Roger Lemaire

High-dose aprotinin reduces blood loss in patients undergoing total hip replacement surgery

BackgroundAprotinin, a proteinase inhibitor, has been reported to reduce blood loss significantly during cardiac surgery. The mechanisms of this effect remain unclear. We studied the effect of aprotinin on blood loss and transfusion requirement during total hip replacement. Potential mechanisms of action and side effects also were investigated. MethodsForty patients scheduled for primary total hip replacement were randomized to receive, in double-blind fashion, either aprotinin given as a bolus of 2 X 104 kallikrein inactivator units (KIU) followed by an infusion of 5 X 105 KIU/h until the end of surgery or an equivalent volume of normal saline. Anesthesia and surgical techniques were standardized and systematic deep venous thrombosis prophylaxis was used. Peri- and postoperative blood loss and transfusion were measured. Fibrinolysis, coagulation pathways, and platelet function were assessed. Renal and hepatic function as well as the incidence of deep venous thrombosis also were assessed. ResultsAprotinin reduced total blood loss from 1,943 ± 700 ml to 1,446 ± 514 ml (P < 0.05). This reduction of blood loss occurred during surgery (P < 0.05) and postoperatively (P < 0.001). Total amounts of blood transfused were 3.4 ± 1.3 units/patient in the control group and 1.8 ± 1.2 units/patient in the aprotinin group (P < 0.001). The activated partial thromboplastin time was significantly prolonged by aprotinin immediately after surgery, at 50.6 ± 12.4 versus 32.3 ± 4.6 s in control patients (P < 0.001), but results of the other coagulation tests were not different between the two groups. No side effects were observed in the aprotinin group. The incidence of deep venous thrombosis in the two groups was not significantly different. ConclusionsThe use of high-dose aprotinin during total hip replacement results in a reduction in both blood loss and the amount of blood transfused. Aprotinins mode of action, however, remains to be elucidated.

Midterm Results with a Bipolar Radial Head Prosthesis: Radiographic Evidence of Loosening at the Bone-Cement Interface

BACKGROUND Metal prostheses are useful for restoring elbow and forearm stability when the radial head cannot be fixed after a fracture. Because the anatomy of the radial head is difficult to reproduce with a prosthesis, two different options have been proposed: a bipolar prosthesis with a fixed stem and a mobile head, and a monoblock prosthesis with a smooth stem that is intentionally fixed loosely in the neck of the radius. One concern with a fixed-stem implant with a mobile head has been the risk of osteolysis. The purpose of this study was to evaluate radiographic changes reflecting or suggesting progressive osteolysis in patients with a bipolar radial head prosthesis. METHODS The functional and radiographic outcomes following treatment of fifty-one comminuted fractures of the radial head with a bipolar radial head prosthesis in fifty-one consecutive patients were evaluated at a mean of 8.4 years postoperatively. There were eleven isolated comminuted fractures involving the entire radial head. Thirty-four fractures were associated with a posterior elbow dislocation, and six patients had a posterior Monteggia lesion. RESULTS According to the Mayo Elbow Performance Index, fourteen elbows were graded as excellent; twenty-five, as good; nine, as fair; and three, as poor. Radiographic changes reflecting or suggesting progressive osteolysis were present in thirty-seven patients. Complications occurred in ten patients, but only one underwent surgical treatment, for an ulnar neuropathy. CONCLUSIONS Although satisfactory midterm functional results were achieved in thirty-nine of the fifty-one patients, the high prevalence of adverse radiographic changes suggesting periprosthetic osteolysis should alert clinicians to this possible drawback of the use of bipolar radial head prostheses, especially in young and/or active patients.

Strategies for blood management in orthopaedic and trauma surgery

Several aspects of the management of an orthopaedic surgical patient are not directly related to the surgical technique but are nevertheless essential for a successful outcome. Blood management is one of these. This paper considers the various strategies available for the management of blood loss in patients undergoing orthopaedic and trauma surgery.

Risk of transmission of blood-borne viral infection in orthopaedic and trauma surgery

3% to 5% of the general population. 1 The annual rate of infection in health-care workers was found to range from 0.5% to 5.0%, compared with 0.1% in the general popu- lation of the USA. 1 An anti-HBV vaccine became available in 1981 and has helped to control this problem; the risk of occupational infection from the hepatitis-C virus (HCV) has been increasingly recognised. A new and threatening problem has arisen from the emergence of the human immunodeficiency virus (HIV) and its rapid spread. reporting system for HIV was set up at European level in 1999 to complement registration of cases of AIDS in order to improve the monitoring of the disease. National registra- tion of HIV infection is now used in 37 countries of the WHO, including 11 in the EU. At the end of 1997, the mean prevalence of adult HIV in western Europe was estimated at 0.23% ranging from 0.01% in Slovenia to 0.69% in Portugal (Table I). There are large variations in the incidence and prevalence of HIV infection which may reflect differences in pathology as well as in the efficiency of surveillance systems. In 1998, 24 978 new cases of HIV infection were reported. Sexual transmis- sion accounted for 88% of those in western Europe while injecting drug users represented 80% of new infections in eastern Europe. Trends in the annual number of cases of HIV reported during the 1990s varied markedly by geo- graphic area. In western Europe, the number decreased in Table I. Cumulated number of HIV and AIDS cases registered in June 1999