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 ‘ 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
©
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
‘
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 C’) -.
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
