Prophylaxis against venous thromboembolism after elective total hip replacement is routinely recommended. Our preference has been to use mechanical prophylaxis without anticoagulant drugs. A randomised controlled trial was performed to evaluate whether the incidence of post-operative venous thromboembolism was reduced by using pharmacological anticoagulation with either fondaparinux or enoxaparin in addition to our prophylactic mechanical regimen. A total of 255 Japanese patients who underwent primary unilateral cementless total hip replacement were randomly assigned to one of three postoperative regimens, namely injection of placebo (saline), fondaparinux or enoxaparin. There were 85 patients in each group. All also received the same mechanical prophylaxis during and after the operation, regardless of their assigned group. The primary measurement of efficacy was the presence of a venous thromboembolic event by day 11, defined as deep-vein thrombosis detected by ultrasonography, documented symptomatic deep-vein thrombosis or documented symptomatic pulmonary embolism. The duration of follow-up was 12 weeks. The rate of venous thromboembolism was 7.2% with the placebo, 7.1% with fondaparinux and 6.0% with enoxaparin (p = 0.95 for the comparison of all three groups). Our study confirmed the effectiveness and safety of mechanical thromboprophylaxis without the use of anticoagulant drugs after total hip replacement in Japanese patients.
We report a case of a teenage male with penetrating cardiac injury (IIIb). He injured himself when he slipped and fell down the stairs into a display case. The glass shards pierced the region around his sternum, and he was transported to the Emergency and Critical Care Center of this hospital. Upon arrival at the hospital, the patient's level of consciousness was 10 on the Japan Coma Scale. His blood pressure was 80 mmHg; he had a heart rate of 130 bpm and decreased breath sounds in his right lung. He was given a rapid fluid infusion intravenously. Echocardiography did not reveal any accumulation of pericardial effusion. Chest drainage was performed because a portable chest Xray revealed a massive right hemothorax. Tracheal intubation was also carried out simultaneously. The chest tube drained 1700 ml of blood when inserted. As the patient responded to infusion and blood transfusion, contrast-enhanced computed tomography scans of the chest and abdomen were taken. The patient went into shock again upon returning to the emergency room, and a decision to perform thoracotomy for hemostasis was made. Through a right anterolateral thoracotomy from the site of incision, pericardial bleeding was ascertained and diagnosed as Type IIIa right atrial damage (The Japanese Association for The Surgery of Trauma, Organ Injury Classification 2008). Transverse sternotomy was performed successively making this a clamshell thoracotomy. Insertion of the index finger into the damaged area of the right atrium stopped the bleeding, and the wound area was then clamped with Satinsky forceps. The damaged site and pericardium were sutured before the chest incision was closed up. The patient progressed favorably and was ambulant at discharge on postoperative day 15. The present case was complicated by mild pericardial damage but it happened to progress without developing into cardiac tamponade, and the hemothorax was of the type that bled slowly into the thoracic cavity; hence, the patient did not experience cardiopulmonary arrest. The key to saving the lives of patients with penetrating trauma is the execution of uninterrupted rapid emergency care and hemostasis by a trauma team.
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