Avoiding Complications from Arthroplasty and Anticoagulation.

Abstract

Achieving the right balance with blood coagulability is tricky before, during, and after joint arthroplasty. Both excessive bleeding and embolic events can lead to catastrophic complications or fatalities. Established coagulation guidelines related to joint arthroplasty are useful for surgeons and other clinicians, but getting the hematology “just right” for individual arthroplasty patients is both a science and an art that often requires multidisciplinary consultations. We present a number of complications arising from the management of anticoagulation parameters in joint replacement patients; these cases focus on the need for vigilance and clinical observation coupled with the importance of monitoring laboratory values. In the July 23, 2014 edition of JBJS Case Connector , Wang et al. describe the case of an eighty-three-year-old man who developed severe skin and soft-tissue necrosis after total knee arthroplasty (TKA), a rare complication that eventually resulted in an above-the-knee amputation. Like many patients nowadays, he had been on chronic warfarin therapy to reduce the risk of blood clots from atrial fibrillation. The warfarin had been withheld six days prior to the knee replacement. After the procedure, he received enoxaparin while hospitalized, and the warfarin therapy was resumed. He was discharged on postoperative day three. The day after discharge, the patient presented to the emergency department with pain that was limiting mobility. Examination revealed a swollen knee and hemorrhagic blisters around the surgical site. Blistering spread over the next two days, and the bullae were drained at the bedside. By postoperative day seven, there were new blisters, and the skin beneath the older blisters appeared dark. Warfarin was discontinued the following day when the patient’s international normalized ratio (INR) peaked at 2.4. The blisters continued to enlarge until …