- Email: [email protected]
Regarding “acute arterial complications associated with total hip and knee arthroplasty”
JOURNAL OF VASCULAR SURGERY May 2004
1148 Letters to the Editor
Regarding “Acute arterial complications associated with total hip and knee arthroplasty” We read with great interest the article by Calligaro et al (J Vasc Surg 2003;38:1170-7) describing their experiences with acute arterial complications related to hip and knee arthroplasty. We find one major point of concern in their work. The authors stated that “patients did not receive routinely anticoagulation therapy” after urgent vascular surgery performed in those patients developing signs of acute arterial complications shortly after arthroplasty. Although the question of routine thromboprophylaxis after major orthopedic surgery has been raised before1 and is also an issue of debate in vascular surgery,2,3 current guidelines still recommend some form of prophylaxis to be used in such patients. Since in patients undergoing lower extremity arthroplasty, an intense activation of the clotting cascade4 is associated with venous stasis and endothelial injury caused by kinking of the femoral vein during intraoperative lower extremity manipulation, these patients are at high risk for venous thromboembolism.5 The use of a tourniquet during total knee arthroplasty is an additional risk factor. Subsequent vascular surgery can only heighten the risk for venous thromboembolism in such patients. Although thromboprophylaxis was not a focus of their work, the authors should have clearly stated on what grounds they chose to go against current guidelines and omit postoperative anticoagulation in such high-risk patients. It should also have been noted whether their patients received some other form of thromboprophylaxis (eg, intermittent pneumatic compression) and how early passive and active limb mobilization was begun. These are points crucial to any patient undergoing total hip or knee arthroplasty. Kresimir Oremus, MD Department of Orthopedic Surgery Clinical Hospital Center Zagreb Zagreb, Croatia Zrinka Safaric, MD Department of Anesthesiology and Intensive Care Medicine Dubrava University Hospital Zagreb, Croatia
REFERENCES 1. Salvati EA, Pellegrini VD, Hershey NE, Lotke PA, Murray DW, Potter H, et al. Recent advances in venous thromboembolic prophylaxis during and after total hip replacement. J Bone Joint Surg 2000;82:252-70. 2. Passman MA, Farber MA, Marston WA, Carlin RE, Owens LV, Burnham CB, et al. Prospective screening for postoperative deep venous thrombosis in patients undergoing infrainguinal revascularization. J Vasc Surg 2000;32:669-75. 3. Hollyoak M, Woodruff P, Muller M, Daunt N, Weir P. Deep venous thrombosis in postoperative vascular surgical patients: a frequent finding without prophylaxis. J Vasc Surg 2001;34:656-60. 4. Sharrock NE, Go G, Harpel PC, Ranawat CS, Sculco TP, Salvati EA. Thrombogenesis during total hip arthroplasty. Clin Orthop 1995;319: 16-27. 5. Turpie AG. Prevention of venous thrombosis after elective hip surgery. Orthopedics 1998;21:1275-81. doi:10.1016/j.jvs.2004.02.007
Reply We appreciate the inquiry of Drs Oremus and Safaric. We did not mean to imply that anticoagulation medications were not given at all postoperatively following acute limb revascularization after knee and hip surgery. We continued the routine postoperative anticoagulation protocol used by the orthopedic service. However, we did not add any additional or stronger anticoagulation medications such as a continuous heparin drip, which is occasionally administered after other thrombectomy or revascularization procedures. Keith D. Calligaro, MD Pennsylvania Hospital Philadelphia, Pa doi:10.1016/j.jvs.2004.02.008
1148 Letters to the Editor
Regarding “Acute arterial complications associated with total hip and knee arthroplasty” We read with great interest the article by Calligaro et al (J Vasc Surg 2003;38:1170-7) describing their experiences with acute arterial complications related to hip and knee arthroplasty. We find one major point of concern in their work. The authors stated that “patients did not receive routinely anticoagulation therapy” after urgent vascular surgery performed in those patients developing signs of acute arterial complications shortly after arthroplasty. Although the question of routine thromboprophylaxis after major orthopedic surgery has been raised before1 and is also an issue of debate in vascular surgery,2,3 current guidelines still recommend some form of prophylaxis to be used in such patients. Since in patients undergoing lower extremity arthroplasty, an intense activation of the clotting cascade4 is associated with venous stasis and endothelial injury caused by kinking of the femoral vein during intraoperative lower extremity manipulation, these patients are at high risk for venous thromboembolism.5 The use of a tourniquet during total knee arthroplasty is an additional risk factor. Subsequent vascular surgery can only heighten the risk for venous thromboembolism in such patients. Although thromboprophylaxis was not a focus of their work, the authors should have clearly stated on what grounds they chose to go against current guidelines and omit postoperative anticoagulation in such high-risk patients. It should also have been noted whether their patients received some other form of thromboprophylaxis (eg, intermittent pneumatic compression) and how early passive and active limb mobilization was begun. These are points crucial to any patient undergoing total hip or knee arthroplasty. Kresimir Oremus, MD Department of Orthopedic Surgery Clinical Hospital Center Zagreb Zagreb, Croatia Zrinka Safaric, MD Department of Anesthesiology and Intensive Care Medicine Dubrava University Hospital Zagreb, Croatia
REFERENCES 1. Salvati EA, Pellegrini VD, Hershey NE, Lotke PA, Murray DW, Potter H, et al. Recent advances in venous thromboembolic prophylaxis during and after total hip replacement. J Bone Joint Surg 2000;82:252-70. 2. Passman MA, Farber MA, Marston WA, Carlin RE, Owens LV, Burnham CB, et al. Prospective screening for postoperative deep venous thrombosis in patients undergoing infrainguinal revascularization. J Vasc Surg 2000;32:669-75. 3. Hollyoak M, Woodruff P, Muller M, Daunt N, Weir P. Deep venous thrombosis in postoperative vascular surgical patients: a frequent finding without prophylaxis. J Vasc Surg 2001;34:656-60. 4. Sharrock NE, Go G, Harpel PC, Ranawat CS, Sculco TP, Salvati EA. Thrombogenesis during total hip arthroplasty. Clin Orthop 1995;319: 16-27. 5. Turpie AG. Prevention of venous thrombosis after elective hip surgery. Orthopedics 1998;21:1275-81. doi:10.1016/j.jvs.2004.02.007
Reply We appreciate the inquiry of Drs Oremus and Safaric. We did not mean to imply that anticoagulation medications were not given at all postoperatively following acute limb revascularization after knee and hip surgery. We continued the routine postoperative anticoagulation protocol used by the orthopedic service. However, we did not add any additional or stronger anticoagulation medications such as a continuous heparin drip, which is occasionally administered after other thrombectomy or revascularization procedures. Keith D. Calligaro, MD Pennsylvania Hospital Philadelphia, Pa doi:10.1016/j.jvs.2004.02.008