One-stage Bilateral Total Knee Arthroplasty Research Articles

Bilateral diz protezi yapılan hastalarda postoperatif analjezi için standart intravenöz hasta kontrollü analjezi dozu yeterli olur mu?

The aim of this study is to investigate whether patients undergoing one-stage bilateral total knee arthroplasty and those undergoing unilateral total knee arthroplasty differed in their responses to a standard intravenous patient-controlled analgesia protocol. Data from patients with the physiological status I-III according to American Society of Anesthesiologists, aged 18-99 years, undergoing one-stage bilateral or unilateral total knee arthroplasty under spinal anesthesia between January 2014 and December 2017 and offered a standard intravenous patient-controlled analgesia with morphine were retrospectively reviewed. Demographic data, Visual Analogue Scale scores and postoperative complications were examined. The total dose of analgesics consumed, analgesia demands, doses delivered and the ratio of delivered doses to demands in 0- 24 hours and 24-48 hours after surgery available in the patient-controlled analgesia pump monitoring forms were recorded. 
 Records about 68 patients who had one-stage bilateral total knee arthroplasty and 124 patients who had unilateral total knee arthroplasty were accessed. The analgesia demands and analgesic doses delivered and utilized by the patients with one-stage bilateral total knee arthroplasty were significantly higher in 0-24 hours and 24-48 hours after surgery. Side-effects of the analgesia were similar in both groups. Visual Analogue Scale scores in 24-48 hours after surgery were higher in the patients with unilateral total knee arthroplasty. 
 Although the patients with one-stage total knee arthroplasty received significantly higher doses of morphine, side-effects due to this opioid did not differ significantly. This showed that the standard intravenous patient-controlled analgesia protocol utilized was reliable and effective in both patient groups.

Efficacy of preoperative autologous blood storage in one-stage bilateral total knee arthroplasty

BackgroundOne-stage bilateral total knee arthroplasty (TKA) has the advantages of a single hospital stay, shorter rehabilitation, and reduced financial burden on patients. However, perioperative bleeding is greater with one-stage bilateral TKA than with unilateral TKA and is more likely to require allogeneic blood transfusion. At our hospital, we normally store autologous blood about 1 month before surgery to reduce the need for allogeneic blood transfusion and avoid its adverse reactions as much as possible. The purpose of this study was to determine the efficacy of preoperative autologous blood storage for patients undergoing one-stage bilateral TKA. MethodsWe retrospectively examined the allogeneic blood transfusion avoidance rate and the perioperative decrease in hemoglobin (Hb) level in 166 patients according to whether or not they had preoperative autologous blood stored. The patients for whom blood was stored were then subdivided according to whether the amount of blood stored was 400 mL or 200 mL. ResultsExcluding allogeneic transfusion cases, the mean perioperative decrease in Hb was significantly lower in the patients with stored blood than in those without stored blood (3.5 g/dL vs 4.4 g/dL, p < 0.001). The allogeneic blood transfusion avoidance rate was significantly higher in the group with stored blood (98.5% vs 86.7%, p < 0.01). In the group with stored blood, the transfusion avoidance rate was higher, but not significantly, in the subgroup with 400 mL of blood stored than in those with 200 mL of blood stored (100% vs 97.5%) and the mean perioperative decrease in Hb was 3.5 g/dL in both blood storage volume groups. ConclusionsPreoperative autologous blood storage can help increase the likelihood of avoiding allogeneic blood transfusion in patients undergoing one-stage bilateral TKA.

Reply to Letter to Editor: Safety of one-stage bilateral total knee arthroplasty—one-surgeon sequential vs. two surgeons simultaneous: a randomized controlled study

Reply to Letter to Editor: Safety of one-stage bilateral total knee arthroplasty—one-surgeon sequential vs. two surgeons simultaneous: a randomized controlled study

Effect of Steroid in Local Infiltration Analgesia in One-Stage Bilateral Total Knee Arthroplasty: A Paired-Randomized Controlled Study

Although local infiltration analgesia (LIA) is effective in relieving pain after total knee arthroplasty (TKA), its effect is short lasting and the optimal combination of drugs is unknown. Steroids being a potent and long-acting anti-inflammatory drug might extend LIA's effect. This study aims to evaluate the role of steroids in LIA. This is a paired-randomized controlled study involving one-stage bilateral TKA patients. LIA containing ropivacaine, ketorolac, and adrenaline with or without triamcinolone was given. One knee was randomized to receive LIA with steroids, while the other received LIA without steroids. The primary outcome was knee pain in terms of the visual analog scale (VAS). Secondary outcomes were rehabilitation progress, functional scores, and complications. Outcomes were compared between the knees of the same patient and documented up to 1 year. A total of 45 patients (90 TKAs) were included. LIA with steroid knees showed lower VAS score at rest and during activity from postoperation day 1 to 5 and at 6 weeks (p < 0.05). Passive and active range of movement was also greater in LIA with steroid group from day 1 to 7 and day 2 to 5, respectively (p < 0.05). Steroid-treated knees also achieved active straight leg raise earlier (1.2 vs. 2.0 days, p < 0.05). No differences in Knee Society Score and complication rates between both groups. Steroids in LIA offer additional and extended benefit in pain control and rehabilitation after TKA, while no adverse effects were found up to 1-year follow-up.

The analgesic efficacy and safety of peri-articular injection versus intra-articular injection in one-stage bilateral total knee arthroplasty: a randomized controlled trial

BackgroundAs an essential component of multimodal analgesia approaches after total knee arthroplasty (TKA), local infiltration analgesia (LIA) can be classified into peri-articular injection (PAI) and intra-articular injection (IAI) according to administration techniques. Currently, there is no definite answer to the optimal choice between the two techniques. Our study aims to investigate analgesic efficacy and safety of PAI versus IAI in patients receiving simultaneous bilateral TKA.MethodsThis randomized controlled trial was conducted from February 2017 and finished in July 2018. Sixty patients eligible for simultaneous bilateral total knee arthroplasty were randomly assigned to receive PAI on one side and IAI on another. Primary outcomes included numerical rating scale (NRS) pain score at rest or during activity at 3 h, 6 h, 12 h, 24 h, 48 h, and 72 h following surgery. Secondary outcomes contained active or passive range of motion (ROM) at 1, 2, and 3 days after surgery, time to perform straight leg raise, wound drainage, operation time, and wound complications.ResultsPatients experienced lower NRS pain scores of the knee receiving PAI compared with that with PAI during the first 48 h after surgery. The largest difference of NRS pain score at rest occurred at 48 h (PAI: 0.68, 95%CI[0.37, 0.98]; IAI: 2.63, 95%CI [2.16, 3.09]; P < 0.001); and the largest difference of NRS pain score during activity also took place at 48 h (PAI: 2.46, 95%CI [2.07, 2.85]; IAI: 3.90, 95%CI [3.27, 4.52]; P = 0.001). PAI group had better results of range of motion and time to perform straight leg raise when compared with IAI group. There were no differences in operation time, wound drainage, and wound complication.ConclusionPAI had the superior performance of pain relief and improvement of range of motion to IAI. Therefore, the administration technique of peri-articular injection is recommended when performing local infiltration analgesia after total knee arthroplasty.Trial registrationThe trial was retrospectively registered in the Chinese Clinical Trial Registry as ChiCTR1800020420 on 29th December, 2018.Level of evidenceTherapeutic Level I.

Resurfacing versus not-resurfacing the patella in one-stage bilateral total knee arthroplasty: a prospective randomized clinical trial

PurposeResurfacing the patella in one-stage bilateral total knee arthroplasty (TKA) remains debatable. This study aimed to assess the mid-term outcomes of patients after one-stage bilateral TKA performed with and without patellar resurfacing, respectively, with at least five years of follow-up.MethodsSixty-six patients (132 knees) scheduled for first-ever one-stage bilateral TKA due to osteoarthritis received patellar resurfacing and retention, respectively, on one knee and the other, randomly selected. All patients received Scorpio NRG knee prostheses and were evaluated by radiology (anteroposterior, lateral, and axial views) pre-operatively and yearly post-operatively, for at least five years. Knee Society Score and Feller Score values were measured. Anterior knee pain, patellar clunk, and patient satisfaction were assessed.ResultsOne patient died within five years of operation and four were lost to follow-up. One patient developed severe dementia and could not be constructively questioned. Therefore, 60 patients (120 knees) were finally analyzed. There were significantly improved Knee Society and Feller scores (P < 0.001) in the resurfacing group compared with the non-resurfacing group post-operatively. Anterior knee pain and patellar clunk rates were lower on the resurfaced side compared with the non-resurfaced side (P < 0.001). Meanwhile, 47% and only 7% patients preferred the resurfaced and non-resurfaced sides, respectively, at final follow-up. No revision was performed for patellofemoral complications, and no significant differences were found between the two groups in radiographic outcomes.ConclusionsUsing the Scorpio NRG knee prosthesis, patellar resurfacing is superior to non-resurfacing in patients with osteoarthritis observed for ≥ five years.Registration trials numberNCT03600922Key Points• Findings Patellar resurfacing is superior to non-resurfacing in osteoarthritis (OA) patients undergoing total knee arthroplasty (TKA) with the Scorpio NRG knee prosthesis.• Implications Patellar resurfacing should be performed in OA patients during TKA.• Caution Several prosthesis types should be assessed in the same study setting, and multicenter studies are required before generalizability of the present findings.

Investigation of perioperative safety and clinical results of one-stage bilateral total knee arthroplasty in selected low-risk patients

BackgroundAn increased perioperative complication rate has been a concern with one-stage bilateral total knee arthroplasty (TKA). The purpose of this study was to retrospectively investigate the perioperative safety and clinical results of one-stage bilateral TKA in selected low-risk patients.MethodsSixty-seven patients who received one-stage bilateral TKAs for osteoarthritis who were American Society of Anesthesiology (ASA) class 1 or 2 were included in this study. Perioperative complications, blood loss, transfusion rate, blood laboratory results, and clinical results were evaluated up to 1 year after surgery.ResultsNo major complications (deep infection, pulmonary embolism, cerebrovascular accident, myocardial infarction, death, or removal or revision of the implants) were observed. The average total blood loss was 1139.5 ml. The transfusion rate was 95.5%. Postoperative hemoglobin level and C-reactive protein level gradually improved up to postoperative day 21 (P < 0.01). Bilateral knee extension knee angles and clinical scores improved postoperatively as compared with preoperative values (P < 0.01).ConclusionsAlthough total blood loss and transfusion rate can be high, this preliminary case series suggested that the one-stage bilateral TKA in ASA class 1 or 2 patients can have high perioperative safety levels, and good clinical results can be obtained up to 1 year after surgery. If low-risk patients are selected for bilateral TKA, a one-stage procedure can be beneficial for patients, with a minimal increase in the risk of complications.

Optimizing Intraoperative Blood Management for One-Stage Bilateral Total Knee Arthroplasty.

Effective blood management strategies are a major determinant of successful outcomes after one-stage bilateral total knee arthroplasty (BTKA). Proper patient selection with preoperative optimization and intra- and postoperative interventions can reduce transfusion risk and associated morbidity in these patients. The purpose of this study was to evaluate intraoperative blood management modalities based on three keystone questions: (1) What is the role of the anesthesiologist?, (2) Which are the surgeon-dependent strategies?, and (3) Is there any place for pharmacologic interventions? We searched the established electronic literature database MEDLINE. After critical appraisal, 94 studies were deemed eligible from which to draw documented evidence. A number of blood-conserving methods are currently implemented in patients undergoing one-stage BTKA. Among them, regional anesthesia, tourniquet use, and tourniquet deflation after wound closure, femoral canal sparing or femoral canal plugging, avoidance of drains, and tranexamic acid use were the intraoperative strategies with documented efficacy in blood conservation. Combined proper intraoperative anesthesiologic, surgical, and pharmacologic interventions reduce blood loss and need for transfusion in BTKA patients. However, contemporary relevant literature is lacking evidence-based guidelines.

A Meta-analysis of complications of total knee arthroplasty with or without drainage

Objective To compare the complication rate of one stage total knee arthroplasty (TKA) with or without drainage. Methods Studies published up to March 2014 were searched in the databases of Pub Med, Embase, Cochrane Library, CNKI and Wan Fang databases, supplemented with manual searching of relevant references of key studies, using the searching terms“drainage”, “one-stage”,“total knee arthroplasty”and“randomized controlled trials”. The methodological quality of included studies was evaluated by Physiotherapy Evidence Database scale. The analyses were performed with Cochrane Rev Man software version 5. 0. Results A total of three randomized controlled trials reporting on 125 patients with an average follow-up of 14 months met the predetermined inclusion criteria. There were 56 total complications in TKA without drainage and 17 with drainage,P 0. 05). Conclusion Both drainage and non-drainage have similar clinical value in one-stage bilateral TKA. However, the conclusion should be used with caution due to the limitations of the current study. Key words: Total knee arthroplasty; Drainage; Randomized controlled trials

The Efficacy of Unilateral Use of a Blood Reinfusion Device in One-Stage Bilateral Total Knee Arthroplasty

PurposeTo assess the efficacy of unilateral use of a blood reinfusion device in one-stage bilateral total knee arthroplasty (TKA).Materials and MethodsWe carried out a retrospective cohort study on 100 patients having one-stage bilateral TKA. In 50 of these patients (study group), a blood reinfusion device was applied on one knee and a standard suction drain on the other, and they were compared with 50 matched controls who received bilateral suction drains (control group). The hemoglobin (Hb) level, the hematocrit (Hct) and the platelet count were checked preoperatively, immediately postoperatively, and the third and seventh days postoperatively. The total drain output and the amount of allogeneic blood transfusion were also compared.ResultsThere were no significant differences in the total drain output and required amount of allogeneic blood transfusions between groups (p>0.05). However, the study group had significantly lower Hb and Hct values by the first day postoperatively and significantly lower platelet count values by the third day postoperatively than the control group (p<0.05).ConclusionsCompared with use of bilateral suction drains, unilateral use of reinfusion device was not advantageous in reducing allogeneic transfusion in one-stage bilateral TKA.

Do patients care about higher flexion in total knee arthroplasty? A randomized, controlled, double-blinded trial

BackgroundLittle information exists to support that patients care about flexion beyond what is needed to perform activities of daily living (ADL) after Total knee arthroplasty (TKA). The purpose of this study was to investigate if the achievement of a higher degree of knee flexion after TKA would result in a better patient perceived outcome.MethodsThe study is a randomized, double-blinded, controlled trial in which 36 patients (mean age: 67.2 yrs) undergoing one-stage bilateral TKA randomly received a standard cruciate-retaining (CR) TKA in one knee and a high-flex posterior-stabilized (PS) TKA in the contra lateral knee. At follow-up ROM, satisfaction, pain, “feel” of the knee and the abilities in daily activities were assessed.ResultsAt 1-year follow-up we found an expected significantly higher degree of knee flexion of 7° in the high-flex knees (p = 0.001). The high-flex TKA’s showed a mean active flexion of 121°. In both TKA’s the median VAS pain score was 0, the median VAS satisfaction score was 9, and the median VAS score of the patient “feel” of the knee was 9 at 1-year follow-up. Further, there were no significant differences between the knees in the performance of daily activities.ConclusionsAs expected the high-flex TKA showed increased knee flexion, but no significant differences in the patient perceived outcomes were found. This suggests little relevance to the patients of the difference in knee flexion – when flexion is of this magnitude – as pain free ROM and high patient satisfaction were achieved with both TKA’s.Trial registrationClinicalTrials.gov: NCT00294528

Bilateral Fatigue Fracture of the Femoral Components in a Cruciate-retaining Cementless Total Knee Prosthesis

This article reports a case of bilateral fatigue fracture of the femoral components in a cruciate-retaining uncemented total knee arthroplasty (TKA). A 75-year-old woman (height, 158 cm; weight, 72 kg; body mass index, 29.2) had undergone one-stage bilateral TKA for osteoarthritis 11 years previously at the author's institution. Surgery was performed using an uncemented Flexible Nichidai Knee. Equal tension of the collateral ligaments and normal mechanical axis were achieved during the primary procedure. The patient was an ardent lover of the game of badminton and had higher activity levels with daily playing. At 8 years postoperatively, she started complaining of mild pain in both knees. The pain gradually increased, and at 11 years postoperatively, she had difficulty walking. Anteroposterior radiographs showed narrowing of the medial joint space, indicating wear of the polyethylene insert. Lateral radiographs showed signs of broken implants in both knees. There were no signs of gross implant loosening or osteolysis. One-stage revision surgery was performed, and the knees were converted to cemented posterior-stabilized TKAs. At revision, the bilateral femoral components were found to be fractured at the junction between the trochlear flange and the medial condyle, anteriorly to the medial peg. The polyethylene insert showed mild wear at the medial middle portion. In the majority of case reports, stress fractures of the femoral component have predominantly affected the medial condyle, following uncemented implantation of fixed-bearing knees. In this case, failure of bone ingrowth in uncemented components, higher body mass index, and a higher athletic activity led to fatigue fracture of the femoral components.

Comparative study of one stage bilateral total knee arthroplasty with or without drainage

To compare the impact of rehabilitative process of placing drainage versus no drainage during total knee arthroplasty (TKA). A prospective study was performed in 30 osteoarthritic patients who underwent one-stage bilateral TKA between October 2007 and December 2008. For every patient, drainage was randomly placed intra-operatively only on one knee side. Pain VAS scores, extremity swelling, incision healing, recovery of knee joint flexion and extension function and early postoperative complications were compared statistically as a self-control study. All patients were followed up for at least one month. Comparing drainage side with non-drainage side, the mean pain VAS scores at Day 3 post-operation were 4.7 +/- 1.8 and 4. 9 +/- 1.9 respectively; the mean extremity swelling differences of supra patellar (infra patellar) perimeter at Day 6 post-operation were 1.8 +/- 1.7 (0.7 +/- 1.0) cm and 1.7 +/- 1.3 (1.0 +/- 1.0) cm respectively; the mean flexion (extension) differences at Day 30 post-operation were 12.5 +/- 21.6 (4.4 +/- 6.9) degrees and 11.7 +/- 23.9 (4.2 +/- 6.4) degrees respectively. There was no obvious statistical difference between placing drainage and no drainage in all the above aspects (paired t-test, P > 0.05). There was also no statistical difference of early postoperative complications between two groups (exact Fisher test, P > 0.05). For unsophisticated TKA, placing drainage had no effect upon reducing the pain, extremity swelling and incision exudation. It also had no effect upon reducing the incidence of hematoma to prevent early infections and promoting rehabilitation. Comparing with no drainage, placing drainage had no obvious advantage. On the contrary, it might complicate the surgical steps and increase the chances of post-operative hemorrhage and retrograde infections. Thus no drainage is recommended in such a kind of operation.

Efficiency of Autologous Blood Donation in Combination with a Cell Saver in Bilateral Total Knee Arthroplasty

The increased blood loss and resulting need for allogenic blood has been a major concern of one-stage bilateral total knee arthroplasty (TKA). One hundred eighteen consecutive patients donating either 2 units (87 patients) or 3 units (31 patients) of autologous blood prior to one-stage bilateral TKA were retrospectively evaluated to determine: (1) how many patients received allogenic transfusion; (2) what percentage of autologous blood was wasted; and (3) whether donating 2 or 3 units of autologous blood before surgery is more cost-effective. Fifteen patients in the 2-units donation group (17.2%) and one patient in the 3-units donation group (3.2%) required allogenic blood transfusions. In the 2-units group, 37.9% of the patients wasted 21.8% of predonated autologous blood, and in the 3-units group, 64.5% of the patients wasted 32.3% of predonated autologous blood. The estimated cost for patients donating 2 or 3 units of blood was $1,814.17 and $1,996.10, respectively. Donating 2 units of autologous blood is more cost-effective; however, patients donating 3 units of blood required less allogenic blood.

The relative safety of one-stage bilateral total knee arthroplasty

Patients with osteoarthritis of the knee often require bilateral knee replacement before fulfilling their full ambulatory potential. Despite extensive research there is considerable debate about the risks of performing simultaneous bilateral knee replacements under the same anaesthetic. Our aim was to compare the relative short-term morbidity of one-stage bilateral with unilateral total knee arthroplasty in a retrospective, consecutive cohort of patients. Seventy-two bilateral knee replacements were case-matched for age and gender with 144 unilateral knees. One-stage bilateral arthroplasty was associated with increased morbidity with respect to wound (6.0 vs 0.7%; p = 0.003) and deep prosthetic (3.5% vs 0.7 %; p = 0.02) infections, cardiac complications (3.5% vs 0.7%; p = 0.04) and chest infections (7.0% vs 1.4%; p = 0.04). No differences were observed in the mortality rates (p = 0.30) and risk of thrombo-embolism (p = 0.70). We conclude that one-stage bilateral total knee arthroplasty is associated with increased morbidity compared with unilateral knee replacement.

Epidural Infusions of Bupivacaine and Fentanyl Do Not Improve Rehabilitation Following One-Stage Bilateral Total Knee Arthroplasty

Abstract Epidural analgesia with local anaesthetic minimizes the catabolic response to surgery. To determine whether this could enhance the rate of recovery following orthopaedic surgery, 51 patients undergoing bilateral one-stage total knee arthroplasty were allocated to receive infusions of either continuous epidural bupivacaine/fentanyl or continuous intravenous fentanyl to compare the efficacy of these modes of pain relief on postoperative clinical outcomes and rates of rehabilitation. Infusions were maintained for 36 to 48 hours in a post-anaesthesia care unit (PACU). Postoperatively, pain relief (visual analogue scale), attainment of physical therapy goals and cardiopulmonary complications were measured daily for 7 days. Epidural analgesia with a combination of bupivacaine and fentanyl did not result in any measurable improvement in rehabilitation milestones or reduction in postoperative complications following bilateral total knee arthroplasty than with fentanyl infusions alone.

Arterial and pulmonary arterial concentrations of the enantiomers of bupivacaine after epidural injection in elderly patients.

Bupivacaine HCl is a 50:50 racemic mixture of the levo [S(-)] and dex [R(+)] enantiomers. The R(+) enantiomer exhibits greater cardiac tissue binding and toxicity. To determine whether the lung exhibits selective uptake of one of the enantiomers of bupivacaine, we measured pulmonary artery and radial artery blood concentrations of the two enantiomers after a lumbar epidural injection of 20 mL of 0.75% bupivacaine in 10 elderly patients undergoing one-stage bilateral total knee arthroplasty. Significantly lower concentrations of R(+) than S(-) were noted in both pulmonary artery and arterial blood. Both enantiomers were absorbed by the lung to a similar extent within the first 5 min after epidural injection (extraction ratio approximately equal to 0.1 or 10%). Mean time of maximal concentration (Tmax) was 6 min. In 3 of the 10 patients, Tmax occurred in 1-3 min. We conclude that the lung absorbs both the R(+) and S(-) enantiomers of bupivacaine to a similar extent after epidural injection and that this is of doubtful clinical significance. This study also suggests that peak concentrations of bupivacaine may occur earlier after epidural injection in certain elderly patients than previously believed. In the first 5 min after epidural injection, approximately 10% of the local anesthetic bupivacaine was absorbed by the lung. Absorption of the two enantiomers (mirror images) of bupivacaine were similar. Lung absorption of bupivacaine is unlikely to influence local anesthetic toxicity.

Incidence of fatal pulmonary embolism after 1,390 knee arthroplasties without routine prophylactic anticoagulation, except in high-risk cases

A consecutive series of 1,390 primary total knee arthroplasty (TKA) procedures (1,201 patients, 1,600 arthroplasties) performed between January 1980 and July 1994 were reviewed to establish the incidence of death from pulmonary embolism (PE). Nine hundred twenty-three bi- or tricompartment TKAs and 467 unicompartment TKAs were performed as one-stage procedures. Chemical thromboprophylaxis was used only in high-risk cases in which there was a history of previous thromboembolism or obesity. There were no deaths from PE after unicompartment arthroplasty procedures. Autopsy confirmed PE as the cause of death in 2 patients following bi- and tricompartment TKAs (0.22%; 95% confidence interval [CI], 0.03-0.8%). The incidence was higher for one-stage bilateral TKA as 1 of the autopsy-confirmed deaths occurred in this group 0.7% (95% CI, 0.02–3.78%). Two other deaths were certified without postmortem examination (pneumonia and myocardial infarction in each case). As PE could not be ruled out as the cause of death in the latter 2 cases, these were considered as possible PE deaths to provide the maximum possible death rate that could result. Thus, the maximum possible incidence of fatal PE after TKA without routine use of chemical anticoagulation was 0.4% (95% CI, 0.1–1.1%). It is concluded that the risk of fatal PE after unilateral TKA and unicompartment knee arthroplasty is low. The risk of clinical, nonfatal thromboembolic events, which might themselves warrant prophylaxis, was not quantified in this article.

Prophylaxis against Deep Venous Thrombosis after Total Knee Arthroplasty. Pneumatic Plantar Compression and Aspirin Compared with Aspirin Alone*

A prospective, randomized study was conducted to assess the efficacy of pulsatile pneumatic plantar compression for prophylaxis against deep venous thrombosis after total knee arthroplasty performed with use of regional anesthesia. One hundred and twenty-two patients (164 knees) who were scheduled to have a unilateral or a one-stage bilateral total knee arthroplasty were separately randomized to be managed with either aspirin alone or the pulsatile pneumatic plantar-compression device and aspirin. The prevalence of deep venous thrombosis was 27 per cent (twenty-two of eighty-one knees) in the group treated with pneumatic plantar compression compared with 59 per cent (forty-nine of eighty-three knees) in the patients managed with aspirin alone (the control group) (p < 0.001). A significant difference was also noted in the group that had had a unilateral arthroplasty (a prevalence of 27 per cent [eleven of forty-one knees] in the group treated with pneumatic plantar compression, compared with 67 per cent [twenty-six of thirty-nine knees] in that treated with aspirin alone; p < 0.006) and in the group that had had a one-stage bilateral procedure (a prevalence of 28 per cent [eleven of forty knees] in the group treated with pneumatic plantar compression, compared with 52 per cent [twenty-three of forty-four knees] in that treated with aspirin alone; p < 0.03). No proximal thrombi were noted in any patient who used the pulsatile pneumatic plantar-compression device, while the prevalence of proximal thrombosis in the popliteal or femoral veins was 14 per cent (twelve of eighty-three knees) in the group treated with aspirin alone (p < 0.0003). In the group treated with a unilateral procedure and aspirin alone the prevalence of proximal thrombosis was 13 per cent (five of thirty-nine knees; p < 0.02), while in the group treated with a bilateral procedure and aspirin alone it was 16 per cent (seven of forty-four knees; p < 0.01). Only in the patients who had had a unilateral procedure was use of the compression device associated with significantly less edema postoperatively than was use of aspirin alone. The change between the preoperative and postoperative circumferences of the thigh and leg was significantly less (9 +/- 4.1 millimeters [mean and standard deviation] less for the thigh [p < 0.01] and 6 +/- 3.9 millimeters less for the leg [p < 0.049]) with the compression device than with aspirin alone. In addition, there was significantly less mean drainage (98 +/- 61.1 milliliters) in the group treated with a unilateral procedure and pneumatic compression, compared with that treated with a unilateral procedure and aspirin alone (p < 0.041). An internal timer of the compression device was used to assess the compliance of the patient with use of the device, and a relationship between deep venous thrombosis and the total duration of treatment with the device was found. The patients in whom deep venous thrombosis did not develop used the device for a mean of 96 +/- 23.4 hours (range, sixty to 164 hours) postoperatively, or 19.2 +/- 5.1 hours a day, while those in whom thrombosis developed used it for a mean of 67 +/- 21.1 hours (range, twenty-six to 101 hours), or 13.4 +/- 4.3 hours a day (p < 0.001). No untoward effects were noted in any patient who used the device. This study confirms the safety and efficacy of pulsatile pneumatic plantar compression and aspirin compared with aspirin alone and supports the use of mechanical compression for prophylaxis against deep venous thrombosis and for reduction of edema in patients who have had a total knee arthroplasty. In addition, we found a direct relationship between compliance with the use of this device and its efficacy in reducing deep venous thrombosis.

Fatal fat embolism following total condylar knee arthroplasty

Although fatality from fat emboli syndrome following total knee arthroplasty has been reported, most cases occurred following the insertion of hinged prostheses and few are documented with detailed pathology. The authors present the case of a 75-year-old patient with long-standing rheumatoid arthritis who underwent a total condylar type total knee arthroplasty procedure using an intramedullary femoral alignment system and expired 6 hours following surgery. On autopsy he had multiple organ involvement with fat emboli. Especially with the present use of intramedullary alignment systems and the increasing numbers of one-stage bilateral total knee arthroplasty procedures the potential for this problem must be recognized so that early therapy can be instituted.