Complications of anticoagulation for thromboembolism in early postoperative total joint arthroplasty

In the study reported here, we analyzed the complications associated with anticoagulation in total joint arthroplasty patients treated for venous thromboembolism (VTE) in the early postoperative period. Twenty-nine consecutive cases from a 1-year period were identified and retrospectively reviewed. VTE treatment, which in most instances (79%) consisted of a heparin drip, was begun a mean of 2.3 days after surgery. Patients received a mean (SD) of 4.4 (5.0) units of packed red blood cells. There were no differences in bleeding parameters with respect to timing of initiation of anticoagulation. Local and systemic bleeding complications were common. The proportion of patients who were transfused was significantly (P<.0001) higher for VTE patients than for control patients, and transfused VTE patients received significantly (P = .0004) more blood products. In total joint arthroplasty patients, VTE treatment began 2.3 days after surgery and had a high incidence of complications related to bleeding.     

Complications of heparin therapy after total joint arthroplasty

The cases of 112 patients who were treated intravenously with heparin for thromboembolic disease after total joint arthroplasty were reviewed. The over-all frequency of bleeding complications that were associated with therapy with heparin was approximately 30 per cent. In patients who were treated within six days after total joint replacement, the frequency of bleeding complications was 45 per cent. The prevalence of bleeding problems declined to 15 per cent in patients who were treated more than one week after arthroplasty. In roughly 35 per cent of the patients, therapy with heparin had to be discontinued because of complications. Thrombocytopenia developed in fewer than 5 per cent of the patients. It was concluded that anticoagulation therapy with heparin for clinically unimportant thromboembolic problems in the immediate postoperative period is not justified.     

The use of controlled-release versus scheduled oxycodone in the immediate postoperative period following total joint arthroplasty

This prospective study examined whether better pain control could be achieved in the first 48 hours after joint arthroplasty with controlled-release oxycodone compared to scheduled oxycodone with acetaminophen. In the study group, controlled-release oxycodone was administered on the day of surgery and was continued during patients' hospital stay. The study group then was compared to a previous group in which effective pain control was obtained with around-the-clock oxycodone with acetaminophen. Findings indicated controlled-release oxycodone did not provide better pain control compared to scheduled oxycodone with acetaminophen in the first 48 hours following total joint arthroplasty.     

全髋关节置换围手术期静脉应用氢化可的松对术后早期康复疗效的影响

目的 探讨全髋关节置换(total hip arthroplasty,THA)围手术期静脉应用氢化可的松对术后早期康复的影响.方法 选取2016年1月至2020年6月在我院行初次单侧THA的病人80例,随机分为氢化可的松组和对照组,每组40例.术前2 h和术后6、14 h,氢化可的松组的病人给予氢化可的松(氢化可的松1...     

Detection of gentamicin emission from bone cement in the early postoperative period following total hip arthroplasty

This article describes the characteristics of gentamicin emission from the bone cement-antibiotic complex in the early postoperative period following total hip arthroplasty. Gentamicin levels of the drain fluid taken at 6, 24, and 48 hours postoperatively were measured with a fluorescent polarization immunoassay method. Mean gentamicin concentrations were 2.6, 1.2, and 0.6 mcg/mL, respectively. Age, sex, and body mass index had no significant influence on the outcome. Results showed that the amount of gentamicin in the wound fluid is inversely proportional to the total amount excreted. Twenty-four hours postoperatively, the average gentamicin concentrations in the drain fluid taken from around the endoprosthesis implanted with Palacos-R bone cement (Zimmer Warsaw, Ind), diminished, yet remained above the minimal inhibitory concentration level.     

Torsional loads in the early postoperative period following total hip replacement

Torques generated in one subject during the early postoperative period were measured with a telemeterized total hip component. The patient was examined during gait, stair ascent, rising from a chair, and single-limb stance. The torques were plotted against both the resultant joint contact force and the force component directed along the stem axis. During gait, the maximum torque was 35 Nm, recorded at a walking velocity of 1.7 m/sec. The peak torques during stair ascent and during rising from a seated position were found to be 23 and 15 Nm, respectively. The maximum value for torque measured in this study was 37 Nm during one attempt at single-limb stance. Comparison of plots for torque versus stem-axis component for the four activities shows that the torque increased more rapidly for chair exits than for gait up to resultant contact force values of as much as 1,000 N. For stair ascent, the same was true to values of 1,400 N. Within any given activity, the relationship between stem torque and resultant or stem-axis force showed considerable variability. These results indicate that experiments evaluating the stability of femoral components in total hip arthroplasty should incorporate a component directed along the stem axis, as well as a component normal to the plane of the prosthesis. The results also suggest that theoretical stress analysis models should consider the broad variability in the orientation of the joint force at the hip.     

Evaluation of fever in the immediate postoperative period in patients who underwent total joint arthroplasty

Forty percent to 50% of patients may experience an immediate postoperative fever. Research suggests that these are of aseptic cause due to inflammatory mediators. This is a retrospective analysis of fevers in total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients from 2006 to 2008. Thirty-six percent of THA and 31% of TKA patients developed a fever, with most developing a maximum temperature on postoperative day (POD) 2. The maximum mean temperature between the THA and TKA group was not significantly different. Fevers in the immediate postoperative period are a normal variant in patients undergoing THA or TKA. Urinalysis, urine culture and sensitivity, and chest x-ray are not required during this period because most of these fevers stem from aseptic causes.     

Variability of gait in the early postoperative period of total knee arthroplasty with different surgical technique

Purpose

The purpose of this study was to work out an objective and sensitive method for the early postoperative period following total knee arthroplasty (TKA) in which analysis of the gait parameters is possible and also to investigate the influence of different surgical approaches for TKA on the gait during stepping in the first three months of the postoperative period.

Methods

Three groups of patients: age-matched healthy elderly patients as a control group, patients operated upon by the conventional technique and finally by the minimally invasive technique combined with computer-assisted navigation. All three groups included ten patients. The motions of knee, shoulder and pelvis were measured by ZEBRIS ultrasound-based system preoperatively plus six and 12 weeks postoperatively. From the joint motion, the variability of cadence, and the variability of knee joint motion and that of pelvis and shoulder girdle was determined.

Results

Osteoarthritis (OA) of the knee joint and TKA using both operation techniques significantly influenced the variability of stepping parameters compared to the controls. In the early postoperative period a significant difference was detected between the two groups of the operated patients in all parameters.

Conclusion

Our data prove that our method seems appropriate to provide objective measurement of the gait in the early postoperative period. The variability of motion of the patient groups approaches that of the healthy control group steadily, but does not reach them.     

Value of postoperative heparin therapy in peripheral arterial thromboembolism

The experience with 359 patients with arterial thromboembolism from 1963 to 1982 has been reported. Combined operative and anticoagulant therapy appears the most beneficial form of treatment. Treatment with heparin after catheter embolectomy was associated with a decrease in mortality (7.6 percent), number of amputations (5 percent), and recurrent emboli (6 percent). Serious wound complications occurred less frequently than anticipated (8 percent). We advocate prompt arteriography and revascularization procedures to ensure long-term limb function after initial embolectomy for salvage, if the result is less than optimal or expected. Postoperative heparin seems to buy time in marginal cases, enabling secondary operations to ensure a satisfactory outcome in most patients.     

Duplex ultrasonography in patients suspected of postoperative pulmonary embolism following total joint arthroplasty

Duplex ultrasonography of the deep venous system of the lower extremities is often utilized in the diagnostic evaluation of total hip and knee arthroplasty patients suspected of pulmonary embolism in an attempt to identify the embolic source. A retrospective review of 135 patients who were clinically suspected of pulmonary embolism after 71 total knee arthroplasties and 64 total hip arthroplasties was performed. Of the 35 patients diagnosed with pulmonary embolism, 2 (5.7%) had deep venous thrombosis identified by duplex ultrasonography. The routine use of this imaging modality is not an effective strategy for identifying clinically significant deep venous thrombosis that leads to pulmonary embolism. A negative duplex ultrasound result should not preclude an extensive evaluation for pulmonary thrombosis in symptomatic patients.     

Mechanical measures in the prophylaxis of postoperative thromboembolism in total knee arthroplasty

Total knee arthroplasty patients are at high risk for deep venous thrombosis and pulmonary embolism. Prophylaxis against deep venous thrombosis and pulmonary embolism in these patients seems mandatory. Pharmacologic agents such as dextran 40, aspirin, and warfarin are effective but may be associated with significant complications such as drug reaction, bleeding, hematoma, and hemarthrosis. Heparin was not effective and was associated with significant bleeding complications. Mechanical methods such as continuous passive motion and sequential pneumatic compression stockings were without complications and seemed equal to or more effective than pharmacologic agents. Adding warfarin to mechanical methods did not seem to augment the antithromboembolic effect of the mechanical methods.     

The effect of intraoperative intravenous fixed-dose heparin during total joint arthroplasty on the incidence of fatal pulmonary emboli

All patients who underwent primary total knee arthroplasty (TKA), revision TKA, primary total hip arthroplasty (THA), and revision THA between January 1, 1990, and December 31, 1996, were retrospectively reviewed to determine the incidence of fatal pulmonary emboli. All TKA patients received 1,000 U of intravenous heparin sodium before the tourniquet was inflated and an additional 500 U of intravenous heparin sodium before the inflation of the second tourniquet during bilateral TKA. All THA patients received 1,000 U of intravenous heparin sodium at the time of the skin incision and 500 U of intravenous heparin sodium before preparation of the femoral canal. The overall incidence of fatal pulmonary emboli was extremely low (TKA, 0.096%; THA, 0.16%). With this regimen of intravenous intraoperative heparin, postoperative aspirin, thromboembolic disease hose, and early ambulation, there is no risk of postoperative bleeding, it is inexpensive, and there is no concern on how long to keep the patients on this regimen postoperatively. We recommend this regimen for the prevention of fatal pulmonary emboli after total joint arthroplasty.     

Optimal duration of prophylaxis for venous thromboembolism following total hip arthroplasty and total knee arthroplasty

Elective total hip arthroplasty and total knee arthroplasty are associated with a high risk of postoperative venous thromboembolism. Traditionally, antithrombotic prophylaxis has been administered during the hospital stay. However, with patients spending less time in the hospital after surgery, there is a need to continue thromboprophylaxis beyond hospital discharge. The current recommendation for prophylaxis in total joint arthroplasty patients is a minimum of 10 days, with extended prophylaxis up to 28 to 35 days following total hip arthroplasty. Prophylaxis with low-molecular-weight heparins for approximately 4 weeks following hip arthroplasty has resulted in clinically significant reductions in the incidence of venographically confirmed deep vein thrombosis. Currently, no data support extended thromboprophylaxis beyond 10 days following total knee arthroplasty. Using weighted risk factors to assess individual risk for venous thromboembolism can help the physician determine the optimal duration of prophylaxis.     

Pathomechanics of the femoropatellar joint following total knee arthroplasty

Persistent discomfort in the femoropatellar joint is still one of the most disappointing aspects following total knee arthroplasty (TKA). Especially, TKA without patellofemoral replacement has a significant incidence of patellofemoral problems with a frequency between 5% and 45%. Pathomechanical factors in the development of retropatellar problems are loss of patellar thickness and retropatellar erosions. In 157 TKAs using Gschwend, Scheier, B?hler (GSB) joints without patellar resurfacing, pathomechanically postoperative vertical patellar malposition appeared to be the main cause of dysfunction. In many cases, the implantation technique leads to an artificial form of patella alta. This altered knee anatomy results in pathologic biomechanics, thus leading to reduced function. The combination of altered anatomy and reduced function leads to extensive patellar destruction and ultimately to intractable retropatellar pain.     

Heparin-induced thrombocytopenia after elective hip joint replacement with postoperative prevention of thromboembolism with low-molecular-weight heparin

BACKGROUND: Heparin-induced thrombocytopenia (HIT) is a severe side effect of the prophylaxis of venous thromboembolism with unfractionated heparin. The aim of the present study is to gain more information on the incidence of HIT during prophylaxis of venous thromboembolism with low-molecular-weight heparin in elective hip surgery. METHODS: 586 consecutive patients were included into the prospective study, who were admitted to hospital for elective hip replacement. The incidence of thrombocytopenia, clinically manifest venous thromboembolism and of the heparin-induced IgG antibodies were analysed during prophylaxis with low molecular-weight heparin. Patients received once daily subcutaneously low molecular-weight heparin for a mean of 28 days postoperatively. Platelet counts and clinical examinations for the presence of venous thromboembolism were done at days 0, 2, 7 (+/- 1) and 12 (+/- 2). Heparin-induced IgG antibodies were determined before and after a 12 (+/- 2) days prophylaxis with low molecular-weight heparin in 265 of 586 patients randomly. Patients were reexamined for thromboembolic complications after 3 and 6 months. The clinical suspicion of thromboembolic complication was documented objectively. RESULTS: None of the patients developed a decrease of platelets of < 50% of the initial value. Ten of 265 patients had elevated IgG antibodies against heparin/platelet factor 4 before prophylaxis (3.8%). After the 12 (+/- 2) days prophylaxis 13 of 265 patients had elevated IgG antibodies (4.9%). C14 serotonin assay was positive in 0 of 10 patients before treatment and in 3 of 19 patients at day 12 (+/- 2). Ten patients developed venous thromboembolism postoperatively (8 x deep venous thrombosis, 2 x pulmonary embolism, no fatal embolism). Only 1/19 patients with elevated antiheparin IgG titres developed venous thromboembolism. The C14 serotonin assay was negative in this patient. Two patients died in the postoperative phase due to underlying cardiovascular diseases. CONCLUSIONS: In patients with elective hip replacement prophylaxis of venous thromboembolism with low molecular-weight heparin was associated with a very low incidence of HIT, and hence screening for HIT antibodies is not required.     

Portable compression device and low-molecular-weight heparin compared with low-molecular-weight heparin for thromboprophylaxis after total joint arthroplasty

This preliminary prospective study to determine the rate of deep venous thrombosis (DVT) examined 277 patients undergoing total knee or total hip arthroplasty (TKA or THA) who were randomized to use a portable, continuous enhanced circulation therapy (CECT) compression device and low-molecular-weight heparin (LMWH) or to receive LMWH alone. Patients were screened for DVT using duplex ultrasound at hospital discharge and followed clinically for 3 months. In TKA, 5 DVTs (6.6%) occurred in the CECT + LMWH group compared with one pulmonary embolism and 14 DVTs (19.5%) in the LMWH group (P = .018). In THA, 1 DVT (1.5%) occurred in the CECT + LMWH group and 2 DVTs (3.4%) occurred in the LMWH group. This preliminary study demonstrated significant reduction in rate of DVT after TKA when the CECT device was combined with LMWH.     

Effect of immediate postoperative physical therapy on length of stay for total joint arthroplasty patients

The isolated effect of physical therapy (PT) on total joint arthroplasty hospital length of stay (LOS) has not been studied. A prospective cohort study was conducted on 136 primary total joint arthroplasties (58 hips, 78 knees). The LOS was determined by the operative start time until the time of discharge. On postoperative day (POD) 0, 60 joints remained in bed, 51 moved to a chair, and 25 received PT (22 ambulated, 3 moved to a chair). Length of stay differed for patients receiving PT on POD 0 (2.8 ± 0.8 days) compared with POD 1 (3.7 ± 1.8 days) (P = .02). There was no difference in PT treatment based on nausea/vomiting, pain levels, or discharge location. Isolated PT intervention on POD 0 shortened hospital LOS, regardless of the intervention performed.     

Efficiency of immediate postoperative inpatient physical therapy following total knee arthroplasty: an RCT

Background  

The main goal of physical therapy treatment (PT) in the clinical stage following total knee arthroplasty (TKA) is to prepare patients for discharge from the hospital as soon as possible after their operation. Although aggressive rehabilitation is believed to be important, evidence of effects of different exercise programmes following TKA is limited. This led to the question whether the intensity of PT (once versus twice daily) following TKA affects short-term recovery, measured as range of motion.     

Knee joint synovial cyst following total knee arthroplasty with bone allograft

Allograft has been shown to be highly successful for managing large osseous defects in total knee arthroplasty. We report a 68-year-old woman in whom a bone allograft had been used during total knee arthroplasty owing to a massive segmental medial tibia plateau defect 4 years earlier. Eighteen months after surgery, a 10 × 10 cm knee synovial cyst was detected by computed tomography scanning on the anteromedial side of the tibial plateau, and an en-bloc surgical excision was performed. At 36-month follow-up, a 16 × 12 cm cyst was found. Excision was again performed with removal of the allograft and application of an autologous iliac graft. After allograft removal, clinically and radiologically satisfactory results were achieved at the final follow-up.