Over two decades of orthopaedic surgery in patients with inhibitors-Quantifying the complication of bleeding.

Patients with haemophilia who have developed inhibitors against factor VIII (FVIII) or factor IX present a significant concern to those surgeons who operate on them. The evidence base for bypassing agents such as recombinant factor VIIa and activated prothrombin complex concentrate has amassed over several decades. The literature is open to positive interpretation on the successful use of these agents in the treatment of inhibitor-positive patients. However, there are equally persistent concerns amongst surgeons, in particular orthopaedic surgeons, regarding the high complication rate of bleeding. To explore and quantify this concern, we present a literature review spanning two decades of publications on haemophilia patients with inhibitors undergoing orthopaedic surgery. Irrespective of the progress made with haemostatic protocols, trepidation on embarking on surgery is valid. The high risk of bleeding is a function of the inherent complexity of the disease and rightfully translates into difficulties in its management. Combined with the prospect of orthopaedic surgery, those involved in the care of such patients are justified in their continued anxiety and diligence when considering the benefits in quality of life against the prevalent complications.

Extracciones dentales atraumáticas en pacientes pediátricos con trastornos de la coagulación: descripción de la técnica y reporte de un caso / Atraumatic tooth extractions in pediatric patients with bleeding disorders: a technical description and report of a case

Se detalla y fundamenta la técnica de extracción atraumática de dientestemporales unirradiculares en pacientes pediátricos con trastornos de lacoagulación utilizando separadores elastoméricos. Se expone el caso deun paciente pediátrico con diagnóstico de defi ciencia de factor X de lacoagulación, quien requirió de la extracción atraumática de los órganosdentarios centrales superiores temporales debido a la gingivorragiapropia de la exfoliación natural.

We describe the technique of atraumatic tooth extraction for single-rooted temporary and permanent teeth in pediatric patients with bleed-ing disorders using elastomeric separators and discuss its benefi ts. We present the case of a pediatric patient diagnosed with coagulation factor X defi ciency who required the atraumatic extraction of his temporary upper central teeth due to gingival bleeding caused by natural exfoliation.

Preventing postsurgical venous thromboembolism: pharmacological approaches.

The use of antithrombotic drugs for the prevention of venous thromboembolism (VTE) in patients undergoing surgery is presently based on solid principles and high-level scientific evidence. This article reviews current strategies of pharmacological thromboprophylaxis. The level of VTE risk following surgery depends on a variety of factors that the surgeon should take into account, including the type of surgery and the presence of additional risk factors, such as elderly age and cancer. In patients undergoing minor general surgery, early mobilization is sufficient as prophylaxis, whereas in those undergoing major general surgery, thromboprophylaxis with low molecular weight heparin (LMWH), low-dose unfractionated heparin, or the pentasaccharide fondaparinux is recommended. Patients undergoing major orthopedic surgery have a particularly high risk of VTE, and routine thromboprophylaxis with LMWH, fondaparinux, or a vitamin K antagonist (international normalized ratio target: 2.0 to 3.0) is the standard of care in this group of patients. Recently, two new oral anticoagulants, rivaroxaban (a factor Xa inhibitor) and dabigatran etexilate (a direct thrombin inhibitor) have been licensed to be used for thromboprophylaxis after orthopedic surgery in Europe. Mechanical methods of thromboprophylaxis (compression stockings, intermittent pneumatic compression, vena cava filters), not discussed in detail in this review, should always be considered in patients at high thrombotic risk, in association with the pharmacological strategies, or in cases of contraindications to anticoagulants, as in patients or procedures at high risk of bleeding.