The John Charnley Award. Thrombogenesis during total hip arthroplasty.

The activation of the clotting cascade leading to deep venous thrombosis begins during total hip arthroplasty, but few studies have assessed changes in coagulation during surgery. A better understanding of thrombogenesis during total hip arthroplasty may provide a more rational basis for treatment. In 3 separate studies, the following observations were made. Circulating indices of thrombosis and fibrinolysis: prothrombin F1.2, thrombin-antithrombin complexes, fibrinopeptide A, and D-dimer, did not increase during osteotomy of the neck of the femur or during insertion of the acetabular component, but rose significantly during insertion of the femoral component. Thrombin-antithrombin complexes, fibrinopeptide A, and D-dimer were higher after insertion of a cemented component than insertion of a noncemented femoral component. A significant decline in central venous oxygen tension was observed after relocation of the hip joint and after insertions of cemented and noncemented femoral components, providing evidence of femoral venous occlusion during insertion of the femoral component. In patients receiving a cemented femoral component, mean pulmonary artery pressure increased after relocation of the hip joint, indicating intraoperative pulmonary embolism. No changes in mean pulmonary artery pressure were noted with noncemented total hip arthroplasty. Administration of 1000 units of unfractionated heparin before insertion of a cemented femoral component blunted the rise of fibrinopeptide A. The results of these studies suggest that (1) the greatest risk of activation of the clotting cascade during total hip arthroplasty occurs during insertion of the femoral component; (2) femoral venous occlusion and use of cemented components are factors in thrombogenesis during total hip arthroplasty; and (3) measures to prevent deep venous thrombosis during total hip arthroplasty (such as intraoperative anticoagulation) should begin during surgery rather than during the postoperative period and be applied during insertion of the femoral component.

[1]  B. Eriksson,et al.  Impaired fibrinolysis and postoperative thromboembolism in orthopedic patients. , 1991, Thrombosis research.

[2]  M. Sakon,et al.  Activation of coagulation and fibrinolysis during surgery, analyzed by molecular markers. , 1990, Thrombosis research.

[3]  S Ghera,et al.  Prophylaxis against deep-vein thrombosis in total hip replacement. Comparison of heparin and foot impulse pump. , 1994, The Journal of bone and joint surgery. British volume.

[4]  R. Collins,et al.  Antiplatelet therapy to prevent thrombosis after hip fracture. Rationale for a randomised trial. , 1994, The Journal of bone and joint surgery. British volume.

[5]  P. Alburger,et al.  Operative venodilation: a previously unsuspected factor in the cause of postoperative deep vein thrombosis. , 1989, Surgery.

[6]  E. Salvati,et al.  The effect of total hip replacement and general surgery on antithrombin III in relation to venous thrombosis. , 1979, The Journal of bone and joint surgery. American volume.

[7]  T. Sculco,et al.  Augmentation of calf blood flow by epinephrine infusion during lumbar epidural anesthesia. , 1994, Anesthesia and analgesia.

[8]  G. Raskob,et al.  A comparison of subcutaneous low-molecular-weight heparin with warfarin sodium for prophylaxis against deep-vein thrombosis after hip or knee implantation. , 1993, The New England journal of medicine.

[9]  R. Burnett,et al.  Echocardiography of transatrial embolism during cemented and uncemented hemiarthroplasty of the hip. , 1994, The Journal of bone and joint surgery. British volume.

[10]  P. Levin.  Use of enoxaparin, a low-molecular-weight heparin, and unfractionated heparin for the prevention of deep venous thrombosis after elective hip replacement. A clinical trial comparing efficacy and safety. , 1994, The Journal of bone and joint surgery. American volume.

[11]  R. Pho,et al.  Femoral vein occlusion during hip arthroplasty. , 1990, Clinical orthopaedics and related research.

[12]  W. Nieuwenhuizen,et al.  Haemostatic Activation before and after Surgery in Patients with and without Gastric Malignancy , 1994, Thrombosis and Haemostasis.

[13]  R. Canfield,et al.  Measurement of fibrinopeptide A in human blood. , 1974, The Journal of clinical investigation.

[14]  G. Raskob,et al.  Effectiveness of intermittent pneumatic leg compression for preventing deep vein thrombosis after total hip replacement. , 1990, JAMA.

[15]  S. Woolson,et al.  Intermittent pneumatic compression to prevent proximal deep venous thrombosis during and after total hip replacement. A prospective, randomized study of compression alone, compression and aspirin, and compression and low-dose warfarin. , 1991, The Journal of bone and joint surgery. American volume.

[16]  P. Pellicci,et al.  Effect of aspirin on heterotopic ossification after total hip arthroplasty in men who have osteoarthrosis. , 1991, The Journal of bone and joint surgery. American volume.

[17]  J. Brock‐Utne,et al.  Segmental Wall Motion Abnormalities in Patients Undergoing Total Hip Replacement: Correlations with Intraoperative Events , 1993, Anesthesia and analgesia.

[18]  M. Abel,et al.  Cemented versus noncemented total hip arthroplasty--embolism, hemodynamics, and intrapulmonary shunting. , 1992, Mayo Clinic proceedings.

[19]  A. Clarke.  Femoral vein thrombosis and total hip replacement. , 1977, British medical journal.

[20]  N. Sharrock,et al.  The Hemodynamic and Fibrinolytic Response to Low Dose Epinephrine and Phenylephrine Infusions During Total Hip Replacement Under Epidural Anesthesia , 1992, Thrombosis and Haemostasis.

[21]  R. Blasier,et al.  Efficacy and Safety of Enoxaparin to Prevent Deep Venous Thrombosis after Hip Replacement Surgery , 1994, Annals of Internal Medicine.

[22]  P. Kierulf,et al.  Studies on coagulation, fibrinolysis, kallikrein-kinin and complement activation in systemic and pulmonary circulation during hip arthroplasty with acrylic cement. , 1988, Thrombosis research.

[23]  R. Byrick,et al.  Cardiopulmonary function and pulmonary microemboli during arthroplasty using cemented or non-cemented components. The role of intramedullary pressure. , 1987, The Journal of bone and joint surgery. American volume.

[24]  W. Geerts,et al.  Prevention of venous thromboembolism after total hip and knee arthroplasty. , 1994, The Journal of bone and joint surgery. American volume.

[25]  R. Johnson,et al.  Deep venous thrombosis following Charnley arthroplasty. , 1978, Clinical orthopaedics and related research.

[26]  C. Francis,et al.  LOWER RISK OF THROMBOEMBOLIC DISEASE AFTER TOTAL HIP REPLACEMENT WITH NON-CEMENTED THAN WITH CEMENTED PROSTHESES , 1986, The Lancet.

[27]  M. Blombäck,et al.  Activation of cascade systems by hip arthroplasty. No difference between fixation with and without cement. , 1987, Acta orthopaedica Scandinavica.

[28]  D. Pinsky,et al.  Hypoxia-mediated induction of endothelial cell interleukin-1 alpha. An autocrine mechanism promoting expression of leukocyte adhesion molecules on the vessel surface. , 1992, The Journal of clinical investigation.

[29]  J. Caprini,et al.  The effect of intravenous fixed-dose heparin during total hip arthroplasty on the incidence of deep-vein thrombosis. A randomized, double-blind trial in patients operated on with epidural anesthesia and controlled hypotension. , 1991, The Journal of bone and joint surgery. American volume.

[30]  O. Reikerås,et al.  Generation of procoagulant (thromboplastin) and plasminogen activator activities in peripheral blood monocytes after total hip replacement surgery. Effects of high doses of corticosteroids. , 1991, Thrombosis research.

[31]  P. Malone,et al.  The sequestration and margination of platelets and leucocytes in veins during conditions of hypokinetic and anaemic hypoxia: Potential significance in clinical post‐operative venous thrombosis , 1978, The Journal of pathology.

[32]  J. Verheijen,et al.  The postoperative fibrinolytic shutdown: a rapidly reverting acute phase pattern for the fast-acting inhibitor of tissue-type plasminogen activator after trauma. , 1985, Scandinavian journal of clinical and laboratory investigation.

[33]  P. Malone,et al.  A hypothesis concerning the aetiology of venous thrombosis. , 1977, Medical hypotheses.