Effects of epidural anesthesia on the incidence of deep-vein thrombosis after total knee arthroplasty.

Sharrock, Nigel E.; Haas, Steven B.; Hargett, Mary J.; Urquhart, Barbara; Insall, John N.; Scuderi, Giles R.

doi:10.2106/00004623-199173040-00004

Cited by 116 publications

(53 citation statements)

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“…3,4,7,8,17,23,[29][30][31] Other studies have also reported an association between DVT and risk factors such as age, gender, obesity, varicosities, hypertension, immobilisation, tourniquet time and the use of bone cement. 13,24,27 However, the data presented in this study did not show an association between recurrent DVT and such risk factors after between three and four years.…”

Section: Discussioncontrasting

confidence: 81%

Outcome of calf deep-vein thrombosis after total knee arthroplasty

Wang

Weng

et al. 2003

The Journal of Bone and Joint Surgery. British volume

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e investigated the outcome of deep-vein thrombosis (DVT) in the calf after total knee arthroplasty (TKA) in 48 patients (45 women and three men) by clinical assessment and venographic study between three and four years after surgery. The mean age of the patients was 67.2 ± 7.7 years (52 to 85) and the mean follow-up was 42.6 ± 2.7 months (38 to 48). The diagnosis was osteoarthritis in 47 patients and rheumatoid arthritis in one patient. There were 44 calf thrombi, four popliteal thrombi but no thrombi in the femoral or iliac regions. Of the 48 patients, 24 were clinically symptomatic and 24 were asymptomatic. WDeep-vein thrombosis (DVT) after total knee arthroplasty (TKA) is common. Many studies have reported that a large thrombus proximal to the knee poses a higher risk of pulmonary embolism. [1][2][3][4][5][6][7][8] Others have shown that all thrombi can propagate into or above the popliteal vein despite early anticoagulation therapy and have recommended that prophylaxis should be targeted at the intraoperative and immediate postoperative periods. 9 The importance of DVT in the calf, however, is poorly understood and the treatment is controversial. Some studies have reported that the risks of treatment may be greater than those of the thrombosis itself.2,3,10 The incidence of DVT after TKA is 84% in unprotected patients and may be as high as 68% in patients who receive prophylaxis for DVT.7 There is controversy as to which pharmacological agent or form of mechanical prophylaxis should be used. Consequently, many issues concerning DVT are poorly understood, especially the duration of prophylaxis and the outcome of DVT in the calf. Our aim was to investigate the outcome of DVT in the calf after TKA between three and four years after surgery. Patients and MethodsIn 1998 and 1999, a prospective clinical study with ascending venography was conducted at our institution in order to determine the incidence of DVT after TKA. The results showed that 55 (55 knees) of 102 (105 knees) patients had positive venographic findings for DVT, an incidence of 53%. Fifty-one (93%) of the thrombi were in the calf veins, four (7%) in the popliteal vein, and none in the femoral or iliac veins. There were no pulmonary emboli.Our study was designed to assess the outcome of these thrombi between three and four years later. Seven patients were excluded; two had died from unrelated causes and five were lost to follow-up. The remaining 48 were available for assessment. There were 45 women and three men with a mean age of 67.2 ± 7.7 years (52 to 85). Their mean bodyweight was 63.5 ± 8.4 kg (46 to 80.9), and their mean height was 150.6 ± 4.9 cm (138 to 162). In 47 patients, the diagnosis was osteoarthritis and in one, rheumatoid arthritis. No DVT prophylaxis had been used at the time of operation. There were 44 DVTs in the calf veins, including the anterior and posterior tibial veins, the peroneal veins and muscular branches, four in the popliteal vein but none in the femoral

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Section: Discussioncontrasting

confidence: 81%

Outcome of calf deep-vein thrombosis after total knee arthroplasty

Wang

Weng

et al. 2003

The Journal of Bone and Joint Surgery. British volume

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“…References from these papers were also reviewed as well as the proceedings and abstracts from Orthopaedic Transactions and the haematological abstracts in Thrombosis and Haemostasis. 3,6,11,[15][16][17][18][19][20][21]23,31,32,34,[39][40][41][42][43][44][45][46][47] If an explanation of the data was required the authors of the papers were contacted.…”

Section: Methodsmentioning

confidence: 99%

Meta-analysis of thromboembolic prophylaxis after total knee arthroplasty

Westrich

Haas

Mosca

et al. 2000

The Journal of Bone and Joint Surgery. British volume

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We performed a meta-analysis of the English literature to assess the efficacy of four common regimes for thromboembolic prophylaxis after total knee arthroplasty: aspirin, warfarin, low-molecular-weight heparin (LMWH) and pneumatic compression. We reviewed 136 articles and abstracts published between January 1980 and December 1997. Papers not using routine venography and a lung scan or angiography to detect deep-venous thrombosis (DVT) and pulmonary emboli (PE) respectively, were excluded. Of the 136 studies, 23 with 6001 patients were selected.The incidence of DVT was 53% (1701/3214) in the aspirin group, 45% (541/1203) in the warfarin group, 29% (311/1075) in the LMWH group, and 17% (86/509) in the pneumatic compression device group. Intermittent pneumatic compression devices and LMWH were significantly better than warfarin (p < 0.0001) or aspirin (p < 0.0001) in preventing DVT.The incidence of asymptomatic PE was 11.7% in the aspirin group (222/1901), 8.2% (101/1229) in the warfarin group and 6.3% (24/378) in the pneumatic compression group. No studies with LMWH used routine lung scans. Warfarin and pneumatic compression were significantly better than aspirin in preventing asymptomatic PE (p < 0.05).The incidence of symptomatic PE was 1.3% (23/1800) in the aspirin group, 0.4% (2/559) in the warfarin group, 0.5% (2/416) in the LMWH group and 0% (0/177) in the pneumatic compression group. No statistically significant difference was noted between the above prophylatic regimes due to the very small incidence of symptomatic PE. measurements to document a propagation rate of 24% in the calf. Therefore prophylaxis after TKA is essential to prevent thromboembolic disease. Current prophylactic methods include pharmacological regimes such as aspirin, warfarin, and low molecularweight heparin (LMWH) and mechanical techniques such as intermittent pneumatic compression devices. 1,3,5,6,11,13-18,21-25,27,29,32-38. While pharmacological prophylaxis may be useful for the prevention of thromboembolic disease, associated morbidity such as haemorrhagic complications, routine phlebotomy, excessive cost, and dosing by injection after discharge may limit its use. 1,3,6,11,13,17,18,[22][23][24]29,[32][33][34][35][37][38][39] Pneumatic compression devices offer prophylaxis without such associated morbidity, but compliance by patients and nurses is essential. In addition, the type and duration of prophylaxis after hospital discharge are controversial.To determine the relative benefit of different types of prophylaxis after TKA, we performed a meta-analysis to assess the effectiveness of four commonly used regimes of thromboembolic prophylaxis: aspirin, warfarin, LMWH and intermittent pneumatic compression devices. A metaanalysis is a technique which follows a set of statistical methods that can integrate the results of individual studies. Thus, a quantitative summary of studies with an increase in statistical power and an improvement of the estimated size of an effect can be presented.

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“…Apart from lowering the blood loss and preventing deep vein thrombosis, regional anesthesia avoids central nervous depression, has a different spectrum of effects on the cardiopulmonary system, may modify the stress response to surgery, provides excellent pain relief, and allows early painless range of motion and weight bearing, enhancing overall patient satisfaction [13,17,28,36]. For the vast majority of our patients, hypotensive regional anesthesia is utilized; we reserve general anesthesia for rare instances in which the anesthesiologist is unable to perform the spinal or epidural anesthesia for medical or technical reasons (eg, severe lumbar degenerative disease).…”

Section: General Versus Regional Anesthesiamentioning

confidence: 99%

Multimodal Pain Management after Total Hip and Knee Arthroplasty at the Ranawat Orthopaedic Center

Maheshwari

Blum

Shekhar

et al. 2009

Clin Orthop Relat Res

282

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Improvements in pain management techniques in the last decade have had a major impact on the practice of total hip and knee arthroplasty (THA and TKA). Although there are a number of treatment options for postoperative pain, a gold standard has not been established. However, there appears to be a shift towards multimodal approaches using regional anesthesia to minimize narcotic consumption and to avoid narcotic-related side effects. Over the last 10 years, we have used intravenous patient-controlled analgesia (PCA), femoral nerve block (FNB), and continuous epidural infusions for 24 and 48 hours with and without FNB. Unfortunately, all of these techniques had shortcomings, not the least of which was suboptimal pain control and unwanted side effects. Our practice has currently evolved to using a multimodal protocol that emphasizes local periarticular injections while minimizing the use of parenteral narcotics. Multimodal protocols after THA and TKA have been a substantial advance; they provide better pain control and patient satisfaction, lower overall narcotic consumption, reduce hospital stay, and improve function while minimizing complications. Although no pain protocol is ideal, it is clear that patients should have optimum pain control after TKA and THA for enhanced satisfaction and function. Level of Evidence: Level V, expert opinion. See the Guidelines for Authors for a complete description of levels of evidence.

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Effects of epidural anesthesia on the incidence of deep-vein thrombosis after total knee arthroplasty.

Cited by 116 publications

References 0 publications

Outcome of calf deep-vein thrombosis after total knee arthroplasty

Outcome of calf deep-vein thrombosis after total knee arthroplasty

Meta-analysis of thromboembolic prophylaxis after total knee arthroplasty

Multimodal Pain Management after Total Hip and Knee Arthroplasty at the Ranawat Orthopaedic Center

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