Elective Hip Replacement Surgery Research Articles

Patients' experiences with at-home preoperative skin disinfection before elective hip replacement surgery.

The aim of the study was to describe patients' experiences with preoperative skin disinfection carried out in their home before elective hip replacement surgery with the aim of lowering the microbial burden and avoiding surgical site infections. The literature was reviewed for relevant studies. Optimal preparations before surgery depend on patients being able to assimilate preoperative information and instructions. The study was based on 14 interviews with patients who had undergone elective hip replacement surgery. Data were analysed with qualitative manifest content analysis according to Graneheim and Lundman (2004). The main categories of findings were: patients' experience of obstacles and limitations, the importance of supportive surroundings, and personal resources as strength when performing preoperative skin disinfection. The findings of this study agree with earlier studies showing a lack of compliance to preoperative skin disinfection. The findings also suggest reasons for non-compliance. Preoperative skin disinfection involves many important steps that need to be accomplished to ensure the maximum effect on microbial burden on skin surface. These steps can be difficult for some patient groups. Perioperative dialogue is one way to identify patients' individual needs and to help patients participate in the process. The study concludes that patients who carried out skin disinfection at home before surgery have a great responsibility to prepare themselves. The challenge for perioperative nurses who work with preoperative information is to identify and individually guide those patients who need extended support so that all patients with elective hip replacement surgery receive the same quality of care. Further research should focus on how caregivers discover individuals with extended needs and on identifying the kind of support that is effective to achieve optimal conditions for hip replacement surgery.

Emergency Department Visits Following Elective Total Hip and Knee Replacement Surgery: Identifying Gaps in Continuity of Care.

Major joint replacement surgical procedures are common, elective procedures with a care episode that includes both inpatient readmissions and postoperative emergency department (ED) visits. Inpatient readmissions are well studied; however, to our knowledge, little is known about ED visits following these procedures. We sought to characterize 30-day ED visits following a major joint replacement surgical procedure. We used administrative records from California, Florida, and New York, from 2010 through 2012, to identify adults undergoing total knee and hip arthroplasty. Factors associated with increased risk of an ED visit were estimated using hierarchical regression models controlling for patient variables with a fixed hospital effect. The main outcome was an ED visit within 30 days of discharge. Among the 152,783 patients who underwent major joint replacement, 5,229 (3.42%) returned to the inpatient setting and 8,883 (5.81%) presented to the ED for care within 30 days. Among ED visits, 17.94% had a primary diagnosis of pain and 25.75% had both a primary and/or a secondary diagnosis of pain. Patients presenting to the ED for subsequent care had more comorbidities and were more frequently non-white with public insurance relative to those not returning to the ED (p < 0.001). There was a significantly increased risk (p < 0.05) of isolated ED visits with regard to type of insurance when patients with Medicaid (odds ratio [OR], 2.28 [95% confidence interval (CI), 2.04 to 2.55]) and those with Medicare (OR, 1.38 [95% CI, 1.29 to 1.47]) were compared with patients with private insurance and with regard to race when black patients (OR, 1.38 [95% CI, 1.25 to 1.53]) and Hispanic patients (OR, 1.12 [95% CI, 1.03 to 1.22]) were compared with white patients. These increases in risk were stronger for isolated ED visits for patients with a pain diagnosis. ED visits following an elective major joint replacement surgical procedure were numerous and most commonly for pain-related diagnoses. Medicaid patients had almost double the risk of an ED or pain-related ED visit following a surgical procedure. The future of U.S. health-care insurance coverage expansions are uncertain; however, there are ongoing attempts to improve quality across the continuum of care. It is therefore essential to ensure that all patients, particularly vulnerable populations, receive appropriate postoperative care, including pain management. Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Visits to the Emergency Department After Joint Replacement: Commentary on an article by Micaela A. Finnegan, BA, et al.: "Emergency Department Visits Following Elective Total Hip and Knee Replacement Surgery: Identifying Gaps in Continuity of Care".

Visits to the Emergency Department After Joint Replacement: Commentary on an article by Micaela A. Finnegan, BA, et al.: "Emergency Department Visits Following Elective Total Hip and Knee Replacement Surgery: Identifying Gaps in Continuity of Care".

Parecoxib Supplementation to Morphine Analgesia Decreases Incidence of Delirium in Elderly Patients After Hip or Knee Replacement Surgery: A Randomized Controlled Trial.

Severe pain and high-dose opioids are both associated with increased risk of postoperative delirium. The authors investigated whether parecoxib-supplemented IV morphine analgesia could decrease the incidence of delirium in elderly patients after total hip or knee replacement surgery. In a randomized, double-blind, 2-center trial, patients of 60 years or older who underwent elective total hip or knee replacement surgery were assigned in a 1:1 ratio to receive either parecoxib (40 mg at the end of surgery and then every 12 hours for 3 days) or placebo (normal saline). All patients received combined spinal-epidural anesthesia during surgery and IV morphine for postoperative analgesia. The primary outcome was the incidence of delirium within 5 days after surgery. Between January 2011 and May 2013, 620 patients were enrolled and were included in the intention-to-treat and safety analyses. The incidence of delirium was significantly reduced from 11.0% (34/310) with placebo to 6.2% (19/310) with parecoxib (relative risk 0.56, 95% confidence interval 0.33-0.96, P = .031). The severity of pain and the cumulative consumptions of morphine at 24, 48, and 72 hours after surgery were significantly lower with parecoxib than with placebo (all P < .001), although the differences were small. There was no difference in the incidence of postoperative complications between the 2 groups (12.3% [38/310] with placebo versus 11.6% [36/310] with parecoxib; P = .80). For low-risk elderly patients undergoing elective total hip or knee replacement surgery, multidose parecoxib supplemented to IV morphine decreased the incidence of postoperative delirium without increasing adverse events.

Managing hip fracture and lower limb surgery in the emergency setting: Potential role of non-vitamin K antagonist oral anticoagulants.

Trauma, immobilization, and subsequent surgery of the hip and lower limb are associated with a high risk of developing venous thrombo-embolism (VTE). Individuals undergoing hip fracture surgery (HFS) have the highest rates of VTE among orthopedic surgery and trauma patients. The risk of VTE depends on the type and location of the lower limb injury. Current international guidelines recommend routine pharmacological thromboprophylaxis based on treatment with heparins, fondaparinux, dose-adjusted vitamin K antagonists and acetylsalicylic acid for patients undergoing emergency HFS; however, not all guidelines recommend pharmacological prophylaxis for patients with lower limb injuries. Non-vitamin K antagonist oral anticoagulants (NOACs) are indicated for VTE prevention after elective hip or knee replacement surgery, but at present are not widely recommended for other orthopedic indications despite their advantages over conventional anticoagulants and promising real-world evidence. In patients undergoing HFS or lower limb surgery, decisions on whether to anticoagulate and the most appropriate anti-coagulation strategy can be guided by weighing the risk of thromboprophylaxis against the benefit in relation to each patient's medical history and age. In addition, the nature and location of the fracture, operating times and times before fracture fixation should be considered. The current review discusses the need for anticoagulation in patients undergoing emergency HFS or lower limb surgery together with the current guidelines and available evidence on the use of NOACs in this setting. Appropriate thromboprophylactic strategies and practical advice on the peri-operative management of patients who present to the Emergency Department on a NOAC before emergency surgery are further outlined.

Pharmacoeconomic study on rivaroxaban vs conventional venous thromboembolism prophylaxis following elective total hip or knee replacement surgery in Serbia: Single centre study

Introduction: Venous thromboembolism (VTE) is often clinically unobservable, showing the first symptoms only after the patient has been discharged from the hospital, owing to which symptoms may not be recognized in time and serious complications may arise after hip or knee replacement surgery. The outcome for a patient who has had a symptomatic episode of VTE may be bad due to a risk of recurrent VTE and the development of postthrombotic syndrome. The annual incidence of VTE is around 80-180 cases in 100.000, based on population studies. Worldwide, orthopaedists and anaesthesiologists mostly refer to ACCP guidelines from America, or guidance from NICE and Scottish Medicines Consortium in Europe. All the guidelines include rivaroxaban as a therapy of choice for the prevention of VTE following elective arthroplasty as the therapy with rivaroxaban has shown both effectiveness and cost-savings. Many countries have included rivaroxaban as a medicine of first choice in the therapy for the above described indication. Aim: The objective of this analysis is to demonstrate cost-effectiveness of the new therapy with rivaroxaban versus conventional in VTE prophylaxis for patients undergoing elective hip or knee replacement surgery. Methodology: This paper is a part of the academic IV phase pharmacoecconomic study using extrapolation datas (RECORD 1, RECORD 2, RECORD 3) done in Serbia as single center expirience of Institute for Orthopaedic Surgery 'Banjica', in 2015. Information on drug prices, basic pharmacological characteristics, and on services of health institutions, are taken from the List of Drugs and Pricelist of the Republic Health Insurance Fund, as well as the Thromboembolism Prophylaxis Guide of the Institute 'Banjica'. The Incremental cost-effectiveness ratio (ICER) and Cost-utility analysis (CUA) have also been used in relation to the Quality-adjusted life-year (QALY). Furthermore, in the calculation the proposed price of a defined daily dose (DDD) of rivaroxaban was 3.36 EUR. Results: Total savings obtained annually through the application of rivaroxaban instead of usual prophylaxis (6,900 surgeries) could lead to cost savings of EUR 511,248.35 with the ICER value shows that therapy with rivaroxaban is dominant. Conclusions: The introduction of rivaroxaban in the therapy will enable patients to receive more conformable oral therapy with the same amount of health insurance resources spent, while on the other hand significant savings will be obtained owing to a decrease in the number of inpatient days in hospitals, as well as owing to the fact that regular control examinations of INR and number of blood platelets will not be necessary, which otherwise may amount to EUR 511,248.35annually for the said indication. The authors suggest support for the IV phase of the investigator initiated academic clinical trials with the intention of gaining security and personal experiences of doctors who use rivaroxaban in clinical practice.

The significance of social rules in group training sessions

Purpose: To identify what types of social rules are involved in group interventions led by physiotherapists (PTs), and how these rules influence individual recovery.Methods: Eight patients; six women and two men, which had recently undergone elective hip or knee replacement surgery, were recruited as informants from an intervention group that investigated effect of task specific exercise. The data comprise observational notes from group training sessions and one-on-one semi-structured interviews with the eight patients. Observational notes contributed to the development of the research questions. The interviews were audio-recorded and transcribed, and a theoretically-oriented analytical approach guided by performance theory was conducted to identify the rules.Results: Several implicit rules for behavior when attending this group intervention were identified. The compulsory style enhances recovery in an explicit manner.Conclusion: When giving advice and home exercise PTs must acknowledge that the roles patients are subtly exposed to during the actual clinical encounter are probably quite different from the roles the patients can merge into outside the therapy context. This might shed some light on the notion of patient adherence/concordance.The significance of social rules in group training sessions.Implications for RehabilitationHealth professionals should be aware of the implicit social regulations of the clinical encounter. They will influence whether and how patients adhere to advice.By acknowledging that patients have different roles to merge into, depending on context, health professionals may significantly broaden our understanding of patient adherence and compliance.The social rules identified in this study contribute to individual recovery processes. We encourage health professionals to regard “group dynamics” as something that is going on during the group session, and worthwhile taking advantage of when planning and implementing group interventions.

Pentasaccharides for the prevention of venous thromboembolism.

Pentasaccharides for the prevention of venous thromboembolism.

The relationship between the use of cement during total hip replacement and blood pressure values

Background Total hip replacement is a common orthopaedic procedure associated with an elevated cardiovascular risk. There are several methods for total hip replacement, including whether or not to use cement for the prosthesis fixation. The aim of the study was to compare clinical characteristics, including blood pressure, in patients undergoing total hip replacement with and without the use of cement. Material and methods The study included patients with elective total hip replacement surgery, who were divided into those in whom the procedure was performed with or without the use of medical cement. The criteria for using cement were assessed during operation by the operator, according to the current protocol. All patients were interviewed, screened, and had their medical records checked for the prior diagnosis of cardiovascular risk factors. Blood pressure values were measured before and after the procedure according to the current guidelines. Results The study population consisted of 65 patients in whom the total hip replacement was performed (mean age 61.5 ± 15.0 years; 50.8% male). 60% of patients had the hip replacement without cement and 40.0% had a procedure with the use of cement. Patients in whom the cement was used were significantly older (75.0 ± 8.5 vs. 53.0 ± 11.5 years; p < 0.0001) and more often diagnosed with arterial hypertension (61.5 vs. 33.3%; p = 0.04), than those in whom it was not used. Systolic blood pressure values were significantly higher before and after the procedure (138.8 ± 18.2 vs. 130.8 ± 21.5 mm Hg, p = 0.04; 122.6 ± 13.3 vs. 113.8 ± 14.1 mm Hg, p = 0.03; respectively) in the group which required cement. Conclusions Patients with hip replacement using cement have higher systolic values before, and after the surgery than in patients in whom cement wasn’t used. Therefore careful management and risk assessment is especially important in patients receiving the total hip replacement with the use of cement.

A clinical audit of the utilisation of red cell products in elective total hip replacement surgery.

Previous studies have documented a marked variation in transfusion practice for total hip replacement (THR) surgery. To audit red cell product utilisation for THR at two Western Cape tertiary referral hospitals (HY and HG). The folders of 207 consecutive patients undergoing elective THR surgery from January 2013 to December 2013 were reviewed. Information relating to age, sex, clinical observations, indications for surgery, pre- and postoperative haemoglobin (Hb) values, comorbidities, length of hospital stay and transfusion history was recorded. The transfusion rate at HY (41.6%) was significantly higher than that at HG (10.0%). The mean postoperative Hb in the transfused patients at HG was 8.3 g/dL v. 9.1 g/dL at HY. Females had a significantly higher transfusion rate (33.0%) than males (15.0%) (p&lt;0.05), and the mean age of transfused patients was significantly greater than that of untransfused patients (p&lt;0.005). Although patients with comorbidities had a higher transfusion rate than those without, this did not reach statistical significance. Of 120 patients with complete data, 113 (94.2%) had a blood bank order, of which the vast majority, 102/113 (90.3%), were group-and-screen (G&amp;S) requests; 29/113 (25.7%) were converted to a full crossmatch. Overall, the transfusion rate for both hospitals was 25.8%, which is well within published rates. A guideline Hb trigger of 8.0 g/dL is recommended as per published guidelines, with the caveat that the clinical judgement of the attending clinician whether a transfusion is indicated is paramount. Causes of preoperative anaemia should be investigated and treated. Routine cross-matching preoperatively is unnecessary, and a G&amp;S order is sufficient.

Incidence, risk factors and the healthcare cost of falls postdischarge after elective total hip and total knee replacement surgery: protocol for a prospective observational cohort study.

IntroductionThe number of major joint replacement procedures continues to increase in Australia. The primary aim of this study is to determine the incidence of falls in the first 12 months after discharge from hospital in a cohort of older patients who undergo elective total hip or total knee replacement.Methods and analysesA prospective longitudinal observational cohort study starting in July 2015, enrolling patients aged ≥60 years who are admitted for elective major joint replacement (n=267 total hip replacement, n=267 total knee replacement) and are to be discharged to the community. Participants are followed up for 12 months after hospital discharge. The primary outcome measure is the rate of falls per thousand patient-days. Falls data will be collected by 2 methods: issuing a falls diary to each participant and telephoning participants monthly after discharge. Secondary outcomes include the rate of injurious falls and health-related quality of life. Patient-rated outcomes will be measured using the Oxford Hip or Oxford Knee score. Generalised linear mixed modelling will be used to examine the falls outcomes in the 12 months after discharge and to examine patient and clinical characteristics predictive of falls. An economic evaluation will be conducted to describe the nature of healthcare costs in the first 12 months after elective joint replacement and estimate costs directly attributable to fall events.Ethics and disseminationThe results will be disseminated through local site networks and will inform future services to support older people undergoing hip or knee joint replacement and also through peer-reviewed publications and medical conferences. This study has been approved by The University of Notre Dame Australia and local hospital human research ethics committees.Trial registration numberACTRN12615000653561; Pre-results.

An open-label study of the pharmacokinetics and pharmacodynamics of dabigatran etexilate 150 mg once daily in Caucasian patients with moderate renal impairment undergoing primary unilateral elective total knee or hip replacement surgery

BackgroundIn adults with moderate renal impairment (creatinine clearance [CrCl] 30–50mL/min) undergoing total hip or knee replacement (THR/TKR), the recommended dose of dabigatran etexilate is 150mg once daily (qd). We investigated the steady state pharmacokinetics, pharmacodynamics and safety in these patients. MethodsSingle-arm, open-label phase 4 study (NCT01184989) in Caucasian patients receiving dabigatran etexilate 75mg 1–4h after surgery and 150mg qd on days 2–10 (TKR) or days 2–35 (THR). Plasma total dabigatran concentrations (day 6±1) were determined by high-performance liquid chromatography tandem mass spectrometry and indirectly using the commercially available diluted thrombin time (dTT) assay (Hemoclot® Thrombin Inhibitors). ResultsOf 112 patients (mean CrCl 42.5mL/min, age 79.1years, 69.6% female), 100 completed the study. Geometric mean trough and peak dabigatran concentrations were 47.5ng/mL (10th–90th percentile 19.7–120) and 166ng/mL (49.1–364), respectively. There were four major bleeding events and no venous thromboembolic events. Dabigatran concentrations determined from dTT (and falling within the assay range of 50–500ng/mL) underestimated actual values by 7.6% (90% confidence interval 5.3, 9.9), which is within the acceptance limits of ±15%. ConclusionsThese findings in Caucasians with moderate renal impairment undergoing THR or TKR support the use of the 150mg qd dose of dabigatran etexilate. With adequate set-up, calibration and quality control the dTT assay might be appropriate for situations, such as serious bleeding or a need for urgent surgery, where determination of dabigatran levels would be helpful.

Epidemiology of arterial hypertension in patients scheduled for elective hip replacement

Background: Assessment of blood pressure values and early diagnosis of hypertension are especially important in high-risk group, including patients in preoperative and postoperative period. The aim of the current study was the assessment of blood pressure values and prevalence of hypertension in patients undergoing elective hip replacement surgery — an orthopedic procedure associated with one of the highest cardiovascular complication rate. Material and methods: Two hundred and eighty-four consecutive patients admitted for elective hip replacement surgery were screened for arterial hypertension. All patients had their medical records reviewed for prior diagnosis and had their blood pressure measured on admission by a qualified physician prior to the procedure, according to the current guidelines. Results: The mean age of the study population was 62.2 ± 13.9 years and 42.7% of the patients were male. The body mass index (BMI) in the study population was 27.0 ± 4.2 kg/m 2 . Fifty-eight point two percent of patients were diagnosed with arterial hypertension previously. Mean blood pressure values on admission for systolic blood pressure (SBP) and diastolic blood pressure (DBP) were 134.5 ± 20.4 and 78.6 ± 13.1 mm Hg, respectively. In 43.2% of patients, the on admission blood pressure values exceeded the threshold of ≥ 140 and/or 90 mm Hg. Arterial hypertension was diagnosed de novo in 33 (15.0%) patients. Patients with the disease were older (67.5 ± 12.3 vs. 54.4 ± 13.9 years; p < 0.0001), and had higher BMI (27.6 ± 4.3 vs. 26.2 ± 3.8 kg/m 2 ; p = 0.05) than patients without the diagnosed disease. Diabetes mellitus was more often found in hypertensive patients (13.3% vs. 3.3%; p = 0.02), they also more often had history of myocardial infarction (p = 0.02), stable coronary artery disease (p = 0.001) and heart failure (p = 0.006) compared to patients without the diagnosis. Conclusions: The majority of patients scheduled for elective hip replacement surgery is diagnosed with arterial hypertension. The disease is also diagnosed de novo in 15% of these patients. Screening for arterial hypertension is important in this group of patients and can potentially reduce the complication rates of the hip replacement surgery.

Anticoagulants (extended duration) for prevention of venous thromboembolism following total hip or knee replacement or hip fracture repair.

Anticoagulants (extended duration) for prevention of venous thromboembolism following total hip or knee replacement or hip fracture repair.

Evidence-Based Development and Rationale for Once-Daily Rivaroxaban Dosing Regimens Across Multiple Indications

Background:Rivaroxaban, a direct factor Xa inhibitor, has been developed to meet clinical needs in a broad range of indications in adults: prevention of venous thromboembolism after elective hip or knee replacement surgery, treatment and secondary prevention of venous thromboembolism, prevention of stroke and systemic embolism in patients with nonvalvular atrial fibrillation having one or more risk factors, and in Europe, prevention of atherothrombotic events after an acute coronary syndrome in patients with elevated cardiac biomarkers. However, the precise dose and regimen vary with the indication, leading to this effort to provide clarity concerning the appropriate use of rivaroxaban. This article reviews the clinical development program for rivaroxaban and summarizes the evidence for each approved, indication-specific dose regimen.Results:Although initially investigated for twice-daily dosing, early observations, including the finding that the pharmacodynamic effects of rivaroxaban last longer than the elimination half-life, suggested that once-daily dosing might be attainable and effective. These observations were evaluated within the extensive phase II program, which, together with pharmacology studies, provides the evidence underpinning the selection of once-daily regimens for most, but not all, of the approved clinical indications for rivaroxaban.Conclusion:The evidence for each dosing regimen demonstrates that although pharmacology studies are of paramount importance, dose regimens must be subjected to careful empirical validation. Once-daily dosing was shown to be clinically appropriate for most rivaroxaban indications. Furthermore, a “one size fits all” approach to dosing frequency is unlikely to result in a regimen that yields optimal patient outcomes across different indications.

Perte de sang occulte dans les arthrodèses rachidiennes lombaires antérieures (ALIF)

BackgroundA retrospective study was performed to determine the factors affecting the total perioperative blood loss during anterior lumbar interbody fusion (ALIF). Measurements of intraoperative blood loss underestimate the true blood loss during surgery. Our research project was to examine the hidden blood loss in lumbar spine surgery. Hidden blood loss in elective knee and hip replacement surgeries range between 100% and 30%. Hidden blood loss was about 40% in posterior spine surgery. MethodsThe factors analyzed included gender, body mass index (BMI), duration of surgery, type of surgery, aspiration, and number of fusion levels. Estimated blood loss (EBL) was obtained from the clinical records of patients as the blood collected from suctioning and the cumulative weight of the saturated sponges. Actual blood loss (ABL) was calculated from the estimated blood volume and hemoglobin level of patients. Hidden blood loss was calculated as the difference between ABL and EBL. ResultsSeventy-eight consecutive patients who underwent ALIF were reviewed. The average values (mean±SD) for EBL and ABL were 700.1±562.3mL and 1150.6±770.0mL, respectively (P=0.001, Student's t-test). The hidden blood loss averaged 39.2% of the ABL. According to linear regression analysis, surgical duration, type of surgery, and the inclusion of the L4/5 level were independent factors contributing to the ABL (P<0.05), whereas BMI and gender did not correlate with ABL or EBL. ConclusionsALIF is associated with substantial perioperative hidden blood loss. Length of surgery, type of surgery, and the inclusion of L4/5 in the procedure are significant risk factors for increased blood loss. Level of evidenceLevel IV: retrospective or historical series.

Hidden blood loss in anterior lumbar interbody fusion (ALIF) surgery

BackgroundA retrospective study was performed to determine the factors affecting the total perioperative blood loss during anterior lumbar interbody fusion (ALIF). Measurements of intraoperative blood loss underestimate the true blood loss during surgery. Our research project was to examine the hidden blood loss in lumbar spine surgery. Hidden blood loss in elective knee and hip replacement surgeries range between 100% and 30%. Hidden blood loss was about 40% in posterior spine surgery. MethodsThe factors analyzed included gender, body mass index (BMI), duration of surgery, type of surgery, aspiration, and number of fusion levels. Estimated blood loss (EBL) was obtained from the clinical records of patients as the blood collected from suctioning and the cumulative weight of the saturated sponges. Actual blood loss (ABL) was calculated from the estimated blood volume and hemoglobin level of patients. Hidden blood loss was calculated as the difference between ABL and EBL. ResultsSeventy-eight consecutive patients who underwent ALIF were reviewed. The average values (mean±SD) for EBL and ABL were 700.1±562.3mL and 1150.6±770.0mL, respectively (P=0.001, Student's t-test). The hidden blood loss averaged 39.2% of the ABL. According to linear regression analysis, surgical duration, type of surgery, and the inclusion of the L4/5 level were independent factors contributing to the ABL (P<0.05), whereas BMI and gender did not correlate with ABL or EBL. ConclusionsALIF is associated with substantial perioperative hidden blood loss. Length of surgery, type of surgery, and the inclusion of L4/5 in the procedure are significant risk factors for increased blood loss. Level of evidenceLevel IV: retrospective or historical series.

Exploring unmet needs in venous and arterial thromboembolism with rivaroxaban.

The vast clinical research programme for the direct, oral factor Xa inhibitor rivaroxaban has generated a wealth of data since the first rivaroxaban approval in 2008 for the prevention of venous thromboembolism (VTE) in patients undergoing elective hip or knee replacement surgery. While rivaroxaban is widely used across a spectrum of seven indications, there is continuous commitment to investigating its wider benefits in new indications and attempts to refine current evidence. Key data from recently completed randomised controlled trials (RCTs) have shown that rivaroxaban is a feasible anticoagulation option for patients with non-valvular atrial fibrillation (NVAF) undergoing cardioversion or catheter ablation. Now, a number of Phase II and III RCTs are underway that seek to uncover further roles for rivaroxaban in patients at risk of thrombosis and aim to improve quality of life. This article will introduce and provide context for these RCTs in the contemporary management of arterial and venous thromboembolism in the following underserved areas: Patients with both NVAF and acute coronary syndrome (ACS) requiring percutaneous coronary intervention (PCI); patients with embolic stroke of undetermined source (ESUS); patients who require transcatheter aortic valve replacement (TAVR); patients with acute or chronic coronary artery disease (CAD; including those with heart failure [HF]); those at risk of or suffering from cancer-associated thrombosis (CAT) and those requiring long-term anticoagulation. It is hoped that this collection of studies provides clarity around the use of rivaroxaban as a fundamental component of antithrombotic therapy in an array of clinical situations.

Selective spinal anesthesia using low concentration bupivacaine and fentanyl versus ordinary bupivacaine as a prophylaxis against deep venous thrombosis in total hip replacement surgery

Objective The aim of the present study was to detect the efficacy of early postoperative calf muscle exercise to decrease the risk of deep venous thrombosis achieved by intrathecal 3 ml bupivacaine 0.25% and fentanyl 25 μg instead of 3 ml bupivacaine 0.5%. In total, 40 patients of either sex, aged between 18 and 60 years, with American Society of Anesthesiologists (ASA) I and II were included in the study. Patients and methods A total of 40 ASA I and II patients undergoing elective total hip replacement surgery were randomly assigned to two equal groups of 20 patients each (group A and B). Group A received bupivacaine 0.5% (3 ml) and group B received bupivacaine 0.25% (3 ml)+fentanyl 25 μg. Patients were instructed on how to do cuff muscle exercise once they regained the full strength of the lower limbs muscles postoperatively. Five venous blood samples were taken from each patient for the D-dimer assessment as an indicator for the occurrence of venous thromboembolism. The first sample was taken preoperatively at the time of induction of anesthesia; the rest of samples were then taken at 12, 24, 48 h, and 7 days postoperatively. Results Group B, in which patients received intrathecal bupivacaine 0.25% plus fentanyl, had an earlier recovery of motor power; patients in this group started doing calf muscle exercise earlier than did those in group A, and this group had significantly lower postoperative D-dimer level, denoting less susceptibility to deep venous thrombosis. Conclusion Early postoperative calf muscle exercise decreased the incidence of venous thromboembolism risk as indicated by the results of the D-dimer assessment.

The Association of Vitamin D Status and Pre-operative Physical Activity in Patients with Hip or Knee Osteoarthritis.

Vitamin D is important for musculoskeletal health and may have significant implications for maintaining physical activity in elderly patients. Our goal was to investigate whether serum 25-hydroxyvitamin D (25OHD) levels are associated with pre-operative physical activity in patients who are offered elective knee or hip joint replacement surgery. We performed a single-center, retrospective analysis of patients who had elective knee or hip replacement surgery from 2002 to 2012. To investigate the association of serum 25OHD levels with pre-operative physical activity, as assessed by the University of California, Los Angeles (UCLA) activity scale, we performed a multivariable logistic regression analysis while controlling for age, sex, race, body mass index, American Society of Anesthesiologists physical status score, and season. We identified 182 patients who met inclusion criteria. Mean (± standard deviation) 25OHD level and UCLA activity scale score were 29±13 ng/mL and 4±2, respectively. Patients with 25OHD levels <20 ng/mL were almost three times more likely to have UCLA activity scale scores ≤3 [adjusted odds ratio 2.78; 95% confidence interval 1.72-9.17]. Further adjusting for "type of 25OHD assay" or "type of joint surgery" did not materially change this result. In our cohort of knee or hip joint replacement surgery patients, 25OHD levels were associated with pre-operative physical activity scores. Prospective, randomized, clinical trials are needed to verify whether optimizing pre-operative vitamin D status may improve physical activity and influence clinical decision-making in knee or hip joint replacement surgery candidates.