Thrombocytosis After Hip and Knee Surgery
Thrombocytosis After Hip and Knee Surgery
Consecutive patients discharged from the orthopaedic unit and admitted to the intensive rehabilitation unit of our hospital were identified. The ward uses multidisciplinary staff and a multidisciplinary approach to treating patients. Our staff work in teams to apply management and rehabilitation strategies coupled with a comprehensive geriatric assessment aimed at preventing complications and caring for concomitant diseases. With approval from the ethics committee of our Hospital IRCCS "Casa Sollievo della Sofferenza" and after obtaining written informed consent, patients who had undergone hip and knee surgery due to severe arthritis or fracture who required surgical intervention or arthroplasty were enrolled. Those with infections, malignancy, neurological diseases, renal and liver failure, osteomyelitis, multiple trauma, rheumathoid arthritis, primary thrombocytosis or previously ascertained blood disorders were excluded because of potential confounding effects on the results.
Comorbidities and data regarding the causes of major joint surgery, including the type of orthopaedic surgery, the time elapsed after surgery before rehabilitation admission, and the length of stay were collected. Comorbidities were evaluated using the Cumulative Illness Rating Scale (CIRS) on admission. A global functional evaluation was undertaken using the Barthel Scale (BS) and the Functional Independence Measure (FIM) on admission and at discharge. A limitation of these scales lies in the definition of functional modifications in ambulation. To offset this inadequacy, gait was independently classified into four functional levels graded from zero to three: grade zero, no gait or bedridden; grade one, uses a wheelchair; grade two, uses a double support or walker; and grade three, walks unaided or uses a cane. The BS provides a quantification of the global functional recovery and dependence in some of the basic activities of self-care. It ranges from zero to 100, with zero indicating a totally dependent, bedridden state and 100 indicating that the patient is fully independent. The activities can be divided into behaviour that relates to self-care (feeding, grooming, bathing, dressing, bowel and bladder care and toilet use) and behaviour related to mobility (ambulation, transfers and stairs climbing).
Motor and cognitive FIM subscales include 18 items. Each item uses a seven-point ordinal scale from total assistance (a score of one) to complete independence (a score of seven). The motor FIM scores are divided into four subscales that include 13 items as follows: self-care (eating, grooming, bathing, upper body dressing, lower body dressing, and toileting), sphincter control (bladder management and bowel management), mobility (bed, chair and wheelchair transfer, toilet transfer, and bathtub or shower transfer), and locomotion (walking or wheelchair and ability to climb stairs).
Blood parameters including PLTC, red blood cells (RBC), haemoglobin (Hb) and albumin level were assessed on admission and at discharge. Furthermore, fibrinogen, erythrocyte sedimentation rate (ESR), and D-dimers were assessed at the same time. PLTC was evaluated using an automatic counter (Coulter LH780, Haematology Analyser, Beckman, Miami, USA). Blood samples were collected in tubes with potassium EDTA and were analysed 1 h after venipuncture. D-dimers were measured using an Elisa technique (VidasD-dimer, Biomerieux, France).
Thrombocytosis refers to a PLTC above the normal value. For our laboratory, the normal PLTC range was 150–380 × 100/L. A PLTC was considered elevated or abnormal when the value was higher than the established normal laboratory range. The PLTC for each subject was recorded as either mildly high (381–500 × 100/L), high (501–600 × 100/L), or very high (>600 × 100/L). Thrombocytosis was considered to be present when a PLTC was greater than or equal to 500 × 100/L. All subjects with thrombocytosis underwent lower limb duplex scan ultrasonography to assess deep venous thrombosis (DVT) occurrence. The examination was repeated in those who had persistent thrombocytosis at discharge. Furthermore, in order to ascertain the difference in platelet change between old and young people, the enrolled sample was divided into young and old groups where the subjects ages were equal to or less than 75 years or more than 75 years, respectively.
All subjects received rehabilitation treatment for approximately two hours a day, six days per week in accordance with their clinical condition. Upon admission, the subjects were moved from beds to chairs. The rehabilitation program consisted of joint mobilisation, proprioceptive neuromuscular facilitation, flexibility exercises, strength exercises and gait training. An unrestricted weight-bearing regimen was initiated in those who had TKA and THA. Subjects with dynamic compression hip screws with a plate received a gradually increasing load on the affected limb.
Longitudinal measures were analysed using repeated measurements ANOVA. Between groups comparisons were performed using the Mann–Whitney U test or unpaired two-tailed Student's t-test at each time point. The Pearson chi-square test was used to compare categorical variables. For the ANOVA analyses, values missing for a patient were linearly interpolated. Correlations between continuous variables were assessed using the Spearman coefficient. A p-value < 0.05 was considered as statistically significant. All analyses were performed using SAS Release 9.3 statistical software.
Methods
Consecutive patients discharged from the orthopaedic unit and admitted to the intensive rehabilitation unit of our hospital were identified. The ward uses multidisciplinary staff and a multidisciplinary approach to treating patients. Our staff work in teams to apply management and rehabilitation strategies coupled with a comprehensive geriatric assessment aimed at preventing complications and caring for concomitant diseases. With approval from the ethics committee of our Hospital IRCCS "Casa Sollievo della Sofferenza" and after obtaining written informed consent, patients who had undergone hip and knee surgery due to severe arthritis or fracture who required surgical intervention or arthroplasty were enrolled. Those with infections, malignancy, neurological diseases, renal and liver failure, osteomyelitis, multiple trauma, rheumathoid arthritis, primary thrombocytosis or previously ascertained blood disorders were excluded because of potential confounding effects on the results.
Clinical and Functional Assessment
Comorbidities and data regarding the causes of major joint surgery, including the type of orthopaedic surgery, the time elapsed after surgery before rehabilitation admission, and the length of stay were collected. Comorbidities were evaluated using the Cumulative Illness Rating Scale (CIRS) on admission. A global functional evaluation was undertaken using the Barthel Scale (BS) and the Functional Independence Measure (FIM) on admission and at discharge. A limitation of these scales lies in the definition of functional modifications in ambulation. To offset this inadequacy, gait was independently classified into four functional levels graded from zero to three: grade zero, no gait or bedridden; grade one, uses a wheelchair; grade two, uses a double support or walker; and grade three, walks unaided or uses a cane. The BS provides a quantification of the global functional recovery and dependence in some of the basic activities of self-care. It ranges from zero to 100, with zero indicating a totally dependent, bedridden state and 100 indicating that the patient is fully independent. The activities can be divided into behaviour that relates to self-care (feeding, grooming, bathing, dressing, bowel and bladder care and toilet use) and behaviour related to mobility (ambulation, transfers and stairs climbing).
Motor and cognitive FIM subscales include 18 items. Each item uses a seven-point ordinal scale from total assistance (a score of one) to complete independence (a score of seven). The motor FIM scores are divided into four subscales that include 13 items as follows: self-care (eating, grooming, bathing, upper body dressing, lower body dressing, and toileting), sphincter control (bladder management and bowel management), mobility (bed, chair and wheelchair transfer, toilet transfer, and bathtub or shower transfer), and locomotion (walking or wheelchair and ability to climb stairs).
Assessment of Platelet and Blood Parameters
Blood parameters including PLTC, red blood cells (RBC), haemoglobin (Hb) and albumin level were assessed on admission and at discharge. Furthermore, fibrinogen, erythrocyte sedimentation rate (ESR), and D-dimers were assessed at the same time. PLTC was evaluated using an automatic counter (Coulter LH780, Haematology Analyser, Beckman, Miami, USA). Blood samples were collected in tubes with potassium EDTA and were analysed 1 h after venipuncture. D-dimers were measured using an Elisa technique (VidasD-dimer, Biomerieux, France).
Degree of Thrombocytosis
Thrombocytosis refers to a PLTC above the normal value. For our laboratory, the normal PLTC range was 150–380 × 100/L. A PLTC was considered elevated or abnormal when the value was higher than the established normal laboratory range. The PLTC for each subject was recorded as either mildly high (381–500 × 100/L), high (501–600 × 100/L), or very high (>600 × 100/L). Thrombocytosis was considered to be present when a PLTC was greater than or equal to 500 × 100/L. All subjects with thrombocytosis underwent lower limb duplex scan ultrasonography to assess deep venous thrombosis (DVT) occurrence. The examination was repeated in those who had persistent thrombocytosis at discharge. Furthermore, in order to ascertain the difference in platelet change between old and young people, the enrolled sample was divided into young and old groups where the subjects ages were equal to or less than 75 years or more than 75 years, respectively.
Rehabilitative Interventions
All subjects received rehabilitation treatment for approximately two hours a day, six days per week in accordance with their clinical condition. Upon admission, the subjects were moved from beds to chairs. The rehabilitation program consisted of joint mobilisation, proprioceptive neuromuscular facilitation, flexibility exercises, strength exercises and gait training. An unrestricted weight-bearing regimen was initiated in those who had TKA and THA. Subjects with dynamic compression hip screws with a plate received a gradually increasing load on the affected limb.
Statistical Analysis
Longitudinal measures were analysed using repeated measurements ANOVA. Between groups comparisons were performed using the Mann–Whitney U test or unpaired two-tailed Student's t-test at each time point. The Pearson chi-square test was used to compare categorical variables. For the ANOVA analyses, values missing for a patient were linearly interpolated. Correlations between continuous variables were assessed using the Spearman coefficient. A p-value < 0.05 was considered as statistically significant. All analyses were performed using SAS Release 9.3 statistical software.