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Núñez JH, Moreira F, Escudero-Cisneros B, Martínez-Peña J, Bosch-García D, Angles F, Guerra-Farfán E. [Translated article] Risk of venous thromboembolism in thromboprophylaxis between aspirin and low molecular weight heparins after total hip arthroplasty or total knee arthroplasty: Systematic review and meta-analysis. Rev Esp Cir Ortop Traumatol (Engl Ed) 2024; 68:T409-T421. [PMID: 38325570 DOI: 10.1016/j.recot.2024.01.024] [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: 02/15/2023] [Revised: 07/16/2023] [Accepted: 07/27/2023] [Indexed: 02/09/2024] Open
Abstract
INTRODUCTION The aim of this study was to evaluate the efficacy of aspirin versus low molecular weight heparins (LMWH) for the prophylaxis of venous thromboembolism (VTE), deep vein thrombosis (DVT) and pulmonary embolism (PE) in patients undergoing total knee arthroplasty (TKA) and/or total hip arthroplasty (THA). MATERIALS AND METHODS Systematic review and meta-analysis. Sixteen studies were selected. The risk of VTE, DVT and PE were analysed. Mortality, risk of bleeding and surgical wound complications was also analysed. RESULTS 248,461 patients were included. 176,406 patients with thromboprophylaxis with LMWH and 72,055 patients with aspirin thromboprophylaxis. There were no significant differences in the risk of VTE (OR=0.93; 95% CI: 0.69-1.26; p=0.64), DVT (OR=0.72; 95% CI: 0.43-1.20; p=0.21) or PE (OR=1.13; 95% CI: 0.86-1.49; p=0.38) between both groups. No significant differences were found in mortality (p=0.30), bleeding (p=0.22), or complications in the surgical wound (p=0.85) between both groups. These same findings were found in the sub-analysis of only randomised clinical trials (p>0.05). CONCLUSIONS No increased risk of PE, DVT, or VTE was found among patients with aspirin thromboprophylaxis versus patients with LMWH thromboprophylaxis. There was also no greater mortality, greater bleeding, or greater complications in the surgical wound found among patients with aspirin thromboprophylaxis versus patients with LMWH thromboprophylaxis.
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Affiliation(s)
- J H Núñez
- Servicio de Traumatología y Cirugía Ortopédica, Hospital Universitario de Mutua Terrassa, Plaça del Doctor Robert, 5, 08221 Terrassa, Barcelona, Spain; Artro-Esport, Centro Médico Teknon, Carrer de Vilana, 12, 08022 Barcelona, Spain.
| | - F Moreira
- Artro-Esport, Centro Médico Teknon, Carrer de Vilana, 12, 08022 Barcelona, Spain
| | - B Escudero-Cisneros
- Servicio de Traumatología y Cirugía Ortopédica, Hospital Universitario de Mutua Terrassa, Plaça del Doctor Robert, 5, 08221 Terrassa, Barcelona, Spain
| | - J Martínez-Peña
- Servicio de Traumatología y Cirugía Ortopédica, Hospital Universitario de Mutua Terrassa, Plaça del Doctor Robert, 5, 08221 Terrassa, Barcelona, Spain
| | - D Bosch-García
- Servicio de Traumatología y Cirugía Ortopédica, Hospital Universitario de Mutua Terrassa, Plaça del Doctor Robert, 5, 08221 Terrassa, Barcelona, Spain
| | - F Angles
- Servicio de Traumatología y Cirugía Ortopédica, Hospital Universitario de Mutua Terrassa, Plaça del Doctor Robert, 5, 08221 Terrassa, Barcelona, Spain
| | - E Guerra-Farfán
- Artro-Esport, Centro Médico Teknon, Carrer de Vilana, 12, 08022 Barcelona, Spain
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Núñez JH, Moreira F, Escudero-Cisneros B, Martínez-Peña J, Bosch-García D, Anglès F, Guerra-Farfán E. Risk of venous thromboembolism in thromboprophylaxis between aspirin and low molecular weight heparins after total hip arthroplasty or total knee arthroplasty: Systematic review and meta-analysis. Rev Esp Cir Ortop Traumatol (Engl Ed) 2024; 68:409-421. [PMID: 37544408 DOI: 10.1016/j.recot.2023.07.003] [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: 02/15/2023] [Revised: 07/16/2023] [Accepted: 07/27/2023] [Indexed: 08/08/2023] Open
Abstract
INTRODUCTION The aim of this study was to evaluate the efficacy of aspirin versus low molecular weight heparins (LMWH) for the prophylaxis of venous thromboembolism (VTE), deep vein thrombosis (DVT) and pulmonary embolism (PE) in patients undergoing total knee arthroplasty (TKA) and/or total hip arthroplasty (THA). MATERIALS AND METHODS Systematic review and meta-analysis. Sixteen studies were selected. The risk of VTE, DVT and PE were analyzed. Mortality, risk of bleeding and surgical wound complications was also analyzed. RESULTS 248,461 patients were included. 176,406 patients with thromboprophylaxis with LMWH and 72,055 patients with aspirin thromboprophylaxis. There were no significant differences in the risk of VTE (OR = 0.93; 95% CI: 0.69-1.26; P = .64), DVT (OR = 0.72; 95% CI: 0.43-1.20; P = .21) or PE (OR = 1.13; 95% CI: 0.86-1.49; P = .38) between both groups. No significant differences were found in mortality (P = .30), bleeding (P = .22), or complications in the surgical wound (P = .85) between both groups. These same findings were found in the sub-analysis of only randomized clinical trials (P>.05). CONCLUSIONS No increased risk of PE, DVT, or VTE was found among patients with aspirin thromboprophylaxis versus patients with LMWH thromboprophylaxis. There was also no greater mortality, greater bleeding, or greater complications in the surgical wound found among patients with aspirin thromboprophylaxis versus patients with LMWH thromboprophylaxis.
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Affiliation(s)
- Jorge H Núñez
- Servicio de Traumatología y Cirugía Ortopédica, Hospital Universitario de Mutua Terrassa, Terrassa, Barcelona, España; Artro-Esport, Centro Médico Teknon, Terrassa, Barcelona, España.
| | - Felipe Moreira
- Artro-Esport, Centro Médico Teknon, Terrassa, Barcelona, España
| | - Berta Escudero-Cisneros
- Servicio de Traumatología y Cirugía Ortopédica, Hospital Universitario de Mutua Terrassa, Terrassa, Barcelona, España
| | - Judith Martínez-Peña
- Servicio de Traumatología y Cirugía Ortopédica, Hospital Universitario de Mutua Terrassa, Terrassa, Barcelona, España
| | - David Bosch-García
- Servicio de Traumatología y Cirugía Ortopédica, Hospital Universitario de Mutua Terrassa, Terrassa, Barcelona, España
| | - Francesc Anglès
- Servicio de Traumatología y Cirugía Ortopédica, Hospital Universitario de Mutua Terrassa, Terrassa, Barcelona, España
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Haac BE, O'Hara NN, Haut ER, Manson TT, Slobogean GP, O'Toole RV, Stein DM. Venous thromboembolism testing practices after orthopaedic trauma: prophylaxis regimen does not influence testing patterns. OTA Int 2024; 7:e331. [PMID: 38623266 PMCID: PMC11013691 DOI: 10.1097/oi9.0000000000000331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 01/17/2024] [Accepted: 02/01/2024] [Indexed: 04/17/2024]
Abstract
Objectives To determine venous thromboembolism (VTE) testing patterns in an orthopaedic trauma population and to evaluate for differences in VTE surveillance by prophylaxis regimen through a secondary analysis of the ADAPT trial. Design Prospective randomized trial. Setting Level I trauma center. Patients Three hundred twenty-nine adult (18 years and older) trauma patients presenting with an operative extremity fracture proximal to the metatarsals/carpals or any pelvic or acetabular fracture requiring VTE prophylaxis. Intervention VTE imaging studies recorded within 90 days post injury. Main Outcome Measurements Percentage of patients tested for VTE were compared between treatment groups using Fisher's exact test. Subsequently, multivariable regression was used to determine patient factors significantly associated with risk of receiving a VTE imaging study. Results Sixty-seven patients (20.4%) had VTE tests ordered during the study period. Twenty (29.9%) of these 67 patients with ordered VTE imaging tests had a positive finding. No difference in proportion of patients tested for VTE by prophylaxis regimen (18.8% on aspirin vs. 22.0% on LMWH, P = 0.50) was observed. Factors associated with increased likelihood of VTE testing included White race (adjusted odds ratio [aOR]: 2.61, 95% CI: 1.26-5.42), increased Injury Severity Score (aOR for every 1-point increase: 1.10, 95% CI: 1.05-1.15), and lower socioeconomic status based on the Area Deprivation Index (aOR for every 10-point increase: 1.14, 95% CI: 1.00-1.30). Conclusions VTE surveillance did not significantly differ by prophylaxis regimen. Patient demographic factors including race, injury severity, and socioeconomic status were associated with differences in VTE surveillance. Level of Evidence Level I, Therapeutic.
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Affiliation(s)
- Bryce E. Haac
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
| | - Nathan N. O'Hara
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD
| | - Elliott R. Haut
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Theodore T. Manson
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD
| | - Gerard P. Slobogean
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD
| | - Robert V. O'Toole
- R Adams Cowley Shock Trauma Center, Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD
| | - Deborah M. Stein
- Department of Surgery, University of Maryland School of Medicine, Baltimore, MD
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Habibi AA, Brash A, Rozell JC, Ganta A, Schwarzkopf R, Arshi A. Aspirin prophylaxis is not associated with increased risk of venous thromboembolism in arthroplasty for femoral neck fractures: a non-inferiority study. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:1405-1411. [PMID: 38197969 DOI: 10.1007/s00590-023-03816-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 12/15/2023] [Indexed: 01/11/2024]
Abstract
PURPOSE Venous thromboembolism (VTE) is a known complication of hip arthroplasty for femoral neck fractures (FNF) with various prophylactic anticoagulants utilized to decrease risk. The purpose of this study was to assess the efficacy and perioperative outcomes associated with aspirin for VTE prophylaxis following arthroplasty for FNF. METHODS Medical records of 1,220 patients who underwent hip hemiarthroplasty (HHA) or total hip arthroplasty (THA) at an urban academic center from 2011 to 2022 were retrospectively reviewed. Patient characteristics and perioperative outcomes, including length of stay (LOS), VTE, 90-day hospital encounters, and discharge disposition, were collected. Outcomes for patients prescribed aspirin (n = 214) were compared to those prescribed non-aspirin VTE prophylaxis (n = 1006) using propensity score matching. RESULTS Patients who received aspirin had higher rates of THA (36.0 vs 26.7%; p = 0.008). There were no significant risk-adjusted differences in the incidence of VTE (0.5 vs 0.5%, p = 1.000) and 90-day readmissions (10.4 vs 12.3%, p = 0.646) between patients prescribed aspirin and non-aspirin VTE prophylaxis, respectively. Patients prescribed non-aspirin agents had higher rates of non-home discharge (73.9 vs 58.5%; p < 0.001) and longer LOS (143.5 vs 124.9 h; p = 0.005). Sub-analysis of patients prescribed aspirin and non-aspirin prophylaxis based on comorbidity scores demonstrated no difference in VTE incidence for low (0.0 vs 1.6%, p = 1.000) and high scores (0.0 vs 0.0%, p = 1.000), respectively. CONCLUSION Aspirin is not associated with increased incidence of VTE after HHA or THA for FNF. Aspirin prophylaxis should be considered in hip fracture patients to mitigate bleeding risk, particularly those with low to intermediate VTE risk. LEVEL OF EVIDENCE Level III, Retrospective study.
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Affiliation(s)
- Akram A Habibi
- Department of Orthopedic Surgery, NYU Langone Health, 301 East 17th Street, 14th Floor, Suite 14-02, New York, NY, 10003, USA
| | - Andrew Brash
- Department of Orthopedic Surgery, NYU Langone Health, 301 East 17th Street, 14th Floor, Suite 14-02, New York, NY, 10003, USA
| | - Joshua C Rozell
- Department of Orthopedic Surgery, NYU Langone Health, 301 East 17th Street, 14th Floor, Suite 14-02, New York, NY, 10003, USA
| | - Abhishek Ganta
- Department of Orthopedic Surgery, NYU Langone Health, 301 East 17th Street, 14th Floor, Suite 14-02, New York, NY, 10003, USA
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, 301 East 17th Street, 14th Floor, Suite 14-02, New York, NY, 10003, USA
| | - Armin Arshi
- Department of Orthopedic Surgery, NYU Langone Health, 301 East 17th Street, 14th Floor, Suite 14-02, New York, NY, 10003, USA.
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Lins RC, Rolim E, Lima YA, Moura RRDS. RANDOMIZED CLINICAL TRIAL OF ASPIRIN AS PROPHYLAXIS FOR THROMBOEMBOLISM IN HIP ARTHROPLASTY. ACTA ORTOPEDICA BRASILEIRA 2024; 32:e272229. [PMID: 38532864 PMCID: PMC10962067 DOI: 10.1590/1413-785220243201e272229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 04/28/2023] [Indexed: 03/28/2024]
Abstract
Objective This study aims to evaluate aspirin as a chemical prophylaxis (200 mg) in total hip arthroplasty. Methods the study compared two groups and used ultrasonography (USG) to screen for low-deep venous thrombosis. Group 1 received 600 mg (control), and Group 2 received 200 mg of (intervention), associated with the use of elastic compression stockings and early walking. Results fourteen patients were allocated to Group A (200mg), and 16 to Group B (600mg); in group A (200mg), 3 cases with thrombus below the popliteal vein were detected at the first USG examination. All of them are in the left lower limb (21.4%). In group B (600 mg), 5 cases were identified after the first exam (31.2%). All cases were asymptomatic and followed the protocol with prophylaxis only with Aspirin. Conclusion In the statistical data, there were no differences in the presence of thrombus between the 200- and 600 mg groups, which is credited to using low-dose aspirin in low doses (200mg). Hematimetric levels returned to baseline levels and suggested there was no chronic or acute bleeding related to the use of aspirin. The manuscript was prepared according to the CONSORT guideline 2010. Level of Evidence I; Longitudinal Randomized Comparative Clinical Study.
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Affiliation(s)
- Raul Carneiro Lins
- Universidade Federal de Pernambuco, Department of Surgery, Recife, PE, Brazil
| | - Epitacio Rolim
- Universidade Federal de Pernambuco, Department of Surgery, Recife, PE, Brazil
| | - Yago Andrade Lima
- Universidade Federal de Pernambuco, Orthopedics Service at Hospital das Clinicas, Recife, PE, Brazil
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Uzel K, Azboy İ, Parvizi J. Venous thromboembolism in orthopedic surgery: Global guidelines. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2023; 57:192-203. [PMID: 37823737 PMCID: PMC10724754 DOI: 10.5152/j.aott.2023.23074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 09/11/2023] [Indexed: 10/13/2023]
Abstract
Venous thromboembolism (VTE) is a severe complication that can occur after major orthopedic procedures. As VTE-related morbidity and mortality are a significant concern for both medical professionals and patients, and preventative measures are typically employed. Multiple organizations, including the American College of Chest Physicians (ACCP) and the American Academy of Orthopedic Surgeons (AAOS), have developed guidelines for VTE prophylaxis specifically in patients undergoing joint replacement procedures. However, recently, the International Consensus Meeting (ICM) was convened, which brought together over 600 experts from 68 countries and 135 international societies. These experts, spanning a range of medical disciplines including orthopedic surgery, anesthesia, cardiology, hematology, vascular, and internal medicine, conducted a comprehensive review of the literature using a strict Delphi process to generate practical recommendations for VTE prophylaxis across all types of orthopedic procedures. This review article summarizes some of the recommendations of the ICM.
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Affiliation(s)
- Kadir Uzel
- Department of Orthopaedics and Traumatology, Medipol Mega University Hospital, İstanbul, Turkey
| | - İbrahim Azboy
- Department of Orthopaedics and Traumatology, Medipol Mega University Hospital, İstanbul, Turkey
| | - Javad Parvizi
- Thomas Jefferson University, Rothman Orthopaedic Institute, Philadelphia, USA
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Coveney EI, Hutton C, Patel N, Whitehouse SL, Howell JR, Wilson MJ, Hubble MJ, Charity J, Kassam AAM. Incidence of Symptomatic Venous Thromboembolism (VTE) in 8,885 Elective Total Hip Arthroplasty Patients Receiving Post-operative Aspirin VTE Prophylaxis. Cureus 2023; 15:e36464. [PMID: 37090282 PMCID: PMC10117228 DOI: 10.7759/cureus.36464] [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: 03/20/2023] [Indexed: 04/25/2023] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is a potentially reducible cause of morbidity and mortality in patients undergoing elective hip arthroplasty surgery. The balance of post-operative VTE prophylaxis and risk of post-operative haemorrhage remains at the forefront of surgeon's mind. The National Institute for Health and Care Excellence (NICE) published updated guidelines in 2018 which recommend the use of both mechanical and pharmacological methods in patients undergoing elective total hip arthroplasty (THA). OBJECTIVES The aim of this study was to present the symptomatic VTE incidence in 8,885 patients who underwent THA between January 1998 and March 2018 with Aspirin as the primary agent for pharmacological thromboprophylaxis. Intermittent calf compression stockings are routinely used from the time of surgery until mobilization (usually the following day) with prophylactic doses of low molecular weight heparin (LMWH) during inpatient stay (from 2005 onwards) and then Aspirin 150mg once daily for six weeks on hospital discharge (or Aspirin only prior to 2005), with use of other therapies occasionally as required. METHODS Analysis of prospective data collection from consecutive patients at a single institution undergoing THA was performed with the incidence of symptomatic deep vein thrombosis (DVT) and pulmonary embolism (PE) occurring within six months of the index operation as the primary outcome measure. Ninety-day all-cause mortality of this cohort of patients was also analysed. RESULTS 8,885 patients were reviewed. This included 7230 primary, 224 complex primary and 1431 revision cases. The overall incidence of symptomatic VTE after elective THA was 1.11% (99/8885) - with the incidence of symptomatic DVT of 0.59% (52/8885) and the incidence of symptomatic PE of 0.53% (47/8885). There was no significant difference (χ2 test, p=0.239) in the symptomatic VTE incidence between primary (1.20% - 89/7230), complex primary (0.89% - 2/224) and revision cases (0.70% - 10/1431). The 90-day all-cause mortality was 0.88% (78/8885). Cardiovascular and respiratory disease were the main causes of death following surgery. Only 0.03% of deaths (n= 3) within 90 days of index surgery were due to PE. There was no significant difference (p=0.327) in length of stay (and hence amount of pharmacologic prophylaxis with LMWH received by patients before commencement of Aspirin) with the average length of stay for those patients who did not suffer a VTE of 6.8 days compared with 7.6 days for those who did suffer a VTE. CONCLUSION Our results support the use of aspirin as an effective form of prophylaxis against symptomatic VTE following THA in contradiction to NICE and American Academy of Orthopaedic Surgery (AAOS) recommendations. It is not associated with an increased incidence in symptomatic DVT, PE or death compared to other published studies. The fact that it is inexpensive, readily available, requires no monitoring and does not pose an increased risk of bleeding are other advantages of using aspirin for VTE prophylaxis.
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Affiliation(s)
- Eamonn I Coveney
- Exeter Hip Unit, Royal Devon University Healthcare NHS Foundation Trust, Exeter, GBR
| | - Christopher Hutton
- Exeter Hip Unit, Royal Devon University Healthcare NHS Foundation Trust, Exeter, GBR
| | - Nimesh Patel
- Exeter Hip Unit, Royal Devon University Healthcare NHS Foundation Trust, Exeter, GBR
| | - Sarah L Whitehouse
- Orthopaedic Research Unit, Queensland University of Technology, Brisbane, AUS
- Exeter Hip Unit, Royal Devon University Healthcare NHS Foundation Trust, Exeter, GBR
| | - Jonathan R Howell
- Exeter Hip Unit, Royal Devon University Healthcare NHS Foundation Trust, Exeter, GBR
| | - Matthew J Wilson
- Exeter Hip Unit, Royal Devon University Healthcare NHS Foundation Trust, Exeter, GBR
| | - Matthew J Hubble
- Exeter Hip Unit, Royal Devon University Healthcare NHS Foundation Trust, Exeter, GBR
| | - John Charity
- Exeter Hip Unit, Royal Devon University Healthcare NHS Foundation Trust, Exeter, GBR
| | - Al-Amin M Kassam
- Exeter Hip Unit, Royal Devon University Healthcare NHS Foundation Trust, Exeter, GBR
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Dhillon NK, Haut ER, Price MA, Costantini TW, Teichman AL, Cotton BA, Ley EJ. Novel therapeutic medications for venous thromboembolism prevention in trauma patients: Findings from the Consensus Conference to Implement Optimal Venous Thromboembolism Prophylaxis in Trauma. J Trauma Acute Care Surg 2023; 94:479-483. [PMID: 36729880 PMCID: PMC9974825 DOI: 10.1097/ta.0000000000003853] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
ABSTRACT Trauma patients are at high risk for venous thromboembolism (VTE). Despite evidence-based guidelines and concerted efforts in trauma centers to implement optimal chemoprophylaxis strategies, VTE remains a frequent diagnosis in trauma patients. Current chemoprophylaxis strategies largely focus on the subcutaneous injection of low-molecular-weight heparin, which is administered twice daily. Novel approaches to pharmacologic VTE prophylaxis have the potential to reduce VTE rates by improving patient compliance through oral administration or through their ability to target alternative pathways that mediate thrombosis. While novel pharmacologic VTE prophylaxis strategies have been studied in nontrauma patients, there is a paucity of literature in trauma patients where the risk of thrombosis versus hemorrhage must be carefully considered. As a component of the 2022 Consensus Conference to Implement Optimal VTE Prophylaxis in Trauma, this review provides an update of the novel chemoprophylaxis agents for potential use in trauma patients. Here, we will consider the relative risks and benefits related to the use of these drugs, evaluate the current literature in nontrauma patients, and consider future directions that could potentially improve posttrauma VTE prophylaxis.
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Affiliation(s)
- Navpreet K Dhillon
- R Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, MD
| | - Elliott R Haut
- Division of Acute Care Surgery, Department of Surgery; Department of Anesthesiology and Critical Care Medicine; Department of Emergency Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD
- The Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, MD
- Department of Health Policy and Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | | | - Todd W Costantini
- Division of Trauma, Surgical Critical Care, and Burns, and Acute Care Surgery, Department of Surgery, University of California San Diego School of Medicine, San Diego, CA
| | - Amanda L Teichman
- Division of Acute Care Surgery, Rutgers-Robert Wood Johnson School of Medicine, New Brunswick, NJ
| | - Bryan A Cotton
- Division of Acute Care Surgery, Department of Surgery, McGovern Medical School, Memorial Hermann Hospital, Houston, TX
| | - Eric J Ley
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA
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9
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Anil U, Kirschner N, Teo GM, Lygrisse KA, Sicat CS, Schwarzkopf R, Aggarwal VK, Long WJ. Aspirin thromboprophylaxis following primary total knee arthroplasty is associated with a lower rate of early prosthetic joint infection compared with other agents. J Arthroplasty 2023; 38:S345-S349. [PMID: 36828050 DOI: 10.1016/j.arth.2023.02.041] [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: 11/20/2022] [Revised: 02/13/2023] [Accepted: 02/15/2023] [Indexed: 02/26/2023] Open
Abstract
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.
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Affiliation(s)
- Utkarsh Anil
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY.
| | - Noah Kirschner
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | - Greg M Teo
- Hospital for Special Surgery, New York, NY
| | | | - Chelsea S Sicat
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | - Vinay K Aggarwal
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
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10
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Parvizi J, DeMik DE, Hozack WJ, Dunbar MJ, Mont MA, Lachiewicz PF. Low-Molecular-Weight Heparin Is Superior to Aspirin in the Prevention of Thromboembolic Disease: Or Is It? J Arthroplasty 2023; 38:1-2. [PMID: 36351554 DOI: 10.1016/j.arth.2022.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 09/13/2022] [Indexed: 11/09/2022] Open
Affiliation(s)
- Javad Parvizi
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania
| | - David E DeMik
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania
| | | | | | - Michael A Mont
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
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11
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Parvizi J, DeMik DE, Dunbar M, Hozack WJ, Mont MA, Lachiewicz PF. Low-Molecular-Weight Heparin Is Superior to Aspirin in the Prevention of Thromboembolic Disease: Or Is It? J Bone Joint Surg Am 2022; 104:2045-2046. [PMID: 36476736 DOI: 10.2106/jbjs.22.01024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Javad Parvizi
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania
| | - David E DeMik
- Rothman Orthopaedic Institute, Philadelphia, Pennsylvania
| | | | | | - Michael A Mont
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
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Low-Dose Aspirin for Venous Thromboembolism Prophylaxis is Associated With Lower Rates of Periprosthetic Joint Infection After Total Joint Arthroplasty. J Arthroplasty 2022; 37:2444-2448.e1. [PMID: 35843380 DOI: 10.1016/j.arth.2022.07.006] [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: 04/05/2022] [Revised: 07/06/2022] [Accepted: 07/08/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Aspirin as a venous thromboembolism (VTE) prophylactic agent has been shown to have antistaphylococcal and antibiofilm roles. Optimal acetylsalicylic acid (ASA) dosage would facilitate antimicrobial effects while avoiding over-aggressive inhibition of platelet antimicrobial function. Our purpose was to determine the periprosthetic joint infection (PJI) rate after total joint arthroplasty in patients receiving low-dose ASA (81 mg twice a day), in comparison to high-dose ASA (325 mg twice a day). METHODS We conducted a retrospective cohort study between 2008 and 2020. Eligible patients were older than 18 years, underwent primary total joint arthroplasty, both total knee arthroplasty and total hip arthroplasty, had a minimum 30-day follow-up, and received a full course ASA as VTE prophylaxis. Patients' records were reviewed for PJI, according to Musculoskeletal Infection Society criteria. Patients were excluded if they underwent revision arthroplasty, had a history of coagulopathy, or had an ASA regimen that was not completed. In total 15,825 patients were identified, 8,761 patients received low-dose ASA and 7,064 received high-dose ASA. RESULTS The high-dose cohort had a higher PJI rate (0.35 versus 0.10%, P = .001). This relationship was maintained when comparing subgroups comprising total knee arthroplasty (0.32 versus 0.06%, P = .019) or total hip arthroplasty (0.38 versus 0.14%, P = .035) and accounting for potentially confounding demographic and surgical variables (odds ratio = 2.59, 95% CI = 1.15-6.40, P = .028). CONCLUSION Comparing low-dose to high-dose ASA as a VTE prophylactic agent, low-dose ASA had a lower PJI rate. This may be attributable to a balance of anti-infective properties of ASA and antiplatelet effects.
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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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14
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Meloxicam versus Celecoxib for Postoperative Analgesia after Total Knee Arthroplasty: Safety, Efficacy and Cost. J Am Acad Orthop Surg Glob Res Rev 2022; 6:01979360-202204000-00002. [PMID: 35389917 PMCID: PMC8989775 DOI: 10.5435/jaaosglobal-d-22-00032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 01/28/2022] [Indexed: 12/03/2022]
Abstract
Introduction: Nonsteroidal anti-inflammatory drugs (NSAIDs) are commonly used as part of multimodal analgesia in total knee arthroplasty (TKA). Selective cyclooxygenase (COX)-2 inhibitors (e.g., celecoxib) are believed to have fewer gastrointestinal (GI) adverse effects than nonselective NSAIDS. Meloxicam is less selective for COX-2 than celecoxib is and partially inhibits COX-1 at higher doses. Nonetheless, some surgeons prefer using nonselective NSAIDs because of their lower expense. Methods: Four thousand nine hundred ninety-four patients who underwent TKA between January 2015 and February 2020 and took either celecoxib (n = 3,174), meloxicam 15 mg/d (n = 1,819), or meloxicam 7.5 mg/d (n = 451) were studied. Mutlimodal postoperative analgesia protocols were otherwise similar. GI bleeding and wound complication incidence were determined, as well as average 30-day prescription costs. Results: GI bleeding incidence was similar in the three cohorts (P = 0.4). The incidence of wound complications did not significantly differ between the groups: 0.06%, 0.07%, and 0.22% in the celecoxib, meloxicam 15 mg/d, and meloxicam 7.5 mg/d groups, respectively (P = 0.06). Subsituting meloxicam for celecoxib results in an average savings of $183 per prescription. Discussion: Meloxicam used at higher doses (15 mg/d) does not markedly increase the risk of GI or wound complications associated with COX-1 inhibition and is less costly for multimodal analgesia after TKA.
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17
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Goh GS, Kozaily E, Tan TL, Parvizi J. Patients Who Do Not Receive Aspirin Because of Allergy Have an Increased Risk of Venous Thromboembolism Following Total Joint Arthroplasty. J Bone Joint Surg Am 2022; 104:107-114. [PMID: 34780388 DOI: 10.2106/jbjs.21.00528] [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] [Indexed: 02/01/2023]
Abstract
BACKGROUND Patient-reported allergies to aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs) may preclude certain patients from receiving aspirin as venous thromboembolism (VTE) prophylaxis after total joint arthroplasty (TJA). The purpose of the study was to (1) determine whether the use of non-aspirin agents due to a self-reported aspirin or NSAID allergy was associated with a higher incidence of VTE and (2) determine the rate of true allergic reactions in patients who reported an allergy but still received aspirin. METHODS Prospectively collected data from 45,171 patients who underwent primary TJA between 2000 and 2019 were reviewed. Patients who reported an allergy to aspirin or NSAIDs were identified (n = 823). Using a validated VTE risk calculator, each patient was assigned a risk score based on 26 comorbidities. Bleeding complications, VTEs that occurred within 90 days postoperatively, and allergic reactions were collected as end points. Multivariable logistic regression was performed to determine the factors associated with VTE. RESULTS The overall incidence of aspirin or NSAID allergy was 1.8%. Only 80 of 267 patients (30%) reported an allergy to only aspirin and still received aspirin. Compared with patients who received aspirin without a history of allergy (n = 17,648), patients who received non-aspirin thromboprophylaxis due to allergy (n = 383) had a higher incidence of VTE (2.87% versus 0.24%, p < 0.001). On multivariable regression, these patients had an 8-fold increase in VTE risk (adjusted odds ratio, 7.94; 95% confidence interval, 2.86 to 22.07; p < 0.001). The incidence of true allergic reactions to aspirin among those with a reported allergy was 1.8% (number needed to harm = 55). No patients developed anaphylaxis or severe hypersensitivity reactions. CONCLUSIONS Patients with a self-reported allergy to aspirin or NSAIDs were at a significantly increased risk for VTE if they received non-aspirin thromboprophylaxis agents following TJA. Future research should evaluate the usefulness of preoperative allergy testing when selecting a VTE prophylactic agent in patients with self-reported allergies. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Graham S Goh
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Elie Kozaily
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Timothy L Tan
- Department of Orthopaedic Surgery, University of California, San Francisco, San Francisco, California
| | - Javad Parvizi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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18
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Matzko C, Berliner ZP, Husk G, Mina B, Nisonson B, Hepinstall MS. Equivalent VTE rates after total joint arthroplasty using thromboprophylaxis with aspirin versus potent anticoagulants: retrospective analysis of 4562 cases across a diverse healthcare system. ARTHROPLASTY 2021; 3:45. [PMID: 35236505 PMCID: PMC8796388 DOI: 10.1186/s42836-021-00101-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 09/24/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Guidelines support aspirin thromboprophylaxis for primary total hip and knee arthroplasty (THA and TKA) but supporting evidence has come from high volume centers and the practice remains controversial. METHODS We studied 4562 Medicare patients who underwent elective primary THA (1736, 38.1%) or TKA (2826, 61.9%) at 9 diverse hospitals. Thirty-day claims data were combined with data from the health system's electronic medical records to compare rates of venous thromboembolism (VTE) between patients who received prophylaxis with: (1) aspirin alone (47.3%), (2) a single, potent anticoagulant (29%), (3) antiplatelet agents other than aspirin or multiple anticoagulants (21.5%), or (4) low-dose subcutaneous unfractionated heparin or no anticoagulation (2.2%). Sub-analyses separately evaluating THA, TKA and cases from lower volume hospitals (n = 975) were performed. RESULTS The 30-day VTE incidence was 0.6% (29/4562). VTE rates were equal in patients receiving aspirin and those receiving a single potent anticoagulant (0.5% in both groups). Patients with VTE were significantly older than patients without VTE (mean 76.5 vs. 73.1 years, P = 0.04). VTE rate did not associate with sex or hospital case volume. On bivariate analysis considering age, aspirin did not associate with greater VTE risk compared to a single potent anticoagulant (OR = 2.1, CI = 0.7-6.3) with the numbers available. Odds of VTE were increased with use of subcutaneous heparin or no anticoagulant (OR = 6.4, CI = 1.2-35.6) and with multiple anticoagulants (OR = 3.6, CI = 1.1-11.2). THA and TKA demonstrated similar rates of VTE (0.5% vs. 0.7%, respectively, P = 0.43). Of 975 cases done at lower volume hospitals, 387 received aspirin, none of whom developed VTE. CONCLUSIONS This study provides further support for aspirin as an effective form of pharmacological VTE prophylaxis after total joint arthroplasty in the setting of a multi-modal regimen using 30-day outcomes. VTE occurred in 0.7% of primary joint arthroplasties. Aspirin prophylaxis did not associate with greater VTE risk compared to potent anticoagulants in the total population or at lower volume hospitals.
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Affiliation(s)
- Chelsea Matzko
- Department of Orthopedic Surgery, Lenox Hill Hospital, Northwell Health, New York, New York, USA
| | - Zachary P Berliner
- Department of Orthopedic Surgery, Lenox Hill Hospital, Northwell Health, New York, New York, USA.,Department of Orthopedic Surgery, Boston University Medical Center, Boston, Massachusetts, USA
| | - Gregg Husk
- Department of Orthopedic Surgery, Lenox Hill Hospital, Northwell Health, New York, New York, USA
| | - Bushra Mina
- Department of Orthopedic Surgery, Lenox Hill Hospital, Northwell Health, New York, New York, USA
| | - Barton Nisonson
- Department of Orthopedic Surgery, Lenox Hill Hospital, Northwell Health, New York, New York, USA
| | - Matthew S Hepinstall
- Department of Orthopedic Surgery, Lenox Hill Hospital, Northwell Health, New York, New York, USA. .,Department of Orthopedic Surgery, NYU Langone Health, 301 E 17th St, Suite 1402, New York, 10003, New York, USA.
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Inpatient compliance with venous thromboembolism prophylaxis after orthopaedic trauma: results from a randomized controlled trial of aspirin versus low molecular weight heparin. OTA Int 2021; 4:e150. [PMID: 34765900 PMCID: PMC8575420 DOI: 10.1097/oi9.0000000000000150] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 08/10/2021] [Indexed: 12/21/2022]
Abstract
Objectives: To compare inpatient compliance with venous thromboembolism prophylaxis regimens. Design: A secondary analysis of patients enrolled in the ADAPT (A Different Approach to Preventing Thrombosis) randomized controlled trial. Setting: Level I trauma center. Patients/Participants: Patients with operative extremity or any pelvic or acetabular fracture requiring venous thromboembolism prophylaxis. Intervention: We compared patients randomized to receive either low molecular weight heparin (LMWH) 30 mg or aspirin 81 mg BID during their inpatient admission. Main Outcome Measurements: The primary outcome measure was the number of doses missed compared with prescribed number of doses. Results: A total of 329 patients were randomized to receive either LMWH 30 mg BID (164 patients) or aspirin 81 mg BID (165 patients). No differences observed in percentage of patients who missed a dose (aspirin: 41.2% vs LMWH: 43.3%, P = .7) or mean number of missed doses (0.6 vs 0.7 doses, P = .4). The majority of patients (57.8%, n = 190) did not miss any doses. Missed doses were often associated with an operation. Conclusions: These data should reassure clinicians that inpatient compliance is similar for low molecular weight heparin and aspirin regimens.
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20
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Olukoya O, Fultang J. Aspirin Compared With Other Anticoagulants for Use as Venous Thromboembolism Prophylaxis in Elective Orthopaedic Hip and Knee Operations: A Narrative Literature Review. Cureus 2021; 13:e18249. [PMID: 34692356 PMCID: PMC8526075 DOI: 10.7759/cureus.18249] [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] [Accepted: 09/24/2021] [Indexed: 11/05/2022] Open
Abstract
Although total hip and knee arthroplasty are effective methods for treating arthritis, they have an associated risk of venous thromboembolism (VTE). To reduce this risk, prophylactic agents including aspirin, low-molecular-weight Heparin, vitamin K antagonists, and direct oral anticoagulants are employed for up to 35 days after surgery. This narrative literature review utilised a systematic approach to critically assess the current evidence surrounding the use of aspirin for VTE prophylaxis compared to anticoagulants. An advanced multistage electronic search was performed in May 2021 using the OVID/Medline and Embase online libraries to identify available studies relevant to the subject from 1974. Additional studies identified during the review process were also included. The final studies meeting the inclusion criteria were then assessed using the Critical Appraisal Skills Programme tool. A total of 12 (60%) studies (two meta-analyses, three randomised trials, seven retrospective studies) favoured aspirin over anticoagulants for VTE prophylaxis. A total of 15 (75%) studies (two meta-analyses, three randomised trials, nine retrospective, one matched cohort) reported that aspirin had better bleeding profiles and complication rates, which was statistically significant in seven (46.7%) studies (one randomised trial, six retrospective studies). A total of eight studies (one randomised trial, six retrospective studies, one matched cohort) reported statistically significant results for aspirin. Five (62.5%) studies reported aspirin to be superior for VTE prophylaxis, while seven (87.5%) reported aspirin to be superior in terms of bleeding complications. The current evidence indicates that aspirin is superior to anticoagulants, in their various iterations, for VTE prophylaxis in terms of their bleeding profiles.
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Affiliation(s)
- Olatomiwa Olukoya
- Neurocritical Care, National Hospital for Neurology and Neurosurgery, London, GBR
| | - Joshua Fultang
- Surgery, University of Glasgow, Glasgow, GBR
- General Surgery, University Hospital Ayr/University of West of Scotland, Ayr, GBR
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21
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Grosso MJ, Kozaily E, Parvizi J, Austin MS. Aspirin Is Safe for Venous Thromboembolism Prophylaxis for Patients With a History of Gastrointestinal Issues. J Arthroplasty 2021; 36:S332-S336. [PMID: 33610409 DOI: 10.1016/j.arth.2021.01.069] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 01/06/2021] [Accepted: 01/24/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The safety of acetylsalicylic acid (ASA, aspirin) in patients with prior history of gastroesophageal reflux or peptic ulcer disease remains unclear. The purpose of this study was to determine the safety of ASA for venous thromboembolism (VTE) prophylaxis after total joint arthroplasty in patients with prior history of gastrointestinal (GI) issues. METHODS This was an institutional, retrospective cohort study of 19,044 patients who underwent primary total hip and total knee arthroplasty from 2013 to 2019. We divided the patients into two cohorts based on the presence or absence of pre-existing GI issues. Patient demographics, VTE prophylaxis, and postoperative complications were collected. The primary outcome measure was GI bleed. RESULTS In our series, 3090 patients had a preoperative GI issue and 15,954 did not have a GI issue. ASA was the most common mode of VTE prophylaxis (89%), followed by Coumadin (4.7%), direct oralanticoagulants (4.2%), low-molecular-weight heparin (1.7%), and others (0.4%). In the cohort of patients given ASA, there was no significant difference in postoperative GI bleeding between those with (2/1781, 0.11%) and without preoperative GI issues (8/7,628, 0.10%, P = 1.0). In the overall cohort, history of preoperative GI issues was associated with an increased risk of postoperative GI bleeding (0.32% vs 0.11%, P = .031). In logistic regression analysis, ASA was associated with a protective effect against GI bleed (OR = 0.09, 95% CI 0.01-0.40, P = .003). CONCLUSION ASA is safe for VTE prophylaxis after total joint arthroplasty in patients with history of GI issues and is not associated with an increased risk of postoperative GI bleeds.
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Affiliation(s)
- Matthew J Grosso
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA; Connecticut Joint Replacement Institute, Hartford, CT
| | - Elie Kozaily
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Javad Parvizi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Matthew S Austin
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
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Watts PJ, Kopstein M, Harkness W, Cornett B, Dziadkowiec O, Jenkins P, Hicks ME, Hassan S, Scherbak D. A Retrospective Analysis Comparing Post-Operative Bleeding with Various Doses of Aspirin after Lower Extremity Joint Arthroplasty or Revision. Pharmacotherapy 2021; 41:616-622. [PMID: 34050970 DOI: 10.1002/phar.2598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/21/2021] [Accepted: 04/22/2021] [Indexed: 11/09/2022]
Abstract
STUDY OBJECTIVE Previous studies have shown that aspirin is noninferior to other anticoagulation therapies in preventing postoperative venous thromboembolism following lower extremity arthroplasty or revision; however, its optimal dosing for this indication is less clear. This study aims to compare the odds of bleeding between different aspirin dosages following lower extremity joint arthroplasty or revision. DESIGN This is a 3-year retrospective multi-center cohort study across the United States and its territories. SETTING This study included patients admitted for total hip or knee arthroplasty or revision and were treated with prophylactic aspirin. PATIENTS, INTERVENTION, MEASUREMENTS Patients were assigned to groups based on a total daily aspirin dose of 81, 162, 325, or 650 mg. Data were analyzed for postsurgical bleeding and thromboembolism events occurring during the initial admission and up to 40 days following surgery. Other exploratory variables included type of surgery, hip or knee arthroplasty, length of stay, and patient demographic data. MAIN RESULTS Among 53,848 patients receiving aspirin, 3922 received a total daily dose of 81 mg, 19,341 received a total daily dose of 162 mg, 5256 received a total daily dose of 325 mg, and 25,329 received a total daily dose of 650 mg. Bleeding occurred in 466 (0.87%) patients and venous thromboembolism (VTE) in 209 patients (0.39%). The odds of bleeding were compared using logistic regression, with the 650-mg dose as the reference group. None were statistically significant for bleeding between all studied aspirin doses: 81 mg (OR 1.12, 95% CI 0.83-1.51, p = 0.451), 162 mg (OR 0.83, 95% CI 0.67-1.03, p = 0.097), and 325 mg (OR 0.83, 95% CI 0.59-1.13, p = 0.245). The odds of VTE were also not statistically significant: 81 mg (OR 0.71, 95% CI 0.40-1.17, p = 0.181), 162 mg (OR 0.75 95% CI 0.54-1.03, p = 0.072), and 325 mg (OR 1.00, 95% CI 0.64-1.53, p = 0.989). CONCLUSIONS There were no significant differences in the odds of bleeding or venous thromboembolism among all studied aspirin dosages in patients receiving aspirin for thromboprophylaxis following lower extremity joint arthroplasty or revision.
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Affiliation(s)
- Paula J Watts
- Graduate Medical Education, HCA HealthONE - Sky Ridge Medical Center, Lone Tree, Colorado, USA.,Rocky Vista University, Parker, Colorado, USA.,Critical Care and Pulmonary Consultants, Greenwood Village, Colorado, USA
| | - Michael Kopstein
- Graduate Medical Education, HCA HealthONE - Sky Ridge Medical Center, Lone Tree, Colorado, USA.,Rocky Vista University, Parker, Colorado, USA.,Inova Loudoun Hospital, Leesburg, Virginia, USA
| | - Weston Harkness
- Graduate Medical Education, HCA HealthONE - Sky Ridge Medical Center, Lone Tree, Colorado, USA.,Rocky Vista University, Parker, Colorado, USA.,Graduate Medical Education, Samaritan Health Services, Corvallis, Oregon, USA
| | | | | | - Patrick Jenkins
- Graduate Medical Education, HCA HealthONE - Sky Ridge Medical Center, Lone Tree, Colorado, USA.,Rocky Vista University, Parker, Colorado, USA
| | - Mary E Hicks
- Graduate Medical Education, HCA HealthONE - Sky Ridge Medical Center, Lone Tree, Colorado, USA.,Rocky Vista University, Parker, Colorado, USA.,Critical Care and Pulmonary Consultants, Greenwood Village, Colorado, USA
| | - Shakib Hassan
- Graduate Medical Education, HCA HealthONE - Sky Ridge Medical Center, Lone Tree, Colorado, USA.,Rocky Vista University, Parker, Colorado, USA.,Critical Care and Pulmonary Consultants, Greenwood Village, Colorado, USA
| | - Dmitriy Scherbak
- Graduate Medical Education, HCA HealthONE - Sky Ridge Medical Center, Lone Tree, Colorado, USA.,Rocky Vista University, Parker, Colorado, USA.,Critical Care and Pulmonary Consultants, Greenwood Village, Colorado, USA
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23
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O'Toole RV, Stein DM, Frey KP, O'Hara NN, Scharfstein DO, Slobogean GP, Taylor TJ, Haac BE, Carlini AR, Manson TT, Sudini K, Mullins CD, Wegener ST, Firoozabadi R, Haut ER, Bosse MJ, Seymour RB, Holden MB, Gitajn IL, Goldhaber SZ, Eastman AL, Jurkovich GJ, Vallier HA, Gary JL, Kleweno CP, Cuschieri J, Marvel D, Castillo RC. PREVENTion of CLots in Orthopaedic Trauma (PREVENT CLOT): a randomised pragmatic trial protocol comparing aspirin versus low-molecular-weight heparin for blood clot prevention in orthopaedic trauma patients. BMJ Open 2021; 11:e041845. [PMID: 33762229 PMCID: PMC7993181 DOI: 10.1136/bmjopen-2020-041845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 01/27/2021] [Accepted: 02/25/2021] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Patients who sustain orthopaedic trauma are at an increased risk of venous thromboembolism (VTE), including fatal pulmonary embolism (PE). Current guidelines recommend low-molecular-weight heparin (LMWH) for VTE prophylaxis in orthopaedic trauma patients. However, emerging literature in total joint arthroplasty patients suggests the potential clinical benefits of VTE prophylaxis with aspirin. The primary aim of this trial is to compare aspirin with LMWH as a thromboprophylaxis in fracture patients. METHODS AND ANALYSIS PREVENT CLOT is a multicentre, randomised, pragmatic trial that aims to enrol 12 200 adult patients admitted to 1 of 21 participating centres with an operative extremity fracture, or any pelvis or acetabular fracture. The primary outcome is all-cause mortality. We will evaluate non-inferiority by testing whether the intention-to-treat difference in the probability of dying within 90 days of randomisation between aspirin and LMWH is less than our non-inferiority margin of 0.75%. Secondary efficacy outcomes include cause-specific mortality, non-fatal PE and deep vein thrombosis. Safety outcomes include bleeding complications, wound complications and deep surgical site infections. ETHICS AND DISSEMINATION The PREVENT CLOT trial has been approved by the ethics board at the coordinating centre (Johns Hopkins Bloomberg School of Public Health) and all participating sites. Recruitment began in April 2017 and will continue through 2021. As both study medications are currently in clinical use for VTE prophylaxis for orthopaedic trauma patients, the findings of this trial can be easily adopted into clinical practice. The results of this large, patient-centred pragmatic trial will help guide treatment choices to prevent VTE in fracture patients. TRIAL REGISTRATION NUMBER NCT02984384.
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Affiliation(s)
- Robert V O'Toole
- Department of Orthopaedics, University of Maryland Baltimore, Baltimore, Maryland, USA
| | - Deborah M Stein
- Department of Surgery, University of California in San Francisco, San Francisco, California, USA
| | - Katherine P Frey
- METRC Coordinating Center, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Nathan N O'Hara
- Department of Orthopaedics, University of Maryland Baltimore, Baltimore, Maryland, USA
| | - Daniel O Scharfstein
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah, USA
| | - Gerard P Slobogean
- Department of Orthopaedics, University of Maryland Baltimore, Baltimore, Maryland, USA
| | - Tara J Taylor
- METRC Coordinating Center, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Bryce E Haac
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Anthony R Carlini
- METRC Coordinating Center, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Theodore T Manson
- Department of Orthopaedics, University of Maryland Baltimore, Baltimore, Maryland, USA
| | - Kuladeep Sudini
- METRC Coordinating Center, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - C Daniel Mullins
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Stephen T Wegener
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Reza Firoozabadi
- Department of Orthopaedic Surgery and Sports Medicine, University of Washington - Harborview Medical Center, Seattle, Washington, USA
| | - Elliott R Haut
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Michael J Bosse
- Department of Orthopaedic Surgery, Atrium Health, Charlotte, North Carolina, USA
| | - Rachel B Seymour
- Department of Orthopaedic Surgery, Atrium Health, Charlotte, North Carolina, USA
| | - Martha B Holden
- Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Ida Leah Gitajn
- Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Samuel Z Goldhaber
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Alexander L Eastman
- Department of Surgery, University of Texas Southwestern Medical School, Dallas, Texas, USA
| | - Gregory J Jurkovich
- Department of Surgery, University of California Davis, Davis, California, USA
| | - Heather A Vallier
- Department of Orthopaedics, MetroHealth System, Cleveland, Ohio, USA
| | - Joshua L Gary
- Department of Orthopedic Surgery, University of Texas McGovern Medical School, Houston, Texas, USA
| | - Conor P Kleweno
- Department of Orthopaedic Surgery and Sports Medicine, University of Washington - Harborview Medical Center, Seattle, Washington, USA
| | - Joseph Cuschieri
- Department of Surgery, University of Washington - Harborview Medical Center, Seattle, Washington, USA
| | - Debra Marvel
- PREVENT CLOT Stakeholder Committee, Baltimore, Maryland, USA
| | - Renan C Castillo
- METRC Coordinating Center, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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Rate of venous thromboembolism after surgical treatment of proximal humerus fractures. Arch Orthop Trauma Surg 2021; 141:403-409. [PMID: 32504179 DOI: 10.1007/s00402-020-03505-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 05/31/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION The rate of venous thromboembolism following surgical treatment of proximal humerus fractures is not well established. METHODS A retrospective review of all patients undergoing surgical treatment for proximal humerus fractures from September 2011 to May 2017 was performed. Included patients received only mechanoprophylaxis using sequential compression devises. All patients had at least 6 months follow-up. The primary outcome of interest was the rate of postoperative DVT and PE. RESULTS 131 patients underwent 139 surgeries for proximal humerus fracture. After exclusion criteria were applied, 92 patients who underwent 92 surgeries were included. There were 47 females and 45 males. Five (5.4%) were taking Aspirin 81 mg preoperatively. There were 76 cases of open reduction and internal fixation (ORIF), 8 cases of reverse total shoulder arthroplasty, 4 cases of hemiarthroplasty, 3 cases of closed reduction percutaneous pinning (CRPP), 1 case of open reduction without fixation. 53.3% of patients had one or more risk factors for VTE. There were no cases of fatal PE or DVT. There were two cases of symptomatic PE (2.2%) following one ORIF and one CRPP. There was one additional case of asymptomatic PE found incidentally after ORIF. Overall VTE rate was 3.3%. Fisher's exact test yielded that there was no significant association between the presence of VTE risk factors and prevalence of VTE postoperatively (p = 0.245). CONCLUSIONS The incidence of symptomatic VTE after surgery for proximal humerus fractures is low. Chemical VTE prophylaxis in patients after surgical fixation for proximal humerus fractures is not universally indicated. Selective prophylaxis for patients with systemic risk factors may be warranted.
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Peng HM, Chen X, Wang YO, Bian YY, Feng B, Wang W, Weng XS, Qian WW. Risk-Stratified Venous Thromboembolism Prophylaxis after Total Joint Arthroplasty: Low Molecular Weight Heparins and Sequential Aspirin vs Aggressive Chemoprophylaxis. Orthop Surg 2021; 13:260-266. [PMID: 33448672 PMCID: PMC7862181 DOI: 10.1111/os.12926] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 12/03/2020] [Accepted: 12/20/2020] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE Venous thromboembolism (VTE) is a significant concern post total joint arthroplasty (TJA). However, the optimal prevention method of VTE remains controversial at present. This study aims to evaluate a risk-stratified VTE prophylaxis protocol for patients undergoing TJA. METHODS A total of 891 TJA patients from January 2011 to November 2019 were retrospectively investigated. The study was divided into two cohorts. In cohort 1, 410 patients (250 females and 160 males, mean age 64.32 years) were treated with an aggressive VTE chemoprophylaxis protocol. In cohort 2, 481 patients were treated with a risk-stratified protocol that utilized low molecular weight heparins (LMWH) and sequential aspirin (ASA) for standard-risk patients (a total of 288 containing 177 females and 111 males, mean age 65.4 years), and targeted anticoagulation for high-risk patients (a total of 193 containing 121 females and 72 males, mean age 66.8 years). The patients were followed up at 2-4 weeks for an initial visit and at 6-10 weeks for a subsequent visit after surgery. A chart review of all patient medical records was performed to record the demographics, comorbidities, deep vein thrombosis, pulmonary embolus, superficial infection, deep infection, bleeding complications, and 90-day readmissions. RESULTS The VTE rate was 1.71% (7/410) in cohort 1 and 1.46% (7/481) in cohort 2 respectively. For cohort 2, the VTE rate was 2.07% (4/193) in high-risk group and 1.04% (3/288) in standard-risk group. The readmission rate was 2.44% (10/410) in cohort 1 and 2.08% (10/481) in cohort 2. For cohort 2, the readmission rate was 2.07% (4/193) in high-risk group and 2.08% (6/288) in standard-risk group. The reasons for readmission were as follows: infection, 1.3% (5/410) in cohort 1 and 1.3% (6/481) in cohort 2; wound or bleeding complications, 0.48% (2/410) in cohort 1 and 0.2% (1/481) in cohort 2; trauma, 0.2% (1/410) in cohort 1 and 0.2% (1/481) in cohort 2; VTE, 0.2% (1/410) in cohort 1 and 0.2% (1/481) in cohort 2; others, 0.2% (1/410) in cohort 1 and 0.6% (3/481) in cohort 2. There was a decrease in VTE events and readmissions in the risk-stratified cohort, although this did not reach statistical significance. However, it was found that there was a significant reduction in costs (P < 0.001) with the use of LMWH/ASA, when compared with aggressive anticoagulation agents in the risk-stratified cohort. CONCLUSION The use of LMWH/ASA in a risk-stratified TJA population is a safe and cost-effective method of VTE prophylaxis.
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Affiliation(s)
- Hui-Ming Peng
- Department of Orthopaedics, Peking Union Medical College Hospital, CAMS & PUMC, Beijing, China
| | - Xi Chen
- Department of Orthopaedics, Peking Union Medical College Hospital, CAMS & PUMC, Beijing, China
| | - Yi-Ou Wang
- Department of Orthopaedics, Peking Union Medical College Hospital, CAMS & PUMC, Beijing, China
| | - Yan-Yan Bian
- Department of Orthopaedics, Peking Union Medical College Hospital, CAMS & PUMC, Beijing, China
| | - Bin Feng
- Department of Orthopaedics, Peking Union Medical College Hospital, CAMS & PUMC, Beijing, China
| | - Wei Wang
- Department of Orthopaedics, Peking Union Medical College Hospital, CAMS & PUMC, Beijing, China
| | - Xi-Sheng Weng
- Department of Orthopaedics, Peking Union Medical College Hospital, CAMS & PUMC, Beijing, China
| | - Wen-Wei Qian
- Department of Orthopaedics, Peking Union Medical College Hospital, CAMS & PUMC, Beijing, China
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Singh V, Shahi A, Saleh U, Tarabichi S, Oliashirazi A. Persistent Wound Drainage among Total Joint Arthroplasty Patients Receiving Aspirin vs Coumadin. J Arthroplasty 2020; 35:3743-3746. [PMID: 32788061 DOI: 10.1016/j.arth.2020.07.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 06/20/2020] [Accepted: 07/02/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Persistent wound drainage (PWD) is one of the major risk factors for periprosthetic joint infections (PJI), arguably the most dreaded complications after a total hip and knee arthroplasty (THA and TKA). The aim of this study is to identify the rates of PWD among THA and TKA patients who received aspirin (ASA) or Coumadin for postoperative venous thromboembolism (VTE) prophylaxis. METHODS Retrospective review of 5516 primary THA and TKA was performed. Patients with PWD were identified. Chi-square test was used to compare the incidences of PWD, 30-day VTE, and PJI at 6 months between the ASA and Coumadin groups. Multivariate regression model was used to identify independent risk factors for PWD using Charlson and Elixhauser comorbidity indexes. RESULTS The prevalence of PWD was 6.4% (353/5516). Patients receiving ASA had lower incidence of PWD (3.2% vs 8.5%, P < .0001) while having comparable rates of 30-day VTE (1.3% vs 1.4%, P = .722) and PJI at 6 months (1.8% vs 1.4%, P = .233) compared to those receiving Coumadin. Risk factors for PWD were diabetes (odds ratio [OR], 19.3; 95% confidence interval [CI], 11.8-23.2), rheumatoid arthritis (OR, 15.3; 95% CI, 10.8-17.2), morbid obesity (OR, 13.2; 95% CI, 9.7-17.5), chronic alcohol use (OR, 3.5; 95% CI, 1.8-5.5), hypothyroidism (OR, 1.9; 95% CI, 1.1-3.2), and Coumadin (OR, 1.7; 95% CI, 1.2-2.2). CONCLUSION Use of ASA is associated with significantly lower rates of PWD after THA and TKA when compared to Coumadin while being equally efficacious at preventing VTE. Coumadin was found to be an independent risk factor for PWD.
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Affiliation(s)
| | - Alisina Shahi
- Cooper Bone and Joint Institute at Cooper University Hospital, Camden, NJ
| | - Usama Saleh
- Orthopaedic Department, Med Care Hospital, Dubai, UAE
| | | | - Ali Oliashirazi
- Oliashirazi Institute at Marshall University, Huntington, WV
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Ashkenazi I, Schermann H, Gold A, Gurel R, Chechik O, Warschawski Y, Schwarzkopf R, Snir N. Is continuation of anti-platelet treatment safe for elective total hip arthroplasty patients? Arch Orthop Trauma Surg 2020; 140:2101-2107. [PMID: 33040197 DOI: 10.1007/s00402-020-03629-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 09/30/2020] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Acetylsalicylic acid (aspirin) is a commonly prescribed medication, especially in the age group of individuals who undergo elective total hip arthroplasty (THA). Preoperative discontinuation of aspirin is believed to reduce intraoperative bleeding and other complications, but it may increase the risk of perioperative cardiovascular events. In this study we have sought to evaluate the safety of continuous aspirin treatment in patients undergoing elective THA. MATERIALS AND METHODS This is a retrospective analysis of a consecutive cohort who underwent elective THA in a tertiary medical center between 2011 and 2018. The cohort was divided into two groups-one that received continuous preoperative aspirin treatment and one that did not. Blood loss, peri- and postoperative complications, readmissions, and short- and long-term mortality were compared between groups. RESULTS Out of 757 consecutive patients (293 males, 464 females) who underwent elective primary THA, 552 were in the "non-aspirin" group and 205 were in the "aspirin" group and were not treated preoperative with other medication affecting hemostasis. Perioperative continuation of aspirin treatment did not significantly increase perioperative bleeding, as indicated by changes in hemoglobin levels (P = 0.72). There were no significant differences in short- and long-term mortality (P = 0.47 and P = 0.4, respectively) or other perioperative complications, such as readmission (P = 0.78), deep or superficial infection (P = 1 and P = 0.47, respectively), and cardiovascular events (none in both groups). CONCLUSION Peri-operative continuation of aspirin treatment in patients undergoing elective primary THA did not increase perioperative complications or mortality compared to the non-aspirin-treated patients. The protective effects of aspirin from postoperative thrombotic and cardiovascular events are well documented. The current findings dispute the need to preoperatively withhold aspirin treatment in patients undergoing elective primary THA.
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Affiliation(s)
- Itay Ashkenazi
- Adult Reconstruction Unit, Division of Orthopedics, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel.
| | - Haggai Schermann
- Adult Reconstruction Unit, Division of Orthopedics, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Aviram Gold
- Adult Reconstruction Unit, Division of Orthopedics, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Ron Gurel
- Adult Reconstruction Unit, Division of Orthopedics, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Ofir Chechik
- Adult Reconstruction Unit, Division of Orthopedics, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Yaniv Warschawski
- Adult Reconstruction Unit, Division of Orthopedics, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Ran Schwarzkopf
- Hospital for Joint Diseases, NYU Langone Orthopedic Hospital, New York, USA
| | - Nimrod Snir
- Adult Reconstruction Unit, Division of Orthopedics, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
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Aspirin versus low-molecular-weight heparin for venous thromboembolism prophylaxis in orthopaedic trauma patients: A patient-centered randomized controlled trial. PLoS One 2020; 15:e0235628. [PMID: 32745092 PMCID: PMC7398524 DOI: 10.1371/journal.pone.0235628] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 06/17/2020] [Indexed: 01/28/2023] Open
Abstract
Background Emerging evidence suggests aspirin may be an effective venous thromboembolism (VTE) prophylaxis for orthopaedic trauma patients, with fewer bleeding complications. We used a patient-centered weighted composite outcome to globally evaluate aspirin versus low-molecular-weight heparin (LMWH) for VTE prevention in fracture patients. Methods We conducted an open-label randomized clinical trial of adult patients admitted to an academic trauma center with an operative extremity fracture, or a pelvis or acetabular fracture. Patients were randomized to receive LMWH (enoxaparin 30-mg) twice daily (n = 164) or aspirin 81-mg twice daily (n = 165). The primary outcome was a composite endpoint of bleeding complications, deep surgical site infection, deep vein thrombosis, pulmonary embolism, and death within 90 days of injury. A Global Rank test and weighted time to event analysis were used to determine the probability of treatment superiority for LMWH, given a 9% patient preference margin for oral administration over skin injections. Results Overall, 18 different combinations of outcomes were experienced by patients in the study. Ninety-nine patients in the aspirin group (59.9%) and 98 patients in the LMWH group (59.4%) were event-free within 90 days of injury. Using a Global Rank test, the LMWH had a 50.4% (95% CI, 47.7–53.2%, p = 0.73) probability of treatment superiority over aspirin. In the time to event analysis, LMWH had a 60.5% probability of treatment superiority over aspirin with considerable uncertainty (95% CI, 24.3–88.0%, p = 0.59). Conclusion The findings of the Global Rank test suggest no evidence of superiority between LMWH or aspirin for VTE prevention in fracture patients. LMWH demonstrated a 60.5% VTE prevention benefit in the weighted time to event analysis. However, this difference did not reach statistical significance and was similar to the elicited patient preferences for aspirin.
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Tang A, Zak S, Iorio R, Slover J, Bosco J, Schwarzkopf R. Low-Dose Aspirin Is Safe and Effective for Venous Thromboembolism Prevention in Patients Undergoing Revision Total Hip Arthroplasty: A Retrospective Cohort Study. J Arthroplasty 2020; 35:2182-2187. [PMID: 32334898 DOI: 10.1016/j.arth.2020.03.040] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 03/22/2020] [Accepted: 03/24/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Currently, there is no established universal standard of care for prophylaxis against venous thromboembolism (VTE) in orthopedic patients undergoing revision total hip arthroplasty (rTHA). The aim of this study is to determine whether a protocol of 81-mg aspirin (ASA) bis in die (BID) is safe and/or effective in preventing VTE in patients undergoing rTHAs vs 325-mg ASA BID. METHODS In 2017, a large academic medical center adopted a new protocol for VTE prophylaxis in arthroplasty patients at standard risk. Initially, patients received 325-mg ASA BID but switched to 81-mg ASA BID. A retrospective review (2011-2019) was performed to identify 1361 consecutive rTHA patients and their associated 90-day postoperative complications such as VTE, including pulmonary embolism (PE) and/or deep vein thrombosis (DVT), as the primary outcome; and gastrointestinal and wound bleeding, acute periprosthetic joint infection, and mortality as the secondary outcome. RESULTS From 2011 to 2017, 973 rTHAs were performed and 13 total VTE cases were diagnosed (1.34%). From 2017 to 2019, 388 rTHAs were performed with 3 total VTE cases identified (0.77%). Chi-squared analyses and logistic regression models showed no differences in rates or odds in postoperative PE (P = .09), DVT (P = .79), PE and DVT (P = .85), and total VTE (P = .38) using either dose. There were also no differences between bleeding complications (P = .14), infection rate (P = .46), and mortality (P = .53). CONCLUSION Using a protocol of 81-mg of ASA BID is noninferior to 325-mg ASA BID and may be safe and effective in maintaining low rates of VTE in patients undergoing rTHA.
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Affiliation(s)
- Alex Tang
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | - Stephen Zak
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | - Richard Iorio
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA
| | - James Slover
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | - Joseph Bosco
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
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Landy DC, Bradley AT, King CA, Puri L. Stratifying Venous Thromboembolism Risk in Arthroplasty: Do High-Risk Patients Exist? J Arthroplasty 2020; 35:1390-1396. [PMID: 32057606 DOI: 10.1016/j.arth.2020.01.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 01/03/2020] [Accepted: 01/08/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND While there are many possible complications associated with total joint arthroplasty (TJA), venous thromboembolism (VTE) is both frequent and potentially severe. Despite this importance, there are inconsistent recommendations for prophylaxis based on patient risk factors. METHODS A predictive model was constructed to compare low-molecular-weight heparin(LMWH) and aspirin (ASA) for prevention of VTE-associated complications following TJA.The model used risks from prior prophylaxis studies to estimate the risk of developing a symptomatic deep vein thrombosis, pulmonary embolism, thrombocytopenia, and operative or nonoperative site bleeding. We also evaluated the progression to 4 possible final health states: postphlebitis syndrome, intracranial hemorrhage, death, or baseline health. Within published ranges, we selected assumptions that were favorable to LMWH such that these analyses represent a best case scenario for LMWH or an alternative more aggressive low-molecular-weight heparin alternative (LMWHA). Events and outcomes were assigned quality-adjusted life-year (QALY) losses according to prior studies to determine the effect on patients' outcomes for ASA and LMWHA prophylaxis. RESULTS Assessing VTE risk populations from 0.2% to 2% with life expectancies ranging from 5 to 40 years postoperatively, patients with a risk ratio less than 3.7 showed increased expected QALY with ASA compared to LMWHA. For patients with a baseline VTE risk of 1% and a 15 year life expectancy, a risk ratio of 13.4 was needed to identify patients that would benefit from LMWHA. With life expectancy increased to 30 years, the risk ratio needed to idetify these patients was 7.4. CONCLUSION Patients undergoing TJA should receive ASA chemoprophylaxis in nearly all situations, unless the patient has a significantly increased VTE risk compared to the baseline population and a long life expectancy.
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Affiliation(s)
- David C Landy
- Hospital for Special Surgery, Department of Orthopaedic Surgery, New York, NY
| | | | - Connor A King
- Orthopaedic Surgery Department, University of Chicago, Chicago, IL
| | - Lalit Puri
- Northshore University HealthSystem, Skokie, IL
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Azboy I, Groff H, Goswami K, Vahedian M, Parvizi J. Low-Dose Aspirin Is Adequate for Venous Thromboembolism Prevention Following Total Joint Arthroplasty: A Systematic Review. J Arthroplasty 2020; 35:886-892. [PMID: 31733981 DOI: 10.1016/j.arth.2019.09.043] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 09/09/2019] [Accepted: 09/26/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Patients undergoing total joint arthroplasty (TJA) are at risk of developing venous thromboembolism (VTE) without adequate prophylaxis. Since the American Academy of Orthopedic Surgeons issued guidelines in 2007 recommending aspirin 325 mg bis in die for 6 weeks, aspirin has been favored as the main VTE prophylaxis. However, the appropriate dose and duration of aspirin are not well-studied. This systematic review aims to identify any differences between high and low dose as well as duration for aspirin thromboprophylaxis after TJA as outlined by previous studies. METHODS A search was performed using Ovid MEDLINE, EMBASE, and PubMed, including articles up to July 2016. Studies were included if they contained at least 1 cohort that underwent TJA with aspirin as the sole chemoprophylaxis and reported either (1) symptomatic VTE or (2) secondary outcomes such as major bleeding or 90-day mortality. RESULTS Forty-five papers were included. There were no significant differences in symptomatic pulmonary embolism, symptomatic deep vein thrombosis, 90-day mortality, or major bleeding between patients receiving low-dose or high-dose aspirin. Patients treated with aspirin for <4 weeks had a higher risk of major bleeding (1.59%) vs patients treated for 4 weeks (0.15%), which may be attributed to premature cessation or differential reporting. Patients treated with aspirin for <4 weeks had a statistically higher 90-day mortality (1.95%) vs patients treated for 4 weeks (0.07%). There was no significant difference between incidence of pulmonary embolism or deep vein thrombosis and the durations of aspirin treatment. CONCLUSION This review suggests that low-dose aspirin is not inferior to high-dose aspirin for VTE thromboprophylaxis in TJA patients. Additionally, patients treated with aspirin for less than 4 weeks may have a higher risk of major bleeding and 90-day mortality compared to patients treated for a longer duration.
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Affiliation(s)
- Ibrahim Azboy
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA; Department of Orthopaedics and Traumatology, Istanbul Medipol University School of Medicine, Istanbul, Turkey
| | - Hannah Groff
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Karan Goswami
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Mohammed Vahedian
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Javad Parvizi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
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An VVG, Levy YD, Walker PM, Bruce WJ. Thrombosis rates using aspirin and a compression device as multimodal prophylaxis for lower limb arthroplasty in a screened population. J Clin Orthop Trauma 2020; 11:S187-S191. [PMID: 32189937 PMCID: PMC7067987 DOI: 10.1016/j.jcot.2018.10.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 10/11/2018] [Accepted: 10/15/2018] [Indexed: 10/28/2022] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) (Deep vein thrombosis (DVT), and pulmonary embolism (PE)), is a common complication in patients undergoing total joint arthroplasty (TJA). Recently, aspirin was recommended by the American Academy of Orthopaedic Surgeons (AAOS) as VTE prophylaxis following TJA. This study investigates VTE rates in TJA patients using as thromboprophylaxis. METHODS DVT was screened for in 396 consecutive total hip or knee arthroplasty procedures. Patients were treated with early mobilisation, calf compression device and 300 mg aspirin for 5 days and then 100 mg aspirin for 5 weeks. All patients received lower-limb duplex ultrasonography prior to discharge. Patients were clinically evaluated at 6 weeks post-op documenting any VTE. RESULTS 51 TJA's (12.87%) were complicated by VTE: one proximal, 47 distal DVT and 3 PE. No fatal PE occurred. Only four DVT were symptomatic. Of 159 THA, 2 (1.25%) had VTE: one distal DVT and one PE. Of 237 TKA, 49 (20.67%) had VTE: 1 proximal, 46 distal DVT and 2 PE. Patients with a history of diabetes and those receiving TKA were at higher risk of DVT. CONCLUSION Multimodal VTE prophylaxis demonstrated a low rate of proximal DVT, PE and bleeding complications. The rate of asymptomatic DVT was high, but most were distal and unlikely to be clinically significant. Patients with diabetes and those receiving TKA could be at higher risk of asymptomatic DVT, and may benefit from closer clinical assessment. These findings suggest aspirin is safe and efficacious when used in combination with mechanical compressors and early mobilisation. However, our findings require further validation, particularly with larger, prospective comparative studies.
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Affiliation(s)
- Vincent V. G An
- Faculty of Medicine, University of Sydney, Camperdown, Australia,Corresponding author. 93 Arthur Street, Strathfield, NSW, 2135, Australia.
| | - Yadin D. Levy
- Sydney Olympic Park Hip and Knee Clinic, Sydney Olympic Park, Australia
| | - Peter M. Walker
- Sydney Olympic Park Hip and Knee Clinic, Sydney Olympic Park, Australia,Department of Orthopaedics, Concord Repatriation General Hospital, Concord, Australia
| | - Warwick J.M. Bruce
- Faculty of Medicine, University of Sydney, Camperdown, Australia,Sydney Olympic Park Hip and Knee Clinic, Sydney Olympic Park, Australia,Department of Orthopaedics, Concord Repatriation General Hospital, Concord, Australia
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Tan TL, Foltz C, Huang R, Chen AF, Higuera C, Siqueira M, Hansen EN, Sing DC, Parvizi J. Potent Anticoagulation Does Not Reduce Venous Thromboembolism in High-Risk Patients. J Bone Joint Surg Am 2019; 101:589-599. [PMID: 30946192 DOI: 10.2106/jbjs.18.00335] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Based on current guidelines from the American Academy of Orthopaedic Surgeons (AAOS), a number of prophylactic modalities for the prevention of venous thromboembolism in total joint arthroplasty may be used. It is common practice that more potent prophylactic agents are used for patients at higher risk of venous thromboembolism. However, we are aware of no studies that have investigated the efficacy of potent anticoagulation in higher-risk individuals. Therefore, the purpose of our study was to test the hypothesis that low-molecular-weight heparin and warfarin result in a reduction in venous thromboembolism events in high-risk patients. METHODS A retrospective, multi-institutional study of 60,467 primary and revision total joint arthroplasties from 2000 to 2015 was performed. Identified medications were classified as aspirin, low-molecular-weight heparin, or warfarin. Patients with unavailable venous thromboembolism prophylaxis information or those not receiving the aforementioned prophylaxis were excluded. Information pertinent to the objective of this study was collected and a venous thromboembolism risk score was calculated based on 26 variables. Treatment outcomes assessed included 90-day rate of symptomatic venous thromboembolism and periprosthetic joint infection. Propensity score matching was performed (1:1), as well as logistic regression analysis on the total sample. RESULTS Aspirin prophylaxis demonstrated a lower rate of deep vein thrombosis, pulmonary embolism, and venous thromboembolism than warfarin and low-molecular-weight heparin alone throughout all risk scores. In the matched propensity score analysis, low-molecular-weight heparin and warfarin demonstrated increased odds of venous thromboembolism for both standard-risk and high-risk patients undergoing total knee arthroplasties compared with aspirin. For primary total hip arthroplasty, warfarin demonstrated an increased risk for high-risk patients and low-molecular-weight heparin demonstrated an increased risk for standard-risk patients. The prevalence of periprosthetic joint infection was higher in patients receiving warfarin (p < 0.001 for both comparisons of warfarin with aspirin and low-molecular-weight heparin). CONCLUSIONS The results of this multi-institutional study demonstrate that the use of warfarin and low-molecular-weight heparin in higher-risk patients does not necessarily result in a reduction in symptomatic venous thromboembolism. Aspirin administered to higher-risk patients seems to be as effective as potent anticoagulation and more effective than warfarin. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Timothy L Tan
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Carol Foltz
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Ronald Huang
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Antonia F Chen
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | | | - Erik N Hansen
- University of California San Francisco, San Francisco, California
| | - David C Sing
- University of California San Francisco, San Francisco, California
| | - Javad Parvizi
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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Haykal T, Kheiri B, Zayed Y, Barbarawi M, Miran MS, Chahine A, Katato K, Bachuwa G. Aspirin for venous thromboembolism prophylaxis after hip or knee arthroplasty: An updated meta-analysis of randomized controlled trials. J Orthop 2019; 16:312-319. [PMID: 30976146 DOI: 10.1016/j.jor.2019.02.032] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2018] [Accepted: 02/22/2019] [Indexed: 11/18/2022] Open
Abstract
Background Patients who undergo knee or hip arthroplasty are at a significant risk of venous thromboembolism (VTE) development (pulmonary embolism and/or deep-vein thrombosis). Many different thromboprophylactic strategies have been used for the prevention of VTE in these patients with different outcomes. Therefore, our aim was to evaluate the efficacy and safety of aspirin prophylaxis when compared with placebo or anticoagulants in this population of patients. Methods A comprehensive electronic database search was conducted for all randomized controlled trials (RCTs) comparing the clinical outcomes of aspirin versus placebo or anticoagulants for the prevention of VTE after knee or hip arthroplasty. The primary outcome was VTE incidence. Secondary outcomes included any bleeding, major bleeding and mortality. We calculated risk ratios (RRs) and 95% confidence intervals (CIs) using a random-effects model at the longest possible follow-up period. Results We included 13 RCTs with a total of 20,115 patients with a mean age of 67.15 ± 9.54 and 24.39% males. Aspirin was found to be associated with a non-significantly reduced VTE events compared with other thromboprophylactic methods (RR 0.87; 95% CI: 0.61-1.23; P = 0.43). Compared with placebo, aspirin was associated with significant reduction of VTE (RR 0.65; 95% CI: 0.47-0.89; P = 0.008). There were no significant differences in the clinical outcomes between all groups with regard to mortality (RR 0.98; 95% CI: 0.86-1.11; P = 0.72), major bleeding events (RR 0.96; 95% CI: 0.50-1.84; P = 0.91), and any bleeding events (RR: 1.09; 95% CI: 0.82-1.44; P = 0.56). Conclusion Among patients who underwent knee or hip arthroplasty, aspirin prophylaxis was found to be associated with similar efficacy and safety outcomes when compared with anticoagulants. When compared with placebo, aspirin prophylaxis was associated with significantly reduced VTE and a comparable safety profile.
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Affiliation(s)
- Tarek Haykal
- Hurley Medical Center, Department of Internal Medicine, Flint, MI, USA
- Michigan State University, College of Human Medicine, East Lansing, MI, USA
| | - Babikir Kheiri
- Hurley Medical Center, Department of Internal Medicine, Flint, MI, USA
- Michigan State University, College of Human Medicine, East Lansing, MI, USA
| | - Yazan Zayed
- Hurley Medical Center, Department of Internal Medicine, Flint, MI, USA
- Michigan State University, College of Human Medicine, East Lansing, MI, USA
| | - Mahmoud Barbarawi
- Hurley Medical Center, Department of Internal Medicine, Flint, MI, USA
- Michigan State University, College of Human Medicine, East Lansing, MI, USA
| | - Muhammad Shah Miran
- Hurley Medical Center, Department of Internal Medicine, Flint, MI, USA
- Michigan State University, College of Human Medicine, East Lansing, MI, USA
| | - Adam Chahine
- Hurley Medical Center, Department of Internal Medicine, Flint, MI, USA
- Michigan State University, College of Human Medicine, East Lansing, MI, USA
| | - Khalil Katato
- Hurley Medical Center, Department of Internal Medicine, Flint, MI, USA
- Michigan State University, College of Human Medicine, East Lansing, MI, USA
- Genessee Hematology & Oncology, PC, Flint, MI, USA
| | - Ghassan Bachuwa
- Hurley Medical Center, Department of Internal Medicine, Flint, MI, USA
- Michigan State University, College of Human Medicine, East Lansing, MI, USA
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Haykal T, Kheiri B, Zayed Y, Barbarawi M, Miran MS, Chahine A, Katato K, Bachuwa G. Aspirin for venous thromboembolism prophylaxis after hip or knee arthroplasty: An updated meta-analysis of randomized controlled trials. J Orthop 2019; 16:294-302. [PMID: 30976143 DOI: 10.1016/j.jor.2019.03.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background Patients who undergo knee or hip arthroplasty are at a significant risk of venous thromboembolism (VTE) development (pulmonary embolism and/or deep-vein thrombosis). Many different thromboprophylactic strategies have been used for the prevention of VTE in these patients with different outcomes. Therefore, our aim was to evaluate the efficacy and safety of aspirin prophylaxis when compared with placebo or anticoagulants in this population of patients. Methods A comprehensive electronic database search was conducted for all randomized controlled trials (RCTs) comparing the clinical outcomes of aspirin versus placebo or anticoagulants for the prevention of VTE after knee or hip arthroplasty. The primary outcome was VTE incidence. Secondary outcomes included any bleeding, major bleeding and mortality. We calculated risk ratios (RRs) and 95% confidence intervals (CIs) using a random-effects model at the longest possible follow-up period. Results We included 13 RCTs with a total of 20,115 patients with a mean age of 67.15 ± 9.54 and 24.39% males. Aspirin was found to be associated with a non-significantly reduced VTE events compared with other thromboprophylactic methods (RR 0.87; 95% CI: 0.61-1.23; P = 0.43). Compared with placebo, aspirin was associated with significant reduction of VTE (RR 0.65; 95% CI: 0.47-0.89; P = 0.008). There were no significant differences in the clinical outcomes between all groups with regard to mortality (RR 0.98; 95% CI: 0.86-1.11; P = 0.72), major bleeding events (RR 0.96; 95% CI: 0.50-1.84; P = 0.91), and any bleeding events (RR: 1.09; 95% CI: 0.82-1.44; P = 0.56). Conclusion Among patients who underwent knee or hip arthroplasty, aspirin prophylaxis was found to be associated with similar efficacy and safety outcomes when compared with anticoagulants. When compared with placebo, aspirin prophylaxis was associated with significantly reduced VTE and a comparable safety profile.
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Affiliation(s)
- Tarek Haykal
- Hurley Medical Center, Department of Internal Medicine, Flint, MI, USA
- Michigan State University, College of Human Medicine, East Lansing, MI, USA
| | - Babikir Kheiri
- Hurley Medical Center, Department of Internal Medicine, Flint, MI, USA
- Michigan State University, College of Human Medicine, East Lansing, MI, USA
| | - Yazan Zayed
- Hurley Medical Center, Department of Internal Medicine, Flint, MI, USA
- Michigan State University, College of Human Medicine, East Lansing, MI, USA
| | - Mahmoud Barbarawi
- Hurley Medical Center, Department of Internal Medicine, Flint, MI, USA
- Michigan State University, College of Human Medicine, East Lansing, MI, USA
| | - Muhammad Shah Miran
- Hurley Medical Center, Department of Internal Medicine, Flint, MI, USA
- Michigan State University, College of Human Medicine, East Lansing, MI, USA
| | - Adam Chahine
- Hurley Medical Center, Department of Internal Medicine, Flint, MI, USA
- Michigan State University, College of Human Medicine, East Lansing, MI, USA
| | - Khalil Katato
- Hurley Medical Center, Department of Internal Medicine, Flint, MI, USA
- Genessee Hematology & Oncology, PC, Flint, MI, USA
| | - Ghassan Bachuwa
- Hurley Medical Center, Department of Internal Medicine, Flint, MI, USA
- Michigan State University, College of Human Medicine, East Lansing, MI, USA
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Rondon AJ, Shohat N, Tan TL, Goswami K, Huang RC, Parvizi J. The Use of Aspirin for Prophylaxis Against Venous Thromboembolism Decreases Mortality Following Primary Total Joint Arthroplasty. J Bone Joint Surg Am 2019; 101:504-513. [PMID: 30893231 DOI: 10.2106/jbjs.18.00143] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The use of aspirin as prophylaxis against venous thromboembolism (VTE) following total joint arthroplasty (TJA) has increased in popularity; however, the potential cardioprotective effects of aspirin when administered as VTE prophylaxis remain unknown. The present study investigated the influence of VTE prophylaxis, including aspirin, on mortality following TJA. METHODS We retrospectively reviewed 31,133 patients who underwent primary TJA from 2000 to 2017. Patient demographics, body mass index, and comorbidities were obtained from an electronic chart query. Patients were allocated into 2 cohorts on the basis of the VTE prophylaxis administered: aspirin (25.9%, 8,061 patients) and non-aspirin (74.1%, 23,072 patients). Mortality was assessed with use of an institutional mortality database that is updated biannually. Univariate and multivariate regression analyses were performed. RESULTS The overall mortality rate was 0.2% and 0.6% at 30 days and 1 year after TJA, respectively. The use of aspirin was independently associated with lower risk of death at both 30 days (odds ratio [OR], 0.39; p = 0.020) and 1 year (OR, 0.51; p = 0.004). Patients in the non-aspirin cohort showed 3 times the risk of death at 30 days compared with the aspirin cohort (0.3% compared with 0.1%; p = 0.004), and twice the risk of death at 1 year (0.7% compared with 0.3%; p < 0.001). At 1 year, the primary cause of death in the non-aspirin group was cardiac-related (46 of 23,072, 0.20%). In the aspirin group, the rate of cardiac-related death was almost 5 times lower (3 of 8,061, 0.04%; p = 0.005). Risk factors for mortality at 1 year included higher age (p < 0.001), male sex (p = 0.020), history of congestive heart failure (p = 0.003), cerebrovascular disease (p < 0.001), malignancy (p < 0.001), and history of prior myocardial infarction (p < 0.001). CONCLUSIONS The present study demonstrates that the use of aspirin as prophylaxis against VTE following TJA may reduce the risk of mortality. Given the numerous options available and permitted by the current guidelines, orthopaedic surgeons should be aware of the potential added benefits of aspirin when selecting a VTE-prophylactic agent. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Alexander J Rondon
- The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Noam Shohat
- The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania.,Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Timothy L Tan
- The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Karan Goswami
- The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | - Javad Parvizi
- The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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Kim HA, Lee J, Park SH, Kang J, Choi KS, Rhie SJ. Clinical outcomes and risk factors of thromboprophylaxis with rivaroxaban versus aspirin in patients undergoing hip arthroplasty in low‐incidence population: A nationwide study in Korea. Pharmacoepidemiol Drug Saf 2019; 28:507-514. [DOI: 10.1002/pds.4737] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 09/20/2018] [Accepted: 12/26/2018] [Indexed: 12/19/2022]
Affiliation(s)
- Hong Ah Kim
- Division of Life and Pharmaceutical Sciences Graduate SchoolEwha Womans University Seoul Republic of Korea
| | - Ju‐Yeun Lee
- College of PharmacySeoul National University Seoul Republic of Korea
| | - So Hyun Park
- Division of Life and Pharmaceutical Sciences Graduate SchoolEwha Womans University Seoul Republic of Korea
| | - JiEun Kang
- Division of Life and Pharmaceutical Sciences Graduate SchoolEwha Womans University Seoul Republic of Korea
| | - Kyung Suk Choi
- Division of Life and Pharmaceutical Sciences Graduate SchoolEwha Womans University Seoul Republic of Korea
| | - Sandy Jeong Rhie
- Division of Life and Pharmaceutical Sciences Graduate SchoolEwha Womans University Seoul Republic of Korea
- College of PharmacyEwha Womans University Seoul Republic of Korea
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Is Obesity Associated With Increased Risk of Deep Vein Thrombosis or Pulmonary Embolism After Hip and Knee Arthroplasty? A Large Database Study. Clin Orthop Relat Res 2019; 477:523-532. [PMID: 30624321 PMCID: PMC6382191 DOI: 10.1097/corr.0000000000000615] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Deep venous thrombosis (DVT) and pulmonary embolus (PE) remain an important cause of morbidity and mortality after THA and TKA. Prior recommendations have advocated for more aggressive prophylaxis for patients with obesity, whereas the evidence supporting these recommendations is conflicting and often based on underpowered studies. QUESTIONS/PURPOSES (1) What is the association between obesity and DVT and PE after primary and revision THA and TKA? (2) Is there a body mass index (BMI) threshold beyond which DVT and PE risk is elevated? METHODS We reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2008 to 2016 to evaluate the reported 30-day rates of DVT, PE, and combined venous thromboembolism (VTE) after primary THA, primary TKA, revision THA, and revision TKA according to BMI as a continuous variable and a categorical variable as defined by the World Health Organization cutoffs for underweight, normal weight, overweight, and obesity. This database is risk-adjusted and designed to capture complications after surgery, thus making it ideal for this study. The diagnosis of DVT and PE is included in the ACS-NSQIP database for any DVT or PE requiring treatment. Proximal versus distal DVT is not specified within the database. Multivariate logistic regression was performed to determine if obesity was independently associated with DVT and PE risk by controlling for age, sex, race, American Society of Anesthesiologists score, diabetes, hypertension, smoking status, general anesthesia, and hypoalbuminemia. RESULTS After controlling for potential confounding variables such as medical comorbidities and procedure type, patients undergoing primary and revision THA and TKA with World Health Organization classification as underweight (BMI < 18.5 kg/m), overweight (BMI 25-29.9 kg/m), Class I obese (BMI 30-34.9 kg/m), Class II obese (BMI 35-39.9 kg/m), or Class III obese (BMI ≥ 40 kg/m) did not demonstrate an association with increased risk of DVT compared with patients classified as normal weight (BMI 18.5-25 kg/m). Compared with patients undergoing primary THA classified as normal weight, the risk of PE was elevated in patients with Class II obesity (odds ratio [OR], 2.36; 95% confidence interval [CI], 1.23-4.50; p = 0.009) and all heavier categories. Compared with patients undergoing TKA classified as normal weight, the risk of PE was elevated in patients classified as overweight (OR, 1.56; 95% CI, 1.03-2.36; p = 0.035) and all heavier categories. CONCLUSIONS This large administrative database study suggests that patient classification as overweight or obese is associated with increased risk of development of PE but not DVT after primary THA or TKA. Because aggressive pharmacologic anticoagulation regimens can decrease the DVT rate but have not been shown to affect the rate of PE or death, the data do not currently support increased anticoagulation in patients with obesity without other risk factors for VTE undergoing THA or TKA. Additional studies are required to refine VTE prophylaxis protocols to reduce PE risk while maintaining acceptable postoperative bleeding risk. LEVEL OF EVIDENCE Level III, therapeutic study.
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Richardson SS, Schairer WW, Sculco PK, Bostrom MP. Comparison of pharmacologic prophylaxis in prevention of venous thromboembolism following total knee arthroplasty. Knee 2019; 26:451-458. [PMID: 30700390 DOI: 10.1016/j.knee.2019.01.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Revised: 12/07/2018] [Accepted: 01/08/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Anticoagulants are used following total knee arthroplasty (TKA) to prevent venous thromboembolism (VTE). These drugs reduce VTE risk but may lead to bleeding-related complications. Recently, surgeons have advocated using antiplatelet agents including aspirin (ASA). However, there is no consensus regarding which medication has the optimal risk/benefit profile. The purpose of this study was to compare rates of VTE using different anticoagulants in anticoagulation-naïve patients being discharged home after TKA. METHODS A national private insurance database was used to identify patients undergoing unilateral TKA. Patients with a prior history of VTE were excluded. Anticoagulants included ASA, low molecular weight heparin (LMWH), warfarin, factor Xa inhibitors (XaI), and fondaparinux. Postoperative complications, including VTE, blood transfusion, myocardial infarction, and hematoma, were identified using ICD-9 diagnosis codes. Risk of each complication was compared between groups using multivariate logistic regression controlling for demographics, length of stay, and comorbidities. RESULTS Of 30,813 patients, 1.82% were diagnosed with VTE. Using ASA as a baseline, there was significantly decreased risk of VTE with LMWH (OR 0.47), XaI (OR 0.50), and fondaparinux (OR 0.32). There was significantly higher risk of transfusion with LMWH (OR 1.56) and fondaparinux (OR 1.84), but no difference in hematoma between medications. CONCLUSIONS This study shows that there is a decreased risk of VTE with LMWH, XaI, and fondaparinux compared to ASA. However, these medications also had higher rates of bleeding-associated complications. The choice of pharmacologic prophylaxis should be made based on a balance of the risk/benefit profile of each medication. LEVEL OF EVIDENCE III.
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No Difference Between Low- and Regular-dose Aspirin for Venous Thromboembolism Prophylaxis After THA. Clin Orthop Relat Res 2019; 477:396-402. [PMID: 30624322 PMCID: PMC6370078 DOI: 10.1097/corr.0000000000000613] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Aspirin is established as an effective prophylaxis for venous thromboembolism (VTE) after THA; however, there is no consensus as to whether low- or regular-dose aspirin is more effective at preventing VTE. QUESTIONS/PURPOSES (1) Is there a difference in the incidence of symptomatic VTE within 90 days of elective THA using low-dose aspirin compared with regular-dose aspirin? (2) Is there a difference in the risk of significant bleeding (gastrointestinal and wound bleeding) and mortality between low- and standard-dose aspirin within 90 days after surgery? METHODS We retrospectively evaluated 7488 patients in our database who underwent THA between September 2012 and December 2016. A total of 3936 (53%) patients received aspirin alone for VTE prophylaxis after THA. During the study period, aspirin was prescribed as a monotherapy for VTE prophylaxis after surgery in low-risk patients (no history of VTE, recent orthopaedic surgery, hypercoagulable state, history of cardiac arrhythmia requiring anticoagulation, or receiving anticoagulation for any other medical conditions before surgery). Patients were excluded if aspirin use was contraindicated because of peptic ulcer disease, intolerance, or other reasons. Patients received aspirin twice daily (BID) for 4 to 6 weeks after surgery and were grouped into two cohorts: a low-dose (81 mg BID) aspirin group (n = 1033) and a standard-dose (325 mg BID) aspirin group (n = 2903). The primary endpoint was symptomatic VTE (deep vein thrombosis [DVT] and pulmonary embolism [PE]). Secondary endpoints included significant bleeding (gastrointestinal [GI] and wound) and mortality. Exploratory univariate analyses were used to compare confounders between the study groups. Multivariate regression was used to control for confounding variables (including age, sex, body mass index, comorbidities, and surgeon) as we compared the study groups with respect to the proportion of patients who developed symptomatic VTE, bleeding (GI or wound), and mortality within 90 days of surgery. RESULTS The 90-day incidence of symptomatic VTE was 1.0% in the 325-mg group and 0.6% in the 81-mg group (p = 0.35). Symptomatic DVT incidence was 0.8% in the 325-mg group and 0.5% in the 81-mg group (p = 0.49), and the incidence of symptomatic PE was 0.3% in the 325-mg group and 0.2% in the 81-mg group (p = 0.45). Furthermore, bleeding was observed in 0.8% of the 325-mg group and 0.5% of the 81-mg group (p = 0.75), and 90-day mortality was not different (0.1%) between the groups (p = 0.75). After accounting for confounders, regression analyses showed no difference between aspirin doses and the 90-day incidence of symptomatic VTE (odds ratio [OR], 0.90; 95% confidence interval [CI], 0.29-2.85; p = 0.85) or symptomatic DVT (OR, 0.96; 95% CI, 0.26-3.59; p = 0.95). CONCLUSIONS We found no difference in the incidence of symptomatic VTE after THA with low-dose compared with standard-dose aspirin. In the absence of compelling evidence to the contrary, low-dose aspirin appears to be a reasonable option for VTE prophylaxis in otherwise healthy patients undergoing elective THA. LEVEL OF EVIDENCE Level III, therapeutic study.
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Trivedi NN, Fitzgerald SJ, Schmaier AH, Wera GD. Venous Thromboembolism Chemoprophylaxis in Total Hip and Knee Arthroplasty: A Critical Analysis Review. JBJS Rev 2019; 7:e2. [PMID: 30601202 DOI: 10.2106/jbjs.rvw.18.00010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Nikunj N Trivedi
- University Hospitals, Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Steven J Fitzgerald
- University Hospitals, Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Alvin H Schmaier
- University Hospitals, Cleveland Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Glenn D Wera
- MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
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Woon CYL, Shah RR, Pardi BM, Schwartz BE, Goldstein JM, Cipparrone NE, Goldstein WM. Aspirin Alone Is Not Enough to Prevent Deep Venous Thrombosis After Total Joint Arthroplasty. Orthopedics 2019; 42:48-55. [PMID: 30602046 DOI: 10.3928/01477447-20181227-02] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 12/03/2018] [Indexed: 02/03/2023]
Abstract
Thromboembolic events after total joint arthroplasty are potentially devastating complications. This study evaluated the efficacy of 4 different anticoagulants in preventing deep venous thrombosis and pulmonary embolism after total joint arthroplasty. The demographics and anticoagulant use (warfarin, enoxaparin, and aspirin with and without outpatient mechanical pumps) for patients who underwent primary unilateral total joint arthroplasties performed by a single surgeon from January 2013 to October 2014 were retrospectively reviewed. All patients underwent lower extremity ultrasound at the 3-week postoperative visit. A total of 613 primary unilateral total joint arthroplasties met the study inclusion criteria. There were 288 primary total knee arthroplasties and 325 primary total hip arthroplasties. The patients were 62.2% female, having a mean age of 67.6±10.6 years and a mean body mass index of 30.2±5.9 kg/m2. There were 119 patients in group 1 (aspirin alone), 40 patients in group 2 (aspirin plus pumps), 246 patients in group 3 (warfarin), and 208 patients in group 4 (enoxaparin). The overall 3-week symptomatic and asymptomatic deep venous thrombosis and symptomatic pulmonary embolism rates in the entire cohort were 5.7% and 0.3%, respectively. The venous thromboembolism rate was significantly affected by the anticoagulant of choice (P<.01). Compared with aspirin alone, warfarin decreased the risk of venous thromboembolism (P<.01). Increasing age led to increased risk of venous thromboembolism (P=.05). This study indicated that aspirin chemoprophylaxis alone was not as efficacious as warfarin and enoxaparin in preventing asymptomatic and symptomatic venous thromboembolism found during routine postoperative surveillance with lower extremity ultrasound. Aspirin alone may be inadequate and should be augmented with an outpatient mechanical pump as part of multimodal prophylaxis. [Orthopedics. 2019; 42(1):48-55.].
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Carr P, Ehredt DJ, Dawoodian A. Prevention of Deep Venous Thromboembolism in Foot and Ankle Surgery. Clin Podiatr Med Surg 2019; 36:21-35. [PMID: 30446043 DOI: 10.1016/j.cpm.2018.08.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Although rare, deep vein thrombosis (DVT) and pulmonary embolism remain a concern for foot and ankle surgeons. Most prophylactic measures against DVT formation are synthesized from orthopedic hip and knee data, and therefore the routine use of these recommendations may place patients at risk for complications associated with unnecessary prophylaxis. In this article we review and present the most current literature specific to venous thromboembolism (VTE) in foot and ankle surgery. It is clear that, given our current literature, a case-by-case approach for VTE prophylaxis should be used following foot and ankle surgery.
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Affiliation(s)
- Preston Carr
- Kent State University College of Podiatric Medicine, 6000 Rockside Woods Boulevard, Independence, OH 44131, USA
| | - Duane J Ehredt
- Division of Foot and Ankle Surgery, Kent State University College of Podiatric Medicine, 6000 Rockside Woods Boulevard, Independence, OH 44131, USA; Podiatric Medicine and Surgery Residency Program, Saint Vincent Charity Medical Center, 2351 East 22nd Street, Cleveland, OH 44115, USA.
| | - Alex Dawoodian
- Podiatric Medicine and Surgery Residency Program, Saint Vincent Charity Medical Center, 2351 East 22nd Street, Cleveland, OH 44115, USA
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Ng C, Zavala S, Davis ES, Adams W, Pinzur MS. Evaluation of a Simplified Risk Stratification Twice-Daily Aspirin Protocol for Venous Thromboembolism Prophylaxis After Total Joint Replacement. J Pharm Pract 2018; 33:443-448. [PMID: 30572759 DOI: 10.1177/0897190018815050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To determine using a simplified risk-stratified protocol to select candidates for aspirin therapy have similar death and postoperative complications as universal warfarin therapy in patients undergoing total joint replacement (TJR). METHODS Retrospective cohort study comparing 30-day postoperative outcomes 6 months before and after the implementation of the aspirin protocol (January 1, 2015) in patients undergoing TJR. The control group was comprised of patients using warfarin for VTE prophylaxis. The protocol group included patients who used aspirin 325 mg twice-daily or warfarin if deemed high thrombotic risk or aspirin intolerant by the criteria set forth by the aspirin protocol. RESULTS This study included 449 patients. No difference was found in the rates of 30-day postoperative bleeding, VTE, death, composite end point of VTE and death, and length of stay between the control and the protocol groups (all P > .05). Thirty-day postoperative surgical site infections (SSIs; 5.8% vs 1.2%; P = .02) and return to operative room (OR; 3.9% vs 0.4%; P = .03) were less frequent in the protocol group. CONCLUSION A simplified risk-stratified protocol used to choose patients for aspirin 325 mg twice-daily therapy is safe and effective in patients undergoing TJR, and SSI and return to OR rates may be lower when compared to universal warfarin therapy.
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Affiliation(s)
- Candy Ng
- Department of Pharmacy, Loyola University Medical Center, Maywood, IL, USA
| | - Sarah Zavala
- Department of Pharmacy, Loyola University Medical Center, Maywood, IL, USA
| | - Elissa S Davis
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Health System, Maywood, IL, USA
| | - William Adams
- Clinical Research Office Biostatistics Core, Loyola University Chicago, Maywood, IL, USA
| | - Michael S Pinzur
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Health System, Maywood, IL, USA
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Groff H, Azboy I, Parvizi J. Differences in Reported Outcomes in Industry-Funded vs Nonfunded Studies Assessing Thromboprophylaxis After Total Joint Arthroplasty. J Arthroplasty 2018; 33:3398-3401. [PMID: 30017220 DOI: 10.1016/j.arth.2018.06.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 06/14/2018] [Accepted: 06/19/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND There are numerous studies discussing thromboprophylaxis after total joint arthroplasty (TJA), with varying conclusions. Patient inclusion criteria may be different for each study, which may lead to selection bias and misrepresentation of data. This study aimed to investigate if industry funding impacted patient demographics and overall reported outcomes of studies analyzing venous thromboembolism (VTE) prevention after TJA. METHODS Electronic searches were completed using Ovid, PubMed, and Embase databases. Studies were included if (1) they are published in the English language between 2000 and 2016; (2) they included patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA); and (3) they evaluated prevention and control of postoperative VTE with at least one of the following thromboprophylactic agents: aspirin, enoxaparin, dalteparin, dabigatran, apixaban, rivaroxaban, dabigatran, ximelagatran, fondaparinux, or coumadin. Data were extracted and analyzed via mixed-effect logistic regression. RESULTS Fifty-seven studies were included; 29 were industry funded, and 28, nonfunded. There were no significant differences between patient's age, body mass index, or revision exclusions between funded and nonfunded studies. Funded studies reported less pulmonary embolisms, fewer events of major bleeding, and significantly less 90-day mortality compared with nonfunded studies. CONCLUSION Industry-funded studies reported less pulmonary embolisms, major bleeding, and mortality compared with nonfunded studies. Detailed demographic data were missing from the literature, and we were unable to demonstrate the cause of different reported outcomes between industry-funded and nonfunded studies. Further investigations should be aimed toward understanding how funded studies report less adverse outcomes in analyzing VTE after TJA.
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Affiliation(s)
- Hannah Groff
- Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Ibrahim Azboy
- Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania; Department of Orthopaedics and Traumatology, Istanbul Medipol University School of Medicine, Istanbul, Turkey
| | - Javad Parvizi
- Rothman Institute, Thomas Jefferson University, Philadelphia, Pennsylvania
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Bingham JS, Salib CG, Labban K, Morrison Z, Spangehl MJ. A dedicated anticoagulation clinic does not improve postoperative management of warfarin after total joint arthroplasty. Arthroplast Today 2018; 4:340-342. [PMID: 30186918 PMCID: PMC6123344 DOI: 10.1016/j.artd.2018.04.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2018] [Revised: 04/26/2018] [Accepted: 04/27/2018] [Indexed: 11/22/2022] Open
Abstract
Background Periprosthetic joint infections (PJIs) are devastating complications. Excessive anticoagulation with warfarin is an independent risk factor for PJIs. The use of a dedicated anticoagulation clinic to improve warfarin management has not been proven. Methods Between 2006 and 2014, we identified 92 patients who were placed on postoperative warfarin, and later developed PJI. These patients were compared to 313 patients who underwent total joint arthroplasty placed on warfarin without developing PJI. Patients were included if they had no history of a venous thromboembolic event, were warfarin naive, and enrolled in the anticoagulation clinic. A univariate analysis compared independent variables, and statistical analysis was performed using Student's t-test and Pearson chi-square test for continuous and categorical variables. Results Thirty-six PJI patients and 297 control patients met the inclusion criteria. The venous thromboembolism rate was 2.1%. At discharge, 82% of all patients were subtherapeutic. Patients were within their target international normalized ratio (INR) range 26.7% of the time. The mean INR in the initial postoperative period for the PJI group was 1.46 and 1.29 in the control group (P < .001). In the acute postoperative period, 13.3% of the knee PJI group were therapeutic or supratherapeutic compared with 3.5% in the knee control group (P = .002). Conclusions Despite utilization of a dedicated anticoagulation clinic, patients were only within their target INR range 27% of the time. Total knee arthroplasty patients who developed a PJI were more likely to be therapeutic or supratherapeutic in the initial postoperative period. Consequently, the risks associated with warfarin as a venous thromboembolism prophylaxis may outweigh the potential benefits.
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Affiliation(s)
| | | | - Kyle Labban
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, AZ, USA
| | | | - Mark J Spangehl
- Department of Orthopedic Surgery, Mayo Clinic, Phoenix, AZ, USA
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Roman F, Allen JS, Wurm HC, MacLaughlin K. Pulmonary Embolism While on Aspirin for Venous Thromboembolism Prophylaxis After Total Knee Arthroplasty. J Prim Care Community Health 2018; 9:2150132718797446. [PMID: 30168355 PMCID: PMC6120175 DOI: 10.1177/2150132718797446] [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] [Indexed: 11/17/2022] Open
Abstract
A 62-year-old Caucasian man with past medical history significant for coronary artery disease, status post drug eluting stent to the left anterior descending artery 10 years prior, was admitted for elective total right knee arthroplasty. His intraoperative course was uneventful, and he was discharged on hospital day 2 on aspirin 325 mg twice daily for 6 weeks for venous thromboembolism (VTE) prophylaxis. Three weeks later the patient developed chest pain shortly after an approximately 1-hour flight and presented to a local emergency department where computed tomography angiogram showed pulmonary emboli involving segmental and subsegmental pulmonary arteries bilaterally. He was transitioned from aspirin 325 mg twice a day to rivaroxaban 15 mg twice daily for 21 days, with a plan to transition to 20 mg daily to complete a 3-month course. He returned to his primary care physician 6 days after discharge with questions about his current anticoagulation therapy as well as the regimen he was on prior to the pulmonary embolism. Two major organizations, The American Academy of Orthopedic Surgeons and The American College of Chest Physicians, provide recommendations for VTE prophylaxis, but they differ regarding the preferred pharmacologic modality and duration. Although the goal is to provide optimal patient care, lack of guideline consensus may lead to different postoperative recommendations. It is important for clinicians to discuss with their patients the pharmacologic options available for VTE prophylaxis, how organizations differ in their recommendations, and the limitations of these pharmacologic agents.
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Rondon AJ, Goswami K, Tan TL, Shohat N, Parvizi J. Majority of Total Joint Arthroplasties Are Subtherapeutic on Warfarin at Time of Discharge: Another Reason to Avoid Warfarin as a Venous Thromboembolism Prophylaxis? J Arthroplasty 2018; 33:2787-2791. [PMID: 29871833 DOI: 10.1016/j.arth.2018.04.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 04/08/2018] [Accepted: 04/23/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Warfarin has been used as prophylaxis against venous thromboembolism (VTE) after total joint arthroplasty (TJA) for over 60 years. With trends of shorter hospital stays for TJA patients, it is important to examine how many patients achieve therapeutic international normalized ratio (INR) at time of discharge. We aimed at elucidating the proportion of patients discharged at therapeutic INR and whether this is affected by inpatient specialty anticoagulation management service (AMS) involvement. METHODS We conducted a retrospective review of 2927 primary TJA patients who received warfarin as postoperative VTE chemoprophylaxis from 2011 to 2016. An electronic chart query determined AMS input, length of stay (LOS), INR at discharge, and in-hospital complications. INR results were categorized as subtherapeutic (INR < 2.0), therapeutic (2.0 ≤ INR < 3.0), and supratherapeutic (INR ≥ 3.0). Descriptive statistics, chi-square, and t-tests were performed for analysis. RESULTS At discharge, 93.9% of patients had subtherapeutic INR. Average INR was 1.41 with average LOS of 2.53 days. Factors associated with being subtherapeutic included male gender, shorter LOS, fewer comorbidities, reduced in-hospital complications, and higher body mass index. AMS supervised postoperative warfarin dosing in 64.9% of patients. Patients managed by AMS were less likely to be subtherapeutic at discharge compared to those without AMS input; however, the absolute difference in INR may not be clinically significant. There were 19 VTEs, of which 13 had prolonged hospitalization to achieve therapeutic INR. CONCLUSION The majority of patients are discharged at subtherapeutic INR levels despite management by AMS. Patients may not be adequately anticoagulated with warfarin at time of discharge, raising significant patient safety concerns as well as medicolegal implications.
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Affiliation(s)
- Alexander J Rondon
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Karan Goswami
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Timothy L Tan
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Noam Shohat
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Javad Parvizi
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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Kahlenberg CA, Richardson SS, Schairer WW, Sculco PK. Type of Anticoagulant Used After Total Knee Arthroplasty Affects the Rate of Knee Manipulation for Postoperative Stiffness. J Bone Joint Surg Am 2018; 100:1366-1372. [PMID: 30106817 DOI: 10.2106/jbjs.17.01110] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The aim of this study was to perform a population-level analysis on the effect of different types of anticoagulation on postoperative stiffness after total knee replacement, requiring manipulation under anesthesia. We hypothesized that patients receiving warfarin would have a higher rate of manipulation under anesthesia compared with patients receiving low-molecular-weight heparin. We also hypothesized that aspirin, direct factor Xa inhibitors, and fondaparinux would have no effect on the rate of manipulation under anesthesia. METHODS Using the PearlDiver patient database, we analyzed 32,320 patients who underwent a primary unilateral total knee replacement from 2007 to 2015. Patients were included if they filled a prescription for anticoagulation medication within 2 days of their discharge and were excluded if they were taking a prescription anticoagulation medication (except for aspirin) in the 3 months before total knee replacement. The primary outcome was manipulation under anesthesia performed within 6 months after a primary total knee replacement. RESULTS The most commonly prescribed postoperative anticoagulation was warfarin (38.0%), followed by low-molecular-weight heparin (33.8%). There were 1,178 patients (3.64%) who underwent manipulation under anesthesia within 6 months of total knee replacement. In multivariable analysis using low-molecular-weight heparin as a comparison group and accounting for age, sex, comorbidities, and length of stay, there was a significant increase in the risk of manipulation under anesthesia for patients who received warfarin (hazard ratio [HR], 1.17 [95% confidence interval (CI), 1.01 to 1.36]; p = 0.032), direct factor Xa inhibitors (HR, 1.42 [95% CI, 1.20 to 1.66]; p < 0.001), or fondaparinux (HR, 1.33 [95% CI, 1.01 to 1.72]; p = 0.038). Although patients who received aspirin had the same risk estimate as patients who received warfarin, there was not a significantly increased risk of manipulation under anesthesia in patients who received aspirin compared with low-molecular-weight heparin (HR, 1.17 [95% CI, 0.72 to 1.80]; p = 0.493). CONCLUSIONS We found an increased rate of manipulation under anesthesia after total knee replacement in patients who received oral anticoagulants including warfarin, direct factor Xa inhibitors, and fondaparinux, in comparison with patients who received aspirin or low-molecular-weight heparin. We recommend that patients receiving oral anticoagulants after total knee replacement should be counseled about associated stiffness. Furthermore, surgeons should take these data into account when selecting thromboprophylaxis for patients after total knee replacement. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
| | - Shawn S Richardson
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - William W Schairer
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | - Peter K Sculco
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
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Low-Dose Aspirin Is Safe and Effective for Venous Thromboembolism Prophylaxis Following Total Knee Arthroplasty. J Arthroplasty 2018; 33:S131-S135. [PMID: 29656974 DOI: 10.1016/j.arth.2018.03.001] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Revised: 03/02/2018] [Accepted: 03/03/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Aspirin is an effective prophylaxis for venous thromboembolism (VTE) after total knee arthroplasty (TKA). The optimal prophylactic aspirin dose has not been established. The study aims to compare 2 aspirin regimens with regard to the incidence of (1) symptomatic deep venous thrombosis (DVT), (2) pulmonary embolism (PE), (3) bleeding, and (4) mortality within 90 days after TKA. METHODS We retrospectively identified 5666 patients who received aspirin twice daily for 4 to 6 weeks after TKA. A total of 1327 patients received 81-mg BID and 4339 patients received 325-mg BID aspirin. Postoperative complications collected were VTEs (DVT and PE), bleeding (gastrointestinal or wound bleeding), and mortality. RESULTS The incidence of VTE was 1.5% in the 325-mg group and 0.7% in the 81-mg group (P = .02). Symptomatic DVT was 1.4% in the 325-mg aspirin compared with 0.3% for the 81-mg aspirin (P = .0009). Regression model showed no correlation between aspirin dose and VTE incidence (odds ratio [OR] = 1.03; 95% confidence interval [95% CI], 0.45-2.36; P = .94) or DVT (OR = 0.50; 95% CI, 0.16-1.55; P = .20). The incidence of PE was 0.2% in the high-aspirin group compared with 0.4% in the low-aspirin group (P = .13). Bleeding was 0.2% in the 325-mg aspirin group and 0.2% in the 81-mg aspirin group (P = .62), and 90-day mortality was similar (0.1%) between the groups (P = .56). CONCLUSION Low-dose aspirin was not inferior to high-dose aspirin for the prevention of VTE after TKA. Low-dose aspirin can be considered a safe and effective agent in the prevention of VTE after TKA.
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