Efficacy and Safety of Enoxaparin versus New Oral Anticoagulants to Prevent Venous Thromboembolism after Total Hip Replacement: A Systematic Review and Meta-Analysis

Prophylactic anticoagulant therapy is recommended for reducing the risk of venous thromboembolism (VTE) after a total hip replacement (THR). However, it is not clear which anticoagulant is preferable. Hence, a systematic review and meta-analysis of randomized double-blind controlled trials (RDBCTs) were conducted to investigate the clinical efficacy and safety of enoxaparin in comparison with newer oral anticoagulants for the prevention of VTE after THR. The Cochrane Library, Scopus, Web of Science, Embase, and PubMed/Medline databases were used for PICO search strategy. Relative risks (RR) of symptomatic VTE, clinically relevant bleeding, mortality, and a net clinical endpoint were estimated employing a random effect meta-analysis. ITC and RevMan software were used for indirect and direct comparisons, respectively. Nine RDBCTs comprising 24,584 patients were included. As compared to enoxaparin, a reduced risk for symptomatic VTE was observed with rivaroxaban (confidence interval [CI]: 0.32–0.77; RR: 0.46%) and comparable with apixaban (0.12–1.26; 0.42%) and dabigatran (0.22–2.20; 0.70%). Contrarily to enoxaparin, a greater risk for clinically relevant bleeding was observed with rivaroxaban (1.03–1.48; 1.23%), comparable with dabigatran (0.96–1.33; 1.10%) and reduced with apixaban (0.19–5.66; 0.96%). In indirect or direct comparisons, the interventions did not differ on the net clinical endpoint. In conclusion, the findings of this meta-analysis revealed no significant difference in the efficacy and safety of new oral anticoagulants as compared to enoxaparin for the prevention of VTE after total hip replacement surgery.

Are dogs with hip dysplasia in less pain after total hip replacement than femoral head ostectomy?

PICO question In large breed juvenile dogs with hip dysplasia and radiographic bilateral osteoarthritis, is a total hip replacement superior/inferior/or equivalent to bilateral femoral head ostectomy at reducing the severity of long-term hip pain? Clinical bottom line Category of research question Treatment The number and type of study designs reviewed Twelve papers were critically appraised. One paper was a systematic review. Six papers were prospective case series. Five papers were retrospective case series Strength of evidence Weak Outcomes reported Besides one systematic review, there are no other studies available that directly compare pain reduction with total hip replacement and femoral head ostectomy for the treatment of hip dysplasia in large breed juvenile dogs with radiographic evidence of secondary osteoarthritis. In one study, 12/12 (100%)of owners that responded to an owner outcome questionnaire reported no hip pain with femoral head and neck ostectomy. In this study, owners assessed pain based on activity level of the dog (running, playing, jumping, using stairs normally), gait abnormalities (only when running or after strenuous exercise), and duration of postoperative medications. In eight studies, 91–100% of cases had no hip pain with total hip replacement reported via clinical examination and/or owner outcome questionnaire Conclusion There is evidence suggesting that both total hip replacement and femoral head ostectomy may be capable of reducing long-term pain as a result of osteoarthritis, secondary to hip dysplasia, however, based on the current literature, it is challenging to say whether total hip replacement is superior to femoral head and neck ostectomy at reducing long-term hip pain. It is important to recognise that other factors considered as outcomes (i.e. range of motion, ground reaction forces, force-plate analysis, etc.) may contribute to differing outcomes overall for total hip replacement vs femoral head ostectomy, but this paper focused specifically on pain. While there is a systematic review that provides evidence supporting that total hip replacement is superior at returning dogs to normal function, evaluating return to normal function was not the focus of this Knowledge Summary How to apply this evidence in practice The application of evidence into practice should take into account multiple factors, not limited to: individual clinical expertise, patient’s circumstances and owners’ values, country, location or clinic where you work, the individual case in front of you, the availability of therapies and resources. Knowledge Summaries are a resource to help reinforce or inform decision making. They do not override the responsibility or judgement of the practitioner to do what is best for the animal in their care.

Worse patient-reported outcomes and higher risk of reoperation and adverse events after total hip replacement in patients with opioid use in the year before surgery: a Swedish register-based study on 80,483 patients

Background and purpose — Recent studies indicate that preoperative use of opioids could be associated with higher rates of complications and worse patient-reported outcomes (PROs) after orthopedic surgery. We investigated the prevalence of preoperative opioid use and analyzed its influence on risk of revision, adverse events (AE), and PROs in patients with total hip replacement (THR). Patients and methods — This observational study included 80,483 patients operated on in 2008–2016 with THRs due to osteoarthritis. Data was obtained from the Swedish Hip Arthroplasty Register, Statistics Sweden’s sociodemographic registers, the Swedish National Patient Register, and the Prescribed Drug Register. We focused on patients with ≥ 4 opioid prescriptions filled 1 year prior to THR. To control for confounding, we used propensity scores to weight subjects in our analyses. Logistic and linear regression was used for outcome variables with adjustments for sociodemographic variables and comorbidities. Results — Patients with ≥ 4 opioid prescriptions in the year before THR (n = 14,720 [18%]) had a higher risk of revision within 2 years (1.8% vs. 1.1% OR 1.4, 95% CI 1.3–1.6) and AE within 90 days (9.4% vs. 6.4% OR 1.2, 95% CI 1.2–1.3) compared with patients without opioid treatment in the preoperative period. Patients with ≥ 4 opioid prescriptions rated 5 points worse on a 0–100 scale of Pain VisualAnalogue Scale (VAS) and 9 points worse on a generalhealth (EQ) VAS 1 year postoperatively. Interpretation — Having ≥ 4 opioid prescriptions filled in the year before surgery is associated with a higher risk of revision, adverse events, and worse PROs after THR. Consequently, preoperative opioid treatment should be addressed in the clinical assessment of patients eligible for THR.

Management of Primary AVN with Total Hip Replacement

Introduction: Avascular necrosis (AVN) of femoral head is a dreadful and disabling condition. Total Hip Replacement (THR) is an effective solution. In this study we have analyzed the results of total hip replacement performed in ShSMCH, Dhaka for AVN of femoral head from July 2018 up to June 2020. Patients and Methods: In this prospective study, 19 total hip replacement were done. All patients were diagnosed as primary AVN of Ficat and Arlet Grade III and IV. Out of 19 patients, 15 patients operated with cementless pressfit implants and 4 patients with cemented implants. Results: Among the 19 patients 12 were male (63.15%) and 7 were female (36.85%). Mean age was 35.57 year. Operation done on right hip in 10 patients (52.63%) and on left hip 9 patients (47.37%). All the patients were evaluated pre-operatively and Harris Hip Score was poor ie, average 41.84. Three months post operatively Harris Hip Score improved significantly 47.36% patients value was 90-100 ie, excellent, 31.57% patients value was 80-90 ie, good and 21.05% patients value was 70-80 ie, fair. None documented as poor. In complication, 1 patient (5.26%) developed serous discharge which resolved with antibiotic treatment after culture and sensitivity. Conclusion: THR is the most effective method of removing pains and distress of end stage AVN of hip. J Shaheed Suhrawardy Med Coll 2020; 12(2): 87-89

Comparison of the accuracy of 2D and 3D templating methods for planning primary total hip replacement: a systematic review and meta-analysis

There are advocates of both two-dimensional (2D) and three-dimensional (3D) templating methods for planning total hip replacement. The aim of this study was to compare the accuracy of implant size prediction when using 2D and 3D templating methods for total hip arthroplasty, as well as to compare the inter- and intra-observer reliability in order to determine whether currently available methods are sufficiently reliable and reproducible. Medline, EMBASE and PubMed were searched to identify studies that compared the accuracy of 2D and 3D templating for total hip replacement. Results were screened using the PRISMA flowchart and included studies were assessed for their level of evidence using the Oxford CEBM criteria. Non-randomized trials were critically appraised using the MINORS tool, whilst randomized trials were assessed using the CASP RCT checklist. A series of meta-analyses of the data for accuracy were also conducted. Ten studies reported that 3D templating is an accurate and reliable method of templating for total hip replacement. Six studies compared 3D templating with 2D templating, all of which concluded that 3D templating was more accurate, with three finding a statistically significant difference. The meta-analyses showed that 3D CT templating is the most accurate method. This review supports the hypothesis that 3D templating is an accurate and reliable method of preoperative planning, which is more accurate than 2D templating for predicting implant size. However, further research is needed to ascertain the significance of this improved accuracy and whether it will yield any clinical benefit.