Eduardo A. Salvati

Despite the favorable results in cemented femoral fixation, there is a growing tendency to use uncemented stems. Due to the successful results of cementless acetabular fixation, the most versatile and easy implantation technique, to the misinformation about the "cement disease" and the poor performance of cemented stems with a rough surface. However, the advantages of cemented femoral fixation are numerous: it can be implemented successfully in femurs of diverse morphology and quality of bone, the surgeon can position the implant with the desired femoral anteversion, without it being determined by th natural femoral anteversion, very low incidence of intraoperative and postoperative fractures, allows the addition of antibiotics in patients with a history or predisposition to infection and minimal risk of postoperative leg pain during walking.

To determine the incidence of thromboembolism after one-stage bilateral total hip arthroplasty and the role of two different chemoprophylaxis agents, we retrospectively studied 644 consecutive patients who underwent one-stage bilateral total hip arthroplasties. All patients received a similar multimodal prophylaxis protocol, which differed only in the postoperative chemoprophylaxis: 292 patients received warfarin (Group 1) and 352 received aspirin (Group 2). All patients were followed for a minimum of 3 months. We observed no difference in the incidence of symptomatic venous thrombosis, pulmonary embolism, or mortality in the two groups. Twenty patients in each group had deep venous thrombosis (7% and 5.7%, respectively) develop. Seven patients (2.39%) in Group 1 and eight (2.27%) in Group 2 had proximal deep venous thrombosis. Four patients in each group had a nonfatal pulmonary embolism (1.36% and 1.13%, respectively). There were two deaths in each group, neither related to venous thromboembolism. One-stage bilateral total hip arthroplasties were associated with a low rate of venous thrombosis and embolism with our multimodal prophylaxis protocol, and we found no difference in the incidence of either in patients who received warfarin or aspirin for chemoprophylaxis. Level of Evidence: Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Total hip arthroplasty is an operation with a high risk for venous thromboembolism. Three decades of research conducted at the Hospital for Special Surgery identified the exact timing of the thrombogenic stimulus during surgery, defined the role of magnetic resonance venography, and established the role of certain genetic and acquired predispositions. Based on these studies, we implemented a multimodal prophylaxis consisting of a series of safe preventive measures applied before, during, and immediately after surgery to reduce the risk of venous thromboembolism. If these safe preventive measures are strictly observed, postoperative pharmacologic prophylaxis does not need to be aggressive in the patient without predisposing factors who mobilizes promptly, thus diminishing the risk of bleeding associated with the use of anticoagulants and the overall cost of care. Our clinical experience with more than 5000 total hip arthroplasties performed during the last decade and closely followed prospectively for a minimum of 3 months clearly shows this multimodal prophylaxis is safe and effective resulting in a very low prevalence of thromboembolism.

We evaluated the safety and efficacy of a multimodal approach for prophylaxis of thromboembolism after total hip arthroplasty, which includes preoperative discontinuation of procoagulant medication; autologous blood donation; hypotensive epidural anesthesia; intravenous administration of heparin during surgery and before femoral preparation; aspiration of intramedullary contents; pneumatic compression; knee-high elastic stockings; and early mobilization and chemoprophylaxis for 4 to 6 weeks (aspirin 83%; warfarin 17%). One thousand nine hundred forty-seven consecutive, nonselected patients (2032 total hip arthroplasties) who received this multimodal prophylaxis were observed prospectively for 3 months. The incidence of asymptomatic deep vein thrombosis assessed by ultrasound in the first 171 patients was 6.4%. The incidence of clinical deep vein thrombosis in the subsequent 1776 patients was 2.5%. Symptomatic pulmonary embolism occurred in 0.6% (12 of 1947; nine in patients receiving aspirin and three in patients receiving Coumadin), none of them fatal. One patient died of a myocardial infarct. This multimodal approach is safe and efficacious and compares favorably with those reported in the literature and with our historic controls. If these preventive measures are strictly observed during the perioperative period, postoperative chemoprophylaxis does not need to be aggressive in the patient without predisposing factors. Our low rate of deep vein thrombosis and pulmonary embolism do not support routine anticoagulation prophylaxis with drugs that increase risk of bleeding. Level of Evidence: Therapeutic study, Level IV (case series). See the Guidelines for Authors for a complete description of levels of evidence.

We retrospectively assessed whether heritable thrombophilia-hypofibrinolysis was more common in patients developing venous thromboembolism after total hip replacement than among control patients who did not develop venous thromboembolism, as an approach to better identify causes of venous thromboembolism after total hip arthroplasty. Twenty patients with proximal deep venous thrombosis after THA and 23 patients with symptomatic pulmonary embolism were compared with 43 control patients who did not have postoperative venous thromboembolism. Five of 42 patients with venous thromboembolism (12%) and 0 of 43 control patients (0%) had antithrombin III deficiency (< 75%). Nine of 42 patients with venous thromboembolism (21%) and 2 of 43 control patients (4.7%) had protein C deficiency (< 70%). Ten of 43 patients with venous thromboembolism (9 heterozygous, 1 homozygous; 23%) and 1 of 43 control patients (heterozygous; 2%) had the prothrombin gene mutation. Patients who had venous thromboembolism after total hip arthroplasty were more likely than matched control patients to have heritable thrombophilia with antithrombin III or protein C deficiency, or homo-heterozygosity for the prothrombin gene mutation. Screening for these three tests of heritable thrombophilia before total hip arthroplasty should improve the identification of patients with a reduced risk of venous thromboembolism who may need only mild thromboprophylaxis, and of those patients with heritable thrombophilia in whom prophylaxis should be more aggressive. Prognostic study, Level II-1 (lesser-quality RCT). See the Guidelines for Authors for a complete description of levels of evidence.

We assessed whether heritable thrombophilia was more common in cases with symptomatic venous thromboembolism (VTE) after total hip replacement (THA) than among asymptomatic controls without VTE. After THA, 20 cases with deep venous thrombosis (DVT) documented by magnetic resonance venogram (MRV), and 23 with pulmonary embolism (PE) documented by ventilation/perfusion or spiral CT scan, were compared to 43 controls without VTE, matching cases to controls by age, gender, BMI, hip diagnosis, clinical predisposing factors, and VTE prophylaxis. Five of 42 cases (12%) and 0/43 controls (0%) had antithrombin III deficiency (ATIII) (< 75%) (p = .026). Nine of 42 cases (21%) and 2/43 controls (4.7%) had protein C deficiency (< 70%) (p = .021). Ten of 43 cases (9 heterozygous, 1 homozygous) (23%) and 1/43 controls (heterozygous) (2%) had the prothrombin gene mutation (PTG) (p = .004). VTE cases were more likely to have ≥ 1 abnormality of ATIII, protein C, or PTG (21/42 [50%] vs 3/43 [7%]) controls (p<0.0001), with sensitivity 50% and specificity 93% distinguishing cases from controls. For our 1769 cohort prevalence of VTE (2%), the predictive value of a positive test (≥ 1 abnormality of ATIII, protein C, PTG) was 12.8% and for a negative test 98.9%. ATIII deficiency had 11.9% sensitivity and 100% specificity distinguishing cases from controls; the predictive value of a positive test for ATIII deficiency was 100%, the predictive value of a negative test was 98.2%. The PTG mutation had 23.3% sensitivity and 97.7% specificity distinguishing cases from controls; the predictive value of a positive test was 16.9%, the predictive value of a negative test was 98.4%. Deficiencies of ATIII (r = .25, p = .02), protein C (r = .25, p = .021), and PTG (r = .31, p = .003) correlated with postoperative VTE. Having ≥ 1 abnormality of ATIII, protein C, or PTG correlated with VTE status, r = 0.48, p<.0001. Cases with VTE after THA were more likely than controls to have heritable thrombophilia (ATIII or protein C deficiency, PTG homo-heterozygosity). Pre-THA screening for these 3 heritable thrombophilias should improve identification of cases with reduced risk of VTE, who may only need mild thromboprophylaxis, and those with heritable thrombophilia in whom prophylaxis should be more aggressive.

Costs-benefits of 3 strategies to deal with pulmonary emboli (PE) and deep venous thrombosis (DVT) after total hip replacement (THR) in 1769 cases were assessed. Based on examining 23 PE and 20 DVT cases and 43 matched controls, PE-DVT cases were more likely to have ≥ 1 abnormality of antithrombin III, protein C, or the prothrombin gene mutation (21/42 [50%] vs 3/43 [7%]) (p<0.0001), with sensitivity 50% and specificity 93%. Using sensitivity of 50% and specificity of 93%, we compared 3 strategies, no coagulation screening-aspirin-no low molecular weight heparin (LMWH)-no warfarin (W), no coagulation screening-universal LMWH-W, and universal coagulation screening-selective LMWH-W in cases with thrombophilia. We used cost estimates for short-term and for lifetime treatment of PE-DVT. We included costs due to major bleeding on LMWH-W in 3% of cases. We used short-term (˜ 10 days post THR) documented PE (1.5%) (by spiral CT) and DVT (48.5%) (by venogram). We estimated PE and DVT events not detected by the coagulation screening, and PE-DVT despite LMWH, pneumatic compression, or W. With no coagulation screening, aspirin, and no LMWH-W, 27 PE and 858 DVT would be expected, for a cost of $10,692/case. With universal LMWH-W, 3 PE and 313 DVT would be expected on LMWH, 366 DVT with pneumatic compression, and 410 on W, but 53 bleeding cases would occur. Using universal LMWH-W, on LMWH cost was $6,143/case, on W $7,239, and with pneumatic compression $6,743. Using universal coagulation screening and selective LMWH-W in cases with thrombophilia, 15 PE and 634 DVT would be expected; 1265 cases would not get LMWH-W, 38 bleeding events would be avoided, and 45% of PE and 26% of DVT avoided vs no coagulation screening, no LMWH-W. Universal coagulation screening with selective LMWH-W costs $8,630/case for LMWH, $8,930 for compression alone, and $9,178 for W. As our knowledge of thrombophilia-hypofibrinolysis improves, current sensitivity (50%) and specificity (93%) for coagulation screening should improve, allowing more selective LMWH-W for high risk cases, avoiding LMWH-W in cases without coagulation disorders.

Well as improved locking mechanisms, a polished inner surface, and increased conformity with the liner. The purpose of the present study was to evaluate the clinical and radiographic results associated with the use of a second-generation acetabular component for primary total hip arthroplasty....