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Sanchez JG, Jiang WM, Dhodapkar MM, Radford ZJ, Rubin LE, Grauer JN. Total Hip Arthroplasty in Patients Who Have Factor V Leiden: Elevated Risks Isolated to Venous Thromboembolism Events. J Arthroplasty 2024:S0883-5403(24)00555-2. [PMID: 38838962 DOI: 10.1016/j.arth.2024.05.083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 05/26/2024] [Accepted: 05/27/2024] [Indexed: 06/07/2024] Open
Abstract
BACKGROUND Total hip arthroplasty (THA) is a common procedure that requires consideration of preexisting comorbidities. Factor V Leiden (FVL), an inherited thrombophilia, is one such condition that predisposes patients to venous thromboembolism (VTE, deep vein thrombosis, and pulmonary embolism). The present study aimed to characterize the risks associated with FVL patients undergoing THA and evaluate the effect of VTE chemoprophylactic agents on these risks. METHODS A total of 544,022 adult patients who underwent primary THA for osteoarthritis indications between 2010 and October 2021 were identified in an administrative claims database. Of these, FVL was identified in 1,138 (0.21%). Patients who had and did not have FVL were matched at a 1:4 ratio (1,131 with FVL and 4,519 without FVL) based on age, sex, and Elixhauser comorbidity index. Univariable and multivariable analyses were assessed for 90-day complications. Implant survival at 5 years was assessed and compared with log-rank tests. The relative use of different chemoprophylactic agents, including aspirin, warfarin, heparin, or direct oral anticoagulant (DOAC), was assessed. Bleeding events and VTE were compared for those prescribed either aspirin or warfarin, heparin, or DOAC. A Bonferroni correction was applied. RESULTS On multivariable analysis, FVL patients were found to have increased odds of 90-day deep vein thrombosis (odds ratio (OR) = 9.20), pulmonary embolism (OR = 6.89), and aggregated severe and all adverse events (OR = 4.74 and 1.98, respectively), but not elevated risk of other perioperative adverse events or 5-year reoperations. More potent chemoprophylactic agents (warfarin, heparin, DOAC) reduced, but did not completely eliminate, the increased VTE risks (without increasing bleeding events). CONCLUSIONS This study quantified the significantly elevated VTE risk associated with FVL patients undergoing THA. The lack of difference in other specific adverse events and 5-year reoperations is reassuring. Clearly, chemoprophylactic agents are important in this population and may need further attention.
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Affiliation(s)
- Joshua G Sanchez
- Yale Department of Orthopaedics and Rehabilitation, New Haven, Connecticut
| | - Will M Jiang
- Yale Department of Orthopaedics and Rehabilitation, New Haven, Connecticut
| | - Meera M Dhodapkar
- Yale Department of Orthopaedics and Rehabilitation, New Haven, Connecticut
| | - Zachary J Radford
- Yale Department of Orthopaedics and Rehabilitation, New Haven, Connecticut
| | - Lee E Rubin
- Yale Department of Orthopaedics and Rehabilitation, New Haven, Connecticut
| | - Jonathan N Grauer
- Yale Department of Orthopaedics and Rehabilitation, New Haven, Connecticut
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Liu KC, Bagrodia N, Richardson MK, Piple AS, Kusnezov N, Wang JC, Lieberman JR, Heckmann ND. Risk Factors Associated with Thromboembolic Complications After total Hip Arthroplasty: An Analysis of 1,129 Pulmonary Emboli. J Am Acad Orthop Surg 2024:00124635-990000000-00928. [PMID: 38626438 DOI: 10.5435/jaaos-d-23-01213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Accepted: 02/28/2024] [Indexed: 04/18/2024] Open
Abstract
INTRODUCTION Venous thromboembolism (VTE) remains a dangerous complication after total hip arthroplasty (THA), despite advances in chemoprophylactic measures. This study aimed to identify risk factors of developing pulmonary embolism (PE) and deep vein thrombosis (DVT) after THA using a modern cohort of patients reflecting contemporary practices. METHODS The Premier Healthcare Database was queried for primary, elective THAs from January 1st, 2015, to December 31st, 2021. Patients who developed PE or DVT within 90 days of THA were compared with patients who did not develop any postoperative VTE. Differences in patient demographics, comorbidities, hospital factors, perioperative medications, chemoprophylactic agents, and allogeneic blood transfusion were compared between cohorts. Multivariable logistic regression models were used to identify independent risk factors of PE and DVT. In total, 544,298 THAs were identified, of which 1,129 (0.21%) developed a PE and 1,799 (0.33%) developed a DVT. RESULTS Patients diagnosed with a PE had significantly higher rates of in-hospital death (2.6% vs 0.1%, P < 0.001) compared with those without a PE. Age (adjusted odds ratio: 1.02 per year, 95% confidence interval [CI]: 1.01 to 1.03) and Black race (aOR: 1.52, 95% CI: 1.24 to 1.87) were associated with an increased risk of PE. Comorbidities associated with increased risk of PE included chronic pulmonary disease (aOR: 1.58, 95% CI: 1.36 to 1.84), pulmonary hypertension (aOR: 2.06, 95% CI: 1.39 to 3.04), and history of VTE (aOR: 2.38, 95% CI: 1.98 to 2.86). Allogeneic blood transfusion (aOR: 2.40, 95% CI: 1.88 to 3.06) was also associated with an increased risk of PE while dexamethasone utilization was associated with a reduced risk (aOR: 0.83, 95% CI: 0.73 to 0.95). DISCUSSION Increasing age; Black race; allogeneic blood transfusion; and comorbidities, including chronic pulmonary disease, pulmonary hypertension, and history of VTE, were independent risk factors of PE after THA. Given the increased mortality associated with PE, patients should be carefully evaluated for these factors and managed with an appropriate chemoprophylactic regimen.
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Affiliation(s)
- Kevin C Liu
- From the Department of Orthopaedic Surgery, Keck School of Medicine of USC, Los Angeles, CA
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3
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Birinci M, Hakyemez ÖS, Korkmaz O, Bingöl İ, Ata N, Ülgü MM, Birinci Ş, Ayvalı MO, Başarır K, Azboy İ. Unseen Threefold Mortality After the First Ten Days in Hemodialysis Patients Following Joint Arthroplasty: A Nationwide Retrospective Cohort Study of 1,287 Arthroplasty Patients on Hemodialysis. J Arthroplasty 2024:S0883-5403(24)00252-3. [PMID: 38522803 DOI: 10.1016/j.arth.2024.03.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 03/13/2024] [Accepted: 03/15/2024] [Indexed: 03/26/2024] Open
Abstract
BACKGROUND The study addresses the growing number of hemodialysis (HD) patients undergoing joint arthroplasty, who are at higher risk of complications and mortality. Previous research has often overlooked deaths after discharge. This study aimed to examine early outcomes in a large nationwide cohort of patients who underwent arthroplasty for elective and fracture-related reasons. METHODS Between 2016 and 2022, a study was conducted using the e-Nabız database of the Türkiye Ministry of Health, focusing on patients aged 18 years and above who underwent elective or fracture-related arthroplasty. This study included 1,287 patients reliant on dialysis who underwent total hip arthroplasty, total knee arthroplasty, or hemiarthroplasty (HA), with 7.7% of them receiving dialysis for the first time. Propensity score matching was used to create an equally sized group of non-dialysis-dependent patients, ensuring demographic balance in terms of age, sex, a comorbidity index, and surgery type. The primary objective was to compare mortality rates 10, 30, and 90 days after arthroplasty. RESULTS The first-time dialysis patients who underwent HA had significantly higher 30- and 90-day mortality rates compared to the chronic dialysis group (P = .040 and P < .001, respectively). Also, the HD patients consistently exhibited higher 90-day mortality rates across all surgery types. With total knee arthroplasty, HD patients had a mortality rate of 8.7%, in stark contrast to 0% among non-HD patients (P < .001). Similarly, with total hip arthroplasty, HD patients had a 12% mortality rate, while non-HD patients had a markedly lower rate of 2.7% (P = .008). In the case of HA, HD patients had a significantly elevated 90-day mortality rate of 31.9%, in contrast to 17.1% among non-HD patients (P < .001). CONCLUSIONS Joint arthroplasty has higher rates of mortality and complications among HD patients. Surgical decisions must be based on patients' overall health, necessitating collaboration among specialists. These patients should be closely monitored.
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Affiliation(s)
- Murat Birinci
- Faculty of Medicine, Department of Orthopaedics and Traumatology, İstanbul Medipol University, İstanbul, Türkiye
| | - Ömer S Hakyemez
- Faculty of Medicine, Department of Orthopaedics and Traumatology, İstanbul Medipol University, İstanbul, Türkiye
| | - Oğuzhan Korkmaz
- Faculty of Medicine, Department of Orthopaedics and Traumatology, İstanbul Medipol University, İstanbul, Türkiye
| | - İzzet Bingöl
- Faculty of Medicine, Department of Orthopaedics and Traumatology, Ankara Oncology Training and Research Hospital, Health Sciences University, Ankara, Türkiye
| | - Naim Ata
- Ministry of Health, General Directorate of Health Information Systems, Ankara, Türkiye
| | - Mahir M Ülgü
- Ministry of Health, General Directorate of Health Information Systems, Ankara, Türkiye
| | | | - Mustafa O Ayvalı
- Ministry of Health, General Directorate of Health Information Systems, Ankara, Türkiye
| | - Kerem Başarır
- Faculty of Medicine, Department of Orthopaedics and Traumatology, Haliç University, İstanbul, Türkiye
| | - İbrahim Azboy
- Department of Orthopaedics and Traumatology, School of Medicine, İstanbul Medipol University, İstanbul, Türkiye
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Moore MC, Dubin JA, Bains SS, Hameed D, Nace J, Delanois RE. Trends in deep vein thrombosis prophylaxis after total hip arthroplasty: 2016 to 2021. J Orthop 2024; 48:77-83. [PMID: 38059214 PMCID: PMC10696429 DOI: 10.1016/j.jor.2023.11.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 11/12/2023] [Indexed: 12/08/2023] Open
Abstract
Introduction Venous thromboembolism (VTE) has long been acknowledged as a potential complication of total hip arthroplasty (THA) contributing to heightened patient morbidity, mortality, and substantial healthcare costs. We aimed to: 1) assess trends in VTE prophylaxis utilization between 2016 and 2021; 2) determine the incidence of postoperative VTE and transfusions; and 3) identify independent risk factors for 90-day VTE and transfusion risks following THA in relation to the use of aspirin, dabigatran, enoxaparin, rivaroxaban, and warfarin. Methods A national, all-payer database was queried from January 1, 2016 and December 31, 2022. Use trends for aspirin, enoxaparin, rivaroxaban, dabigatran, and warfarin as thromboprophylaxis following THA was assessed. Incidence of ninety-day postoperative outcomes assessed included rates of 90-day postoperative VTE and transfusion. Results From 2016 to 2021, aspirin (n = 36,346) was the most used agent for VTE prophylaxis after THA, followed by dabigatran (n = 13,065), rivaroxaban (n = 11,790), enoxaparin (n = 11,380), and warfarin (n = 6326). Independent risk factors for 90-day VTE included CKD, COPD, CHF, obesity, dabigatran, enoxaparin, rivaroxaban, and warfarin (all p < 0.05). Conclusion Aspirin was used with increasing frequency and demonstrated lower rates of VTE and transfusion following THA, compared to dabigatran, enoxaparin, rivaroxaban, and warfarin. These findings seem to indicate that the increasing use of aspirin in VTE prophylaxis has been accomplished in appropriately selected patients.
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Affiliation(s)
- Mallory C. Moore
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, MD, USA
| | - Jeremy A. Dubin
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, MD, USA
| | - Sandeep S. Bains
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, MD, USA
| | - Daniel Hameed
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, MD, USA
| | - James Nace
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, MD, USA
| | - Ronald E. Delanois
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, MD, USA
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Marigi EM, Sperling JW, De Marinis R, Gupta P, Hassett LC, Soza F, Sanchez-Sotelo J. Venous thromboembolism following surgical management of proximal humerus fractures: a systematic review. JSES REVIEWS, REPORTS, AND TECHNIQUES 2023; 3:494-498. [PMID: 37928990 PMCID: PMC10624987 DOI: 10.1016/j.xrrt.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/07/2023]
Abstract
Background Currently, there is limited information on the incidence of venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE) after surgical treatment of proximal humerus fractures (PHFs). Therefore, the purpose of this systematic review is to evaluate the incidence of VTE, DVT, and PE following surgery for PHFs. Methods A comprehensive search of several databases was performed from inception to May 27, 2022. Studies were screened and evaluated by 2 reviewers independently utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Only original, English studies that evaluated the incidences of VTE following surgical management of PHFs were included. Surgical procedures consisted of shoulder arthroplasty (SA) including both hemiarthroplasty (Hemi) and reverse shoulder arthroplasty (RSA) in addition to open reduction and internal fixation (ORIF). A pooled incidence for postoperative DVT, PE, and overall VTE was reported. Results Twelve studies met the inclusion and exclusion criteria, encompassing a total of 18,238 patients. The overall DVT, PE, and VTE rates were 0.14%, 0.59%, and 0.7%, respectively. VTE was more frequently reported after SA than ORIF, (1.27% vs. 0.53%, respectively). Among SA patients, a higher rate of DVT was seen with RSA (1.2%) with the lowest DVT rate was observed for ORIF with 0.03%. Conclusions Symptomatic VTEs following surgical treatment of PHFs, are rare, yet still relevant as a worrisome postoperative complication. Among the various procedures, VTE was the most frequently reported after SA when compared to ORIF, with RSA having the highest VTE rate.
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Affiliation(s)
- Erick M. Marigi
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - John W. Sperling
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Rodrigo De Marinis
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
- Department of Orthopedic Surgery, Pontificia Universidad Católica de Chile, Santiago, Chile
- Shoulder and Elbow Unit, Hospital Dr. Sótero del Río, Santiago, Chile
| | - Puneet Gupta
- Department of Orthopaedic Surgery, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | | | - Francisco Soza
- Department of Orthopedic Surgery, Pontificia Universidad Católica de Chile, Santiago, Chile
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Dragosloveanu S, Dragosloveanu C, Petre M, Gherghe ME, Cotor DC. The Impact of Tourniquet Usage on TKA Outcome: A Single-Center Prospective Trial. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:medicina59050870. [PMID: 37241102 DOI: 10.3390/medicina59050870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 04/03/2023] [Accepted: 04/28/2023] [Indexed: 05/28/2023]
Abstract
Background and Objectives: Total knee arthroplasties (TKAs) are the most effective surgical treatment for end-stage knee osteoarthritis. The tourniquet is used to reduce intraoperative blood loss, improving surgical field visualization. There is much controversy regarding the effectiveness and safety of using a tourniquet during total knee arthroplasties. The purpose of this prospective study is to determine the effect of tourniquet usage during TKAs on early functional outcomes and pain in our center. Materials and Methods: We conducted a randomized controlled trial of patients following a primary total knee replacement between October 2020 and August 2021. We recorded presurgical data, which included age, sex and knee range of motion. Intraoperatively, we measured the amount of blood aspiration and the surgical room time. After the surgery, we measured the amount of blood aspirated through the drains and the hemoglobin. We measured flexion, extension, Visual Analogue Scale (VAS) scores, and Western Ontario and McMaster Universities Arthritis Index (WOMAC score) scores for the functional evaluation. Results: We included 96 patients in the T group and 94 in the NT group, respectively, who remained until the last follow-up. Regarding blood loss, the NT group demonstrated significantly lower levels: 245 ± 97.8 mL intraoperative and 324.8 ± 151.65 mL postoperative, compared to the T group, where we recorded 276 ± 109.2 mL during the surgical procedures and 353.44 ± 101.55 mL after the surgery, (p < 0.05). We also recorded significantly shorter operative room time for the NT group, (p < 0.05). During the follow-up, we noticed postoperative improvements but without significant differences between the groups. Conclusions: We found a significant decrease in bleeding after no tourniquet usage during total knee replacements and shorter operative times. On the other hand, the knee function demonstrated no significant differences between the groups. Further studies may be required in order to assess complications.
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Affiliation(s)
- Serban Dragosloveanu
- Department of Orthopaedics, "Foisor" Orthopaedics Hospital, 030167 Bucharest, Romania
- "Carol Davila" Faculty of Medicine, University of Medicine and Pharmacy, 050474 Bucharest, Romania
| | - Christiana Dragosloveanu
- "Carol Davila" Faculty of Medicine, University of Medicine and Pharmacy, 050474 Bucharest, Romania
- Clinical Hospital for Ophthalmological Emergencies, 030167 Bucharest, Romania
| | - Mihnea Petre
- Department of Orthopaedics, "Foisor" Orthopaedics Hospital, 030167 Bucharest, Romania
| | - Mihai E Gherghe
- Department of Orthopaedics, "Foisor" Orthopaedics Hospital, 030167 Bucharest, Romania
| | - Dragos C Cotor
- Department of Orthopaedics, "Foisor" Orthopaedics Hospital, 030167 Bucharest, Romania
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O'Rourke RJ, Milto AJ, Kurcz BP, Scaife SL, Allan DG, El Bitar Y. Decreased patient comorbidities and post-operative complications in technology-assisted compared to conventional total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2023; 31:1168-1175. [PMID: 35419705 DOI: 10.1007/s00167-022-06966-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 03/27/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE The use of computer-assisted and robotic surgery was developed to improve component position and outcomes of total knee arthroplasty (TKA). The goal of this study is to identify differences in patient demographics, comorbidities, and complications between technology-assisted and conventional TKA. METHODS A Nationwide Inpatient Sample database was used to identify patients who underwent technology-assisted and conventional TKA from 2016 to 2018. Analysed variables include demographics, length of stay (LOS), payer-status, geographic region, comorbidities, complications, and mortality. Univariate and multivariate analyses were performed to identify differences between both groups. RESULTS The analysis includes 2,208,434 TKA patients, of which 2,054,879 (93.05%) were conventional and 153,555 (6.95%) were technology assisted. Patients undergoing technology-assisted TKA were more likely to be older than 65 years, had higher median income quartile, and had surgery in urban teaching hospitals. Patients were less likely to undergo technology-assisted TKA if they were female gender, had Medicare payer status, were black race, were obese, were living in rural location, or had higher Charlson comorbidity score and baseline comorbidities. Technology-assisted TKA patients had shorter LOS, and fewer pulmonary and infection complications. CONCLUSION Patients undergoing technology-assisted TKA are being carefully selected with less baseline comorbidities, improved health, and living in urban areas. Subsequently, those carefully selected patients are discharged home, have a shorted hospital LOS, and have fewer complications compared to conventional TKA. Rural patients, black race and female gender are less likely to undergo technology-assisted TKA, further emphasizing the healthcare disparity for that segment of the population. LEVEL OF EVIDENCE Therapeutic level III.
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Affiliation(s)
- Ryan J O'Rourke
- Division of Orthopaedic Surgery, Southern Illinois University School of Medicine, P.O. Box 19638, Springfield, IL, 62794-9679, USA
| | - Anthony J Milto
- Division of Orthopaedic Surgery, Southern Illinois University School of Medicine, P.O. Box 19638, Springfield, IL, 62794-9679, USA
- Center for Clinical Research, Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Brian P Kurcz
- Division of Orthopaedic Surgery, Southern Illinois University School of Medicine, P.O. Box 19638, Springfield, IL, 62794-9679, USA
| | - Steven L Scaife
- Center for Clinical Research, Southern Illinois University School of Medicine, Springfield, IL, USA
| | - D Gordon Allan
- Division of Orthopaedic Surgery, Southern Illinois University School of Medicine, P.O. Box 19638, Springfield, IL, 62794-9679, USA
- Orthopaedic Center of Illinois, Springfield, IL, USA
| | - Youssef El Bitar
- Division of Orthopaedic Surgery, Southern Illinois University School of Medicine, P.O. Box 19638, Springfield, IL, 62794-9679, USA.
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Coveney EI, Hutton C, Patel N, Whitehouse SL, Howell JR, Wilson MJ, Hubble MJ, Charity J, Kassam AAM. Incidence of Symptomatic Venous Thromboembolism (VTE) in 8,885 Elective Total Hip Arthroplasty Patients Receiving Post-operative Aspirin VTE Prophylaxis. Cureus 2023; 15:e36464. [PMID: 37090282 PMCID: PMC10117228 DOI: 10.7759/cureus.36464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2023] [Indexed: 04/25/2023] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is a potentially reducible cause of morbidity and mortality in patients undergoing elective hip arthroplasty surgery. The balance of post-operative VTE prophylaxis and risk of post-operative haemorrhage remains at the forefront of surgeon's mind. The National Institute for Health and Care Excellence (NICE) published updated guidelines in 2018 which recommend the use of both mechanical and pharmacological methods in patients undergoing elective total hip arthroplasty (THA). OBJECTIVES The aim of this study was to present the symptomatic VTE incidence in 8,885 patients who underwent THA between January 1998 and March 2018 with Aspirin as the primary agent for pharmacological thromboprophylaxis. Intermittent calf compression stockings are routinely used from the time of surgery until mobilization (usually the following day) with prophylactic doses of low molecular weight heparin (LMWH) during inpatient stay (from 2005 onwards) and then Aspirin 150mg once daily for six weeks on hospital discharge (or Aspirin only prior to 2005), with use of other therapies occasionally as required. METHODS Analysis of prospective data collection from consecutive patients at a single institution undergoing THA was performed with the incidence of symptomatic deep vein thrombosis (DVT) and pulmonary embolism (PE) occurring within six months of the index operation as the primary outcome measure. Ninety-day all-cause mortality of this cohort of patients was also analysed. RESULTS 8,885 patients were reviewed. This included 7230 primary, 224 complex primary and 1431 revision cases. The overall incidence of symptomatic VTE after elective THA was 1.11% (99/8885) - with the incidence of symptomatic DVT of 0.59% (52/8885) and the incidence of symptomatic PE of 0.53% (47/8885). There was no significant difference (χ2 test, p=0.239) in the symptomatic VTE incidence between primary (1.20% - 89/7230), complex primary (0.89% - 2/224) and revision cases (0.70% - 10/1431). The 90-day all-cause mortality was 0.88% (78/8885). Cardiovascular and respiratory disease were the main causes of death following surgery. Only 0.03% of deaths (n= 3) within 90 days of index surgery were due to PE. There was no significant difference (p=0.327) in length of stay (and hence amount of pharmacologic prophylaxis with LMWH received by patients before commencement of Aspirin) with the average length of stay for those patients who did not suffer a VTE of 6.8 days compared with 7.6 days for those who did suffer a VTE. CONCLUSION Our results support the use of aspirin as an effective form of prophylaxis against symptomatic VTE following THA in contradiction to NICE and American Academy of Orthopaedic Surgery (AAOS) recommendations. It is not associated with an increased incidence in symptomatic DVT, PE or death compared to other published studies. The fact that it is inexpensive, readily available, requires no monitoring and does not pose an increased risk of bleeding are other advantages of using aspirin for VTE prophylaxis.
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Affiliation(s)
- Eamonn I Coveney
- Exeter Hip Unit, Royal Devon University Healthcare NHS Foundation Trust, Exeter, GBR
| | - Christopher Hutton
- Exeter Hip Unit, Royal Devon University Healthcare NHS Foundation Trust, Exeter, GBR
| | - Nimesh Patel
- Exeter Hip Unit, Royal Devon University Healthcare NHS Foundation Trust, Exeter, GBR
| | - Sarah L Whitehouse
- Orthopaedic Research Unit, Queensland University of Technology, Brisbane, AUS
- Exeter Hip Unit, Royal Devon University Healthcare NHS Foundation Trust, Exeter, GBR
| | - Jonathan R Howell
- Exeter Hip Unit, Royal Devon University Healthcare NHS Foundation Trust, Exeter, GBR
| | - Matthew J Wilson
- Exeter Hip Unit, Royal Devon University Healthcare NHS Foundation Trust, Exeter, GBR
| | - Matthew J Hubble
- Exeter Hip Unit, Royal Devon University Healthcare NHS Foundation Trust, Exeter, GBR
| | - John Charity
- Exeter Hip Unit, Royal Devon University Healthcare NHS Foundation Trust, Exeter, GBR
| | - Al-Amin M Kassam
- Exeter Hip Unit, Royal Devon University Healthcare NHS Foundation Trust, Exeter, GBR
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9
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Al-Mugheed K, Totur Dikmen B, Bayraktar N, Farghaly Abdelaliem SM, Ahmed Alsenany S. Nursing Care and Barriers for Prevention of Venous Thromboembolism in Total Knee and Hip Arthroplasty Patients: A Qualitative Study. J Multidiscip Healthc 2023; 16:547-556. [PMID: 36879650 PMCID: PMC9985420 DOI: 10.2147/jmdh.s403383] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2023] [Accepted: 02/20/2023] [Indexed: 03/04/2023] Open
Abstract
Purpose To determine barriers to preventing venous thromboembolism in total knee and hip arthroplasty patients by surgical nurses. Methods This qualitative study used a phenomenological approach. The semi-structured interview questionnaire included two questions focused on nursing care practices for VTE prevention and barriers faced during VTE prophylaxis in total knee and hip arthroplasty patients. Study data were collected from 10 surgical nurses through semi-structured interviews in July 2021. Results After analyzing the data, two main themes, five categories, and fourteen subcategories were developed. The main themes included "Nursing care" and "Barriers." Two categories were reflected in terms of nursing care: general care and mechanical prophylaxis. Regarding barriers, the analysis of the interview reflected three main categories: "lack of professional competence", "work conditions challenges", and "resistance from patients". Conclusion Educational institutions must play a critical role in preparing surgical nurses by establishing clinical nurse specialist programs and post-graduate diplomas programs that sufficiently prepare nurses for clinical settings.
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Affiliation(s)
- Khalid Al-Mugheed
- Adult Health Nursing Department, College of Nursing, Riyadh Elm University, Riyadh, 12734, Saudi Arabia
| | - Burcu Totur Dikmen
- Surgical Nursing Department, Faculty of Nursing, Near East University, Nicosia, Cyprus
| | - Nurhan Bayraktar
- Nursing Department, School of Health Sciences, Atılım University, Golbasi, Ankara, Turkey
| | - Sally Mohammed Farghaly Abdelaliem
- Department of Nursing Management and Education, College of Nursing, Princess Nourah bint Abdulrahman University, Riyadh, 11671, Saudi Arabia
| | - Samira Ahmed Alsenany
- Department of Community Health Nursing, College of Nursing, Princess Nourah bint Abdulrahman University, Riyadh, 11671, Saudi Arabia
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Gao Y, Fu XJ, Lei MX, Yin PB, Meng YT, Wang QM, Pi HY. The effects of information platform-based nursing on preventing venous thromboembolism in patients with hip fractures. Chin J Traumatol 2022; 25:367-374. [PMID: 35927125 PMCID: PMC9751533 DOI: 10.1016/j.cjtee.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Revised: 04/16/2022] [Accepted: 05/12/2022] [Indexed: 02/04/2023] Open
Abstract
PURPOSE Venous thromboembolism (VTE) is a major health issue among hip fracture patients. This study aimed to develop an information platform based on a mobile application and then evaluate whether information platform-based nursing could improve patient's drug compliance and reduce the incidence of VTE in hip fracture patients. METHODS This study retrospectively analyzed hip fracture patients who were treated with conventional prevention and intervention methods for VTE (control group) between January 2008 and November 2012, and prospectively analyzed hip fracture patients who were treated with nursing intervention based on the information platform (study group) between January 2016 and September 2017. All the patients included in the both groups were hip fracture patients who had an age over 50 years, treated with surgery, and hospitalized ≥ 48 h. Patients were excluded if they admitted to hospital due to old fractures, had a severe bleeding after 72 h of admission, diagnosed with any type of VTE, or refused to participate in the study. The information platform was divided into medical, nursing, and patient interface. Based on the information platform, medical practitioners and nurses could perform risk assessments, monitoring management and early warnings, preventions and treatments, health educations, follow-up, and other aspects of nursing interventions for patients. This study compared essential characteristics, drug compliance, VTE occurrence, and mean length of hospitalization between the two groups. Besides, a subgroup analysis was performed in the study group according to different drug compliances. SPSS 18.0 software (IBM Corp., NY, and USA) was used for statistical analysis. RESULTS Altogether 1177 patients were included in the control group, and 491 patients in the study group. Regarding baseline data, patients in the study group had more morbidities than those in the control group (p < 0.05). The difference of drug compliance between the two groups was statistically significant (p < 0.001): 761 (64.7%) of the patients in the control group and only 30 (6.1%) patients in the study group had poor drug compliance. In terms of VTE, 10.7% patients (126/1177) in the control group had VTE, and the rate in the study group was 7.1% (35/491), showing a statistically significant difference (p = 0.02). Moreover, the average length of hospitalization in the study group was also significantly lower than that in the control group (10.4 days vs. 13.7 days, p < 0.001). Subgroup analyses of the study group showed that the incidence of VTE in patients with poor, partial, and good compliances were 56.7% (17/30), 5.8% (10/171), and 2.8% (8/290), respectively, revealing a significantly huge difference (p < 0.001). CONCLUSIONS Poor drug compliance leads to higher VTE occurrence. The information platform-based nursing can effectively improve the compliance of hip fracture patients and thus considerably reduce the incidence of VTE. The mobile application may be an effective tool to prevent VTE in hip fracture patients.
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Affiliation(s)
- Yuan Gao
- Nursing Department, The First Medical Center of Chinese PLA General, Beijing, 100853, China
| | - Xiao-Jie Fu
- Department of Orthopedics, The First Medical Center of Chinese PLA General Hospital, Beijing, 100853, China
| | - Ming-Xing Lei
- Department of Orthopedics, The First Medical Center of Chinese PLA General Hospital, Beijing, 100853, China
| | - Peng-Bin Yin
- Department of Orthopedics, The First Medical Center of Chinese PLA General Hospital, Beijing, 100853, China
| | - Yu-Tong Meng
- Department of Orthopedics, Beijing ChaoYang Hospital, Capital Medical University, Beijing, 100020, China
| | - Qing-Mei Wang
- Nursing Department, The First Medical Center of Chinese PLA General, Beijing, 100853, China,Corresponding author.
| | - Hong-Ying Pi
- Health Service Training Center of PLA General Hospital, Beijing, 100853, China,Corresponding author.
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11
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Centeno CJ, Money BT, Dodson E, Stemper I, Steinmetz NJ. The rate of venous thromboembolism after knee bone marrow concentrate procedures: should we anticoagulate? INTERNATIONAL ORTHOPAEDICS 2022; 46:2213-2218. [PMID: 35844014 PMCID: PMC9492566 DOI: 10.1007/s00264-022-05500-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Accepted: 06/23/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE Intra-articular injections of autologous, minimally manipulated, cell therapies such as bone marrow concentrate (BMC) to treat knee osteoarthritis (OA) may delay or prevent future total knee arthroplasty (TKA). Arthroplasty has the known and substantial risk of venous thromboembolism (VTE) and requires routine prophylaxis, whereas the VTE risk associated with knee BMC injections is unknown. We report on the rate of VTE from a large orthobiologics patient registry and assess whether knee BMC procedures require routine prophylaxis. METHODS A retrospective analysis of knee osteoarthritis cases tracked in a treatment registry and treated at 72 clinical sites with BMC from 2007 to 2020 who were not prophylactically anticoagulated was performed to identify adverse events (AEs) associated with VTE. Treating physicians were contacted to improve discovery of possible occurrences of VTE. RESULTS Twenty cases (0.16%) of VTE were identified from the registry of 12,780 knee BMC treatments. These events were less frequent than the published data demonstrate for anticoagulated TKA patients. CONCLUSION Based on the rates of VTE from our retrospective treatment registry analysis compared to the risk of medication-induced haemorrhage, routine prophylactic anticoagulation is not recommended for intra-articular knee BMC procedures. Further research into safety and efficacy of BMC treatment for knee OA is warranted. CLINICAL TRIAL IDENTIFIER NCT03011398, retrospectively registered.
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Affiliation(s)
- Christopher J Centeno
- Centeno-Schultz Clinic, Broomfield, CO, USA
- Regenexx, LLC, Research and Development, Broomfield, CO, USA
| | | | - Ehren Dodson
- Regenexx, LLC, Research and Development, Broomfield, CO, USA.
| | - Ian Stemper
- Regenexx, LLC, Research and Development, Broomfield, CO, USA
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12
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Yang Y, Feng G, Yan J, Wu L, Wang F, Ding D, Wang H, Jin Q. Plasminogen activator inhibitor-1, thrombin-antithrombin, and prothrombin fragment F1+2 have higher diagnostic values than D-dimer for venous thromboembolism after TKA. Clin Appl Thromb Hemost 2022; 28:10760296221097383. [PMID: 35535394 PMCID: PMC9096184 DOI: 10.1177/10760296221097383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective To investigate the diagnostic values of D-dimer, plasminogen activator inhibitor-1 (PAI-1), thrombin–antithrombin (TAT), and prothrombin fragment F1 + 2 (F1 + 2) for predicting venous thromboembolism (VTE) after total knee arthroplasty (TKA). Methods Ultrasonography and CTPA were performed to diagnose VTE in 252 patients who underwent TKAs. Plasma D-dimer, PAI-1, TAT, and F1 + 2 levels were assessed 1–3 days prior to operation (T1), second hour (T2), first (T3), and third day (T4) after the operation. Receiver–operating characteristic curves (ROC) analysis was conducted and pairwise compared to evaluate the diagnostic value of those biomarkers. Results Plasma D-dimer levels differed between patients with and without VTE significantly on T4, PAI-1, TAT, and F1 + 2 levels differed on T3 and T4. The areas under ROC of D-dimer, PAI-1, TAT and F1 + 2 levels were 0.645, 0.773, 0.771 and 0.797, respectively. The most feasible cutoff values of D-dimer, PAI-1, TAT and F1 + 2 in predicting VTE after TKA were 2.24 ug/ml, 35.96 ng/ml, 13.36 ng/mg and 11.1 ng/ml, respectively. Pairwise comparison of ROC curves revealed that D-dimer level had the lowest diagnostic accuracy, whereas PAI-1, TAT and F1 + 2 level had similar diagnostic accuracy. There were significant differences in duration of tourniquet time and duration of anesthesia between patients with and without VTE. Conclusion After TKA, using 2.24ug/mL as the threshold value of D-dimer is more accurate than using 0.5ug/mL in the monitoring of VTE, PAI-1, TAT and F1 + 2 are more valuable than D-dimer in predicting VTE. Duration of tourniquet and duration of anesthesia are risk factors for the development of VTE.
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Affiliation(s)
- Yong Yang
- Department of orthopedics, General Hospital of Ningxia Medical University, 804 Shengli street, Xingqing district, Yinchuan, Ningxia 750004, China
| | - Gangning Feng
- Ningxia Medical University, 1160 Shengli street, Xingqing district, Yinchuan, Ningxia 750004, China
| | - Jiangbo Yan
- Ningxia Medical University, 1160 Shengli street, Xingqing district, Yinchuan, Ningxia 750004, China
| | - Long Wu
- Department of orthopedics, General Hospital of Ningxia Medical University, 804 Shengli street, Xingqing district, Yinchuan, Ningxia 750004, China
| | - Faxuan Wang
- School of Public Health, Ningxia Medical University, 1160 Shengli street, Xingqing district, Yinchuan, Ningxia 750004, China
| | - Dong Ding
- Ningxia Medical University, 1160 Shengli street, Xingqing district, Yinchuan, Ningxia 750004, China
| | - Hui Wang
- Ningxia Medical University, 1160 Shengli street, Xingqing district, Yinchuan, Ningxia 750004, China
| | - Qunhua Jin
- Department of orthopedics, General Hospital of Ningxia Medical University, 804 Shengli street, Xingqing district, Yinchuan, Ningxia 750004, China
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13
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Zuke WA, Chughtai M, Emara AK, Zhou G, Koroukian SM, Molloy RM, Piuzzi NS. What Are Drivers of Readmission for Readmission-Requiring Venous Thromboembolic Events After Primary Total Hip Arthroplasty? An Analysis of 544,443 Cases. J Arthroplasty 2022; 37:958-965.e3. [PMID: 35065217 DOI: 10.1016/j.arth.2022.01.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 01/07/2022] [Accepted: 01/11/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is a potential postoperative complication after total hip arthroplasty (THA). These events present with a range of severity, and some require readmission. The present study aimed to identify unexplored risk factors for severe VTE that lead to hospital readmission. METHODS The Agency of Healthcare Research and Quality's National Readmissions Database was retrospectively queried for all patients who underwent primary THA (January 2016 to December 2018). Study population included patients who were readmitted for VTE within 90 days after an elective THA. Bivariate and multivariate regression analyses were performed using patient demographics, insurance status, elective nature of the surgery, healthcare institution characteristics, and baseline comorbidities. RESULTS Higher risk of readmission for VTE was evident among elderly (71-80 years vs <40 years: odds ratio [OR] 1.7, 95% confidence interval [CI] 1.3-2.2, P = .0002), male patients (OR 1.2, 95% CI 1.2-1.3). Nonelective THAs were associated with markedly higher odds of readmission for VTE (OR 20.5, 95% CI 18.9-22.2), peripheral vascular disease (OR 1.2, 95% CI 1.1-1.4), lymphoma (OR 1.5, 95% CI 1.1-2.1), metastatic cancer (OR 1.8, 95% CI 1.4-2.2), obesity (OR 1.5, 95% CI 1.4-1.6), and fluid-electrolyte imbalance (OR 1.1, 95% CI 1.0-1.2). Home health care (OR 0.8, 95% CI 0.7-0.8) and discharge to skilled nursing facility (OR 0.7, 95% CI 0.7-0.8) had lower odds of readmission for VTE vs unsupervised home discharge, while insurance type was not a significant driver(P > .05). CONCLUSION One in 135 THA patients is likely to experience a VTE requiring readmission after THA. Male patients, age >70 years, and specific baseline comorbidities increase such risk. Furthermore, discharge to a supervised setting mitigated the risk of VTE requiring readmission compared to unsupervised discharge. As VTE prophylaxis protocols continue to evolve, these patients may require optimized perioperative care pathways to mitigate VTE complications.
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Affiliation(s)
- William A Zuke
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Morad Chughtai
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Ahmed K Emara
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Guangjin Zhou
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
| | | | - Robert M Molloy
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Nicolas S Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
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14
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Song W, Ma T, Cheng Q, Wen P, Wu J, Hao L, Zhang B, Wang Y, Wang Q, Zhang Y. Global Research Status and Trends in Venous Thromboembolism After Hip or Knee Arthroplasty From 1990 to 2021: A Bibliometric Analysis. Front Med (Lausanne) 2022; 9:837163. [PMID: 35462997 PMCID: PMC9021752 DOI: 10.3389/fmed.2022.837163] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 03/21/2022] [Indexed: 11/13/2022] Open
Abstract
Background Venous thromboembolism (VTE) after hip or knee arthroplasty has attracted increasing attention over the past few decades. However, there is no bibliometric report on the publications in this field. The purpose of this study was to analyze the global research status, hotspots, and trends in VTE after arthroplasty. Methods All articles about VTE research after hip or knee arthroplasty from 1990 to 2021 were retrieved from the Web of Science Core Collection database. The information of each article including citation, title, author, journal, country, institution, keywords, and level of evidence was extracted for bibliometric analysis. Results A total of 1,245 original articles from 53 countries and 603 institutions were retrieved. The USA contributed most with 457 articles, followed by England and Canada. McMaster University in Canada was the leading institution for publications. The journals with the highest output and citation were the Journal of Arthroplasty and the Thrombosis and Haemostasis, respectively. The median number of citations was significantly different among the levels of evidence (F = 128.957, P < 0.001). The research hotspots switched from VTE diagnosis and heparin to factor Xa inhibitors (fondaparinux, rivaroxaban, apixaban) and direct thrombin inhibitors (dabigatran etexilate, ximelagatran), and finally to aspirin, risk factor studies, which can be observed from the keyword analysis and co-cited reference cluster analysis. Conclusions This study observed an increasing trend of research articles on VTE after arthroplasty. Publications with higher levels of evidence gained further popularity among researchers and orthopedic surgeons. Additionally, individualized VTE prevention and the development of new, safe, effective, and inexpensive oral agents would be emerging trends in the future.
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Affiliation(s)
- Wei Song
- Department of Joint Surgery, Honghui Hospital, Xi'an Jiaotong University, Shaanxi, China
| | - Tao Ma
- Department of Joint Surgery, Honghui Hospital, Xi'an Jiaotong University, Shaanxi, China
| | | | - Pengfei Wen
- Department of Joint Surgery, Honghui Hospital, Xi'an Jiaotong University, Shaanxi, China
- *Correspondence: Pengfei Wen
| | - Jiayuan Wu
- Department of Spine Surgery, Honghui Hospital, Shaanxi, China
| | - Linjie Hao
- Department of Joint Surgery, Honghui Hospital, Xi'an Jiaotong University, Shaanxi, China
| | - Binfei Zhang
- Department of Joint Surgery, Honghui Hospital, Xi'an Jiaotong University, Shaanxi, China
| | - Yakang Wang
- Department of Joint Surgery, Honghui Hospital, Xi'an Jiaotong University, Shaanxi, China
| | - Qiuyuan Wang
- Department of Orthopedics, China-Japan Friendship Hospital, Beijing, China
| | - Yumin Zhang
- Department of Joint Surgery, Honghui Hospital, Xi'an Jiaotong University, Shaanxi, China
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15
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Tang A, Zak SG, Waren D, Iorio R, Slover JD, Bosco JA, Schwarzkopf R. Low-Dose Aspirin is Safe and Effective for Venous Thromboembolism Prevention in Patients Undergoing Revision Total Knee Arthroplasty: A Retrospective Cohort Study. J Knee Surg 2022; 35:553-559. [PMID: 32898907 DOI: 10.1055/s-0040-1716377] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Venous thromboembolism (VTE) events are rare, but serious complications of total joint replacement affect patients and health care systems due to the morbidity, mortality, and associated cost of its complications. There is currently no established universal standard of care for prophylaxis against VTE in patients undergoing revision total knee arthroplasty (rTKA). The aim of this study was to determine whether a protocol of 81-mg aspirin (ASA) bis in die (BID) is safe and/or sufficient in preventing VTE in patients undergoing rTKAs versus 325-mg ASA BID. In 2017, our institution adopted a new protocol for VTE prophylaxis for arthroplasty patients. Patients initially received 325-mg ASA BID for 1 month and then changed to a lower dose of 81-mg BID. A retrospective review from 2011 to 2019 was conducted identifying 1,438 consecutive rTKA patients and 90-day postoperative outcomes including VTE, gastrointestinal, and wound bleeding complications, acute periprosthetic joint infection, and mortality. In the 74 months prior to protocol implementation, 1,003 rTKAs were performed and nine VTE cases were diagnosed (0.90%). After 26 months of the protocol change, 435 rTKAs were performed with one VTE case identified (0.23%). There was no significant difference in rates or odds in postoperative pulmonary embolism (PE; p = 0.27), DVT (p = 0.35), and total VTE rates (p = 0.16) among patients using either protocol. There were also no differences in bleeding complications (p = 0.15) or infection rate (p = 0.36). No mortalities were observed. In the conclusion, 81-mg ASA BID is noninferior to 325-mg ASA BID in maintaining low rates of VTE and may be safe for use in patients undergoing rTKA.
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Affiliation(s)
- Alex Tang
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Stephen G Zak
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Daniel Waren
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Richard Iorio
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - James D Slover
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Joseph A Bosco
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
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16
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The Effect of Obstructive Sleep Apnea on Venous Thromboembolism Risk in Patients Undergoing Total Joint Arthroplasty. J Am Acad Orthop Surg Glob Res Rev 2022; 6:01979360-202204000-00017. [PMID: 35442925 PMCID: PMC9022776 DOI: 10.5435/jaaosglobal-d-21-00248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 02/25/2022] [Indexed: 11/18/2022]
Abstract
Obstructive sleep apnea (OSA) is a known risk factor for venous thromboembolism (VTE), defined as pulmonary embolism (PE) or deep vein thrombosis (DVT); however, little is known about its effect on VTE rates after total joint arthroplasty (TJA). This study sought to determine whether patients with OSA who undergo TJA are at greater risk for developing VTE versus those without OSA.
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17
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Crespi Z, Hasan AI, Pearl A, Ismail A, Awad ME, Irfan FB, Jaffar M, Patel P, Saleh KJ. Current Guidelines and Practice Recommendations to Prevent Hospital-Acquired Conditions After Major Orthopaedic Surgeries. JBJS Rev 2022; 10:01874474-202203000-00012. [PMID: 35290253 DOI: 10.2106/jbjs.rvw.21.00152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
» In 2016, a total of 48,771 hospital-acquired conditions (HACs) were reported in U.S. hospitals. These incidents resulted in an excess cost of >$2 billion, which translates to roughly $40,000 per patient with an HAC. » Current guidelines for the prevention of venous thromboembolism and surgical site infection consist primarily of antithrombotic prophylaxis and antiseptic technique, respectively. » The prevention of catheter-associated urinary tract infection (CA-UTI) and in-hospital falls and trauma is done best via education. In the case of CA-UTI, this consists of training staff about the indications for catheters and their timely removal when they are no longer necessary, and in the case of in-hospital falls and trauma, advising the patient and family about the patient's fall risk and communicating the fall risk to the health-care team. » Blood incompatibility is best prevented by implementation of a pretransfusion testing protocol. Pressure ulcers can be prevented via patient positioning, especially during surgery, and via postoperative skin checks.
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Affiliation(s)
- Zachary Crespi
- College of Medicine, Central Michigan University, Mount Pleasant, Michigan
| | - Ahmad I Hasan
- School of Medicine, Wayne State University, Detroit, Michigan.,FAJR Scientific, Northville, Michigan
| | - Adam Pearl
- School of Medicine, Wayne State University, Detroit, Michigan
| | - Aya Ismail
- FAJR Scientific, Northville, Michigan.,University of Michigan, Dearborn, Michigan
| | - Mohamed E Awad
- FAJR Scientific, Northville, Michigan.,NorthStar Anesthesia, Detroit Medical Center, Detroit, Michigan.,Michigan State University-College of Osteopathic Medicine, Detroit, Michigan.,Department of Surgery, John D. Dingell Veterans Affairs Medical Center, Detroit, Michigan
| | - Furqan B Irfan
- Michigan State University-College of Osteopathic Medicine, Detroit, Michigan
| | - Muhammed Jaffar
- NorthStar Anesthesia, Detroit Medical Center, Detroit, Michigan.,Department of Surgery, John D. Dingell Veterans Affairs Medical Center, Detroit, Michigan
| | - Padmavathi Patel
- NorthStar Anesthesia, Detroit Medical Center, Detroit, Michigan.,Department of Surgery, John D. Dingell Veterans Affairs Medical Center, Detroit, Michigan
| | - Khaled J Saleh
- FAJR Scientific, Northville, Michigan.,Michigan State University-College of Osteopathic Medicine, Detroit, Michigan.,Department of Surgery, John D. Dingell Veterans Affairs Medical Center, Detroit, Michigan
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18
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Buitrago G, Ortiz JR, Camacho F. Clinical Outcomes, Health Care Costs and Prognostic Factors for Total Knee Arthroplasty: A Multilevel Analysis of a National Cohort Study Using Administrative Claims Data. J Knee Surg 2022; 35:384-392. [PMID: 32838453 DOI: 10.1055/s-0040-1715097] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Total knee arthroplasty (TKA) is one of the most frequent orthopaedic surgeries. The purpose of this study was to determine the 30-day postoperative mortality rate, total episode-of-care costs, and prognostic factors associated with these outcomes, for adult patients who underwent TKA in Colombia's contributory health care system. A retrospective cohort study of all adult patients enrolled in Colombia's contributory health system, who underwent TKA between January 1, 2012 and November 30, 2015 was performed. Thirty-day postoperative mortality rates, 30-day ICU admissions rates, 30-day hospital readmission rates, 1-year arthroplasty revision rates, and total episode-of-care costs were estimated. Multilevel, generalized linear models were generated, to determine the prognostic factors associated with outcomes presented. A total of 12,453 patients were included. The 30-day mortality rate was 0.13 per 100 surgeries and the ICU admissions rate at 30 days postoperative was 4.44 per 100 surgeries. The 30-day hospital readmission rate was 4.28 per 100 surgeries and the 1-year arthroplasty revision rate was 1.22 per 100 surgeries. The prognostic factors associated with mortality were age, Charlson Index, and type of insurer. The prognostic factors associated with hospital readmission were age category, Charlson Index, and geographic region; younger age and higher Charlson Index were found to be associated with a higher 1-year arthroplasty revision rate. The median of total episode-of-care costs was USD$ 6,190.07 (interquartile range: 2,299-7,282). The multivariate model found that age, the Charlson Index, the Atlantic region, and type of insurer were associated with the costs incurred by the health system. For patients undergoing TKA in Colombia, age, the Charlson Index, insurers, and geographic region are associated with mortality, ICU admissions, 30-day hospital readmissions, 1-year arthroplasty revisions, and total costs incurred by the health system.
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Affiliation(s)
- Giancarlo Buitrago
- Department of Surgery, Clinical Research Institute, Universidad Nacional de Colombia, Bogota, DC, Colombia.,Department of Surgery, Hospital Universitario Nacional de Colombia, Bogotá, DC, Colombia
| | - Jorge R Ortiz
- Department of Surgery, Hospital Universitario Nacional de Colombia, Bogotá, DC, Colombia.,Orthopedics and Traumatology Unit, Department of Surgery, Universidad Nacional de Colombia, Bogota, DC, Colombia
| | - Felipe Camacho
- Department of Surgery, Hospital Universitario Nacional de Colombia, Bogotá, DC, Colombia.,Orthopedics and Traumatology Unit, Department of Surgery, Universidad Nacional de Colombia, Bogota, DC, Colombia
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19
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Xu J, Chang D, Chui J, Cao J, Negus J. The efficacy and cost-effectiveness of enoxaparin versus rivaroxaban in the prevention of venous thromboembolism following total hip or knee arthroplasty: A meta-analysis. J Orthop 2022; 30:1-6. [PMID: 35210718 PMCID: PMC8844751 DOI: 10.1016/j.jor.2022.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 02/02/2022] [Indexed: 10/19/2022] Open
Abstract
INTRODUCTION Thromboprophylaxis following total hip and knee arthroplasty is variable across institutions, but commonly consists of enoxaparin, and more recently rivaroxaban. We aimed to analyze the current evidence on the efficacy, safety and cost-effectiveness of rivaroxaban versus enoxaparin for thromboprophylaxis following TKA or THA. METHODS This study was conducted according to PRISMA guidelines. Electronic database searches were performed using three databases from their dates of inception to June 2020. Relevant randomized controlled studies were identified, with data extracted and analyzed. RESULTS From eight studies, 13,384 patients were included, with 5700 undergoing TKA and 7684 undergoing THA. There were 6629 patients receiving rivaroxaban and 6755 patients receiving enoxaparin. From the total cohort, rivaroxaban was associated with significantly lower rates of major VTE (p = 0.009) and DVT (p < 0.001) when compared to enoxaparin. There was no significant difference in bleeding complications between rivaroxaban and enoxaparin groups (p = 0.14). Subgroup analysis of patients undergoing THA demonstrated that rivaroxaban reduced risk of major VTE (p = 0.002) and DVT (p = 0.01) with no significant differences in any other complications. For those undergoing TKA, rivaroxaban significantly reduced the risk of DVT (p < 0.001) but was associated with higher rates of post-operative blood transfusion (p = 0.03). Cost-analysis revealed that rivaroxaban was superior to enoxaparin, with the medication cost needed to prevent one DVT being $1081 and $432 less with rivaroxaban for THA and TKA respectively. CONCLUSIONS Rivaroxaban may be a safe and cost-effective alternative to enoxaparin for routine thromboprophylaxis following total knee or hip arthroplasty.
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Affiliation(s)
- Joshua Xu
- Department of Orthopaedics and Traumatic Surgery, Royal North Shore Hospital, Sydney, Australia,Sydney Medical School, The University of Sydney, Sydney, Australia,Corresponding author. Suite 102, Level 1/10 Tilley Ln, Frenchs Forest, NSW, 2000, Australia.
| | - David Chang
- Department of Orthopaedics, Northern Beaches Hospital, Sydney, Australia
| | - Juanita Chui
- Sydney Medical School, The University of Sydney, Sydney, Australia
| | - Jacob Cao
- Sydney Medical School, The University of Sydney, Sydney, Australia,Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Jonathan Negus
- Sydney Medical School, The University of Sydney, Sydney, Australia,Department of Orthopaedics, Northern Beaches Hospital, Sydney, Australia
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Marrannes S, Victor K, Arnout N, De Backer T, Victor J, Tampere T. Prevention of venous thromboembolism with aspirin following knee surgery: A systematic review and meta-analysis. EFORT Open Rev 2021; 6:892-904. [PMID: 34760289 PMCID: PMC8559566 DOI: 10.1302/2058-5241.6.200120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
| | - Klaas Victor
- Department of Orthopedic Surgery, University of Leuven, Belgium
| | - Nele Arnout
- Department of Orthopedic Surgery, Ghent University, Belgium
| | | | - Jan Victor
- Department of Orthopedic Surgery, Ghent University, Belgium
| | - Thomas Tampere
- Department of Orthopedic Surgery, Ghent University, Belgium
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Tong K, Liu H, Qin J, Pan Z, Shangguan Y, Xiao H, Wang H, Chen L, Tan Y. Current status survey of the extramural hospital management of venous thromboembolism after total hip and knee arthroplasty in China. BMC Musculoskelet Disord 2021; 22:787. [PMID: 34517870 PMCID: PMC8438984 DOI: 10.1186/s12891-021-04663-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 08/26/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is a potentially fatal complication after arthroplasty. Numerous prophylactic strategies and studies to reduce VTEs have focused on the duration of the hospital stay and on few extramural hospitals. This study aimed to investigate extramural hospital management of VTE after total hip/knee arthroplasty (THA/TKA) in China with a novel survey tool. METHODS A total of 180 patients undergoing arthroplasty, including 68 THA patients and 112 TKA patients, were enrolled in this study. All patients received anticoagulant treatment management. A survey querying VTE management and adherence, such as therapy information, understanding of anticoagulation, satisfaction with the ability of medical staff, and satisfaction with health care costs, was administered by a questionnaire (TKA/THA Patients' Experience with Anticoagulation in the Post-discharge Period) for quality improvement. RESULTS The average age of the patients was 65.27 ± 13.62 years. All patients knew their follow-up times. 85 % of them were suggested that re-examine at the next 14 days, and the others at the next 28 days. All patients continued to visit the orthopaedic clinic after discharge without choosing other types of outpatient services, such as an anticoagulant clinic or home visit with a nurse/pharmacist or remote evaluation by telephone. A total of 96.6 % of all patients used new oral anticoagulants, and the most common treatment duration was 2-4 weeks (93.3 %). 48 % informed their physicians that they were taking anticoagulation medications when they visited ophthalmology, dentistry, dermatology, and other departments. The overall rate of satisfaction with anticoagulation management was 81.67 %, and 6.67 % of patients were not unsatisfied with their medical expenses. Patient compliance decreased with increasing follow-up time. Continuous follow-ups after discharge significantly improved patient compliance. CONCLUSIONS These results elucidate how we can improve the quality of anticoagulation. Continuous follow-up appointments for 30 days after discharge, especially for individuals over 65 years old, significantly improved patient satisfaction and reduced the incidence of VTE and medical costs.
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Affiliation(s)
- Kai Tong
- Division of Joint Surgery and Sports Medicine, Department of Orthopedic Surgery, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan City, Hubei Province, 430071, PR China
| | - Hankun Liu
- Division of Joint Surgery and Sports Medicine, Department of Orthopedic Surgery, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan City, Hubei Province, 430071, PR China
| | - Jun Qin
- Division of Joint Surgery and Sports Medicine, Department of Orthopedic Surgery, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan City, Hubei Province, 430071, PR China
| | - Zhengqi Pan
- Division of Joint Surgery and Sports Medicine, Department of Orthopedic Surgery, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan City, Hubei Province, 430071, PR China
| | - Yangfan Shangguan
- Division of Joint Surgery and Sports Medicine, Department of Orthopedic Surgery, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan City, Hubei Province, 430071, PR China
| | - Hao Xiao
- Division of Joint Surgery and Sports Medicine, Department of Orthopedic Surgery, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan City, Hubei Province, 430071, PR China
| | - Hua Wang
- Division of Joint Surgery and Sports Medicine, Department of Orthopedic Surgery, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan City, Hubei Province, 430071, PR China
| | - Liaobin Chen
- Division of Joint Surgery and Sports Medicine, Department of Orthopedic Surgery, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan City, Hubei Province, 430071, PR China
| | - Yang Tan
- Division of Joint Surgery and Sports Medicine, Department of Orthopedic Surgery, Zhongnan Hospital of Wuhan University, 169 Donghu Road, Wuhan City, Hubei Province, 430071, PR China.
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Aspirin Use for Venous Thromboembolism Prevention Is Safe and Effective in Overweight and Obese Patients Undergoing Revision Total Hip and Knee Arthroplasty. J Arthroplasty 2021; 36:S337-S344. [PMID: 33376036 DOI: 10.1016/j.arth.2020.12.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 11/29/2020] [Accepted: 12/06/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Venous thromboembolism (VTE), defined as pulmonary embolism or deep venous thrombosis, is a rare but serious complication following revision total hip arthroplasty (RTHA) and revision total knee arthroplasty (RTKA). Previous studies show that obesity may be associated with an increased risk for pulmonary embolism, wound complications, and infection. With no current universal standard of care for VTE prophylaxis, we sought to determine whether aspirin prescribed (ASA) is safe and effective in obese patients undergoing RTHA/RTKA. METHODS A retrospective review of 1578 consecutive RTHA/RTKA cases (751 RTHAs and 827 RTKAs) was conducted identifying patients prescribed 325 or 81 mg ASA. Ninety-day postoperative VTE rates, bleeding, wound complications, deep infections, and mortality were collected. Cohorts were stratified according to body mass index (BMI): normal (18-24.9 kg/m2), overweight (25-29.9 kg/m2), obese (30-34.9 kg/m2), severely obese (35-39.9 kg/m2), and morbidly obese (≥40 kg/m2). RESULTS The cohort comprised of 335 patients with a normal BMI, 511 were overweight, 408 obese, 232 severely obese, and 92 morbidly obese. Total VTE rates were statistically similar between BMI groups (0.90% vs 0.78% vs 0.74% vs 0.43% vs 0%, P = .89). There were no differences in bleeding rates (0.90% vs 0% vs 0% vs 0.43% vs 0%, P = .08), wound complications (0.30% vs 0.20% vs 0.25% vs 0% vs 0%, P = .93), infection (1.49% vs 1.57% vs 0.98% vs 1.29% vs 1.09%, P = .66), or mortality (0% vs 0.20% vs 0% vs 0% vs 0%, P = .72). CONCLUSION ASA is safe and effective for VTE prevention in obese patients with similar complication rates to nonobese patients undergoing RTHA/RTKA.
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Comparison of 2013 and 2009 versions of Caprini risk assessment models for predicting VTE in Chinese cancer patients: a retrospective study. J Thromb Thrombolysis 2021; 50:446-451. [PMID: 31975322 DOI: 10.1007/s11239-020-02038-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
This study aimed to compare the predictive value of 2009 and 2013 version of Caprini risk assessment models (RAM) for venous thromboembolism (VTE) in cancer patients by receiver operating characteristic (ROC) analysis. This retrospective study reviewed a total of 1439 VTE and 1439 non-VTE Chinese cancer inpatients. The baseline demographic data of these patients were recorded. 2009 and 2013 versions Caprini RAMs were applied, and cumulative risk scores were obtained by adding the scores of each risk factor. The specificity, sensitivity, positive predictive value and negative predictive value of these two models were analyzed. ROC curve was drawn to calculate the area under the curve (AUC) and the Youden index. Significant differences were observed in the risk factors between VTE and non-VTE Group. The specificity and negative predictive value of 2013 version were higher than those of 2009 version (P < 0.05). No significant differences were found in the sensitivity or positive predictive value between 2009 and 2013 versions of the Caprini RAM (P > 0.05). The AUC and Youden index of 2013 Caprini RAM were significantly higher than those of 2009 Caprini RAM (P < 0.001), whereas the Youden index of the 2009 Caprini RAM at critical point 4 was higher than that at critical point 3 (0.362 vs 0.067, P < 0.05). Compared with 2009 version, 2013 version of the Caprini RAM provides a more accurate and efficacious method for the risk assessment of VTE in Chinese cancer patients.
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Rezapour A, Souresrafil A, Arabloo J. Economic Evaluation of New Oral Anticoagulants in Prevention of Venous Thrombosis Following Joint Replacement Surgery: A Systematic Review. Clin Ther 2021; 43:e139-e156. [PMID: 33875243 DOI: 10.1016/j.clinthera.2021.03.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Revised: 03/05/2021] [Accepted: 03/17/2021] [Indexed: 11/19/2022]
Abstract
PURPOSE The main purpose of prescribing oral anticoagulants in patients undergoing total knee and total hip replacement surgery is to prevent venous thromboembolism (VTE). The present study aimed to summarize evidence from economic evaluations regarding new oral anticoagulants (NOACs) used in VTE prophylaxis after joint replacement surgery. METHODS To obtain relevant literature on economic evaluations of NOACs used in the prevention of VTE following joint replacement surgery, we searched the Cochrane Library, PubMed, Web of Science, Embase, and Scopus, as well as specialized economic evaluation databases, for articles published from January 2008 to December 2019. Next, 2 reviewers screened the titles and abstracts of studies, extracted data from the full-text articles, and assessed the quality of the methodologies using the Quality of Health Economic Studies checklist. FINDINGS Twenty-eight studies of economic evaluations met the inclusion criteria of the research. The quality assessment showed that 20 articles had scores within the range of 75 to 100 (high quality), and 9 studies had scores within the range of 50 to 74 (moderate quality). All of the identified studies had been carried out based on modelling, and 23 studies used decision trees to model acute events after surgery. In addition, 20 studies utilized a Markov model to capture long-term complications of VTE. The results showed that rivaroxaban was more cost-effective than apixaban and dabigatran from a perspective of the health care system in the prevention of VTE after total knee and total hip replacement surgery. In addition, apixaban was associated with a lower risk for bleeding events than other NOACs, making it the most cost-effective NOAC from the perspective of the payer. IMPLICATIONS The results suggest that NOACs are cost-effective alternatives to low-molecular-weight heparins. Rivaroxaban and dabigatran were assessed as the most and least cost-effective prophylaxis options, respectively, after joint replacement surgery for the prevention of VTE. It is recommended that future research be conducted on economic evaluations of edoxaban.
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Affiliation(s)
- Aziz Rezapour
- Health Management and Economics Research Center, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran.
| | - Aghdas Souresrafil
- Department of Health Economics, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran.
| | - Jalal Arabloo
- Health Management and Economics Research Center, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
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Ahmed I, Chawla A, Underwood M, Price AJ, Metcalfe A, Hutchinson CE, Warwick J, Seers K, Parsons H, Wall PDH. Time to reconsider the routine use of tourniquets in total knee arthroplasty surgery. Bone Joint J 2021; 103-B:830-839. [PMID: 33683139 PMCID: PMC8091001 DOI: 10.1302/0301-620x.103b.bjj-2020-1926.r1] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Aims Many surgeons choose to perform total knee arthroplasty (TKA) surgery with the aid of a tourniquet. A tourniquet is a device that fits around the leg and restricts blood flow to the limb. There is a need to understand whether tourniquets are safe, and if they benefit, or harm, patients. The aim of this study was to determine the benefits and harms of tourniquet use in TKA surgery. Methods We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled trials, and trial registries up to 26 March 2020. We included randomized controlled trials (RCTs), comparing TKA with a tourniquet versus without a tourniquet. Outcomes included: pain, function, serious adverse events (SAEs), blood loss, implant stability, duration of surgery, and length of hospital stay. Results We included 41 RCTs with 2,819 participants. SAEs were significantly more common in the tourniquet group (53/901 vs 26/898, tourniquet vs no tourniquet respectively) (risk ratio 1.73 (95% confidence interval (CI) 1.10 to 2.73). The mean pain score on the first postoperative day was 1.25 points higher (95% CI 0.32 to 2.19) in the tourniquet group. Overall blood loss did not differ between groups (mean difference 8.61 ml; 95% CI -83.76 to 100.97). The mean length of hospital stay was 0.34 days longer in the group that had surgery with a tourniquet (95% CI 0.03 to 0.64) and the mean duration of surgery was 3.7 minutes shorter (95% CI -5.53 to -1.87). Conclusion TKA with a tourniquet is associated with an increased risk of SAEs, pain, and a marginally longer hospital stay. The only finding in favour of tourniquet use was a shorter time in theatre. The results make it difficult to justify the routine use of a tourniquet in TKA surgery. Cite this article: Bone Joint J 2021;103-B(5):830–839.
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Affiliation(s)
- Imran Ahmed
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK.,Trauma and Orthopaedic Surgery, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | | | - Martin Underwood
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Andrew J Price
- Nuffield Deparment of Orthopaedics, Musculoskeletal Sciences and Rheumatology, University of Oxford, Oxford, UK
| | - Andrew Metcalfe
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK.,Trauma and Orthopaedic Surgery, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | | | - Jane Warwick
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Kate Seers
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Helen Parsons
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK
| | - Peter D H Wall
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK.,Trauma and Orthopaedic Surgery, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
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Acuña AJ, Grits D, Samuel LT, Emara AK, Kamath AF. Perioperative Blood Transfusions Are Associated with a Higher Incidence of Thromboembolic Events After TKA: An Analysis of 333,463 TKAs. Clin Orthop Relat Res 2021; 479:589-600. [PMID: 33165044 PMCID: PMC7899570 DOI: 10.1097/corr.0000000000001513] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 09/04/2020] [Indexed: 01/31/2023]
Abstract
BACKGROUND Given the morbidity, mortality, and financial burden associated with venous thromboembolism (VTE) after TKA, orthopaedic providers continually seek to identify risk factors associated with this devastating complication. The association between perioperative transfusion status and VTE risk has not been thoroughly explored, with previous studies evaluating this relationship being limited in both generalizability and power. QUESTIONS/PURPOSES Therefore, we sought to determine whether perioperative transfusions were associated with an increased risk of (1) pulmonary embolism (PE) or (2) deep vein thrombosis (DVT) after primary TKA in a large, multi-institutional sample. METHODS The American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database was implemented for our analysis. The definitions of complications, such as DVT and PE, and risk adjustment validation is monitored by the central ACS NSQIP office to ensure participating hospitals are adhering to the same guidelines to log patients. Additionally, both preoperative and intraoperative/72 hour postoperative transfusion status is included for all patients. Therefore, ACS NSQIP was determined to be the most appropriate database for our analysis. All patients who underwent primary TKA between 2011 and 2018 were identified using Current Procedural Terminology code 27447. Primary TKAs designated as "non-elective" were excluded, thereby providing a cohort composed solely of patients undergoing unilateral primary elective TKA for further analysis. The final analysis included 333,463 patients undergoing TKA (mean age 67 ± 9 years, 62% female). Preoperative transfusions were received by < 0.01% (48 of 333,463) of the patients, while 4% (14,590 of 333,463) received a transfusion within the interim between the start of surgery up to 72 hours postoperatively. All missing values were imputed through multiple imputation by chained equation to avoid variable availability-based selection and the subsequent listwise deletion-associated bias in the estimate of parameters. A multivariable logistic regression analysis was conducted using variables identified in a univariate model to calculate adjusted odds ratios and 95% confidence intervals for risk factors associated with symptomatic DVT and/or PE. For variables that maintained significance in the multivariable model, an additional model without confounders was used to generate fully adjusted ORs and 95% CIs. A propensity score matched comparison between recipients versus nonrecipients (1:1) of transfusion (preoperative and intraoperative/72 hours postoperative) was then conducted to evaluate the independent association between DVT/PE development and patients' transfusion status. Significance was determined at a p value < 0.05. RESULTS Adjusted multivariable regression analysis accounting for patient age, sex, race, BMI, American Society of Anesthesiologists (ASA) class and baseline comorbidities demonstrated the absence of an association between preoperative (OR 1.75 [95% CI 0.24 to 12.7]; p = 0.58) or intraoperative/72 hours postoperative (OR 1.12 [95% CI 0.93 to 1.35]; p = 0.23) transfusions and higher odds of developing PE. Similar findings were demonstrated after propensity score matching. Although multivariable regression demonstrated the absence of an association between preoperative transfusion and the odds of developing DVT within the 30-day postoperative period (OR 1.85 [95% CI 0.43 to 8.05]; p = 0.41), intraoperative/postoperative transfusion was associated with higher odds of DVT development (OR 3.68 [95% CI 1.14 to 1.53]; p < 0.001) relative to transfusion naïve patients. However, this significance was lost after propensity score matching. CONCLUSION After controlling for various potential confounding variables such as ASA Class, age, anesthesia type, and BMI, the receipt of an intra- or postoperative transfusion was found to be associated with an increased risk of DVT. Our findings should encourage orthopaedic providers to strictly adhere to blood management protocols, further tighten transfusion eligibility, and adjust surgical approach and implant type to reduce the incidence of transfusion among patients with other DVT risk factors. Additionally, our findings should encourage a multidisciplinary approach to VTE prophylaxis and prevention, as well as to blood transfusion guideline adherence, among all providers of the care team. LEVEL OF EVIDENCE Level III, therapeutic study.
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Affiliation(s)
- Alexander J Acuña
- A. J. Acuña, L. T. Samuel, A. K. Emara, A. F. Kamath, Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
- D. Grits, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | - Daniel Grits
- A. J. Acuña, L. T. Samuel, A. K. Emara, A. F. Kamath, Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
- D. Grits, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | - Linsen T Samuel
- A. J. Acuña, L. T. Samuel, A. K. Emara, A. F. Kamath, Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
- D. Grits, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | - Ahmed K Emara
- A. J. Acuña, L. T. Samuel, A. K. Emara, A. F. Kamath, Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
- D. Grits, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
| | - Atul F Kamath
- A. J. Acuña, L. T. Samuel, A. K. Emara, A. F. Kamath, Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
- D. Grits, Cleveland Clinic Lerner College of Medicine, Cleveland, OH, USA
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Salomon B, Dasa V, Krause PC, Hall L, Chapple AG. Hospital Length of Stay Is Associated With Increased Likelihood for Venous Thromboembolism After Total Joint Arthroplasty. Arthroplast Today 2021; 8:254-257.e1. [PMID: 34095400 PMCID: PMC8167317 DOI: 10.1016/j.artd.2020.12.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Revised: 11/06/2020] [Accepted: 12/20/2020] [Indexed: 02/06/2023] Open
Abstract
Background The prevalence of venous thromboembolism (VTE) after total joint arthroplasty (TJA) is 0.40%-1.2%. Trends in TJA are for shorter hospital stays with lower complication rates. The aim of this study is to evaluate whether hospital length of stay (LOS) is associated with risk of a thromboembolic event after TJA. Methods This was a retrospective study of patients undergoing TJA during 2013-2017 at Louisiana and Texas hospitals. Univariable analyses and multivariable logistic regression examined patient characteristics (sex, race, age, body mass index, Charlson Comorbidity Index, TJA type, and LOS) associated with experiencing a VTE event after discharge and before 1-year follow-up. Results Of the 13,969 patients who met inclusion criteria, 338 (2.4%) had a VTE event after discharge. In multivariable regression analysis, more severe comorbidities (odds ratio: 1.30, 95% confidence interval: 1.23-1.37; P < .001) and LOS days (odds ratio: 1.07, 95% confidence interval: 1.01 to 1.14; P = .0215) were associated with an increased risk of VTE. Conclusion Patients with more severe comorbidities or a longer LOS had a greater risk of VTE after discharge following TJA.
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Affiliation(s)
- Brett Salomon
- LSU HSC NO School of Medicine, New Orleans, LA, USA
- Corresponding author. 1901 Perdido Street, New Orleans, LA 70112, USA. Tel.: +1 504 655 6754.
| | - Vinod Dasa
- LSU HSC NO Department of Orthopaedics, New Orleans, LA, USA
| | | | - Lauren Hall
- Baylor Scott and White Research Institute, Dallas, TX, USA
| | - Andrew G. Chapple
- LSU HSC NO Department of Public Health and Biostatistics, New Orleans, LA, USA
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Wang Y, Zhu LY, Deng HB, Yang X, Wang L, Xu Y, Wang XJ, Pang D, Sun JH, Cao J, Liu G, Liu Y, Ma YF, Wu XJ. Quality appraisal of clinical guidelines for venous thromboembolism prophylaxis in patients undergoing hip and knee arthroplasty: a systematic review. BMJ Open 2020; 10:e040686. [PMID: 33303451 PMCID: PMC7733196 DOI: 10.1136/bmjopen-2020-040686] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 10/25/2020] [Accepted: 11/05/2020] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Venous thromboembolism (VTE) occurs in up to 40%-80% of patients after hip and knee arthroplasty. Clinical decision-making aided by guidelines is the most effective strategy to reduce the burden of VTE. However, the quality of guidelines is dependent on the strength of their evidence base. The objective of this article is to critically evaluate the quality of VTE prevention guidelines and the strength of their recommendations in VTE prophylaxis in patients undergoing hip and knee arthroplasty. METHODS Relevant literature up to 16 March 2020 was systematically searched. We searched databases such as Web of Science, PubMed, EMBASE, Cumulative Index of Nursing and Allied Health Literature, China National Knowledge Infrastructure and WanFang and nine guidelines repositories. The identified guidelines were appraised by two reviewers using the Appraisal of Guidelines for Research and Evaluation II and appraised the strength of their recommendations independently. Following quality assessment, a predesigned data collection form was used to extract the characteristics of the included guideline. RESULTS We finally included 15 guidelines. Ten of the included guidelines were rated as 'recommended' or 'recommended with modifications'. The standardised scores were relatively high in the domains of Clarity of Presentation, and Scope and Purpose. The lowest average standardised scores were observed in the domains of Applicability and Stakeholder Involvement. In reference to the domains of Rigour of Development and Editorial Independence, the standardised scores varied greatly between the guidelines. The agreement between the two appraisers is almost perfect (intraclass correlation coefficients higher than 0.80). A considerable proportion of the recommendations is based on low-quality or very-low-quality evidence or is even based on working group expert opinion. CONCLUSIONS In summary, the majority of the recommendations are based on low-quality evidence, and further confirmation is needed. Furthermore, guideline developers should pay more attention to methodological quality, especially in the Stakeholder Involvement domain and the Applicability domain.
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Affiliation(s)
- Yu Wang
- Department of Nursing, Chinese Academy of Medical Sciences - Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Li-Yun Zhu
- Department of Nursing, Chinese Academy of Medical Sciences - Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Hai-Bo Deng
- Department of Cardiac Surgery, Chinese Academy of Medical Sciences - Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Xu Yang
- Department of Orthopedic Surgery, Chinese Academy of Medical Sciences - Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Lei Wang
- Department of Vascular Surgery, Chinese Academy of Medical Sciences - Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Yuan Xu
- Department of Orthopedic Surgery, Chinese Academy of Medical Sciences - Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Xiao-Jie Wang
- Department of Breast Surgery, Chinese Academy of Medical Sciences - Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Dong Pang
- School of Nursing, Peking University, Beijing, China
- Evidence-Based Nursing: A Joanna Briggs Institute Centre of Excellence, Peking University Health Science Centre, Beijing, China
| | - Jian-Hua Sun
- Intensive Care Unit, Chinese Academy of Medical Sciences - Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Jing Cao
- Department of Nursing, Chinese Academy of Medical Sciences - Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Ge Liu
- Department of Neurological Surgery, Chinese Academy of Medical Sciences - Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Ying Liu
- Department of General Surgery, Chinese Academy of Medical Sciences - Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Yu-Fen Ma
- Outpatient Department, Chinese Academy of Medical Sciences - Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
| | - Xin-Juan Wu
- Department of Nursing, Chinese Academy of Medical Sciences - Peking Union Medical College, Peking Union Medical College Hospital, Beijing, China
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Wu L, Cheng B. Analysis of perioperative risk factors for deep vein thrombosis in patients with femoral and pelvic fractures. J Orthop Surg Res 2020; 15:597. [PMID: 33302974 PMCID: PMC7731763 DOI: 10.1186/s13018-020-02131-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 11/29/2020] [Indexed: 11/20/2022] Open
Abstract
Objective Clinical characteristics, anticoagulant protocols, and risk factors of deep vein thrombosis (DVT) in patients with femoral and pelvic fractures were analyzed throughout the perioperative period to provide references for early identification and optimization of risk factors. Methods This was a retrospective study. A total of 569 patients undergoing surgery of femoral and pelvic fractures from May 2018 to December 2019 were included. The clinical data including general conditions, trauma, surgery, anticoagulant protocols, and laboratory indexes were collected. According to the results of deep vein Doppler ultrasonography of the lower extremities, the patients were divided into non-DVT group and DVT group. Univariate analysis and multivariate logistic regression analysis were used to identify the independent risk factors of preoperative and postoperative DVT. Results The incidence of DVT was 40.25% and preoperative DVT was 26.71%, which was higher than the incidence of postoperative DVT of 17.22%. Most of them were thrombus on the affected side (60.26%) and distal thrombus (81.66%). The average time of DVT formation was 6.55 ± 0.47 days after trauma and 6.67 ± 0.48 days after surgery. Chronic obstructive pulmonary disease (COPD), anemia, hypoproteinemia, non-anticoagulation before surgery, delayed anticoagulation after trauma and admission, high-energy trauma, multiple injuries, drinking history, and advanced age were independent risk factors for perioperative DVT. The increased level of fibrinogen degradation products was an independent risk factor for preoperative DVT. These risk factors were identified to be independently associated with postoperative DVT, including intraoperative blood transfusion, postoperative blood transfusion, pulmonary infection, preoperative non-anticoagulation, postoperative delayed anticoagulation, preoperative waiting time > 7 days, operative time > 2 h, c-reactive protein, fibrinogen level, platelet count 1 day after surgery, c-reactive protein, fibrinogen, and hemoglobin levels 3 days after surgery, comminuted fracture. Conclusions At present, anticoagulation and other DVT prevention and treatment programs have not changed the current situation that the incidence of DVT is still high. Through the analysis of the risk factors of DVT throughout the perioperative period, optimizing the perioperative blood transfusion, preoperative lung disease, hypoproteinemia, anemia, inflammation, etc., and surgery as soon as possible after trauma may further reduce its incidence.
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Affiliation(s)
- Linqin Wu
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Yuzhong District, Chongqing, 400000, China
| | - Bo Cheng
- Department of Anesthesiology, The First Affiliated Hospital of Chongqing Medical University, Yuzhong District, Chongqing, 400000, China.
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Sloan M, Lee GC. Mortality and Complications in Patients with Metastatic Disease after Primary Total Hip and Total Knee Arthroplasty. J Arthroplasty 2020; 35:3512-3516. [PMID: 32690429 DOI: 10.1016/j.arth.2020.06.080] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Revised: 06/26/2020] [Accepted: 06/26/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Although palliative therapies such as radiation are usually performed to improve quality of life in patients with metastatic disease, arthroplasty for joint pain may be indicated in some cases. Therefore, the purpose of this study is to evaluate the 30-day mortality risk, the risk of complications including infection and venous thromboembolic events, and the rate of 30-day reoperations and readmissions in patients with metastatic disease undergoing primary total hip and total knee arthroplasty (THA/TKA). METHODS We reviewed the National Surgical Quality Improvement Program database from 2008 to 2018 to evaluate rates of postoperative complications after elective primary THA/TKA in patients with disseminated cancer. After exclusions, 205,007 patients undergoing primary THA and 352,337 undergoing primary TKA were retained for analysis: 942 (0.2%) with disseminated cancer. Chi-square was used to compare proportions between groups. Univariate and multivariate logistic regression was used to model the odds ratio of patients with disseminated cancer compared with those without disseminated cancer. RESULTS After adjustment for covariates, patients with disseminated cancer had a higher risk of death (OR: 5.25, 95% CI: 2.47-11.17), any complication (OR: 1.95, 95% CI: 1.63-2.33), deep venous thrombosis (OR: 2.39, 95% CI: 1.32-4.35), pulmonary embolism (OR: 3.07, 95% CI: 1.52-6.17), cardiovascular complications (OR: 2.98, 95% CI: 1.47-6.04), transfusion (OR: 2.21, 95% CI: 1.82-2.69), reoperations (OR: 1.89, 95% CI: 1.28-2.78), readmissions (OR: 2.51, 95% CI: 1.95-3.23), and longer length of stay (4.3 vs 2.7 days). CONCLUSION Patients with disseminated cancer have significantly elevated risk of complications after elective primary THA/TKA. Understanding the severity of complications is critical to the risk-benefit analysis that confronts patients and surgeons considering surgery. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Matthew Sloan
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA
| | - Gwo-Chin Lee
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA
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Yang Y, Li Z, Liang H, Tian J. Association between metabolic syndrome and venous thromboembolism after total joint arthroplasty: a meta-analysis of cohort studies. J Orthop Surg Res 2020; 15:570. [PMID: 33256765 PMCID: PMC7706034 DOI: 10.1186/s13018-020-02097-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 11/18/2020] [Indexed: 02/06/2023] Open
Abstract
Objective Metabolic syndrome (MetS) has been associated with hypercoagulative status. However, previous studies evaluating the association between MetS and incidence of venous thromboembolism (VTE) after total joint arthroplasty (TJA) showed inconsistent results. We performed a meta-analysis to evaluate the influence of MetS on the risk of VTE following TJA. Methods Cohort studies were identified by the search of PubMed, Embase, and the Cochrane’s Library databases. A random-effect model was used if considerable heterogeneity was detected; otherwise, a fixed-effect model was used. Subgroup analyses according to the category of VTE, definition of MetS, category of procedure, and follow-up durations were performed. Results Seven cohort studies with 1,341,457 patients that underwent TJA were included, with 118,060 MetS patients (8.8%) at baseline. With a follow-up duration up to 3 months after surgery, 9788 patients had VTE. Pooled results with a random-effect model showed that MetS was not associated with increased overall VTE after TJA (adjusted risk ratio [RR] = 1.24, 95% confidence interval [CI] 0.89 ~ 1.72, p = 0.20; I2 = 69%). The results were not significantly affected by the diagnostic criteria of MetS, category of the procedure, and follow-up durations. Subgroup analyses showed that MetS was not associated with an increased the risk of pulmonary embolism ([PE], RR 1.06, 95% CI 0.37 ~ 3.02, p = 0.91), but an increased risk of deep vein thrombosis (DVT) after TJA (RR 3.38, 95% CI 1.83 ~ 6.24, p < 0.001). Conclusions Current evidence from observational studies suggests MetS might be associated with an increased risk of DVT but not PE after TJA.
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Affiliation(s)
- Yipei Yang
- Department of Orthopedic and Joint Surgery, Zhu Jiang Hospital, Southern Medical University, No. 253 Middle Gongye Dadao, Haizhu District, Guangzhou, 510000, China
| | - Ziyue Li
- Department of Doppler Ultrasonic Department, Shen Zhen Hospital, Southern Medical University, Shenzhen, 518000, China
| | - Haifeng Liang
- Department of Orthopedic and Joint Surgery, Zhu Jiang Hospital, Southern Medical University, No. 253 Middle Gongye Dadao, Haizhu District, Guangzhou, 510000, China
| | - Jing Tian
- Department of Orthopedic and Joint Surgery, Zhu Jiang Hospital, Southern Medical University, No. 253 Middle Gongye Dadao, Haizhu District, Guangzhou, 510000, China.
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Bala A, Murasko MJ, Burk DR, Huddleston JI, Goodman SB, Maloney WJ, Amanatullah DF. Venous thromboprophylaxis after total hip arthroplasty: aspirin, warfarin, enoxaparin, or factor Xa inhibitors? Hip Int 2020; 30:564-571. [PMID: 30990095 DOI: 10.1177/1120700019841600] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Debate over the ideal agent for venous thromboembolism (VTE) prophylaxis after total hip arthroplasty (THA) has led to changes in prescribing trends of commonly used agents. We investigate variation in utilisation and the differences in VTE incidence and bleeding risk in primary THA after administration of aspirin, warfarin, enoxaparin, or factor Xa inhibitors. METHODS 8829 patients were age/sex matched from a large database of primary THAs performed between 2007 and 2016. Utilisation was calculated using compound annual growth rate. Incidence of postoperative deep venous thrombosis (DVT), pulmonary embolism (PE), bleeding-related complications, postoperative anaemia, and transfusion were identified at 2 weeks, 30 days, 6 weeks, and 90 days. RESULTS Aspirin use increased by 33%, enoxaparin by 7%, and factor Xa inhibitors by 31%. Warfarin use decreased by 1%. Factor Xa inhibitors (1.7%) and aspirin (1.7%) had the lowest incidence of DVT followed by enoxaparin (2.6%), and warfarin (3.7%) at 90 days. Factor Xa inhibitors (12%) and aspirin (12%) had the lowest incidence of blood transfusion followed by warfarin (15%) and enoxaparin (17%) at 90 days. There was no difference in incidence of blood transfusion or bleeding-related complications nor any detectable difference in symptomatic PE incidence. CONCLUSIONS The utilisation of aspirin and factor Xa inhibitors increased over time. Aspirin and factor Xa inhibitors provided improved DVT prophylaxis with lower rates of postoperative anaemia compared to enoxaparin and warfarin.
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Affiliation(s)
- Abiram Bala
- Department of Orthopaedic Surgery, Stanford Hospital and Clinics, Redwood City, CA, USA
| | - Marlon J Murasko
- Department of Orthopaedic Surgery, Stanford Hospital and Clinics, Redwood City, CA, USA
| | - David R Burk
- Department of Orthopaedic Surgery, Stanford Hospital and Clinics, Redwood City, CA, USA
| | - James I Huddleston
- Department of Orthopaedic Surgery, Stanford Hospital and Clinics, Redwood City, CA, USA
| | - Stuart B Goodman
- Department of Orthopaedic Surgery, Stanford Hospital and Clinics, Redwood City, CA, USA
| | - William J Maloney
- Department of Orthopaedic Surgery, Stanford Hospital and Clinics, Redwood City, CA, USA
| | - Derek F Amanatullah
- Department of Orthopaedic Surgery, Stanford Hospital and Clinics, Redwood City, CA, USA
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Tang A, Zak S, Iorio R, Slover J, Bosco J, Schwarzkopf R. Low-Dose Aspirin Is Safe and Effective for Venous Thromboembolism Prevention in Patients Undergoing Revision Total Hip Arthroplasty: A Retrospective Cohort Study. J Arthroplasty 2020; 35:2182-2187. [PMID: 32334898 DOI: 10.1016/j.arth.2020.03.040] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 03/22/2020] [Accepted: 03/24/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Currently, there is no established universal standard of care for prophylaxis against venous thromboembolism (VTE) in orthopedic patients undergoing revision total hip arthroplasty (rTHA). The aim of this study is to determine whether a protocol of 81-mg aspirin (ASA) bis in die (BID) is safe and/or effective in preventing VTE in patients undergoing rTHAs vs 325-mg ASA BID. METHODS In 2017, a large academic medical center adopted a new protocol for VTE prophylaxis in arthroplasty patients at standard risk. Initially, patients received 325-mg ASA BID but switched to 81-mg ASA BID. A retrospective review (2011-2019) was performed to identify 1361 consecutive rTHA patients and their associated 90-day postoperative complications such as VTE, including pulmonary embolism (PE) and/or deep vein thrombosis (DVT), as the primary outcome; and gastrointestinal and wound bleeding, acute periprosthetic joint infection, and mortality as the secondary outcome. RESULTS From 2011 to 2017, 973 rTHAs were performed and 13 total VTE cases were diagnosed (1.34%). From 2017 to 2019, 388 rTHAs were performed with 3 total VTE cases identified (0.77%). Chi-squared analyses and logistic regression models showed no differences in rates or odds in postoperative PE (P = .09), DVT (P = .79), PE and DVT (P = .85), and total VTE (P = .38) using either dose. There were also no differences between bleeding complications (P = .14), infection rate (P = .46), and mortality (P = .53). CONCLUSION Using a protocol of 81-mg of ASA BID is noninferior to 325-mg ASA BID and may be safe and effective in maintaining low rates of VTE in patients undergoing rTHA.
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Affiliation(s)
- Alex Tang
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | - Stephen Zak
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | - Richard Iorio
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA
| | - James Slover
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | - Joseph Bosco
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
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Zhang S, Chu W, Wang H, Liang Y, Fan Y, Liu H, Wei G. Evaluation of stability of deep venous thrombosis of the lower extremities using Doppler ultrasound. J Int Med Res 2020; 48:300060520942098. [PMID: 32841580 PMCID: PMC7526051 DOI: 10.1177/0300060520942098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective This study aimed to assess using Doppler ultrasound for analyzing stability of deep venous thrombosis (DVT) of the lower extremities. Methods Patients with DVT of the lower extremities who were treated from August 2017 to December 2019 were selected. The patients were divided into stable and unstable groups according to whether thrombus was collected in a filter. Related ultrasound and blood test results were analyzed and compared. Results A total of 126 patients with DVT of the lower extremities were included, of whom 74 were in the stable group and 52 were in the unstable group. There were significant differences in the prothrombin time (PT), and lipoprotein alpha, D-dimer, and triglyceride levels between the groups. D-dimer levels >2800 ug/L, smoking, history of venous thrombosis, PT >13.15 s, and body mass index >24.45 kg/m2 were independent risk factors for stability of DVT of the lower extremities. The area under the curve with combined detection of DVT was significantly higher than that for body mass index, PT, and D-dimer alone. Conclusion Doppler ultrasound may be reliable for analyzing the stability of DVT of the lower extremities. Related strategies targeting risk factors are required for reducing DVT of the lower extremities.
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Affiliation(s)
- Shefang Zhang
- Department of Ultrasound, Luoyang Central Hospital Affiliated to Zhengzhou University, Luoyang City, Henan Province, China
| | - Wen Chu
- Department of Ultrasound, Luoyang Central Hospital Affiliated to Zhengzhou University, Luoyang City, Henan Province, China
| | - Hua Wang
- Department of Ultrasound, Luoyang Central Hospital Affiliated to Zhengzhou University, Luoyang City, Henan Province, China
| | - Yajun Liang
- Department of Ultrasound, Luoyang Central Hospital Affiliated to Zhengzhou University, Luoyang City, Henan Province, China
| | - Yajuan Fan
- Department of Ultrasound, Luoyang Central Hospital Affiliated to Zhengzhou University, Luoyang City, Henan Province, China
| | - Hui Liu
- Department of Ultrasound, Luoyang Central Hospital Affiliated to Zhengzhou University, Luoyang City, Henan Province, China
| | - Guoshi Wei
- Department of Clinical Pharmacy, Luoyang Central Hospital Affiliated to Zhengzhou University, Luoyang City, Henan Province, China
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Core and adjunctive interventions for osteoarthritis: efficacy and models for implementation. Nat Rev Rheumatol 2020; 16:434-447. [DOI: 10.1038/s41584-020-0447-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/26/2020] [Indexed: 12/13/2022]
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Maron SZ, Neifert SN, Ranson WA, Nistal DA, Rothrock RJ, Cooke P, Lamb CD, Cho SK, Caridi JM. Elixhauser Comorbidity Measure is Superior to Charlson Comorbidity Index In-Predicting Hospital Complications Following Elective Posterior Cervical Decompression and Fusion. World Neurosurg 2020; 138:e26-e34. [DOI: 10.1016/j.wneu.2020.01.141] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 01/17/2020] [Accepted: 01/18/2020] [Indexed: 02/02/2023]
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Tripp H, Fencl JL. Perioperative Nursing Considerations for Patients Undergoing Total Hip or Knee Arthroplasty. AORN J 2020; 111:227-232. [PMID: 31997331 DOI: 10.1002/aorn.12943] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Warren JA, Sundaram K, Anis HK, Kamath AF, Higuera CA, Piuzzi NS. Have Venous Thromboembolism Rates Decreased in Total Hip and Knee Arthroplasty? J Arthroplasty 2020; 35:259-264. [PMID: 31530463 DOI: 10.1016/j.arth.2019.08.049] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 08/13/2019] [Accepted: 08/22/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is a major cause of morbidity, mortality, and healthcare costs in arthroplasty patients. In an effort to reduce VTEs, numerous strategies and guidelines have been implemented, but their impact remains unclear. The purpose of this study is to compare annual trends in 30-day VTE, deep vein thrombosis (DVT), pulmonary embolism (PE), and all-cause mortality in (1) total hip arthroplasty (THA) and (2) total knee arthroplasty (TKA). METHODS The American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database identified 363,530 patients who received a TKA or THA from 2008 to 2016. Bivariate analysis was performed to assess the association between the year in which surgery was performed and demographics and comorbidities. Bimodal multivariate logistic regression models for THA and TKA were developed for 2009-2016 using 2008 as a reference. RESULTS Overall incidence of VTE, DVT, PE, and mortality for THA were 0.6%, 0.4%, 0.3%, and 0.2%, respectively. Based off of multivariate regression VTE, DVT, PE, and mortality rates have shown no significant (P > .05) change from 2008 to 2016 in THA patients. Overall incidence of VTE, DVT, PE, and mortality for TKA were 1.4%, 0.9%, 0.6%, and 0.1%, respectively. Multivariate regression revealed reductions when compared to 2008 for VTEs and DVTs from 2009 to 2016 (P < .05) for TKA patients. A significant reduction in PEs (P = .002) was discovered for 2016, while no significant change was observed in mortality (P > .05). CONCLUSION Approximately 1 in 71 patient undergoing TKA, and 1 in 167 undergoing THA developed a VTE within 30 days after surgery. Our study demonstrated that VTE incidence rates have decreased in TKA, while remaining stable in THA over the past 8 years. Further research to determine the optimal prophylaxis algorithm that would allow for a personalized, efficacious, and safe thromboprophylaxis regimen is needed. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Jared A Warren
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Kavin Sundaram
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Hiba K Anis
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Atul F Kamath
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Carlos A Higuera
- Department of Orthopedic Surgery, Cleveland Clinic Florida, Weston, FL
| | - Nicolas S Piuzzi
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, OH
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Warren JA, Sundaram K, Kamath AF, Molloy RM, Krebs VE, Mont MA, Piuzzi NS. Venous Thromboembolism Rates Did Not Decrease in Lower Extremity Revision Total Joint Arthroplasty From 2008 to 2016. J Arthroplasty 2019; 34:2774-2779. [PMID: 31153709 DOI: 10.1016/j.arth.2019.05.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 04/24/2019] [Accepted: 05/06/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND In revision total knee arthroplasty (rTKA) and revision total hip arthroplasty (rTHA), venous thromboembolism (VTE) has been reported to be a relatively common and potentially serious complication. To mitigate this risk, strategies such as rapid recovery programs and thromboprophylaxis guidelines have been utilized. This study sought to identify the annual incidence and recent trends of VTE (defined as the presence of deep vein thrombosis [DVT] and/or pulmonary embolism [PE] in the same patient), DVT, PE, and mortality in the 30-day period after rTKA and rTHA. METHODS We identified 30,406 rTKA and rTHA patients from 2008 to 2016 using the National Surgical Quality Improvement Program database. Thirty-day incidences for VTE, DVT, PE, and mortality for each year and the overall study period were calculated. Bivariate and multivariate regressions were performed using patient demographics and comorbidities to assess trends in the outcomes of interest. RESULTS The overall incidences of 30-day VTE, DVT, PE, and mortality for rTKA were 1.2%, 0.9%, 0.4%, and 0.5%. Bivariate analysis revealed no significant change over the study period for VTE (P = .137), DVT (P = .406), PE (P = .121; 99% confidence interval 0.112-0.129), and mortality (P = .463). The incidences over the study period of VTE, DVT, PE, and mortality in rTHA were 1.0%, 0.7%, 0.4%, and 0.7%. Bivariate analysis revealed no changes in VTE (P = .393), DVT (P = .376), and PE (P = .602). However, bivariate analysis revealed significant decrease in mortality (P = .010) over the study period. CONCLUSION Within 30 days of surgery, approximately 1 in 83 rTKA patients and 1 in 100 rTHA patients experienced a VTE. Furthermore, the rates of VTE remained largely unchanged from 2008 to 2016. Further research regarding the optimal individualized prophylaxis algorithm in rTKA and rTHA is warranted to prevent this complication. This study represents the first investigation of thromboembolic events in rTHA and rTKA.
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Affiliation(s)
- Jared A Warren
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Kavin Sundaram
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Atul F Kamath
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Robert M Molloy
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Viktor E Krebs
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Michael A Mont
- Department of Orthopedic Surgery, Lenox Hill Hospital, New York, NY
| | - Nicolas S Piuzzi
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, OH
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Jawhar A, Skeirek D, Stetzelberger V, Obertacke U. Influence of the Tourniquet on Pain and Function in Total Knee Arthroplasty: a Systematic Review and Meta-Analysis. ZEITSCHRIFT FUR ORTHOPADIE UND UNFALLCHIRURGIE 2019; 158:630-640. [PMID: 31556080 DOI: 10.1055/a-0983-3808] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The use of the tourniquet in total knee arthroplasty is still a subject of controversial discussion. Previous studies mainly focus on parameters like blood loss and operation time. The aim of this systematic review is to evaluate the postoperative outcome involving parameters such as pain intensity, analgesic consumption, knee function and complication rate with and without tourniquet use, to find a recommendation for future application in total knee arthroplasty. MATERIAL AND METHODS This review is based on the PRISMA Checklists. A systematic research was performed in PubMed using the key words "tourniquet", "total knee arthroplasty", "TKA" and "knee endoprosthesis" up to and including January 2018. The initial search revealed 686 Papers which were extracted by the parameters intensity of pain, analgesic consumption, function (range of motion, Hospital for Special Surgery Score, Knee Society Score) and complications (deep vein thrombosis, surgical side infection, pulmonary embolism). The program Review Manager Version 5.3 was used for statistical analysis. A significance level of p < 0,05 was defined. RESULTS 18 studies were included in this review with 1279 total knee arthroplasties overall (646 with the use of tourniquet and 633 without). The analysis shows a significant lower pain intensity until the fifth postoperative day (p = 0,03) and also after one to three months (p = 0,04) without using the tourniquet. Range of motion is significantly higher in two to three days postoperatively (p < 0,00 001) when the surgery was performed without tourniquet. Knee Society Score shows no difference between the two groups. A deep vein thrombosis appears significantly more often when using a tourniquet (p = 0,04). There was no higher occurrence in pulmonary embolism and surgical side infections. CONCLUSION The use of a pneumatic tourniquet in total knee arthroplasty affects especially the early postoperative pain and functional recovery.
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Affiliation(s)
- Ahmed Jawhar
- Orthopaedic-Trauma Surgery Centre, University Medicine Mannheim; Medical Faculty Mannheim of the University of Heidelberg, Mannheim
| | - Dania Skeirek
- Orthopaedic-Trauma Surgery Centre, University Medicine Mannheim; Medical Faculty Mannheim of the University of Heidelberg, Mannheim
| | - Vera Stetzelberger
- Orthopaedic-Trauma Surgery Centre, University Medicine Mannheim; Medical Faculty Mannheim of the University of Heidelberg, Mannheim
| | - Udo Obertacke
- Orthopaedic-Trauma Surgery Centre, University Medicine Mannheim; Medical Faculty Mannheim of the University of Heidelberg, Mannheim
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Krauss ES, Segal A, Cronin M, Dengler N, Lesser ML, Ahn S, Caprini JA. Implementation and Validation of the 2013 Caprini Score for Risk Stratification of Arthroplasty Patients in the Prevention of Venous Thrombosis. Clin Appl Thromb Hemost 2019; 25:1076029619838066. [PMID: 30939898 PMCID: PMC6714918 DOI: 10.1177/1076029619838066] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Appropriate chemoprophylaxis choice following arthroplasty requires accurate patient risk
assessment. We compared the results of our prospective department protocol to the Caprini
risk assessment model (RAM) retrospectively in this study group. Our goal was to determine
whether the department protocol or the Caprini score would identify venous thromboembolism
(VTE) events after total joint replacement. A secondary purpose was to validate the 2013
Caprini RAM in joint arthroplasty and determine whether patients with VTE would be
accurately identified using the Caprini score. A total of 1078 patients met inclusion
criteria. A Caprini score of 10 or greater is considered high risk and a score of 9 or
less is considered low risk. The 2013 version of the Caprini RAM retrospectively
stratified 7 of the 8 VTE events correctly, while only 1 VTE was identified with the
prospective department protocol. This tool provided a consistent, accurate, and
efficacious method for risk stratification and selection of chemoprophylaxis.
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Affiliation(s)
- Eugene S Krauss
- 1 Department of Orthopaedic Surgery, Northwell Health, Syosset Hospital, Syosset, NY, USA
| | - Ayal Segal
- 1 Department of Orthopaedic Surgery, Northwell Health, Syosset Hospital, Syosset, NY, USA
| | - MaryAnne Cronin
- 3 Emeritus, NorthShore University Health System, Evanston, IL, USA
| | - Nancy Dengler
- 1 Department of Orthopaedic Surgery, Northwell Health, Syosset Hospital, Syosset, NY, USA
| | - Martin L Lesser
- 2 Biostatistics Unit, Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - Seungjun Ahn
- 2 Biostatistics Unit, Feinstein Institute for Medical Research, Manhasset, NY, USA
| | - Joseph A Caprini
- 3 Emeritus, NorthShore University Health System, Evanston, IL, USA.,4 University of Chicago Pritzker School of Medicine, Chicago, IL, USA
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Örgel M, Aschoff HH, Krettek C, Graulich T, Omar M, Harb A, Alazzawi S. Perioperative mortality secondary to a pulmonary embolism during a surgical implantation of the Endo-Exo-Prosthesis: a case report. ESC Heart Fail 2019; 6:1092-1095. [PMID: 31290287 PMCID: PMC6816062 DOI: 10.1002/ehf2.12489] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2018] [Revised: 04/10/2019] [Accepted: 06/07/2019] [Indexed: 11/25/2022] Open
Abstract
We report on a 53‐year‐old female patient who suffered a perioperative death secondary to a pulmonary embolism (PE) during an implantation of Endo‐Exo‐Prosthesis. This is a retrospective review of medical case for a patient who had a previous above‐the‐knee amputation secondary to a failed previous arthroplasty surgery. Our planned surgery was a stage 1 implantation of an Endo‐Exo‐Prosthesis, and it was performed under general anaesthesia. After 25 min from starting the surgical procedure, the patient sustained a cardiac arrest, and despite an active cardiopulmonary resuscitation for 50 min, the patient did not recover, the ventilator machine was stopped later on, and the patient was declared deceased at that stage. Fatal intraoperative PE is a rare but significant complication during orthopaedic procedures. There are few reports of similar events but include mainly trauma patients with fractured neck of femur. Endo‐Exo‐Prosthesis is a relatively newly evolved procedure in a unique group of patients. To our knowledge, this is the first case report of such complication during Endo‐Exo‐Prosthesis implantation. Patient and surgeon should be aware of it, and additional preventive measures like preoperative scoring systems and in special cases using inferior vena cava filter should be considered in patients with high risk of developing venous thromboembolism.
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Affiliation(s)
- Marcus Örgel
- Trauma Department, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Horst-Heinrich Aschoff
- Trauma Department, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Christian Krettek
- Trauma Department, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Tilman Graulich
- Trauma Department, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Mohamed Omar
- Trauma Department, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Afif Harb
- Trauma Department, Hannover Medical School, Carl-Neuberg-Straße 1, 30625, Hannover, Germany
| | - Sulaiman Alazzawi
- Orthopaedic Department, UBC Hospital, 2211 Wesbrook Mall, Vancouver, BC, V6T 2B5, Canada
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Xu H, Zhang S, Xie J, Lei Y, Cao G, Chen G, Pei F. A nested case-control study on the risk factors of deep vein thrombosis for Chinese after total joint arthroplasty. J Orthop Surg Res 2019; 14:188. [PMID: 31234861 PMCID: PMC6591890 DOI: 10.1186/s13018-019-1231-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 06/07/2019] [Indexed: 02/05/2023] Open
Abstract
Background Deep vein thrombosis (DVT) is one of the life-threatening complications of total joint arthroplasty (TJA) postoperatively, and its risk factors are still controversial. The aim of this study was to identify the risk factors of DVT after TJA. Study design and methods A nested case-control study based on a large dataset of 15,326 patients undergoing TJA was performed. Potential risk factors of DVT and demographic information were extracted from the electronic health record. Patients with DVT (73 patients) were treated as study group while non-DVT patients who were matched 1:4 according to the anticoagulant type, were considered as control group (292 patients). These variables of potential risk factors for DVT including age, sex, body mass index (BMI), American Society of Anesthesiologists class, comorbidity, preoperative hemoglobin (HB) level and analgesic use, surgical site (knee or hip) and type, the start time of drug anticoagulation, ambulation time, transfusion, and whether to use tranexamic acid (TXA), drain, human serum albumin, and measures of physical thromboprophylaxis after operation were collected and evaluated by survival analysis and presented as P value and odds ratio with 95% confidence interval. Results There were 15,326 patients underwent TJA and 73 (0.48%) patients had DVT among them, and the occurrence rates were 0.71% for the patients underwent total knee arthroplasty (TKA) while 0.24% for total hip arthroplasty. The risk factors associated with DVT included TKA (compared with THA), advanced age (> 70 years), drain use, and delayed ambulation (≥ 72 h) postoperatively. Conclusion The present results suggest that the occurrence rate of DVT on the patients underwent TJA was low (0.48%) relatively. And the risk factors associated with increased risk of DVT included TKA (compared with THA), advanced age, drain use, and delayed ambulation postoperatively. Individualized and more efficient risk stratification protocols of anticoagulation after TJA for Chinese may need to be developed in the future.
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Affiliation(s)
- Hong Xu
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Shaoyun Zhang
- Department of Orthopedics, The Third Hospital of Mianyang • Sichuan Mental Health Center, No. 190 The East Jiannan Road, Mianyang, 621000, People's Republic of China
| | - Jinwei Xie
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Yiting Lei
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Guorui Cao
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Guo Chen
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China
| | - Fuxing Pei
- Department of Orthopaedic Surgery, West China Hospital, Sichuan University, Chengdu, 610041, People's Republic of China.
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