Emboli Observed with Use of Transesophageal Echocardiography Immediately after Tourniquet Release during Total Knee Arthroplasty with Cement*

Patients with knee osteoarthritis (OA) often present with symptoms that warrant bilateral TKAs. There are potential benefits to operating on both knees on the same day, but the safety of simultaneous bilateral TKAs has been questioned. To evaluate whether there were any differences in 30-day mortality between patients having simultaneous bilateral TKAs and those having staged bilateral TKAs, we analyzed data from the Swedish Knee Arthroplasty Register and the Swedish Cause of Death Register. We included 48,931 patients with OA having 60,062 primary TKAs during 1985 to 2004; 1139 had surgery on both knees on the same day (simultaneous bilateral) and 3432 had surgery on both knees on two different occasions with less than 1 year between operations (staged bilateral). The 30-day mortality after simultaneous bilateral TKAs was 7.53 (confidence interval, 2.62-21.69) times higher than after the second of staged TKA and 3.77 (confidence interval, 2.04-6.98) times higher than after a primary unilateral TKA. Assuming the total risk for a staged procedure is twice that of a unilateral procedure, the risk of mortality within 30 days is 1.94 (confidence interval, 1.05-3.59) times higher with simultaneous than staged TKA. It is safer to operate on one knee at a time.

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“…The use of a pneumatic tourniquet, intramedullary guides, and cement are factors that probably are of importance [1,15,16].…”

Section: Discussionmentioning

confidence: 99%

Higher Early Mortality with Simultaneous Rather than Staged Bilateral TKAs: Results From the Swedish Knee Arthroplasty Register

Stefánsdóttir¹,

Lidgren²,

Robertsson³

2008

Clinical Orthopaedics &Amp; Related Research

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“…Perioperative DVT can be detected with venography or ultrasonography, but larger numbers are needed (in the hundreds) and the cost is substantial. Intraoperative thrombogenesis has also been assessed using transesophageal echocardiography [19] and by quantifying the embolic load during surgery [4,18]. This requires an intubated patient and cannot be used with epidural anesthesia.…”

Section: Discussionmentioning

confidence: 99%

Markers of Thrombin Generation During Resurfacing and Noncemented Total Hip Arthroplasty: A Pilot Study

Chatzoudis

Sioros

et al. 2011

Clinical Orthopaedics &Amp; Related Research

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Background Hip resurfacing arthroplasty (HRA) could be associated with an increased risk of deep vein thrombosis (DVT) compared to traditional noncemented THA because it involves greater dissection, increased kinking and distortion of the femoral vessels, takes longer to perform, and involves insertion of some cement into the femur. Questions/purposes Does HRA lead to greater risk of thromboembolism compared with noncemented THA? Methods We prospectively studied 20 patients receiving HRA and 20 receiving THA. All patients were younger than 67 years old and were similar in height, weight, American Society of Anesthesiologists status, and gender mix. Patients undergoing HRA were younger (mean, 50 versus 59 years), their surgery was longer (mean, 87 versus 65 minutes), and they required more crystalloid during surgery (mean, 2160 versus 1662 mL). Radial artery blood samples were taken at six events during surgery and assayed for prothrombin fragment F1 + 2 and thrombinantithrombin III complex (TAT) using enzyme-linked immunosorbent assays. Results We observed no differences in the intraoperative increases in F1 + 2 and TAT between the two groups and no differences in surgical events. Conclusion Based on these data, HRA and THA should have similar risk of thromboembolism as THA based on the parameters we measured. Level of Evidence Level I, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.

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“…2,36 In addition, marrow contents are known to be thrombogenic causing activation of the coagulation and fibrinolytic pathways, as well as that which would be expected from the surgical stimulus alone. 2,3,37 Although the coagulative and cardiopulmonary effects of replacement arthroplasty of the hip and knee have previously been examined, 38,39 this is the first clinical study to attempt specifically to quantify these effects in patients undergoing reamed nailing. We have shown that reamed nailing is associated with the activation of coagulation pathways.…”

Section: Discussionmentioning

confidence: 99%

The coagulative and cardiorespiratory responses to reamed intramedullary nailing of isolated fractures

Robinson

Ludlam

Ray

et al. 2001

The Journal of Bone and Joint Surgery. British volume

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We measured the changes during operation in seven markers of coagulation in a prospective series of 84 patients with fractures of the tibia or femur who were undergoing reamed intramedullary nailing. All patients were also continually monitored using transoesophageal echocardiography to assess marrow embolism. In a subset of 40 patients, intraoperative cardiopulmonary function was monitored, using pulmonary and systemic arterial catheterisation.The procedure produced a significant increase in prothrombin time, activated partial thromboplastin time, the level of prothrombin fragments F 1+2 and D-dimers, and a decrease in the fibrinogen level, suggesting activation of both the coagulation and fibrinolytic pathways. There was evidence of both platelet hyper-reactivity and depletion, as estimated by an increase in ␤-thromboglobulin levels and a decrease in the platelet count. In the patients who had invasive monitoring there was an incremental increase in mean pulmonary arterial pressure, with the changes being greatest during insertion of the guide-wire and reaming.The change in markers of coagulation, pulmonary artery pressure and arterial oxygen partial pressures correlated with the intraoperative embolic response. Greater changes in these parameters were observed during stabilisation of pathological fractures and in those patients in whom surgery had been delayed for more than 48 hours.Seven patients with pathological fractures developed more severe hypoxic episodes during reaming, which were associated with significantly greater arterial hypoxaemia, a fall in the right ventricular ejection fraction and an increase in the mean pulmonary artery pressure, pulmonary capillary wedge pressure, central venous pressure and the pulmonary vascular resistance index. These changes suggested that the patients had transient intraoperative right heart strain.Eight patients developed significant postoperative respiratory compromise. They all had severe intraoperative embolic responses and, in the three who had invasive monitoring, there was a significantly greater increase in pulmonary artery pressure and alveolar-arterial oxygen gradient, and a fall in the ratio of arterial partial pressure of oxygen to the inspired oxygen concentration. Operative delay, intraoperative paradoxical embolisation and the scores for the severity of the coagulative and embolic responses were predictive of the development of postoperative respiratory complications on univariate logistic regression analysis. On multivariate analysis, however, only the embolic and coagulative scores were significant independent predictors of respiratory complications.

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Emboli Observed with Use of Transesophageal Echocardiography Immediately after Tourniquet Release during Total Knee Arthroplasty with Cement*

Cited by 109 publications

References 19 publications

Higher Early Mortality with Simultaneous Rather than Staged Bilateral TKAs: Results From the Swedish Knee Arthroplasty Register

Higher Early Mortality with Simultaneous Rather than Staged Bilateral TKAs: Results From the Swedish Knee Arthroplasty Register

Markers of Thrombin Generation During Resurfacing and Noncemented Total Hip Arthroplasty: A Pilot Study

The coagulative and cardiorespiratory responses to reamed intramedullary nailing of isolated fractures

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