Venous Thromboembolism Prophylaxis After TKA: Aspirin, Warfarin, Enoxaparin, or Factor Xa Inhibitors?

Risks of major bleeding and venous thromboembolism in patients undergoing total hip or total knee arthroplasty using therapeutic dosages of DOACs

About 1.5% of patients undergoing total hip (THA) or total knee arthroplasty (TKA) still develop postoperative venous thromboembolism (VTE), indicating that the current thromboprophylaxis strategy is not optimal. To evaluate the feasibility of therapeutic dosages of direct oral anticoagulants (DOACs) as thromboprophylaxis for high VTE risk patients, we determined the risks of major bleeding and VTE in patients who underwent THA/TKA and were treated with DOACs in therapeutic dosages for atrial fibrillation (AF). We conducted a registry-based cohort study from 2010 to 2018 in Denmark and included AF patients on therapeutic DOACs dose who underwent THA/TKA. AF patients were utilized as proxy since they have a life-long indication for therapeutic anticoagulant medication. The 49-days cumulative incidence (with death as competing risk) of major bleeding was assessed. The same was done for VTE at 49- and 90-days. 1,354 THA and TKA procedures were included. The 49-days cumulative incidence of major bleeding was 1.40% (95%Confidence Interval[CI] 0.88-2.14%). Most bleeding events occurred at the surgical site. The cumulative incidence of VTE at 49-days was 0.59% (95%CI 0.28-1.13%) and 0.74% (95%CI 0.38-1.32%) at 90-days. The incidence of major bleeding in THA/TKA patients on DOACs in therapeutic dosages was in line with previously reported incidences among THA/TKA patients on thromboprophylaxis dosages, while the incidence of VTE was relatively low. These data provide a solid basis for the design of randomized controlled trials to establish the safety and efficacy of therapeutic dosages of DOACs to prevent VTE in high-risk patients.

Is outpatient joint arthroplasty safe in a high volume academic centre? A retrospective monocentric study using an institutional pathway

PURPOSE

Hip and knee arthroplasties are daily procedures in orthopaedic departments. Recently, same-day discharge (SDD) became increasingly popular, but doubts remain about its safety and generalization. Our hypothesis is that outpatient arthroplasty, in a high volume centre and with an institutional protocol, is an effective and reliable practice.

METHODS

We realized a monocentric retrospective study of patients undergoing outpatient partial (UKA) or total (TKA) knee or hip arthroplasty (THA) in a high volume academic centre using a well-defined institutional pathway. Epidemiological data and complications occurring in the month following surgery were studied.

RESULTS

498 patients undergoing 501 arthroplasties (219 hips and 282 knees) were examined. The percentage of men and women was 60.28% and 39.72% respectively, mean age was 64.56 ± 9.59 years, mean BMI was 26.87 ± 4.2 and the most represented ASA score was 2. The success rate for same-day discharge was 97.21%. The most frequent causes of failure were urinary retention (28.6%), orthostatic hypotension (28.6%) and insufficiently controlled pain (14.3%). The readmission rate in the month following the operation was 0.8% and the rate of emergency department visits was 1.6%. Finally, the rate of early consultation visits was 7.98%. The comparison between success and failure subgroups in the outpatient setting of our cohort did not highlight statistically significant differences for studied parameters.

CONCLUSION

Outpatient arthroplasty, performed in a center used to managing such operations and with a well-established institutional pre- and post-operative protocol, is a safe practice.

Trends in Venous Thromboembolism and Chemoprophylaxis Utilization in Elective Total Knee Arthroplasty From 2011 to 2020

BACKGROUND

Venous thromboembolism (VTE) is a feared complication of joint arthroplasty, leading to recent clinical practice guidelines aimed at VTE prevention and prophylaxis. However, limited studies have examined national changes in practice regarding chemoprophylaxis and the resultant changes in VTE rates. The purpose of this study was to identify: (1) the temporal trends in thrombotic complications; and (2) changes in chemoprophylaxis utilization in patients undergoing elective total knee arthroplasty (TKA).

METHODS

A retrospective study was conducted using a large all-payer claims dataset. Patients who underwent osteoarthritis-indicated TKA between 2011 and 2020 were identified. Annual rates of VTE, including deep vein thrombosis and pulmonary embolism, within 90 days of TKA were determined. Utilization patterns for postoperative aspirin and anticoagulant medications were observed. Temporal trends were analyzed with linear regression and the calculation of the cumulative annual growth rate. Multivariable logistic regression was conducted to account for the effects of age and comorbidities.

RESULTS

A total of 1,263,351 TKA patients were identified between 2011 and 2020. There were significant reductions in VTE rates (2.9% in 2011 to 1.8% in 2020), deep vein thrombosis rates (2.0% in 2011 to 1.3% in 2020), and pulmonary embolism rates (1.1% in 2011 to 0.6% in 2020). Postoperative utilization of aspirin increased from 5.9% in 2011 to 53.2% in 2020, whereas utilization of anticoagulants decreased from 94.1% in 2011 to 46.8% in 2020. Among anticoagulants, direct factor Xa inhibitors had the greatest increase in utilization (4.6 to 69.7%). The average reimbursement associated with VTE after TKA decreased from $18,061 in 2011 to $7,835 in 2020.

CONCLUSIONS

The incidence rate and economic burden of VTE after TKA have significantly declined since 2011. There has been a trend toward increased aspirin and direct oral anticoagulant utilization for postoperative chemoprophylaxis.

LEVEL OF EVIDENCE

Level III.

Prevalence of risk factors for venous thromboembolism and aspirin resistance in Australian patients undergoing total hip and knee arthroplasty

INTRODUCTION

Aspirin is used for venous thromboembolism (VTE) prophylaxis after total hip and knee arthroplasty (THA/TKA). However, its efficacy is unclear in patients with multiple VTE risk factors and at risk of aspirin resistance (AR).

BACKGROUND AND AIMS

To determine the prevalence of risk factors for VTE and AR in patients after THA/TKA and to determine the relationship between risk factors and drugs prescribed for thromboprophylaxis.

METHODS

A retrospective cohort study of elective-THA/TKA in six Australian hospitals over a 1-year period. Medical records were manually reviewed to determine demographics, thromboprophylaxis regimen and presence of risk factors. The relationship between individual and cumulative risk factors with the thromboprophylaxis regimen was determined.

RESULTS

In total, 1011 patients were included with a mean (SD) age of 65.9 (±11.0) years, and 56.4% were female. The five most prevalent risk factors were obesity (59.1%), age ≥65 years (58.2%), hypertension (45.3%), dyslipidaemia (35.9%) and diabetes (19.7%). Most patients had ≥1 risk factor for VTE (93.6%) and AR (93.6%), with 49.0% and 35.0% having ≥3 concurrent VTE and AR risk factors, respectively. The only significant relationship between risk factors and drugs was diabetes (P < 0.01). Rivaroxaban was more commonly used as the number of concurrent VTE risk factors increased (P < 0.05).

CONCLUSION

Patients had a high prevalence of VTE and AR risk factors, suggesting aspirin may not be beneficial in many patients. Only diabetes was linked to the selection of thromboprophylaxis. Patients who received rivaroxaban had a greater average number of VTE risk factors. Guidelines should promote individualised prescribing in higher-risk patients.

Trends in Deep Vein Thrombosis Prophylaxis After Total Knee Arthroplasty: 2016 to 2021

BACKGROUND

In 2011, the American Academy of Orthopaedic Surgeons released a consensus recommending venous thromboembolism (VTE) prophylaxis after total knee arthroplasty (TKA). The purpose of our study was to examine (1) incidences of postoperative complications, including pulmonary embolism (PE), deep vein thrombosis (DVT), and transfusion rates; (2) trends from 2016 to 2021 in VTE prophylaxis; and (3) independent risk factors for 90-day total complications following TKA between aspirin, enoxaparin, rivaroxaban, and warfarin.

METHODS

Using a national, all-payer database from 2016 to 2021, we identified all patients who underwent primary TKA. Exclusions included all patients who had prescribed anticoagulants within 1 year prior to TKA, hypercoagulable states, and cancer. Data were collected on baseline demographics, including age, sex, diabetes, and a comorbidity index, in each of the VTE prophylaxis cohorts. Postoperative outcomes included rates of PE, DVT, and transfusion. Multivariable regressions were performed to determine independent risk factors for total complications at 90 days following TKA.

RESULTS

From 2016 to 2021, aspirin was the most used anticoagulant (n = 62,054), followed by rivaroxaban (n = 26,426), enoxaparin (n = 20,980), and warfarin (n = 13,305). The cohort using warfarin had the highest incidences of PE (1.8%) and DVT (5.7%), while the cohort using aspirin had the lowest incidences of PE (0.6%) and DVT (1.6%). The rates of aspirin use increased the most from 2016 to 2021 (32.1% to 70.8%), while the rates of warfarin decreased the most (19.3% to 3.0%). Enoxaparin, rivaroxaban, and warfarin were independent risk factors for total complications at 90 days.

CONCLUSIONS

An epidemiological analysis of VTE prophylaxis use from 2016 to 2021 shows an increase in aspirin following TKA compared to other anticoagulant cohorts in a nationally representative population. This approach provides more insight and a better understanding of anticoagulation trends over this time period in a nationally representative sample.

Prevalence and risk factors for proximal deep vein thrombosis at admission in patients with traumatic fractures: a multicenter retrospective study

Objective

This study aimed to determine the associated risk factors for proximal deep vein thrombosis (DVT) in patients with lower extremity and pelvic-acetabular fractures.

Methods

The medical records of 4,056 patients with lower extremity and pelvic-acetabular fractures were retrospectively reviewed. The patients were classified into proximal or non-proximal DVT groups. Logistic regression models were used to determine the independent risk variables for proximal DVT. The predictive value of the related risk factors was further analyzed using receiver operating characteristic curves.

Results

The prevalence of proximal DVT was 3.16%. Sex, body mass index (BMI), fracture site, injury mechanism, diabetes, coronary heart disease (CHD), injury-to-admission interval, hematocrit, platelet counts, and D-dimer levels differed significantly between the two groups. BMI ≥ 24.0 kg/m2, femoral shaft fractures, high-energy injury, diabetes, injury-to-admission interval >24 h were independent risk factors for proximal DVT. CHD decreased the risk of proximal DVT. The platelet and D-dimer had high negative predictive value for predicting proximal DVT formation, with cut-off values of 174 × 109/L and 2.18 mg/L, respectively.

Conclusion

BMI ≥ 24.0 kg/m2, femoral shaft fractures, high-energy injury, diabetes, injury-to-admission interval >24 h were independent risk factors for proximal DVT in patients with lower extremity and pelvic-acetabular fractures. Platelet count and D-dimer level were effective indicators for excluding proximal DVT occurrence. CHD decreased the risk of proximal DVT.

Impact of preoperative anemia on patients undergoing total joint replacement of lower extremity: a systematic review and meta-analysis

PURPOSE

Preoperative anemia increases postoperative morbidity, mortality, and the risk of allogeneic transfusion. However, the incidence of preoperative anemia in patients undergoing total hip arthroplasty and total knee arthroplasty (TKA) and its relationship to postoperative outcomes has not been previously reported.

METHODS

We conducted a comprehensive literature search through PubMed, Cochrane Library, Web of Sincien, and Embase from inception to July 2023 to investigate the prevalence of preoperative anemia in patients undergoing Total Joint Arthroplasty, comorbidities between anemic and non-anemicpatients before surgery, and postoperative outcomes. postoperative outcomes were analyzed. Overall prevalence was calculated using a random-effects model, and heterogeneity between studies was examined by Cochran's Q test and quantified by the I2 statistic. Subgroup analyses and meta-regression analyses were performed to identify sources of heterogeneity. Publication bias was assessed by funnel plots and validated by Egger's test.

RESULTS

A total of 21 studies with 369,101 samples were included, all of which were retrospective cohort studies. 3 studies were of high quality and 18 studies were of moderate quality. The results showed that the prevalence of preoperative anemia was 22% in patients awaiting arthroplasty; subgroup analyses revealed that the prevalence of preoperative anemia was highest in patients awaiting revision of total knee arthroplasty; the highest prevalence of preoperative anemia was found in the Americas; preoperative anemia was more prevalent in the female than in the male population; and preoperative anemia with a history of preoperative anemia was more common in the female than in the male population. patients with a history of preoperative anemia; patients with joint replacement who had a history of preoperative anemia had an increased risk of infection, postoperative blood transfusion rate, postoperative blood transfusion, Deep vein thrombosis of the lower limbs, days in hospital, readmission within three months, and mortality compared with patients who did not have preoperative anemia.

CONCLUSION

The prevalence of preoperative anemia in patients awaiting total joint arthroplasty is 22%, and is higher in TKA and female patients undergoing revision, while preoperative anemia is detrimental to the patient's postoperative recovery and will increase the risk of postoperative complications, transfusion rates, days in the hospital, readmission rates, and mortality.

Aspirin or enoxaparin for VTE prophylaxis after primary partial, total or revision hip or knee arthroplasty: A secondary analysis from the CRISTAL cluster randomized trial

BACKGROUND

This study compares aspirin to enoxaparin for symptomatic VTE prophylaxis within 90 days of any type of hip or knee arthroplasty performed for any diagnosis, in patients enrolled in the CRISTAL trial.

MATERIALS AND METHODS

CRISTAL was a cluster-randomised crossover, registry-nested non-inferiority trial across 31 hospitals in Australia. The primary publication was restricted to patients undergoing primary total hip or knee arthroplasty for a diagnosis of osteoarthritis. This report includes all enrolled patients undergoing hip or knee arthroplasty procedures (partial or total, primary or revision) performed for any indication. Hospitals were randomized to administer patients aspirin (100mg daily) or enoxaparin (40mg daily), for 35 days after hip arthroplasty and 14 days after knee arthroplasty. Crossover occurred after the patient enrolment target had been met for the first group. The primary outcome was symptomatic VTE within 90 days. Analyses were performed by randomization group.

RESULTS

Between April 20, 2019 and December 18, 2020, 12384 patients were enrolled (7238 aspirin group and 5146 enoxaparin). Of these, 6901 (95.3%) given aspirin and 4827 (93.8%) given enoxaparin (total 11728, 94.7%) were included in the final analyses. Within 90 days, symptomatic VTE occurred in 226 (3.27%) aspirin patients and 85 (1.76%) enoxaparin patients, significant for the superiority of enoxaparin (estimated treatment difference 1.85%, 95% CI 0.59% to 3.10%, p = 0.004). Joint-related reoperation within 90 days was lower in the enoxaparin group (109/4827 (2.26%) vs 171/6896 (2.47%) with aspirin, estimated difference 0.77%; 95% CI 0.06% to 1.47%, p = 0.03). There were no significant differences in the other secondary outcomes.

CONCLUSION

In patients undergoing hip or knee arthroplasty (of any type, performed for any indication) enrolled in the CRISTAL trial, aspirin compared to enoxaparin resulted in a significantly higher rate of symptomatic VTE and joint-related reoperation within 90 days. These findings extend the applicability of the CRISTAL trial results.

TRIAL REGISTRATION

Anzctr.org.au, identifier: ACTRN12618001879257.

The Financial Burden of Aspirin versus Oral Factor Xa Inhibitors for Thromboprophylaxis Following Total Knee Arthroplasty

BACKGROUND

Aspirin and oral factor Xa inhibitor thromboprophylaxis regimens are associated with similarly low rates of venous thromboembolism following total knee arthroplasty (TKA). However, the rate of prosthetic joint infection (PJI) is lower with aspirin use. This study aimed to compare the cost differential between aspirin and factor Xa inhibitor thromboprophylaxis with respect to PJI management.

METHODS

We used previously published rates of PJI following aspirin and factor Xa inhibitor thromboprophylaxis in primary TKA patients at a single, large institution. Prices for individual drugs were obtained from our hospital's pharmacy service. The cost of PJI included that of 2-stage septic revision, with or without the cost of 1-year follow-up. National data were obtained to determine annual projected TKA volume.

RESULTS

The per-patient costs associated with a 28-day course of aspirin versus factor Xa inhibitor thromboprophylaxis were $17.36 and $3,784.20, respectively. Including cost of follow-up, per-patient costs for a 28-day course of aspirin versus factor Xa inhibitors increased to $73,358.76 and $77,125.60, respectively. The weighted average per-patient costs for a 28-day course were $237.38 and $4,370.93, respectively. The annual cost difference could amount to over $14.1 billion in the United States by 2040.

CONCLUSIONS

The per-patient cost associated with factor Xa inhibitor thromboprophylaxis is as much as 1,980.6% higher than that of an aspirin regimen due to increased costs of primary treatment, differential PJI rates, and high costs of management. In an era of value-based care, the use of aspirin is associated with major cost advantages.

Establishment and validation of a nomogram predicting the risk of deep vein thrombosis before total knee arthroplasty

PURPOSE

This study aimed to analyze the independent risk factors contributing to preoperative DVT in TKA and constructed a predictive nomogram to accurately evaluate its occurrence based on these factors.

METHODS

The study encompassed 496 patients who underwent total knee arthroplasty at our hospital between June 2022 and June 2023. The dataset was randomly divided into a training set (n = 348) and a validation set (n = 148) in a 7:3 ratio. The least absolute shrinkage and selection operator (LASSO) and multivariate logistic regression analysis were used to screen the predictors of preoperative DVT occurrence in TKA and construct a nomogram. The performance of the predictive models was evaluated using the concordance index (C-index), calibration curves, and the receiver operating characteristic (ROC) curves. Decision curve analysis was used to analyze the clinical applicability of nomogram.

RESULTS

A total of 496 patients who underwent TKA were included in this study, of which 28 patients were examined for lower extremity DVT preoperatively. Platelet crit, Platelet distribution width, Procalcitonin, prothrombin time, and D-dimer were predictors of preoperative occurrence of lower extremity DVT in the nomograms of the TKA patients. In addition, the areas under the curve of the ROC of the training and validation sets were 0.935 (95%CI: 0.880-0.990) and 0.854 (95%CI: 0.697-1.000), and the C-indices of the two sets were 0.919 (95%CI: 0.860-0.978) and 0.900 (95%CI: 0.791-1.009). The nomogram demonstrated precise risk prediction of preoperative DVT occurrence in TKA as confirmed by the calibration curve and decision curve analysis.

CONCLUSIONS

This Nomogram demonstrates great differentiation, calibration and clinical validity. By assessing individual risk, clinicians can promptly detect the onset of DVT, facilitating additional life monitoring and necessary medical interventions to prevent the progression of DVT effectively.

Comparison of efficacy and safety between aspirin and oral anticoagulants for venous thromboembolism prophylaxis after major orthopaedic surgery: a meta-analysis of randomized clinical trials

Background: venous thromboembolism (VTE) is one of the most common complications after major orthopaedic surgery. Recent studies have suggested that aspirin may also be effective in preventing VTE, but it is still controversial whether it can be routinely used. Objectives: To compare the efficacy and safety of aspirin against oral anticoagulants in the prevention of VTE following total hip arthroplasty (THA), total knee arthroplasty (TKA) or hip fracture surgery (HFS). Methods: Relevant publications have been obtained using electronic search databases such as PubMed, Embase, Web of Science, Cochrane Library, and Clinical Trials. gov. from inception to 20 July 2023. Only RCTs evaluating the efficacy and safety of aspirin compared with oral anticoagulants undergoing major orthopaedic surgery were included in the meta-analysis. The primary outcome reported was any VTE event (including deep vein thrombosis (DVT) and pulmonary embolism (PE)). Secondary outcomes included mortality, major bleeding (including gastrointestinal bleed, cerebrovascular hemorrhage, or any bleeding requiring a return to the theater), minor bleeding (ecchymosis, epistaxis, hematuria), and wound complications. The risk of bias for all included studies was assessed according to the Cochrane Collaboration's tool. Results: After screening 974 studies, 12 randomized clinical trials (RCTs) were included, involving 5,088 participants, including 2,540 participants in aspirin, 2,205 participants in rivaroxaban, and 323 participants in warfarin. Aspirin was found to be less effective than oral anticoagulants in thromboprophylaxis after major orthopedic surgery (RR = 1.206, 95% CI 1.053-1.383). After subgroup analysis according to the type of oral anticoagulant, the results showed that aspirin was similar to rivaroxaban and inferior to warfarin. Considering that the studies in the warfarin group were all conducted before 2000, our results need to be further confirmed. In addition, the aspirin group had a higher risk of VTE than the control group in other subgroups, including a follow-up time of ≤3 months, type of procedure as TKA, high-dose aspirin (≥650 mg qd), and no combined use of mechanical prophylaxis. In terms of safety events, aspirin did not show significant differences in major bleeding (RR = 0.952, 95% CI 0.499-1.815), all-cause mortality (RR = 1.208, 95% CI 0.459-3.177), and wound-related events (RR = 0.618, 95% CI 0.333-1.145) compared with oral anticoagulants, and aspirin was associated with a reduction in the risk of minor bleeding (RR = 0.685, 95% CI 0.552-0.850) events and total bleeding (RR = 0.726, 95% CI 0.590-0.892). Conclusion: Aspirin reduces bleeding risk after major orthopedic surgery compared with oral anticoagulants, but may sacrifice VTE prevention to some extent. Updated evidence is needed to analyze the thromboprophylaxis effects of aspirin in patients undergoing major orthopedic surgery. Systematic Review Registration: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=463481, identifier CRD42023463481.

Current Evidence and Expert Opinion on Thromboprophylaxis After Total Knee and Hip Replacement

An effective anticoagulant provides a balance between the risk for venous thromboembolism (VTE) and bleeding and is crucial in achieving optimal clinical outcomes in patients undergoing total hip replacement (THR) and total knee replacement (TKR) surgeries. We performed a review of the literature on thromboprophylaxis for patients undergoing total hip or knee replacement. This review article summarizes current guidelines and evidence for anticoagulation along with the expert opinion about pharmacological VTE prophylaxis, particularly non-Vitamin K antagonist oral anticoagulants (NOACs), for patients after total hip or knee replacement. Aspirin for VTE prophylaxis after TKR/THR has been controversial and most of the evidence is reported from observational research. Although the guidelines do not recommend any specific thromboprophylaxis agent, available evidence suggests that NOACs are as effective as low molecular weight heparins (LMWHs) in preventing VTE. Oral administration and the lack of dose monitoring make NOACs easy to use in outpatient settings in cases with challenging treatment compliances. They can be used for two weeks after TKR and five weeks after THR - six weeks after TKR and THR to cover the at-risk period for VTE post-discharge. Owing to the lack of evidence for a head-to-head comparison of NOACs, an anticoagulant with better efficacy and safety may be suggested in special patient populations (elderly, obese patients, or those with renal dysfunction). The expert opinion on pharmacological VTE prophylaxis provided in this article could address some gaps in the management of anticoagulation in patients with total hip or knee replacement.

Venous Thromboembolism in Total Hip and Total Knee Arthroplasty

Importance

The optimal pharmacologic thromboprophylaxis agent after total hip and total knee arthroplasty is uncertain and consensus is lacking. Quantifying the risk of postoperative venous thromboembolism (VTE) and bleeding and evaluating comparative effectiveness and safety of the thromboprophylaxis strategies can inform care.

Objective

To quantify risk factors for postoperative VTE and bleeding and compare patient outcomes among pharmacological thromboprophylaxis agents used after total hip and knee arthroplasty.

Design, Setting, and Participants

This retrospective cohort study used data from a large health care claims database. Participants included patients in the United States with hip or knee arthroplasty and continuous insurance enrollment 3 months prior to and following their surgical procedure. Patients were excluded if they received anticoagulation before surgery, received no postsurgical pharmacological thromboprophylaxis, or had multiple postsurgery thromboprophylactic agents. In a propensity-matched analysis, patients receiving a direct oral anticoagulant (DOAC) were matched with those receiving aspirin.

Exposures

Aspirin, apixaban, rivaroxaban, enoxaparin, or warfarin.

Main Outcomes and Measures

The primary outcome was 30-day cumulative incidence of postdischarge VTE. Other outcomes included postdischarge bleeding.

Results

Among 29 264 patients included in the final cohort, 17 040 (58.2%) were female, 27 897 (95.2%) had inpatient admissions with median (IQR) length of stay of 2 (1-2) days, 10 948 (37.4%) underwent total hip arthroplasty, 18 316 (62.6%) underwent total knee arthroplasty; and median (IQR) age was 59 (55-63) years. At 30 days, cumulative incidence of VTE was 1.19% (95% CI, 1.06%-1.32%) and cumulative incidence of bleeding was 3.43% (95% CI, 3.22%-3.64%). In the multivariate analysis, leading risk factors associated with increased VTE risk included prior VTE history (odds ratio [OR], 5.94 [95% CI, 4.29-8.24]), a hereditary hypercoagulable state (OR, 2.64 [95% CI, 1.32-5.28]), knee arthroplasty (OR, 1.65 [95% CI, 1.29-2.10]), and male sex (OR, 1.34 [95% CI, 1.08-1.67]). In a propensity-matched cohort of 7844 DOAC-aspirin pairs, there was no significant difference in the risk of VTE in the first 30 days after the surgical procedure (OR, 1.14 [95% CI, 0.82-1.59]), but postoperative bleeding was more frequent in patients receiving DOACs (OR, 1.36 [95% CI, 1.13-1.62]).

Conclusions and Relevance

In this cohort study of patients who underwent total hip or total knee arthroplasty, underlying patient risk factors, but not choice of aspirin or DOAC, were associated with postsurgical VTE. Postoperative bleeding rates were lower in patients prescribed aspirin. These results suggest that thromboprophylaxis strategies should be patient-centric and tailored to individual risk of thrombosis and bleeding.

Development and validation of a nomogram for predicting the risk of immediate postoperative deep vein thrombosis after open wedge high tibial osteotomy

PURPOSE

This study aimed to identify independent risk factors for immediate postoperative deep vein thrombosis (DVT) in patients with open wedge high tibial osteotomy (OWHTO) and to develop and validate a predictive nomogram.

METHODS

Patients who underwent OWHTO for knee osteoarthritis (KOA) from June 2017 to December 2021 were retrospectively analyzed. Baseline data and laboratory test results were collected, and the occurrence of DVT in the immediate postoperative period was regarded as the study outcome event. Multivariable logistic regression identified independent risk factors associated with a higher incidence of immediate postoperative DVT. The predictive nomogram was constructed based on the analysis results. The stability of the model was further assessed in this study using patients from January to September 2022 as an external validation set.

RESULTS

741 patients were enrolled in the study, of which 547 were used in the training cohort and the other 194 for the validation cohort. Multivariate analysis revealed a higher Kellgren-Lawrence (K-L) grade (III vs. I-II OR 3.09, 95% CI 0.93-10.23. IV vs. I-II OR 5.23, 95% CI 1.27-21.48.), platelet to hemoglobin ratio (PHR) > 2.25 (OR 6.10, 95% CI 2.43-15.33), Low levels of albumin (ALB) (OR 0.79, 95% CI 0.70-0.90), LDL-C > 3.40 (OR 3.06, 95% CI 1.22-7.65), D-dimer > 1.26 (OR 2.83, 95% CI 1.16-6.87) and BMI ≥ 28 (OR 2.57, 95% CI 1.02-6.50) were the independent risk factors of immediate postoperative DVT. The concordance index (C-index) and Brier score of the nomogram were 0.832 and 0.036 in the training set, and the corrected values after internal validation were 0.795 and 0.038, respectively. The receiver-operating characteristic (ROC) curve, the calibration curve, the Hosmer-Lemeshow test, and the decision curve analysis (DCA) performed well in both the training and validation cohorts.

CONCLUSION

This study developed a personalized predictive nomogram with six predictors, which allows surgeons to stratify risk and recommended immediate ultrasound scans for patients with any of these factors.

LEVEL OF EVIDENCE

III.

The efficacy and safety of aspirin in preventing venous thrombosis in major orthopedic surgery: An updated meta-analysis of randomized controlled trials

BACKGROUND

Major orthopedic surgery, including hip and knee replacement and lower extremity trauma fractures surgery, is associated with a high risk of venous thromboembolism (VTE), especially proximal deep vein thrombosis (DVT), and pulmonary embolism (PE), and is linked with high morbidity and mortality rates. Chemical anticoagulation is routinely used to prevent VTE, with previous meta-analyses reporting on the efficacy and safety of aspirin and other anticoagulants, however, opinions are divided. In the past 2 years, several large randomized controlled trials have been published, therefore, we reanalyzed aspirin efficacy and safety when compared with other anticoagulants in preventing VTE in major orthopedic surgery.

METHODS

Using PubMed, The Cochrane Library, Embase, and Web of Science databases, we conducted a RCT search in August 2023. The main outcomes included VTE, proximal DVT or PE. Additional outcomes included bleeding events, wound complications, wound infections, blood transfusions, and death events.

RESULTS

In total, 17 eligible articles, involving 29,522 patients (15,253 aspirin vs 14,269 other anticoagulant cases), were included. Primary outcomes showed that VTE incidence was more high in the aspirin group when compared with other anticoagulants (risk ratio [RR] = 1.45, 95% confidence interval [CI] = 1.18-1.77, P = .0004) and proximal in the aspirin group the DVT and/or PE incidence was significantly higher in the aspirin group when compared with other anticoagulants (RR = 1.19, 95% CI = 1.02-1.39, P = .03). No significant secondary outcome differences were identified in the aspirin group when compared with other anticoagulants (bleeding events [RR] = 0.83, 95% CI = 0.63-1.10, P = .20); wound complications (RR = 0.45, 95% CI = 0.20-1.04, P = .06); wound infection (RR = 1.08, 95% CI = 0.85-1.38, P = .53); blood transfusion events (RR = 1.00, 95% CI = 0.84-1.19, P = 1.00) and death events (RR = 1.11, 95% CI = 0.78-1.57, P = .55).

CONCLUSIONS

Our updated meta-analysis showed that aspirin was inferior to when compared with other anticoagulants in VTE-related orthopedic major surgery, including proximal DVT and/or PE, and was more likely to form VTE. No differences between groups were identified for bleeding, wound complications, wound infections, transfusion, or death events.

Aspirin is a safe and effective thromboembolic prophylaxis after total knee arthroplasty: a systematic review and meta-analysis

PURPOSE

Patients undergoing total knee arthroplasty (TKA) are at high risk for thromboembolic events compared to non-surgical patients. Both anticoagulants and antiplatelet agents are used as antithrombotic prophylaxis in TKA. The aim of this review is to understand the role of aspirin in the prevention of thromboembolic events and to compare its efficacy and safety with the main anticoagulants used in antithromboembolic prophylaxis in TKA.

METHODS

A systematic review and meta-analysis was performed according to the PRISMA guidelines. An electronic systematic search was conducted using PubMed, Scopus, and the Cochrane Central Registry to evaluate studies that compared aspirin with other anticoagulants, in terms of deep venous thrombosis and pulmonary embolism after TKA. The meta-analysis compared the rate of complications between aspirin and other anticoagulants.

RESULTS

Thirteen studies were included in the systematic review for a total of 163,983 patients, and 10 studies were included in the meta-analysis. The meta-analysis demonstrated no statistically significant differences between aspirin and other anticoagulants in terms of the rate of deep venous thrombosis (OR 0.93, 95% CI 0.81-1.08, p = 0.35) and pulmonary embolism (OR 0.89, 95% CI 0.56-1.41, p = 0.61).

CONCLUSION

Aspirin is safe, effective, and not inferior to other main anticoagulants in preventing thromboembolic events following TKA.

Comparative effectiveness of aspirin for symptomatic venous thromboembolism prophylaxis in patients undergoing total joint arthroplasty, a cohort study

BACKGROUND

This study compares the symptomatic 90-day venous thromboembolism (VTE) rates in patients receiving aspirin to patients receiving low-molecular weight heparin (LMWH) or direct oral anticoagulants (DOACs), after total hip (THA) and total knee arthroplasty (TKA).

METHODS

Data were collected from a multi-centre cohort study, including demographics, confounders and prophylaxis type (aspirin alone, LMWH alone, aspirin and LMWH, and DOACs). The primary outcome was symptomatic 90-day VTE. Secondary outcomes were major bleeding, joint related reoperation and mortality within 90 days. Data were analysed using logistic regression, the Student's t and Fisher's exact tests (unadjusted) and multivariable regression (adjusted).

RESULTS

There were 1867 eligible patients; 365 (20%) received aspirin alone, 762 (41%) LMWH alone, 482 (26%) LMWH and aspirin and 170 (9%) DOAC. The 90-day VTE rate was 2.7%; lowest in the aspirin group (1.6%), compared to 3.6% for LMWH, 2.3% for LMWH and aspirin and 2.4% for DOACs. After adjusted analysis, predictors of VTE were prophylaxis duration < 14 days (OR = 6.7, 95% CI 3.5-13.1, p < 0.001) and history of previous VTE (OR = 2.4, 95% CI 1.1-5.8, p = 0.05). There were no significant differences in the primary or secondary outcomes between prophylaxis groups.

CONCLUSIONS

Aspirin may be suitable for VTE prophylaxis following THA and TKA. The comparatively low unadjusted 90-day VTE rate in the aspirin group may have been due to selective use in lower-risk patients.

TRIAL REGISTRATION

This study was registered at ClinicalTrials.gov, trial number NCT01899443 (15/07/2013).

Deep vein thrombosis and validation of the Caprini risk assessment model in Chinese orthopaedic trauma patients: a multi-center retrospective cohort study enrolling 34,893 patients

BACKGROUND

The risk of venous thromboembolism among orthopaedic trauma patients is high, but prevalence of deep vein thrombosis (DVT) remains unknown. In addition, the Caprini risk assessment model (RAM) score in orthopaedic trauma patients is undetermined in previous research. This study is aimed to determine the incidence of DVT and then validate the Caprini RAM in orthopaedic trauma patients.

METHODS

This is a retrospective cohort study enrolling orthopaedic trauma inpatients from seven tertiary and secondary hospitals during a 3-year period (from April 1, 2018 through April 30, 2021). Caprini RAM scores were assessed by experienced nurses on admission. The patients with suspected DVT were verified through duplex ultrasonography by qualified radiologists, and then prospectively followed once a year after discharge.

RESULTS

In total, 34,893 patients were enrolled in our study. The Caprini RAM identified 45.7% of patients at low risk (Caprini score 0-2), 25.9% at medium risk (3-4), and 28.3% at high risk (5-6), highest risk (7-8), and superhigh risk (> 8). Patients with Caprini score > 5 were likely to be older, female, and with longer length of hospital stay. Moreover, 8695 patients had received ultrasonography to detect DVT. The prevalence of DVT was determined to be 19.0% [95% confidence interval (CI) 18.2-19.9%], which significantly increased with Caprini score. The area under curve of the Caprini RAM for DVT was 0.77 (95% CI 0.76-0.78) with a threshold of 4.5. Furthermore, 6108 patients who had received ultrasonography completed the follow-up. DVT patients had a hazard ratio of 1.75 (95% CI 1.11-2.76; P = 0.005) in the mortality, compared to non-DVT ones. Caprini scores were significantly associated with increase in the mortality [odds ratio (OR) 1.14; 95% CI 1.07-1.21; P < 0.001]; DVT remained an independent effect (OR 1.5; 95% CI 1.02-2.26; P = 0.042).

CONCLUSIONS

The Caprini RAM may be valid in Chinese orthopaedic trauma patients. Prevalence of DVT and higher Caprini score were significantly associated with increased all-cause mortality among orthopaedic trauma patients after discharge. Further study is warranted to explore the causes of higher mortality in patients with DVT.

Thirty day low-dose versus regular-dose aspirin for venous thromboembolism prophylaxis in primary total joint arthroplasty

BACKGROUND

The optimal dosing of aspirin (ASA) monotherapy for prophylaxis after total joint arthroplasty is debatable. The objective of this study was to compare two ASA regimens with regards to symptomatic deep venous thrombosis (DVT), pulmonary embolism (PE), bleeding, and infection 90 days after primary total hip arthroplasty (THA) and total knee arthroplasty (TKA).

METHODS

We retrospectively identified 625 primary THA and TKA surgeries in 483 patients who received ASA for 4 weeks post-op. 301 patients received 325 mg once daily (QD) and 324 patients received 81 mg twice daily (BID). Patients were excluded if they were minors, had a prior venous thromboembolism (VTE), had ASA allergy, or received other VTE prophylaxis drugs.

RESULTS

There was a significant difference in rate of bleeding and suture reactions between the two groups. Bleeding was 7.6% for 325 mg QD and 2.5% for 81 mg BID (p = .0029 Χ2, p = .004 on multivariate logistic regression analysis). Suture reactions were 3.3% for 325 mg QD and 1.2% for 81 mg BID (p = .010 Χ2, p = .027 on multivariate logistic regression analysis). Rates of VTE, symptomatic DVT, and PE were not significantly different. The incidence of VTE was 2.7% for 325 mg QD and 1.5% for 81 mg BID (p = .4056). Symptomatic DVT rates were 1.6% for 325 mg QD and 0.9% for 81 mg BID (p = .4139). Deep infection was 1.0% for 325 mg QD and 0.31% for 81 mg BID (p = .3564).

CONCLUSION

Low-dose ASA in patients with limited comorbidities undergoing primary THA and TKA is associated with significant lower rates of bleeding and suture reactions than high dose ASA. Low-dose ASA was not inferior to higher dose ASA for the prevention of VTE, wound complications, and infection 90 days postoperatively.

Comparison of 90-Day Adverse Events Associated With Aspirin and Potent Anticoagulation Use for Venous Thromboembolism Prophylaxis: A Cohort Study of 72,288 Total Knee and 35,142 Total Hip Arthroplasty Patients

BACKGROUND

While aspirin is acceptable for venous thromboembolism (VTE) prophylaxis following total joint arthroplasty in most patients, more potent agents are used in patients considered higher risk for VTE. We evaluated the efficacy and safety of aspirin versus potent anticoagulation agents following total knee arthroplasty (TKA) and total hip arthroplasty (THA).

METHODS

A cohort study of 72,288 TKA and 35,142 THA from the Kaiser Permanente Total Joint Replacement Registry was performed (2009 to 2019). Identified medications were aspirin, factor Xa inhibitors, low-molecular-weight heparin (LMWH), and warfarin. A validated VTE risk score was assigned to each patient. Propensity score-weighted logistic regressions were used to evaluate 90-day VTEs. Noninferiority testing was performed with a margin of 1.25 using the upper bound (UB) of the 1-sided 95% CI.

RESULTS

For TKA, aspirin was not inferior to LMWH (odds ratio [OR] = 0.77, UB = 1.09) and warfarin (OR = 0.64, UB = 0.90); there was no evidence to support noninferiority of aspirin compared to factor Xa inhibitors. Findings were consistent for THA (LMWH: OR = 0.59, UB = 0.75; warfarin: OR = 0.69, UB = 0.89). TKA was considered higher risk for VTE, whereas aspirin use demonstrated noninferiority compared to warfarin (OR = 0.54, UB = 0.81), we lacked evidence of noninferiority when compared to LMWH and factor Xa inhibitors. We lacked evidence of noninferiority of aspirin versus any potent anticoagulation in higher-risk THA.

CONCLUSION

Aspirin was found to be effective and safe for VTE prevention in primary total joint arthroplasty, including in patients considered higher risk for VTE.

LEVEL OF EVIDENCE

III.

Using machine learning to predict venous thromboembolism and major bleeding events following total joint arthroplasty

Venous thromboembolism (VTE) and major bleeding (MBE) are feared complications that are influenced by numerous host and surgical related factors. Using machine learning on contemporary data, our aim was to develop and validate a practical, easy-to-use algorithm to predict risk for VTE and MBE following total joint arthroplasty (TJA). This was a single institutional study of 35,963 primary and revision total hip (THA) and knee arthroplasty (TKA) patients operated between 2009 and 2020. Fifty-six variables related to demographics, comorbidities, operative factors as well as chemoprophylaxis were included in the analysis. The cohort was divided to training (70%) and test (30%) sets. Four machine learning models were developed for each of the outcomes assessed (VTE and MBE). Models were created for all VTE grouped together as well as for pulmonary emboli (PE) and deep vein thrombosis (DVT) individually to examine the need for distinct algorithms. For each outcome, the model that best performed using repeated cross validation was chosen for algorithm development, and predicted versus observed incidences were evaluated. Of the 35,963 patients included, 308 (0.86%) developed VTE (170 PE's, 176 DVT's) and 293 (0.81%) developed MBE. Separate models were created for PE and DVT as they were found to outperform the prediction of VTE. Gradient boosting trees had the highest performance for both PE (AUC-ROC 0.774 [SD 0.055]) and DVT (AUC-ROC 0.759 [SD 0.039]). For MBE, least absolute shrinkage and selection operator (Lasso) analysis had the highest AUC (AUC-ROC 0.803 [SD 0.035]). An algorithm that provides the probability for PE, DVT and MBE for each specific patient was created. All 3 algorithms had good discriminatory capability and cross-validation showed similar probabilities comparing predicted and observed failures indicating high accuracy of the model. We successfully developed and validated an easy-to-use algorithm that accurately predicts VTE and MBE following TJA. This tool can be used in every-day clinical decision making and patient counseling.

Anemia and formation of deep vein thrombosis before operation in patients with knee osteoarthritis: a cross-sectional study

BACKGROUND

Preoperative anemia is a common complication in knee osteoarthritis (KOA) patients. However, the association between anemia and preoperative deep vein thrombosis (DVT) in osteoarthritis patients remains unknown. The aim of this study was to investigate such association.

METHODS

In this retrospective study, we included 1005 KOA patients undergoing total knee arthroplasty (TKA) in our hospital. According to preoperative hemoglobin levels, the patients were divided into anemia group and non-anemia group. According to the results of Doppler ultrasonography for the lower extremities, the patients were divided into DVT group and non-DVT group. A logistic model was established through propensity score matching (PSM), with anemia before TKA as the dependent variable, DVT-related variable as the covariate, and 0.03 as the Caliper value. The anemia group and non-anemia group were matched at a 1:1 ratio and 310 successfully matched. After matching, logistic regression analysis was used to evaluate the correlation between preoperative anemia and DVT in KOA patients.

RESULTS

In this study, 342 cases (33.6%) had preoperative anemia and 73 cases (7.2%) had DVT before TKA. After matching, 46 DVT cases (7.42%) were found. By using binary logistic regression after PSM, we found that the risk for preoperative DVT formation in TKA patients with preoperative anemia increased by 1.97 times [95% (CI 1.05-3.69)], P = 0.035.

CONCLUSION

Preoperative anemia is considered as an independent risk factor for the formation of preoperative DVT in KOA patients.

TRIAL REGISTRATION

ChiCRT2100054844.

Effectiveness of different antithrombotic agents in combination with tranexamic acid for venous thromboembolism prophylaxis and blood management after total knee replacement: a prospective randomized study

BACKGROUND

Tranexamic acid (TXA) has been widely applied in total knee arthroplasty (TKA) to significantly reduce perioperative blood loss and improve knee function recovery in patients after surgery. The choice of antithrombotic agents for venous thromboembolism (VTE) prevention after TKA is controversial. Therefore, this study aimed to compare the effects of different antithrombotic agents on patients after primary unilateral TKA in the context of applied TXA.

METHODS

A total of 180 patients undergoing primary unilateral TKA from October 2020 to December 2021 were included in this study. All patients were given an intraoperative drip of 60 mg/kg TXA. Thereafter, patients were divided into three groups (n = 60 each). Baseline data were comparable among the three groups. The average follow-up time was 3.02 ± 0.09 months. Group 1 enrolled patients receiving oral rivaroxaban (RA) at 10 mg, Group 2 included patients who received subcutaneous Dalteparin sodium at 2500 IU, while Group 3 included patients taking oral aspirin (ASA) at 100 mg. Patients in all the three groups received treatment once a day for 30 days at 12 h postoperatively. The primary outcomes in this study were post-treatment drainage volume and thrombotic complication rate. The secondary outcomes included hematologic parameters, transfusion rate, intraoperative blood loss, total blood loss (TBL), and bleeding complication rate.

RESULTS

The average drainage volume after treatment was significantly lower in Group 3 than in Group 1 and Group 2 (205.2 ± 69.0 vs 243.4 ± 72.5 vs 295.4 ± 72.5 ml, P < 0.001), and there was a significant difference between Group 1 and Group 2 (243.4 ± 72.5 mL vs 295.4 ± 72.5 mL, P < 0.001). The blood transfusion rate of Group 2 dramatically increased compared with Group 1 and Group 3 (20.0% vs 6.7% vs 5.0%, P = 0.01). The bleeding complication rate in Group 1 apparently increased relative to Group 2 and Group 3 (26.7% vs 10.0% vs 8.3%, P = 0.008). Besides, there was no significant difference in the thrombotic complication rate among the three groups.

CONCLUSION

Under the background of TXA application, ASA, RA, and Dalteparin sodium were all effective on preventing VTE after TKA. In addition, ASA effectively reduced post-treatment Hemoglobin (Hb) loss, drainage volume, TBL, transfusion rate, and bleeding complications compared with RA and Dalteparin sodium.

TRIAL REGISTRATION

The trial was registered at the Chinese Clinical Trial Registry (ChiCTR2200060169). Date of Registration: 21/05/2022.

Association Between Platelet Indices and Preoperative Deep Vein Thrombosis in Elderly Patients Undergoing Total Joint Arthroplasty: A Retrospective Study

To investigate the association between platelet (PLT) indices and preoperative deep vein thrombosis (DVT) in elderly patients undergoing total joint arthroplasty (TJA). A total of 1391 patients were enrolled. We created receiver operator characteristic (ROC) curve using the ratio of PLT indices to DVT before TJA, divided the enrolled patients into groups based on the cut-off value, and then analyzed risk factors for DVT before TJA in the multivariate binary logistic regression analysis. Preoperative DVT occurred in 103 cases. Based on the ROC curve, we determined that the cut-off values for PLT, mean platelet volume (MPV), platelet distribution width (PDW), platelet large cell ratio (P-LCR), and plateletcrit (PCT) were 202 × 109/L, 11.4 fL, 13.2 fL, 34.6%, and 0.228%. And the areas under the curve were 0.606, 0.605, 0.617, 0.616, and 0.598. Multivariate binary regression analysis revealed that the risk of preoperative DVT in TJA patients with PLT≥202 × 109/L, MPV≤11.4 fL, PDW≤13.2 fL, P-LCR≤34.6%, and PCT≥0.228% increased by 2.32 (P < .001, 95% confidence interval [CI] [1.50-3.60]), 1.86 (P < .001, 95% CI [1.22-2.83]), 2.17 (P < .001, 95% CI [1.43-3.31]), 2.27 (P < .001, 95% CI [1.50-3.45]), and 1.76 times (P = .013, 95% CI [1.13-2.76]), respectively. Age, P < .001, odds ratio (OR) = 1.08, 95% CI [1.04-1.11]; corticosteroid use, P = .011, OR = 3.66, 95% CI [1.34-9.96]. We found that increased PLT count and PCT, decreased MPV, PDW, and P-LCR, old age, and corticosteroid use were independent risk factors for preoperative DVT in elderly TJA patients.

Association Between Red Blood Cell Indices and Preoperative Deep Vein Thrombosis in Patients Undergoing Total Joint Arthroplasty: A Retrospective Study

PURPOSE

To investigate the association of red blood cell (RBC), hemoglobin (Hb), red cell distribution width-coefficient of variation (RDW-CV), and red cell distribution width-standard deviation (RDW-SD) with preoperative deep vein thrombosis (DVT) in patients undergoing total joint arthroplasty (TJA).

METHODS

A total of 2059 TJA patients were enrolled. We used the ratios of RBC, Hb, RDW-CV, and RDW-SD to DVT before TJA to create the receiver operator characteristic (ROC) curve, thereby calculating the cut-off values and the area under the curve (AUC). The patients were categorized into groups based on cut-off value, and risk factors for DVT before TJA were subsequently analyzed. We included the variates that were statistically significant in the univariate analysis in the multivariate binary logistic regression analysis.

RESULTS

Preoperative DVT occurred in 107 cases (5.20%). Based on the ROC curve, we found that the AUC for RBC, Hb, RDW-CV, and RDW-SD were 0.658, 0.646, 0.568, and 0.586, respectively. Multivariate binary regression analysis revealed that the risk of preoperative DVT in TJA patients with RBC≤3.92*10⁹ /L, Hb≤118g/L, RDW-CV≥13.2%, and RDW-SD≥44.6fL increased 3.02 (P < 0.001, 95% confidence interval (CI) [2.0-4.54]), 2.15 (P < 0.001, 95% CI [1.42-3.24]), 1.54 (P = 0.038, 95% CI [1.03-2.3]), and 1.98 times (P = 0.001, 95% CI [1.32-2.98]), respectively. The risk of preoperative DVT in patients with corticosteroid use increased approximately 2.6 times (P = 0.002, 95% CI [1.22-5.81]).

CONCLUSION

We found that decreased RBC and Hb, increased RDW-CV and RDW-SD, and corticosteroid use were independent risk factors for preoperative DVT in patients undergoing TJA.

Correlation of the severity of anemia in patients undergoing total joint arthroplasty with preoperative deep vein thrombosis: a retrospective cohort study

BACKGROUND

To explore the correlation of the severity of preoperative anemia with deep vein thrombosis (DVT) in patients undergoing total joint arthroplasty (TJA).

METHODS

A total of 2461 TJA patients were classified into anemia and non-anemia groups or DVT and non-DVT groups. A logistic regression model was established using propensity score matching (PSM) analysis with preoperative anemia of TJA patients as a dependent variable and DVT-related variables as covariates. The caliper value was set as 0.01, and the anemia and non-anemia groups were matched based on the ratio of 1:1 (835 pairs). Finally, data of all patients were analyzed by binary logistic regression.

RESULTS

Preoperative anemia was observed in 872 cases (35.43%) and DVT in 170 cases (6.91%). Binary logistic regression after PSM revealed that the DVT risk of patients with preoperative, moderate and severe anemia increased by 1.82 [P = 0.00, 95% confidence interval (95% CI) (1.32-2.48)], 2.77 [P = 0.00, 95% CI (1.72-4.45)], and 8.26 [P = 0.00, 95% CI (3.22-21.16)] times, respectively. The risks of blood transfusion in the perioperative period in patients with anemia, mild anemia, moderate anemia, and severe anemia increased by 3.52 times [P = 0.00, 95% CI (2.78-4.47)], 2.13 [P = 0.00, 95% CI (1.63-2.79)], 7.22 [P = 0.00, 95% CI (5.30-9.83)], and 61.37 [P = 0.00, 95% CI (14.21-265.04)] times, respectively.

CONCLUSION

Preoperative anemia is an independent risk factor for preoperative DVT and blood transfusion in the perioperative period for TJA patients. The more severe the preoperative anemia, the greater the risk of preoperative DVT and perioperative blood transfusion in TJA patients. Therefore, patients with preoperative anemia, especially with moderate and severe anemia, should be screened for DVT formation before undergoing TJA. Trial registration ChiCRT2100054844.

Association between glycosylated hemoglobin, diabetes mellitus, and preoperative deep vein thrombosis in patients undergoing total joint arthroplasty: a retrospective study

Background

To investigate the association between the level of glycosylated hemoglobin (HbA1c) and preoperative deep vein thrombosis (DVT) and that between diabetes mellitus (DM) and preoperative DVT in patient undergoing total joint arthroplasty (TJA).

Methods

A total of 1386 patients were enrolled. We created the receiver operating characteristic (ROC) curve of HbA1c, and based on the cutoff value, patients were divided into two groups. Risk factors were subsequently examined. Chi-square test or Fisher’s exact test was adopted for enumeration data. The results were expressed in percentages (%), and DVT-related variates were analyzed. We included the variates that were statistically significant in the univariate analysis in the multivariate binary logistic regression analysis and calculated the adjusted odds ratio (OR) and 95% confidence interval (95% CI).

Results

Preoperative DVT was 100 cases (7.22%) and DM in 301 cases (21.7%). We determined the cutoff value of HbA1c of 6.15% using the ROC curve as the area under the curve (AUC) was 0.548. Univariate logistic regression revealed that the risk of preoperative DVT in TJA patients with HbA1c ≥ 6.15%, HbA1c between 7 and 7.9%, HbA1c ≥ 8%, DM, female, and major surgery in the last 12 months increased by 1.84 (P = 0.005; 95% CI [1.20–2.80]), 2.22 (P = 0.028, 95% CI [1.09–4.52]), 2.47 (P = 0.013, 95% CI [1.21–5.04]), 2.03 (P = 0.004, 95% CI [1.25–3.30]); 1.85 (P = 0.010, 95% CI [1.16–2.95]); and 2.86 times (P = 0.006, 95% CI [1.35–6.05]), respectively. And multivariate logistic regression revealed that the risk of preoperative DVT in TJA patients with HbA1c ≥ 6.15%, HbA1c between 7 and 7.9%, HbA1c ≥ 8%, DM patients, female patients, and major surgery in the last 12 months increased by 1.77 (P = 0.009, 95% CI [1.16–2.72]); 2.10 (P = 0.043, 95% CI [1.02–4.30]); 2.50 (P = 0.013, 95% CI [1.22–5.14]); 2.01 (P = 0.005, 95% CI [1.23–3.28]); 1.80 (P = 0.014, 95% CI [1.13–2.89]); and 3.04 times (P = 0.004, 95% CI [1.42–6.49]), respectively.

Conclusion

We conclude that HbA1c ≥ 6.15%, DM, female and major surgery in the last 12 months are the independent risk factors for preoperative DVT in patients undergoing TJA. And patients with a higher HbA1c level are at an increased risk of preoperative DVT.

Trial registration: ChiCRT2100054844.

COVID-19 Infection Risk Following Elective Arthroplasty and Surgical Complications in COVID-19 Vaccinated Patients: A Multicenter Comparative Cohort Study

Background

We aimed to determine symptomatic Coronavirus disease 2019 (COVID-19) rates within 1 month of elective arthroplasty for vaccinated individuals and to determine whether vaccination guarantees protection against COVID-19 after arthroplasty (primary outcome). In addition, the 90-day surgical complications were compared to those of an unvaccinated group (secondary outcome).

Methods

A prospective cohort study was conducted on elective joint arthroplasty patients at 3 tertiary hospitals in 2 major cities (Tehran and Isfahan) in our country (Iran). The outcomes of the COVID-19-vaccinated group were assessed between October 2021 and March 2022. Ninety-day surgical complications were compared with a historical cohort of unvaccinated patients treated earlier in the pandemic (April 2020-March 2021).

Results

The study included 1717 consecutive patients: 962 vaccinated and 755 unvaccinated. In the vaccinated group, 38 patients (3.9%) contracted COVID-19, 4 (10.5%) were hospitalized again, and none required intensive care unit admission. The multivariate logistic regression analysis revealed that COVID-19-positive cases are more likely to be female (odds ratio [OR] = 12.5), to have visitors to their home (OR = 4.7), and to stay longer in the hospital (OR = 1.2) than COVID-19-negative cases. Compared to unvaccinated patients, the postoperative COVID-19 rate was not significantly different (3.9% vs 2.4%, P = .07). The incidence of surgical complications was similar between the 2 groups (P > .05).

Conclusions

The vaccination does not provide a guarantee that a patient will not contract COVID-19 following their arthroplasty surgery, especially in a region with a high rate of COVID-19. We believe reasonable perioperative COVID-19 precautions may be warranted even in vaccinated patients.

The application of Caprini Risk Assessment Model in evaluation of deep vein thrombosis for patients with end-stage osteoarthritis before arthroplasty

Background

Deep vein thrombosis (DVT) was a fatal complication of knee arthroplasty. We had neglected the risk factors of preoperative DVT although patients undergoing knee arthroplasty were at high risk for VTE. This study was to determine the risk factors for preoperative DVT and application of Caprini Risk Assessment Model (RAM) in patients with end-stage knee osteoarthritis (OA).

Methods

We retrospectively analyzed 1808 cases with end-stage knee OA undergoing primary knee arthroplasty from May 2015 to December 2020. Based on the results of ultrasonography in lower extremities, all patients were divided into non-DVT group and DVT group. Distribution of risk factors and risk levels were compared using χ² test between two groups. Binary logistic regression analysis was used to determine the risk factors and relationship of risk levels and preoperative DVT.

Results

The incidence of preoperative DVT was 5.53% (n = 100). Distribution of the study population by risk level was low, 4.09%; moderate, 23.95%; high, 66.98%; and highest 4.98%. Female (P = 0.002), age (P = 0.012), swollen legs (P = 0.035) and history of blood clots (P < 0.001) was correlated with preoperative DVT. Difference among four risk levels was significant (P = 0.007). Patients with highest risk level had statistically significant association with preoperative DVT (P = 0.005, OR = 2.93, 95%CI [1.375–6.246]).

Conclusion

The incidence of preoperative DVT was 5.53% in end-stage knee OA patients. The gender (female) and age were independent risk factors for preoperative DVT. The risk group classification by Caprini RAM was significantly associated with preoperative DVT. The usage of Caprini RAM before knee arthroplasty may be beneficial for prophylaxis of DVT.

Discontinued Use of Outpatient Portable Intermittent Pneumatic Compression Devices May Be Safe for Venous Thromboembolism Prophylaxis in Primary Total Knee Arthroplasty Using Low-Dose Aspirin

Venous thromboembolism (VTE) is a rare, but serious complication following total knee arthroplasty (TKA). Current VTE guidelines recommend pharmacologic agents with or without intermittent pneumatic compression devices (IPCDs). At our institution, both 81-mg aspirin (ASA) twice a day (BID) and portable IPCDs were previously prescribed to TKA patients at standard risk for VTE, but the IPCDs were discontinued and patients were treated with ASA alone going forward. The aim of this study is to determine if discontinued use of outpatient IPCDs is safe and does not increase the rate of VTE or any other related complications in patients following TKA. A retrospective review of 2,219 consecutive TKA cases was conducted, identifying patients with VTE, bleeding complications, infection, and mortality within 90 days postoperatively. Patients were divided into two cohorts. Patients in cohort one received outpatient IPCDs for a period of 14 days (control), while those in cohort two did not (ASA alone). All study patients received inpatient IPCDs and were maintained on 81-mg ASA BID for 28 days. A posthoc power analysis was performed using a noninferiority margin of 0.25 (α = 0.05; power = 80%), which showed that our sample size was fully powered for noninferiority for our reported deep vein thrombosis (DVT) rates, but not for pulmonary embolism (PE) rates. A total of 867 controls and 1,352 patients treated with ASA alone were identified. Only two control patients were diagnosed with a PE (0.23%), while one patient in the ASA alone group had DVT (0.07%). There was no statistical difference between these rates (p = 0.33). Furthermore, no differences were found in bleeding complications (p = 0.12), infection (p = 0.97), or 90-day mortality rates (p = 0.42) between both groups. The discontinued use of outpatient portable IPCDs is noninferior to outpatient IPCD use for DVT prophylaxis. Our findings suggest that this protocol change may be safe and does not increase the rate of VTE in standard risk patients undergoing TKA while using 81-mg ASA BID.

Avoiding Femoral Canal Instrumentation in Computer-Assisted Total Knee Arthroplasty With Contemporary Blood Management Had Minimal Differences in Blood Loss and Transfusion Rates Compared to Conventional Techniques

BACKGROUND

Computer-assisted surgery that does not utilize femoral canal instrumentation is theorized to have less blood loss. However, there is a paucity of data on this, particularly in the era of tranexamic acid use. We sought to analyze the association of computer navigation with total calculated blood loss and transfusion rate in patients undergoing primary total knee arthroplasty (TKA).

METHODS

We identified 14,890 patients who underwent unilateral primary TKA at a single institution from 2016 to 2020. Computer-assisted surgery in the form of an accelerometer or robotics was utilized in 4,165 TKAs (28%). Drains were utilized in 4,860 TKAs (32%). We used multivariate logistic regression analysis to determine if computer navigation reduced the rate of blood transfusion and linear regression analysis to determine the impact of computer navigation on blood loss.

RESULTS

In total, 542 patients (3.6%) underwent a transfusion. The average change in hemoglobin (Hgb) was 2.1 g/dL (standard deviation [SD] 0.91) and average total calculated blood loss was 310 mL (SD = 154). In a multivariate regression model, computer navigation was not protective of transfusion (odds ratio [OR] 1.04, P = .73). Preoperative Hgb <10 (OR 10.5, P < .0001) and drain use (OR 2.25, P < .0001) were the most significant risk factors for transfusion. In a linear regression model, computer navigation reduced blood loss by 19 mL (SD 2.94, P < .0001) per case.

CONCLUSION

In this large retrospective cohort analysis of contemporary TKA patients, computer-assisted surgery that eliminates intramedullary femoral canal instrumentation during primary TKA was not associated with reduced transfusion rates and had minimal differences in overall blood loss.

Does Aspirin Provide Adequate Chemoprophylaxis for Venous Thromboembolic Events in Operative Pelvic and Acetabular Fractures?

BACKGROUND

Several strategies exist to prevent venous thromboembolism (VTE) in operative pelvic and acetabular fractures, however literature lacks consensus on the optimal thromboprophylaxis. Even more debated, and perhaps controversial, is whether aspirin provides adequate thromboprophylaxis in the setting of these injuries. The primary objective was to evaluate the efficacy of aspirin in the prevention of venous thromboembolism (VTE) events, including deep vein thrombosis (DVT) and pulmonary embolism (PE) in operative pelvic and acetabular fractures compared to other anticoagulants.

METHODS

A retrospective chart review of pelvic and acetabular fractures that underwent operative fixation was completed. The incidence of VTE and hematoma formation was evaluated and compared between patients who received aspirin versus enoxaparin or heparin. Multivariate analysis was performed to control for confounding demographic, comorbidity, and injury-related variables. The outcome measurements included development of DVT and/or PE and hematoma formation.

RESULTS

Of patients with operative pelvic and acetabular fractures, 4.2% developed a DVT and 3.5% developed a PE, with 1.4% developing both. Of these patients 37.5% were treated with aspirin versus the 62.5% treated with heparin or enoxaparin. There was no significant difference in the incidence of DVT or PE between cohorts (p=0.498 and p=0.262). Aspirin trended toward significance as protective against post-operative hematoma (p=0.085).

CONCLUSION

This study suggests that aspirin is an acceptable method of VTE thromboprophylaxis with no inferior results to other common anticoagulants used in operative pelvis and acetabular fractures. As a chemoprophylactic agent, aspirin is an efficacious option in these complex injuries that shows no increase in the incidence in symptomatic VTE events. Level of Evidence: III.

Does the publication of NICE guidelines for venous thromboembolism chemical prophylaxis influence the prescribing patterns of UK hip and knee surgeons?

INTRODUCTION

We assessed the practice of surgeons regarding venous thromboembolism (VTE) chemical prophylaxis for total hip replacement (THR) and total knee replacement (TKR), before and after issuing of updated National Institute for Health and Care Excellence (NICE) guidance in 2018.

METHODS

A survey, circulated through the British Hip Society and regional trainee networks/collaboratives, was completed by 306 UK surgeons at 187 units. VTE chemical prophylaxis prescribing patterns for surgeons carrying out primary THR (n=258) and TKR (n=253) in low-risk patients was assessed after publication of 2018 NICE recommendations. Prescribing patterns before and after the NICE publication were subsequently explored.

RESULTS

Following the new guidance, 34% (n=87) used low-molecular-weight heparin (LMWH) alone, 33% (n=85) aspirin (commonly preceded by LMWH) and 31% (n=81) direct oral anticoagulants (DOACs: with/without preceding LMWH) for THR. For TKR, 42% (n=105) used aspirin (usually monotherapy), 31% (n=78) LMWH alone and 27% (n=68) DOAC (with/without preceding LMWH). NICE guidance changed the practice of 34% of hip surgeons and 41% of knee surgeons, with significantly increased use of aspirin preceded by LMWH for THR (before=25% vs after=73%; p<0.001), and aspirin for TKR (before=18% vs after=84%; p<0.001). Significantly more regimens were NICE guidance compliant after the 2018 update for THR (before=85.7% vs after=92.6%; p=0.011) and TKR (before=87.0% vs after=98.8%; p<0.001).

CONCLUSION

Over one-third of surveyed surgeons changed their VTE chemical prophylaxis in response to 2018 NICE recommendations, with more THR and TKR surgeons now compliant with latest NICE guidance. The major change in practice was an increased use of aspirin for VTE chemical prophylaxis.

Enoxaparin Versus Direct Oral Anticoagulants for Venous Thromboembolism in Asians Undergoing Total Knee Arthroplasty: A Meta-Analysis and Systematic Review

BACKGROUND

The introduction of direct oral anticoagulants (DOACs) shows promise for their role as a chemoprophylaxis agent after total knee arthroplasty (TKA) for the prevention of venous thromboembolism (VTE). However, existing studies are largely based on Western populations that do not account for the different risk profiles and lower rates of VTE in Asians. This systematic review and meta-analysis aimed to evaluate the efficacy of DOACs compared with enoxaparin in an Asian-based population study.

METHODS

The review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. All studies that compared outcomes between enoxaparin and DOACs as VTE prophylaxis after TKA in the Asian population were included.

RESULTS

Five studies with 121,153 patients were included. DOACs demonstrated a convincing benefit over enoxaparin in overall VTE prevention (odds ratio [OR] = 0.42, 95% confidence interval [CI]: 0.24-0.74). However, although the OR trended in favor of DOACs for the reduction of deep vein thrombosis events (OR = 0.54, 95% CI: 0.20-1.48) and pulmonary embolism (OR = 0.75, 95% CI: 0.07-8.20), statistical significance was not reached. In terms of bleeding complications, both arms had similar rates of major (0.91% vs 0.20%), clinically relevant nonmajor (3.28% vs 2.94%), and minor bleeding complications (12.8 vs 13.3%). A nonsignificance advantage of enoxaparin over DOACs was revealed in the OR for major bleeding (OR = 3.17; 95% CI: 0.81-12.43), whereas DOACs were favored to reduce risk of clinically relevant nonmajor (OR = 0.82; 95% CI: 0.01-91.51) and minor bleeding (OR = 0.76; 95% CI: 0.11-5.33).

CONCLUSION

DOACs confer a significantly reduced rate of overall VTE compared with enoxaparin in Asians after TKA. No significant differences in deep vein thrombosis, pulmonary embolism, and rates of bleeding complications exist.

Aspirin Thromboprophylaxis Is Associated With Less Major Bleeding Events Following Total Joint Arthroplasty

BACKGROUND

There is ongoing debate on what is optimal prophylactic agent to reduce venous thromboembolism (VTE) following total joint arthroplasty (TJA). Although many studies assess the efficacy of these agents in VTE prevention, no attention is given to their adverse effect on major bleeding events (MBEs). This study compared the incidence of MBE in patients receiving aspirin as VTE prophylaxis vs other chemoprophylaxis.

METHODS

A single-institution, retrospective study of 35,860 patients undergoing TJA between 2009 and 2020 was conducted. Demographic variables, co-morbidities, type of chemoprophylaxis, and intraoperative factors were collected. MBE was defined using the 2010 criteria for major bleeding in surgical patients presented by the Scientific and Standardization Committee of the International Society on Thrombosis and Haemostasis. To enhance capture rate, comprehensive queries utilizing MBE keywords were conducted in clinical notes, physician dictations, and phone call logs. Univariate followed by multivariate regression was performed as well as propensity score matched analysis.

RESULTS

Overall, 270 patients (0.75%) in this cohort developed MBE. The MBE rate was 0.5% in the aspirin group and 1.2% in the non-aspirin group. After adjusting for confounders, multiple logistic regression and propensity score matched analysis revealed almost 2 times lower odds of MBE in patients who received aspirin. Variables independently associated with increased MBE risk included increasing age, body mass index, American Society of Anesthesiologists score, revision surgery, peptic ulcer disease, coagulopathy, intraoperative blood transfusion, and active smoking.

CONCLUSION

Administration of aspirin for VTE prophylaxis, compared to other chemoprophylaxis agents may have an association with lower risk of major bleeding following TJA. Future randomized controlled trials should examine these findings.

Efficacy and Safety of Enoxaparin versus New Oral Anticoagulants to Prevent Venous Thromboembolism after Total Hip Replacement: A Systematic Review and Meta-Analysis

Prophylactic anticoagulant therapy is recommended for reducing the risk of venous thromboembolism (VTE) after a total hip replacement (THR). However, it is not clear which anticoagulant is preferable. Hence, a systematic review and meta-analysis of randomized double-blind controlled trials (RDBCTs) were conducted to investigate the clinical efficacy and safety of enoxaparin in comparison with newer oral anticoagulants for the prevention of VTE after THR. The Cochrane Library, Scopus, Web of Science, Embase, and PubMed/Medline databases were used for PICO search strategy. Relative risks (RR) of symptomatic VTE, clinically relevant bleeding, mortality, and a net clinical endpoint were estimated employing a random effect meta-analysis. ITC and RevMan software were used for indirect and direct comparisons, respectively. Nine RDBCTs comprising 24,584 patients were included. As compared to enoxaparin, a reduced risk for symptomatic VTE was observed with rivaroxaban (confidence interval [CI]: 0.32–0.77; RR: 0.46%) and comparable with apixaban (0.12–1.26; 0.42%) and dabigatran (0.22–2.20; 0.70%). Contrarily to enoxaparin, a greater risk for clinically relevant bleeding was observed with rivaroxaban (1.03–1.48; 1.23%), comparable with dabigatran (0.96–1.33; 1.10%) and reduced with apixaban (0.19–5.66; 0.96%). In indirect or direct comparisons, the interventions did not differ on the net clinical endpoint. In conclusion, the findings of this meta-analysis revealed no significant difference in the efficacy and safety of new oral anticoagulants as compared to enoxaparin for the prevention of VTE after total hip replacement surgery.

Comparison of the Effects of Epidural Anesthesia and General Anesthesia on Perioperative Cognitive Function and Deep Vein Thrombosis in Patients Undergoing Total Knee Arthroplasty

Objective

To explore the effects of epidural anesthesia and general anesthesia on perioperative cognitive function and deep vein thrombosis (DVT) in patients undergoing total knee arthroplasty (TKA).

Methods

Total of 68 patients undergoing TKA in our hospital from September 2019 to March 2021 were selected and divided into the control group under general anesthesia and the observation group under epidural anesthesia according to the different anesthesia methods, 34 patients in each group. TKA was selected in both groups and performed by the same group of physicians, anesthesiologists, and nursing staff. The mean arterial pressure (MAP), heart rate (HR), and blood oxygen saturation (SpO₂) were observed immediately before anesthesia (T1), 30 min after anesthesia (T2), after surgery (T3), and 1 d after surgery (T4). The changes of platelet (PLC), fibrinogen (Fbg), prothrombin time (PT), activated partial thrombin time (APTT), and other coagulation indicators were recorded. The Montreal Cognitive Assessment (MoCA) scores before surgery and 1 d and 3 d after surgery were observed. The blood samples of the two groups were collected before surgery and 1 d and 3 d after surgery, and the levels of brain-derived neurotrophic factor (BDNF) and nerve growth factor (NGF) in the peripheral blood of the two groups were measured by ELISA. The number of postoperative mental disorders and DVT in the two groups was calculated.

Results

The MAP and HR of T4 were lower than those of T1, T2, and T3. The MAP of T2, T3, and T4 in the observation group was lower than that in the control group (P < 0.05), and the SpO₂ of T1–T4 in the two groups did not change significantly, and there was no significant difference between the two groups (P > 0.05). Compared with T1, there was no significant difference in PLC, Fbg, and PT in the observation group T4 (P > 0.05), and APTT was lower than T1 (P < 0.05). The PLC, PT, and APTT of T4 in the control group were all lower than those of T1 (P < 0.05), and there was no significant difference between Fbg and T1 (P > 0.05). The PLC, Fbg, and PT of T4 in the observation group were higher than those in the control group, while APTT was lower than that in the control group (P < 0.05). The MoCA scores of patients in both groups on the 1st and 3rd day after operation were lower than those before operation, and the observation group was higher than that in the control group (P < 0.05). The BDNF and NGF of patients in both groups were lower than those before operation on the 1st day after operation, and the BDNF and NGF in the observation group were higher than those in the control group on the 1st and 3rd day after operation (P < 0.05). The mental disorder (2.94%) and DVT incidence (2.94%) in the observation group were lower than those in the control group (29.41%, 26.47%) (P < 0.05).

Conclusion

Epidural anesthesia for patients with TKA can obtain better clinical effects, maintain stable hemodynamic and coagulation states, reduce stress response of patients at the same time, and reduce perioperative cognitive dysfunction and the incidence of DVT in patients.

Aspirina versus rivaroxabana na prevenção do tromboembolismo venoso após artroplastia total do joelho: Um ensaio clínico randomizado, controlado e duplo-cego

Objetivo A aspirina (ácido acetilsalicílico, AAS) e a rivaroxabana são anticoagulantes que vêm ganhando popularidade devido à facilidade de uso na prevenção do tromboembolismo venoso (TEV) após artroplastia total do joelho (ATJ). Este estudo teve como objetivo avaliar a eficácia do AAS em comparação com a da rivaroxabana na profilaxia de TEV em pacientes submetidos a ATJ.

Método Quarenta pacientes com osteoartrite primária do joelho, que seriam submetidos a ATJ, foram randomizados em dois grupos. No total, 20 pacientes do grupo AAS usaram aspirina oral, na dose de 300 mg/dia, para a profilaxia do TEV após ATJ; e 20 pacientes do grupo rivaroxabana receberam uma dose oral de 10 mg/dia. No 4° e 14° dias do pós-operatório, trombose venosa profunda (TVP) dos membros inferiores no lado da cirurgia foi detectada por meio de ultrassonografia duplex. Foram registradas outras complicações durante catorze dias.

Resultados Não foram detectados achados positivos de TVP com a ultrassonografia duplex nos grupos de pacientes, e não se observou a ocorrência de embolia pulmonar. No total, 4 pacientes apresentaram equimose subcutânea no 4° dia do pós-operatório (2 pacientes no grupo AAS e 2 pacientes no grupo rivaroxabana; p = 1,0), e outros 4 pacientes, no 14° dia do pós-operatório (1 paciente no grupo AAS e 3 pacientes no grupo rivaroxabana; p = 0,292). Nenhum paciente da amostra apresentou hematoma da ferida cirúrgica, sangramento de órgão importante, infecção da ferida, ou necessidade de nova cirurgia.

Conclusão A aspirina e a rivaroxabana apresentaram eficácia comparável na prevenção do TEV, sem aumentar a incidência de complicações da ferida e sangramento após ATJ.

Safety of apixaban in Indian patients undergoing elective total knee replacement or total hip replacement surgery: A multi-center, phase-IV study

Background:

Venous thromboembolism is a significant source of morbidity and mortality following total hip replacement and total knee replacement. Apixaban has been proven to be efficacious without increased risk of bleeding in phase-III trials in patients undergoing total knee replacement and total hip replacement. Due to paucity of data on safety of apixaban in Indian patients, this phase-IV study was conducted to evaluate safety of apixaban in patients undergoing total knee replacement and total hip replacement.

Methods:

In this non-comparative phase-IV clinical trial, patients undergoing elective total knee replacement or total hip replacement surgery, or a revision of at least one component of total knee replacement or total hip replacement, were enrolled. The eligible patients were given the approved dosage of apixaban 12 to 24 h after completing the skin wound closure. The primary safety outcome was the composite of the International Society on Thrombosis and Haemostasis–defined major bleeding and clinically relevant non-major bleeding events at the end of the treatment. The secondary efficacy endpoint was the composite of venous thromboembolism/all-cause death at the end of the treatment.

Results:

A total of 498 patients received apixaban prophylaxis therapy. Six (1.2%) bleeding adverse events were observed during the treatment period. Only one bleeding event was adjudicated as an International Society on Thrombosis and Haemostasis–defined clinically relevant non-major bleeding event (moderate severity). There were no fatal bleeding events and no deaths following the treatment. One venous thromboembolism event, that is, symptomatic distal left leg DVT, was reported in a total knee replacement patient and was adjudicated during the treatment period.

Conclusion:

Apixaban demonstrated a favorable safety profile for venous thromboembolism prevention in Indian patients undergoing total knee replacement or total hip replacement.

Prevention of venous thromboembolism with aspirin following knee surgery: A systematic review and meta-analysis

Venous thromboembolism (VTE) is a well-known complication following orthopaedic surgery. The incidence of this complication has decreased substantially since the introduction of routine thromboprophylaxis. However, concerns have been raised about increased bleeding complications caused by aggressive thromboprophylaxis.Attention has grown for aspirin as a safer thromboprophylactic agent following orthopaedic surgery.A systematic review using MEDLINE, Embase and Web of Science databases was undertaken to compare the effectiveness of aspirin prophylaxis following knee surgery with the current standard prophylactic agents (low molecular weight heparin [LMWH], vitamin K antagonists and factor Xa inhibitors).No significant difference in effectiveness of VTE prevention was found between aspirin, LMWH and warfarin. Factor Xa inhibitors were more effective, but increased bleeding complications were reported.As evidence is limited and of low quality with substantial heterogeneity, further research with high-quality, adequately powered trials is needed. Cite this article: EFORT Open Rev 2021;6:892-904. DOI: 10.1302/2058-5241.6.200120.

No Increased Risk of Venous Thromboembolism in High-Risk Patients Continuing Their Dose of 75 mg Aspirin Compared to Healthier Patients Given Low-Molecular-Weight Heparin

BACKGROUND

Optimum venous thromboembolism (VTE) prophylaxis for patients undergoing total hip or knee arthroplasty remains undefined. The purpose of this study is to compare complication rates among total joint arthroplasty patients using either low-dose aspirin (75 mg once daily) or low-molecular-weight heparin (LMWH; Fragmin/dalteparin 5000 U) for VTE prophylaxis.

METHODS

This is a prospective observational study. All total hip or knee arthroplasties from 2014 to 2020 were included. One thousand eighty-four patients already taking aspirin 75 mg as primary or secondary prophylaxis for cardiovascular disease continued their daily aspirin dose throughout their hospital stay and after discharge without any other kind of thromboprophylaxis. Five thousand ten patients not already taking aspirin were given LMWH for 12-14 days starting the day of surgery. Both groups consisted of patients undergoing either primary or revision total hip or knee arthroplasty. The aspirin group was older (73 ± 7.8 vs 66 ± 10.2 years, P < .01, 95% CI -7.6, -6.3) with more comorbidities but otherwise did not differ from the LMWH group. Outcome measures were recorded at 3-month follow-up and included the following complications: clinically deep venous thrombosis (DVT), pulmonary embolism (PE), deep infection, blood transfusion, and death.

RESULTS

The aspirin group had 0.28% DVT and 0.28% PE, and the LMWH group had 0.24% DVT and 0.16% PE (P = .42 and .74, respectively). No difference in deep infection, allogenic blood transfusion, or mortality was found.

CONCLUSION

No statistically significant difference in complication rates was found between aspirin 75 mg and LMWH used for VTE prophylaxis. Aspirin 75 mg daily is safe for VTE prophylaxis after total hip or knee arthroplasty.

Aspirin Compared With Other Anticoagulants for Use as Venous Thromboembolism Prophylaxis in Elective Orthopaedic Hip and Knee Operations: A Narrative Literature Review

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.

Outcomes following Revision Total Knee Arthroplasty Septic versus Aseptic Failure: A National Propensity-Score-Matched Comparison

Although periprosthetic joint infection (PJI) has been hypothesized to increase the risk of complications following revision total knee arthroplasty (TKA), strong evidence linking the two is lacking. The aim of this study was to determine whether PJI is an independent risk factor for inpatient perioperative complications, and increased resource use in patients undergoing revision TKA. We relied on the US Nationwide Inpatient Sample (NIS) to identify patients with PJI or non-PJI treated with revision TKA between 2002 and 2014. Overall, 5,316 (16.4%) and 27,033 (83.6%) patients were categorized as PJI and non-PJI, respectively. To adjust for potential baseline differences between the two groups, propensity-score-based matching was performed. This resulted in 5,187 (50%) PJI patients matched to 5,187 (50%) non-PJI patients. The rates of postoperative complications, blood transfusions, prolonged length of stay (pLOS), in-hospital cost, and in-hospital mortality were assessed for both groups. Multivariable logistic regression analyses were performed within the cohort after propensity-score matching. For PJI versus non-PJI, respectively, the following rates were recorded: blood transfusions, 28.3 versus 18.4% (p < 0.0001); postoperative complications, 27.5 versus 19.8% (p < 0.0001); pLOS (>4 d), 61.9 versus 26.9% (p < 0.0001); in-hospital cost (>$39,929), 55.8 versus 44.2% (p < 0.0001); in-hospital mortality, 0.6 versus 0.3% (p = 0.016). In multivariable logistic regression analyses, PJI patients were more likely to receive a blood transfusion (odds ratio [OR]: 1.78; p < 0.0001), to experience postoperative complications (OR: 1.56; p < 0.0001), to have a higher in-hospital cost (OR: 1.65; p < 0.0001), to have a pLOS following surgery following surgery (OR: 4.69; p < 0.0001), and to have a higher in-hospital mortality (OR: 2.14; p = 0.019). After adjustment for potential selection biases, PJI is associated with more adverse perioperative outcomes and resource use than non-PJI patients. This is a Level II (level of evidence), prognostic study.

Incidence of Symptomatic Venous Thromboembolism in Proximal Hamstring Repair: A Prospective Cohort Study

Background:

Surgical repair of proximal hamstring avulsion injuries can enable the return to preinjury levels of sporting function and minimize the risk of recurrence in both professional and recreational athletes. While venous thromboembolism (VTE) is a recognized complication of surgical repair, the incidence thereof is poorly reported in the literature.

Purpose/Hypothesis:

To report the incidence of symptomatic VTE after proximal hamstring avulsion repair and assess the efficacy of our thromboprophylaxis protocol. It was hypothesized that the incidence of VTE after proximal hamstring avulsion repair is low and that aspirin is an adequate choice of chemical prophylaxis.

Study Design:

Cohort study; Level of evidence, 2.

Methods:

We performed a prospective cohort study of 2 groups of patients who underwent proximal hamstring avulsion (partial and complete) repair between 2000 to 2020 with different thromboprophylaxis protocols. No patients were routinely screened for VTEs, and VTE was investigated only if clinically indicated. Prospectively collected data included demographics, the mechanism and sport that caused injury, use of bracing, and clinical diagnosis of deep vein thrombosis (DVT) or pulmonary embolism (PE). The first cohort (n = 380) was given mechanical prophylaxis in the form of compression stockings for 6 weeks postoperatively. The second cohort (n = 600) was given compression stockings and aspirin 150 mg once daily routinely, or prophylactic low–molecular weight heparin in high-risk individuals, until the 6-week follow-up. Patients in both cohorts underwent early mobilization after surgery; a hinged knee brace locked at 60° to 120° was provided if the tendon repair was under significant tension. The surgical technique and rehabilitation protocol remained consistent throughout the study.

Results:

The overall incidence of symptomatic VTE was 0.51%. A total of 5 patients developed symptomatic VTEs (3 DVTs, 2 PEs) in the first cohort, and no patients developed symptomatic VTEs in the second cohort (1.32% vs 0%; P = .0048).

Conclusion:

The incidence of symptomatic VTE after proximal hamstring avulsion repairs was extremely low. A combination of aspirin, early mobilization despite bracing, compression stockings, and good hydration was an effective thromboprophylaxis strategy.