The selection of a prophylaxis agent is a balance between efficacy and safety. Total knee arthroplasty patients receive DVT prophylaxis because orthopaedic surgeons are concerned about the morbidity and mortality associated with pulmonary embolism. However, at the same time there is great concern about excessive bleeding. The goal is to provide the appropriate anticoagulation to prevent symptomatic pulmonary embolism (PE) and DVT but at the same time avoid over anticoagulation which can be associated with bleeding and other wound problems. Therefore, risk stratification is necessary. Although risk stratification is the ideal way to determine the appropriate prophylaxis agent to use for a specific patient, there is no validated risk stratification strategy available today. There is general agreement at this time that patients who have had a prior PE or symptomatic DVT are at higher risk for development of a pulmonary embolism. In addition, there is a general belief that patients who have coagulation abnormalities (i.e. Factor V Leiden, Protein C and S deficiency) have an increased risk of developing a pulmonary embolism. Other factors that have been mentioned as associated with PE after total hip arthroplasty include age, female gender, and higher body mass index. The selection of a prophylaxis regimen should be influenced by the ability to mobilise the patient after surgery

Introduction. Total knee arthroplasty (TKA) is one of the most successful surgeries to relieve pain and dysfunction caused by severe arthritis. However, it is a still big problem that there is a possibility of death in pulmonary embolism (PE) after TKA. We previously reported that there was more incidence of asymptomatic PE than estimated in general by detail examinations. But it was difficult to whom we decided to perform additional examinations except the patients with some doubtful symptoms. Therefore, we investigated detail of PE patients after primary TKA to find out anything key point in PE. Methods. Consecutive ninety-nine patients who underwent primary TKA from January 2015 to March 2018 were applied. There were 23 male and 76 females included, and the mean age was 73.7 years old. There were 96 cases of osteoarthritis, 2 cases of osteonecrosis and one of rheumatoid arthritis. A single knee surgery team performed all operations with cemented type prostheses and air tourniquet during operation. There were 35 cases of one-staged bilateral TKA and 64 of unilateral TKA. Detail examinations with contrast enhanced CT (CE-CT) and venous ultrasonography (US) were performed at the 3rd day after surgery. Next, we applied ultra sound cardiogram (UCG) to the patients diagnosed as PE by CE-CT, we checked right ventricular overload (RVO) to treat PE. These images were read by a single senior radiologist team. Results. CE-CT was performed in 87 patients (87.8%) and US was in all patients. The incidence of deep vein thrombosis (DVT) was 67 patients (67.6%), and all of these was distal type DVT. PE was 17 patients (17.1%), and each of patients had no symptoms. RVO was detected in 5 patients (5.0%), and two of them (2.0%) had decreased SpO2 in early 90% perioperative period. All patients did not change rehabilitation protocol and progress was good until discharge. Conclusion. We investigated consecutive 99 patients for DVT/PE after primary TKA using CE-CT and venous US. And we performed UCG to PE patients. One of the important findings to decide detail examination for asymptomatic PE was decrease in SpO2 during early perioperative period. It might be the only finding except symptom. We also have to be more aware about high incidence of asymptomatic PE and more careful to the patients after TKA to prevent complications. For any figures or tables, please contact authors directly

Venous thromboembolism (VTE) is the second most common complication and pulmonary embolism (PE) is the fourth most common cause of death after a hip fracture. Despite thromboprophylaxis, deep vein thrombosis (DVT) is detected in up to 45% of hip fracture patients. Thrombelastography (TEG) is a whole-blood, point of care test capable of providing clinicians with a global assessment of the clotting process, from fibrin formation to clot lysis. Maximal amplitude (mA) from TEG analysis is a measure of clot strength. Elevated admission mA values of >65mm and >72mm have been determined to be independent predictors of in-hospital PE. The coagulation index (CI) is calculated based on TEG parameters and defines hypercoagulable state as CI >3. This study aimed to use serial TEG analysis to determine the duration of hypercoagulable state after hip fracture. A prospective cohort of hip fracture patients >50 years of age amenable to surgical treatment (AO 31A1–A3 & 31B1–B3) were enrolled at a Level I trauma centre. Serial TEG analysis (TEG 6S) was performed every 24-hours from admission until 5-days post-operatively and at 2- and 6-week follow-up visits. All patients received a minimum of 28 days of thromboprophylaxis. Descriptive statistics and single sample t-tests were used for comparison of mA to the 65mm threshold. Thirty-five patients (26 female) with a median age of 83 (range = 71–86) years were included. On admission, 31.4% and 82.9% of patients were hypercoagulable based on mA >65mm and CI, respectively. At 2 weeks, all patients remained hypercoagulable, however, mA >72mm showed that 16 patients (47.1%) were at even higher risk for VTE. At 6-weeks, 65.7% and 97.1% of patients were hypercoagulable based on mA >65mm and CI, respectively. When compared with the mA >65mm threshold, patients were hypocoagulable at the time of admission (mA = 62.2 (±6.3), p = 0.011), but became significantly more hypercoagulable at 2-weeks (mA = 71.6 (±2.6), p < 0 .001), followed by continued hypercoagulability at 6-weeks, however not significantly elevated above the 65mm threshold (mA = 66.2 (±3.8), p = 0.058). One patient developed a symptomatic DVT at 2-weeks and had a mA = 72.9 and a CI of 5.9. This is the first study to demonstrate that >50% of hip fracture patients remain hypercoagulable 6 weeks post fracture despite thromboprophylaxis, and there are individual hypercoagulable responses. This is critical, as guidelines only recommend 28 to 35 days of thromboprophylaxis in this high-risk population. Previously determined mA thresholds may be a more sensitive test for risk-stratifying patients' VTE risk than the CI threshold. Additionally, assessing ΔmA using serial TEG may better predict VTE risk

Venous thromboembolic (VTE) events including deep vein thrombosis (DVT) and pulmonary embolism (PE) remain a significant concern following total joint arthroplasty. The American Academy of Orthopaedic Surgeons (AAOS) guidelines for VTE prophylaxis have focused on the safety of prophylactic regimens, with the primary endpoint being prevention of symptomatic events while avoiding the risks of hematoma, infection, and re-operation associated with aggressive anticoagulation. In 2007, the AAOS clinical practice guideline recommended “risk stratification” of patients for VTE events and bleeding. Unfortunately, there remains limited evidence as to specific factors that should be used during pre-operative risk stratification. A prior investigation has demonstrated the effectiveness of using a history of VTE events, active cancer, and hypercoagulable state (i.e. Factor V Leiden) as criteria for high-risk patients undergoing total joint arthroplasty. In addition, large national database systems have been used to identify risk factors for VTE events. Unfortunately, these investigations emphasise different risk factors and their importance in increasing the risk of VTE events. Thus, criteria to be used for risk stratification of patients undergoing total joint arthroplasty remain unclear. What remains clear is that even in healthy patients who are aggressively anticoagulated, a VTE event can still occur

INTRODUCTION. The direct anterior approach (DAA) for total hip arthroplasty has become a popular technique. Proponents of the anterior approach cite advantages such as less muscle damage, lower dislocation risk, faster recovery, and more accurate implant placement for the approach. However, there is a steep, complex learning curve associated with the technique. The present study seeks to define the learning curve based on individual surgical and outcome variables for a high-volume surgeon. METHODS. 300 consecutive patients were retrospectively analyzed. Intraoperative outcomes measured include surgery time and estimated blood loss (EBL). Complications include intraoperative fracture, post-operative fracture, infection, dislocation, leg length discrepancy, loosening, and medical complications such as deep vein thrombosis (DVT) and pulmonary embolism (PE). Segmented regression models were used to elucidate the presence of a learning curve and mastery of the procedure with regard to each individual variable. RESULTS. The mean operative time was 77.1 minutes (range 40–213). Operative time improved at a rate of 6.6 minutes per case for the first 15 cases then by an average of 5 seconds per subsequent case. The mean EBL for the series was 288.6 mL. Segmented regression shows EBL decreased at a rapid rate until case 52, followed by a more gradual decline. Complications were higher in the first 7 surgeries, with a 48% decrease in the likelihood of complication with each subsequent surgery. The improvement continued through the rest of the series with a 0.5% decrease in likelihood with each surgery. DISCUSSION. Our data contributes to the current body of literature by defining the learning curve with what we consider the most pertinent outcomes. First, we show that operative efficiency can be gained quite quickly (15 cases) while the slower improvement in EBL demonstrates continued learning about the anatomy. Our data is consistent with previous published reports regarding complication improvement. The present study will provide surgeons considering DAA useful information regarding what to expect during their learning curve. Furthermore, the data can be useful for surgeons charged with teaching the technique to critically evaluate what learning curve variables can be improved to hasten the learning curve

Venous thromboembolic events (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), remain one of the most common complications following total joint arthroplasty. Reported rates of symptomatic VTE following THA and TKA range from 0.83% to 15% and 2% to 10%, respectively. Thus, VTE prophylaxis should be routinely administered following total joint arthroplasty. However, while orthopaedic surgeons have considerable flexibility regarding their VTE prophylaxis regimen, it remains unclear which is optimal. Patients at low risk of VTE may receive excessive anticoagulation and unnecessarily risk further perioperative morbidity (wound complications, bleeding) following total joint arthroplasty. With an evolving health care landscape, emphasis on complications and readmissions, and shorter inpatient hospitalizations, it is imperative that a VTE prophylaxis regimen is simple, effective, easy to monitor, and has high patient compliance. Mobile pneumatic compression devices (MCDs) have been used with greater frequency following total joint arthroplasty, with multiple reports demonstrating their effectiveness in VTE prevention with or without the addition of aspirin for chemical prophylaxis. The use of MCDs allows the avoidance of more aggressive anticoagulation in the majority of patients undergoing total joint arthroplasty, decreases the incidence of wound complications, and achieves a low overall incidence of symptomatic VTE. Future investigations are necessary to determine the necessity and impact of the addition of aspirin to the use of MCDs for VTE prophylaxis

Previous studies have indicated that prolonged surgical time may lead to higher rates of infection following total hip arthroplasty (THA). The purpose of this study was to evaluate the influence of surgical time on 30-day complications following THA and to determine if there was a time interval associated with worse outcomes. Patients ≥18 years who underwent THA between 2005 and 2016 were identified from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database using procedural codes. Patients with surgical durations >240 minutes were excluded. Patient demographics, operation length, and 30-day major and minor complications were ascertained. Multivariable regression was used to determine if the rate of complications differed depending on length of operation, while adjusting for relevant covariables, and to identify independent predictors of operation length. Covariables of interest included age, sex, American Society of Anaesthesiologists (ASA) class, smoking status, functional status, comorbidities, anesthesia type, and Body Mass Index (BMI). A total of 131,361 THA patients (average age 65 ±12 years) were identified from the database. Of these, 2,177 (1.64%) experienced a major complication, and 3,504 (2.64%) experienced a minor complication within 30-days of the initial procedure. Average operation length was 91.9 minutes (range 20 – 240 minutes). Independent predictors of prolonged operation length included overweight/obese BMI, male sex, cancer, dependent functional status, epidural anaesthetic, lower pre-operative hematocrit, and ASA class II, III or IV vs. I Alternatively, older age, current smoking, and spinal anaesthetic were associated with shorter surgical durations. Unadjusted rates of both major and minor complications were significantly higher for patients whose operation lengths were ≥ 120 minutes (P>0.001). Specifically, patients whose operations lasted ≥ 120 minutes had higher rates of septic shock, sepsis, pulmonary embolism (PE), deep vein thrombosis (DVT), urinary tract infection (UTI), renal insufficiency, surgical site infection(SSI) and wound disruption. After covariable adjustment, surgical durations of 90–119 minutes increased the risk of minor complications by 1.2 (95%Confidence interval [95%CI] 1.1–1.3), while surgical durations of 120–179 minutes increased the risk of major complications by 1.4 (95%CI 1.3 – 1.6), and minor complications by 1.4 (95%CI 1.2 – 1.5), and surgical durations ≥180 minutes increased the risk of major complications by 2.1 (95%CI 1.8 – 2.6), and minor complications by 1.9 (95%CI 1.6 – 2.3). There was no difference in the overall risk of complications for operation times lasting 20 – 39, 40 – 59, or 60 – 89 minutes (P>0.05). In terms of specific complications, operation length ≥90 minutes was determined to be an independent risk factor for deep and superficial incisional SSI, as well as wound disruption, while operation length ≥ 120 minutes was an independent risk factor for sepsis, UTI, and deep, non-incisional SSI and operation length ≥ 180 minutes was an independent risk factor for PE, DVT, and cardiac arrest (p < 0 .05). These data indicate that prolonged surgical durations may be an independent predictor of major and minor complications following THA. This suggests that quality improvements could be made to improve operating room efficiency and surgical times and therefore postoperative outcomes

Introduction. Venous thromboembolism (VTE), including pulmonary embolism (PE) resulting from deep vein thrombosis (DVT), remains a well-known serious complication after femoral fractures. The low molecular heparin is widely used to prevent VTE. This study compared the effectiveness of VTE prevention between dalteparin and enoxaparin. Materials and Methods. From 2013 to 2014, we retrospectively recruited 712 patients who had femoral fractures with operative treatment. All patients receiving VTE chemoprophylaxis with perioperative period using dalateparin in Group 1(N=395) and enoxaparin in Group 2(N=317). The prophylactic dosing was determined using individual product labeling and identified as enoxaparin 40 mg every 12 hours and dalteparin 2500 international unit (IU) once daily, based on clinical practice guidelines. The prophylaxis was started at admission, and maintained during average 8.43.5 days after operation. The outcome including the incidence of clinically significant deep vein thrombosis, pulmonary embolism, perioperative bleeding and cost of drugs were evaluated between two groups. Results. The two study groups did not differ significantly in fracture type, age, gender, ASA score. The overall incidence of VTE is similar between two groups. However, the incidence of fatal PE is significantly lower in patients with dalteparin (Group 1: 4/395(1.00%), Group 2: 10/317(3.15%), p<0.001). And the overall cost of each group is significantly different between two groups (Group 1: average KRW 89,426, Group 2: average KRW 32,188, p<0.001). Conclusion. Both dalteparin and enoxaparin could be safely used without notable complications in VTE prophylaxis. However, dalteparin had more advantages for prevention of fatal PE, compared to enoxaparin in patients with femoral fractures with significant cost effectiveness

Thromboembolic disease (TED) remains as a major concern for orthopaedic surgeons and is a well-known complication of lower extremity joint replacement procedures. While there is voluminous literature on the topic, it is difficult for the average orthopaedic surgeon to keep up with all the advancements in this area as well as the newer pharmacological options for prophylaxis. To address this, the American Academy of Orthopaedic Surgeons (AAOS) has developed a clinical practice guideline (CPG) in this area to provide treatment recommendations based on the best available evidence. Historically, guidelines for TED prophylaxis have been based largely on randomised controlled trials whose outcome measure was venographically documented deep vein thrombosis (DVT). However, many venographically documented DVTs, particularly those distal to the popliteal vein, are of no clinical consequence. Therefore, in the AAOS CPG the systematic review of the literature was focused on those outcomes that have the most clinical relevance: all-cause mortality, symptomatic or fatal pulmonary embolism (PE), proximal DVT, major bleeding and symptomatic DVT rates. Using these as the clinically important endpoints, it is evident that the extant literature is insufficient to provide definitive guidance in this area and to make specific recommendations about optimal pharmacological prophylaxis. Nonetheless, one strong recommendation has emerged from this systematic review: the guideline recommended against routine post-operative duplex ultrasonography screening of patients who undergo elective hip or knee arthroplasty. Only one risk factor – previous history of TED – had evidence demonstrating a higher risk beyond the risk from elective hip or knee arthroplasty itself (weak recommendation). There was not sufficient evidence that other potential risk factors increase the risk of TED, likely because of the relatively high background risk of elective hip or knee arthroplasty. In addition, there is very little evidence defining populations at increased risk for bleeding and bleeding-associated complications associated with pharmacological prophylaxis. However, the panel did come to a consensus that patients with known bleeding disorders or active liver disease are at an increased risk for post-operative bleeding. In these circumstances, it is recommended that mechanical compressive devices be the primary modality of prophylaxis as pharmacologic prophylaxis may increase the risk of bleeding. There was a moderate strength recommendation for the superiority of neuraxial anesthesia to limit blood loss even though there is no demonstrable effect on the incidence of TED. Finally, there was a moderate grade recommendation that pharmacologic agents (including aspirin) and/or mechanical compression devices be utilised for the prevention of VTE in patients that are undergoing elective hip or knee arthroplasty who are not at elevated risk beyond that of the surgery itself for VTE or bleeding. Clearly there is great need for better evidence with appropriately powered studies that examine the most clinically relevant outcomes in TED prophylaxis

Surgery for pelvic or acetabular fractures carries a high risk of deep-vein thrombosis (DVT). Reports indicate that fondaparinux is a more effective thromboprophylactic agent than low molecular weight heparin (LMWH) after major orthopaedic surgery. We prospectively evaluated a new protocol for DVT prophylaxis using fondaparinux. Patients and methods. One hundred and eight patients with pelvic or acetabular fractures were randomised to receive either fondaparinux or enoxaparin. Specific review points included the primary end-point of clinical deep vein thrombosis (DVT) or pulmonary embolism (PE) and any evidence of adverse effects such as bleeding or allergic reactions. Results. Two patients that received enoxaparin were found to have a DVT (3%) and one patient died from a PE (1%). There was no documented DVT or PE in patients that received fondaparinux. The mean number of units of blood transfused was significantly higher in the enoxaparin group and this was significant post-operatively (p<0.05). The current study supports that post-operative fondaparinux, in patients with pelvic and acetabular fractures, is more effective and equally safe to enoxaparin

In his classic monograph entitled Low Friction Arthroplasty of the Hip, which was published in 1979, John Charnley dedicated a chapter to thromboembolic complications. The overall incidence of pulmonary embolism (PE) was approximately 8% and the incidence of death from PE approximately 1%. Surveys of orthopaedic surgeons who undertake total joint replacement conducted by The American Association of Hip and Knee Surgeons (AAHKS), 30 years later, showed that there was still no consensus as to the best form of prophylaxis with a wide variation of methods being used. In the past 3 years, for the first time there is uniformity in the recommendations of the American Academy of Orthopaedic Surgeons (AAOS) and the American College of Chest Physicians (ACCP). Both groups have reached an agreement that the rate of DVT formation is not the ideal endpoint to use when assessing the efficacy of thromboprophylaxis after joint replacement, as had been done in previous drug trials. Most of these DVTs are asymptomatic and of questionable clinical significance. At least one recent study brings into question the association between the rate of DVT formation and that of subsequent symptomatic events. Both groups also focus on minimizing iatrogenic bleeding complications, which can lead to compromised clinical results, including limited movement and pain in the case of knee replacement and increased risk of infection in both knee and hip replacement. To further complete the uniformity of approach in the United States, the Center for Medicare and Medicaid Services (CMS), which administers the Surgical Care Improvement Program (SCIP) that monitors hospital compliance with VTE prophylaxis of hospitalised patients, has also changed their policy. Beginning January 2014, either aspirin or a compression device has been considered as acceptable measures for THR, TKR and hip fracture. The remarkable success reported from many centers with the use of aspirin and/or the use of a mobile compression device in patients without major risk factors, such as a prior history of symptomatic VTE, clearly indicate that aggressive pharmacoprophylaxis is not necessary for the vast majority of patients who undergo joint replacement

Since NICE issued guidance on preventing venous thromboembolism (VTE), the use of chemoprophylaxis has increased dramatically in trauma and orthopaedics. However, enthusiasm is tempered by a lack of data regarding the true incidence of VTE in everyday practice. We investigated the epidemiology of VTE among ambulatory patients with lower limb injuries within our Trust. We identified all patients who suffered pulmonary embolism (PE) or deep vein thrombosis (DVT) over an 18 month period, and cross-referenced them with our trauma database. All lower limb injuries were included, whether operated or not. Hip fractures routinely receive dalteparin and were excluded. There were 11,594 new attendances or post-operative attendances in all fracture clinics over 18 months. Of these, 4530 had lower limb injuries and were immobilised. There were 21 DVTs and 7 PEs in these patients, an incidence of 0.43% and 0.14% respectively. Of note, three DVTs were in patients with Achilles tendon rupture. The incidence of symptomatic VTE is low in a population of ambulant patients with lower limb injuries in casts, without chemical thromboprophylaxis. Prophylaxis for VTE would thus have a large number needed to treat. The costs and complications of chemoprophylaxis should also be considered before it is introduced universally

Surgeons want to counsel their patients accurately about the risks of rare complications. This is difficult for venous thromboembolism (VTE), as most studies report rates of asymptomatic disease. We calculated the rate of confirmed, symptomatic deep vein thrombosis (DVT) and pulmonary embolism (PE) after elective lower limb surgery in our hospital. We scrutinised referrals for venous Doppler ultrasound and computed tomography pulmonary angiography, identifying all cases of DVT or PE over an 18 month period. These patients were cross-referenced with our elective orthopaedic database and Healthcare Resource Group coding data. Out of 1071 total hip replacements, there were three DVTs and two PEs, giving an incidence of 0.28% for DVT and 0.19% for PE. Out of 1351 total knee replacements, there were four DVTs and three PEs (incidence 0.29% and 0.22% respectively). Out of 1988 non-arthroplasty hip and knee procedures, there were no DVTs and two PEs (incidence 0.1%). For 1763 elective surgical foot procedures, there were five DVTs (incidence 0.28%), and no PEs. Currently, Rivaroxaban is offered to patients undergoing hip and knee replacement surgery, but other patients do not receive anticoagulants routinely. Our low incidence of VTE supports this policy and is reassuring for surgeons

Introduction. Recent UK national guidelines advocate using a combination of mechanical and pharmacological VTE prophylaxis in patients undergoing lower limb arthroplasty. We compared the results from our two series of patients: one treated with clexane and the other treated with rivaroxaban. Methods. Both groups received mechanical prophylaxis. In the first group 89 patients were given 40 mg subcutaneous clexane once daily from the day prior to surgery until they were independently mobile. The second group comprised 99 patients who were given 10 mg of oral rivaroxaban. Results. The mean length of stay was 5 days in the clexane group and 5.5 days in the rivaroxaban group. 24 patients stayed in hospital for 5 days or more because of wound leakage in the rivaroxaban group compared to 10 in the clexane group. 5 patients were readmitted in the clexane group: 3 for pulmonary embolism (PE), 1 for dislocation and 1 for periprosthetic fracture. 5 patients were also readmitted from the rivaroxaban group: 4 for infection and 1 for PE. No patients in the clexane group required re-operations. 2 patients in the rivaroxaban group went back to theatre: 1 for haematoma evacuation and 1 for haematoma evacuation and subsequent revision knee arthroplasty. Conclusion. This study raises concern regarding the rates of postoperative complications with rivaroxaban prophylaxis

Aim. To assess the incidence of fatal pulmonary embolism (PE) following elective total knee replacement (TKR) with a standardised multi-modal prophylaxis regime in a large teaching DGH over a 10 year period. Material and methods. Information was gathered from a prospective audit database, utilising clinical coding for TKR and those that had died within 42 and 90 days. The 10 years from April 2000 were analysed to establish both 42 and 90 day mortality rates. A multi-modal prophylaxis regime for all patients included regional anaesthesia (when possible), mechanical prophylaxis (Flo-tron calf garment per-operatively, AV impulse boots until mobile and anti-embolism stockings for 6 weeks), mobilisation within 24 hours and 75mg aspirin for 4 weeks. A case note review was performed to ascertain the causes of death. Where a patient had been referred to the coroner, the coroner's office was contacted for PM results. Results. There were 6,584 cases; the mortality rates at 42 and 90 days were 0.36 and 0.52%. There were no fatal PE's within 42 days of surgery. 2 fatal PE's occurred subsequently at 48 and 57 days (0.03%) The leading causes of death were myocardial infarction and cerebro-vascular accident. Conclusion. Fatal pulmonary embolus following elective TKR with a multi-modal prophylaxis regime is not a significant cause of mortality

Background. Post-operative deep venous thrombosis (DVT) and subsequent pulmonary embolism (PE) remain a serious complication after total joint replacement. Although with modern chemical and mechanical prophylaxis and rapid rehabilitation the rate of symptomatic DVT and PE has reduced, isolation of pre-operative DVT, especially in patients with prior history of DVT remains a challenge. The aim of this study was to assess the utility of pre-operative dopplers as a tool to screen and reduce DVT/PE rate in patients undergoing total joint replacement. Methods. Between January 2014 and December 2014, 211 elective primary hip and knee arthroplasty were identified from our prospective institutional database as two consecutive cohorts (115 cases had pre-operative dopplers and 96 did not). All cases were performed by two adult reconstruction specialists. All primary total hip arthroplasties (THA) were non-cemented and all primary total knee arthroplasties (TKA) were cemented with similar implant and technique. In the first cohort, all cases underwent routine pre-operative doppler screening and in the control cohort, only patients with prior history of DVT or PE underwent pre-operative dopplers. All patients with clinical symptoms of calf pain underwent post-operative dopplers. Patients were followed for a minimum of 3 month post-operatively. All emergency room (ER) visits for role out DVT were identified. No patient was lost to follow. Results. In the cohort with pre-operative dopplers, none of the pre-operative dopplers were positive for DVT, including three patients that had a history of prior DVT. 34 patients in this group (29%) underwent post-operative dopplers, either during the hospital stay or in the ER within 3 month after index surgery. Only one patient (no prior history of DVT) developed symptomatic DVT/PE (0.8%) after total knee arthroplasty. In the control cohort, 3 of which (3%) had symptomatic DVT, one of which had PE (1%) during hospital stay, all after total knee arthroplasty. There was no statistical difference for rate of symptomatic DVT/PE between the two groups (p=0.3). There was no correlation between DVT and age, gender or BMI. Discussion and Conclusions. Utilization of routine pre-operative dopplers for all patients did not lower the rate of symptomatic DVT/PE and are not helpful in early detection and prevention in asymptomatic patients prior to routine total joint replacement. Pre-operative dopplers should be used in selected patients with high risk of DVT

Introduction. We investigated the incidence of venous thromboembolism (VTE) and pulmonary embolism (PE) after total knee arthroplasty (TKA) and assessed the efficacy and complications of three different chemical prophylactic regimens. Materials and Methods. From May, 2011 to November 2013, 268 patients, 330 knees were randomly allocated to three groups, low molecular weight heparin (LMWH) 5000IU for 2 days followed by aspirin 100mg for 5 days (Group HA, 110 knees), rivaroxaban 10mg for 7 days (Group X7, 110 knees), or for 10 days (Group X10, 110 knees) postoperatively. Intermittent pneumatic compression device was applied on all patients. The multidetector row computed tomography (MDCT) was done at postoperative 10 days to evaluate VTE (PE & DVT separately), and MDCT was rechecked to evaluate the changes of VTE at postoperative 3 months in VTE patients. Additionally, major and minor bleeding complications, amounts of bleeding, and bruise around wound were checked. Results. The incidence of VTE was 42 (38.2%) in Group HA, 22 (20.0%) in Group X7, 11 (10.0%) in Group X10. Deep vein thrombosis (DVT) was revealed 39 (35.5%) in Group HA, 17 (15.5%) in Group X7, 8 (7.3%) in Group X10. Group HA showed statistically higher prevalence in VTE and DVT than rivaroxavan groups. PE was detected 21 (19.1%) in Group HA, 11 (10.0%) in Group X7, 3 (2.7%) in Group X10. Group X10 was statistically significantly lower PE incidence than Group HA (p=0.0001) and Group X7 (p=0.027). Asymptomatic distal DVT was completely resolved in 88.8% with no specific treatment. There was no major or minor bleeding complications and bleeding amounts were not statistically different in 3 groups. Conclusion. Rivaroxaban has better prophylactic efficacy with no increasing bleeding complications than LMWH followed by aspirin. Ten days rivaroxaban was more effective for PE and VTE prevention than 7 days rivaroxavan. However, most of reduced VTEs were asymptomatic and distal DVTs

Background. Post-operative deep venous thrombosis (DVT) and subsequent pulmonary embolism (PE) remain a serious complication after total joint replacement. Although with modern chemical and mechanical prophylaxis and rapid rehabilitation the rate of symptomatic DVT and PE has reduced, isolation of pre-operative DVT, specially in patients with prior history of DVT remains a challenge. The aim of this study was to assess the use of pre-operative dopplers as a tool to detect and identify prior DVT in patients undergoing total joint replacement. Methods. Between January 2014 and December 2014, 211 elective primary and revision hip and knee arthroplasty were identified from our prospective institutional database. All cases were performed by two adult reconstruction specialists. All primary total hip arthroplasties (THA) were non-cemented and all primary total knee arthroplasties (TKA) were cemented with similar implant and technique. Prior to July 2014, only patients with prior history of DVT or PE underwent pre-operative dopplers. From July 2014, all cases underwent routine pre-operative doppler screening. All patients with clinical symptoms of calf pain underwent post-operative dopplers. Patients were followed for a minimum of 3 month post-operatively. All emergency room (ER) visits for role out DVT were identified. No patient was lost to follow. Results. 115 patients patient underwent pre-operative dopplers. Three patients had a history of prior popliteal DVT, none of which had post-operative DVT or PE. In the remaining 112 patients, none of the pre-operative dopplers were positive for DVT. 34 patients in this group (29%) underwent post-operative dopplers, either during the hospital stay or in the ER within 3 month after index surgery. Only one patient developed symptomatic PE (0.8%) after total knee arthroplasty. 96 patients did not have pre-operative dopplers, 3 of which (3%) had symptomatic DVT and PE during hospital stay, all after total knee arthroplasty. There was no statistical difference for rate of symptomatic DVT/PE between the two groups (p=0.3). There was no correlation between DVT and obesity, age, or revision versus primary cases. Discussion and Conclusions. Routine pre-operative dopplers do not significantly lower rate of symptomatic DVT/PE and are not helpful in early detection and prevention in asymptomatic patients prior to routine total joint replacement

Purpose. To investigate the incidence of deep vein thrombosis (DVT) and pulmonary embolism (PE) with external fixator use and to help establish whether current guidelines are appropriate. Methods. Case notes of individuals undergoing external fixator application by the senior author (PC) from March 2005 to June 2011 were examined. In this period 207 individuals underwent 255 primary applications of Ilizarov, Taylor Spatial Frame (TSF) or monolateral fixator. Fixators applied were 173 tibial, 63 femoral and 19 to other bones. Records were obtained for 182 individuals (88%), representing 214 operations (84%). Results. Two cases of DVT were found (1%). In both cases mechanical and chemical prophylaxis had been used, as guided by risk assessment. One of these individuals also experienced a PE. This person was of notably high risk, surgery involving excision of tibial adamantinoma and a high body mass index (45). He had also recently travelled from overseas (a travel time of over 3 hours). Other than surgical time there was one additional risk factor in 39 cases, two additional risk factors in four and three additional risk factors in four. Conclusions. Little evidence exists about the incidence of DVT and PE with the use of external fixators. The National Institute of Health and Clinical Excellence (NICE) provide guidance for thromboprophylaxis in orthopaedic surgery with specific recommendations for hip and knee arthroplasty and hip fracture. For orthopaedic surgery other than lower limb arthroplasty NICE recommends thromboprophylaxis is guided by risk factors on a case by case basis. Our findings raise the question of whether extended course chemical thromboprophylaxis, as for lower limb arthroplasty, should be employed for high risk individuals undergoing application of external fixator

Purpose. With the advent of newer diagnostic imaging tools, the reported prevalence of acute pulmonary embolism (PE) following total hip (THA) and total knee (TKA) arthroplasty appears to be increasing. However, the true prevalence and clinical relevance of these events are unclear. Our study was designed to evaluate the results of routine multi-detector computed tomography (MDCT) in this patient population in the early postoperative period. Method. We prospectively performed MDCT scans on 48 consecutive THA/TKA patients on the first postoperative day in 2009. Patients underwent routine postoperative care and data were collected regarding the development of symptoms such as tachycardia, fever, chest pain, or shortness of breath. Scans were kept blinded and read at the end of study recruitment for the diagnosis of acute PE. Results. Our cohort included 27 TKA patients and 21 THA patients. None of the 48 patients had any symptoms of PE. Among the TKR patients, 11 (41%) of the CT scans were read as positive for acute PE compared with 1 (5%) of the THR patients (p=0.004). All of the patients diagnosed with asymptomatic PE were discharged from hospital without treatment for venous thromboembolism (VTE) and without developing any clinical symptoms suggestive of VTE. One TKA patient, who had a negative CT scan on the first postoperative day, was diagnosed with symptomatic PE the following day. Conclusion. Our study demonstrates a high rate of abnormal MDCT early following lower extremity arthroplasty, the clinical significance of which may be benign. This finding is also important in the interpretation of MDCT obtained after a clinical suspicion of PE in these patients