FEMUR FRACTURES 

Minerva Ortopedica e Traumatologica 2003 October;54(5):381-401

Copyright © 2003 EDIZIONI MINERVA MEDICA

language: English

Current concepts on the pathogenesis, diagnosis and multimodal prophylaxis of thromboembolic disease after total hip arthroplasty

Salvati E. A. ^{1, 2}, Sharrock N. ³, González Della Valle A. ^{2, 4}

¹ Hip and Knee Service Hospital for Special Surgery, New York, NY, USA 2 Department of Orthopaedic Surgery Weill Medical College Cornell University, Ithaca, New York, NY, USA 3 Department of Anesthesiology Hospital for Special Surgery, New York, NY, USA 4 Department of Orthopaedic Surgery Hospital for Special Surgery, New York, NY, USA

The strong thrombogenic stimulus that occurs during total hip replacement (THR) places patients at particular risk for development of proximal deep venous thrombosis (DVT) and pulmonary embolism (PE) after surgery. The risk of this life-threatening complication has decreased markedly during the past 3 decades, as a result of numerous improvements in anesthesia, surgical procedures, and perioperative patient care. Critical factors which in our experience have reduced the risk of thromboembolism include preoperative autologous blood donation; hypotensive epidural anesthesia (HEA) with epinephrine infusion; intravenous administration of unfractionated heparin during surgery, before femoral preparation when the thrombogenesis is maximally activated; expeditious surgery, minimizing femoral vein occlusion and blood loss; pneumatic compression; patient mobilization with active foot and ankle dorsiflexion exercises immediately after surgery and early ambulation. If these preventive measures are strictly observed during the perioperative period, the postoperative chemoprophylaxis does not need to be aggressive in the patient without predisposing factors. This is supported by our collective experience, which includes over 4.000 patients undergoing THR studied closely from 1988 to 2000, where there was only 1 fatal PE. Conver-sely, if these perioperative precautions are not observed, the postoperative thromboembolic chemoprophylaxis may need to be more aggressive, particularly in the patient with predisposing factors, and who does not mobilize promptly. Future investigations should concentrate in establishing reliable means of identifying patients who are predisposed to postoperative thromboembolism. The results of the recent study we conducted suggest that certain genetic and functional characteristics associated with primary thrombophilia and hypofibrinolysis might have predictive value for patients undergoing hip surgery. If such patients could be routinely identified prior to surgery, they could be successfully managed, with the appropriate medical prophylaxis and means of surveillance selectively chosen to match their individual predisposition.