The Journal of Bone and Joint Surgery (American) 84:39-48 (2002)
© 2002 The Journal of Bone and Joint Surgery, Inc.
Prophylaxis Against Fat and Bone-Marrow Embolism During Total Hip Arthroplasty Reduces the Incidence of Postoperative Deep-Vein Thrombosis
A Controlled, Randomized Clinical Trial
Rocco Paolo Pitto, MD, PhD,
Hendrik Hamer, MD,
Renato Fabiani, MD,
Martin Radespiel-Troeger, MD and
Matthias Koessler, MD
Investigation performed at the Departments of Orthopaedic Surgery;
Internal Medicine; Medical Informatics, Biometry, and Epidemiology;
and Anesthesiology and Intensive Care, Friedrich-Alexander University
Erlangen-Nuremberg, Erlangen, Germany
Rocco Paolo Pitto, MD, PhD
Department of Orthopaedic Surgery, University of Auckland, Middlemore
Hospital, Private Bag 93311, Otahuhu, Auckland, New Zealand. E-mail
address: rpitto{at}middlemore.co.nz
Hendrik Hamer, MD
Renato Fabiani, MD
Martin Radespiel-Troeger, MD
Matthias Koessler, MD
Departments of Internal Medicine (H.H. and R.F.), Medical Informatics,
Biometry, and Epidemiology (M.R.-T.), and Anesthesiology and Intensive
Care (M.K.), Friedrich-Alexander University Erlangen-Nuremberg,
Waldkrankenhaus, Rathsbergerstrasse 57, D-91054 Erlangen, Germany.
E-mail address for M. Koessler: matthias.koessler@freenet.de
In support of their research or preparation of this manuscript, one
or more of the authors received grants or outside funding from Siemens
AG, Erlangen, Germany. None of the authors 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,
educational institution, or other charitable or nonprofit organization with
which the authors are affiliated or associated.
Background: Clinical and experimental studies
have suggested that the maximum risk of thrombogenesis occurs during,
rather than after, total hip arthroplasty. With use of conventional
cementing techniques, insertion of a femoral component results in marrow
embolization of tissue thromboplastin into the veins of the proximal
part of the femur, leading to activation of the clotting cascade
and thrombogenesis. We hypothesized that an operative technique
designed for the prevention of fat and bone-marrow embolism can
also reduce the incidence of postoperative deep-vein thrombosis
and pulmonary embolism.
Methods: A total of 130 consecutive patients with
osteoarthritis who were to have a primary total hip arthroplasty
were randomly assigned to one of two groups. One group consisted
of sixty-five patients (sixty-five hips) who had the femoral component inserted
with our standard cementing technique without use of a bone vacuum,
and the other group included sixty-five patients (sixty-five hips)
who had the femoral component cemented with use of a bone-vacuum
technique. In the hips managed with the bone vacuum, suction (–800
mbar) was applied to a drainage cannula placed along the linea aspera
of the femur in order to prevent an increase in intramedullary pressure
during the insertion of the stem. We measured the incidence of intraoperative
fat and bone-marrow embolism with use of echocardiography and a
transesophageal probe and the incidence of deep-vein thrombosis
with use of serial duplex ultrasonography on the day before the
operation and on postoperative days 4, 14, and 45. All patients
were managed with prolonged pharmacological prophylaxis (low-molecular-weight
heparin) against deep-vein thrombosis.
Results: The control group had significantly more
severe and prolonged echocardiographic embolic events than did the
group managed with the bone-vacuum technique (p < 0.05).
A cascade of fine echogenic particles or embolic masses with a diameter
of £5 mm was observed during the insertion of the stem
in fifty-nine hips (91%) in which our standard cementing technique
was used and in ten hips (15%) in which the bone-vacuum
cementing technique was used. Deep-vein thrombosis was detected
on postoperative day 4 in twelve patients (18%) in the
control group and in two patients (3%) in the group managed
with the bone-vacuum technique; the difference was significant (p < 0.05).
Conclusions: Intraoperative prophylaxis against
fat and bone-marrow embolism during total hip arthroplasty with
cement can reduce the incidence of postoperative deep-vein thrombosis. We
now use the bone-vacuum technique routinely in all total hip arthroplasties
performed with cement.
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