Replacement Arthroplasty

Eikelboom JW, Karthikeyan G, Fagel N, Hirsh J. · Department of Medicine, McMaster University, Hamilton, ON, Canada. · Chest. · Pubmed #19201714 No free full text.

Abstract: The recently published American Association of Orthopedic Surgeons (AAOS) guidelines for the prevention of venous thromboembolism (VTE) in patients undergoing hip or knee surgery conflict with long-established and widely used American College of Chest Physicians (ACCP) guidelines. Both guidelines accepted that the most important goal of thromboprophylaxis in patients undergoing hip or knee replacement is to prevent pulmonary embolism (PE). The ACCP guidelines included asymptomatic (and symptomatic) deep vein thrombosis (DVT) detected by venography as a measure of the efficacy of thromboprophylaxis, whereas the AAOS rejected DVT as a valid outcome because the panelists considered the link between DVT and PE to be unproven. The AAOS position is inconsistent with evidence from imaging studies linking DVT with PE and from clinical studies demonstrating a parallel reduction of DVT and PE when antithrombotic agents are compared with placebo or untreated controls. The AAOS panel ignored the randomized data demonstrating that thromboprophylaxis reduces both DVT and PE, and many of their recommendations are based on expert opinion and lack a scientific basis. We recommend the ACCP guidelines because the methodology is explicit and rigorous and the treatment recommendations reflect all of the evidence from the randomized trials. Adoption of the ACCP guideline will ensure that patients undergoing hip and knee arthroplasty receive the best available therapies for prevention of VTE and reduce disability and death due to this common and potentially preventable condition.

Barrois B, Gouin F, Ribinik P, Revel M, Rannou F, Anonymous00213. · Service de MPR, centre hospitalier de Gonesse, 25, rue Pierre-de-Theilley, BP 30071, 95503 Gonesse cedex, France. · Ann Readapt Med Phys. · Pubmed #17850912 No free full text.

Abstract: OBJECTIVES: To develop clinical practice guidelines concerning the interest of post-operative rehabilitation in a physical medicine and functional rehabilitation (PMR) ward after total hip arthroplasty (THA). METHOD: The SOFMER (French Physical Medicine and Rehabilitation Society) methodology, associating a systematic literature review, collection of everyday clinical practice, and external review by a multidisciplinary expert panel, was used. Main outcomes were impairment, disability, medico-economic implications and postoperative complications. RESULTS: Post-operative rehabilitation in a PMR ward after THA is recommended for frail patients because of their functional status, and/or associated co-morbidities, and/or post-operative complications. For patients in whom sustained rehabilitation is not necessary, but who cannot return home, a stay in a non-specific (non-PMR) post-operative center could be recommended. Post-operative rehabilitation in a PMR ward after THA could reduce the length of stay in a surgical ward and increase the functional status of patients. The total cost of the different modalities of post-operative rehabilitation after THA needs evaluation. CONCLUSION: This study suggests a value of rehabilitation in a PMR ward after THA, but good methodological quality studies are needed to evaluate the cost/benefit ratio of rehabilitation in a PMR ward after THA in the French health care system.

Postel JM, Thoumie P, Missaoui B, Biau D, Ribinik P, Revel M, Rannou F, Anonymous00070. · Clinique Arago, 95, boulevard Arago, 75014 Paris, France. · Ann Readapt Med Phys. · Pubmed #17412445 No free full text.

Abstract: OBJECTIVE: To develop clinical practice guidelines concerning the use of continuous passive motion (CPM) compared with intermittent mobilization after total knee arthroplasty (TKA). METHOD: We used the SOFMER (French Physical Medicine and Rehabilitation Society) methodology, combining systematic literature review and collection of everyday clinical practice concerning postoperative rehabilitation techniques and external review by a multidisciplinary expert panel, to develop the guidelines. RESULTS: The literature contains no evidence of the advantages of CPM over other techniques of mobilization, although CPM could be adjuvant therapy used to accelerate short-term recovery. However, in France, CPM remains widely used after TKA, both in orthopedic surgery units and in physical medicine and rehabilitation services. CONCLUSION: Good methodological quality studies are needed to assess different CPM modalities and compare them to alternative intermittent mobilization techniques, particularly those with therapy starting from a flexed position.

Sidebottom AJ, Anonymous00025, Anonymous00026. · Maxillofacial Unit, Queens Medical Centre, Nottingham, UK. · Br J Oral Maxillofac Surg. · Pubmed #17223231 No free full text.

Abstract: BAOMS has requested that guidelines be formulated for the replacement of the temporomandibular joint (TMJ). This is an expensive and technique sensitive method of TMJ reconstruction and in the current climate warrants an agreed approach. The following document states the indications and contraindications for this technique as discussed and agreed amongst surgeons currently carrying out this procedure in the UK.

Colwell CW, Anonymous00376. · Shiley Center for Orthopaedic Research and Education at Scripps Clinic, La Jolla, California, USA. · Am J Orthop. · Pubmed #16846140 No free full text.

Abstract: More than 2 million people undergo major orthopedic surgery each year, and this rate is expected to continue rising as our population ages. Our patients are at particularly high risk for deep vein thrombosis (DVT) and pulmonary embolism. The latest guidelines from the American College of Chest Physicians recommend thromboprophylaxis for high-risk orthopedic surgery patients. Although specific recommendations vary by type of surgery, low-molecular-weight heparin, fondaparinux, warfarin, and sometimes low-dose unfractionated heparin are effective alone or with mechanical prophylaxis. Goals of treatment are to prevent proximal and distal DVT, pulmonary death, chronic pulmonary hypertension, and postthrombotic syndrome.

Maurer TB, Ochsner PE. · Interdisziplinäre Einheit Orthopädie - Infektiologie, Orthopädische Klinik, Kantonsspital, Rheinstrasse 26, CH-4410, Liestal. · Orthopade. · Pubmed #16835763 No free full text.

Abstract: The algorithm differentiates between several surgical treatment options depending on the duration of the infection, on the amount of soft tissue damage, on the stability of the implant and the type of micro-organism. If the symptoms of infection exist for less then 3 weeks, a radical debridement is indicated under the condition of a stable implant and good soft tissue conditions. A one-stage exchange is possible with satisfactory conditions of soft tissue and the absence of difficult-to-treat, resistant micro-organisms. In patients with sinustracts or compromised soft tissue, a two-stage exchange is necessary. The placement of a spacer combined with a short interval of 2-3 weeks until reimplantation is possible for easy-to-treat bacteria. For difficult-to-treat micro-organisms, an interval of 8 weeks without spacer until reimplantation is necessary. While stabilised by a fixateur extern, antimicrobial treatment is administered for the first 6 weeks. If the tissue specimens at reimplantation two weeks later do not show growth of bacteria or signs of acute inflammation, antimicrobial treatment can be discontinued. For all other above-mentioned treatment protocols, we administer antimicrobial treatment for a total of 6 months. We present the results of 40 consecutive infected total knee arthroplasties treated according to our algorithm, including a detailed presentation of the two-stage revision procedure.

Zochling J, van der Heijde D, Burgos-Vargas R, Collantes E, Davis JC, Dijkmans B, Dougados M, Géher P, Inman RD, Khan MA, Kvien TK, Leirisalo-Repo M, Olivieri I, Pavelka K, Sieper J, Stucki G, Sturrock RD, van der Linden S, Wendling D, Böhm H, van Royen BJ, Braun J, Anonymous00003, Anonymous00004. · Rheumazentrum-Ruhrgebiet, St Josefs-Krankenhaus, Landgrafenstr 15, 44652 Herne, Germany. · Ann Rheum Dis. · Pubmed #16126791 links to  free full text

Abstract: OBJECTIVE: To develop evidence based recommendations for the management of ankylosing spondylitis (AS) as a combined effort of the 'ASsessment in AS' international working group and the European League Against Rheumatism. METHODS: Each of the 22 participants was asked to contribute up to 15 propositions describing key clinical aspects of AS management. A Delphi process was used to select 10 final propositions. A systematic literature search was then performed to obtain scientific evidence for each proposition. Outcome data for efficacy, adverse effects, and cost effectiveness were abstracted. The effect size, relative risk, number needed to treat, and incremental cost effectiveness ratio were calculated. On the basis of the search results, 10 major recommendations for the management of AS were constructed. The strength of recommendation was assessed based on the strength of the literature evidence, risk-benefit trade-off, and clinical expertise. RESULTS: The final recommendations considered the use of non-steroidal anti-inflammatory drugs (NSAIDs) (conventional NSAIDs, coxibs, and co-prescription of gastroprotective agents), disease modifying antirheumatic drugs, treatments with biological agents, simple analgesics, local and systemic steroids, non-pharmacological treatment (including education, exercise, and physiotherapy), and surgical interventions. Three general recommendations were also included. Research evidence (categories I-IV) supported 11 interventions in the treatment of AS. Strength of recommendation varied, depending on the category of evidence and expert opinion. CONCLUSION: Ten key recommendations for the treatment of AS were developed and assessed using a combination of research based evidence and expert consensus. Regular updating will be carried out to keep abreast of new developments in the management of AS.

Anonymous00126. · No affiliation provided · Probl Tuberk Bolezn Legk. · Pubmed #15881970 No free full text.

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Zhang W, Doherty M, Arden N, Bannwarth B, Bijlsma J, Gunther KP, Hauselmann HJ, Herrero-Beaumont G, Jordan K, Kaklamanis P, Leeb B, Lequesne M, Lohmander S, Mazieres B, Martin-Mola E, Pavelka K, Pendleton A, Punzi L, Swoboda B, Varatojo R, Verbruggen G, Zimmermann-Gorska I, Dougados M, Anonymous00408. · Academic Rheumatology, University of Nottingham, UK. · Ann Rheum Dis. · Pubmed #15471891 links to  free full text

Abstract: OBJECTIVE: To develop evidence based recommendations for the management of hip osteoarthritis (OA). METHODS: The multidisciplinary guideline development group comprised 18 rheumatologists, 4 orthopaedic surgeons, and 1 epidemiologist, representing 14 European countries. Each participant contributed up to 10 propositions describing key clinical aspects of hip OA management. Ten final recommendations were agreed using a Delphi consensus approach. Medline, Embase, CINAHL, Cochrane Library, and HTA reports were searched systematically to obtain research evidence for each proposition. Where possible, outcome data for efficacy, adverse effects, and cost effectiveness were abstracted. Effect size, rate ratio, number needed to treat, and incremental cost effectiveness ratio were calculated. The quality of evidence was categorised according to the evidence hierarchy. The strength of recommendation was assessed using the traditional A-D grading scale and a visual analogue scale. RESULTS: Ten key treatment propositions were generated through three Delphi rounds. They included 21 interventions, such as paracetamol, NSAIDs, symptomatic slow acting disease modifying drugs, opioids, intra-articular steroids, non-pharmacological treatment, total hip replacement, osteotomy, and two general propositions. 461 studies were identified from the literature search for the proposed interventions of efficacy, side effects, and cost effectiveness. Research evidence supported 15 interventions in the treatment of hip OA. Evidence specific for the hip was strikingly lacking. Strength of recommendation varied according to category of research evidence and expert opinion. CONCLUSION: Ten key recommendations for the treatment of hip OA were developed based on research evidence and expert consensus. The effectiveness and cost effectiveness of these recommendations were evaluated and the strength of recommendation was scored.

Punzi L, Canesi B, Carrabba M, Cimmino MA, Frizziero L, Lapadula G, Arioli G, Chevallard M, Cozzi F, Cricelli C, Fioravanti A, Giannini S, Iannone F, Leardini G, Mannoni A, Meliconi R, Modena V, Molfetta L, Monteleone V, Nava T, Parente L, Paresce E, Patrignani P, Ramonda R, Salaffi F, Spadaro A, Marcolongo R. · Cattedra ed UOC di Reumatologia, Università di Padova, Padova. · Reumatismo. · Pubmed #15470525 links to  free full text

Abstract: The recommendations for the management of osteoarthritis (OA) of the knee firstly proposed by the EULAR in 2000, have been updated in 2003. One of the most important objectives of the expert charged to provide these recommendations was their dissemination. Thus, the information generated may be used by each individual country to produce their own set of management guidelines and algorithms for treatment in primary care. The Italian Society of Rheumatology (SIR) and the Italian League against Rheumatism (LIMAR) have organised a Consensus on the EULAR recommendations 2003 with the aim to analyse their acceptability and applicability according to our own experience and local situations in the Italy. The results of this Consensus have demonstrated that a large majority of the EULAR recommendations are endorsed by the Italian experts. Furthermore, the final document of the Italian Consensus clearly indicated the need that specialists involved in the management of knee OA strongly encourage the dissemination of the EULAR 2003 recommendations also in Italy.

Eikelboom JW, Mazzarol A, Quinlan DJ, Beaver R, Williamson J, Yi Q, Hankey GJ, Anonymous00171. · Department of Hematology, Royal Perth Hospital, Wellington Street, Perth, WA, 6001. Australia. · Haematologica. · Pubmed #15136222 links to  free full text

Abstract: BACKGROUND AND OBJECTIVES: Evidence-based international guidelines recommend that all patients undergoing elective hip or knee arthroplasty receive thromboprophylaxis with low-molecular-weight heparin or adjusted-dose warfarin. Our objective was to determine what proportion of patients undergoing elective hip or knee arthroplasty actually receive recommended thromboprophylaxis according to international guidelines. DESIGN AND METHODS: We performed a prospective cohort study of 396 consecutive patients undergoing elective hip or knee arthroplasty between 1 May and 30 October, 2002. We collected baseline data, surgical and anesthetic details and recorded use of thromboprophylaxis and episodes of venous thromboembolism that occurred within 3 months of surgery. RESULTS: The mean age of the patients was 69.4 years (SD 11.5 years), and 62.2% (95% CI: 57.3 to 66.9%) were female. Hip arthroplasty was performed in 39.4% (34.6 to 44.2%) and knee arthroplasty in 57.1% (52.2 to 61.9%). Recommended thromboprophylaxis with low-molecular-weight heparin or warfarin was administered to 51.5% (46.6 to 56.4%). Objectively diagnosed venous thromboembolism occurred in 5.3% (3.3 to 8.0%) of patients; 3.5% (1.9 to 5.9%) of events occurred during hospitalization and 1.8% (0.7 to 3.6%) occurred following discharge from hospital. There was no significant reduction in the incidence of venous thromboembolism among patients treated with recommended thromboprophylaxis compared with those who did not but this is not a randomized comparison and is potentially confounded by the indication for treatment. INTERPRETATION AND CONCLUSIONS: Current thromboprophylaxis practice at our institutions falls substantially short of national and international guidelines. The reasons for low thromboprophylaxis use should be further explored and strategies for change implemented in order to optimize clinical practice.

Anonymous00347, Anonymous00348. · No affiliation provided · J Urol. · Pubmed #12686841 No free full text.

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Fink B. · No affiliation provided · Oper Orthop Traumatol. · Pubmed #19326062 No free full text.

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Mont MA, Seyler TM. · No affiliation provided · Clin Orthop Relat Res. · Pubmed #19263181 No free full text.

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Lieberman JR. · No affiliation provided · J Am Acad Orthop Surg. · Pubmed #19202118 No free full text.

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Cannon SR. · No affiliation provided · J Bone Joint Surg Br. · Pubmed #19190043 No free full text.

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Lustig S, Bruderer J, Servien E, Neyret P. · No affiliation provided · Knee. · Pubmed #19138856 No free full text.

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Eikelboom JE, Weitz JI. · Department of Medicine, McMaster University and Henderson Research Centre, Hamilton, Ontario, L8V 1C3, Canada. · Thromb Haemost. · Pubmed #19132179 No free full text.

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Zhang H. · No affiliation provided · Zhonghua Wai Ke Za Zhi. · Pubmed #19094554 No free full text.

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Li ZR. · No affiliation provided · Zhonghua Wai Ke Za Zhi. · Pubmed #19094553 No free full text.

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Spierings PT. · No affiliation provided · Acta Orthop. · Pubmed #19085487 links to  free full text

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Engebretsen L, Forssblad M. · No affiliation provided · Knee Surg Sports Traumatol Arthrosc. · Pubmed #19048231 No free full text.

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Harwin SF. · No affiliation provided · J Knee Surg. · Pubmed #18979930 No free full text.

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Della Valle CJ. · No affiliation provided · J Knee Surg. · Pubmed #18979925 No free full text.

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Babis GC, Soucacos PN. · No affiliation provided · J Surg Orthop Adv. · Pubmed #18851796 No free full text.

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