Background
Preventing pulmonary embolism is a priority after major musculoskeletal surgery. The literature contains discrepant data regarding the influence of anticoagulation on the incidence of ...pulmonary embolism after joint arthroplasty. The American College of Chest Physicians guidelines recommend administration of oral anticoagulants (warfarin), aiming for an international normalized ratio (INR) level between 2 and 3. However, recent studies show aggressive anticoagulation (INR > 2) can lead to hematoma formation and increased risk of subsequent infection.
Questions/purposes
We asked whether an INR greater than 2 protects against pulmonary embolism.
Patients and Methods
We identified 9112 patients with 10,122 admissions for joint arthroplasty between 2004 and 2008. All patients received warfarin for prophylaxis, aiming for an INR level of 2 or lower. We assessed 609 of 10,122 admissions (6%) for pulmonary embolism using CT, ventilation/perfusion scan, or pulmonary angiography, and 163 of 10,122 admissions (1.6%) had a proven pulmonary embolism.
Results
Fifteen of 163 admissions (9%) had an INR greater than 2 before or on the day of workup compared to 35 of 446 admissions (8%) who were negative. We observed no difference between the INR values in patients with or without pulmonary embolism.
Conclusions
We found no clinically relevant difference in the INR values of patients who did or did not develop pulmonary embolism. The risk of bleeding should be weighed against the risk of pulmonary embolism when determining an appropriate target INR for each patient, as an INR less than 2 may reduce the risk of bleeding while still protecting against pulmonary embolism.
Level of Evidence
Level III, therapeutic study. See Instructions to Authors for a complete description of levels of evidence.
Conflicting results are available about the efficacy of routine preoperative autologous donation (PAD) in reducing allogenic blood transfusion during total joint arthroplasty (TJA). This study aimed ...to determine if PAD is effective in reducing the need for allogenic transfusion after TJA. For this retrospective study, data on 409 patients who received total knee arthroplasty (TKA) and 513 who underwent total hip arthroplasty (THA) from January to June 2005 were evaluated. It is our institutional policy to offer preoperative donation to all patients. Based on patient decision, preoperative hemoglobin, and other factors, PAD may or may not take place. Five hundred forty-six (61%) patients donated on average 1.3 units (range, 1 to 2) of blood. Autologous and allogenic transfusions were respectively performed in 91% (514 patients) and 24% of our cohort. The rate of allogenic transfusion after TKA was lower in the PAD group at 21% versus 27% among the nondonors, although it was not statistically significant (p = 0.10). The allogenic transfusion rate after THA was significantly lower among autologous donors (16% versus 34%, p = 0.003). Advanced age, lower body mass index, simultaneous bilateral arthroplasty, and lower preoperative hemoglobin were independently associated with increased allogenic blood transfusion. PAD seems to be effective in reducing allogenic transfusions after THA but not TKA.
An accurate computable representation of food and drug allergy is essential for safe healthcare. Our goal was to develop a high-performance, easily maintained algorithm to identify medication and ...food allergies and sensitivities from unstructured allergy entries in electronic health record (EHR) systems.
An algorithm was developed in Transact-SQL to identify ingredients to which patients had allergies in a perioperative information management system. The algorithm used RxNorm and natural language processing techniques developed on a training set of 24 599 entries from 9445 records. Accuracy, specificity, precision, recall, and F-measure were determined for the training dataset and repeated for the testing dataset (24 857 entries from 9430 records).
Accuracy, precision, recall, and F-measure for medication allergy matches were all above 98% in the training dataset and above 97% in the testing dataset for all allergy entries. Corresponding values for food allergy matches were above 97% and above 93%, respectively. Specificities of the algorithm were 90.3% and 85.0% for drug matches and 100% and 88.9% for food matches in the training and testing datasets, respectively.
The algorithm had high performance for identification of medication and food allergies. Maintenance is practical, as updates are managed through upload of new RxNorm versions and additions to companion database tables. However, direct entry of codified allergy information by providers (through autocompleters or drop lists) is still preferred to post-hoc encoding of the data. Data tables used in the algorithm are available for download.
A high performing, easily maintained algorithm can successfully identify medication and food allergies from free text entries in EHR systems.
Metal on Metal: Is It Worth the Risk? Crawford, Ross, DPhil; Ranawat, Chitranjan S., MD; Rothman, Richard H., MD, PhD
The Journal of arthroplasty,
2010, 2010-Jan, 2010-01-00, 20100101, Letnik:
25, Številka:
1
Journal Article
We compared the outcomes of bilateral total hip arthroplasty performed as a one-stage or two-stage procedure. We retrospectively identified 196 patients (392 hips) with bilateral arthritis of the hip ...who underwent total hip arthroplasties: 98 patients (196 hips) as a one-stage procedure (one-stage group) and 98 (196 hips) as a two-stage procedure (two-stage group). All patients had uncemented components implanted under spinal anesthesia and had the same postoperative rehabilitation protocol. Both groups' functional outcomes were similar. The mean preoperative hemoglobin was 12.6 g/dL in the one-stage group and 12.9 g/dL in the two-stage group. The mean cumulative blood transfusion was 2.6 units in the one-stage group and 3.5 units in the two-stage group. Patients in the two-stage group had more complications, most commonly anemia and wound drainage. The total mean hospital stay was longer in the two-stage group (8.1 days; range, 5-39 days) compared with the one-stage group (4.3 days; range, 3-11 days). The mean total expenses were higher in the two-stage group (dollar 64,600) compared with the one-stage group (dollar 45,900). Young and healthy patients may be candidates for one-stage bilateral total hip arthroplasty without an increase in complications and with lower costs.
Cementless total hip arthroplasty is an accepted alternative to total hip arthroplasty with cement in younger patients, but it remains controversial for elderly patients. The purpose of this study ...was to evaluate the clinical and radiographic outcomes of cementless total hip arthroplasty with use of a proximally coated stem in patients who were at least eighty years of age at the time of the operation.
One hundred and twenty-three cementless total hip replacements were performed for the treatment of osteoarthritis in 114 patients between the ages of eighty and eighty-nine years. Seven patients (eight hips) died within two years after the surgery, seventeen patients (eighteen hips) died more than two years postoperatively but were not followed for at least two years, and five hips were lost to follow-up; this left ninety-two hips in eighty-six patients for review. The mean duration of follow-up was five years (range, two to eleven years). For the clinical evaluation, the Charnley modification of the Merle d'Aubigné and Postel scale was used. In addition, preoperative and postoperative Harris hip scores were available for sixty-nine hips. Seventy-eight hips were followed radiographically for two years or more. The focus of the radiographic evaluation was the status of the fixation of the femoral and acetabular components as well as cup wear.
Perioperative medical complications occurred in association with 24% (thirty) of the 123 operations, but there were no deaths. The mean Charnley scores for pain and function for the ninety-two hips that were followed clinically for at least two years improved by 3.0 and 1.4 points, respectively. The sixty-nine hips for which preoperative and postoperative Harris hip scores were available had a mean improvement of 42 points, with a mean score of 82 points at the last follow-up evaluation. Mild thigh pain was present in four patients, but it did not limit their activity. There were no femoral component revisions. All of the femoral components were radiographically stable and had bone ingrowth. No acetabular component failed by loosening, but 41% (thirty) of the seventy-three hips with radiographs available for measurement of wear showed polyethylene wear. Of the seventy-eight cups that were followed radiographically for two years or more, 4% (three) were associated with lysis, but none had been revised.
Cementless fixation in the elderly is safe, effective, and durable at the time of two to eleven-year follow-up.
Abstract It is assumed that prevention of deep venous thrombosis (DVT) is likely to lead to a reduction in the incidence of pulmonary embolus (PE). This study examines the association between ...symptomatic DVT and PE in patients undergoing orthopedic procedures. We reviewed medical records of 1495 patients who underwent evaluation for DVT or PE within 90 days of an index orthopedic procedure at our institution between 2004 and 2008. Only 27 cases were positive for both DVT and PE (1.7% of the total cohort, 10.8% of cases scanned for both DVT and PE). Tests of association, performed across the entire cohort and within specific subsets of patients, did not demonstrate that patients were more likely to have both DVT and PE than to have either DVT or PE. The high association between DVT and PE that is assumed to exist does not seem to hold true for orthopedic surgery patients.
The anterolateral approach in the supine position provides excellent visualization of the acetabulum. The main advantage of the approach, a low dislocation rate, has been demonstrated in the ...literature, while the purported disadvantage of abductor dysfunction has not been clearly delineated in the literature. The technique requires meticulous attention to preservation of the gluteus medius and minimus tendons. Impingement and dislocation are avoided by careful attention to the preparation of acetabulum, critical assessment of the implanted components, and intraoperative trialing. Leg lengths are assessed through direct palpation of the malleoli. Routine use of postoperative hip precautions is not necessary when this approach is utilized. The anterolateral approach in the supine position allows for a reproducible result with a low dislocation rate.
Level of Evidence:
Level V, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
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