Copyright © 2008 by The Journal of Bone and Joint Surgery, Inc.
Commentary & Perspective
Commentary & Perspective by
Javad Parvizi MD, FRCS*,
Rothman Institute of Orthopedics, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
Posted November 2008
The study by Galat et al., entitled "Early Return to Surgery
for Evacuation of a Postoperative Hematoma After Primary Total Knee
Arthroplasty," reveals that hematoma formation following joint arthroplasty,
particularly when surgical intervention is required, is a serious problem.
Among a cohort of over 17,000 total knee arthroplasties, forty-two patients
(0.24%) required return to the operating room for evacuation of hematoma within
thirty days of index surgery. When compared with the overall cohort and
controls (a case-controlled study model), patients requiring surgical
intervention for evacuation of hematoma were at significantly increased risk
for the development of deep infection and/or the need to undergo subsequent
major surgery (p < 0.001). The authors concluded that it would be beneficial
to implement strategies to minimize the development of postoperative hematoma
formation.
To avoid this complication, one important preventative
strategy is avoidance of certain therapeutic anticoagulation regimens1-3.
Although, with the number of cases studied, the authors did not detect a
significant association between hematoma formation and administration of
various anticoagulants, some agents, such as low molecular weight heparin, are
known to be associated with a higher prevalence of bleeding and hematoma
formation than others are1,3. The authors also noted a suggestive, but
not significant, association between a history of postoperative deep venous
thrombosis requiring heparinization and development of postoperative hematoma.
A prior study from the same institution has also shown that administration of
intravenous heparin for treatment of presumed pulmonary embolus was associated
with increased and important complications4. These compelling
findings raise a concern regarding the administration of "aggressive"
anticoagulation in general and after diagnosis of an (asymptomatic) distal
venous thrombosis in particular. These concerns are reflected in the criticisms
of anticoagulation strategies5, such as those recommended by the
American College of Chest Physicians (ACCP)6, that aim to minimize
development of distal deep venous thrombosis. The concern of the orthopaedic
community is that the well-intentioned objectives of the ACCP to design
guidelines that minimize thromboembolic disease following total joint
arthroplasty do not sufficiently take into account issues such as bleeding,
hematoma formation, need for further surgical intervention, and subsequent
development of deep infection, which can have just as dire consequences as
thromboembolism. The study by Galat et al. provides further evidence that
orthopaedic surgeons walk a tightrope with regard to prevention of
complications following total joint arthroplasty. We, as physicians, must be
wary of exchanging one problem (thromboembolism) for another (hematoma
formation).
It is important to note, however, that postoperative
hematoma formation has a multifactorial etiology. To place the blame solely on
anticoagulation agents would be a simplistic approach to this complex issue.
This elegant article does, however, throw further weight behind the notion that
hematoma formation following total joint arthroplasty is a serious issue.
Hence, we should make every attempt to stratify our patients on the basis of
their risk of bleeding and thromboembolism formation. The effort invested by
the work group convened by the American
Academy of Orthopaedic Surgeons in producing
guidelines for prevention of thromboembolism takes this exact issue into
account7.
*The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated.
References
1. Burnett RS, Clohisy JC, Wright RW, McDonald DJ, Shively RA, Givens SA, Barrack RL: Failure of the American College of Chest Physicians-1A protocol for lovenox in clinical outcomes for thromboembolic prophylaxis. J Arthroplasty. 2007;22:317-24.
2. Parvizi J, Ghanem E, Joshi A, Sharkey PF, Hozack WJ, Rothman RH: Does "excessive" anticoagulation predispose to periprosthetic infection? J Arthroplasty. 2007;22(6 Suppl 2):24-8.
3. Dorr LD, Gendelman V, Maheshwari AV, Boutary M, Wan Z, Long WT. Multimodal thromboprophylaxis for total hip and knee arthroplasty based on risk assessment. J Bone Joint Surg Am. 2007;89:2648-57.
4. Lawton RL, Morrey BF. The use of heparin in patients in whom a pulmonary embolism is suspected after total hip arthroplasty. J Bone Joint Surg Am. 1999;81:1063-72.
5. Callaghan JJ, Dorr LD, Engh GA, Hanssen AD, Healy WL, Lachiewicz PF, Lonner JH, Lotke PA, Ranawat CS, Ritter MA, Salvati EA, Sculco TP, Thornhill TS; American College of Chest Physicians. Prophylaxis for thromboembolic disease: recommendations from the American College of Chest Physicians--are they appropriate for orthopaedic surgery? J Arthroplasty. 2005;20:273-4.
6. Geerts WH, Bergqvist D, Pineo GF, Heit JA, Samama CM, Lassen MR, Colwell CW; American College of Chest Physicians. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008;133(6 Suppl): 381S-453S.
7. American Academy of Orthopaedic Surgeons. Clinical Practice Guidelines: Guideline on the Prevention of Symptomatic Pulmonary Embolism in Patients Undergoing Total Hip or Knee Arthroplasty. 2007 May 18. Available at http://www.aaos.org/Research/guidelines/guide.asp. 2007. Accessed 2008 Oct 21.
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