Low molecular weight heparin (enoxaparin) compared with unfractionated heparin in prophylaxis of deep venous thrombosis and pulmonary embolism in patients undergoing hip replacement.

Prophylactic efficacy and safety of a low molecular weight heparin (LMWH) and those of conventional unfractionated heparin (UH) were investigated in a randomized study. Totally, 167 consecutive patients undergoing total hip replacement were allocated to two groups. Patients in the LMWH-group (n = 83) received a fixed dose of enoxaparin 40 mg once daily, starting 12 hours preoperatively and continuing for 10 days. Patients in the UH-group (n = 84) received UH 5000 IU twice a day subcutaneously (sc), starting two hours before operation and continuing for 10 days. Deep venous thrombosis (DVT) was diagnosed by bilateral ultrasonography and confirmed by venography. Proximal DVTs were observed in four patients of UH-group (4.8%) and in one of LMWH-group (1.2%, P > 0.05). There was only one pulmonary embolism (PE) in a patient belonging to UH-group (1.2%). Low rates of thromboembolic events could be explained, in addition to heparin prophylaxis, also by early mobilization and regional anaesthesia. Local tolerance (size of haematoma), blood loss and transfusion requirements during the operation and the postoperative period did not show differences between the two study groups. The results of our study indicate that enoxaparin once daily is an effective and safe form of DVT prophylaxis in patients undergoing elective hip replacement.

Survival of the Lubinus hip prosthesis. An eight- to 12-year follow-up evaluation of 444 cases.

The Kaplan-Meier survival method was used to analyze 444 Lubinus arthroplasties in 398 patients who were observed between eight and 12 years. The indication for arthroplasty was osteoarthrosis in 316 hips, rheumatoid arthritis in 84 hips, and various other conditions for the other 44 hips. Survival was determined for the entire prosthesis, as well as separately for the femoral stem, the acetabulum cup, and their four subgroups. Four patient-related variables (diagnosis, gender, age, and weight) were analyzed. The overall survival of the Lubinus implants was 97.1% at five years and 87.1% at ten years. No significant difference in survival was found between the acetabular and femoral components. Survival was not significantly better with a new anatomic (SP1) stem than with the old curved one (IP). Of the four patient-related variables studied, only diagnosis and age had a significant effect on prosthesis survival. There was no difference in survival between osteoarthrosis and rheumatoid arthrosis hips, but survival was clearly poorer at ten years in the miscellaneous diagnosis group. The authors obtained a significantly lower survival percentage for patients younger than 65 years of age than for those 65 years and older. There were no deep postoperative infections in this series. The revision rate was 11.5%. The wear seen at the lower front edge of cups that were removed is discussed.

Outcome of closed injuries exceeding 20-unit blood transfusion need.

A series of 129 patients with closed injuries receiving more than 20 units (1 unit = 500 ml) of blood within the first 48 h of accident was analysed. The transfusion policy included type-specific crossmatched whole blood stored with citrate phosphate-adenine as the main replacement. One unit of fresh whole blood was transfused for every 5 to 6 units of stored blood. Also platelet concentrates and fresh frozen plasma were in routine use. The patients required 340 surgical procedures, on average 2.6 per patient. Thrombocytopenia with a lowest recorded platelet count of less than 100,000/mm3 occurred in 81 patients (63 per cent) of whom 18 had disseminated intravascular coagulation. This serious complication seemed to be associated with large retroperitoneal blood accumulations, the latter possibly acting as an enhancing factor. The mortality rate in the whole series was slightly lower than recorded previously in the literature. Among patients receiving 21 to 39 blood units the mortality was 25 per cent and among those receiving 40 units or more the mortality was 52 per cent.

Operative control of massive haemorrhage in comminuted pelvic fractures.

In 42 patients, massive haemorrhage following comminuted pelvic fractures was treated by operation through a mid-line, Pfannenstiel, anterior iliac crest-femoral or posterolateral approach, or using these in combination. The superior and inferior gluteal, pudendal and obturator arteries were the usual source of bleeding. Bleeding from the pelvic bone tissue was of minor importance. Temporary compression of the abdominal aorta was sometimes required to help control bleeding before ligation of injured vessels could be accomplished. An average of nine units of blood was given to each patient before operation and 30 units during or after the procedure. Of the 12 deaths, only three were attributable to bleeding from the pelvic fractures, indicating the value of operation in the treatment of massive haemorrhage from such injuries.

External fixation of unstable pelvic fractures.

The Hoffmann external fixator was used to stabilize unstable pelvic fractures in 56 patients with multiple injuries. It was applied under general anaesthesia and the dislocated pelvis reduced and secured with a single tie bar. In 16 cases residual dislocation of less than 1.5 cm was noted after the reduction and the reduced position was maintained in 48 out of 51 cases, a minor redislocation occurred in the remaining 3 patients. Few complications could be attributed to the method, infection was noted in one patient, the iliac crest was fractured in one case and an exostosis of the iliac crest occurred in one youth. Forty-three patients were symptom free with regard to the pelvis at the time of review whereas 5 patients had residual pain and 3 diffuse symptoms. The technique of application is simple but requires two surgeons at the time of reduction and fixation of the pelvis.

Primary operative fixation of long bone fractures in patients with multiple injuries.

Early mobilization is essential for patients with multiple long bone fractures associated with other injuries in order to avoid complications. Therefore, in 1969 we adopted a policy of rigid internal fixation of long bone fractures in such cases. To assess the results of this active treatment a number of consecutive patients were followed. The following conditions were necessary for the case to be included in this series: multiple injuries; treatment at the intensive care unit; and at least two long-bone fractures treated with internal fixation. During the period from 1969 to 1974 47 patients met all requirements. With primary operative fixation of long bone fractures of patients with multiple injuries it was possible to mobilize on crutches 29 patients out of 47 within 2 1/2 months of the accident, and 32 were allowed to leave the hospital within 3 months. With the exception of the death of an 80-year-old woman, no severe complications attributed to the operative treatment of these fractures occurred and 32 out of 47 patients returned to work within 16 months. The results in these 47 cases show that in patients with multiple injuries associated with several long bone fractures, primary internal fixation is preferable to the more conventional conservative methods.

Subcapital fractures of the femur treated with two thin Smith-Petersen nails.

The results of treatment of 71 patients with subcapital fractures of the femur, fixed with two thin Smith-Petersen nails, are presented, after a follow-up time of between 2 and 4 years. Excellent results of treatment were achieved in 39 out of 60 cases and good results in 11 cases. Six cases of ischemic necrosis of the femoral head were recorded, and there were four cases with pseudarthrosis of the femoral neck, one developed because of postoperative infection and three were attributed to an imperfect operative technique. The method is recommended for subcaptial femoral neck fractures amenable to closed reduction and internal fixation. Pseudarthrosis may be prevented by good reduction of the fracture and a careful nailing technique.

Pertrochanteric fractures of the femur treated with a Küntscher trochanter nail.

Thirty-nine patients with pertrochanteric fractures were treated with the Küntscher trochanter nail. Six were males and 33 females. Their mean age was 76 years. Excellent or good results of treatment were recorded in 25 cases, and good union of the fracture was noted in 19 patients within 4 months and in 15 cases as early as 2 months after the operation. The primary mortality rate was of the same order as with other methods of nailing, 15% in this series. The operation is easy and short, and is suitable at least for stable pertrochanteric fractures of elderly patients.