High complication rate after total knee and hip replacement due to perioperative bridging of anticoagulant therapy based on the 2012 ACCP guideline

Preoperative and Postoperative Therapeutic Anticoagulation in Orthopaedic Surgery Increases the Risk of Bleeding: A Systematic Review and Meta-Analysis

INTRODUCTION

Patients requiring postoperative therapeutic anticoagulation may have increased risk of bleeding complications, infection, and poor wound healing. The purpose of this study was to perform a systematic review and meta-analysis assessing bleeding complication rates among orthopaedic surgery patients receiving perioperative therapeutic anticoagulation.

METHODS

A systematic review and meta-analysis was performed in concordance with the Preferred Reporting Items for Systematic Review and Meta Analysis 2020 guidelines. PubMed was queried for articles related to therapeutic anticoagulation in orthopaedic surgery and complications using keywords and medical subject headings. Inclusion/exclusion criteria were any study reporting bleeding complications after orthopaedic surgery among patients on perioperative therapeutic anticoagulation with a minimum 1-year follow-up. Studies were reviewed for heterogeneity and risk of bias. Pooled analysis was done to determine postoperative complication rates among patients on therapeutic anticoagulation.

RESULTS

Thirty-seven studies with 3,990 patients were included. Studies were grouped by their surgical subspecialty with 16 from arthroplasty, one foot and ankle, two spine, one sports, 13 trauma, and four upper extremity. Among patients on therapeutic anticoagulation, the pooled rate and 95% confidence intervals of bleeding complications was 8% (5 to 11%) overall, 10% (5 to 15%) in arthroplasty, 6% (3 to 11%) in trauma, and 5% (1 to 30%) in upper extremity. The overall rates (95% CI) of venous thromboembolism (VTE) were 2% (2 to 4%), infection 5% (3 to 10%), and revision surgery 4% (3 to 6%). Upper extremity VTE rates were 0% (0 to 15%), infection 4% (3 to 6%), and revision surgery 4% (3 to 6%). Trauma VTE rates were 4% (2 to 5%), infection 2% (1 to 6%), and revision surgery 3% (2 to 4%). Arthroplasty VTE rates were 2% (1 to 5%), infection 9% (4 to 18%), and revision surgery 4% (2 to 7%).

CONCLUSIONS

Therapeutic postoperative anticoagulation may increase the risk of bleeding complications when compared with the general population. Incidence of VTE was similar when compared with historical data.

Evaluation of the Safety of Uninterrupted Warfarin Anticoagulation With Tranexamic Acid in Total Joint Arthroplasty

BACKGROUND

The continuation of long-term warfarin therapy is gaining acceptance in minor surgeries but maintaining therapeutic international normalized ratio (INR) values among patients during major orthopedic procedures raises concern. While bridging therapy with low-molecular-weight heparin is currently recommended for patients receiving anticoagulation, few studies have evaluated the safety of continuing warfarin during total joint arthroplasty. This study evaluated the safety and efficacy of continuous warfarin anticoagulation through total joint arthroplasty with and without prophylactic tranexamic acid (TXA).

MATERIALS AND METHODS

We conducted a retrospective, matched-pair analysis of two experimental groups of patients who underwent primary total hip arthroplasty or total knee arthroplasty performed by a single surgeon. Our first experimental group, warfarin plus TXA (warfarin+TXA), consisted of 21 patients who underwent arthroplasty while receiving therapeutic anticoagulation with warfarin (INR, 2.0-3.0) and who received prophylactic TXA. Our second experimental group, warfarin without TXA (warfarin-TXA), consisted of 40 patients who underwent arthroplasty while receiving therapeutic anticoagulation with warfarin (INR, 2.0-3.0) without prophylactic TXA.

RESULTS

The percent change in hemoglobin value after surgery, red blood cells transfused, surgical site infections, bleeding complications, and thrombotic complications were similar between both experimental and control groups. When comparing the historical group with the warfarin+TXA group, the addition of TXA resulted in a statistical decrease in mean red blood cells transfused and estimated blood loss, with no statistically significant increase in complications.

CONCLUSION

Many factors must be considered when choosing perioperative thromboembolic prophylaxis for arthroplasty candidates with medical comorbidities requiring long-term anticoagulation. This study presents data indicating that it could be safe and effective to continue therapeutic warfarin while using prophylactic TXA. [Orthopedics. 2024;47(4):211-216.].

Effect of Low-Level Laser Therapy on Knee Range of Motion and Functional Abilities After Total Knee Arthroplasty

OBJECTIVE

The aim of this study was to determine the effectiveness of combined low-level laser therapy (LLL) and rehabilitation in patients following recent total knee replacement (TKR).

METHODS

A double-blind randomized controlled study was conducted at the Orthopedic Department of Mansoura University Hospital. Forty-four patients were chosen from a total of 58 patients who met the inclusion criteria and were assigned randomly into control and experimental groups of equal size. Ultimately, 40 patients completed the study (20 from each group). Both groups participated in an intensive functional rehabilitation program, and the experimental group also received LLL therapy around the knee at the incisional line, the medial and lateral intra-articular space, above and below the patella, and at the popliteal fossa at low fluence (6 J/cm2, 650 nm continuous wave) and 60 s per point with a total dose of 48 J per session over 12 treatment sessions for six weeks. Knee range of motion (ROM) was measured with a digital goniometer, and functional abilities were assessed with the Arabic version of the Western Ontario and McMaster Universities Osteoarthritis (WOMAC) index.

RESULTS

There were significant differences in all variables pre- and post-treatment within each group. Before treatment, there was no significant difference in any of the measured variables between the groups (P>0.05). After treatment, there were significant differences in knee flexion ROM and WOMAC index (P<0.05) but no significant difference in knee extension ROM between the groups (P>0.05).

CONCLUSION

The addition of low-level laser therapy to a rehabilitation program post-TKR resulted in substantial enhancements in knee flexion range of motion and the WOMAC index.

The correlates of post-surgical haematoma in older adults with proximal femoral fractures

BACKGROUND

Little is known about the incidence of haematoma, and clinical correlates among orthogeriatric patients.

AIMS

This study aims to describe the incidence of haematoma after surgical repair of hip fracture and to identify the clinical correlates of haematoma among orthogeriatric patients.

METHODS

Two orthopaedic surgeons and a dedicated operator using ultrasound technique, each other in blindness, evaluated 154 orthogeriatric patients during their hospital stay. All patients received a comprehensive geriatric assessment. We investigated the concordance between clinical diagnosis and ultrasound detection of haematoma, and then we explored the clinical correlates of the onset of post-surgical haematoma.

RESULTS

Blood effusion at the surgical site was detected in 77 (50%) patients using ultrasound technique; orthopaedic surgeons reached a clinical agreement about post-surgical haematoma in 18 (23%) patients. The sensitivity of clinical evaluation was 0.66, and the specificity was 0.70. Independent of age, clinical, pharmacological, and surgical confounders, proton pump inhibitors (PPIs) were associated with post-surgical haematoma (OR 2.28; 95% CI 1.15-4.49). A tendency towards association was observed between selective serotonin reuptake inhibitors and post-surgical haematoma (OR 2.10; 95% CI 0.97-4.54), CONCLUSIONS: Half of older patients undergoing surgical repair of proximal femoral fracture develop a post-surgical haematoma. Clinical assessment, even if made by senior orthopaedic surgeons, underestimates the actual occurrence of post-surgical haematoma compared to ultrasound detection. Ultrasound technique may help to detect haematoma larger than 15 mm better than clinical assessment. PPIs's use is a risk factor for post-surgical haematoma independent of several medical and surgical confounders.

Aspirin thromboprophylaxis following primary total knee arthroplasty is associated with a lower rate of early prosthetic joint infection compared with other agents

BACKGROUND

Patients undergoing total knee arthroplasty (TKA) are at increased risk of venous thromboembolism (VTE). Aspirin has been shown to be effective at reducing rates of VTE. In select patients, more potent thromboprophylaxis is indicated, which has been associated with increased rates of bleeding and wound complications. This study aimed to evaluate the effect of thromboprophylaxis choice on rates of early prosthetic joint infection (PJI) following TKA.

METHODS

A review of 11,547 primary TKA patients from 2013 to 2019 at a single academic orthopaedic hospital was conducted. The primary outcome measure was PJI within 90 days of surgery as measured by Musculoskeletal Infection Society criteria. There were 59 (0.5%) patients diagnosed with early PJI. Chi-square and Welch-Two Sample t-tests were used to determine statistically significant relationships between thromboprophylaxis and demographic variables. Significance was set at p<0.05. Multivariate logistic regression adjusted for age, body mass index, sex, and Charlson comorbidity index was performed to identify and control for independent risk factors for early PJI.

RESULTS

There was a statistically significant difference in the rates of early PJI between the aspirin and non-aspirin group (0.3 vs 0.8%, p<0.001). Multivariate logistic regressions revealed that patients given aspirin thromboprophylaxis had significantly lower odds of PJI (odds ratios (OR)=0.51, 95% Confidence Interval (CI) 0.29 to 0.89, p=0.019) compared to non-aspirin patients.

CONCLUSIONS

The use of aspirin thromboprophylaxis following primary TKA is independently associated with a lower rate of early PJIs. Arthroplasty surgeons should consider aspirin as the gold standard thromboprophylaxis in all patients in which it is deemed medically appropriate and should carefully weigh the morbidity of PJI in patients when non-aspirin thromboprophylaxis is considered.

Inhaled Corticosteroids, Vitamin K Antagonists and Amlodipine Were Associated with an Increased Risk of Acute Periprosthetic Joint Infection in Patients with Total Hip Arthroplasty: A Retrospective Case–Cohort Study

The perioperative use of certain medication may influence the risk of developing a periprosthetic joint infection (PJI). Inhaled corticosteroids (ICSs) and cardiovascular drugs are widely used against pulmonary and cardiovascular diseases. While oral corticosteroids and anticoagulants have been shown to increase the risk of developing PJI, this is not clear for ICSs. In contrast, some cardiovascular drugs, such as amlodipine, nifedipine and statins, have been documented to show an antimicrobial effect, suggesting a synergistic effect with antibiotics in the treatment of (multi-resistant) microorganisms. We performed a case–cohort study to assess the association between the occurrence of PJI after THA and the use of inhaled corticosteroids, anticoagulants, or previously mentioned cardiovascular agents. In a cohort of 5512 primary THAs, we identified 75 patients with a PJI (1.4%), and randomly selected 302 controls. A weighted Cox proportional hazard regression model was used for the study design and to adjust for potential confounders (age, sex, smoking, and cardiovascular/pulmonary disease). We found ICS use (HR 2.6 [95% CI 1.1–5.9]), vitamin K antagonist use (HR 5.3 [95% CI 2.5–11]), and amlodipine use (HR 3.1 [95% CI 1.4–6.9]) to be associated with an increased risk of developing PJI after THA. The effect remained after correction for the mentioned possible confounders. The underlying diseases for which the medications are prescribed could also play a role in the mentioned association; we believe, however, that the usages of ICSs, vitamin K antagonists and amlodipine appear to be potential modifiable risk factors for PJI, and therefore have to be questioned during preoperative screening and consultation.

Multiple Venous Thromboembolism Pharmacologic Agents Are Associated with an Increased Risk for Early Postoperative Complications following a Total Joint Arthroplasty

The purpose of this study was to determine the effect that concurrent venous thromboembolism (VTE) medications had on early outcomes following primary total joint arthroplasty (TJA). 2653 total knee and hip arthroplasties were reviewed at a tertiary medical center. The study performed a multivariable comparison of outcomes in patients on 2 or more VTE medications, as well as a logistic regression on outcomes following each addition of a VTE medication postoperatively (number of VTE medications was 1–4). Controlling for gender, age, body mass index, and preoperative American Society of Anesthesiologists score throughout the analysis, patients who received 2 or more VTE prophylaxis medications had increased LOS (p < 0.001), transfusions (p < 0.001), emergency department visits (p=0.001), readmissions (p < 0.001), 90dPOE (p < 0.001), and PE (p < 0.001). Every additional postoperative VTE medication incrementally increased the risk for longer LOS (p < 0.001), transfusions (p < 0.001), 90dPOE (p < 0.001), deep vein thrombosis (p=0.049), PE (p < 0.001), emergency department visits (p=0.005), and readmission (p=0.010). Patients on multiple VTE medications following TJA demonstrate significantly poorer outcomes. The current study's findings caution the use of multiple VTE medications whenever possible immediately following a TJA.

Stiffness after unicompartmental knee arthroplasty: Risk factors and arthroscopic treatment

Introduction: One of the principal complications after total knee arthroplasty (TKA) is stiffness. There are no publications concerning stiffness after unicompartmental knee arthroplasty (UKA). Study objectives were to describe the incidence of stiffness after UKA, to look for risk factors, and to describe safe and effective arthroscopic treatment. Methods: There were 240 UKA performed between March 2016 and January 2019 included. Robotic-assisted surgery was performed in 164 patients and mechanical instrumentation in 76 patients. Stiffness was defined as flexion < 90° or a flexion contracture > 10° during the first 45 post-operative days. Patients with stiffness were treated with arthroscopic arthrolysis. Several factors were studied to look for risk factors of stiffness: body mass index, gender, age, mechanical or robotic instrumentation, preoperative flexion, previous meniscectomy, and anticoagulant treatment. Arthrolysis effectiveness was evaluated by flexion improvement and UKA revision rate. Results: 22 patients (9%) developed stiffness. Mechanical instrumentation significantly increased the risk of stiffness with OR = 0.26 and p = 0.005. Robotic-assisted surgery decreased the risk of stiffness by five-fold. Before arthrolysis, mean knee flexion was 79°, versus 121° (53% improvement) after arthroscopic arthrolysis. Only 2 patients (9%) underwent UKA revision after arthrolysis. Discussion: Stiffness after UKA is an important complication with an incidence of 9% in this study. Arthroscopic arthrolysis is a safe and effective treatment with a range of motion improvement of > 50%. Robotic-assisted surgery significantly decreases the risk of postoperative stiffness.

Level of evidence: Level III, therapeutic study, retrospective cohort study

Perioperative Management of Chronic Antithrombotic Agents in Elective Hip and Knee Arthroplasty

Total hip and knee arthroplasty are common major orthopedic operations being performed on an increasing number of patients. Many patients undergoing total joint arthroplasty (TJA) are on chronic antithrombotic agents due to other medical conditions, such as atrial fibrillation or acute coronary syndrome. Given the risk of bleeding associated with TJAs, as well as the risk of thromboembolic events in the post-operative period, the management of chronic antithrombotic agents perioperatively is critical to achieving successful outcomes in arthroplasty. In this review, we provide a concise overview of society guidelines regarding the perioperative management of chronic antithrombotic agents in the setting of elective TJAs and summarize the recent literature that may inform future guidelines. Ultimately, antithrombotic regimen management should be patient-specific, in consultation with cardiology, internal medicine, hematology, and other physicians who play an essential role in perioperative care.

Postoperative Complications Causing Readmission in 30 Days after Total Knee Arthroplasty: A Retrospective Nested Case-Control Study of Risk Factors Based on Propensity Score Matching

We performed this study to identify independent risk factors for life-threatening postoperative complications causing 30-day readmissions after total knee arthroplasty (TKA). Improved understanding of these risks may improve efficiency and safety of treatment. We performed a retrospective, nested case-control study using an open-access database of 2,622 patients who underwent primary TKA at a tertiary academic medical center in Singapore between January 2013 and June 2014. Patients were grouped according to the incidence of complications. Multivariate logistic analysis was performed to identify predictive factors for TKA complications. The incidence of postoperative complications was 1.72%. Compared with cases performed with an operative time < 70 minutes, increased operative time was associated with a higher risk of complications. Case duration > 90 minutes was associated with an increased risk (adjusted odds ratio [aOR] = 4.57, p = 0.001; case duration ≥ 111 minutes, aOR = 4.64, p = 0.04; and case duration between 91 and 110 minutes, aOR = 3.20, p = 0.03). The correlation between operative time and complications was nonlinear. Cerebrovascular accident (CVA) or transient ischemic attack (TIA) was an independent risk factor for increased complication rate (aOR = 11.59, p = 0.02). Operative duration has been identified as an independent risk factor for complications after TKA. As it remains a modifiable factor to which doctors are interested in bringing quality improvement, the risk of postoperative complications will be reduced by minimizing the operative duration.

Can infection after anterior cruciate ligament surgery be prevented by inserting a Hemovac drain into graft donor site?

Objectives

This study aims to investigate the effect of Hemovac drainage placed in graft harvesting area on preventing deep surgical site infection (SSI) and/or septic arthritis through draining the hematoma formed in the graft area in arthroscopic primary anterior cruciate ligament (ACL) reconstruction surgery using hamstring autograft.

Patients and methods

This retrospective study was conducted between January 2008 and March 2019. A total of 819 patients (769 males, 50 females; mean age 33.7 years; range, 25 to 41 years) who underwent arthroscopic primary ACL reconstruction surgery using hamstring autograft were divided into two groups based on whether a Hemovac drain was also placed at the hamstring graft harvested area. Both groups were compared in terms of the presence of deep SSI and/or development of septic arthritis.

Results

In the non-drained group (group 1, n=401), 16 patients (3.9%) had septic arthritis, four (0.9%) had deep SSI, and two (0.49%) had both wound and joint infections. Septic arthritis was identified in only one patient (0.2%) in the drained group (group 2, n=418). In group 2, the mean amount of blood coming from the drain at the graft harvesting region was 36.85 mL (range, 20-50 mL).

Conclusion

In arthroscopic primary ACL reconstruction surgery using hamstring tendon autograft, we concluded that the use of a Hemovac drain could be effective in preventing deep SSI through reducing the hematoma occurring in this region. However, future studies are needed to validate the effect of Hemovac drain on preventing the septic arthritis.

Evaluation of early wound leakage as a risk factor for prosthetic joint infection

BACKGROUND AND PURPOSE

Prosthetic joint infection (PJI) is a serious complication resulting from total knee arthroplasty (TKA) or total hip arthroplasty (THA). In this study, patients with a PJI are compared with patients with an uncomplicated postoperative course to identify relevant risk factors for PJI.

METHODS

A matched case-control study was performed with patients undergoing fast-track, elective unilateral TKA or THA. The following data were collected: demographics, surgery-related characteristics (perioperative blood loss, use of cement, body temperature), and postoperative characteristics (hematoma formation, wound leakage, blood transfusion, length of stay [LOS]).

CONCLUSIONS

When the PJI group was compared with the control group, there was significantly more wound leakage during hospital stay (88% vs. 36%, p = .001) and early wound dressing changes in the first 3 days after surgery (88% vs. 40%, p = .002). Hematoma formation was observed more in the PJI patients group (44% vs. 10%, p = .005). A trend test revealed a significant association between the total number of wound dressing changes and development of PJI (p < .001); 72% of PJI patients had a length of stay of ≥4 days compared with 34% of controls (odds ratio 10.5; 95% CI [2.1-52.3]; p = .004).

IMPLICATIONS FOR PRACTICE

Early postoperative wound drainage and hematoma formation directly correlate with PJI. This resulted in a significantly higher number of dressing changes and longer LOS. The nurse practitioner has a central role in postoperative care and is the first to recognize signs of an adverse postoperative clinical course.

Tranexamic acid use and risk of thrombosis in regular users ofantithrombotics undergoing primary total knee arthroplasty: a prospectivecohort study

BACKGROUND

The effect of tranexamic acid has not been examined in patients who are regular users of antithrombotics before undergoing total knee arthroplasty. The aim of this study was to determine the impact of tranexamic acid on bleeding and the risk of transfusion and thrombosis in patients taking an antithrombotic treatment before primary unilateral total knee arthroplasty.

MATERIAL AND METHODS

A prospective observational study was conducted in a series of 385 consecutive primary total knee arthroplasties performed with and without the administration of tranexamic acid. We compared post-operative bleeding, as determined by a bleeding index, and postoperative haemoglobin and haematocrit between patients taking an antithrombotic treatment before the operation (ATT+ group) and those naïve or non-regular users of antithrombotics (ATT- group). Post-operatively, rivaroxaban was prescribed for deep vein thrombosis prophylaxis, unless contraindicated. Antiplatelet therapy and vitamin K antagonist anticoagulants were not resumed during the early post-operative period.

RESULTS

The prevalence of total knee arthroplasty performed in patients who are regular users of antithrombotics was 33%. Tranexamic acid was administered during 62% of the arthroplasties in the ATT+ group and to 90% in the ATT- group. In both study groups, the bleeding index was significantly lower in patients who received tranexamic acid, both in the ATT+ (p<0.001) and in the ATT- group (p=0.001). No patients in the ATT+ group received a blood transfusion during the first post-operative week. No thrombotic complications were identified for up to 2 months in the ATT+ group.

DISCUSSION

Tranexamic acid use after the induction of general anaesthesia in total knee arthroplasty represents a fast, inexpensive, and effective opportunity to reduce peri-operative blood loss in patients on chronic antithrombotic treatment undergoing total knee arthroplasty.

Effect of joint mobilization techniques for primary total knee arthroplasty: Study protocol for a randomized controlled trial

BACKGROUND

Total knee arthroplasty (TKA) has become the most preferred procedure by patients for the relief of pain caused by knee osteoarthritis. TKA patients aim a speedy recovery after the surgery. Joint mobilization techniques for rehabilitation have been widely used to relieve pain and improve joint mobility. However, relevant randomized controlled trials showing the curative effect of these techniques remain lacking to date. Accordingly, this study aims to investigate whether joint mobilization techniques are valid for primary TKA.

METHODS/DESIGN

We will manage a single-blind, prospective, randomized, controlled trial of 120 patients with unilateral TKA. Patients will be randomized into an intervention group, a physical modality therapy group, and a usual care group. The intervention group will undergo joint mobilization manipulation treatment once a day and regular training twice a day for a month. The physical modality therapy group will undergo physical therapy once a day and regular training twice a day for a month. The usual care group will perform regular training twice a day for a month. Primary outcome measures will be based on the visual analog scale, the knee joint Hospital for Special Surgery score, range of motion, surrounded degree, and adverse effect. Secondary indicators will include manual muscle testing, 36-Item Short Form Health Survey, Berg Balance Scale function evaluation, Pittsburgh Sleep Quality Index, proprioception, and muscle morphology. We will direct intention-to-treat analysis if a subject withdraws from the trial.

DISCUSSION

The important features of this trial for joint mobilization techniques in primary TKA are randomization procedures, single-blind, large sample size, and standardized protocol. This study aims to investigate whether joint mobilization techniques are effective for early TKA patients. The result of this study may serve as a guide for TKA patients, medical personnel, and healthcare decision makers.

TRIAL REGISTRATION

It has been registered at http://www.chictr.org.cn/showproj.aspx?proj=15262 (Identifier:ChiCTR-IOR-16009192), Registered 11 September 2016. We also could provide the correct URL of the online registry in the WHO Trial Registration. http://apps.who.int/trialsearch/Trial2.aspx?TrialID=ChiCTR-IOR-16009192.

American College of Foot and Ankle Surgeons® Clinical Consensus Statement: Perioperative Management

A wide range of factors contribute to the complexity of the management plan for an individual patient, and it is the surgeon's responsibility to consider the clinical variables and to guide the patient through the perioperative period. In an effort to address a number of important variables, the American College of Foot and Ankle Surgeons convened a panel of experts to derive a clinical consensus statement to address selected issues associated with the perioperative management of foot and ankle surgical patients.

Thromboembolic and major bleeding events in relation to perioperative bridging of vitamin K antagonists in 649 fast-track total hip and knee arthroplasties

Background - The benefit of preoperative bridging in surgical patients with continuous anticoagulant therapy is debatable, and drawing of meaningful conclusions may have been limited by mixed procedures with different thromboembolic and bleeding risks in most published studies. Patients and methods - This was an observational cohort treatment study in consecutive primary unilateral total hip and knee arthroplasty patients between January 2010 and November 2013 in 8 Danish fast-track departments. Data were collected prospectively on preoperative comorbidity and anticoagulants in patients with preoperative vitamin K antagonist (VKA) treatment. We performed 30-day follow-up on in-hospital complications and re-admissions through the Danish National Patient Registry and patient records. Results - Of 13,375 procedures, 649 (4.7%) were in VKA patients with a mean age of 73 (SD 9) years and a median length of stay of 3 days (IQR: 2-4). Preoperative bridging was used in 430 (67%), while 215 (33%) were paused. Of 4 arterial thromboembolic events (ATEs) (0.6%), 2 were in paused patients and 2 were in bridged patients (p = 0.6). Of 3 venous thromboembolic events (VTEs) (0.5%), 2 were in paused patients and 1 was in a bridged patient (p = 0.3). Of 8 major bleedings (MBs) (1.2%), 1 was in a paused patient and 7 were in bridged patients (p = 0.3), 5 of whom received therapeutic bridging. Similar results were found in a propensity-matched cohort. Interpretation - In contrast to recent studies in mixed surgical procedures, no statistically significant differences in ATE, VTE, or MB were found between preoperative bridging and pausation of VKA patients. However, the higher number of thromboembolic events in paused patients and the higher number of major bleedings in bridged patients warrant more extensive investigation.

Preventing Venous Thromboembolism with Use of Intermittent Pneumatic Compression after Total Hip Arthroplasty in Korean Patients

Intermittent Pneumatic Compression (IPC) device has been used to prevent venous thromboembolism (VTE). This study investigated the effectiveness of IPC device. We evaluated incidences of deep vein thrombosis (DVT) and pulmonary embolism (PE) in total hip arthroplasty (THA) patients after use of IPC device, and compared with historical incidences from our institution. We applied IPC device in 741 patients who underwent 870 elective primary THAs from January 2010 to December 2013, DVT was detected in 3 patients (0.3%) by sonography, and one (0.1%) of them was symptomatic. Symptomatic PE occurred in 1 patient (0.1%) and there were no cases of fatal PE. The incidence of symptomatic DVT was significantly lower than the historical control (P = 0.042). The IPC is a safe and effective prophylaxis of VTE after primary THA in Korea.

Balancing Thromboprophylaxis and Bleeding in Total Joint Arthroplasty: Impact of Eliminating Enoxaparin and Predonation and Implementing Pneumatic Compression and Tranexamic Acid

BACKGROUND

Venous thromboembolic disease (VTED) after total hip arthroplasty (THA) and total knee arthroplasty (TKA) poses substantial risk. Pharmacologic prophylaxis against VTED can cause bleeding, transfusion, and associated complications. The ActiveCare+SFT is a portable, intermittent pneumatic compression device (IPCD), providing equivalent VTED prophylaxis to pharmacologic agents without associated bleeding. Tranexamic acid (TXA) is an antifibrinolytic that reduces blood loss after THA and TKA. Our objective was to measure blood transfusion and VTED after eliminating enoxaparin, introducing an IPCD, eliminating autologous blood transfusion, and administering TXA during primary TKA and THA.

METHODS

Four consecutive cohorts of THA and TKA patients were studied. Group A, the historical control, received enoxaparin VTED prophylaxis. Group B received IPCD VTED prophylaxis. Group C received IPCD VTED prophylaxis along with TXA (1 g intravenous at incision and closure). Groups A, B, and C predonated 1 unit of autologous blood. Group D received IPCD VTED prophylaxis, TXA as above, but did not donate blood preoperatively.

RESULTS

Seventeen of 50 patients (34%) in Group A, 7 of 47 (14.9%) patients in Group B, 4 of 43 (9.3%) patients in Group C, and 0 of 46 patients in Group D received transfusions. There were no major symptomatic VTED events.

CONCLUSION

Using an IPCD and TXA and discontinuing enoxaparin and preoperative autologous blood donation eliminated blood transfusion in primary THA and TKA without any increase in VTED. Using an IPCD instead of enoxaparin, adding TXA, and eliminating preoperative autologous donation each had an incremental dose response effect. This protocol provides effective VTED prophylaxis equivalent to pharmacologic methods and eliminates transfusion risk in the primary THA and TKA population.