Orthopedic Procedures In Patients Research Articles

Guidelines for Ambulatory Surgery Centers for the Care of Surgically Necessary/Time-Sensitive Orthopaedic Cases During the COVID-19 Pandemic

Overview The current pandemic caused by the novel coronavirus disease 2019 (COVID-19) has created unprecedented times. As communities strive to control infectious outbreaks, the virus continues to cause substantial economic, social, and political disruption. As emergency departments are preparing for increased volume because of infected patients, the closure of non-emergency health-care facilities may further increase inappropriate demand on emergency medical staff. Approximately 77% of all injury-related health-care visits in the U.S. are for musculoskeletal injuries1, totaling >65 million visits in 2010 and 2011. Thus, to lessen the burden on emergency department personnel, it is vital for continued limited operation of orthopaedic outpatient centers. Additionally, recent government mandates are now excluding medical care and treatment for elective procedures, thus causing ambulatory surgery centers (ASCs) to cease operations for non-urgent orthopaedic-related procedures; however, for certain pathologies, inability to operate or failure to recognize injuries that are “surgically necessary” may result in serious long-term health consequences, including neurological, vascular, and joint morbidity. Currently, the Centers for Disease Control and Prevention, the Ambulatory Surgery Center Association, the Centers for Medicare & Medicaid Services, and the American College of Surgeons have provided guidelines on the postponement of elective surgical procedures because of the current COVID-19 outbreak. In addition to minimizing the exposure of patients to the coronavirus, the purpose of this recommendation is to also limit the use of essential items, such as personal protective equipment (PPE), ventilators, and cleaning supplies2. These recommendations also aim to minimize the potential for complications following elective procedures that would result in further depletion of the aforementioned items and increase need for the hospital beds required to care for COVID-19 patients, as well as to prepare for a potential surge of critically ill patients at all inpatient centers. Guidelines allow a health-care provider the time and availability necessary care for COVID-19 patients, and minimize potential exposure to COVID-19 for patients and health-care workers. Currently, these guidelines note that elective procedures should be rescheduled and that urgent or emergency procedures may still be performed. Elective or non-urgent cases have been reported to be those for which there would be no anticipated short or long-term negative impact in delaying the procedure3. Surgical necessity in the context of the current pandemic can be defined as urgent pathologies that could lead to long-term disability and/or chronic pain if acute surgical treatment is delayed. These decisions regarding elective versus elective-urgent cases should be made concurrently with the input of local and state governmental officials (such as the Department of Health) with the input of the individual surgical facility and hospital system leadership, as well as the treating surgeon. In addition, these decisions should be refined on the basis of the duration of the COVID-19 crisis, current and projected prevalence of COVID-19 cases, health and age of the patient, staffing availability, and the local PPE supply until officials are confident that the COVID-19 cases have peaked and that the local health-care infrastructure can support a return to normalcy4. As reported, there is a current critical shortage of PPE, and thus the priority remains to secure adequate PPE for front-line medical professionals5. As the supply chain is mobilized and front-line demand is met, ASCs could be resupplied. This would allow ASCs to then unload the burden of outpatient cases from larger facilities. Critical aspects of the virus, such as the reproductive number, morbidity, and mortality, must be established to determine allocation of resources, including the use of outpatient surgery centers. The initial response to a pandemic will evolve and thus the evaluation around the allocation and utilization of health-care resources must be a dynamic process. The manner in which resources are utilized in the initial phases could potentially be different from that in latter phases. Although these guidelines are considered definitive for most inpatient centers, in orthopaedic surgery, many procedures are now performed in outpatient surgery centers. In particular for this COVID-19 crisis, outpatient surgical procedures that are scheduled for inpatient facilities should be considered for rescheduling to outpatient facilities whenever possible in order to minimize asymptomatic individuals being exposed to facilities that have relatively higher levels of exposure to COVID-19 (e.g., hospitals). In addition, limiting visitors to all but minor patients, the mentally/physically disabled, and elderly patients who require assistance should be performed. Furthermore, to help reduce the likelihood of disease transmission, ASCs should institute additional measures to maximize patient safety, such as the administration of appropriate screening tests (e.g., travel history and/or history of recent illness), body temperature, respiratory symptoms, and screening of staff for signs of illness or other risk factors until an accurate and highly sensitive rapid test for the diagnosis of COVID-19 illness or antibodies is available. We recommend that each outpatient facility should follow protective guidelines for staff during procedures and ensure that all who are present during intubation and extubation have access to appropriate PPE, including N95 masks, and ensure that terminal cleaning of all operating rooms and equipment be performed between cases. Recommended Guidelines for “Surgically Necessary” Orthopaedic Cases in an ASC Setting It is essential to follow the principles of social distancing, hand washing, and avoidance of crowds to help flatten the curve of the COVID-19 trajectory. It is also important to be forward-thinking and clearly define those patients who could suffer long-term consequences if a surgical procedure is postponed. Currently, although there are recommendations on which surgical procedures to avoid and which are emergencies (such as fractures, vascular compromise, compartment syndrome, and infection), there are no clear recommendations on which procedures should be considered important enough to be performed in outpatient centers because of the long-term negative impact that a delayed procedure could pose to these patients. A rationale and data-driven process to assess and communicate which procedures should be allowed to be performed is essential. In order to both limit orthopaedic surgical procedures and best manage health-care resources during this public health emergency, detailed criteria are needed to indicate which patients are deemed necessary candidates for acute surgical treatment for elective procedures. In general, surgical procedures ought to be considered necessary for: Acute and/or disabling injuries to health-care workers, first responders, and members of the military and police and fire departments. Osseous fractures and/or irreducible joint dislocations. Wound/joint infections or postoperative wound dehiscence. Specifically, surgical necessity ought to be considered for pathologies that could lead to long-term disability and chronic pain if acute surgical management is delayed (Table I). TABLE I - Types of Acute Orthopaedic Injuries Recommended as “Surgically Necessary” for Elective-Urgent Procedures, Stratified by Joint* Joint Location Acute Injury Details Justification Shoulder Locked labral tears Unstable glenohumeral joints following dislocation Grade 4-5 acromioclavicular joint separations with severe pain or tenting of the skin Acute/severe rotator cuff tears Pectoralis major ruptures Irreducible joint dislocations, patients with high risk of recurrent instability/dislocation causing further injury, young patients with chondral injuries that are repairable, large tendon ruptures that are susceptible to retracting and becoming irreparable with delayed surgical treatment, any injury with neurovascular compromise Elbow Distal biceps tendon tears Unstable elbow subluxations or dislocations Locked osteochondral defects of the elbow Triceps tendon tears Young patients with chondral injuries that can be repaired, any patient who has high risk of compromised or unrepairable tendon rupture with delayed surgical treatment Hand/wrist Carpal subluxations or dislocations Unstable scaphoid fractures Acute tendon tears Unstable wrist/carpal or phalangeal subluxations or dislocations Unstable scaphoid fractures that cannot be treated in a cast/conservatively, patients with high risk of recurrent instability of carpal, metacarpal, or phalangeal dislocations/subluxations that would lead to loss of function Foot/ankle Dislodged or unstable osteochondritis dissecans lesions Ankle dislocation or subluxation Syndesmosis disruption Jones fracture Acute tendon tears (e.g., Achilles) Acute unstable ligament tears Young patients with chondral injuries that are repairable, irreducible joint dislocations, severe/acute unstable ankle sprains with low likelihood of success with nonoperative management, fractures susceptible to nonunion with conservative treatment Knee Locked knees Bucket-handle tears of the menisci Young patients with vulnerable/repairable meniscal tears Meniscal root tears Acute osteochondral fractures Lingering knee instability due to a patellar dislocation or multi-ligament knee injury Acute tendon ruptures (patellar or quadriceps) Dislodged osteochondritis dissecans lesions Anterior/posterior cruciate ligament osseous avulsion fractures Manipulations after total knee replacement or ligament reconstructions Young patients with chondral injuries or acute meniscal tears that would lead to long-term decreased function, meniscal root tears at risk for cartilage wear progression, patients with bucket-handle meniscal tears, acute patellar dislocation with loose body/chondral fracture, knee dislocation, high risk of lower function or unrepairable tendon rupture with delayed surgical treatment, locked knee Hip Dislocated/unstable arthroplasties Hip subluxation or dislocation that is not reducible or is unstable post-reduction Acute proximal hamstring ruptures Acute disability due to a locked hip secondary to intra-articular loose body/bodies or an incarcerated labrum Irreducible hip subluxation/dislocation, high risk of unrepairable proximal hamstring rupture with delayed surgical treatment, locked hip Spine Neurological deficit or impending deficit that can be prevented by decompression Spinal instability such as fractures Cauda equina syndrome, loss of bladder/bowel control, persistent nerve compression, unstable vertebral fracture or spondylolisthesis that could lead to permanent dysfunction *Accordingly, this list is advisory in nature. It is not nor should be considered a medical directive or standard of care in and of itself. Because of the unforeseeable duration of the global quarantine, there is a need for continuous reassessment of the changing situation, which will influence the delivery of clinical care and, under major pressure, might restrict the indications and narrow the list of procedures considered surgically necessary. The decision must then be determined by the assessment of the real risk of proceeding or delaying, the availability of the facility and resources, the safety of the community in the particular region, and the regulations dictated by the local authorities. On the other hand, if the lockdown periods are extended, it might be prudent to consider fewer restrictions on elective procedures for low-risk individuals, which might allow those who are currently restricted from work or unemployed the opportunity to have and recover from these procedures and be better ready to reenter the work force when the governing bodies release restrictions. Not allowing these low-risk patients the opportunity to have a surgical procedure sooner would result in further delays in return to work. The current extraordinary circumstances warrant extraordinary efforts from all sectors involved in public health, including health administrators, medical professionals, and those in political offices. In order to best care for acutely injured patients during this pandemic, communication between health-care providers and government representatives is vitally important. Although the aforementioned list cannot be all-inclusive, nor serve as an exclusive evidence-based surgical recommendation, it does provide a general guideline that has practical implications that can serve to educate and legislate for acutely injured patients during the COVID-19 outbreak. History will judge us on how we respond to this crisis. Although it is essential to best utilize resources in the battle against COVID-19, it will also be important to ensure we delineate our responsibilities and avoid long-term disability, pain, and, if restrictions are substantially prolonged, further loss of employment and production by performing these important orthopaedic procedures in patients who cannot wait until the U.S. health-care system returns to normal operations.

Immediate and Long-Term Outcomes Following Orthopedic Procedures in Patients with Hemophilia: A Three-Decade Retrospective Review

Introduction: Patients with hemophilia are at risk for developing hemophilic arthropathy and may require orthopedic interventions at a young age. It is unclear whether the advent of routine prophylaxis and comprehensive care have reduced the rates of orthopedic procedures in the past several decades, and whether improved supportive care have reduced perioperative complications. Aim: In this study, we aim to evaluate the overall trends of orthopedic procedures, surgical outcomes and healthcare utilization in patients with hemophilia who underwent orthopedic procedure in the past three decades. Methods: In this single-centre retrospective cohort study, adult patients with all severities of hemophilia who underwent at least one orthopedic procedure from January 1990-August 2018 at the University of Alberta Hospital were included. Demographic data, hemophilia history, details of orthopedic procedure, perioperative factor administration were collected. Temporal changes in the types of procedures, factor utilization, and outcomes were examined using descriptive analyses. Results: In the last 3 decades, 17 patients underwent 50 orthopedic procedures in our institution, including total knee arthroplasty (TKA) (n=18), TKA revision (n=8), total hip arthroplasty (n=5), ankle fusion (n=5), synovectomy (n=4), and others (n=10). Median age at the time of the procedure was 41 years (interquartile range IQR 31-48), and median BMI was 25 (IQR 22-39) (Table 1). Fourteen patients have hemophilia A and 3 have hemophilia B, including severe hemophilia in 13 (76%). Four patients (24%) have active inhibitors at the time of surgery. Ten (59%) patients had active hepatitis C infection at the time of surgery, whereas none had HIV infection. There is a reduction in the number of orthopedic surgeries performed over time (Table 2). There was a significant reduction in the length of stay from 1990-2000 to 2001-2018 (median 20 days vs 6 days, P <0.001). Overall perioperative coagulation factor concentrates were prescribed for a median of 10 days (IQR 7-20), whereas active inhibitor patients received bypassing agent coverage for a longer duration (median 17 days, IQR 10-21). There was a significant reduction in the perioperative factor VIII utilization over time (P=0.02), and a similar trend in factor IX utilization (Table 2). Tranexamic acid was used perioperatively in the majority (68%) of procedures for a median of 10 days. Pharmacologic thromboprophylaxis was prescribed in 15 (30%) procedures for a median of 8 days (IQR 7-13), intermittent pneumatic device was prescribed in 2, the remaining procedures had no documented thromboprophylaxis. Postoperative complications include major bleeding (n=2) and clinically relevant non-major bleeding (n=6), prosthetic joint infection (n=10), aseptic loosening requiring revision (n=2), poor wound healing complicated by skin necrosis (n=2), and deep vein thrombosis (n=1). The 10 infectious complications occurred in 6 patients, including early prosthetic joint infection <4 weeks in 6 cases, despite common use of prophylactic antibiotics in 92% of all cases. Pharmacological thromboprophylaxis was not associated with an increased risk of bleeding. There were no inhibitor development or arterial thromboses perioperatively. All complications occurred in surgeries performed prior to 2011. Conclusions: Over the past three decades, we observe a decline in the number of orthopedic procedures performed in patients with hemophilia, likely reflecting the impact of routine prophylaxis and changes in practice patterns. Orthopedic outcomes have improved over time, in conjunction with a reduction in healthcare utilization including shorter length of stay and reduced factor utilization. Disclosures Sun: Octapharma: Consultancy, Research Funding; Novo Nordisk: Consultancy.

Outcomes of Patients With Cirrhosis Undergoing Orthopedic Procedures: An Analysis of the Nationwide Inpatient Sample.

The population of patients with cirrhosis is growing and shifting toward a more elderly demographic and thus are at risk of developing orthopedic complications. There is lack of data on safety of orthopedic procedures in this population. We performed an analysis of the Nationwide Inpatient Sample from 2005 to 2011 for patients undergoing hip arthroplasty, knee arthroplasty, and spinal laminectomy/fusion, stratified by presence of cirrhosis. The primary endpoint was in-hospital mortality and secondary endpoints included length of stay (LOS) and costs. There were 693,610 inpatient stays for orthopedic procedures conducted during the study period, with 3014 (0.43%) patients coded as having cirrhosis. Patients with cirrhosis had a lower median age (62 vs. 66 y; P<0.001) and were more likely to be male (52.3% vs. 41.1%; P<0.001). The inpatient mortality rate was significantly higher in patients with cirrhosis (2.4% vs. 0.4%; P<0.001) as was median LOS (4 vs. 3 d; P<0.001) and mean costs ($19,321 vs. $18,833; P<0.001). Patients with decompensated cirrhosis (vs. compensated cirrhosis) had significantly higher inpatient mortality rates (5.8% vs. 1.1%; P<0.001) with higher LOS and costs (P<0.001). On multivariable analysis, cirrhosis was associated with an increased risk of mortality (odds ratio, 4.22; 95% confidence interval, 2.92-6.10). Hospital cirrhosis volume was inversely associated with mortality, while hospital orthopedic procedure volumes had an inconsistent impact on outcomes. Inpatient orthopedic procedures in patients with cirrhosis result in high postoperative mortality, LOS, and costs. Careful patient selection is warranted to optimize cirrhosis patient postoperative outcomes.

166 Musculoskeletal complications and orthopaedic procedures in patients with X-linked hypophosphataemic rickets

166 Musculoskeletal complications and orthopaedic procedures in patients with X-linked hypophosphataemic rickets

Incidence and Predictive Factors for Orthopedic Surgery in Patients with Psoriatic Arthritis.

To investigate the incidence of orthopedic procedures in patients with psoriatic arthritis (PsA), and how patient characteristics, time of diagnosis, and treatment affect the need for surgery. We reviewed the medical history of 1432 patients with possible PsA at Haukeland University Hospital in Bergen, Norway. There were 590 patients (mean age 49 yrs, 52% women) who had sufficient journal information and a confirmed diagnosis of PsA, and who were included in the present study. Relevant orthopedic procedures were obtained from the hospital's administrative patient records. Survival analyses were completed to evaluate the effect of different factors such as year of diagnosis, age, sex, radiographic changes, disease activity, and treatment, on the risk of surgery. There were 171 procedures (25% synovectomies, 15% arthrodesis, and 53% prostheses) performed on 117 patients. These factors all increased the risk of surgery: female sex [relative risk (RR) 1.9, p = 0.001], age ≥ 70 years at diagnosis (RR 2.4, p = 0.001), arthritis in initial radiographs (RR 2.2, p = 0.006), and maximum erythrocyte sedimentation rate 30-59 mm/h (RR 1.6, p = 0.026). Time period of diagnosis had no effect on the outcome. In a subanalysis of surgery exclusive of hip and knee arthroplasty, diagnosis in earlier years (1954-1985 vs 1999-2011) was a risk factor (RR 2.1, p = 0.042). Antirheumatic treatment changed significantly over time. There were 20% of patients with PsA who needed surgery. We found that the prognosis of patients with PsA did not change regarding the risk of orthopedic surgery, despite the change in treatment. A possible explanation is the increase in large joint replacements in the general population.

European Guidelines on perioperative venous thromboembolism prophylaxis: Executive summary.

This article is part of the European guidelines on perioperative venous thromboembolism prophylaxis. For details concerning background, methods and members of the ESA VTE Guidelines Task Force, please, refer to: Samama CM, Afshari A, for the ESA VTE Guidelines Task Force. European guidelines on perioperative venous thromboembolism prophylaxis. Eur J Anaesthesiol 2018; 35:73–76. Introduction The current Executive Summary includes all the recommendations from the 12 chapters of the European guidelines on perioperative venous thromboembolism (VTE) prophylaxis.1–12 The objective is to allow the reader to examine the guidelines rapidly and globally. The rationale of each chapter and relevant references can be found in each separate article. Surgery in the obese patient Bariatric surgery Laparoscopic bariatric procedures for obese patients have a lower risk of VTE than open procedures.1 We suggest using only anti coagulants or intermittent pneumatic compression (IPC) for obese patients with a low risk of VTE during and after bariatric procedures (Grade 2C). We recommend using anti coagulants and IPC together for obese patients with a high risk of VTE (age >55 years, BMI > 55 kg. m−2, history of VTE, venous disease, sleep apnoea, hypercoagulability and pulmonary hypertension) during and after bariatric procedures (Grade 1C). We recommend the use of low molecular weight heparin (LMWH) over low-dose unfractionated heparin (LDUH) (Grade 1C). We suggest a dose of LMWH (3000 to 4000 anti-Xa IU every 12 h subcutaneously) depending on BMI as acceptable for obese patients with a lower risk of VTE (Grade 2B). We suggest the use of a higher dose of LMWH (4000 to 6000 anti-Xa IU every 12 h subcutaneously) as acceptable for obese patients with a higher risk of VTE (Grade 2B). We recommend extended prophylaxis for patients with a high risk of VTE during the post-discharge period for 10 to 15 days (Grade 1C). Non-bariatric surgery We suggest that in surgery with an indication for VTE prophylaxis, a higher prophylactic dose of LMWH (3000 to 4000 anti-Xa IU every 12 h subcutaneously) should be considered for obese patients with a BMI more than 40 kg m−2 undergoing non-bariatric surgery (Grade 2C). For additional and general recommendations, we refer to the section on ‘VTE prophylaxis of obese patients in bariatric surgery’.1 Surgery during pregnancy and the immediate post-partum period Non-obstetric surgery during pregnancy We recommend thromboprophylaxis following surgery during pregnancy or the post-partum period, when they imply, as a consequence, bed-rest, until full mobility is recovered (Grade 1C).2 We suggest that thromboprophylaxis should be used in cases of perioperative infection during pregnancy or the postpartum period (Grade 2C). Caesarean section Thromboprophylaxis is recommended after caesarean section in all cases, except elective caesarean section in low-risk patients (Grade 1C), but there is no clear consensus on the definition of this population. The duration of thromboprophylaxis following caesarean section should be at least 6 weeks for high-risk patients, and at least 7 days for other patients requiring anticoagulation (Grade 1C). Surgery in the elderly Age over 70 years is a risk factor for postoperative VTE (Grade B).3 In elderly patients, we suggest identification of comorbidities increasing the risk for VTE (e.g. congestive heart failure, pulmonary circulation disorders, renal failure, lymphoma, metastatic cancer, obesity, arthritis, post-menopausal oestrogen therapy), and correction if present (e.g. anaemia, coagulopathy) (Grade 2C). We suggest against bilateral knee replacement in elderly and frail patients (Grade 2C). We suggest timing and dosing of pharmacological VTE prophylaxis as in the non-aged population (Grade 2C). In elderly patients with renal failure, low-dose unfractionated heparin (UFH) may be used or weight-adjusted dosing of LMWH (Grade 2C). In the elderly, we recommend careful prescription of postoperative VTE prophylaxis and early postoperative mobilisation (Grade 1C). We recommend multi-faceted interventions for VTE prophylaxis in elderly and frail patients, including pneumatic compression devices, LMWH [and/or direct oral anticoagulants (DOACs) after knee or hip replacement] (Grade 1C). Day surgery and fast-track surgery We recommend that all patients undergoing an ambulatory/fast-track protocol should be assessed for the VTE risk of the procedure and for any personal/additional VTE risk (Grade 1B).4 For patients undergoing a low-risk procedure, without additional risk according to the Caprini score, we recommend general measures of thromboprophylaxis (including early ambulation and optimal hydration) over other specific measures (mechanical or pharmacological) (Grade 1B). For patients undergoing a low-risk procedure with additional risk factors, we recommend general measures of thromboprophylaxis (e.g. early ambulation and optimal hydration) (Grade 1B). We suggest assessing pharmacological prophylaxis with LMWH over other drugs (Grade 2B). We suggest the use of specific mechanical measures (IPC devices) in patients with an increased bleeding risk (Grade 2C). For patients undergoing a high-risk procedure without additional risk factors, we recommend general measures of thromboprophylaxis (e.g. early ambulation, and optimal hydration) (Grade 1B). We suggest the administration of pharmacological prophylaxis with LMWH over other drugs (Grade 2B). We suggest assessing specific mechanical measures (IPC) in patients with an increased bleeding risk (Grade 2C). For patients undergoing a high-risk procedure with additional risk factors, we recommend general measures of thromboprophylaxis (e.g. early ambulation and optimal hydration) and pharmacological prophylaxis with LMWH over other drugs (Grade 1B), or specific mechanical measures (IPC) in patients with an increased bleeding risk (Grade 2C). We suggest the use of aspirin for VTE prevention after total hip arthroplasty, total knee arthroplasty and hip fracture surgery (high-risk orthopaedic procedures) in patients without high VTE risk (Grade 2C). We suggest the use of aspirin for VTE prevention after low-risk orthopaedic procedures in patients with high VTE risk, or other high-risk orthopaedic procedures (e.g. knee arthroscopy) in patients without high VTE risk (Grade 2C). We recommend no pharmacological VTE prevention after low-risk orthopaedic procedures in patients without high VTE risk (Grade 1C). For pharmacological prophylaxis, we recommend a minimum of 7 days’ duration of treatment over protocols lasting 3 days or single-dose protocols (Grade 1B), although in selected cases of fast-track surgery, thromboprophylaxis only during hospitalisation could be an option (Grade 2C). We recommend extending the duration of thromboprophylaxis for up to 4 weeks in specific cases of high-risk procedures, according to general rules (Grade 2B). When the choice of thromboprophylaxis is a LMWH, the first dose could be administrated before surgery (about 12 h before the beginning of the procedure) or after surgery (optimal time from 6 to 8 h after the end of the procedure) (Grade 2C). In case of planned neuraxial anaesthesia for the procedure, postoperative administration seems to be the preferred option (Grade 2C). Intensive care In critically ill patients, we recommend against the routine use of compression duplex ultrasound screening of deep vein thrombosis (DVT) (Grade 1B).5 We recommend an institution-wide protocol for the prevention of VTE that includes the use of mechanical thromboprophylaxis, that is IPC (Grade 1B). For critically ill patients, we recommend using thromboprophylaxis with LMWH or LDUH (Grade 1B), and we recommend LMWH over LDUH (Grade 1B). For VTE prophylaxis in critically ill patients with severe renal insufficiency, we suggest the use of LDUH (Grade 2C), dalteparin (Grade 2B) or reduced doses of enoxaparin (Grade 2C). Monitoring of anti-Xa activity may be considered when LMWH is used in these patients (Grade 2C). The use of pharmacological prophylaxis in patients with severe liver dysfunction should be carefully balanced against the risk of bleeding. If a treatment is administered, the use of LDUH or LMWH is suggested (Grade 2C). We suggest no prophylaxis or the use of IPC in patients with a platelet count less than 50 ×109 l-1and a high-risk of bleeding (Grade 2C). For critically ill patients, we recommend against the routine use of inferior vena cava (IVC) filters for the primary prevention of VTE (Grade 1C). We suggest the use of IVC filters in patients who can neither receive pharmacological prophylaxis nor IPC (Grade 2C). In critically ill patients with suspected or confirmed diagnosis of heparin-induced thrombocytopaenia (HIT), all forms of heparin must be discontinued (Grade 1B). In these patients, immediate anticoagulation with a non-heparin anticoagulant rather than discontinuation of heparin alone is recommended unless there is a strong contra-indication to anticoagulation (Grade 1C). The selection of non-heparin anticoagulants should be based on patient characteristics: argatroban is the first choice in case of renal insufficiency, and bivalirudin in patients undergoing or after cardiac surgery (Grade 2C). The use of fondaparinux can also be considered in these patients (Grade 2C). Cardiovascular and thoracic surgery Cardiac and vascular surgery In the absence of risk factors, we suggest considering the risk of VTE as moderate in patients undergoing coronary artery bypass graft and bioprosthetic aortic valve implantation surgery (Grade 2C). If the risk of bleeding is to be considered high, we suggest the use of mechanical prophylaxis using IPC (Grade 2C).6 The presence of one or more risk factors (age above 70 years, transfusion of more than four units of red blood cell concentrates/fresh frozen plasma/cryoprecipitate/fibrinogen concentrate, mechanical ventilation more than 24 h, postoperative complication (e.g. acute kidney injury, infection/sepsis, neurological complication) should place the cardiac population at high risk for VTE. In this context, we suggest the use of pharmacologic prophylaxis as soon as satisfactory haemostasis has been achieved, in addition to IPC (Grade 2C). Patients undergoing other valve surgery and those with atrial fibrillation should be considered a specific entity at high risk of VTE, as they will mostly require postoperative therapeutic medical ‘bridging’ prior to long-term anticoagulation. Patients undergoing peripheral vascular surgery are considered to have a low risk of VTE and a low risk of bleeding. Stringent medical prophylaxis appears to reduce the event rate significantly. In this population, we suggest medical therapy (Grade 2C). In patients undergoing abdominal aortic aneurysm repair, particularly when an open surgical approach is used, the risk for VTE is higher, with a high bleeding risk. These patients should be considered as having a moderate risk. Patients with additional risk factors, including BMI at least 30 kg m−2, preoperative dyspnoea, chronic steroid usage, ruptured aneurysm, open surgery, operative duration at least 5 h, transfusion of at least 5 U, postoperative mechanical ventilation more than 48 h, postoperative complication (acute kidney injury, infection/sepsis) and re-operation, should be considered as moderate to high risk. In this context, we suggest the use of pharmacological prophylaxis as soon as satisfactory haemostasis is achieved (Grade 2C). We suggest that low-dose aspirin could be used to decrease the incidence of VTE in cardiac and vascular patients, but should not be considered as the sole agent in high-risk patients. (Grade 2C). UFH is associated with the highest risk of developing the prothrombotic condition of HIT. Therefore, in an attempt to minimise the risk of HIT, we suggest that UFH should be used as briefly as possible and replaced by LMWH as soon as the bleeding risk decreases (Grade 2C). In patients with severely impaired renal function (Cockroft and Gault clearance <30 ml min−1) and a high risk of haemorrhagic complications, we suggest close monitoring of the administration of therapeutic UFH and LMWH and adaptation of the dosage (Grade 2C). Thoracic surgery Based on the current literature, patients undergoing thoracic surgery in the absence of cancer could be considered at low risk of VTE. However, as the vast majority of patients undergoing thoracic surgery have a diagnosis of primary or metastatic cancer, they should be considered at high risk for VTE with an equally high bleeding risk. In the absence of evidence regarding patients undergoing minimally invasive procedures, the same risk stratification should be applied as described above. In low-risk patients, we suggest the use of mechanical prophylaxis using IPC (Grade 2C). In high-risk patients, we suggest the use of pharmacological prophylaxis in addition to IPC (Grade 2B). Neurosurgery Patients undergoing craniotomy We recommend that if IPC is used, it should be applied before the surgical procedure or on admission, used continuously (except when the patient is actually walking) and monitored frequently to optimise compliance (Grade 1C).7 If LMWH or LDUH are used, we suggest delayed initiation until at least 24 h after surgery. (Grade 2C). In craniotomy patients at particularly high risk of VTE (additional risk factors including malignancy, motor impairment, prolonged operative time), we suggest considering the initiation of mechanical thromboprophylaxis with IPC preoperatively with addition of LMWH or LDUH postoperatively when the risk of bleeding is presumed to be decreased (Grade 2C). We suggest that thromboprophylaxis should be continued until discharge (Grade 2C). Patients with non-traumatic intra cranial haemorrhage We suggest thromboprophylaxis with IPC (Grade 2C). We recommend the application of IPC on admission, used continuously (except when the patient is actually walking) and monitored frequently to optimise compliance (Grade 1C). For patients who have had non-traumatic intracranial haemorrhage, we suggest giving consideration to commencement of LMWH or LDUH when the risk of bleeding is presumed to be low (Grade 2C). We suggest continuing thromboprophylaxis until full mobilisation of the patient (Grade 2C). Spinal surgery For patients with no additional risk factors, we suggest no active thromboprophylaxis intervention apart from early mobilisation (Grade 2C). For patients undergoing spinal surgery with additional risk factors (limited mobility, active cancer, complex surgical procedure), we recommend starting mechanical thromboprophylaxis with IPC preoperatively (Grade 1C), and we suggest the addition of LMWH postoperatively when the risk of bleeding is presumed to be decreased (Grade 2C). If LMWH is used, we recommend delayed initiation at least until 24 h after surgery and only when haemostasis occurs (Grade 1C). We suggest continued thromboprophylaxis until discharge in high-risk patients (Grade 2C). In patients with spinal cord injury or significant motor impairment, we suggest extending the thromboprophylaxis into the rehabilitation phase of hospital care (Grade 2C). Chronic treatments with anti-platelet agents In patients receiving anti-platelet agents (APA) chronically, we recommend thromboprophylaxis in case of moderate/high VTE risk, whilst assessing the risk of perioperative bleeding (Grade 1B).8 In patients receiving APA chronically, if the risk of VTE outweighs the risk of bleeding, we suggest pharmacological (anticoagulant) prophylaxis (LMWH, DOAC, fondaparinux, depending on the indication) (Grade 2C). In patients treated with dual anti-platelet therapy (recent coronary stent implantation) undergoing a procedure associated with a high risk of VTE, we suggest resuming both APA shortly after the procedure, prioritising over pharmacological VTE prevention (Grade 2C). If an anti-coagulant is associated with an APA, we suggest the administration of the lowest approved dose (Grade 2C). If the risk of bleeding of a combination of an APA and an anticoagulant outweighs the risk of VTE, we suggest considering IPC over anticoagulant prophylaxis, without discontinuing the APA (Grade 2C). Patients in whom neuraxial anaesthesia is planned, although the administration of aspirin alone does not increase the incidence of spinal haematoma, a higher rate of complications could appear if pharmacological thromboprophylaxis is administered concurrently. In these patients, postoperative thromboprophylaxis initiation should be suggested (Grade 2C). After surgery, the first dose of aspirin should be given as soon as possible, once haemostasis is considered adequate (in general, the day after surgery) (Grade 2B). In the case of clopidogrel, the main recommendation is to give the drug without any loading dose between 24 and 48 h after surgery (Grade 2C). Monitoring for clinical signs of bleeding or unexplained anaemia is recommended during concomitant administration of an anticoagulant for thromboprophylaxis (LMWH, UFH, fondaparinux, warfarin or any other) and an APA throughout the postoperative period (Grade 1C). Non-steroidal anti-inflammatory drugs should be avoided in patients treated with APA (Grade 2C). Patients with pre-existing coagulation disorders and after severe perioperative bleeding In patients with inherited bleeding disorders undergoing surgery, we recommend assessment of individual risk for VTE, taking into account the nature of the surgery and anaesthetic, type and severity of haemophilia, age, BMI, history of thrombosis and the presence of malignancy and other high-risk comorbidities. VTE risk should be balanced against the increased bleeding risk associated with anticoagulant use in patients with haemophilia (Grade 1C).9 For the perioperative management of patients with inherited bleeding disorders, we suggest liaison with haematologists to guide treatment (Grade 2C). We suggest that if factor replacement therapy is required for perioperative haemostasis, excess use should be avoided and factor levels monitored carefully (Grade 2C). In patients with inherited bleeding disorders undergoing major surgery, we suggest mechanical thromboprophylaxis, (Grade 2C), especially in factor VII deficiency (Grade 1C). In patients with inherited bleeding disorders undergoing major surgery, we recommend against routine postoperative use of pharmacological thromboprophylaxis, especially for patients with haemophilia A or B (Grade 1B). If the balance of risks favours pharmacological thromboprophylaxis, we suggest that LMWH should be administered as for patients without haemophilia undergoing the same surgery, and factor VIII/IX levels should be maintained at 0.6 to 1.0 IU ml−1 (Grade 2C). In haemophilia patients with inhibitors, we suggest against the use of pharmacological thromboprophylaxis (Grade 2C). We recommend that patients with haemophilia who require perioperative factor concentrate are monitored with daily factor levels for the first 3 to 5 days to guide treatment and to avoid wide fluctuations in factor levels (Grade 1C). We recommend that, for major surgery, factor levels of 0.8 to 1.0 IU ml−1 should be aimed for and not be allowed to fall below 0.5 IU ml−1 or rise above 1.5 IU ml−1 in the postoperative period (Grade 1B). In general, we recommend against routine thrombophilia screening for patients with haemophilia undergoing surgery (Grade 1C). We recommend that patients treated with factor concentrate in the perioperative and postoperative period should have both factor VIII and von Willebrand factor levels monitored to avoid an excessive rise in factor levels and accumulation of factor VIII. We recommend checking levels every 12 h for the first 24 h after major surgery, and daily thereafter (Grade 1B). We recommend that the use of factor concentrate with the highest ratio between vWF : RCo and factor VIII : C should be considered to minimise the risk of factor VIII accumulation (Grade 1C). We recommend that use of factor XI concentrate is kept to a minimum to avoid increasing the thrombotic risk (Grade 1C). We recommend that all patients receiving factor XI concentrate have mechanical thromboprophylactic measures (Grade 1C) and suggest that they are considered for pharmacological thromboprophylaxis (Grade 2C). We suggest that tranexamic acid alone is useful for patients with mild factor XI deficiency but should not be given as haemostatic prophylaxis to patients receiving factor XI concentrate (Grade 2C). In patients with factor VII deficiency, we suggest that they are considered for pharmacological thromboprophylaxis, if they have associated risk factors (Grade 2C). We suggest that for major surgery, fibrinogen levels should be closely monitored aiming to maintain levels 1 to 1.5 g l−1 for 10 to 14 days postoperatively (Grade 2C). Perioperative management may require simultaneous use of fibrinogen concentrate and LMWH, depending on the clinical phenotype (Grade 2C). Glomerular filtration rate should be assessed before any direct oral anticoagulant (DOAC) is initiated and again, at least once yearly or more frequently as needed, such as postoperatively before the resumption of therapeutic DOAC administration, when it is suspected that renal function could decline or deteriorate (Grade 1C). The use of the Cockroft–Gault method to evaluate renal function of patients with DOAC is suggested (Grade 2C). We suggest that anti-Xa levels may be measured in cases of severe bleeding in patients with renal impairment receiving LMWH (Grade 1C). Clinical exclusion of signs of postoperative bleeding is more relevant for postponing the commencement of VTE prophylaxis rather than relying on any specific laboratory tests (Grade 2C). We suggest against the systematic use of standard laboratory tests to exclude persistence of acquired perioperative coagulopathy before VTE prophylaxis (Grade 2C). Reduced dosages of LMWHs may be used relatively safely during transient severe (<50 × 109 l−1) thrombocytopaenia (Grade 2C). Monitoring anti-Xa level may be used to adjust the doses of LMWH in patients with moderate or severe thrombocytopaenia (Grade 2C). In cancer patients or patients with haematological disorders and mild thrombocytopaenia (platelet count >80 × 109 l−1), pharmacological prophylaxis may be used; if the platelet count is below 80 × 109 l−1, pharmacological prophylaxis may only be considered on a case-by-case basis and careful monitoring is recommended (Grade 2C). Patients with a high thrombotic risk (e.g. mechanical heart valves) may benefit from resuming warfarin therapy despite ongoing risk for recurrent gastrointestinal bleeding (Grade 2C). Patients with a HAS-BLED score lower than the CHADS2 score may benefit from earlier resumption (Grade 2C). The delay between major gastrointestinal bleeding and warfarin resumption should be at least 7 days (Grade 2C). We suggest International Normalised Ratio at the time of bleeding may also be considered to resume anticoagulation (Grade 2C). We suggest resuming anticoagulant therapy 12 h after removal of drains in cases of cardiac tamponade (Grade C). When the risk of bleeding diminishes, pharmacological VTE prophylaxis may be initiated depending on thrombotic risk factors (Grade 2C). We recommend that, when the risk of postoperative bleeding is higher than the risk of a thromboembolic event, full dose anticoagulation may be resumed 48 or 72 h after the procedure (Grade 2B). For patients at high risk for thromboembolism and with a high bleeding risk after surgery, we consider that administering a reduced dose of DOAC on the evening after surgery and on the following day (first postoperative day) after surgery is good practice (Grade 2B). Mechanical prophylaxis We recommend an institution-wide protocol for the prevention of VTE that integrates early ambulation, pharmacological thromboprophylaxis with anticoagulants and mechanical thromboprophylaxis (Grade IB).10 We recommend against the routine use of graduated compression stockings (GCS) without pharmacological thromboprophylaxis to prevent VTE in patients at intermediate and high risk (Grade IB). In patients with contra-indications to pharmacological thromboprophylaxis, we recommend the use of mechanical prophylaxis with IPC or GCS (Grade IB) and suggest the use of IPC over GCS (Grade 2B). In patients with contra-indications for pharmacological thromboprophylaxis who are not at high risk for VTE, we suggest no prophylaxis over GCS alone (Grade 2C). In patients receiving pharmacological thromboprophylaxis who are not at very high risk for VTE, we recommend against the routine use of mechanical thromboprophylaxis with GCS or IPC (Grade IB). We suggest combined mechanical and pharmacological prophylaxis in selected patients at very high risk for VTE (grade 2B). We suggest the use of IPC rather than GCS in selected high-risk patients in addition to pharmacological thromboprophylaxis (Grade 2B). Aspirin We recommend the use of aspirin as an option for VTE prevention after total hip arthroplasty, total knee arthroplasty and hip fracture surgery (Grade 1B).11 We suggest the use of aspirin for VTE prevention after total hip arthroplasty, total knee arthroplasty and hip fracture surgery (high-risk procedures) in patients without high VTE risk (Grade 2C). We suggest the use of aspirin for VTE prevention after low-risk orthopaedic procedures in patients with a high VTE risk or other high-risk orthopaedic procedures in patients without a high VTE risk (Grade 2C). We suggest the use aspirin for VTE prevention after total hip arthroplasty, total knee arthroplasty and hip fracture surgery in patients with an increased bleeding risk (Grade 2C). We suggest the use of aspirin for VTE prevention after total hip arthroplasty or total knee arthroplasty in a rapid recovery (fast-track) programme (Grade 2C). We recommend combining aspirin with IPC devices for VTE prevention after total hip arthroplasty, total knee arthroplasty and hip fracture surgery (Grade 1C). We recommend no pharmacological VTE prevention after low-risk orthopaedic procedure in patients without high VTE risk (e.g. knee arthroscopy) (Grade 1C). No recommendation can be made concerning dose and duration of aspirin treatment and patient selection. We do not recommend aspirin for thromboprophylaxis in general surgery (grade 1C). However, this type of prophylaxis could be interesting, especially in low-income countries (Grade 2C), and adequate large-scale trials with proper study designs should be carried out (Grade 1C). Inferior vena cava filters There is currently no clear evidence on the efficacy and safety of IVC filters (IVCF) in patients with a contra-indication for pharmacological and mechanical thromboprophylaxis undergoing high-thrombotic-risk surgery or procedures (Grade B).12 IVCF-associated complications often seem to outweigh a potential benefit (Grade B). We suggest considering temporary IVCF placement in patients at high VTE risk when pharmacological and mechanical thromboprophylaxis are fully contra-indicated (Grade 2C). We suggest considering temporary IVCF placement in patients with documented recent DVT, and with an absolute contra-indication for full anticoagulation and planned non-deferrable major surgery (Grade 2C). We suggest not systematically using IVCFs to prevent pulmonary embolism in the perioperative setting (Grade 2B). Acknowledgements related to this article Assistance with the guidelines: none. Financial support and sponsorship: expenses for two meetings of the VTE Task Force (Brussels and Berlin) were covered by the ESA for the ESA members. Conflicts of interest: research grants from Bayer and participation in advisory boards for Bayer, Boehringer Ingelheim, Daiichi Sankyo and BMS Pfizer (WA); consultancy work for Masimo, Medtronic and advisory boards for CSL Behring (AA); honoraria or consultation fees from Sanofi and Rovi (JL); honoraria for lecturing and travel reimbursement from CSL, Behring, Octapharma, Biotest and Shire (SK-L); honoraria from Aspen, Bayer, BMS, Daiichi, Medtronics, Pfizer, Portola, Roche, Sanofi, Siemens, Stago (CMS).

Red Wine Again? Commentary on an article by Erin L. Hsu, PhD, et al.: "Dioxin Exposure Impairs BMP-2-Mediated Spinal Fusion in a Rat Arthrodesis Model".

In their article, Hsu et al. describe how a specific constituent of cigarette smoke (dioxin) negatively influences bone morphogenetic protein (BMP)-2-mediated spinal fusion in rats. On the basis of their findings, they speculate on potential therapeutic options to improve fusion in spinal arthrodesis and bone-healing in other orthopaedic procedures in patients who continue smoking. Recently, a detailed overview of the adverse effects of smoking on the musculoskeletal system was published in The Journal of Bone & Joint Surgery 1 . These negative effects can be roughly summarized as (1) prothrombotic effects with, among others, an increased risk of osteonecrosis; (2) metabolic effects resulting in decreased bone strength with subsequent increased fracture risk; (3) anti-osteogenic effects with decreased healing capacity of fractures and osteotomy and arthrodesis sites; and (4) other general adverse effects increasing the risk of perioperative complications such as wound-healing disturbances. Although the specific effects of many toxic substances in cigarette smoke, such as carbon monoxide and nicotine, have been established in terms of tissue oxygenation, carcinogenesis, and addiction, it is unclear which toxic substances specifically cause adverse musculoskeletal effects. The role of nicotine, the main addictive substance, is especially controversial regarding the often-reported positive effect …

Orthopedic Procedures in Patients with Congenital Coagulation Disorders: Single Center Experience

Spontaneous intraarticular bleeds in congenital coagulation disorders result in early and extensive damage to the joints and periarticular structures. Total arthroplasty is the only effective method of treating these defects. Interim surgical procedures (arthroscopy, osteotomy, etc.) exist that can postpone arthroplasty, especially considering the fact that the condition affects young people. The aim of this paper is to discuss the range of trauma care and orthopedic procedures performed in patients with congenital coagulation disorders. Also presented are early results of joint arthroplasty in these patients. A total of 168 trauma care and orthopedic procedures were performed in patients with congenital coagulation disorders at the Clinical Department of Orthopedics and Traumatology of the Central Clinical Hospital of the Ministry of Interior in Warsaw in the years 2010-2013. Among them were total arthroplasties (79 arthroplasties of the knee, 30 of the hip, 3 of the ankle and 1 of the elbow), arthroscopies, filling bone cysts with grafts and trauma procedures. The HHS, KSS, AOFAS and MEPS scales were used to evaluate the respective clinical results of hip, knee, ankle and elbow arthroplasty procedures. A VAS was used to evaluate pain intensity. In knee arthroplasty patients, quality of life parameters were evaluated with the WOMAC index. In patients post hip arthroplasty, HHS scores increased by 50.22 points and VAS scores increased by 6.34 points. An increase of 116.41 points in KSS scores and 6.67 points in VAS scores was recorded in patients after knee arthroplasty. Also, WOMAC scores improved by 53.8 points after surgery. Evaluation of early results of ankle arthroplasty in the AOFAS scale showed a mean improvement of 35.5 points and a 5-point improvement in VAS scores. MEPS scores, used for evaluation of elbow arthroplasty results, improved from 15 to 70 points, with an improvement from 6 to 2 points in VAS scores. 1. Orthopedic procedures in patients with congenital coagulation disorders require thorough preparation of the patient and close cooperation between the orthopedic and hematological teams. 2. Early clinical outcomes are promising. 3. Decreased pain intensity, increased joint range of motion and improved quality of life post-surgery are observed.

Risk of Orthopedic Surgical Site Infections in Patients with Rheumatoid Arthritis Treated with Antitumor Necrosis Factor Alfa Therapy

Introduction. International guidelines recommend interruption of anti-TNF medications in the perioperative period, but there are no randomized trials to support such recommendation. Objectives. To study literature evidence assessing the risk of surgical site infections in orthopedic surgery patients with RA using anti-TNF drugs, compared to untreated patients or those using conventional DMARD. Methods. Systematic review of cohort studies is concerning surgical site infections in orthopedic procedures in patients with RA. Results. Three studies were selected. Only one was considered of high-quality, albeit with low statistical power. The review resulted in inconclusive data, since the best quality study showed no significant differences between groups, while others showed increased risk of infections in patients using anti-TNF medications. Conclusion. It is unclear whether patients with RA using anti-TNF medications are at increased risk of surgical site infections. Randomized controlled trials or new high quality observational studies are needed to clarify the issue.

Effect of triiodothyronine on the maxilla and masseter muscles of the rat stomatognathic system

The maxilla and masseter muscles are components of the stomatognathic system involved in chewing, which is frequently affected by physical forces such as gravity, and by dental, orthodontic and orthopedic procedures. Thyroid hormones (TH) are known to regulate the expression of genes that control bone mass and the oxidative properties of muscles; however, little is known about the effects of TH on the stomatognathic system. This study investigated this issue by evaluating: i) osteoprotegerin (OPG) and osteopontine (OPN) mRNA expression in the maxilla and ii) myoglobin (Mb) mRNA and protein expression, as well as fiber composition of the masseter. Male Wistar rats (~250 g) were divided into thyroidectomized (Tx) and sham-operated (SO) groups (N = 24/group) treated with T3 or saline (0.9%) for 15 days. Thyroidectomy increased OPG (~40%) and OPN (~75%) mRNA expression, while T3 treatment reduced OPG (~40%) and OPN (~75%) in Tx, and both (~50%) in SO rats. Masseter Mb mRNA expression and fiber type composition remained unchanged, despite the induction of hypo- and hyperthyroidism. However, Mb content was decreased in Tx rats even after T3 treatment. Since OPG and OPN are key proteins involved in the osteoclastogenesis inhibition and bone mineralization, respectively, and that Mb functions as a muscle store of O2 allowing muscles to be more resistant to fatigue, the present data indicate that TH also interfere with maxilla remodeling and the oxidative properties of the masseter, influencing the function of the stomatognathic system, which may require attention during dental, orthodontic and orthopedic procedures in patients with thyroid diseases.

Effect of triiodothyronine on the maxilla and masseter muscles of the rat stomatognathic system

The maxilla and masseter muscles are components of the stomatognathic system involved in chewing, which is frequently affected by physical forces such as gravity, and by dental, orthodontic and orthopedic procedures. Thyroid hormones (TH) are known to regulate the expression of genes that control bone mass and the oxidative properties of muscles; however, little is known about the effects of TH on the stomatognathic system. This study investigated this issue by evaluating: i) osteoprotegerin (OPG) and osteopontine (OPN) mRNA expression in the maxilla and ii) myoglobin (Mb) mRNA and protein expression, as well as fiber composition of the masseter. Male Wistar rats (~250 g) were divided into thyroidectomized (Tx) and sham-operated (SO) groups (N = 24/group) treated with T3 or saline (0.9%) for 15 days. Thyroidectomy increased OPG (~40%) and OPN (~75%) mRNA expression, while T3 treatment reduced OPG (~40%) and OPN (~75%) in Tx, and both (~50%) in SO rats. Masseter Mb mRNA expression and fiber type composition remained unchanged, despite the induction of hypo- and hyperthyroidism. However, Mb content was decreased in Tx rats even after T3 treatment. Since OPG and OPN are key proteins involved in the osteoclastogenesis inhibition and bone mineralization, respectively, and that Mb functions as a muscle store of O2 allowing muscles to be more resistant to fatigue, the present data indicate that TH also interfere with maxilla remodeling and the oxidative properties of the masseter, influencing the function of the stomatognathic system, which may require attention during dental, orthodontic and orthopedic procedures in patients with thyroid diseases.

Anaesthesia for total hip replacement in Gaucher's disease

EDITOR: Gaucher's disease, the most common lysosomal storage disorder, is an enzymatic defect with consequent accumulation of undegraded glucocerebroside in cells of the monocyte–macrophage system [1]. Most patients present with enlargement of the spleen and liver resulting in hypersplenism, with thrombocytopaenia generally more significant than anaemia. Skeletal involvement, particularly osteonecrosis of large joints and pathological fractures, invariably is the most significant cause of morbidity and decreased quality of life. In spite of enzyme replacement therapy, osteopaenia and osteonecrosis continue to be clinically important. The need for total hip replacement (THR), and subsequent revision, is relatively common in these patients at a relatively young age. With regard to the anaesthetic management for orthopaedic surgery in patients with Gaucher’s disease, only one case report appears in the literature of an adult with a sub-capital hip fracture who underwent subarachnoid anaesthesia [2]. We wish to report the anaesthetic management of all cases seen in our institution for THR or revision from 1990 to 2005. Patient characteristics and perioperative data are summarized from the clinical records and presented in Table 1.Table 1: Patients with Gaucher’s disease: patient characteristics and perioperative data expressed as mean ± SD (range) or number (%) of patients.There were 14 patients, 10 males and 4 females, who underwent THR. Five of these underwent a revision. Six patients (43%) were homozygous for the mild N370S (1226) mutation; eight patients (57%) had been splenectomized; and six patients (43%) had pulmonary hypertension at the time of surgery. Fifty-three percentage of patients underwent general anaesthesia. Five of the operations (21%) were performed with preoperative platelet counts <80 × 103 mm−3. Perioperative blood product transfusion was required in 68% of the operations. All patients with general anaesthesia were orally intubated utilizing direct laryngoscopy and ventilated with tidal volume 6–8 mL kg−1 and respiratory rate of 10–16 min−1. There were no difficulties in airway management. All patients were given preoperative antibiotic prophylaxis mainly with cefamezine; nonetheless, 37% experienced postoperative wound infections presenting significantly higher rates compared to similar patients in our institution (2%) and the rate reported in medical literature (0.3–2%) [3]. A wound infection was defined as one of the following: wound redness, excessive pain, tissue necrosis, local oedema, purulent discharge from the operation wound and maximal temperature >38.5 and/or white cell count >10 000. Other complications included one inadvertent spinal, one failed spinal and one patient with severe postoperative thrombocytopaenia (21 × 103 mm−3). Joint replacement for patients with Gaucher's disease is an important therapeutic intervention that dramatically reduces pain, improves functionality and increases quality of life. For patients with Gaucher's disease, the preoperative evaluation of haematological status is of primary concern. Many have very low platelet counts with or without abnormal platelet function [4]. Thrombocytopaenia may be sufficiently severe as to preclude regional anaesthesia [5]. In minor procedures (e.g. dental extractions) we have successfully used platelet transfusions immediately prior to and directly after surgery. Coagulation factor deficiencies are also common in this population and may occur independently of platelet abnormalities. A relatively large percentage (44%) in this cohort had pulmonary hypertension at surgery. This complication reflects disease severity but we have also posited a possible connection with enzyme replacement therapy [6], so that a history of enzyme treatment does not preclude abnormal lung function. In these most severe cases, regional anaesthesia may be preferred because of pulmonary hypertension. In conclusion, patients with Gaucher’s disease undergoing THR may have associated medical conditions such as pulmonary hypertension and coagulopathy that complicate their anaesthetic management and postoperative course. Further, they are at high risk for development of postoperative infection. We strongly recommend a multi-disciplinary approach that includes internal medicine, anaesthesiology and orthopaedic surgery when planning of major orthopaedic procedures in patients with Gaucher’s disease.

Elective orthopaedic surgery for inhibitor patients.

We report on a series of 108 elective orthopaedic surgical procedures. It includes 88 radiosynoviortheses and 20 major orthopaedic procedures, performed on 51 patients at nine centres worldwide. The average age of patients was 28.5 years (range 5-40 years), and the average follow-up time was 2 years (range 1-5 years). There were 82 good results, 15 fair and 11 poor. In the synoviorthesis group (41 patients, 88 synoviortheses) the average age was 14.3 years (range 5-40 years) and the average follow-up was 6.5 years (range 1-10 years). There were 66 good results, 14 fair and eight poor. There were no complications. In the group of major orthopaedic procedures, the average age of the 10 patients was 32.5 years (range 27-40 years), and the average follow-up was 2.3 years (range 1-5 years). There were 16 good results, one fair and three poor. Postoperative bleeding complications occurred in three of the 20 major orthopaedic procedures performed (15% complications rate). They occurred in three patients treated with insufficient doses of recombinant activated factor VII. Despite such complications, the study has shown that haemophilic patients with inhibitors requiring elective orthopaedic surgery (EOS) can undergo such procedures with a high expectation of success. In other words, EOS is now possible in haemophilic patients with inhibitors, leading to an improved quality of life for these patients. Thorough analysis of each case as part of a multidisciplinary team will allow us to perform elective orthopaedic procedures in patients with inhibitors.

Orthopaedic surgery in haemophilic patients with inhibitors: an overview.

Our experience and a review of the literature on inhibitors have shown that, with the availability of recombinant factor VIIa (rFVIIa), haemophilic patients with high inhibitor titres requiring elective orthopaedic surgery can undergo such surgery with a high expectation of success. The advent of rFVIIa has made major elective orthopaedic surgery possible in haemophilic patients with high-titre inhibitors, resulting in an improved quality of life. Recombinant FVIIa appears to be an efficient haemostatic product for surgery in patients suffering from haemophilia A and B with inhibitors. The series of major elective orthopaedic surgical procedures using rFVIIa (n=53) is the largest ever reported in haemophilic patients with inhibitors, despite the long-standing presence of other treatment modalities, such as high-dose human factor VIII (FVIII), porcine FVIII (n=8), and prothrombin complex concentrates/activated prothrombin complex concentrates (n=9). Thorough analysis of each case as part of a multidisciplinary team will allow us to perform elective orthopaedic procedures in patients with inhibitors.

Outcomes after selective dorsal rhizotomy for spastic cerebral palsy.

The purpose of this article was to review the published outcomes after selective dorsal rhizotomy (SDR) for treatment of spastic cerebral palsy. A literature search identified all articles related to outcomes after SDR. The outcomes were reviewed according to a paradigm developed by the National Center for Medical Rehabilitation Research (NCMRR). The quality of the evidence for each outcome was assessed using Sackett's criteria and the classification system developed by the Brain Trauma Foundation and the American Association of Neurological Surgeons. There is very strong evidence for benefits of SDR in the impairment domain of the NCMRR classification. SDR has been shown conclusively to decrease lower limb spasticity and increase lower limb range of motion. There is strong, but not as conclusive evidence that SDR has a positive impact in the functional limitation dimension, with improvements in motor function, and in particular the Gross Motor Function Assessment (GMFM). There is a moderate degree of certainty that SDR results in improvements in the disability dimension, as evidenced particularly by improvements in the Functional Independence Measure for Children (WeeFIM) and Pediatric Evaluation of Disability Inventory (PEDI). There is a moderate degree of certainty that SDR results in positive suprasegmental effects, especially related to upper limb function and cognition. There is weak evidence that SDR may reduce the need for orthopedic procedures in patients with spastic cerebral palsy, and the impact on hip subluxation relative to the natural history of this problem is unclear. This information could help to define the role of SDR in the management of the child with spastic cerebral palsy, in the light of alternative therapies, such as intrathecal baclofen and botulinum toxin, which have been introduced more recently. It also reveals the need for further studies, particularly dealing with quality of life and economic impact.