Seminars in Arthroplasty RSS feed: Current Issue. Each issue of Seminars in Arthroplasty provides a comprehensive, current overview of a single topic in arthroplasty. The journal addresses orthopedic surgeons, providing authoritative reviews with emphasis on new developments relevant to their practice. 2009 Issues/Topics February Current Concepts in Hip and Knee Replacement A. Seth Greenwald May Current Concepts in Shoulder Replacement A. Seth Greenwald August Disorders and Treatment of the Patellofemoral Joint David Hungerford December TBD http://www.semarthroplasty.com/?rss=yesElsevier Inc.en © 2009 Published by Elsevier Inc. All rights reserved. Seminars in Arthroplasty1045-4527204December 2009 © 2009 Published by Elsevier Inc. All rights reserved. healthpermissions@elsevier.comhttp://www.semarthroplasty.com/article/PIIS1045452709000728/abstract?rss=yesMasthead10.1053/S1045-4527(09)00072-8Seminars in Arthroplasty 20, 4 (2009)2009-12-01Seminars in Arthroplasty2009-12-01204S1045-4527(09)X0005-2iihttp://www.semarthroplasty.com/article/PIIS1045452709000753/abstract?rss=yesEditorial Board10.1053/S1045-4527(09)00075-3Seminars in Arthroplasty 20, 4 (2009)2009-12-01Seminars in Arthroplasty2009-12-01204S1045-4527(09)X0005-2iiiihttp://www.semarthroplasty.com/article/PIIS1045452709000741/abstract?rss=yesContents10.1053/S1045-4527(09)00074-1Seminars in Arthroplasty 20, 4 (2009)2009-12-01Seminars in Arthroplasty2009-12-01204S1045-4527(09)X0005-2ivvhttp://www.semarthroplasty.com/article/PIIS104545270900073X/abstract?rss=yesIssue Topics10.1053/S1045-4527(09)00073-XSeminars in Arthroplasty 20, 4 (2009)2009-12-01Seminars in Arthroplasty2009-12-01204S1045-4527(09)X0005-2vivihttp://www.semarthroplasty.com/article/PIIS1045452709000534/abstract?rss=yesThromboembolic disease remains a potentially serious complication after hip and knee arthroplasty. There has been a great deal of research on deep vein thrombosis and pulmonary emboli prevention; however, controversy remains. This edition will review the mechanisms which lead to thromboembolic disease and discuss why arthroplasty patients are at risk. Although many thromboses develop intraoperatively, most prophylactic regimens begin postoperatively. In addition to postoperative mechanical and pharmacologic modalities, intraoperative anesthetic and pharmacologic regimens will be reviewed. Organizations including the American Academy of Orthopedic Surgeons (AAOS) and the American College of Chest Physicians (ACCP) have formulated prophylactic guidelines. The advantages and disadvantages of the recommendations will be presented. The edition will conclude with a discussion of the future of thromboembolic disease prophylaxis.IntroductionSteven B. Haas, Geoffrey Westrich10.1053/j.sart.2009.10.001Seminars in Arthroplasty 20, 4 (2009)2009-12-01Seminars in Arthroplasty2009-12-01204S1045-4527(09)X0005-2209209http://www.semarthroplasty.com/article/PIIS1045452709000546/abstract?rss=yesVenous thromboembolic (VTE) disease is an evolving, multifactorial disease spectrum ranging from venous thrombosis to pulmonary embolism. Virchow's triad, as described over a century ago, includes venous stasis, a hypercoaguable state, and endothelial damage of the vessel wall. Patients undergoing orthopaedic procedures, particularly arthroplasty and trauma patients, are at increased risk for VTE. Knowledge of the pathophysiology of VTE can potentially improve the preoperative and postoperative management of patients undergoing orthopaedic procedures, in order to diminish the risk of developing a venous thromboembolic event.Pathophysiology of Venous Thromboembolic DiseaseMichael B. Cross, Friedrich Boettner10.1053/j.sart.2009.10.002Seminars in Arthroplasty 20, 4 (2009)2009-12-01Seminars in Arthroplasty2009-12-01204S1045-4527(09)X0005-2210216http://www.semarthroplasty.com/article/PIIS1045452709000558/abstract?rss=yesThe risk of venous thromboembolism is high in lower extremity joint arthroplasty. Although the fundamental clotting factors are known, evidence implicates a number of less studied genetic elements that predispose patients to adverse venous thromboembolic events. The purpose of this article is to review the fundamentals of the coagulation pathology, relate new findings of the past decade of research concerning inherited coagulopathies and their role in venous thromboembolic disease in lower extremity joint arthroplasty, and highlight their importance for clinical practice. We conclude that there is established evidence linking genetic factors to inherited coagulopathies in hip arthroplasty which could lead to a system for screening and treating high-risk patients.Inherited Coagulopathies Predisposing to Venous Thromboembolic Disease in Lower Extremity Joint ArthroplastyStroh D. Alex, Michael G. Zywiel, Siraj Sayeed, Aaron J. Johnson, Michael A. Mont10.1053/j.sart.2009.10.003Seminars in Arthroplasty 20, 4 (2009)2009-12-01Seminars in Arthroplasty2009-12-01204S1045-4527(09)X0005-2217221http://www.semarthroplasty.com/article/PIIS104545270900056X/abstract?rss=yesBoth neural blockade (spinal or epidural) have been shown to reduce the risk of thrombogenesis after both hip and knee arthroplasty. The mechanism is most likely due to enhanced blood flow in the deep venous system of the legs. Reduction in blood loss during and after surgery may also play a role. Intraoperative heparin during hip and knee arthroplasty in doses of 10-15 U/kg suppresses thrombogenesis without increasing the risk of bleeding. Both these modalities are focused intraoperatively—the period when thrombi initially form.Intraoperative Techniques to Reduce Thromboembolism: Regional Anesthesia and Intraoperative HeparinNigel E. Sharrock10.1053/j.sart.2009.10.004Seminars in Arthroplasty 20, 4 (2009)2009-12-01Seminars in Arthroplasty2009-12-01204S1045-4527(09)X0005-2222226http://www.semarthroplasty.com/article/PIIS1045452709000571/abstract?rss=yesThe American College of Chest Physicians use strict evidence-based medicine methodology to make recommendations regarding deep vein thromboses prophylaxis. The highest level recommendations (1-A) involve routine pharmacoprophylaxis for all total joint patients with protocols that are aggressive by the standards of many arthroplasty specialists. A high incidence of complications has been reported at some centers using 1-A protocols, whereas centers using less aggressive protocols have achieved low complication rates and are also successful in effectively minimizing the incidence of symptomatic thromboembolic events.American College of Chest Physicians Guidelines: Advantages and DisadvantagesRobert L. Barrack10.1053/j.sart.2009.10.005Seminars in Arthroplasty 20, 4 (2009)2009-12-01Seminars in Arthroplasty2009-12-01204S1045-4527(09)X0005-2227229http://www.semarthroplasty.com/article/PIIS1045452709000583/abstract?rss=yesThe American Academy of Orthopedic Surgeons has published a clinical guideline for the prevention of symptomatic pulmonary embolism in patients undergoing total hip and total knee arthroplasty. This guideline includes recommendations from a consensus process and a review and analysis of 42 publications since 1996. The end points for analysis were symptomatic and fatal pulmonary embolism rates, total death rates, and major bleeding complications. The guideline recommends preoperative risk stratification of all patients for “standard” and “high” risks of both pulmonary embolism and major bleeding complications. The use of regional anesthesia, mechanical prophylaxis, rapid mobilization, and patient education were consensus recommendations. The choice of a specific medication postoperatively by the surgeon should be based on an individual risk–benefit analysis of pulmonary embolism and major bleeding complications. The advantages of this guideline include a greater concern for bleeding and other local wound complications that could affect overall patient outcome, and the ability of the surgeon to treat each patient as an individual. The disadvantages of this guideline include placing hip and knee arthroplasty patients into a single group, the lower levels of evidence for the recommendations, and the relative lack of acceptance by other specialty groups and governmental agencies.AAOS Guidelines for the Prevention of Symptomatic Pulmonary Embolism After Total Hip and Total Knee Arthroplasty: Advantages and DisadvantagesPaul F. Lachiewicz10.1053/j.sart.2009.10.006Seminars in Arthroplasty 20, 4 (2009)2009-12-01Seminars in Arthroplasty2009-12-01204S1045-4527(09)X0005-2230234http://www.semarthroplasty.com/article/PIIS1045452709000595/abstract?rss=yesPatients following total hip and knee replacement are at high risk for the development of deep venous thrombosis and pulmonary embolism. Therefore, prophylaxis for thromboembolism is mandatory and should be utilized routinely following joint replacement surgery. Currently, no single method of prophylaxis is ideal and, therefore, a multimodal approach is most prudent. This review details the currently available pharmacologic and mechanical types of prophylaxis and also highlights the multimodal approach that we employ at our institution, which encompasses preoperative, perioperative, and postoperative prophylaxis techniques.Prophylactic Modalities: Pharmacologic and Mechanical CompressionGeoffrey H. Westrich, Lindsey J. Bornstein10.1053/j.sart.2009.10.007Seminars in Arthroplasty 20, 4 (2009)2009-12-01Seminars in Arthroplasty2009-12-01204S1045-4527(09)X0005-2235240http://www.semarthroplasty.com/article/PIIS1045452709000601/abstract?rss=yesTotal hip and knee arthroplasties carry an increased risk for thromboembolic disease. A multimodal prophylaxis protocol developed at the Hospital for Special Surgery and fully implemented since 1995, consists of stratifying the individual patient's risk and implementing a series of safe preventive measures before, during, and after surgery to reduce the risk of venous thromboembolism and bleeding. The measures include discontinuation of procoagulant medication and autologous blood donation before surgery; the use of hypotensive epidural anesthesia and intraoperative intravenous heparin after acetabular work during total hip arthroplasty; the use of pneumatic compression devices, elastic stockings, and frequent, vigorous dorsiflexion of the ankles; and prompt mobilization of the patient after surgery to diminish venous stasis. If these safe measures are observed, postoperative pharmacologic prophylaxis does not need to be aggressive in the patients without predisposing factors for venous thromboembolism and who mobilize promptly, thus diminishing the morbidity and mortality associated with the routine use of potent anticoagulants and the overall cost of care. Our clinical experience with close to 10,000 total hip and knee replacements demonstrates that this multimodal prophylaxis is safe and effective, resulting in a very low prevalence of thromboembolism, bleeding, and all-cause mortality.The Multimodal Approach for the Prevention of Thromboembolic Disease After Total Joint ArthroplastyAlejandro González Della Valle, Francis Jeshira Reynoso, Judith Ben Ari, Eduardo Salvati10.1053/j.sart.2009.10.008Seminars in Arthroplasty 20, 4 (2009)2009-12-01Seminars in Arthroplasty2009-12-01204S1045-4527(09)X0005-2241250http://www.semarthroplasty.com/article/PIIS1045452709000613/abstract?rss=yesFor the last 30 years, surgeons have balanced the need for deep-venous thrombosis (DVT) prophylaxis with the need to avoid complications following total joint arthroplasty. Debate continues regarding prophylaxis against venous thromboembolism (VTE). Despite established guidelines and continued research, no consensus exist as to what agent affords the best balance between reducing DVT rates and minimizing the incidence of bleeding and wound complications. New oral anticoagulants offer the ease of oral administration and excellent efficacy, but remain unavailable in the United States and may lead to increased bleeding. New portable pneumatic compression devices look promising. They allow outpatient use and may improve compliance, but their exact role in the future of DVT prophylaxis remains undetermined.The Future of Thromboembolic ProphylaxisFred D. Cushner, Michael P. Nett10.1053/j.sart.2009.10.009Seminars in Arthroplasty 20, 4 (2009)2009-12-01Seminars in Arthroplasty2009-12-01204S1045-4527(09)X0005-2251254