Venous thromboembolism is rare after total hip and knee joint arthroplasty with long thromboprophylaxis in Finnish fast-track hospitals

Risk-Stratified Venous Thromboembolism Chemoprophylaxis After Total Joint Arthroplasty: Evaluation of an Institutional Approach

Background/Objectives: The optimal venous thromboembolism (VTE) chemoprophylaxis approach after hip or knee total joint arthroplasty (TJA) remains controversial. This study aimed to characterize antithrombotic-related complications associated with various chemoprophylaxis regimens after TJA and to assess our current institutional risk-stratified prescribing tool. Methods: This retrospective case-control study and regression analysis included elective unilateral TJA patients at a single institution between 1 July 2015 and 31 December 2021. The primary outcome was a composite of antithrombotic-related complications within 30 days of surgery, including thrombotic and hemorrhagic/wound-related adverse events. The duration of anticoagulant chemoprophylaxis prescribed prior to aspirin monotherapy (0-28 days) was compared between patients who did vs. did not experience a complication, with stratification by institutionally defined VTE risk categories (Routine, Moderate, or High Risk). The complication rate was then assessed as a function of anticoagulant duration within each risk subgroup. Results: The study included 5420 patients, with 279 (5.2%) experiencing ≥1 complication. Routine VTE risk patients experienced few complications, with no significant difference between aspirin monotherapy and various initial anticoagulant durations (p = 0.6118). Moderate and High VTE Risk patients saw significantly lower complication rates with initial anticoagulant prophylaxis of increasing durations (p = 0.0090 and p = 0.0050), with a significant overall effect of VTE Risk strata observed (p = 0.0006). Conclusions: When both bleeding and thrombotic events are considered, anticoagulant-to-aspirin regimens were associated with lower complication rates than aspirin monotherapy in higher risk patients, while routine patients saw no significant benefit over aspirin. Our risk-stratified prescribing approach should be prospectively evaluated.

Validation of the 5-SNP score for the prediction of venous thromboembolism in a Danish fast-track cohort of 6789 total hip and total knee arthroplasty patients

Background

Venous thromboembolism (VTE) is a serious complication following total hip arthroplasty (THA) and total knee arthroplasty (TKA). Despite improvements with fast-track treatment protocols, 0.5% of patients still develop a VTE within 90-days postoperatively. Previously, the 5-single nucleotide polymorphism (SNP) genetic risk scores (weighted and simplified) were developed to identify people at a high risk for VTE within the general population.

Objectives

We aimed to assess whether the 5-SNP scores could be used to identify high-risk patients in a cohort of fast-track THA/TKA patients.

Methods

A subset of patients from the Lundbeck Centre for Fast-track Hip and Knee Replacement Database was included based on the availability of genetic information. The 5-SNP scores were calculated for these patients, and their discriminatory performance was determined by c-statistic. Furthermore, the 5-SNP scores were added to a simple logistic prediction model containing clinical predictors to assess the added predictive value.

Results

A total of 7753 THA and TKA procedures (6798 patients) were included in this study. The c-statistics for the weighted and simple 5-SNP scores were 0.50 (95% CI, 0.39-0.61) and 0.48 (95% CI, 0.38-0.58), respectively. For the model with clinical predictors, the c-statistic was 0.67 (95% CI, 0.56-0.77). Addition of either of the 5-SNP scores did not improve discrimination in this model.

Conclusion

These findings do not support genetic risk profiling in fast-track THA/TKA patients to predict VTE. Hence, efforts should be directed at optimizing prediction models with clinical predictors.

The incidence of venous thromboembolism is low when risk stratification-based thromboprophylaxis is used after fast-track hip and knee arthroplasty

BACKGROUND

The optimal length of thromboprophylaxis after total hip or knee arthroplasty (THA and TKA) is unknown. Fast-track protocols have improved patient care and led to shorter immobilization and length of stay (LOS) after THA and TKA, thereby diminishing venous thromboembolism (VTE) risk. Here, we investigated risk stratification-based thromboprophylaxis after fast-track THA and TKA.

METHODS

A retrospective register study was conducted in two Finnish hospitals using a fast-track protocol for THA and TKA. These hospitals use risk stratification-based planning of thromboprophylaxis, including risk evaluation of patients' personal VTE risk. Patients at low risk received thromboprophylaxis solely during hospitalization, provided this lasted five days or less. All VTEs and clinically relevant bleedings were obtained from Finnish hospital discharge registers between 1 January 2020 and 31 December 2021 to determine VTE incidences and clinically relevant bleedings 90 days after surgery.

RESULTS

During the study period 3 713 arthroplasties were performed (1 636 THAs and 2 077 TKAs). The 90-day incidence of VTE was 0.7% (CI 0.4 to 0.9), and 25 VTEs occurred within 90 days of surgery. These VTEs comprised 12 pulmonary embolisms and 13 deep vein thromboses, none of which was fatal. The incidence of clinically relevant bleedings (n = 57) within 90 days of surgery was 1.5% (CI 1.1 to 1.9). One intracranial bleeding was fatal. The bleedings typically occurred at the operational site.

CONCLUSION

Risk stratification-based thromboprophylaxis appears safe for fast-track THA and TKA patients as the incidences of VTEs and clinically relevant bleedings were low.

Rates of venous thromboembolism and use of thromboprophylaxis after major orthopedic surgery in patients with congenital hemophilia A or B: a systematic review

BACKGROUND

Venous thromboembolism (VTE) is a well-recognized complication after total joint replacement (TJR). Persons with hemophilia A or B are considered at low postoperative VTE risk due to their coagulation factor deficiencies, and administering pharmacologic thromboprophylaxis is often considered contraindicated. However, using factor replacement therapy could increase the postoperative VTE risk.

OBJECTIVES

To analyze best available evidences of VTE rates in persons with hemophilia A or B undergoing lower limb TJR and the use of postoperative pharmacologic thromboprophylaxis.

METHODS

We systematically screened 4 online biomedical databases to identify studies reporting VTE rates in patients with hemophilia after TJR. Case reports and case series with less than 10 patients were excluded.

RESULTS

Twenty-six observational studies were included in this systematic review, reporting 1181 TJRs in patients with hemophilia A or B. Eight studies had VTE rates as the primary outcome. Five studies reported screen-detected VTE, while 21 reported symptomatic VTE events. Overall, 17 VTE events were reported (1.4%; 95% CI, 0.9%-2.3%), including 10 (6.6%) after 151 surgeries with postoperative VTE screening and 7 (0.7%) after 1080 surgeries without postoperative screening. Thromboprophylaxis protocols were specified in 21 studies; postoperative thromboprophylaxis was used in 15 (1.3%) surgeries. This information was not available for 29.0% of the analyzed population.

CONCLUSION

Despite the low thromboprophylaxis use in patients with hemophilia, rates of symptomatic VTE after TJR appeared to be low. We also highlighted the need to better report the thrombotic outcome in persons with hemophilia to face the ongoing changes in the hemophilia landscape.