deep vein thrombosis after total hip replacement

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The presence of varicose veins, being a non-smoker and having a low body mass index were associated with an increased incidence of deep vein thrombosis.
DEEP

VEIN

THROMBOSIS

A COMPARISON F.

M DAVIS,

V. G.

AFTER

BETWEEN

SPINAL

LAURENSON,

From

TOTAL

W.

Christchurch

AND

REPLACEMENT

GENERAL

J. GILLESPIE,

School

HIP

J. E.

ANAESTHESIA

WELLS,

o,f Medicine,

J. FOATE.

New

E.

NEWMAN

Zealand

The effect of hypobaric spinal anaesthesia or narcotic-halothane-relaxant general anaesthesia on the incidence of postoperative deep vein thrombosis was studied in 140 elective total hip replacements in a prospective randomised manner. Deep vein thrombosis was diagnosed using impedance plethysmography and the ā€˜ 251 fibrinogen uptake test, combined, in selected cases, with ascending contrast venography. The overall incidence of deep vein thrombosis was 20%. Nine patients (13%) developed deep vein thrombosis in the spinal group and nineteen (27%) in the general anaesthetic group (p < 0.05). The incidences of proximal thrombosis and of bilateral thrombi were also less with spinal anaesthesia than with general anaesthesia. It is concluded that spinal anaesthesia reduces the risks of postoperative thromboembolism in hip replacement surgery. The presence of varicose veins, being a non-smoker and having a low body mass index were associated with an increased incidence of deep vein thrombosis.

Postoperative after total Sikorski

est

thromboembolism remains replacement (Salzman and

hip 1984)

cause

and

pulmonary

of early

and Charnley of deep

venous

embolism

is the

death

(Johnson,

postoperative

1977;

Malinque

a problem Harris 1976;

et al. 1986).

thrombosis

(DVT)

examined replacement

common-

Green

The aetiology

is multifactorial

Louden and techniques

and

the

prospective here.

different

and

often

many

drugs

and

markedly

anaesthetic

agents

biomembranes In (Louden

and

F. M. V. G.

by

alter

produce

their

very

cellular

of

than

DVT

with

was

lower

general

nature

W. J. Gillespie,

Divisions Health,

ChM,

FRCS

with

in hip observed spinal

anaesthesia

Orthopaedic Christchurch,

Surgery New

J. Foate,

FFARACS,

Department

of

(Thorburn,

Professor

Orthopaedic

and Anaesthesia, Zealand.

should

Ā©

Editorial

0301 -620X/89/2072 J Bone Joint Surg

VOL.

71-B.

No.

; one

be sent

Society

to Dr.

F.

of Bone

M.

and

of an

six

breaks

major

study,

idiosyncratic

and Davis reaction in

which

the

was

Hospital Board were subsequently response 1985), one to penicillin

study

protocol.

to with a and

Eleven

taken,

to

Centre, Davis.

Joint

because

to the

Canterbury patients

of gave

being

Hospital

Medical

consent North Eight

(Laurenson dermatolytic

for

all with osteoarthritis thromboembolism,

of venous

chlormethiazole life-threatening

Board,

was

were

receive

Surgery

Adelaide,

stopped

one

randomised

either

general

anaesthesia

Clinical

and

(Davis Flinders

989

excluded

techniques

$2.00 [Br] l989,7l-B:l8l-5.

2. MARCH

informed

by the Committee.

presented

of Orthopaedic

Registrar

Correspondence

written

approved Ethical

are

MATERIALS

A total of 1 37 patients, no history

which

in Anaesthesia

of Community Departments of

Canterbury

AND

hip and

their

of

re-

total hip randomised

entered the trial on two occasions, giving a study of 140 total hip replacements (THR). Aspirin, if

Surgeon

and Department Medicine, and

results

following in a

patients group

Australia.

1989 British

patients that the

the

Patients

and Anaesthesia, School of

Anaesthesia,

on

anaesthesia

(GA)

Ed, FRACS,

PhD, Biostatistician FRACS, Consultant

of Surgery Christchurch

act

function.

Davis, FFARCS, FFARACS, Senior Lecturer Laurenson, FFARACS, Specialist Anaesthetist

Surgery J. E. Wells, E. Newman,

and

the

METHODS

Patients.

profound

effects,

circulatory

a study of fibrinogen scanning et al. 1978) it was incidentally

frequency

(SAB)

techniques

different

study the anaesthetic so we have

incidence of DVT under SAB or GA

study,

the potential role ofanaesthesia has been largely ignored, the techniques used having rarely been reported, let alone standardised within studies. This is despite the fact that

Vallance 1980). In that were not randomised,

spinal

1987).

management. described

Briefly,

narcotic-halothane-muscle the SAB group received tetracaine,

separately)

(SAB

group)

supplemented

in

The

anaesthetic

detail

all patients

cated with diazepam 10 mg following induction with sodium

with

pre-operatively.

females

or

group).

anaesthetic been

week

and

anaesthesia

(GA

have

et al.

(males

elsewhere

were

orally. The thiopentone,

relaxant a hypobaric by

general spinal light

premedi-

GA group, received a anaesthetic; anaesthetic

basal

sedation 181

F. M. DAVIS,

I 82

with

a chlormethiazole

of both

V. G. LAURENSON,

(Hemineurin)

anaesthetic

an Exeter

infusion.

techniques

was

total

hip arthroplasty

cement were used.

aim

to achieve

modest

without

laminar

theatre

was performed

a posterolateral approach using without trochanteric osteotomy. methylmethacrylate cement restrictor

The

J. E. WELLS.

a standard Pressure

via

with

of

scans using

oral

antibiotics were given. Postoperatively, supplemental oxygen was breathed for one to two days and intramuscular opioid analgesia given as needed. The patients remained in bed with the

and

of

the

hip,

weight-bearing

started. TED well advanced,

stockings usually

hospital

at ! 1 to 14 days

for

was

anticoagulation

complications

unless

(1 1 cases) (six

mobilisation Discharge

delayed

or

by

was from

70-

need

60-

by the

other

limb

25

for two Iodine Leg

ofseven days The scanning

used

The

were

ā€˜

24 being

intravenously.

criteria (1975).

N69

mobilisation

were worn until for 10 days.

100 uCi of

injected

diagnostic

advocated by Roberts counts on the operated of diagnosis.

started then

1 20 mg daily

operation was

test

gland

iodide

after

(Amersham)

uptake

thyroid

potassium

operated limb elevated in light skin traction (!.5 kg) for three days. On the fourth day, following a satisfactory radiograph

the

were performed daily for a minimum a Pitman 235N Isotope Monitor.

technique

and a polyethylene femoral Pen-operative prophylactic

fibrinogen

operation,

Immediately

fibrinogen

F. NEWMAN

for the

before

weeks.

procedure injection

J. FOATE,

Preparation hours blocked

hypotension for surgery. In a conventional operating

flow,

W. J. GILLESPIE,

were

upper

ignored

those

four

thigh

for the purpose

N71

surgical Cā€™) -.

cases).

50-

z Ui

4

a-

40-

I

0

Table I. . Demographic frequencies or means

patient

data

for

both

groups,

the

numbers

30-

are

(s.d.) Z2

Parameter

SAB group

GA group

Procedures

69

71

31 :38

31 :40

68.3(8.2)

66.7(9.3)

Male/female Age

ratio

in years

Weight

in kilograms

Smokers Varicose

veins

Body mass index

(n = 102)

Hypertension Duration minutes

of

surgery

71.1(13.5)

70.1(12.5)

13

14

22

23

26.4(4.6)

25.7(3.8)

22

28

73(13)

79(21)

n

NO

GA GROUP UNILATERAL DVT

DVT

L.J

L

Fig.

in

.

-----.--

SAB GROUP

The

.

BILATERAL DVT

I

.

incidence

(SAB) and

of general

deep (GA)

vein thrombosis in anaesthetic groups.

the

spinal

*pO.l)

tested,

but

well fitted by a simple three-factor risk only anaesthesia, smoking and varicose

veins

interactions.

without

This

about 50% of patients with varicose veins, non-smoker) all patients

with

(Table II). Body mass index

patients, recorded.

urinary

were

the data were model involving

escape

patients cardio-

during

with clinical

15, all of

In the 20

who

not appear to influence the DVT Several logistic regression models

infections

joint. Six No major

index

scans,

thromboembolic

of DVT. These were the 0.005), being a non-smoker