Patient-Specific Venous Thromboembolic Event Prophylaxis in Total Joint Arthroplasty - Literature-Supported Guidelines.

Following total joint arthroplasty (TJA), venous thromboembolic events (VTE) are a known complication that may result in increased hospitalization cost as well as morbidity. Numerous investigations have documented patient-specific factors that place an individual at increased risk of VTE after TJA. Potential risk factors for VTE include genetic predisposition, history of a prior VTE event, revision surgery and patient comorbidity factors. The American Academy of Orthopedic Surgeons and The American College of Chest Physicians have both provided recommendations for VTE prophylaxis after orthopedic surgery. However, among orthopedic surgeons, there remains a lack of consensus regarding the appropriate agent and time course for prophylactic anticoagulation after TJA. In this study, we review the evidence-supported patient-specific factors that confer an increased risk of VTE in the TJA postoperative period. Furthermore, we describe the VTE prophylaxis regimen used at our home institution after TJA for low- and high-risk patients as well as a recommendation for cessation or continuation of anticoagulation regimens that patients were on preoperatively for comorbid conditions.

Risk factors for incision-healing complications following total ankle arthroplasty.

BACKGROUND: The anterior incision used for the insertion of total ankle arthroplasty systems is at high risk for wound complications, and little has been documented regarding who is at risk for the development of these complications. METHODS: We conducted a retrospective chart review of 106 total ankle arthroplasties. Independent risk variables, including age, sex, body-mass index, diabetes, smoking, medications, preoperative diagnosis, implant size, tourniquet time, closure method, and anticoagulation status, were recorded. Postoperative office notes were reviewed for wound-related complications. Outcomes were divided into three categories: no complications (uncomplicated wound-healing), minor complications (wounds requiring only local care/oral antibiotics), and major complications (requiring a return to the operating room for treatment). Simultaneously, categorical variables were compared with use of chi-square analysis. Multivariate logistic regression and odds ratio assessment were performed as well. RESULTS: When patients who had no complications were compared with those who had minor complications, a history of diabetes was the only variable that was identified as resulting in a significant risk increase (p = 0.04). When patients who had no wound complications or minor wound complications were compared with those who had major wound complications, female sex, a history of corticosteroid use, and underlying inflammatory arthritis were all associated with increased risk. Multivariate logistic regression demonstrated underlying inflammatory arthritis (p = 0.004) to be the only significant risk factor for major wound complications, with an odds ratio demonstrating a 14.03 times increased risk of requiring reoperation. CONCLUSIONS: We recommend that caution be used when selecting and educating patients with inflammatory arthritic conditions who are potential candidates for total ankle arthroplasty.

Total hip arthroplasty: is small incision better?

Outcome data are eagerly awaited at present time to evaluate the role of minimally invasive surgery in orthopedic surgery. This matched-pair study reports the outcome of total hip arthroplasty (THA) performed through regular or small incision technique by a single surgeon. There were 120 patients in this cohort with a mean age of 66.8 years (range, 39-90 years). There was no detectable difference in outcome between the two groups with regard to blood loss, analgesia requirement, functional recovery, length of hospital stay, or disposition at discharge. One patient in the small incision group with undersized femoral component required revision of the femoral stem 8 months later. The recent extensive interest for minimally invasive THA has been attributed to market-driven and patient-driven demand for this procedure. We were not able to detect any difference in outcome parameters for THA performed through small incision compared with the conventional techniques.

The role of patient restrictions in reducing the prevalence of early dislocation following total hip arthroplasty. A randomized, prospective study.

BACKGROUND: It is currently unknown whether functional restrictions following total hip arthroplasty can reduce the prevalence of early postoperative dislocation. Our hypothesis was that dislocation was more likely to occur in patients who were not placed on these restrictions. METHODS: We performed a prospective, randomized study to evaluate the role of postoperative functional restrictions on the prevalence of dislocation following uncemented total hip arthroplasty through an anterolateral approach. Of the 630 eligible consecutive patients, 265 patients (303 hips) consented to be randomized into one of two groups (the "restricted" group or the "unrestricted" group). The patients in both groups were asked to limit the range of motion of the hip to <90 degrees of flexion and 45 degrees of external and internal rotation and to avoid adduction for the first six weeks after the procedure. The patients in the restricted group were instructed to comply with additional hip precautions during the first six weeks postoperatively. Specifically, these patients were managed with the placement of an abduction pillow in the operating room before bed transfer and used pillows to maintain abduction while in bed; used elevated toilet seats and elevated chairs in the hospital, in the rehabilitation facility, and at home; and were prevented from sleeping on the side, from driving, and from being a passenger in an automobile. All patients were followed for a minimum of six months postoperatively. RESULTS: There was one dislocation in the entire cohort (prevalence, 0.33%). This dislocation occurred in a patient in the restricted group during transfer from the operating table to a bed with an abduction pillow in place. Patients in the unrestricted group were found to return to side-sleeping sooner (p < 0.001), to ride in automobiles more often (p < 0.026), to drive automobiles more often (p < 0.001), to return to work sooner (p < 0.001), and to have a higher level of satisfaction with the pace of their recovery (p < 0.001) than those in the restricted group. There was an additional expenditure of approximately $655 per patient in the restricted group. CONCLUSIONS: Total hip arthroplasty through an anterolateral approach is likely to be associated with a low dislocation rate. Removal of several restrictions did not increase the prevalence of dislocation following primary hip arthroplasty at our institution. However, it did promote substantially lower costs and was associated with a higher level of patient satisfaction as patients achieved a faster return to daily functions in the early postoperative period.