Guy D. Paiement

Low-dose warfarin versus external pneumatic compression for prophylaxis against venous thromboembolism following total hip replacement

Lower doses of warfarin are effective in the treatment of proven proximal deep vein thrombosis (DVT), and at a substantially lower risk of bleeding complications than with standard doses. The authors compared low-dose warfarin with external pneumatic compression (EPC) boots for prophylaxis against DVT and efficacy and safety in a population of total hip replacement patients at high risk for DVT and bleeding complications. DVT developed in 12 of 72 patients on low-dose warfarin and 11 of 66 patients on EPC. Both regimens were as efficacious as traditional higher doses of warfarin used in prior studies. No major bleeding complications occurred in either group. Low-dose warfarin appears to be an effective and relatively safe form of prophylaxis against postoperative DVT, as does sequential EPC of the calf and thigh.

Cost-effectiveness of prophylaxis in total hip replacement

A theoretical analysis was performed regarding the cost-effectiveness in terms of lives saved (reduction of fatal pulmonary embolism [PE]) and in terms of money (dollars spent for prevention and treatment) of seven strategies in the management of venous thromboembolic disease in patients over 39 years of age undergoing elective total hip replacement (THR). Strikingly, this theoretical analysis suggests that low-dose warfarin combined with clinical surveillance of deep vein thrombosis would reduce the incidence of fatal PE from 20 per 1,000 patients to 4 per 1,000 patients and simultaneously reduce the charges for venous thromboembolic disease from

Surveillance of deep vein thrombosis in asymptomatic total hip replacement patients. Impedance phlebography and fibrinogen scanning versus roentgenographic phlebography

550,000 to about

Routine use of adjusted low-dose warfarin to prevent venous thromboembolism after total hip replacement.

400,000 per 1,000 patients. Based on this analysis, we strongly recommend this measure on a routine basis. Adding venography or duplex sonography routinely to this prophylactic regimen would, in this theoretical analysis, reduce the incidence of fatal PE from 4 per 1,000 patients to 0.15 per 1,000, but adds charges of

Treatment of supracondylar femoral fractures with a retrograde intramedullary nail.

200,000 per extra life saved in the case of routine venography and

Survey of prophylaxis against venous thromboembolism in adults undergoing hip surgery.

50,000 in the case of routine sonography. Low-dose warfarin prophylaxis combined with routine sonography does not generate more charges than no prophylaxis with no screening while drastically reducing the incidence of fatal PE from 20 to 0.3 per 1,000 patients. Where duplex sonography is not easily available, a 12-week postoperative course of low-dose warfarin for every patient with no routine screening will be efficacious in reducing fatal PE and as cost-effective.

A Study of Intrusion Characteristics of Low Viscosity Cement Simplex-P and Palacos Cements in a Bovine Cancellous Bone Model

Nine hundred thirty-seven limbs in 537 patients over the age of 39 years who underwent total hip replacement were studied by roentgenographic phlebography, cuff-impedance phlebography, and iodine-125 fibrinogen scanning. Cuff-impedance phlebography had a sensitivity of only 12.3 percent for thigh thrombi. Fibrinogen scanning had a sensitivity of only 59.1 percent for calf thrombi and 13.7 percent for thigh thrombi. The combined use of the two methods resulted in only a 23.2 percent sensitivity for thigh thrombi and an overall sensitivity of 47.4 percent. We have concluded that in asymptomatic patients, in contrast with symptomatic patients, the combination of cuff-impedance phlebography and fibrinogen scanning is not an effective screening method.

Prevention of venous thromboembolism in orthopaedics in the United States.

The efficacy and safety of routine use of adjusted low-dose warfarin for twelve weeks--without sonography or venography--for the prophylaxis of deep-vein thrombosis after total hip replacement was assessed in 268 patients (134 men and 134 women) who were between the ages of forty and eighty-five years (average, sixty-one years). The patients were given warfarin orally both before and after the operation. The initial dose was usually ten milligrams on the night before the operation and five milligrams on the night after the operation. Thereafter, the dose was adjusted to keep the prothrombin time between fourteen and sixteen seconds. The control time was ten to twelve seconds. The partial thromboplastin time was also measured, and the dose of warfarin was reduced if the value was more than fifty seconds. All 268 patients continued to take low-dose warfarin for twelve weeks after the operation. There were 170 primary and ninety-eight revisional total hip-replacement operations. Thirty-four patients (13 per cent) had a history of thromboembolic disease or venous stasis in a lower limb. Neither phlebography nor sonography was done routinely. All of the patients were followed for six months after the operation. There were no fatal pulmonary emboli during the period of the study and no known pulmonary emboli after any patient was discharged from the hospital. Two non-fatal pulmonary emboli were identified, both during hospitalization. Ten patients (4 per cent) had an episode of major bleeding--a wound hematoma in nine and a gastrointestinal hemorrhage in one--during hospitalization.(ABSTRACT TRUNCATED AT 250 WORDS)

Influence of prophylaxis on proximal venous thrombus formation after total hip arthroplasty

From August 1992 to January 1995, 24 patients with 26 supracondylar femoral fractures were treated with a retrograde intramedullary nail. There were 22 patients with 24 nails available for review. Eight fractures were open and 13 were intraarticular fractures. There were a significant number of associated injuries. The average followup interval was 18 months (range, 4-36 months). All fractures healed by 4 months, (average, 3 months). Only 1 patient required bone grafting. There were no implant failures or superficial or deep infections. One malunion occurred. Average knee range of motion was 104 °. A previously described rating scale was used to evaluate function. There were 4 excellent, 16 good, 2 fair, and 2 poor results. The supracondylar nail provides rigid internal fixation for rapid healing and comparable functional outcomes to lateral fixation devices with significantly less soft tissue dissection.

Porous-coated uncemented components in experimental total hip arthroplasty in dogs: Effect of plasma-sprayed calcium phosphate coatings on bone ingrowth

Venous thromboembolic disease (VTED) is the most common and potentially the most serious immediate postoperative complication of hip surgery. Prophylaxis of VTED remains controversial and its practice is widely variable. Since the last survey of VTED prophylaxis as practiced by American orthopedists, published in 1974, the literature has expanded tremendously and the number of orthopedists has doubled. The authors surveyed 10% of American orthopedists and the chiefs of training programs and/or major teaching hospitals to assess current practices. The average practicing orthopedist responding was 44-years-old and had performed 17.6 total hip arthroplasties and treated operatively 30.6 hip fractures per year during the last five years. The average responding chief surgeon, was 49 years old and had performed 49 total hip arthroplasties and treated operatively 20.5 hip fractures per year during the last five years. Most surgeons use pharmacologic prophylaxis or external pneumatic compression for total hip arthroplasty patients (84.4%) and hip fracture patients (74%). Warfarin has been tried and abandoned by 50% of all respondents, largely because of bleeding complications. Aspirin was the most popular agent. However, more than 25% of the respondents stated that at least one of their patients who had elective total hip arthroplasties had died of pulmonary embolism during the last five years.