of enoxaparin alone. One should expect an increased transfusion requirement and a longer duration of hospitalization for patients who require intravenous heparin therapy for the treatment of a thromboembolic event.

Adult↗
PubMed2005

Revision arthroplasty with use of a total femur prosthesis.

BACKGROUND: Surgeons performing revision arthroplasties of the hip and knee are confronted with a growing number of patients with extensive loss of bone stock. Implantation of a total femur prosthesis is a possible method of treatment of such patients. The purpose of this study was to assess the functional outcomes and the complications associated with total femur replacements used in revision arthroplasty. METHODS: We evaluated the results associated with 100 total femur prostheses that had been implanted during revision arthroplasty in 100 consecutive patients without infection. The mean duration of follow-up was five years. The prosthesis was implanted because of a complication of a total hip replacement in seventy-seven patients, because of a complication of a total knee replacement in four, and because of a complication affecting the diaphysis of the femur in nineteen. Thirty-nine patients had sustained a periprosthetic fracture, usually in combination with loosening of the prosthesis, before the revision. The radiographs made at the time of the latest follow-up were evaluated for signs of loosening and material failure. The preoperative and postoperative function of the hip and knee was assessed according to the Enneking score. Five patients were lost to follow-up. RESULTS: Sixty-five patients (68%) had no complications. Deep infection was found in twelve patients (13%); dislocation, in six (6%); material failure, in three (3%); patellar problems, in two (2%); and peroneal nerve palsy, in one (1%). The mean preoperative Enneking score for hip function was 1.25 points, and it improved to 3.29 points postoperatively. The mean Enneking score for knee function was 2.09 points preoperatively and 3.29 points postoperatively. CONCLUSIONS: We believe that the total femur prosthesis is a useful implant for patients with extensive bone loss at revision arthroplasty. While the infection rate was high, the overall functional results for both the hip and the knee were rated as better than good with the Enneking classification.

Adult↗
PubMed2005

Prevention of venous thromboembolic disease after total hip and knee arthroplasty.

Patients undergoing total hip and knee arthroplasty are at increased risk for the development of venous thromboembolic disease, and there is general agreement that these patients require prophylaxis. The selection of a prophylactic agent involves a balance between efficacy and safety and often needs to be individualized for specific patients and institutions. Despite extensive research, the ideal agent for prophylaxis against deep venous thrombosis has not been identified. The results of randomized trials indicate that low-molecular-weight heparin, warfarin, and fondaparinux are the most effective prophylactic agents after total hip arthroplasty and that low-molecular-weight heparin, warfarin, fondaparinux, and pneumatic compression boots are the most effective agents after total knee arthroplasty. The duration of prophylaxis against deep venous thrombosis after total hip and knee arthroplasty remains controversial. Prophylaxis should be continued beyond hospital discharge. In the future, the determination of the duration of prophylaxis will be based on the risk stratification of individual patients. The practice of discharging patients from the hospital without prophylaxis, even when the decision is based on negative results of procedures that screen for the presence of deep venous thrombosis, is not cost-effective.

Anticoagulants↗