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Jiang YQ, Wang YZ, Hu AN, Zhou J, Li XL, Qi Q, Dong J. Analysis of D-dimer levels for the detection of deep venous thrombosis for patients with spinal metastasis undergoing decompression with fixation. BMC Musculoskelet Disord 2024; 25:672. [PMID: 39192260 DOI: 10.1186/s12891-024-07792-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2023] [Accepted: 08/16/2024] [Indexed: 08/29/2024] Open
Abstract
BACKGROUND Deep venous thrombosis (DVT) after spinal surgery has recently attracted increasing attention. Patients with spinal metastases who undergo decompression with fixation are at a high risk of developing DVT. D-dimer levels indicate the risk of DVT, and the purpose of our study was to investigate D-dimer levels as a predictor of DVT perioperatively. METHODS We prospectively evaluated 100 patients with spinal metastases. D-dimer tests were performed twice: once before surgery and one day postoperatively. DVT was diagnosed by duplex ultrasonographic assessment of both lower extremities. Pulmonary embolisms (PEs) were diagnosed using multidetector computed tomography and pulmonary angiography. Perioperative serum D-dimer levels were compared between the DVT (+) and DVT (-) groups. The cutoff value of the D-dimer level was calculated using receiver operating characteristic analysis. RESULTS Preoperative and postoperative DVT prevalences were 8.0% (8/100) and 6.6% (6/91), respectively, and none of the patients developed PE. Before surgery, there was no significant differences in D-dimer levels between the pre-DVT (+) and pre-DVT (-) groups. After surgery, the D-dimer level one-day postoperatively for the post-DVT (+) group (17.6 ± 11.8 mg/L) was significantly higher than that of the post-DVT (-) group (5.0 ± 4.7 mg/L). The cutoff value of the postoperative D-dimer level was 9.51(mg/L), and the sensitivity and specificity for the optimum threshold were 83.3% and 89.4%, respectively. CONCLUSIONS Our findings suggest that preoperative D-dimer level may not be a predictor of DVT. Preoperative ultrasound examinations should be routinely performed in patients with spinal metastases. Postoperative D-dimer levels greater than 9.51(mg/L) are a predictive factor for the early diagnosis of DVT after spine surgery. TRIAL REGISTRATION Our study was registered on Chinese Clinical Trial Registry (No.ChiCTR2000029737). Registered 11 February 2020 - Retrospectively registered, https://www.chictr.org.cn/index.aspx.
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Affiliation(s)
- Yun-Qi Jiang
- Department of Orthopaedic Surgery, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, PR China
| | - Yu-Zhu Wang
- Department of Pharmacy, Zhongshan Hospital, Fudan University, Shanghai, PR China
| | - An-Nan Hu
- Department of Orthopaedic Surgery, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, PR China
| | - Jian Zhou
- Department of Orthopaedic Surgery, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, PR China
| | - Xi-Lei Li
- Department of Orthopaedic Surgery, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, PR China
| | - Qing Qi
- Department of Ultrasonography, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, PR China.
| | - Jian Dong
- Department of Orthopaedic Surgery, Zhongshan Hospital, Fudan University, 180 Fenglin Road, Shanghai, 200032, PR China.
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van Oosterom N, Barras M, Cottrell N. Prevalence of risk factors for venous thromboembolism and aspirin resistance in Australian patients undergoing total hip and knee arthroplasty. Intern Med J 2024; 54:1275-1282. [PMID: 38775166 DOI: 10.1111/imj.16407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2023] [Accepted: 04/18/2024] [Indexed: 08/20/2024]
Abstract
INTRODUCTION Aspirin is used for venous thromboembolism (VTE) prophylaxis after total hip and knee arthroplasty (THA/TKA). However, its efficacy is unclear in patients with multiple VTE risk factors and at risk of aspirin resistance (AR). BACKGROUND AND AIMS To determine the prevalence of risk factors for VTE and AR in patients after THA/TKA and to determine the relationship between risk factors and drugs prescribed for thromboprophylaxis. METHODS A retrospective cohort study of elective-THA/TKA in six Australian hospitals over a 1-year period. Medical records were manually reviewed to determine demographics, thromboprophylaxis regimen and presence of risk factors. The relationship between individual and cumulative risk factors with the thromboprophylaxis regimen was determined. RESULTS In total, 1011 patients were included with a mean (SD) age of 65.9 (±11.0) years, and 56.4% were female. The five most prevalent risk factors were obesity (59.1%), age ≥65 years (58.2%), hypertension (45.3%), dyslipidaemia (35.9%) and diabetes (19.7%). Most patients had ≥1 risk factor for VTE (93.6%) and AR (93.6%), with 49.0% and 35.0% having ≥3 concurrent VTE and AR risk factors, respectively. The only significant relationship between risk factors and drugs was diabetes (P < 0.01). Rivaroxaban was more commonly used as the number of concurrent VTE risk factors increased (P < 0.05). CONCLUSION Patients had a high prevalence of VTE and AR risk factors, suggesting aspirin may not be beneficial in many patients. Only diabetes was linked to the selection of thromboprophylaxis. Patients who received rivaroxaban had a greater average number of VTE risk factors. Guidelines should promote individualised prescribing in higher-risk patients.
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Affiliation(s)
- Nameer van Oosterom
- School of Pharmacy, University of Queensland, Brisbane, Queensland, Australia
- Pharmacy Department, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Michael Barras
- School of Pharmacy, University of Queensland, Brisbane, Queensland, Australia
- Pharmacy Department, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Neil Cottrell
- School of Pharmacy, University of Queensland, Brisbane, Queensland, Australia
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Wu J, Huangfu X, Yan X, Dong S, Xie G, Zhao S, Xu C, Xu J, Zhao J. Independent Risk Factors Associated With Venous Thromboembolism After Knee Arthroscopy: A Retrospective Study of 222 Patients. Orthop J Sports Med 2024; 12:23259671241257820. [PMID: 39183971 PMCID: PMC11344252 DOI: 10.1177/23259671241257820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 12/05/2023] [Indexed: 08/27/2024] Open
Abstract
Background A serious complication after knee arthroscopy is venous thromboembolism (VTE), which includes both deep vein thrombosis (DVT) and pulmonary embolism (PE). However, asymptomatic VTE is frequently undetected. Purpose To (1) report the incidence of VTE after knee arthroscopy using ultrasound examination and computed tomography pulmonary angiography (CTPA) and (2) discover the independent risk factors of VTE after knee arthroscopy and determine the corresponding cutoff values of these indicators. Study Design Case-control study; Level of evidence, 3. Methods Included were 222 patients (115 male) who underwent arthroscopic knee procedures between October 2022 and January 2023. Baseline characteristics, blood test results, and VTE assessments were collected. During the 2-week follow-up, routine lower extremity vascular ultrasound was applied for DVT measurement, with CTPA evaluation for suspected PE. Patients were allocated into VTE and no-VTE groups, and descriptive statistics were used to analyze baseline data. Logistic regression analysis was used to determine the correlation between binary variables and the presence of postoperative VTE. Multivariate logistic regression analysis was further performed to determine the independent risk factors of VTE. Results Of the 222 patients, 37 (16.7%) had DVT and 1 (0.5%) had both DVT and PE. Compared to the no-VTE group, the VTE group was significantly older, with more female patients; higher body mass index (BMI) and postoperative D-dimer level; and higher rates of hypertension, hyperlipidemia, varicose veins of the lower extremity, and abnormal postoperative fibrin degradation product level (P≤ .043 for all). Notably, operative time >20 minutes was not significantly associated with postoperative VTE (P = .513). The independent risk factors for VTE included age >32 years (odds ratio [OR], 20.71 [95% CI, 4.40-97.47]; P < .001), BMI >23 kg/m2 (OR, 3.52 [95% CI, 1.11-11.14]; P = .032), hyperlipidemia (OR, 6.81 [95% CI, 1.86-24.88]; P = .004), and postoperative D-dimer level >0.63 mg/L (OR, 34.01 [95% CI, 7.36-157.07]; P < .001). Conclusion The incidence of VTE after knee arthroscopy was 16.7% at the 2-week follow-up. Age >32 years, BMI >23 kg/m2, hyperlipidemia, and postoperative D-dimer >0.63 mg/L were independent risk factors of postoperative VTE within 2 weeks after knee arthroscopy. For patients with knee arthroscopy, the cutoff value of postoperative D-dimer for VTE was found to be 0.63 mg/L for timely intervention.
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Affiliation(s)
- Jinlong Wu
- Department of Sports Medicine, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaoqiao Huangfu
- Department of Sports Medicine, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiaoyu Yan
- Department of Sports Medicine, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Shikui Dong
- Department of Sports Medicine, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Guoming Xie
- Department of Sports Medicine, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Song Zhao
- Department of Sports Medicine, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Caiqi Xu
- Department of Sports Medicine, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Junjie Xu
- Department of Sports Medicine, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jinzhong Zhao
- Department of Sports Medicine, Shanghai Sixth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Yong BSJ, Ling RR, Li R, Poh JW, Tan CS, Ho SWL, Rochwerg B, Arya R, Ramanathan K, Fan BE. Pharmacotherapy for Venous Thromboprophylaxis following Total Hip or Knee Arthroplasty: A Systematic Review and Network Meta-analysis. Semin Thromb Hemost 2024. [PMID: 38950598 DOI: 10.1055/s-0044-1787996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/03/2024]
Abstract
The optimal pharmacological prophylaxis for venous thromboembolism (VTE) after hip or knee arthroplasty is uncertain. We conducted a systematic review and network meta-analysis to compare the efficacy and safety of various medications. We searched multiple databases for randomized clinical trials (RCTs) comparing medications (including factor Xa inhibitors, factor IIa inhibitor, warfarin, unfractionated heparin [UFH], low-molecular-weight heparin [LMWH], aspirin, pentasaccharide) for VTE prophylaxis post-arthroplasty. Outcomes included any postoperative VTE identified with screening, major bleeding, and death. We used LMWH as the main comparator for analysis and performed trial sequential analysis (TSA) for each pairwise comparison. Certainty of evidence was assessed using GRADE (Grading of Recommendations, Assessments, Developments and Evaluations). We analyzed 70 RCTs (55,841 participants). Factor Xa inhibitors decreased postoperative VTE significantly compared with LMWH (odds ratio [OR]: 0.55, 95% confidence interval [CI]: 0.44-0.68, high certainty). Pentasaccharides probably reduce VTE (OR: 0.61, 95% CI: 0.36-1.02, moderate certainty), while the factor IIa inhibitor dabigatran may reduce VTE (OR: 0.75, 95% CI: 0.40-1.42, low certainty). UFH probably increases VTE compared with LMWH (OR: 1.31, 95% CI: 0.91-1.89, moderate certainty), and other agents like warfarin, aspirin, placebo, and usual care without thromboprophylaxis increase VTE (high certainty). Factor Xa inhibitors may not significantly affect major bleeding compared with LMWH (OR: 1.06, 95% CI: 0.81-1.39, low certainty). No medications had a notable effect on mortality compared with LMWH (very low certainty). TSA suggests sufficient evidence for the benefit of factor Xa inhibitors over LMWH for VTE prevention. Compared with LMWH and aspirin, factor Xa inhibitors are associated with reduced VTE after hip or knee arthroplasty, without an increase in bleeding and likely no impact on mortality.
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Affiliation(s)
- Bryan Song Jun Yong
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Ryan Ruiyang Ling
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
| | - Ruiqi Li
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Jane Wenjin Poh
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
| | - Chuen Seng Tan
- Saw Swee Hock School of Public Health, National University of Singapore, National University Health System, Singapore, Singapore
| | - Sean Wei Loong Ho
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
- Department of Orthopaedic Surgery, Tan Tock Seng Hospital, Singapore, Singapore
| | - Bram Rochwerg
- Division of Critical Care, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Roopen Arya
- Department of Haematological Medicine, King's Thrombosis Centre, King's College Hospital Foundation NHS Trust, London, United Kingdom
| | - Kollengode Ramanathan
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
- Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, Singapore, Singapore
| | - Bingwen Eugene Fan
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore, Singapore
- Department of Haematology, Tan Tock Seng Hospital, Singapore, Singapore
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Palmer RC, Telang SS, Ball JR, Chung BC, Hong KM, Lieberman JR, Heckmann ND. Super-Obesity is Associated With an Increased Risk of Complications Following Primary Total Knee Arthroplasty. J Arthroplasty 2024:S0883-5403(24)00624-7. [PMID: 38889806 DOI: 10.1016/j.arth.2024.06.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 06/08/2024] [Accepted: 06/10/2024] [Indexed: 06/20/2024] Open
Abstract
BACKGROUND Obesity, defined as a body mass index (BMI) ≥ 30, is an ever-growing epidemic, with > 35% of adults in the United States currently classified as obese. Super-obese individuals, defined as those who have a BMI ≥ 50, are the fastest-growing portion of this group. This study sought to quantify the infection risk as well as the incidence of surgical, medical, and thromboembolic complications among super-obese patients undergoing total knee arthroplasty (TKA). METHODS An all-payer claims database was used to identify patients who underwent elective, primary TKA between 2016 and 2021. Patients who had a BMI ≥ 50 were compared to those who had a normal BMI of 18 to 25. Demographics and the incidence of 90-days postoperative complications were compared between the 2 groups. Univariate analysis and multivariable regression were used to assess differences between groups. RESULTS In total, 3,376 super-obese TKA patients were identified and compared to 17,659 patients who had a normal BMI. Multivariable analysis indicated that the super-obese cohort was at an increased postoperative risk of periprosthetic joint infection (adjusted odds ratio [aOR] 3.7, 95% confidence interval [CI]: 2.1 to 6.4, P < .001), pulmonary embolism (aOR 2.2, 95%-CI: 1.0 to 5.0, P = .047), acute respiratory failure (aOR 4.1, 95%-CI: 2.7 to 6.1, P < .001), myocardial infarction (aOR 2.5, 95%-CI: 1.1 to 5.8, P = .026), wound dehiscence (aOR 2.3, 95%-CI: 1.4 to 3.8, P = .001), and acute renal failure (aOR 3.2, 95%-CI: 2.4 to 4.2, P < .001) relative to patients who have normal BMI. CONCLUSIONS Super-obese TKA patients are at an elevated risk of postoperative infectious, surgical, medical, and thromboembolic complications. As such, risk stratification, as well as appropriate medical management and optimization, is of utmost importance for this high-risk group.
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Affiliation(s)
- Ryan C Palmer
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Sagar S Telang
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Jacob R Ball
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Brian C Chung
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Kurt M Hong
- Center for Clinical Nutrition, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Jay R Lieberman
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Nathanael D Heckmann
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
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6
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Zhang J, Shao Y, Zhou H, Li R, Xu J, Xiao Z, Lu L, Cai L. Prediction model of deep vein thrombosis risk after lower extremity orthopedic surgery. Heliyon 2024; 10:e29517. [PMID: 38720714 PMCID: PMC11076659 DOI: 10.1016/j.heliyon.2024.e29517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2023] [Revised: 04/08/2024] [Accepted: 04/09/2024] [Indexed: 05/12/2024] Open
Abstract
Purpose This investigation was conceived to engineer and appraise a pioneering clinical nomogram, crafted to bridge the extant chasm in literature regarding the postoperative risk stratification for deep vein thrombosis (DVT) in the aftermath of lower extremity orthopedic procedures. This novel tool offers a sophisticated and discerning algorithm for risk prediction, heretofore unmet by existing methodologies. Methods In this retrospective observational study, clinical records of hospitalized patients who underwent lower extremity orthopedic surgery were collected at the Wuxi TCM Hospital Affiliated to the Nanjing University of Chinese Medicine between Jan 2017 and Oct 2019. The univariate and multivariate analysis with the backward stepwise method was applied to select features for the predictive nomogram. The performance of the nomogram was evaluated with respect to its discriminant capability, calibration ability, and clinical utility. Result A total of 5773 in-hospital patients were eligible for the study, with the incidence of deep vein thrombosis being approximately 1 % in this population. Among 31 variables included, 5 of them were identified to be the predictive features in the nomogram, including age, mean corpuscular hemoglobin concentration (MCHC), D-dimer, platelet distribution width (PDW), and thrombin time (TT). The area under the receiver operating characteristic (ROC) curve in the training and validation cohort was 85.9 % (95%CI: 79.96 %-90.04 %) and 85.7 % (95%CI: 78.96 %-90.69 %), respectively. Both the calibration curves and decision curve analysis demonstrated the overall satisfactory performance of the model. Conclusion Our groundbreaking nomogram is distinguished by its unparalleled accuracy in discriminative and calibrating functions, complemented by its tangible clinical applicability. This innovative instrument is set to empower clinicians with a robust framework for the accurate forecasting of postoperative DVT, thus facilitating the crafting of bespoke and prompt therapeutic strategies, aligning with the rigorous standards upheld by the most esteemed biomedical journals.
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Affiliation(s)
- Jiannan Zhang
- Department of Anesthesiology, Wuxi TCM Hospital, Wuxi, 214071, PR China
| | - Yang Shao
- Department of Anesthesiology, Wuxi TCM Hospital, Wuxi, 214071, PR China
| | - Hongmei Zhou
- Department of Anesthesiology, Wuxi TCM Hospital, Wuxi, 214071, PR China
| | - Ronghua Li
- Department of Anesthesiology, Wuxi TCM Hospital, Wuxi, 214071, PR China
| | - Jie Xu
- Shanghai Artificial Intelligence Laboratory, Shanghai, 200030, PR China
- Université de Montpellier, Montpellier, Languedoc-Roussillon, France
| | - Zhongzhou Xiao
- Shanghai Artificial Intelligence Laboratory, Shanghai, 200030, PR China
| | - Lu Lu
- Shanghai Artificial Intelligence Laboratory, Shanghai, 200030, PR China
| | - Liangyu Cai
- Department of Anesthesiology, Wuxi TCM Hospital, Wuxi, 214071, PR China
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Roberts LN, Arya R, Hunt BJ. Advances and current research in primary thromboprophylaxis to prevent hospital-associated venous thromboembolism. Br J Haematol 2024; 204:1635-1648. [PMID: 38577829 DOI: 10.1111/bjh.19424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 03/13/2024] [Accepted: 03/13/2024] [Indexed: 04/06/2024]
Abstract
Hospital-associated venous thromboembolism (VTE) is defined as any case of VTE occurring during hospital admission and for up to 90 days post discharge. It accounts for over 50% of all cases of VTE internationally; indeed, there are an estimated 10 million cases of hospital-associated VTE annually. Over the last decade, there has been increasing interest in improving VTE risk assessment and thromboprophylaxis. This review summarises all the recent and ongoing major research studies and future challenges in the different areas, including medical, surgical and obstetric patients, as well as special areas such as lower limb immobilisation. We include sections on both pharmacological and mechanical thromboprophylaxis.
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Affiliation(s)
- Lara N Roberts
- Department of Haematological Medicine, King's Thrombosis Centre, King's College Hospital NHS Foundation Trust, London, UK
| | - Roopen Arya
- Department of Haematological Medicine, King's Thrombosis Centre, King's College Hospital NHS Foundation Trust, London, UK
| | - Beverley J Hunt
- Thrombosis & Haemophilia Centre, St Thomas' Hospital, London, UK
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Badge H, Churches T, Naylor JM, Xuan W, Armstrong E, Gray L, Fletcher J, Gosbell I, Lin CWC, Harris IA. Compliance with Australian Orthopaedic Association guidelines does not reduce the risk of venous thromboembolism after total hip and knee arthroplasty. Sci Rep 2024; 14:5955. [PMID: 38467650 PMCID: PMC10928067 DOI: 10.1038/s41598-024-54916-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2022] [Accepted: 02/18/2024] [Indexed: 03/13/2024] Open
Abstract
Preventing avoidable venous-thrombo-embolism (VTE) is a priority to improve patient and service outcomes after total hip and total knee arthroplasty (THA, TKA), but compliance with relevant clinical guidelines varies. This study aims to determine the degree to which prophylaxis was compliant with Australian Orthopaedic Association (AOA) VTE prophylaxis guidelines and whether non-compliance is associated with increased risk of VTE. A prospective multi-centre cohort study of adults with osteoarthritis undergoing primary TKA/THA was completed at 19 high-volume public and private hospitals. Data were collected prior to surgery and for one-year post-surgery. Logistic regression was undertaken to explore associations between non-compliance with AOA VTE prophylaxis guidelines and symptomatic 90-day VTE outcomes. Data were analysed for 1838 participants from 19 sites. The rate of non-compliance with all clinical guideline recommendations was 20.1% (N = 369), with 14.1% (N = 259) non-compliance for risk-stratified prophylaxis, 35.8% (N = 658) for duration, and 67.8% (N = 1246) for other general recommendations. Symptomatic VTE was experienced up to 90-days post-surgery by 48 people (2.6%). Overall guideline non-compliance (AOR = 0.93, 95%CI = 0.4 to 1.3, p = 0.86) was not associated with a lower risk of symptomatic 90-day VTE. Results were consistent when people with high bleeding risk were excluded (AOR = 0.94, 95%CI = 0.44 to 2.34, p = 0.89). Non-compliance with the AOA VTE prophylaxis guidelines was not associated with risk of 90-day VTE after arthroplasty. This counterintuitive finding is concerning and necessitates a rigorous review of the AOA VTE prevention clinical guideline.
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Affiliation(s)
- Helen Badge
- Whitlam Orthopaedic Research Centre, 1 Campbell Street, Liverpool, 2071, Australia.
- South Western Sydney Clinical School, UNSW, 1 Elizabeth Street, Liverpool, 2071, Australia.
- Ingham Institute for Applied Medical Research, 1 Campbell Street, Liverpool, 2071, Australia.
- Australian Catholic University, 8-20 Napier Street, North Sydney, 2060, Australia.
| | - Tim Churches
- South Western Sydney Clinical School, UNSW, 1 Elizabeth Street, Liverpool, 2071, Australia
- Ingham Institute for Applied Medical Research, 1 Campbell Street, Liverpool, 2071, Australia
| | - Justine M Naylor
- Whitlam Orthopaedic Research Centre, 1 Campbell Street, Liverpool, 2071, Australia
- South Western Sydney Clinical School, UNSW, 1 Elizabeth Street, Liverpool, 2071, Australia
- Ingham Institute for Applied Medical Research, 1 Campbell Street, Liverpool, 2071, Australia
| | - Wei Xuan
- South Western Sydney Clinical School, UNSW, 1 Elizabeth Street, Liverpool, 2071, Australia
- Ingham Institute for Applied Medical Research, 1 Campbell Street, Liverpool, 2071, Australia
| | - Elizabeth Armstrong
- School of Public Health, The University of New South Wales, UNSW Kensington Campus, 2033, Botany Street, Kensington, NSW, 2052, Australia
| | - Leeanne Gray
- South Western Sydney Local Health District, 1 Elizabeth Street, Liverpool, 2071, Australia
| | - John Fletcher
- University of Sydney, Fisher Road, Camperdown, NSW, 2006, Australia
- Westmead Hospital, Cnr Hawkesbury Road and Darcy Road, Westmead, NSW, 2145, Australia
| | - Iain Gosbell
- Ingham Institute for Applied Medical Research, 1 Campbell Street, Liverpool, 2071, Australia
- Western Sydney University, Campbelltown, NSW, 2560, Australia
| | - Chung-Wei Christine Lin
- Sydney School of Population Health, The University of Sydney, Edward Ford Building (A27) Fisher Road, Camperdown, NSW, 2006, Australia
| | - Ian A Harris
- Whitlam Orthopaedic Research Centre, 1 Campbell Street, Liverpool, 2071, Australia
- South Western Sydney Clinical School, UNSW, 1 Elizabeth Street, Liverpool, 2071, Australia
- Ingham Institute for Applied Medical Research, 1 Campbell Street, Liverpool, 2071, Australia
- South Western Sydney Local Health District, 1 Elizabeth Street, Liverpool, 2071, Australia
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Budin JS, Ramos T, Segel K, Rumps MV, Mulcahey MK. Venous Thromboembolism Chemical Prophylaxis in Patients Undergoing Shoulder Arthroscopy. JBJS Rev 2024; 12:01874474-202403000-00007. [PMID: 38466802 DOI: 10.2106/jbjs.rvw.23.00228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/13/2024]
Abstract
» Venous thromboembolism (VTE) after shoulder arthroscopy is rare (0.01%-0.38%) but impacts a significant number of patients because of the high procedure volume.» Studies found no significant benefit in reducing VTE risk with aspirin or low-molecular-weight heparins.» Current guidelines for thromboprophylaxis in shoulder arthroscopy lack consensus and need patient-specific considerations.» Further research is required to develop evidence-based thromboprophylaxis guidelines for shoulder arthroscopy.
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Affiliation(s)
- Jacob S Budin
- Tulane University School of Medicine, New Orleans, Louisiana
| | - Tolulope Ramos
- Department of Orthopaedic Surgery, University of Arizona College of Medicine-Phoenix, Phoenix, Arizona
| | - Kalli Segel
- Tulane University School of Medicine, New Orleans, Louisiana
| | - Mia V Rumps
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, Illinois
| | - Mary K Mulcahey
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Maywood, Illinois
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Zou Y, Zhang G, Sun X. Risk factors for venous thromboembolism following knee arthroscopy: A systematic review and meta-analysis of observational studies. Heliyon 2024; 10:e25939. [PMID: 38379989 PMCID: PMC10877282 DOI: 10.1016/j.heliyon.2024.e25939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 02/05/2024] [Accepted: 02/05/2024] [Indexed: 02/22/2024] Open
Abstract
Objectives To evaluate the risk factors for increased risk of venous thrombosis after arthroscopic knee surgery. Methods PubMed, EMBASE and Cochrane Library were searched from their inception to April 4, 2023. Observational studies investigated venous thrombosis following arthroscopic knee surgery were included. The Newcastle Ottawa Scale (NOS) was used to evaluate the methodological quality of included studies. The odd ratios (ORs) and 95% confidence intervals (CIs) pertaining to each risk factor were synthesized through a random effects model by STATA 14 software. Results The protocol this meta-analysis has been registered on PROSPERO (CRD42023410283). A total of 22 observational studies were included in the systematic review, all of which were of moderate or high methodological quality. The results of the meta-analysis revealed that several factors were significantly associated with an elevated risk of venous thrombosis following arthroscopic knee surgery. These factors included age (mean age ≥30 years) [OR = 1.08, 95%CI (1.04, 1.13), P = 0.001], overweight or obesity [OR = 1.31, 95%CI (1.13, 1.52), P<0.001], oral contraceptive use [OR = 1.90, 95%CI (1.52, 2.37), P<0.001], and smoking history [OR = 1.35, 95%CI (1.06, 1.71), P = 0.014]. Furthermore, the subgroup analysis indicated that patients with an average age over 50 years [OR = 3.18, 95%CI (1.17, 8.66), P = 0.001] and those who underwent surgery with a tourniquet for ≥90 min [OR = 4.79, 95%CI (1.55, 14.81), P = 0.007] were at a significantly increased risk of venous thrombosis after knee arthroscopy. Conclusion Age, obesity, oral contraceptives, smoking history, and prolonged tourniquet use may increase the risk of venous thrombosis after arthroscopic knee surgery. The incidence of venous thrombosis after knee arthroscopy is on a downward trend, but due to its severity, increasing awareness of risk factors and implementing effective prophylaxis are important tasks for clinicians to prevent the risk of venous thrombosis after knee arthroscopy.
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Affiliation(s)
- Yue Zou
- Department of Articular Surgery, Yantaishan Hospital, Yantai, Shandong, China
| | - Guodong Zhang
- Department of Articular Surgery, Yantaishan Hospital, Yantai, Shandong, China
| | - Xiujiang Sun
- Department of Articular Surgery, Yantaishan Hospital, Yantai, Shandong, China
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Lin S, Alepuz A, Tritsch T, Schwartz G. Deep Vein Thrombosis Prophylaxis in Orthopedic Surgery. Cureus 2024; 16:e53726. [PMID: 38455781 PMCID: PMC10919879 DOI: 10.7759/cureus.53726] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 02/06/2024] [Indexed: 03/09/2024] Open
Abstract
Deep vein thrombosis (DVT) is a complex and multifactorial process arising from a variety of factors, including recent surgical procedures, traumatic events, and periods of prolonged immobility. The extended period of stasis post-orthopedic surgery places patients at a notably high risk of developing DVT, and DVT-related pulmonary embolism (PE) ranks as the third most common cause of death in orthopedic surgery patients. This review examines the multifaceted risk factors contributing to the development of DVT in orthopedic patients. Additionally, it addresses the importance of DVT prophylaxis in orthopedic settings, the efficacy and safety of various prophylactic methods encompassing both mechanical and pharmacological approaches, and the economic dimensions of DVT prophylaxis, including scrutiny of cost-effectiveness and the exploration of strategies for optimization.
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Affiliation(s)
- Shu Lin
- Medical Education, Nova Southeastern University Dr. Kiran C. Patel College of Allopathic Medicine, Fort Lauderdale, USA
| | - Adrian Alepuz
- Medical Education, Nova Southeastern University Dr. Kiran C. Patel College of Allopathic Medicine, Fort Lauderdale, USA
| | - Tara Tritsch
- Medical Education, Nova Southeastern University Dr. Kiran C. Patel College of Allopathic Medicine, Fort Lauderdale, USA
| | - Gary Schwartz
- Orthopedic Surgery, Nova Southeastern University Dr. Kiran C. Patel College of Allopathic Medicine, Fort Lauderdale, USA
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12
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Momenzadeh K, Yeritsyan D, Mortensen S, Kheir N, Khak M, Caro D, Kahe F, Abbasian M, Mo C, McNichol M, Paschos N, Nazarian A. While the Incidence of Venous Thromboembolism After Shoulder Arthroscopy Is Low, the Risk Factors Are a Body Mass Index Greater than 30 and Hypertension. Arthrosc Sports Med Rehabil 2024; 6:100815. [PMID: 38149088 PMCID: PMC10749995 DOI: 10.1016/j.asmr.2023.100815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 09/20/2023] [Indexed: 12/28/2023] Open
Abstract
Purpose This study aims to determine the overall incidence of venous thromboembolism (VTE) following shoulder arthroscopy and to define potential risk factors associated with its development that may help define guidelines for the use of thromboprophylaxis. Methods A systematic review was performed using PubMed, Embase, Web of Science, CINAHL, and Cochrane databases per PRISMA guidelines. The search terms consisted of variations of "Venous Thromboembolism" and "Shoulder Arthroscopy." Information regarding arthroscopy indication, risk factors, outcomes, and patient demographics was recorded and analyzed, and pooled odds ratios were reported for each variable. Results Six hundred eighty-five articles were identified in the initial search, and 35 articles reported DVT, PE, or VTE incidence following shoulder arthroscopy. Seventeen nonoverlapping articles with a unique patient population incidence rates. Four articles were then used for subgroup meta-analysis. The incidence rate of VTE was 0.24%, ranging from 0.01% to 5.7%. BMI >30 (OR = 1.46; 95% CI = [1.22, 1.74]; I2 = 0%) and hypertension (OR = 1.64; 95% CI = [1.03, 2.6]; I2 = 75%) were significant risk factors (P < .05) for developing VTE following shoulder arthroscopy. Diabetes (OR = 1.2; 95% CI = [0.97, 1.48]; I2 = 0%), insulin-dependent diabetes (OR = 5.58; 95% CI = [0.12, 260.19]; I2 = 85%), smoking (OR = 1.04; 95% CI = [0.79, 1.37]; I2 = 12%), male sex (OR = 0.95; 95% CI = [0.49, 1.85]; I2 = 86%) and age over 65 (OR = 4.3; 95% CI = [0.25, 72.83]; I2 = 85%) were not associated with higher VTE risk. Conclusion The VTE incidence following shoulder arthroscopy is low at 0.24%. Patients with BMI >30 and hypertension are at a higher risk for VTE after shoulder arthroscopy. Level of Evidence Level IV, systematic review and meta-analysis of Level I-IV studies.
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Affiliation(s)
- Kaveh Momenzadeh
- Musculoskeletal Translational Innovation Initiative, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Diana Yeritsyan
- Musculoskeletal Translational Innovation Initiative, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Sharri Mortensen
- Musculoskeletal Translational Innovation Initiative, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Nadim Kheir
- Musculoskeletal Translational Innovation Initiative, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Mohammad Khak
- Musculoskeletal Translational Innovation Initiative, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Daniela Caro
- Musculoskeletal Translational Innovation Initiative, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Farima Kahe
- Cardiovascular Department, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Mohammadreza Abbasian
- Musculoskeletal Translational Innovation Initiative, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Chen Mo
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Megan McNichol
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Nikolaos Paschos
- Orthopaedic Surgery Department, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Ara Nazarian
- Musculoskeletal Translational Innovation Initiative, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, U.S.A
- Department of Orthopaedic Surgery, Yerevan State Medical University, Yerevan, Armenia
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13
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Wang Y, Xu X, Zhu W. Anticoagulant therapy in orthopedic surgery - a review on anticoagulant agents, risk factors, monitoring, and current challenges. J Orthop Surg (Hong Kong) 2024; 32:10225536241233473. [PMID: 38411153 DOI: 10.1177/10225536241233473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/28/2024] Open
Abstract
Orthopedic surgeries are associated with high-risk of thromboembolism which occurs in 40% to 60% of orthopedic patients in the absence of thromboprophylaxis. Conventionally heparin anticoagulants were used for thromboprophylaxis and currently direct oral anticoagulants (DOACs) are widely used due to their minimal complexity. Anticoagulant use carries bleeding risk and requires optimal laboratory monitoring through conventional thrombin-based assays, anti-Xa assay, anti-IIa assay and contemporary ecarin chromogenic assay (ECA) and rotational thromboelastometry. Monitoring requires multiple hospital visits and hence, the development of point-of-care assays is gaining momentum. Also, a thorough risk assessment model (RAM) is necessary for successful anticoagulant therapy since it enables personalized approach for better thromboprophylaxis outcomes. Despite welcoming changes, lack of guideline consensus, population-based thromboprophylaxis, deficiencies in risk stratification and non-adherence are still a concern. Stronger clinical and process support system with uniform guidelines approaches and patient-specific RAM can aid in the successful implementation of anticoagulant therapy.
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Affiliation(s)
- Yiqun Wang
- Department of Orthopedics, Shanghai Songjiang District Central Hospital, Shanghai, China
| | - Xiaobin Xu
- Department of Orthopedics, Shanghai Songjiang District Central Hospital, Shanghai, China
| | - Wei Zhu
- Department of Orthopedics, Shanghai Songjiang District Central Hospital, Shanghai, China
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14
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Mody BS, Wadhwa M, Roy R, Echila S. Current Evidence and Expert Opinion on Thromboprophylaxis After Total Knee and Hip Replacement. Cureus 2023; 15:e51089. [PMID: 38274925 PMCID: PMC10808783 DOI: 10.7759/cureus.51089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/25/2023] [Indexed: 01/27/2024] Open
Abstract
An effective anticoagulant provides a balance between the risk for venous thromboembolism (VTE) and bleeding and is crucial in achieving optimal clinical outcomes in patients undergoing total hip replacement (THR) and total knee replacement (TKR) surgeries. We performed a review of the literature on thromboprophylaxis for patients undergoing total hip or knee replacement. This review article summarizes current guidelines and evidence for anticoagulation along with the expert opinion about pharmacological VTE prophylaxis, particularly non-Vitamin K antagonist oral anticoagulants (NOACs), for patients after total hip or knee replacement. Aspirin for VTE prophylaxis after TKR/THR has been controversial and most of the evidence is reported from observational research. Although the guidelines do not recommend any specific thromboprophylaxis agent, available evidence suggests that NOACs are as effective as low molecular weight heparins (LMWHs) in preventing VTE. Oral administration and the lack of dose monitoring make NOACs easy to use in outpatient settings in cases with challenging treatment compliances. They can be used for two weeks after TKR and five weeks after THR - six weeks after TKR and THR to cover the at-risk period for VTE post-discharge. Owing to the lack of evidence for a head-to-head comparison of NOACs, an anticoagulant with better efficacy and safety may be suggested in special patient populations (elderly, obese patients, or those with renal dysfunction). The expert opinion on pharmacological VTE prophylaxis provided in this article could address some gaps in the management of anticoagulation in patients with total hip or knee replacement.
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Affiliation(s)
- Bharat S Mody
- Joint Replacement Surgery, Welcare Hospital, Vadodara, IND
| | - Manuj Wadhwa
- Orthopaedics & Joint Replacement, Elite Institutes of Orthopaedics & Joint Replacement, Mohali, IND
| | - Ronen Roy
- Orthopaedic Surgery, Fortis Hospitals, Kolkata, IND
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15
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Simon SJ, Patell R, Zwicker JI, Kazi DS, Hollenbeck BL. Venous Thromboembolism in Total Hip and Total Knee Arthroplasty. JAMA Netw Open 2023; 6:e2345883. [PMID: 38039005 PMCID: PMC10692868 DOI: 10.1001/jamanetworkopen.2023.45883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Accepted: 10/23/2023] [Indexed: 12/02/2023] Open
Abstract
Importance The optimal pharmacologic thromboprophylaxis agent after total hip and total knee arthroplasty is uncertain and consensus is lacking. Quantifying the risk of postoperative venous thromboembolism (VTE) and bleeding and evaluating comparative effectiveness and safety of the thromboprophylaxis strategies can inform care. Objective To quantify risk factors for postoperative VTE and bleeding and compare patient outcomes among pharmacological thromboprophylaxis agents used after total hip and knee arthroplasty. Design, Setting, and Participants This retrospective cohort study used data from a large health care claims database. Participants included patients in the United States with hip or knee arthroplasty and continuous insurance enrollment 3 months prior to and following their surgical procedure. Patients were excluded if they received anticoagulation before surgery, received no postsurgical pharmacological thromboprophylaxis, or had multiple postsurgery thromboprophylactic agents. In a propensity-matched analysis, patients receiving a direct oral anticoagulant (DOAC) were matched with those receiving aspirin. Exposures Aspirin, apixaban, rivaroxaban, enoxaparin, or warfarin. Main Outcomes and Measures The primary outcome was 30-day cumulative incidence of postdischarge VTE. Other outcomes included postdischarge bleeding. Results Among 29 264 patients included in the final cohort, 17 040 (58.2%) were female, 27 897 (95.2%) had inpatient admissions with median (IQR) length of stay of 2 (1-2) days, 10 948 (37.4%) underwent total hip arthroplasty, 18 316 (62.6%) underwent total knee arthroplasty; and median (IQR) age was 59 (55-63) years. At 30 days, cumulative incidence of VTE was 1.19% (95% CI, 1.06%-1.32%) and cumulative incidence of bleeding was 3.43% (95% CI, 3.22%-3.64%). In the multivariate analysis, leading risk factors associated with increased VTE risk included prior VTE history (odds ratio [OR], 5.94 [95% CI, 4.29-8.24]), a hereditary hypercoagulable state (OR, 2.64 [95% CI, 1.32-5.28]), knee arthroplasty (OR, 1.65 [95% CI, 1.29-2.10]), and male sex (OR, 1.34 [95% CI, 1.08-1.67]). In a propensity-matched cohort of 7844 DOAC-aspirin pairs, there was no significant difference in the risk of VTE in the first 30 days after the surgical procedure (OR, 1.14 [95% CI, 0.82-1.59]), but postoperative bleeding was more frequent in patients receiving DOACs (OR, 1.36 [95% CI, 1.13-1.62]). Conclusions and Relevance In this cohort study of patients who underwent total hip or total knee arthroplasty, underlying patient risk factors, but not choice of aspirin or DOAC, were associated with postsurgical VTE. Postoperative bleeding rates were lower in patients prescribed aspirin. These results suggest that thromboprophylaxis strategies should be patient-centric and tailored to individual risk of thrombosis and bleeding.
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Affiliation(s)
- Samantha J Simon
- Research Department, New England Baptist Hospital, Boston, Massachusetts
| | - Rushad Patell
- Division of Hematology and Hematologic Malignancies, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Jeffrey I Zwicker
- Hematology Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Dhruv S Kazi
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Brian L Hollenbeck
- Research Department, New England Baptist Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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16
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Wang J, Liu YX, Yan YD, Liu L, Zhang C, Pan MM, Lin HW, Gu ZC. Global Research Hotspots in Venous Thromboembolism Anticoagulation: A Knowledge-Map Analysis from 2012 to 2021. J Interv Cardiol 2023; 2023:4717271. [PMID: 38028026 PMCID: PMC10673674 DOI: 10.1155/2023/4717271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 05/29/2023] [Accepted: 11/03/2023] [Indexed: 12/01/2023] Open
Abstract
Background Venous thromboembolism (VTE) is a common cardiovascular disease that seriously threatens human lives. Anticoagulant therapy is considered to be the cornerstone of VTE treatment. An increasing number of studies has been updated in the VTE anticoagulation field. However, no bibliometric analyses have assessed these publications comprehensively. Therefore, our study aimed to analyze the global status, hotspots, and trends of anticoagulant therapy for VTE. Methods The relevant literature on VTE anticoagulation published between 2012 and 2021 was retrieved and collected from the Web of Science Core Collection database. VOSviewer, Cooccurrence Matrix Builder, gCLUTO, and some online visualization tools were adopted for bibliometric analysis. Results A total of 15,152 related articles were retrieved. In recent years, the research output of VTE anticoagulation gradually increased. The United States was the most productive country. International cooperation is concentrated in North America and Europe; the most influential documents, journals, authors, and organizations were also from these two continents. Research hotspots mainly focus on clinical guidelines, VTE in special populations, non-vitamin K oral anticoagulants (NOACs), and parenteral anticoagulation. The research frontiers and trends include the assessment of NOACs and the antithrombotic management of VTE complicated with coronavirus disease 2019 (COVID-19). Conclusion This bibliometric analysis provides a systematic overview of the VTE anticoagulation research, which will facilitate researchers to better understand the situation of VTE anticoagulation. Future studies should be dedicated to NOACs application and VTE-combined COVID-19 patients.
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Affiliation(s)
- Jia Wang
- Department of Pharmacy, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China
| | - Yang-Xi Liu
- Department of Pharmacy, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China
| | - Yi-Dan Yan
- Department of Pharmacy, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China
| | - Li Liu
- Department of Pharmacy, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China
| | - Chi Zhang
- Department of Pharmacy, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China
| | - Mang-Mang Pan
- Department of Pharmacy, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China
| | - Hou-Wen Lin
- Department of Pharmacy, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China
| | - Zhi-Chun Gu
- Department of Pharmacy, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200127, China
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17
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Moisander AM, Pamilo K, Eskelinen A, Huopio J, Kautiainen H, Kuitunen A, Paloneva J. Venous thromboembolism is rare after total hip and knee joint arthroplasty with long thromboprophylaxis in Finnish fast-track hospitals. Arch Orthop Trauma Surg 2023; 143:5623-5629. [PMID: 37067559 PMCID: PMC10449718 DOI: 10.1007/s00402-023-04842-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Accepted: 03/01/2023] [Indexed: 04/18/2023]
Abstract
INTRODUCTION Pharmacological thromboprophylaxis effectively prevents venous thromboembolism (VTE) after total knee (TKA) and total hip arthroplasty (THA). Less is known about the influence of fast-track arthroplasty on VTE risk. We conducted a register-based study to determine the incidence of VTE after fast-track TKA and THA in Finland using long thromboprophylaxis. MATERIALS AND METHODS All primary TKAs and THAs operated during 2015-2016 in 3 fast-track hospitals were identified from the Finnish Arthroplasty Register. Pulmonary embolism (PE) and deep vein thrombosis (DVT) diagnosed in this patient cohort within 90 days of surgery were identified from the Finnish Hospital Discharge Register. The recommended length of thromboprophylaxis was 10 to 14 days for TKA and 28 days for THA during study period. RESULTS During the study period, 3 831 THAs, 4 394 TKAs and 286 bilateral TKAs (BTKAs) were performed. Of all these patients, 60% were females. Venous thromboembolism (VTE) incidence within 90 days of surgery was 0.3% (95% CI 0.2-0.4). These VTEs comprised 10 PEs and 15 DVTs. None of the VTE patients´ died within the 90-day period. CONCLUSION VTE incidence is low in Finnish fast-track TKA and THA patients with long thromboprophylaxis.
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Affiliation(s)
- Annette M Moisander
- Department of Anesthesia and Intensive Care, Hospital Nova, Wellbeing Services County of Central Finland, Jyväskylä, Finland.
| | - Konsta Pamilo
- Coxa Hospital for Joint Replacement, Wellbeing Services County of Pirkanmaa, Tampere, Finland
| | - Antti Eskelinen
- Coxa Hospital for Joint Replacement, Wellbeing Services County of Pirkanmaa, Tampere, Finland
- Faculty of Medicine and Health Technologies, University of Tampere, Tampere, Finland
| | - Jukka Huopio
- Department of Orthopaedics and Traumatology, Kuopio University Hospital, Wellbeing Servicies County of North Savo, Kuopio, Finland
| | - Hannu Kautiainen
- Primary Health Care Unit, Kuopio University, Folkhälsan Research Center, Helsinki, Finland
| | - Anne Kuitunen
- Department of Intensive Care, Tampere University Hospital, Wellbeing Services County of Pirkanmaa, Tampere, Finland
| | - Juha Paloneva
- Department of Surgery, Hospital Nova, Wellbeing Secvices County of Central Finland, Jyväskylä, Finland
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18
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Jones A, Al-Horani RA. Venous Thromboembolism Prophylaxis in Major Orthopedic Surgeries and Factor XIa Inhibitors. Med Sci (Basel) 2023; 11:49. [PMID: 37606428 PMCID: PMC10443384 DOI: 10.3390/medsci11030049] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 07/26/2023] [Accepted: 08/09/2023] [Indexed: 08/23/2023] Open
Abstract
Venous thromboembolism (VTE), comprising pulmonary embolism (PE) and deep vein thrombosis (DVT), poses a significant risk during and after hospitalization, particularly for surgical patients. Among various patient groups, those undergoing major orthopedic surgeries are considered to have a higher susceptibility to PE and DVT. Major lower-extremity orthopedic procedures carry a higher risk of symptomatic VTE compared to most other surgeries, with an estimated incidence of ~4%. The greatest risk period occurs within the first 7-14 days following surgery. Major bleeding is also more prevalent in these surgeries compared to others, with rates estimated between 2% and 4%. For patients undergoing major lower-extremity orthopedic surgery who have a low bleeding risk, it is recommended to use pharmacological thromboprophylaxis with or without mechanical devices. The choice of the initial agent depends on the specific surgery and patient comorbidities. First-line options include low-molecular-weight heparins (LMWHs), direct oral anticoagulants, and aspirin. Second-line options consist of unfractionated heparin (UFH), fondaparinux, and warfarin. For most patients undergoing knee or hip arthroplasty, the initial agents recommended for the early perioperative period are LMWHs (enoxaparin or dalteparin) or direct oral anticoagulants (rivaroxaban or apixaban). In the case of hip fracture surgery, LMWH is recommended as the preferred agent for the entire duration of prophylaxis. However, emerging factor XI(a) inhibitors, as revealed by a recent meta-analysis, have shown a substantial decrease in the occurrence of VTE and bleeding events among patients undergoing major orthopedic surgery. This discovery poses a challenge to the existing paradigm of anticoagulant therapy in this specific patient population and indicates that factor XI(a) inhibitors hold great promise as a potential strategy to be taken into serious consideration.
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Affiliation(s)
| | - Rami A. Al-Horani
- Division of Basic Pharmaceutical Sciences, College of Pharmacy, Xavier University of Louisiana, New Orleans, LA 70125, USA;
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Jiang YQ, Wang LY, Hu SQ, Li XL, Zhou J, Qi Q, Dong J. Is it safe for the spinal metastasis patients with preoperative deep vein thrombosis to use low-molecular-weight heparin before surgery? A prospective study. J Clin Neurosci 2023; 114:32-37. [PMID: 37290140 DOI: 10.1016/j.jocn.2023.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 05/15/2023] [Accepted: 05/22/2023] [Indexed: 06/10/2023]
Abstract
Spine surgeons should weigh the risks of anticoagulants against their benefits in preventing deep venous thrombosis (DVT), as they may increase the risk of bleeding. Spinal metastasis patients undergoing decompression with fixation are at a high risk for DVT, which may occur preoperatively. Therefore, anticoagulants should be administered preoperatively. This study aimed to evaluate the safety of the administration of anticoagulants in treating spinal metastasis patients with preoperative DVT. Therefore, we prospectively investigated the prevalence of DVT in these patients. Patients who were diagnosed with preoperative DVT were included in an anticoagulant group. Subcutaneous low-molecular-weight heparin (LMWH) was administered. Patients without DVT were included in a non-anticoagulant group. Data on patient information, clinical parameters, blood test results, and bleeding complications were also collected. Moreover, the safety of anticoagulants was analyzed. The prevalence of preoperative DVT was 8.0%. None of the patients developed pulmonary thromboembolism. Furthermore, no significant differences in blood loss, drainage volume, hemoglobin levels, number of transfusions, or preoperative trans-catheter arterial embolization were observed between the two groups. None of the patients developed major bleeding. However, two patients experienced wound hematoma and one experienced incisional bleeding in the non-anticoagulant group. Therefore, LMWH is safe for spinal metastasis patients. Future randomized controlled trials should be conducted to evaluate the validity of perioperative prophylactic anticoagulation therapy in these patients.
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Affiliation(s)
- Yun-Qi Jiang
- Department of Orthopaedic Surgery, Zhongshan Hospital, Fudan University, PR China
| | - Ling-Yan Wang
- Clinical Science Institute, Zhongshan Hospital, Fudan University, PR China
| | - Shun-Qi Hu
- Department of Orthopaedic Surgery, Zhongshan Hospital, Fudan University, PR China
| | - Xi-Lei Li
- Department of Orthopaedic Surgery, Zhongshan Hospital, Fudan University, PR China
| | - Jian Zhou
- Department of Orthopaedic Surgery, Zhongshan Hospital, Fudan University, PR China
| | - Qing Qi
- Department of Ultrasonography, Zhongshan Hospital, Fudan University, PR China.
| | - Jian Dong
- Department of Orthopaedic Surgery, Zhongshan Hospital, Fudan University, PR China.
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Touw CE, Nemeth B, van Adrichem RA, van Hylckama Vlieg A, Nelissen RGHH, Lisman T, Cannegieter SC. Enhanced in vivo and ex vivo thrombin generation after lower-leg trauma, but not after knee arthroscopy. Thromb J 2023; 21:49. [PMID: 37106465 PMCID: PMC10139833 DOI: 10.1186/s12959-023-00493-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Accepted: 04/19/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND There is room for improvement of prevention of venous thromboembolism (VTE) after lower-leg cast application or knee arthroscopy. Information about the mechanism of clot formation in these patients may be useful to identify new prophylaxis targets. We aimed to study the effect of 1) lower-leg injury and 2) knee arthroscopy on thrombin generation. METHODS A cross-sectional study was conducted using plasma samples of POT-(K)CAST trials to measure ex vivo thrombin generation (Calibrated Automated Thrombography [CAT]) and plasma levels of prothrombin fragment 1 + 2 (F1 + 2), thrombin-antithrombin (TAT), fibrinopeptide A (FPA). Plasma was obtained shortly after lower-leg trauma or before and after (< 4 h) knee arthroscopy. Participants were randomly selected from those who did not develop VTE. For aim 1, samples of 88 patients with lower-leg injury were compared with 89 control samples (i.e., preoperative samples of arthroscopy patients). Linear regression was used to obtain mean differences (or ratios if ln-retransformed because of skewedness) adjusted for age, sex, body mass index, comorbidities. For aim 2, pre- and postoperative samples of 85 arthroscopy patients were compared, for which mean changes were obtained. RESULTS In patients with lower-leg injury (aim 1), endogenous thrombin potential, thrombin peak, velocity index, FPA and TAT were increased as compared with controls. In arthroscopy patients (aim 2), pre- and postoperative levels were similar for all parameters. CONCLUSION Lower-leg trauma increases thrombin generation both ex vivo and in vivo, in contrast to knee arthroscopy. This may imply that the pathogenesis of VTE is different in both situations.
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Affiliation(s)
- Carolina E Touw
- Department of Clinical Epidemiology, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands.
| | - Banne Nemeth
- Department of Clinical Epidemiology, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands
- Department of Orthopaedics, Leiden University Medical Center, Leiden, The Netherlands
| | - Raymond A van Adrichem
- Department of Clinical Epidemiology, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands
- Department of Orthopaedics, Leiden University Medical Center, Leiden, The Netherlands
| | - Astrid van Hylckama Vlieg
- Department of Clinical Epidemiology, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands
| | - Rob G H H Nelissen
- Department of Orthopaedics, Leiden University Medical Center, Leiden, The Netherlands
| | - Ton Lisman
- Department of Surgery, Surgical Research Laboratory, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Suzanne C Cannegieter
- Department of Clinical Epidemiology, Leiden University Medical Center, PO Box 9600, 2300 RC, Leiden, The Netherlands
- Department of Internal Medicine, Division of Thrombosis and Haemostasis, Leiden University Medical Center, Leiden, the Netherlands
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21
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Hagedorn JC, Yates SG, Chen J, Adkins BD. Direct Oral Anticoagulants: How Do These Drugs Work, How to Monitor, and What Is Their Role in Orthopaedic Surgery. J Am Acad Orthop Surg 2023; 31:e347-e355. [PMID: 36862808 DOI: 10.5435/jaaos-d-21-00807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 01/19/2023] [Indexed: 03/04/2023] Open
Abstract
Postoperative venous thromboembolism is a major adverse event associated with orthopaedic surgery. With the addition of perioperative anticoagulation and antiplatelet therapy, the rates of symptomatic venous thromboembolism have dropped to 1% to 3%, and as such, practicing orthopaedic surgeons must be familiar with these medications, including aspirin, heparin, or warfarin, and the use of direct oral anticoagulants (DOACs). DOACs are increasingly being prescribed due to their predictable pharmacokinetics and increased convenience, as they do not require routine monitoring, and 1% to 2% of the general population is currently anticoagulated. Although the introduction of DOACs has yielded additional treatment options, this has also led to confusion and uncertainty regarding treatment, specialized testing, and when and what reversal agents are appropriate. This article provides a basic overview of DOAC medications, their suggested use in the perioperative setting, effects on laboratory testing, and consideration for when and how to use reversal agents in orthopaedic patients.
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Affiliation(s)
- John C Hagedorn
- From the Department of Orthopaedic Surgery and Rehabilitation, University of Texas Medical Branch, Galveston, TX (Hagedorn II, and Chen), and Department of Pathology, University of Texas Southwestern, Division of Transfusion Medicine and Hemostasis, Dallas, TX (Yates, and Adkins)
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22
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Levent A, Kose O, Linke P, Gehrke T, Citak M. Tranexamic acid is safe and effective in patients with heterozygous factor V Leiden mutation during total joint arthroplasty. Arch Orthop Trauma Surg 2023; 143:613-620. [PMID: 34342666 DOI: 10.1007/s00402-021-04110-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 07/28/2021] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Patients with an inherent hypercoagulable state are at a higher risk of venous thromboembolism (VTE) following total joint arthroplasty (TJA). Further administration of tranexamic acid (TXA) during TJA may increase the risk of VTE in these high-risk patients. There is no study that specifically analyzes the safety and efficacy of TXA during TJA in patients with factor V Leiden (FVL) mutation; therefore, the purpose of this study was to evaluate the safety and efficacy of TXA use on the risk of VTE and bleeding in patients carrying FVL mutation. MATERIALS AND METHODS A total of 42 patients with FVL mutation (22 hips, 20 knees) and 40 control patients (20 hips, 20 knees) who underwent TJA were retrospectively reviewed. All patients received 1 g TXA intravenously 15 min before the skin incision and 2 g of TXA was administered locally at the surgical site as a periarticular injection. Pharmacological thromboprophylaxis (low-molecular-weight heparin) was administered to all patients. Estimated blood loss and in-hospital thromboembolic complications were compared between the groups. RESULTS In both total knee arthroplasty (TKA) and total hip arthroplasty (THA) patients, there was no significant difference in the amount of estimated blood loss among the groups (p = 0.980, and p = 0963, respectively). None of the patients in the THA group received a blood transfusion. The transfusion rate was similar in the TKA group (p = 0.756, one patient in each group). No VTE, myocardial infarction, or any other complications related to TXA use were observed in any of the patients. CONCLUSIONS The combined local and systemic administration of TXA could be safely used in patients with heterozygous FVL mutation receiving pharmacological thromboprophylaxis during TJA without increasing the risk of VTE.
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Affiliation(s)
- Ali Levent
- Department of Orthopedic Surgery, ENDO-Klinik Hamburg, Holstenstr. 2, 22767, Hamburg, Germany. .,Department of Orthopedics and Traumatology, Sanliurfa Mehmet Akif Inan Training and Research Hospital, Health Sciences University, Şanlıurfa, Turkey.
| | - Ozkan Kose
- Department of Orthopedics and Traumatology, Antalya Training and Research Hospital, Antalya, Turkey
| | - Philip Linke
- Department of Orthopedic Surgery, ENDO-Klinik Hamburg, Holstenstr. 2, 22767, Hamburg, Germany
| | - Thorsten Gehrke
- Department of Orthopedic Surgery, ENDO-Klinik Hamburg, Holstenstr. 2, 22767, Hamburg, Germany
| | - Mustafa Citak
- Department of Orthopedic Surgery, ENDO-Klinik Hamburg, Holstenstr. 2, 22767, Hamburg, Germany
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23
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Badulescu OV, Bararu Bojan I, Badescu MC, Filip N, Chelsău A, Ciocoiu M, Vladeanu M, Filip A, Forna N, Sirbu MT, Ungureanu C, Sîrbu PD. Thromboembolic Disease in Haemophilic Patients Undergoing Major Orthopaedic Surgery: Is Thromboprophylaxis Mandatory? Diagnostics (Basel) 2022; 13:diagnostics13010013. [PMID: 36611305 PMCID: PMC9818461 DOI: 10.3390/diagnostics13010013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 12/05/2022] [Accepted: 12/14/2022] [Indexed: 12/24/2022] Open
Abstract
Haemophilia is a rare genetic disorder, that results from various degrees of deficiency of coagulation factor VIII (haemophilia A), or factor IX (haemophilia B), with an X-linked transmission. The patients affected are in the majority of cases males (who inherit the affected X-chromosome from the maternal side), with rare cases of females with haemophilia (FVIII or FIX < 40 IU/dL), situations in which both X-chromosomes are affected, or one is affected, and the other one is inactive (known as carrier). The hypocoagulable state due to the deficiency of clotting factors, manifests as an excessive, recurrent tendency to bleeding, which positively correlates with plasmatic levels. Severe haemophilia results in hemarthrosis, although recent data have shown that moderate or even mild disease can lead to joint bleeding. Recurrent episodes of haemorrhages, usually affecting large joints such as knees, elbows, or ankles, lead to joint remodelling and subsequent haemophilic arthropathy, which may require arthroplasty as a last therapeutic option. Orthopaedic patients have the highest risk among all for deep vein thrombosis (DVT) and venous thromboembolism (VTE) with morbid and potentially fatal consequences. While for the rest of the population thromboprophylaxis in orthopaedic surgery is efficient, relatively safe, and widely used, for patients with haemophilia who are considered to have a low thromboembolic risk, there is great controversy. The great heterogeneity of this particular population, and the lack of clinical trials, with only case reports or observational studies, makes thromboprophylaxis in major orthopaedic surgery a tool to be used by every clinician based on experience and case particularities. This review aims to briefly summarise the latest clinical data and to offer an insight into the current recommendations that readers would find useful in daily practice.
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Affiliation(s)
- Oana Viola Badulescu
- Department of Pathophysiology, Morpho-Functional Sciences (II), Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Iris Bararu Bojan
- Department of Pathophysiology, Morpho-Functional Sciences (II), Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Minerva Codruta Badescu
- Department of Internal Medicine, Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- Correspondence: (M.C.B.); (N.F.); (A.C.)
| | - Nina Filip
- Department of Biochemistry, Morpho-Functional Sciences (II), Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
- Correspondence: (M.C.B.); (N.F.); (A.C.)
| | - Alina Chelsău
- Institute of Cardiovascular Diseases, G.I.M. Georgescu, 700503 Iasi, Romania
- Correspondence: (M.C.B.); (N.F.); (A.C.)
| | - Manuela Ciocoiu
- Department of Pathophysiology, Morpho-Functional Sciences (II), Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Maria Vladeanu
- Department of Pathophysiology, Morpho-Functional Sciences (II), Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Alexandru Filip
- Department of Orthopedics and Traumatology, Surgical Science (II), Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Norin Forna
- Department of Orthopedics and Traumatology, Surgical Science (II), Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Mihnea Theodor Sirbu
- Department of Orthopedics and Traumatology, Surgical Science (II), Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Carmen Ungureanu
- Department Morpho-Functional Sciences (I), Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
| | - Paul-Dan Sîrbu
- Department of Orthopedics and Traumatology, Surgical Science (II), Faculty of Medicine, “Grigore T. Popa” University of Medicine and Pharmacy, 700115 Iasi, Romania
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Martinazzi BJ, Kirchner GJ, Lorenz FJ, Bonaddio V, Hines S, Kim RY, Gallo RA. Venous Thromboembolism Chemoprophylaxis in Knee Arthroscopy: A Break-Even Analysis of Cost. Am J Sports Med 2022; 50:3832-3837. [PMID: 36326423 PMCID: PMC9729969 DOI: 10.1177/03635465221130990] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Symptomatic venous thromboembolism (VTE) is a serious and costly complication after knee arthroscopy. There continues to be debate regarding the use of VTE prophylaxis after knee arthroscopy, and minimal research has explored its cost-effectiveness. HYPOTHESIS Both aspirin and enoxaparin would be cost-effective in preventing symptomatic VTE. STUDY DESIGN Economic and decision analysis; Level of evidence, 3. METHODS The literature was searched and the TriNetX research database was queried to determine a range of initial rates of VTE. An open-access retail database was used to determine the mean retail price for aspirin (325 mg) and enoxaparin (30 mg and 40 mg). Our institutional records were used to determine the cost of treating VTE. A "break-even" analysis was then performed to determine the absolute risk reduction necessary to make these drugs cost-effective. This value was then used to calculate the number of patients who would need to be treated (NNT) to prevent a single VTE while still breaking even on cost. RESULTS The cost of treating VTE was $9407 (US Dollars). Aspirin (325 mg), enoxaparin (30 mg), and enoxaparin (40 mg) were found to cost $1.86, $188.72, and $99.99, respectively. The low, TriNetX, and high rates of VTE were 0.34%, 0.86%, and 10.9%, respectively. Aspirin was cost-effective at all 3 rates if the initial rate decreased by 0.02% (NNT = 5058). Both formulations of enoxaparin were cost-effective at the high initial rate if they decreased by 2.01% (NNT = 50) and 1.06% (NNT = 94), respectively. However, at the low and TriNetX rates, the 2 doses of enoxaparin were not cost-effective because their final break-even rate exceeded the initial VTE rate. CONCLUSION Aspirin and, in some cases, enoxaparin are cost-effective treatments for VTE prophylaxis after knee arthroscopy.
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Affiliation(s)
- Brandon J. Martinazzi
- Penn State Health, Milton S. Hershey Medical Center, Department of Orthopaedics & Rehabilitation, Hershey, Pennsylvania, USA,Brandon J. Martinazzi, BS, Penn State Health, 700 HMC Crescent Road, Mail Code: H089, Hershey, PA 17033, USA (emails: , )
| | - Gregory J. Kirchner
- Penn State Health, Milton S. Hershey Medical Center, Department of Orthopaedics & Rehabilitation, Hershey, Pennsylvania, USA
| | - F. Jeffrey Lorenz
- Penn State Health, Milton S. Hershey Medical Center, Department of Orthopaedics & Rehabilitation, Hershey, Pennsylvania, USA
| | - Vincenzo Bonaddio
- Penn State Health, Milton S. Hershey Medical Center, Department of Orthopaedics & Rehabilitation, Hershey, Pennsylvania, USA
| | - Shawn Hines
- Penn State Health, Milton S. Hershey Medical Center, Department of Orthopaedics & Rehabilitation, Hershey, Pennsylvania, USA
| | - Raymond Y. Kim
- Penn State Health, Milton S. Hershey Medical Center, Department of Orthopaedics & Rehabilitation, Hershey, Pennsylvania, USA
| | - Robert A. Gallo
- Penn State Health, Milton S. Hershey Medical Center, Department of Orthopaedics & Rehabilitation, Hershey, Pennsylvania, USA
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Holler JT, Salesky M, Halvorson RT, Zhang AL, Ma CB, Feeley BT, Leavitt AD, Colyvas N, Lansdown DA. Perioperative Thromboprophylaxis Is Associated With Lower Risk of Venous Thromboembolism After Knee Arthroscopy. Arthroscopy 2022; 38:3184-3191. [PMID: 35840070 DOI: 10.1016/j.arthro.2022.06.034] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 06/21/2022] [Accepted: 06/25/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE To determine the rate of symptomatic venous thromboembolism (VTE) among patients undergoing arthroscopic knee procedures, risk factors associated with postoperative VTE, and current perioperative thromboprophylaxis prescription patterns associated with this population in the United States. METHODS Medical records for patients ≥18 years of age were queried from the Mariner database using Current Procedural Terminology codes for knee arthroscopy performed in the United States from 2010 to 2020 in this cross-sectional study. Patients who received thromboprophylaxis and those diagnosed with VTE, including deep-vein thrombosis or pulmonary embolism, within 90 days of surgery were identified using International Classification of Diseases and National Drug Codes. Two multivariable logistic regression models were used to identify VTE risk factors and likelihood of perioperative thromboprophylaxis. Covariates included procedure type, age, oral contraceptive pill (OCP) use, and medical comorbidities. RESULTS A total of 718,289 patients met inclusion criteria and 7,618 patients (1.06%) experienced VTE, including deep-vein thrombosis (n = 6,394, 0.9%) and/or pulmonary embolism (n = 2,211, 0.3%). A total of 10,769 patients (1.5%) filled perioperative thromboprophylaxis, including aspirin (n = 5,353, 0.7%), low-molecular-weight heparin (n = 4,563, 0.6%), and oral factor Xa inhibitors (n = 947, 0.1%). Perioperative thromboprophylaxis was associated with decreased odds of experiencing VTE (adjusted odds ratio [aOR] 0.65, 95% confidence interval [CI] 0.51-0.80). Procedure types categorized as moderate-to-greater risk were associated with increased odds of VTE (aOR 1.42, 95% CI 1.34-1.50). OCP use (aOR 1.63, 95% CI 1.38-1.91), obesity (aOR 1.17, 95% CI 1.11-1.24), renal disease (aOR 1.33, 95% CI 1.18-1.50) and congestive heart failure (aOR 1.30, 95% CI 1.13-1.50) were associated with increased odds of VTE. CONCLUSIONS While the overall rate of symptomatic VTE following knee arthroscopy remains low, procedure types that are more complex and generally require restrictive rehabilitation protocols, OCP use, obesity, renal disease, and congestive heart failure are associated with increased odds of postoperative VTE. Conversely, the use of perioperative thromboprophylaxis is associated with significantly lower VTE risk. LEVEL OF EVIDENCE III, retrospective comparative prognostic trial.
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Affiliation(s)
- Jordan T Holler
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California, U.S.A
| | - Madeleine Salesky
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California, U.S.A
| | - Ryan T Halvorson
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California, U.S.A
| | - Alan L Zhang
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California, U.S.A
| | - C Benjamin Ma
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California, U.S.A
| | - Brian T Feeley
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California, U.S.A
| | - Andrew D Leavitt
- Division of Hematology and Oncology, Department of Medicine University of California San Francisco, San Francisco, California, U.S.A
| | - Nicholas Colyvas
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California, U.S.A
| | - Drew A Lansdown
- Department of Orthopaedic Surgery, University of California San Francisco, San Francisco, California, U.S.A..
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A Prospective Randomized Controlled Trial Comparing Enoxaparin & Rivaroxaban for Venous Thromboembolism Prophylaxis in Orthopaedic Trauma. J Orthop Trauma 2022; 36:615-622. [PMID: 36399673 DOI: 10.1097/bot.0000000000002454] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/05/2022] [Indexed: 02/02/2023]
Abstract
OBJECTIVES To determine whether there is a difference in orthopaedic trauma patient medication satisfaction and adherence using an oral versus subcutaneous injectable anticoagulant for venous thromboembolism chemoprophylaxis. DESIGN Randomized controlled trial. SETTING Single academic Level 1 trauma center. PARTICIPANTS One hundred twenty adult orthopaedic trauma patients with operative pelvic or lower extremity fractures were randomized and completed the study. INTERVENTION Three weeks of either the service standard 40 mg once daily enoxaparin versus trial medication 10 mg once daily rivaroxaban postoperatively. MAIN OUTCOME MEASURES Patient satisfaction as measured by the Treatment Satisfaction Questionnaire for Medication (TSQM-9). Medication adherence as measured by the Morisky Medication Adherence Scale (MMAS-8). RESULTS Medication adherence was similar in both groups. Medication satisfaction was significantly higher in the oral rivaroxaban group based on the TSQM-9 and patient-reported data. Secondary outcomes found no significant difference in the incidence of bleeding events or clinically relevant venous thromboembolism. The enoxaparin group experienced more adverse medication-related events. The rivaroxaban medication regimen costs 7.5-10× less out of pocket for uninsured patients. CONCLUSION The results of this randomized controlled trial demonstrate that patients with surgical orthopaedic trauma prefer an oral anticoagulant for postoperative venous thromboembolism chemoprophylaxis and suggest that rivaroxaban may be a viable option. Furthermore, large-scale studies are needed to confirm safety and efficacy for rivaroxaban in this population as a potential alternative to enoxaparin and aspirin. LEVEL OF EVIDENCE Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
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Gouzoulis MJ, Joo PY, Kammien AJ, McLaughlin WM, Yoo B, Grauer JN. Risk factors for venous thromboembolism following fractures isolated to the foot and ankle fracture. PLoS One 2022; 17:e0276548. [PMID: 36264985 PMCID: PMC9584400 DOI: 10.1371/journal.pone.0276548] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 10/07/2022] [Indexed: 11/07/2022] Open
Abstract
OBJECTIVE Venous thromboembolism (VTE) is an uncommon, but potentially morbid, complication following foot and ankle fractures. Current standard is to not administer thromboprophylaxis to patients with such injuries. Nonetheless, patient and fracture factors might affect this risk/benefit consideration. The goal of this study was to determine what patients are most at risk. METHODS The M53Ortho Pearldiver database was used to identify patients with fractures isolated to the foot and ankle that were treated non-operatively or operatively. Patients with pilon, other appendicular fractures remote from the foot and ankle, and other traumatic injuries were excluded. The 90-day occurrence of VTE was identified based on codes for deep vein thrombosis or pulmonary embolism. Characteristics of those patients who did and did not have VTEs were compared using chi-square analyses. Multivariate logistical regression was then performed to determined factors independently associated with VTE. Finally, timing of VTE relative to fracture was analyzed. RESULTS A total of 298,886 patients with isolated foot or ankle fractures were identified, of which 1,661 (0.56%) had VTE in the 90 days following fracture. In terms of timing, 27.3% occurred in the first week, and 49.8% occurred in the first three weeks. Independent risk factors for VTE included (in decreasing order):prior VTE (odd ratio [OR] = 25.44), factor V Leiden (OR = 24.34), active cancer (OR = 1.84), specific fracture relative to metatarsal fracture (multiple fractures [OR: 1.51], ankle fracture [OR = 1.51], and calcaneus fracture [OR = 1.24]), surgical treatment (OR = 1.41), male sex (OR = 1.19), greater Elixhauser index (OR = 1.05), and increasing age (OR:1.05 per decade) (p<0.05 for each). CONCLUSIONS The present study found that, although only 0.56% of isolated foot and ankle fractures had a VTE within ninety days. Defined risk factors, such as Factor V Leiden, prior VTE, surgical treatment, active cancer, specific fracture patterns, and surgical treatment significantly affected the odds of their occurrence.
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Affiliation(s)
- Michael J. Gouzoulis
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, United States of America
| | - Peter Y. Joo
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, United States of America
| | - Alexander J. Kammien
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, United States of America
| | - William M. McLaughlin
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, United States of America
| | - Brad Yoo
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, United States of America
| | - Jonathan N. Grauer
- Department of Orthopaedics and Rehabilitation, Yale School of Medicine, New Haven, CT, United States of America
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Sharma R, Huang Y, Dizdarevic A. Blood Conservation Techniques and Strategies in Orthopedic Anesthesia Practice. Anesthesiol Clin 2022; 40:511-527. [PMID: 36049878 DOI: 10.1016/j.anclin.2022.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Orthopedic surgery procedures involving joint arthroplasty, complex spine, long bone and pelvis procedure, and trauma and oncological cases can be associated with a high risk of bleeding and need for blood transfusion, making efforts to optimize patient care and reduce blood loss very important. Patient blood management programs incorporate efforts to optimize preoperative anemia, develop transfusion protocols and restrictive hemoglobin triggers, advance surgical and anesthesia practice, and use antifibrinolytic therapies. Perioperative management of anticoagulant therapies, a multidisciplinary decision-making task, weighs in risks and benefits of thromboembolic risk and surgical bleeding and is patient- and surgery-specific.
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Affiliation(s)
- Richa Sharma
- Department of Anesthesiology, Columbia University Irving Medical Center, 622 West 168th Street, PH 5, New York, NY 10032, USA. https://twitter.com/Drsharma_richa
| | - Yolanda Huang
- Department of Anesthesiology, Columbia University Irving Medical Center, 622 West 168th Street, PH 5, New York, NY 10032, USA
| | - Anis Dizdarevic
- Department of Anesthesiology, Columbia University Irving Medical Center, 622 West 168th Street, PH 5, New York, NY 10032, USA.
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Maradei-Pereira JAR, Barbosa MC, Newbery DFS, Torres MR, Kuhn A, Demange MK. Preferências e práticas de ortopedistas brasileiros por técnicas de tromboprofilaxia na artroplastia total do joelho: Levantamento entre membros da Sociedade Brasileira de Cirurgia do Joelho (SBCJ). Rev Bras Ortop 2022; 57:747-765. [PMID: 36226205 PMCID: PMC9550374 DOI: 10.1055/s-0042-1745802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 01/31/2022] [Indexed: 11/01/2022] Open
Abstract
Resumo
Objetivo Descrever as preferências e práticas atuais de uma amostra de cirurgiões de joelho do Brasil quanto à forma de tromboprofilaxia na artroplastia total do joelho (ATJ).
Método Na presente pesquisa realizada pela internet, cirurgiões associados à Sociedade Brasileira de Cirurgia do Joelho (SBCJ) foram convidados a responder voluntariamente a um questionário anônimo incluindo o tempo de experiência cirúrgica pessoal, percepções sobre as melhores opções de tromboprofilaxia e as reais práticas no ambiente onde trabalham.
Resultados Entre dezembro de 2020 e janeiro de 2021, 243 participantes responderam ao questionário completo. Exceto por 3 (1,2%) participantes, todos declararam praticar tromboprofilaxia, a maioria (76%) combinando as formas farmacológica e mecânica. A droga mais prescrita é a enoxaparina (87%), com modificação para rivaroxabana (65%) após a alta. O momento de início da tromboprofilaxia variou conforme o tempo de formação do cirurgião de joelho (p ≤ 0,03) e as preferências e práticas variaram conforme a região do país (p < 0,05) e o sistema de saúde no qual trabalham os cirurgiões (público ou privado; p = 0,024). A opção por tromboprofilaxia mecânica também dependeu do tempo de formação do cirurgião.
Conclusão As preferências e práticas de tromboprofilaxia na ATJ são diversas nas regiões do Brasil e sistemas de saúde (público ou privado). Dada a inexistência de uma diretriz clínica nacional, a maior parte dos ortopedistas segue ou a diretriz de seu próprio hospital ou nenhuma. O método de profilaxia mecânica e a pouca utilização do ácido acetilsalicílico são os pontos que mais destoam das diretrizes e práticas internacionais.
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Affiliation(s)
| | | | | | | | - André Kuhn
- Instituto de Ortopedia e Traumatologia, Passo Fundo, RS, Brasil
| | - Marco Kawamura Demange
- Instituto de Ortopedia e Traumatologia, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, SP, Brasil
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Pretorius J, Nemat N, Azeem I, Shaju T, Nadeem S, Hammad Y. Is aspirin still relevant as a single pharmacological agent for venous thromboembolism prophylaxis post hip and knee arthroplasty surgery: A retrospective review. SICOT J 2022; 8:28. [PMID: 35766820 PMCID: PMC9241622 DOI: 10.1051/sicotj/2022029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 06/12/2022] [Indexed: 11/21/2022] Open
Abstract
Introduction: Aspirin is widely used for the prevention of venous thromboembolism (VTE) after total hip arthroplasty (THA) and total knee arthroplasty (TKA). It is well-established that the bleeding and wound complication risk for aspirin is low or equivalent to the other anticoagulant agents, but there is still ongoing controversy regarding the efficacy of aspirin for VTE prophylaxis. The current HSE (2012) guideline suggests 72 h of enoxaparin and 4 weeks of Aspirin therapy. But is this practice still relevant with more recent guidelines, NICE (2021) and SIGN (2014) suggesting that Aspirin is not recommended as a single pharmacological agent for VTE prophylaxis. Method: A Retrospective review was performed of a single centre, between January 2016 and May 2021 assessing for symptomatic VTE post-THA and TKA. All the patients received enoxaparin and aspirin as per the HSE guidelines. Using NIMIS we assessed which patients received a workup for potential symptomatic VTE and who had a confirmed VTE within 3 months post-surgery. The secondary outcome was mortality within 3 months post-surgery. Results: A total of 1178 patients (721 undergoing THR and 457 undergoing TKR) were included in the study. The number of patients who received a workup for potential symptomatic VTE was 124 of 1178 (10.53%). VTE occurred in 13 of 721 patients (1.80%) of the THR patients and 1 of 457 (0.22%) of the TKR patients, and a total of 14 of 1178 patients (1.19%). Of these 7 (0.59%) patients developed a DVT and 7 (0.59%) a PE. No patients suffered a fatal pulmonary embolism within 90 days of index surgery nor any other cause of mortality. Conclusion: Aspirin is not only still relevant but can be considered as one of the most optimal pharmacological agents in preventing VTE after THA and TKA.
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Affiliation(s)
- Jacques Pretorius
- Letterkenny University Hospital, Kilmacrennan Road, Ballyboe, Letterkenny, County Donegal F92AE81, Ireland
| | - Nouman Nemat
- Letterkenny University Hospital, Kilmacrennan Road, Ballyboe, Letterkenny, County Donegal F92AE81, Ireland
| | - Imran Azeem
- Letterkenny University Hospital, Kilmacrennan Road, Ballyboe, Letterkenny, County Donegal F92AE81, Ireland
| | - Tony Shaju
- Letterkenny University Hospital, Kilmacrennan Road, Ballyboe, Letterkenny, County Donegal F92AE81, Ireland
| | - Sayed Nadeem
- Letterkenny University Hospital, Kilmacrennan Road, Ballyboe, Letterkenny, County Donegal F92AE81, Ireland
| | - Yasir Hammad
- Letterkenny University Hospital, Kilmacrennan Road, Ballyboe, Letterkenny, County Donegal F92AE81, Ireland
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Li Y, Shan J. Study on the correlation between high density lipoprotein and lower extremities deep venous thrombosis in patients undergoing hip arthroplasty. Phlebology 2022; 37:516-521. [PMID: 35575216 DOI: 10.1177/02683555221090309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To explore the relationship between high density lipoprotein (HDL) and lower extremities deep venous thrombosis (DVT) in patients undergoing hip arthroplasty. METHODS A total of 348 patients undergoing hip arthroplasty in our hospital were enrolled, and divided into observation (n = 154, 44.25%) and control (n = 194, 55.75%) groups according to the occurrence of lower extremities DVT. The presence of DVT was assessed 1 day before surgery and routinely every 2 days after surgery. The factors of DVT were analyzed by single factor analysis, multivariate logistic regression analysis, and Pearson correlation. RESULTS The age and body mass index in the observation group were significantly higher (p = .045, p = .041, respectively), while HDL-C was significantly lower (p = .032) than the control group. Increase age, high BMI, low apolipoprotein-A1 level and low HDL-C level were risk factors for lower extremities DVT. The mean HDL-C in the observation and control groups was 0.91 ± 0.27 and 1.19 ± 0.37, respectively, the adjusted odds ratio was 1.050; 95% CI 1.010-1.092, p = .014. CONCLUSION Elderly patients with high BMI and low HDL-C level undergoing hip arthroplasty are at risk of lower extremities DVT, and should be paid attention to clinically.
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Affiliation(s)
- Yong Li
- Department of Orthopaedic, 117858Dongyang People's Hospital, Dongyang, China
| | - Junbiao Shan
- Department of Orthopaedic, 117858Dongyang People's Hospital, Dongyang, China
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Naung Tun H, Kyaw MT, Rafflenbeul E, López Suástegui X. Role of Direct Oral Anticoagulants for Post-operative Venous Thromboembolism Prophylaxis. Eur Cardiol 2022; 17:e11. [PMID: 35620356 PMCID: PMC9127635 DOI: 10.15420/ecr.2021.55] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 01/28/2022] [Indexed: 11/19/2022] Open
Abstract
Venous thromboembolism (VTE) is one of the leading causes of post-operative morbidity and mortality. Over previous decades, heparin and warfarin were the predominant therapeutic options for post-operative thromboprophylaxis. However, their use is limited by drawbacks including a narrow therapeutic range, numerous food and drug interactions, and the need for regular monitoring for dose adjustments. Recently, direct oral anticoagulants (DOACs), such as dabigatran etexilate (a direct thrombin inhibitor) and apixaban, rivaroxaban and edoxaban (direct factor Xa inhibitors), have been developed to overcome these issues. DOACs have shown promising results in Phase III clinical trials for post-operative VTE prophylaxis. This review summarises the pharmacological profile of DOACs and highlights the use of DOACs in post-operative VTE prophylaxis based on the available clinical trial data.
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Affiliation(s)
- Han Naung Tun
- Larner College of Medicine, University of Vermont, Burlington, VT, US
| | - May Thu Kyaw
- Heart and Vascular Centre, Victoria Hospital, Yangon, Myanmar
| | - Erik Rafflenbeul
- Department of Cardiology, Schoen Clinic Hamburg Eilbek, Hamburg, Germany
| | - Xiuhtlaulli López Suástegui
- Emergency Department, Intensive Care Unit Hospital Regional de Alta Especialidad de Zumpango, Instituto Mexicano del Seguro Social, Zumpango de Ocampo, Mexico
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The Effect of Obstructive Sleep Apnea on Venous Thromboembolism Risk in Patients Undergoing Total Joint Arthroplasty. J Am Acad Orthop Surg Glob Res Rev 2022; 6:01979360-202204000-00017. [PMID: 35442925 PMCID: PMC9022776 DOI: 10.5435/jaaosglobal-d-21-00248] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 02/25/2022] [Indexed: 11/18/2022]
Abstract
Obstructive sleep apnea (OSA) is a known risk factor for venous thromboembolism (VTE), defined as pulmonary embolism (PE) or deep vein thrombosis (DVT); however, little is known about its effect on VTE rates after total joint arthroplasty (TJA). This study sought to determine whether patients with OSA who undergo TJA are at greater risk for developing VTE versus those without OSA.
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Preventing Venous Thromboembolism after elective total hip arthroplasty surgery - are the current guidelines appropriate? Venous thromboembolism prophylaxis in elective total hip arthroplasty surgery. J Clin Orthop Trauma 2022; 26:101782. [PMID: 35145851 PMCID: PMC8814685 DOI: 10.1016/j.jcot.2022.101782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 01/16/2022] [Accepted: 01/24/2022] [Indexed: 01/27/2023] Open
Abstract
INTRODUCTION Venous Thromboembolism after elective Total Hip Arthroplasty surgery is a well-recognised complication, resulting in fatal pulmonary embolism, post thrombotic syndrome and recurrent thrombotic episodes. Guidelines developed by clinical organisations attempt to provide evidence-based recommendations to clinicians. METHODS This narrative review evaluated the current available literature in relation to the available guidelines, to evaluate whether the current major guidelines reflect the evidence base. All major clinical guidelines were collated through database searching, alongside the relevant clinical studies. PRINCIPAL FINDINGS The promotion of a multi-modal approach, combining mechanical and chemical prophylaxis, does appear to be well validated, with mechanical prophylaxis offering positive clinical effects with little negative clinical consequence. Within the current guidelines surrounding VTE prevention in the elective-THA patient, there does appear to be a lack of prescription in relation to risk stratification and adopting personalised approaches for specific patient subsets. CONCLUSION We suggest moving away from protocolisation of VTE prevention, given the evidence base is not fully developed to allow a 'one-size-fits-all' approach.
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Halbur CR, Gulbrandsen TR, West CR, Brown TS, Noiseux NO. Weight-Based Aspirin Dosing May Further Reduce the Incidence of Venous Thromboembolism Following Primary Total Joint Arthroplasty. J Arthroplasty 2021; 36:3986-3992.e1. [PMID: 34215460 DOI: 10.1016/j.arth.2021.06.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 05/29/2021] [Accepted: 06/08/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Obesity poses a challenge to thromboembolic prophylaxis following total joint arthroplasty (TJA). The purpose of this study is to evaluate a weight-based aspirin dosing regimen for prevention of venous thromboembolism (VTE) following TJA. METHODS This is a retrospective observational study of 2403 patients who underwent primary total hip or knee arthroplasty at one institution. A weight-based aspirin dosing regimen for VTE prophylaxis was administered to 1247 patients: patients weighing ≥120 kg received 325 mg aspirin twice daily (BID) and those weighing <120 kg received 81 mg aspirin BID for 4 weeks. In total, 1156 patients in the comparison cohort received 81 mg aspirin BID. VTE and gastrointestinal bleeding events were identified through chart review at 42 days and 6 months postoperatively. A multivariable logistic regression was performed to adjust for covariates. RESULTS The weight-based aspirin cohort had a significantly lesser incidence of VTE at 42 days (P = .03, relative risk [RR] 0.31, 95% confidence interval 0.12-0.82) and 6 months (P = .03, RR 0.38, 95% confidence interval 0.18-0.80). There was no difference in VTE incidence between total hip arthroplasty and total knee arthroplasty cases (P = .8). There was no difference in gastrointestinal bleeding events between the cohorts at 42 days (P = .69) or 6 months (P = .92). Subanalysis of patients weighing ≥120 kg demonstrated a significant difference between the cohorts with a VTE incidence of 3.48% and 0% in the 81 mg and weight-based cohorts, respectively (P = .02). CONCLUSION Patients prescribed a weight-based aspirin regimen had significantly fewer VTEs after TJA compared to historical controls with an RR reduction of 69% at 6 weeks and 62% at 6 months postoperatively. This suggests the need to factor patient weight when determining postoperative VTE prophylaxis with aspirin.
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Affiliation(s)
- Christopher R Halbur
- Department of Orthopedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Trevor R Gulbrandsen
- Department of Orthopedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA
| | | | - Timothy S Brown
- Department of Orthopedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Nicolas O Noiseux
- Department of Orthopedic Surgery and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA
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Tanaka K, Shimizu Y, Kamada H, Aikawa S, Mishima H, Kanamori A, Nishino T, Sakane M, Ochiai N, Yamazaki M. Feasibility and Safety of a Novel Leg Exercise Apparatus for Venous Thromboembolism Prophylaxis after Total Joint Arthroplasty of the Lower Extremities-A Pilot Study. Tomography 2021; 7:734-746. [PMID: 34842826 PMCID: PMC8628884 DOI: 10.3390/tomography7040061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2021] [Revised: 11/02/2021] [Accepted: 11/02/2021] [Indexed: 12/18/2022] Open
Abstract
Venous thromboembolism (VTE) is a severe complication in orthopedic surgeries. Herein, we developed a novel leg exercise apparatus (LEX) to encourage postoperative limb movement in bedridden patients to prevent VTE. We aimed to evaluate its feasibility and safety in individuals at risk of VTE. Twenty patients (four men, 16 women) who underwent total joint arthroplasty in the lower extremity were enrolled in this prospective study. Exercise using the LEX was performed for 5 min at 30 cycles/min, four times/day during postoperative days 1–7. Clinical assessments included the evaluation of vital signs, venous ultrasonography, and blood tests within seven days postoperatively, and adverse events (pulmonary embolism and cerebral hemorrhage) were monitored. Overall, 16/20 (80%) patients completed the 7-day exercise regimen. There were no cases of severe adverse events, changes in vital signs, or lower-extremity deep vein thrombosis in patients who performed exercises with the LEX. Thus, the results of this pilot study show that this novel apparatus may be a safe and feasible tool for VTE prophylaxis after joint arthroplasty of the lower extremities.
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Affiliation(s)
- Kenta Tanaka
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba 305-8575, Ibaraki, Japan; (K.T.); (H.K.); (H.M.); (A.K.); (T.N.); (M.S.); (N.O.); (M.Y.)
- Department of Orthopaedic Surgery, Nogami Hospital, Tozakimachi 6-8, Tsuchiura 300-0031, Ibaraki, Japan
| | - Yukiyo Shimizu
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba 305-8575, Ibaraki, Japan; (K.T.); (H.K.); (H.M.); (A.K.); (T.N.); (M.S.); (N.O.); (M.Y.)
- Department of Rehabilitation Medicine, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba 305-8575, Ibaraki, Japan
- Correspondence: ; Tel.: +81-29-853-3219
| | - Hiroshi Kamada
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba 305-8575, Ibaraki, Japan; (K.T.); (H.K.); (H.M.); (A.K.); (T.N.); (M.S.); (N.O.); (M.Y.)
| | - Shizu Aikawa
- Department of Cardiovascular Surgery, Tsukuba Medical Center Hospital, 1-3-1 Amakubo, Tsukuba 305-8558, Ibaraki, Japan;
| | - Hajime Mishima
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba 305-8575, Ibaraki, Japan; (K.T.); (H.K.); (H.M.); (A.K.); (T.N.); (M.S.); (N.O.); (M.Y.)
| | - Akihiro Kanamori
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba 305-8575, Ibaraki, Japan; (K.T.); (H.K.); (H.M.); (A.K.); (T.N.); (M.S.); (N.O.); (M.Y.)
| | - Tomofumi Nishino
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba 305-8575, Ibaraki, Japan; (K.T.); (H.K.); (H.M.); (A.K.); (T.N.); (M.S.); (N.O.); (M.Y.)
| | - Masataka Sakane
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba 305-8575, Ibaraki, Japan; (K.T.); (H.K.); (H.M.); (A.K.); (T.N.); (M.S.); (N.O.); (M.Y.)
- Department of Orthopaedic Surgery, Tsukuba Gakuen Hospital, 2573-1 Kamiyokoba, Tsukuba 305-0854, Ibaraki, Japan
| | - Naoyuki Ochiai
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba 305-8575, Ibaraki, Japan; (K.T.); (H.K.); (H.M.); (A.K.); (T.N.); (M.S.); (N.O.); (M.Y.)
- Department of Orthopaedic Surgery, Kikkoman General Hospital, 100 Miyazaki, Noda 278-0005, Chiba, Japan
| | - Masashi Yamazaki
- Department of Orthopaedic Surgery, Faculty of Medicine, University of Tsukuba, 1-1-1 Tennodai, Tsukuba 305-8575, Ibaraki, Japan; (K.T.); (H.K.); (H.M.); (A.K.); (T.N.); (M.S.); (N.O.); (M.Y.)
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Romano D, Boyle M, Isla AE, Teasdall RJ, Srinath A, Aneja A. Hypercoagulable Disorders in Orthopaedics: Etiology, Considerations, and Management. JBJS Rev 2021; 9:01874474-202110000-00003. [PMID: 34637409 DOI: 10.2106/jbjs.rvw.21.00079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
» Hypercoagulable disorders (HCDs) can be inherited or acquired. An HCD of either etiology increases the chance of venous thromboembolic events (VTEs). » Patients with an HCD often have the condition discovered only after surgical complications. » We recommend that patients with a concern for or a known HCD be referred to the appropriate hematological specialist for workup and treatment. » Tourniquet use in the orthopaedic patient with an HCD is understudied and controversial. We recommend that tourniquets be avoided in the surgical management of patients with an HCD, if possible. When tourniquets are applied to patients with unknown HCD status, close follow-up and vigilant postoperative examinations should be undertaken.
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Affiliation(s)
- David Romano
- Riverside Regional Medical Center, Newport News, Virginia
| | - Maxwell Boyle
- Department of Orthopaedic Surgery, University of Kentucky, Lexington, Kentucky
| | - Alexander E Isla
- Department of Orthopaedic Surgery, University of Kentucky, Lexington, Kentucky
| | - Robert J Teasdall
- Department of Orthopaedic Surgery, University of Kentucky, Lexington, Kentucky
| | - Arjun Srinath
- Department of Orthopaedic Surgery, University of Kentucky, Lexington, Kentucky
| | - Arun Aneja
- Department of Orthopaedic Surgery, University of Kentucky, Lexington, Kentucky
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A Review of Current and Future Antithrombotic Strategies in Surgical Patients-Leaving the Graduated Compression Stockings Behind? J Clin Med 2021; 10:jcm10194294. [PMID: 34640311 PMCID: PMC8509226 DOI: 10.3390/jcm10194294] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 09/15/2021] [Accepted: 09/18/2021] [Indexed: 11/16/2022] Open
Abstract
Venous thromboembolism (VTE) remains an important consideration within surgery, with recent evidence looking to refine clinical guidance. This review provides a contemporary update of existing clinical evidence for antithrombotic regimens for surgical patients, providing future directions for prophylaxis regimens and research. For moderate to high VTE risk patients, existing evidence supports the use of heparins for prophylaxis. Direct oral anticoagulants (DOACs) have been validated within orthopaedic surgery, although there remain few completed randomised controlled trials in other surgical specialties. Recent trials have also cast doubt on the efficacy of mechanical prophylaxis, especially when adjuvant to pharmacological prophylaxis. Despite the ongoing uncertainty in higher VTE risk patients, there remains a lack of evidence for mechanical prophylaxis in low VTE risk patients, with a recent systematic search failing to identify high-quality evidence. Future research on rigorously developed and validated risk assessment models will allow the better stratification of patients for clinical and academic use. Mechanical prophylaxis' role in modern practice remains uncertain, requiring high-quality trials to investigate select populations in which it may hold benefit and to explore whether intermittent pneumatic compression is more effective. The validation of DOACs and aspirin in wider specialties may permit pharmacological thromboprophylactic regimens that are easier to administer.
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Khan F, Tritschler T, Kahn SR, Rodger MA. Venous thromboembolism. Lancet 2021; 398:64-77. [PMID: 33984268 DOI: 10.1016/s0140-6736(20)32658-1] [Citation(s) in RCA: 236] [Impact Index Per Article: 78.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 11/06/2020] [Accepted: 12/04/2020] [Indexed: 12/11/2022]
Abstract
Venous thromboembolism, comprising both deep vein thrombosis and pulmonary embolism, is a chronic illness that affects nearly 10 million people every year worldwide. Strong provoking risk factors for venous thromboembolism include major surgery and active cancer, but most events are unprovoked. Diagnosis requires a sequential work-up that combines assessment of clinical pretest probability for venous thromboembolism using a clinical score (eg, Wells score), D-dimer testing, and imaging. Venous thromboembolism can be considered excluded in patients with both a non-high clinical pretest probability and normal D-dimer concentrations. When required, ultrasonography should be done for a suspected deep vein thrombosis and CT or ventilation-perfusion scintigraphy for a suspected pulmonary embolism. Direct oral anticoagulants (DOACs) are the first-line treatment for almost all patients with venous thromboembolism (including those with cancer). After completing 3-6 months of initial treatment, anticoagulation can be discontinued in patients with venous thromboembolism provoked by a major transient risk factor. Patients whose long-term risk of recurrent venous thromboembolism outweighs the long-term risk of major bleeding, such as those with active cancer or men with unprovoked venous thromboembolism, should receive indefinite anticoagulant treatment. Pharmacological venous thromboembolism prophylaxis is generally warranted in patients undergoing major orthopaedic or cancer surgery. Ongoing research is focused on improving diagnostic strategies for suspected deep vein thrombosis, comparing different DOACs, developing safer anticoagulants, and further individualising approaches for the prevention and management of venous thromboembolism.
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Affiliation(s)
- Faizan Khan
- School of Epidemiology and Public Health, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada
| | - Tobias Tritschler
- Department of Medicine, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada; Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Susan R Kahn
- Department of Medicine, McGill University, Montreal, QC, Canada; Division of Internal Medicine and Division of Clinical Epidemiology, Jewish General Hospital/Lady Davis Institute, Montreal, QC, Canada
| | - Marc A Rodger
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, University of Ottawa, Ottawa, ON, Canada; Department of Medicine, McGill University, Montreal, QC, Canada.
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Yu X, Wu Y, Ning R. The deep vein thrombosis of lower limb after total hip arthroplasty: what should we care. BMC Musculoskelet Disord 2021; 22:547. [PMID: 34130675 PMCID: PMC8207610 DOI: 10.1186/s12891-021-04417-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 05/10/2021] [Indexed: 12/22/2022] Open
Abstract
Background Deep vein thrombosis (DVT) of lower limb is one of the common complications after total hip arthroplasty(THA), we aimed to evaluate the potential risk factors of DVT of lower limb in patients with THA, to provide insights into the management of THA. Methods Patients who underwent THA in our hospital from January 1, 2017 to November 30, 2020 were included. The personal characteristics and clinical data of DVT and no-DVT patients were compared and analyzed. Logistic regression analyses were perfomed to identify the potential risk factors of DVT in patients with THA. Results A total of 182 THA patients were included, the incidence of DVT of lower limb in patients with THA was 19.78 %. There were significant differences in the age, BMI, diabetes, number of replacement, duration of surgery, type of prosthesis and duration of days in bed between DVT and no-DVT patients(all P < 0.05). And there were no significant differences in the gender, hypertension, hyperlipidemia, preoperative D-dimer, type of anesthesia and anticoagulant drugs use(all P > 0.05). Logistic regression analysis indicated that age > 70y(OR4.406, 95 %CI1.744 ~ 6.134), BMI ≥ 28(OR2.275, 95 %CI1.181 ~ 4.531), diabetes(OR3.949, 95 %CI1.284 ~ 5.279), bilateral joint replacements(OR2.272, 95 %CI1.402 ~ 4.423), duration of surgery ≥ 120 min(OR3.081, 95 %CI1.293 ~ 5.308), cemented prosthesis(OR2.435, 95 %CI1.104 ~ 4.315), and duration of days in bed > 3 days(OR1.566, 95 %CI1.182 ~ 1.994) were the risk factors of DVT of lower limb in patients with THA. Conclusions DVT in the lower limb after THA is common, and its onset is affected by many factors. In clinical work, attention should be paid to identify the risk factors for DVT and targeted interventions are highlighted to prevent the postoperative DVT.
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Affiliation(s)
- Xinyan Yu
- Department of nursing, The Third Affiliated Hospital of Anhui Medical University, No. 390 Huaihe Road, 230061, Hefei City, Anhui Province, China
| | - Yingying Wu
- Department of nursing, The Third Affiliated Hospital of Anhui Medical University, No. 390 Huaihe Road, 230061, Hefei City, Anhui Province, China
| | - Rende Ning
- Department of nursing, The Third Affiliated Hospital of Anhui Medical University, No. 390 Huaihe Road, 230061, Hefei City, Anhui Province, China. .,Department of nursing, Shannan people's Hospital, Sare Road, Naidong District, Shannan City, 856011, Tibet Autonomous Region, China.
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Acuña AJ, Grits D, Samuel LT, Emara AK, Kamath AF. Perioperative Blood Transfusions Are Associated with a Higher Incidence of Thromboembolic Events After TKA: An Analysis of 333,463 TKAs. Clin Orthop Relat Res 2021; 479:589-600. [PMID: 33165044 PMCID: PMC7899570 DOI: 10.1097/corr.0000000000001513] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 09/04/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Given the morbidity, mortality, and financial burden associated with venous thromboembolism (VTE) after TKA, orthopaedic providers continually seek to identify risk factors associated with this devastating complication. The association between perioperative transfusion status and VTE risk has not been thoroughly explored, with previous studies evaluating this relationship being limited in both generalizability and power. QUESTIONS/PURPOSES Therefore, we sought to determine whether perioperative transfusions were associated with an increased risk of (1) pulmonary embolism (PE) or (2) deep vein thrombosis (DVT) after primary TKA in a large, multi-institutional sample. METHODS The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was implemented for our analysis. The definitions of complications, such as DVT and PE, and risk adjustment validation is monitored by the central ACS NSQIP office to ensure participating hospitals are adhering to the same guidelines to log patients. Additionally, both preoperative and intraoperative/72 hour postoperative transfusion status is included for all patients. Therefore, ACS NSQIP was determined to be the most appropriate database for our analysis. All patients who underwent primary TKA between 2011 and 2018 were identified using Current Procedural Terminology code 27447. Primary TKAs designated as "non-elective" were excluded, thereby providing a cohort composed solely of patients undergoing unilateral primary elective TKA for further analysis. The final analysis included 333,463 patients undergoing TKA (mean age 67 ± 9 years, 62% female). Preoperative transfusions were received by < 0.01% (48 of 333,463) of the patients, while 4% (14,590 of 333,463) received a transfusion within the interim between the start of surgery up to 72 hours postoperatively. All missing values were imputed through multiple imputation by chained equation to avoid variable availability-based selection and the subsequent listwise deletion-associated bias in the estimate of parameters. A multivariable logistic regression analysis was conducted using variables identified in a univariate model to calculate adjusted odds ratios and 95% confidence intervals for risk factors associated with symptomatic DVT and/or PE. For variables that maintained significance in the multivariable model, an additional model without confounders was used to generate fully adjusted ORs and 95% CIs. A propensity score matched comparison between recipients versus nonrecipients (1:1) of transfusion (preoperative and intraoperative/72 hours postoperative) was then conducted to evaluate the independent association between DVT/PE development and patients' transfusion status. Significance was determined at a p value < 0.05. RESULTS Adjusted multivariable regression analysis accounting for patient age, sex, race, BMI, American Society of Anesthesiologists (ASA) class and baseline comorbidities demonstrated the absence of an association between preoperative (OR 1.75 [95% CI 0.24 to 12.7]; p = 0.58) or intraoperative/72 hours postoperative (OR 1.12 [95% CI 0.93 to 1.35]; p = 0.23) transfusions and higher odds of developing PE. Similar findings were demonstrated after propensity score matching. Although multivariable regression demonstrated the absence of an association between preoperative transfusion and the odds of developing DVT within the 30-day postoperative period (OR 1.85 [95% CI 0.43 to 8.05]; p = 0.41), intraoperative/postoperative transfusion was associated with higher odds of DVT development (OR 3.68 [95% CI 1.14 to 1.53]; p < 0.001) relative to transfusion naïve patients. However, this significance was lost after propensity score matching. CONCLUSION After controlling for various potential confounding variables such as ASA Class, age, anesthesia type, and BMI, the receipt of an intra- or postoperative transfusion was found to be associated with an increased risk of DVT. Our findings should encourage orthopaedic providers to strictly adhere to blood management protocols, further tighten transfusion eligibility, and adjust surgical approach and implant type to reduce the incidence of transfusion among patients with other DVT risk factors. Additionally, our findings should encourage a multidisciplinary approach to VTE prophylaxis and prevention, as well as to blood transfusion guideline adherence, among all providers of the care team. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Alexander J Acuña
- A. J. Acuña, L. T. Samuel, A. K. Emara, A. F. Kamath, Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
- D. Grits, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | - Daniel Grits
- A. J. Acuña, L. T. Samuel, A. K. Emara, A. F. Kamath, Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
- D. Grits, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | - Linsen T Samuel
- A. J. Acuña, L. T. Samuel, A. K. Emara, A. F. Kamath, Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
- D. Grits, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | - Ahmed K Emara
- A. J. Acuña, L. T. Samuel, A. K. Emara, A. F. Kamath, Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
- D. Grits, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | - Atul F Kamath
- A. J. Acuña, L. T. Samuel, A. K. Emara, A. F. Kamath, Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
- D. Grits, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
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Petersen PB, Lindberg-Larsen M, Jørgensen CC, Kehlet H. Venous thromboembolism after fast-track elective revision hip and knee arthroplasty - A multicentre cohort study of 2814 unselected consecutive procedures. Thromb Res 2021; 199:101-105. [PMID: 33485092 DOI: 10.1016/j.thromres.2021.01.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 12/07/2020] [Accepted: 01/06/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) prophylaxis is much debated within total hip and knee arthroplasty (THA/TKA). Revision hip and knee arthroplasty (rTHA/rTKA) are more extensive procedures, but data on the risk of postoperative VTE is conflicting and there are no specific guidelines for thromboprophylaxis. Furthermore, data on rTHA/rTKA within a fast-track protocol is sparse. Thus, we aimed at evaluating the incidence and time course of VTE in unselected elective rTHA/rTKA within our established multicentre fast-track collaboration with in-hospital only thromboprophylaxis if length of stay (LOS) ≤ 5 days. METHODS We used an observational study design of unselected consecutive fast-track elective major component rTHA/rTKA from 6 dedicated fast-track centres between 2010 and 2018. We obtained information on revisions through Danish hip and knee arthroplasty registers and complete (>99%) 90 days follow-up through the Danish National Patient Registry in combination with chart review. RESULTS We included 2814 procedures with median LOS 3 days [2-5] and 21% had LOS >5 days. The 90-day incidence of VTE was 0.42% (n = 12), with 8 (0.28%) DVT and 4 (0.14%) PE, after median 14 days [IQR: 11-23] with the latest on day 31. CONCLUSION The 90-day incidence of VTE after elective fast-track rTHA and rTKA was about 0.4% which is comparable to the 90-day VTE incidence after primary fast-track THA, TKA and unicompartmental knee arthroplasty. Future investigations should focus on identification of high-risk patients while the surgical trauma per se may be less important.
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Affiliation(s)
| | - Martin Lindberg-Larsen
- Orthopaedic Research Unit, Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Department of Clinical Research, University of Southern Denmark, Denmark; Lundbeck Foundation Centre for Fast-track Hip and Knee Arthroplasty, Copenhagen, Denmark
| | - Christoffer Calov Jørgensen
- Section for Surgical Pathophysiology, Rigshospitalet, Copenhagen, Denmark; Lundbeck Foundation Centre for Fast-track Hip and Knee Arthroplasty, Copenhagen, Denmark
| | - Henrik Kehlet
- Section for Surgical Pathophysiology, Rigshospitalet, Copenhagen, Denmark; Lundbeck Foundation Centre for Fast-track Hip and Knee Arthroplasty, Copenhagen, Denmark
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Santana DC, Emara AK, Orr MN, Klika AK, Higuera CA, Krebs VE, Molloy RM, Piuzzi NS. An Update on Venous Thromboembolism Rates and Prophylaxis in Hip and Knee Arthroplasty in 2020. MEDICINA (KAUNAS, LITHUANIA) 2020; 56:E416. [PMID: 32824931 PMCID: PMC7558636 DOI: 10.3390/medicina56090416] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 08/10/2020] [Accepted: 08/14/2020] [Indexed: 12/16/2022]
Abstract
Patients undergoing total hip and knee arthroplasty are at high risk for venous thromboembolism (VTE) with an incidence of approximately 0.6-1.5%. Given the high volume of these operations, with approximately one million performed annually in the U.S., the rate of VTE represents a large absolute number of patients. The rate of VTE after total hip arthroplasty has been stable over the past decade, although there has been a slight reduction in the rate of deep venous thrombosis (DVT), but not pulmonary embolism (PE), after total knee arthroplasty. Over this time, there has been significant research into the optimal choice of pharmacologic VTE prophylaxis for individual patients, with the objective to reduce the rate of VTE while minimizing adverse side effects such as bleeding. Recently, aspirin has emerged as a promising prophylactic agent for patients undergoing arthroplasty due to its similar efficacy and good safety profile compared to other pharmacologic agents. However, there is no evidence to date that clearly demonstrates the superiority of any given prophylactic agent. Therefore, this review discusses (1) the current prevalence and trends in VTE after total hip and knee arthroplasty and (2) provides an update on pharmacologic VTE prophylaxis in regard to aspirin usage.
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Affiliation(s)
- Daniel C. Santana
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH 44195, USA; (D.C.S.); (A.K.E.); (M.N.O.); (A.K.K.); (V.E.K.); (R.M.M.)
| | - Ahmed K. Emara
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH 44195, USA; (D.C.S.); (A.K.E.); (M.N.O.); (A.K.K.); (V.E.K.); (R.M.M.)
| | - Melissa N. Orr
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH 44195, USA; (D.C.S.); (A.K.E.); (M.N.O.); (A.K.K.); (V.E.K.); (R.M.M.)
| | - Alison K. Klika
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH 44195, USA; (D.C.S.); (A.K.E.); (M.N.O.); (A.K.K.); (V.E.K.); (R.M.M.)
| | - Carlos A. Higuera
- Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, FL 33331, USA;
| | - Viktor E. Krebs
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH 44195, USA; (D.C.S.); (A.K.E.); (M.N.O.); (A.K.K.); (V.E.K.); (R.M.M.)
| | - Robert M. Molloy
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH 44195, USA; (D.C.S.); (A.K.E.); (M.N.O.); (A.K.K.); (V.E.K.); (R.M.M.)
| | - Nicolas S. Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH 44195, USA; (D.C.S.); (A.K.E.); (M.N.O.); (A.K.K.); (V.E.K.); (R.M.M.)
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