بسم الله الرحمن الرحيم

T. J. A IS STRONG PROPENSITY FOR

T. E COMPLICATION

THAT IS POTENTIALLY LIFE -

THREATENING

OBESITYCANCERPREVIOUS VTEFAMILY HISTORYSMOKINGADMISSION TO ICUDEHYDRATIONTHROMBOPHILIACONTRACEPTIVE USEPOST- OPERATION IMMOBILITY

CHARNLEY & CO:

7959 CASES OF T. J. A 1962- 73

P- E : 8%

FATAL CONDITION: 1%

INSALL INCREASE ATTENTION TO T. E DISEAS

AND EMPHASIS PREVENTION

DVT WITHOUT ANY PREVENTION

84%CLINICALLY P. E

1.7%FATAL P. E: -

POSITIVE VENOGRAPHY NOT ITSELF

ASSOCIATED WITH LOCAL SYMPTOMS

PRESENTATION OF T. E DISEASE FOLLOWING T. H. A & T. K. A IS DIFFERENT

RELATED TO VIRCHOW’S TRIAD

STASIS

INTIMAL INJURY

HYPERCOAGULABILITY

BEFORE ROUTINE USE OF

CHEMOPROPHYLAXIS

PROXIMAL DVT WAS IN 50- 60% OF

T. H. A

DISTAL WAS IN T. K. A

PROXIMAL THROMBI ALMOST IS SEGMENTAL

AND NEAR LESSER TROCH

LARGE

MORE EMBOLIZE

GREAT HEMODYNAMIC IMBALANCE MORE P. E

RESULT

RESULT OF INTIMAL DAMAGE TO

FEMORAL VEIN WHICH IS TWISTED

DURING POSITION OF L- L

PREPARATION & DEVICE INSERTION

POTENT ANTICOAGULANTS

MITIGATE INTIMAL INJURY & REDUCE PROXIMIL THROMBI IN T. H. A

DISTAL THROMBI AFTER T. K. A IS MORE RELATED TO BLOOD STASIS

1 -FOLDING

3 -OCCLUSION

TOURNIQUET & ANTIGOAGULANT AND IPC ALONE ARE NOT EFFECTIVE

IN PREVENTION

OF POPLITEAL VEIN

PREVENTION WITH IPC AND

REGIONAL ANESTHESIA

OR

IPC + CHEMOPROPHYLAXIS

RELEAS OF THE TOURNIQUET AFTER T. K. A TRANSESOPHAGEAL ECHOCARDIOGRAPHY HAS NOISE IN ECHO PATTERN FROM:

1- EMBOLIC

2- BONE MARROW

3- ELMENTS FAT

FAT FROM

AFTER

INTRAMEDULLARY CANAL

INTRAVASATION

CANAL PREPARATION

PRESSURIZATION ON STEM CEMENTATION

ORTHOPEADIC SURGEON EMPHASIS TO:

1- PROPHYLAXIS OF CLINICAL EVENTS

2- BALANCE THE RISK OF BLEEDING

MORE THAN:

PREVENTION OF VENOGRAPHIC DISEASE

AMERICAN COLLEGE OF CHEST-

PHYSICIAN (ACCP)

SUGESST THAT ANTICOAGULANT

NEEDED AS SOON AS ELEVATED

BLEEDING RISK SUBSIDE

REGIONAL ANESTHESIA

REDUCE DVT

VASODILATATION BETTER VENOUS RETURN

RESEMBLE OF SYMPATHECTOMY

NO EFFECT ON INTRAOPERATIVE THROMBOGENIE BUT VASODILATION STIMULATE OF INTIMAL FIBRINOLYSIS

SPINALEPIDURAL

PROXIMAL CLOT 50%DISTAL CLOT 20%

2- PNEUMATIC COMPRESSION:

- I. P. C ALONE IS NOT VERY EFFECTIVE

- I. P. C & REGIONAL ANESTHESIA HAS SYNERGIC EFFECT TO PREVENT OF DVT

WESTRICH & COLLEAGUES

SUGGEST IPC AND HEPARIN

REDUCE DVT THAT

SIGNIFICANTLY BETTER THAN

WARFARIN OR ASPIRIN

3- ASPIRIN

OVERALL ANTIPLATELER ARE

INEFFECTIVE ON THE VENOUS

SIDE OF CIRCULATION

RESULT OF STUDY IN 12291 PATIENT WITH T. J. A THAT ANALYSIS MORTALITY AT

1-6W

2- 3 MON

G:A L. MW. H- XIMELAGTRAN - FONDAPARINUX

G:B REGIONAL ANESTHESIA WITH OR

WITHOUT

1- HEPARIN

2- IPC

3- ASPIRIN

G: C WARFARIN

EMPHASIS THAT MULTIMODAL

ASPIRIN PROPHYLALY IS BETTER

ASPIRIN: REDUCE P. E.

(CLINICAL MANIFESTATION OF V.T)

SPECIALLY USE WITH REG- ANES

ACCORDINGLY: THERE IS BOTH EVIDENCE AND MOMENTUM GROWING TO JUSTIFY A RANDMIZED CLINICAL TRIAL COMPARING ASPIRIN – WARFARIN AND NEWER AGENT IN CONJUCTION WITH REG – ANES FOR VT PROPHYLAXIS AFTER T. J. A

SYMPTOMATIC & FATAL P. T. E IS

MORE IN T. H. A THAN T. K. A

RESIDUAL VENOGRAPHIC

PREVALANCE OF DVT HAS BEEN

MORE AFTER T. K. A

THIS MEAN THAT PREVENTION OF DVT

AFTER T. K. A IS MORE REFRACTORY

TO BOTH TRADITIONAL AND

CONTEMPORARY DRUG

PROPHYLAXIS

L. M. W. H OR FRACTIONAL MORE

BINDING TO ANTI- THROMBIN III

THAN CONVENTIONAL HEPARIN

SO MORE EFFECT TO DVT

PREVENTION IN T. J. A

HEPARIN INDUCED THROMBOCYTOPENIA (HIT)

AND DEVASTING COMPLICATION OF ALL FORM OF HEPARIN UNCOMMON

2.6 % IN CONVENTIONAL- H

0.2 % IN L. M. W. H

FONDAPARINUX IS SYNTHETIC

PENTASACCHARIDE BIND ONLY

TO THE ANTI - THROMBIN III

HEPARIN SITE AND HAD NO RISK

OF HIT

ENOXAPARIN

PROPHYLAXIS POWER,

REDUCE V.T RATES FROM

28% TO 6%

RIVAROXABAN IN 2011 APPROVED BY FOOD & DRUG ADMINISTRATION

REDUCE OVERALL DVT & ALL CAUSE MORTALITY. RATE UNDER 7% (IN 3148 T. K. A)

31.4% REDUCTION COMPARED WITH ENOXAPARIN

RIVAROXABAN 1- NEED NO MONITORING

2- METABOLIZE IN LIVER

3- ONLY ORAL USE

4- 10 mg DAILY

5- NO BLEEDING EVIDENT MORE THAN ENOXAPARIN

− V. T OF CALF MANAGE WITH 6 WEEKS PERIOPERATIVE OF WARFARIN

− PROXIMAL DVT WITH 12 WEEK WARFARIN − P. E WITH 3- 6 MONTHS − THERAPEUTIC (INR 2- 3) WARFARIN AFTER

INITIAL ANTICOAGULATION WITH L. M. W. H

MORE RECENTLY IN THE ERA OF L. M. W. H, IMMEDIATE OUTPATIENT TREATMENT OF V. T HAS BECOME POPULAR

HOW EVER, IN POSTOPERATIVE PATIENT WITH A SBSTANTIAL ATTENDANT RISK OF BLEEDING, INITIATION OF ANTICOAGULATION AS AN INPATIENT FOLLOWED BY OUT PATIENT THERAPY AFTER ANTICOAGULANT DOSING AND INTENSITY HAVE BEEN STABILIZED IS A MORE PRUDENT APPROACH

JBJS 2013/ 1/115670 T. J. A 5- YEAR 90 DAYFOLLOWEDNO DIFFERENCE BETWEEN ASPIRIN ANDL. M. W. H IN: T. E COMPLICATIONP. EMORTALITYCONFIDENCE INTERVALMAJOR HEMORROGE

COMBINED MECHANICAL &

DRUG FOR 10- DAY AFTER

T. K. A IS MORE EFFECTIVE

MORE PATIENT OF ASPIRIN

GROUP MORE RETURN TO

THEATER FOR WOUND

COMPLICATION

CHARNLEY & CO 2012

7959 T. J. A 11 YEARS

1- PE: 8%

2- FATAL CASES 1%

IN T. J. A WITHOUT PROPHYLAXIS DVT 84%

CLINICALLY P.E 1.7%

FATAL CASE

OVERALL: IPC + L. M. W.H IS BETTER OF IPC + ASPIRIN OR WARFARIN

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