Orthopedics
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Hip dislocation is a well-described complication of total hip arthroplasty (THA) and dislocation rates are substantially higher following revision hip arthroplasty. Vascular complications following closed reduction of hip dislocations are exceedingly rare, but a high index of suspicion is essential for patients with underlying vascular abnormalities. Popliteal artery aneurysms are the most common peripheral arterial aneurysms with a prevalence of 1% and they should be suspected in patients with prominent popliteal pulses. ⋯ This case emphasizes the need for a high index of suspicion for vascular injuries following manipulation of limbs with underlying arterial aneurysms. Reduction maneuvers for hip dislocations should be modified to minimize compression of the popliteal fossa in limbs with vascular abnormalities. Serial postreduction neurovascular exams are essential for identification and prompt management of vascular complications.
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Venous thromboembolism remains the most common cause of hospital readmission and death after total joint arthroplasty. The 2008 American College of Chest Physicians (ACCP) guidelines, based on prospective randomized clinical trials with a venography endpoint, endorse the use of low-molecular-weight heparin, fondaparinux, or adjusted dose warfarin (target international normalized ratio, 2.5; range, 2-3) for up to 35 days after total hip arthroplasty (THA) and total knee arthroplasty (TKA). In the past, the ACCP has recommended against the use of aspirin, graduated compression stockings, or venous compression devices as the sole means of prophylaxis, but in 2008 they first recommended the "optimal use of mechanical thromboprophylaxis with venous foot pumps or intermittent pneumatic compression devices" in patients undergoing total joint arthroplasty who "have a high risk of bleeding." When the high risk subsides, pharmacologic thromboprophylaxis is substituted for, or added to, mechanical methods. ⋯ Newer Xa and thrombin inhibitors enjoy greater efficacy with equal or higher bleeding rates. Low-intensity warfarin (target international normalized ratio, 2.0) combines safety (bleeding rates <1%) with efficacy (readmission for clinical DVT or pulmonary embolism 0.2%) after total joint arthroplasty. Warfarin represents a therapeutic compromise by preventing clinical events in exchange for a lower bleeding rate; genetic testing will likely simplify warfarin use and reduce outlier responders.
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Although the long-term results following traditional total joint arthroplasty are excellent, postoperative pain management has been suboptimal. Under-treatment of pain is a focus of growing concern to the orthopedic community. ⋯ Effective protocols are currently available; all include a multimodal approach. Debate continues regarding the ideal approach; however, reliance on narcotic analgesia alone is suboptimal.