Simultaneous removal of a locking plate and implantation of a reversed shoulder prosthesis in elderly patients suffering from fracture sequelae of the proximal humerus.

PURPOSE: Open reduction and internal fixation with a locking plate are performed frequently to treat fractures of the proximal humerus. Avascular necrosis and non-union or malunion are potential complications of this procedure, which lead to specific fracture sequelae. The aim of this study was to investigate the clinical and radiological results of patients treated by removal of a failed locking plate of the proximal humerus and simultaneous implantation of a reverse total shoulder prosthesis. METHODS: Twenty-one patients (f = 17, m = 4; mean age 70 years) out of 29 patients were available for follow-up after a mean period of 45 (30-65) months. At follow-up, all patients were assessed with the constant score and the ASES score as well as plain radiographs. RESULTS: In comparison with the preoperative values, abduction (31° vs. 115°; p < 0.001) and forward flexion (34° vs. 121°; p < 0.001) improved until follow-up, while the pain score on a visual analog scale decreased (6.7 vs. 0.9; p < 0.001). At follow-up, the mean ASES score rated 73 and the constant score rated 62. The radiologic findings included scapular notching (n = 7; 33%), radiolucency (n = 4; 19%), heterotopic ossifications (n = 3; 14%), and stress shielding (n = 4; 19%). CONCLUSION: Reverse total shoulder arthroplasty is a useful instrument for the treatment of failed locking plate osteosynthesis of the proximal humerus in elderly patients. The patients benefit from both pain relief and improved shoulder function. The rate of radiologic changes like scapular notching, radiolucency, stress-shielding and heterotopic ossifications at follow-up is notable.

Five-year outcome after conversion of a hemiarthroplasty when used for the treatment of a proximal humeral fracture to a reverse total shoulder arthroplasty.

Aims: The reasons for failure of a hemirthroplasty (HA) when used to treat a proximal humeral fracture include displaced or necrotic tuberosities, insufficient metaphyseal bone-stock, and rotator cuff tears. Reverse total shoulder arthroplasty (rTSA) is often the only remaining form of treatment in these patients. The aim of this study was to evaluate the clinical outcome after conversions from a failed HA to rTSA. Material and Methods: A total of 35 patients, in whom a HA, as treatment for a fracture of the proximal humerus, had failed, underwent conversion to a rTSA. A total of 28 were available for follow-up at a mean of 61 months (37 to 91), having been initially reviewed at a mean of 20 months (12 to 36) postoperatively. Having a convertible design, the humeral stem could be preserved in nine patients. The stem was removed in the other 19 patients and a conventional rTSA was implanted. At final follow-up, patients were assessed using the American Shoulder and Elbow Surgeons (ASES) score, the Constant Score, and plain radiographs. Results: At final follow-up, the mean ASES was 59 (25 to 97) and the mean adjusted Constant Score was 63% (23% to 109%). Both improved significantly (p < 0.001). The mean forward flexion was 104° (50° to 155°) and mean abduction was 98° (60° to 140°). Nine patients (32%) had a complication; two had an infection and instability, respectively; three had a scapular fracture; and one patient each had delayed wound healing and symptomatic loosening. If implants could be converted to a rTSA without removal of the stem, the operating time was shorter (82 minutes versus 102 minutes; p = 0.018). Conclusion: After failure of a HA in the treatment of a proximal humeral fracture, conversion to a rTSA may achieve pain relief and improved shoulder function. The complication rate is considerable. Cite this article: Bone Joint J 2018;100-B:761-6.

Is reverse total shoulder arthroplasty a feasible treatment option for failed shoulder arthroplasty? A retrospective study of 44 cases with special regards to stemless and stemmed primary implants.

Is reverse total shoulder arthroplasty a feasible treatment option for failed shoulder arthroplasty? A retrospective study of 44 cases with special regards to stemless and stemmed primary implants. BACKGROUND: Due to humeral or glenoid bone-loss and rotator cuff insufficiency reverse total shoulder arthroplasty often means the only remaining treatment option in revision shoulder arthroplasty. This study investigates the clinical outcome of patients treated with a reverse total shoulder in revision cases with special regard to stemless and stemmed primary implants. MATERIALS AND METHODS: From 2010 to 2012 60 failed shoulder arthroplasties were converted to reverse total shoulder arthroplasty. Forty-four patients were available for follow-up after a mean of 24 months. Patients were assessed with X-rays, Constant- and ASES Score and a questionnaire about their subjective satisfaction. RESULTS: The total number of observed complications was seven (16%). Ninety-eight percent of the patients were satisfied with their clinical result. Patients achieved a mean normalized constant score of 70.2% and a mean ASES Score of 65.3. Patients with stemless primary implants achieved a higher normalized constant score than patients with stemmed primary implants (82 vs. 61.8%; p = 0009). CONCLUSION: Reverse total shoulder arthroplasty provides satisfactory clinical results and a high patient satisfaction in revision shoulder arthroplasty. The complication rate needs to be considered and discussed with the patient prior to surgery. Presence or absence of a stem of revised shoulder arthroplasties interferes with the outcome. LEVEL OF EVIDENCE IV: (Retrospective study).

Relapse of primary central nervous system lymphoma 13 years after high-dose methotrexate-based polychemotherapy.

We report a now 74-year-old patient who was successfully treated with a methotrexate (MTX)-ssbased polychemotherapy protocol (Bonn protocol) for primary central nervous system lymphoma (PCNSL) in 1996. When presenting with an unusually late relapse after 13 years of tumor-free survival the diagnosis was made on the basis of clinical and radiological criteria. In the context of the very limited treatment options for recurrent PCNSL, it is reassuring that the re-application of high dose-MTX-based polychemotherapy, including intraventricular treatment, again succeeded in a sustained complete response with still low neurotoxicity.

[Results of open arthrolysis for extrinsic elbow stiffness via radial access. Indications and limits of the procedure]. / Ergebnisse der offenen Arthrolyse bei extrinsischen Ellenbogensteifen über den radialen Zugang. Indikation und Grenzen des Verfahrens.

Open release of elbow stiffness via the lateral approach has proven to be a reliable option in the treatment of elbow stiffness over the last years. For evaluation of patient outcome after this procedure the current literature and studies were reviewed and analyzed with special reference to the increase in range of motion and patient satisfaction. It appears that particularly posttraumatic elbow stiffness with contracture of the capsule and minor alterations of the joint surface can achieve improvement in mobility and patient satisfaction. Therefore careful selection of patients is important for successful therapy.

[Arthroscopic versus open anterior shoulder stabilization. A systematic validation]. / Arthroskopische vs. offene ventrale Schulterstabilisierung. Eine Wertung.

The treatment of traumatic anterior glenohumeral instability has been a topic of debate over the last couple of decades. However, a consensus exists regarding the necessity of an individualized treatment plan based on the type and degree of instability and the patient's functional demands. Various open and arthroscopic techniques are among the currently used surgical procedures. Open reconstruction of the capsulolabral complex had been considered the treatment of choice for many years, but the latest results for arthroscopic anterior shoulder stabilization demonstrate its increasing use. The current literature suggests that with the introduction of suture anchors, it is possible to mirror the principles of open anterior shoulder stabilization and thus combine the general advantages of arthroscopic surgery with a low recurrence rate.

[Shoulder arthroplasty: biomechanics and design]. / Schulterendoprothetik - Biomechanik und Design.

Shoulder arthroplasty is becoming increasingly important in orthopaedic surgery. Continuous development of the implants means that the modern endoprostheses make it possible to recreate the original anatomy with a high degree of accuracy. This is of decisive importance in the long-term restoration of physiological patterns of movement and achievement of pain relief. The modern shoulder arthroplasties allow adjustment of the important parameters: ante-/retroversion, inclination and offset to fit the individual anatomy of the proximal humerus. Fixation is the most important factor for the glenoid component; reduced bone stock can make this difficult. Cemented components are still the gold standard. For young patients surface replacement arthroplasty can be a good alternative treatment for early stages of osteoarthritis. In cuff tear arthropathy reverse prostheses can be used. Reversing the anatomical relationship between glenoid and humerus leads to medialisation and lowering of the center of rotation, which in turn leads to increased tension on the deltoid muscle. Because of the high complication rate this operation should be performed only by experienced shoulder surgeons.

[Recommendations on sport activities for patients with idiopathic scoliosis]. / Empfehlungen zur Sportausübung bei Patienten mit idiopathischer Skoliose.

The idiopathic scoliosis is a three dimensional spinal deformity mostly occurring in female adolescents. Untreated it can progress and result in back pain, impaired lung capacity and psychosocial disorders due to the cosmetic appearance of the deformed trunk. The treatment depends on the severity of the curve and ranges from physiotherapy and observation, brace treatment to surgical treatment with partial correction and fusion of the primary curve. Patients with an idiopathic scoliosis should be encouraged to actively take part in sports activities. Positive influences on the general fitness including the lung function, on the trunk muscles and on the psyche can be expected. There are no scientific data indicating that any kind of sport activities alter the natural history of idiopathic scoliosis.

Acute compartment syndrome following intramedullary pulse lavage and débridement for osteomyelitis of the tibia.

The implantation of gentamicin loaded polymethylmethacrylate (PMMA) beats and other local antibiotic carriers is a common practice in the treatment of chronic osteomyelitis as is the use of local jet lavage débridement. This article presents the case of a patient with chronic osteomyelitis of the tibia, who had no complication after débridement, intramedullary reaming and pulse lavage without tourniquet but sustained a compartment syndrome 2 weeks later during a second procedure in which an intraoperative tourniquet and pulse lavage were combined.

Neuronal regeneration after application of radiofrequency energy to collagenous tissue is affected by limb immobilization: an in vivo animal study.

Despite widespread use of radiofrequency (RF)-shrinkage, there have been no studies on the influence of RF-energy on neural elements of collagenous tissue. The purpose of this study was to examine the effect of RF-shrinkage on neural structures of capsuloligamentous tissue and the recovery of neural elements under different postoperative treatment protocols. One patellar tendon of 46 New-Zealand-White rabbits was shrunk. Six rabbits were sacrificed immediately postoperative. Twenty rabbits were not immobilized, 10 were immobilized for 3 and 10 were immobilized for 6 weeks. A monoclonal antibody, specific against a neurofilament protein, was used to detect nerves and neural structures. Staining pattern of nerve fibres was significantly altered immediately postoperative. After 3 weeks the number of nerve fibres and bundles decreased significantly in immobilized and non-immobilized limbs. The loss of nerve fibres was significantly less in immobilized limbs. At 6 weeks the number of neural elements in immobilized limbs increased to the level of untreated control tissue. In non-immobilized limbs we found no recovery of neural elements 9 weeks postoperatively. At this time the number of nerve fibres and bundles was still significantly less compared to the untreated control limbs. RF-shrinkage causes significant alteration of neural elements. Under immobilization nerve fibres and bundles reach the level of normal untreated tissue. Careful rehabilitation is important after RF-shrinkage. Not only for biomechanical reasons, but also to allow the neural elements to recover, thermally modified tissue should be protected from normal physiologic loads.

Immobilisation after radiofrequency-induced shrinkage of tendon. A histological study in rabbits.

Despite widespread use of radiofrequency (RF) shrinkage, there have been no animal studies on the effects of post-operative immobilisation on the histological properties of the shrunken tissue. We have therefore examined the role of post-operative immobilisation after RF shrinkage with special emphasis on the histological properties of collagenous tissue. One patellar tendon of 66 New Zealand White rabbits was shrunk. Six rabbits were killed immediately after the operation. Twenty rabbits were not immobilised, 20 were immobilised for three weeks and 20 for six weeks. Fibroblasts, collagen and vascular quality and density were evaluated on sections, stained by haematoxylin and eosin. Nine weeks after operation the histological properties were inferior to those of the contralateral control tendons. Shrunk tendons did not return to normal at any time after operation irrespective of whether the animals had been immobilised or not. All the parameters improved significantly between zero and three weeks after operation. Immobilised tendons tended to have a better and faster recovery. Careful rehabilitation is imperative after RF shrinkage. Immobilisation aids recovery of the histological properties. Our findings in this animal model support a period of immobilisation of more than three weeks.

[Final results after operative treatment of shoulder joint infections]. / Endergebnis nach operativer Behandlung von Schultergelenksinfekten.

PURPOSE: In a consecutive case series the results of operative treatment of patients with shoulder joint infections following rotator cuff surgery, endoscopic subacromial decompression or subacromial injection were studied. PATIENTS AND METHODS: Between 1990 and 2001 26 patients developed a postoperative infection. 24 patients were available for a mean follow-up of 4.3 (1-12) years. The mean age of the study group was 59.8 (28-84) years. Patients were divided into three groups. Group I consisted of 9 patients with infection after rotator cuff repair, group II consisted of 4 patients with infection after endoscopic subacromial decompression and there were 11 patients in group III with an infection that developed following subacromial injection. Patient evaluation was done according to the Constant and ASES Scores, the SF-36 and a visual analogue scale (VAS) for postoperative pain and satisfaction. RESULTS: The mean postoperative Constant Score was 68.6 pts (SD 25.1) in group I, 84.6 pts (SD 10.4) in group II and 75.6 pts (SD 25.1) in group III. The mean ASES-Score was 65.6 pts (SD 30.0) in group I, 69.8 pts (23.6) in group II and 78.5 pts (SD 25.7) in group III. The SF-36 showed for the summarized physical scale 37.3 pts (SD 12.6) in the first, 39.8 pts (SD 5.8) in the second and 37.7 pts (SD 12.4) in the third group and for the summarized psychometric scale 40.4 pts (SD 2.7) in the first, 44.3 pts. (SD 10.8) in the second and 45.7 pts. (SD 10.1) in the third group. For the VAS for pain, group I had 4.3, group II 4.0 and group III 2.5 pts Patient satisfaction showed similar results with 6.4 pts in the first, 6.5 pts in the second and 6.8 pts in the third group. CONCLUSION: Considering the functional results of operative revision, infection of the shoulder joint following rotator cuff surgery, endoscopic subacromial decompression or subacromial injection is a rare but severe complication.

Clinical and functional outcome of the Thrust Plate Prosthesis: short- and medium-term results.

OBJECTIVES: The purpose of this study was to objectively assess the functional outcome after implantation of a Thrust Plate Prosthesis. DESIGN: This retrospective study compared the gait patterns of 33 patients to a control group. BACKGROUND: Few studies have been published about this type of prosthesis describing clinical and radiographic outcome. Even though the evaluation of the functional outcome is a commonly accepted way to measure the success of an implant it has not been reported in previous studies. METHODS: Beside clinical (SF-36, and Harris Hip Score) and radiographic evaluation subjects were examined by three dimensional gait analysis and surface electromyography from seven leg and trunk muscles bilaterally. RESULTS: The average Harris Hip Score was 85.7 points, and the SF-36 only differed significantly from controls regarding physical functioning. The radiography showed considerable radiolucencies under the Thrust Plate. Kinematic parameters indicated a slight impairment of the operated limb. The analysis revealed a decreased hip (28.2%) and knee (51.2%) range of motion during gait. The joint moments on the operated side were reduced in hip (72%) and knee abduction (59%) in comparison to controls. The average electromyographic parameters indicated a significantly higher mean and peak amplitude of the tensor fasciae latae (mean 56%, peak 54%), and gluteus medius (mean 33%, peak 21%) and a lower peak activity of the gluteus maximus (19%). CONCLUSIONS: The results indicate a generally good functional outcome even though a slightly asymmetrical loading was observed. No major limitations in physical functioning and health-related quality of life was seen. The radiographic signs of loosening might indicate difficulties in achieving the proximal load transfer of this implant. RELEVANCE: The data provided in this study may serve to establish the Thrust Plate Prosthesis as an alternative procedure in total hip replacement in younger patients.

[Limits in cementless hip revision total hip arthroplasty. Midterm experience with an oblong revision cup]. / Grenzen der zementfreien Revisionsarthroplastik. Mittelfristige Resultate mit der längsovalen Revisionspfanne.

UNLABELLED: Revision of an acetabular component in a patient who has severe periacetabular bone loss is a complex problem, particularly when there is not enough bone stock to allow placement of an acetabular component near the normal anatomical hip center. To fill the defect, a valuable option for revision arthroplasty is the cementless oblong revision cup (LOR). METHODS: 50 consecutive revisions of the acetabular component were performed in 48 patients. The mean age at the time of revision was sixty-one years (range, thirty-three to seventy-eight years). Forty-eight hips were available for follow-up, at a mean of thirty-two months (range, eighteen to sixty-one months). The acetabular defect classified according to Paprosky, the migration and the radiolucencies were followed radiologically. RESULTS: 8 hips (16 %) were revised again: two because of infection (4 %) and six because of instability (12 %). The revised hips are not associated to the preoperative degree of acetabular defect (34 % defect type III) (P > 0.05). The mean Harris Hip score was corrected from 36.5 (range, 7.5 to 92.5) to 78.2 points (range, 47.6 to 97.6) (P < 0.01). The mean d'Aubigné Score was corrected from 8.3 (range, 4 to 6) to 15 points (range, 10 to 18) (P < 0.01). Neither pre- nor postoperative results were associated to the degree of acetabular defect (P > 0.05). However, patients with multiple revisions had a significantly reduced clinical outcome than patients with the first revision (P < 0.05). The hip center of rotation, cranially placed to the contralateral side (0.92 cm) was corrected by the revision to a more normal anatomic rotation center (0.27 cm). Partial zonal radiolucencies, always smaller than 1.5 mm were seen in 30 % of the patients. The mean migration of the acetabular component was not significant (P > 0.05). CONCLUSION: The authors support the use of the cementless oblong revision cup if contact can be made with host bone to more than 50 %. If this is not possible, acetabular bone reconstruction combined with a roof ring and a cemented cup is the component of choice.

[Objective measures of gait following revision hip arthroplasty. First medium-term results 2.6 years after surgery]. / Ganganalyse bei Patienten nach Hüftpfannenwechsel. Erste mittelfristige Ergebnisse 2,6 Jahre postoperativ.

AIM: The purpose of the study was to identify the functional impairments after revision arthroplasty by gait analysis. METHODS: This retrospective study compared 33 patients (mean age 58.5 years) who have undergone revision of an acetabular component (mean follow-up 2.6 years) with a group of normal control subjects. Gait analysis including recording of the three dimensional kinetics and kinematics was performed in all patients. Surface electromyography of seven leg and trunk muscles were registered bilaterally. The vertical ground reaction forces were determined by two force plates. These data were correlated with the Harris Hip Score, the d'Aubigné Score and the radiographic analysis (centre of rotation). RESULTS: The analysis revealed a decreased hip range of motion during gait (p < 0.0001). In the sagittal plane there was a significant decrease in the hip extension at the end of the stance phase (p < 0.0001). The control group reached a mean extension of - 7.6 degrees, the operated patients were limited by the extension deficit (+ 9.1) in step length (p < 0.0016) and velocity (p < 0.0001). Kinetic parameters indicated a reduced hip abductor moment (p < 0.0001). Compensation of gait instability was observed in an extended stance phase (p = 0.0389). The hip muscle activity was increased to stabilize the impaired hip. The changed kinematic parameters are observed with secondary impairments in knee extension and reduced dorsiflexion in ankle motion (p < 0.0001). Neither the Harris Hip score (77.8 points) nor the d'Aubigné score (14.9 points) were associated with the motion analysis (p > 0.05). Deterioration in kinematics are indicated by cranialisation of the centre of rotation (p = 0.18). However, medial movement of the centre of rotation does not influence the kinematic data (p > 0.05). CONCLUSION: Despite sufficient satisfactory clinical data the gait analysis confirmed objective impairments of the operated hip and neighboring joints. Gait instability is revealed in a decreased hip extension and deficient hip abduction.

[Sprengel deformity in a nine-year-old boy: diagnosis and therapy]. / Sprengel-Deformität bei einem neunjährigen Jungen: Diagnostik und Therapie.

Sprengel deformity is a congenital malformation with usually unilateral elevation and medial rotation of the scapula. An omovertebral bone is generally present. Associated skeletal malformations are frequently present. Though functional impairment is mild, the cosmetic and psycho-social impairment can be considerable. The prognosis of early surgical therapy is good. The presented case also justifies surgical correction in the older child.

[Long-term results of quality of life in patients with idiopathic scoliosis after Harrington instrumentation and their relevance for expert evidence]. / Langzeitergebnisse der Lebensqualität nach Harrington Distraktionsspondylodese bei idiopathischen Thorakalskoliosen und deren gutachterliche Relevanz.

AIM: The expert evidence of operated patients with idiopathic scoliosis is determined by functional and pulmonary restriction. The degree of deformity and the extent of fusion is crucial for grading disability. In a retrospective study on the quality of life (SF-36) and low back pain (Roland-Morris Score) of 82 patients (22 - 40 years) with idiopathic scoliosis treated with Harrington instrumentation the grading was registered. METHOD: An average of 16.7 years after the surgery, these data were correlated with the type and size of curve and to the extension of fusion. RESULTS: Compared to the age-matched healthy population, there was no significant difference in the physical SF-36 scale (P = 0.98). Surgically treated patients showed significantly lower scores than at baseline in the psychological SF-36 scale (P = 0.005). Sixty-five (79.3 %) of the eighty-two patients reported no or occasional back pain in the Roland Index. Five patients (6.1 %) complained of chronic back pain. 33 patients (40 %) were legally defined in their rate of disability as severely handicapped patients. The grading disability was associated with the physical SF-36 scale (P < 0.001) and the low back pain (P = 0.02). A significant correlation between the grading disability and the extent of fusion (P = 0.53) or the size of curve (p = 0.4) could not be proven. CONCLUSION: Despite good long-term outcomes, 40 % of operated treated patients with idiopathic scoliosis were legally defined as severely handicapped persons. The additional measurements of quality of life and low-back pain can improve legal assessment in orthopaedics.

[Comparison of the results of the surgical repair of full-thickness tears of the rotator cuff with and without resection of the lateral clavicle]. / Vergleichende Untersuchung der Ergebnisse nach der offenen Naht kompletter Rotatorenmanschettendefekte mit und ohne Resektion der lateralen Klavikula.

PURPOSE: Aim of this study was to compare the results of the surgical repair of full-thickness rotator cuff tears with and without resection of the lateral clavicle. METHODS: 102 patients were retrospectively observed by an independent observer for a mean follow-up of 21 months (12 - 42). 93 patients had medium to large sized tears (1 - 5 cm) and 9 had massive tears (> 5 cm). Additional resection of the lateral end of the clavicle was performed in 20 patients. The mean age of the 68 men and 34 woman was 57.3 years (28 - 80). For the evaluation the Constant score, the ASES score and the visual analogue scales for postoperative satisfaction, function, strength, pain and ADL were used. RESULTS: The subjective results were good to excellent in 79 patients (76 %), fair in 14 patients (13.7 %) and poor in 9 patients (8.9 %), too. After surgery the Constant score was 87 % of the contralateral side for all patients, 89 % for group I and 84 % for group II and the mean ASES score was 86 %, 87 % and 82 % of the contralateral side. Comparing the pre- and post-operative values on the visual analogue scale pain and disability in ADL were decreased highly significantly in all patients (p < 0.001). CLINICAL RELEVANCE: We conclude that in patients with a full-thickness rotator cuff tear the patient's satisfaction and function will improve after acromioplasty and rotator cuff repair. The results are not significantly influenced by an additional resection of the lateral clavicle.

A process for evaluating adverse environmental impacts by cooling-water system entrainment at a California power plant.

A study to determine the effects of entrainment by the Diablo Canyon Power Plant (DCPP) was conducted between 1996 and 1999 as required under Section 316(b) of the Clean Water Act. The goal of this study was to present the U.S. Environmental Protection Agency (EPA) and Central Coast Regional Water Quality Control Board (CCRWQCB) with results that could be used to determine if any adverse environmental impacts (AEIs) were caused by the operation of the plant's cooling-water intake structure (CWIS). To this end we chose, under guidance of the CCRWQCB and their entrainment technical working group, a unique approach combining three different models for estimating power plant effects: fecundity hindcasting (FH), adult equivalent loss (AEL), and the empirical transport model (ETM). Comparisons of the results from these three approaches provided us a relative measure of confidence in our estimates of effects. A total of 14 target larval fish taxa were assessed as part of the DCPP 316(b). Example results are presented here for the kelp, gopher, and black-and-yellow (KGB) rockfish complex and clinid kelpfish. Estimates of larval entrainment losses for KGB rockfish were in close agreement (FH is approximately equals to 550 adult females per year, AEL is approximately equals to 1,000 adults [male and female] per year, and ETM = larval mortality as high as 5% which could be interpreted as ca. 2,600 1 kg adult fish). The similar results from the three models provided confidence in the estimated effects for this group. Due to lack of life history information needed to parameterize the FH and AEL models, effects on clinid kelpfish could only be assessed using the ETM model. Results from this model plus ancillary information about local populations of adult kelpfish suggest that the CWIS might be causing an AEI in the vicinity of DCPP.

[Prevention of thrombosis in hip prosthesis implantation]. / Thromboseprophylaxe in der Hüftendoprothetik.

Deep venous thrombosis is one of the most common perioperative complications after total hip arthroplasty. Systemic anticoagulation has been the gold standard for prophylaxis of postoperative deep venous thrombosis. There is no doubt that early mobilization and the use of pneumatic compression devices decrease the overall deep venous thrombosis rate. Single postoperative prophylaxis may decrease the overall deep venous thrombosis rate to 15-20% and the proximal deep venous thrombosis rate to approximately 7%. However,the activation of thrombogenesis is mainly an intraoperative event. The position of the extremity during the implantation of the femoral component leads to obstruction of the venous outflow. At the same time, the coagulation cascade is activated and markers of thrombogenesis in the blood are increased. By combining intraoperative (hypotensive epidural anesthesia and intraoperative heparin) and postoperative (pneumatic compression devices and aspirin) prophylaxis of deep venous thrombosis, the total deep venous thrombosis rate is reduced to less than 10% and the proximal deep venous thrombosis rate is reduced to 2%. Patients with increased risk for deep venous thrombosis should receive Coumadin or low-molecular weight heparin. In addition, hypotensive epidural anesthesia reduces the intraoperative blood loss and the need for postoperative blood transfusion.