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Barronian T, Scaramella AYE, Ponzio DY, Post ZD, Ong AC. Impact of COVID-19 on Pulmonary Embolism Rates in Patients Undergoing Total Joint Arthroplasty. Orthopedics 2024; 47:233-237. [PMID: 38810130 DOI: 10.3928/01477447-20240520-02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/31/2024]
Abstract
BACKGROUND The purpose of this study was to evaluate the incidence and severity of pulmonary embolism (PE) in patients undergoing total hip and knee arthroplasties after the onset of the coronavirus disease 2019 (COVID-19) pandemic. MATERIALS AND METHODS Patients who underwent a total hip arthroplasty or a total knee arthroplasty between 2017 and 2022 and had a PE within 90 days postoperatively were included. Demographics, medical history, procedural information, and PE outcomes were collected and evaluated. RESULTS There were 5933 procedures and 17 PE events (0.27%) before COVID-19 compared with 3273 procedures and 16 PE events (0.49%) after COVID-19 (P=.12). There was an increase in intensive care unit admission after COVID-19 (44% vs 0%, P<.05). CONCLUSION This study showed a trend toward an increased incidence of PE events in the post-COVID-19 cohort and a statistically significant increase in the severity. [Orthopedics. 2024;47(4):233-237.].
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Gettleman BS, Liu KC, Yoshida B, Vega AN, Kusnezov N, Lieberman JR, Heckmann ND. Perioperative Dexamethasone is Associated with a Decreased Risk of Pulmonary Embolism and Deep Vein Thrombosis Following Total Joint Arthroplasty: An Analysis of 70,000 High-Risk Patients. J Arthroplasty 2024:S0883-5403(24)00453-4. [PMID: 38735549 DOI: 10.1016/j.arth.2024.05.020] [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: 09/23/2023] [Revised: 05/02/2024] [Accepted: 05/03/2024] [Indexed: 05/14/2024] Open
Abstract
BACKGROUND Dexamethasone (DEX) has demonstrated promise with respect to decreasing postoperative thromboembolic complications following total joint arthroplasty (TJA). Therefore, the aim of this study was to investigate the effects of perioperative intravenous DEX on rates of pulmonary embolism (PE) and deep vein thrombosis (DVT) after primary TJA in patients who have a history of venous thromboembolism (VTE). METHODS Patients who have a history of VTE who underwent primary, elective TJA from 2015 to 2021 were identified using a commercial healthcare database. Patients were divided based on receipt of perioperative intravenous DEX [DEX(+) versus DEX(-)] on the day of index TJA. Patient demographics and hospital factors were collected. The 90-day risk of postoperative complications, readmission, and in-hospital mortality were compared. RESULTS Overall, 70,147 patients who had a history of VTE underwent TJA, of which 40,607 (57.89%) received DEX and 29,540 (42.11%) did not. The DEX(+) patients were younger (67 ± 9.8 versus 68 ± 9.9 years, P < 0.001) and had a significantly shorter length of stay compared to the DEX(-) patients (1.8 ± 1.6 versus 2.2 ± 1.8 days, P < 0.001). The DEX(+) patients demonstrated lower rates of PE (1.37 versus 1.75%, P < 0.001) and DVT (2.37 versus 3.01%, P < 0.001) compared to DEX(-) patients. The DEX(+) patients experienced a lower risk of PE (adjusted odds ratio [aOR] 0.78, 95% confidence interval [95%-CI]: 0.66 to 0.93, P = 0.006) and DVT (aOR: 0.84, 95%-CI: 0.74 to 0.95, P = 0.006) compared to DEX(-) patients. The DEX(+) patients demonstrated no differences in the odds of surgical site infection, periprosthetic joint infection, or sepsis compared to the DEX(-) patients (P > 0.05). CONCLUSION The administration of DEX was associated with a decreased risk of PE and DVT in patients who have a history of VTE who underwent TJA. These data warrant further study investigating the postoperative benefits of perioperative DEX administration for high-risk patients undergoing TJA.
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Affiliation(s)
- Brandon S Gettleman
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Kevin C Liu
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Brandon Yoshida
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Andrew N Vega
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Nicholas Kusnezov
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Jay R Lieberman
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California
| | - Nathanael D Heckmann
- Department of Orthopaedic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, California.
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Sochart S, Baryeh K, Sochart DH. The use of pre-operative Inferior Vena Cava filters for thromboprophylaxis in ultra-high-risk patients undergoing total hip and knee arthroplasty: a systematic review and narrative analysis. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2023; 33:2749-2764. [PMID: 37000238 PMCID: PMC10063930 DOI: 10.1007/s00590-023-03531-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 03/20/2023] [Indexed: 04/01/2023]
Abstract
PURPOSE Patients undergoing total hip (THA) or knee (TKA) arthroplasty are at high risk of venous thromboembolism (VTE). As the number performed annually increases, the population at risk of fatal pulmonary embolism (PE) also grows. Ultra-high-risk arthroplasty patients (UHRAPs) include those with additional comorbidities, or a history of VTE, for many of whom routine prophylaxis will previously have failed. Pre-operative insertion of Inferior Vena Cava filters (IVCFs) has been recommended for thromboprophylaxis in UHRAPs, and this review was performed to establish their results. METHODS A systematic search of MEDLINE and Embase databases was performed for studies reporting the use of Inferior Vena Cava filters in hip and knee arthroplasty patients. RESULTS Ten studies met the inclusion criteria, containing 718 IVCFs in Orthopaedic patients, 343 of which were permanent (47.8%), 369 potentially retrievable (51.4%), 5 absorbable (0.6%) and one of unknown design (0.1%). Patient age averaged 64.7yrs (17-95) and 56% were female. Pre-operatively, 415 prophylactic IVCFs were inserted in 409 UHRAPs, undergoing a total of 438 total joint arthroplasties (TJA). There were 11 cases of PE in the entire series (1.5%) only one of which was fatal (0.01%), with four non-fatal PE in the UHRAP group (0.96%). Removal was attempted for 283 of the retrievable filters (76.7%) and was successful in 280 (98.9%). CONCLUSION The use of IVCFs eliminated fatal PE in UHRAPs, but larger, high-quality studies, with standardised reporting, are still required to determine their absolute indications for use, complication profile, efficacy and optimum design.
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Affiliation(s)
- Sarita Sochart
- Hyperacute Stroke Unit, Frimley Park Hospital, Portsmouth Rd, Frimley, Camberley, GU16 7UJ, UK
| | - Kwaku Baryeh
- Postgraduate Medical Education Department, West Middlesex University Hospital, Twickenham Road, Middlesex, TW7 6AF, UK.
| | - David H Sochart
- The Academic Surgical Unit, South West London Elective Orthopaedic Centre (SWLEOC), Dorking Road, Epsom, Surrey, KT18 7EG, UK
- The School of Health and Society, The University of Salford, Salford, UK
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Duke AJ, Bowen S, Baig S, Cohen D, Komatsu DE, Nicholson J. Thirty day low-dose versus regular-dose aspirin for venous thromboembolism prophylaxis in primary total joint arthroplasty. J Orthop Surg (Hong Kong) 2023; 31:10225536231173329. [PMID: 37137821 DOI: 10.1177/10225536231173329] [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] [Indexed: 05/05/2023] Open
Abstract
BACKGROUND The optimal dosing of aspirin (ASA) monotherapy for prophylaxis after total joint arthroplasty is debatable. The objective of this study was to compare two ASA regimens with regards to symptomatic deep venous thrombosis (DVT), pulmonary embolism (PE), bleeding, and infection 90 days after primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). METHODS We retrospectively identified 625 primary THA and TKA surgeries in 483 patients who received ASA for 4 weeks post-op. 301 patients received 325 mg once daily (QD) and 324 patients received 81 mg twice daily (BID). Patients were excluded if they were minors, had a prior venous thromboembolism (VTE), had ASA allergy, or received other VTE prophylaxis drugs. RESULTS There was a significant difference in rate of bleeding and suture reactions between the two groups. Bleeding was 7.6% for 325 mg QD and 2.5% for 81 mg BID (p = .0029 Χ2, p = .004 on multivariate logistic regression analysis). Suture reactions were 3.3% for 325 mg QD and 1.2% for 81 mg BID (p = .010 Χ2, p = .027 on multivariate logistic regression analysis). Rates of VTE, symptomatic DVT, and PE were not significantly different. The incidence of VTE was 2.7% for 325 mg QD and 1.5% for 81 mg BID (p = .4056). Symptomatic DVT rates were 1.6% for 325 mg QD and 0.9% for 81 mg BID (p = .4139). Deep infection was 1.0% for 325 mg QD and 0.31% for 81 mg BID (p = .3564). CONCLUSION Low-dose ASA in patients with limited comorbidities undergoing primary THA and TKA is associated with significant lower rates of bleeding and suture reactions than high dose ASA. Low-dose ASA was not inferior to higher dose ASA for the prevention of VTE, wound complications, and infection 90 days postoperatively.
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Affiliation(s)
- Alexander J Duke
- Department of Orthopaedics and Rehabilitation, Stony Brook University, Stony Brook, NY, USA
| | - Stephen Bowen
- Department of Orthopaedics and Rehabilitation, Stony Brook University, Stony Brook, NY, USA
| | - Samir Baig
- Department of Orthopaedics and Rehabilitation, Stony Brook University, Stony Brook, NY, USA
| | - Dorian Cohen
- Department of Orthopaedics and Rehabilitation, Stony Brook University, Stony Brook, NY, USA
| | - David E Komatsu
- Department of Orthopaedics and Rehabilitation, Stony Brook University, Stony Brook, NY, USA
| | - James Nicholson
- Department of Orthopaedics and Rehabilitation, Stony Brook University, Stony Brook, NY, USA
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Borton ZM, Bhangoo NS, Quah CS, Stephen AB, Howard PW. Aspirin monotherapy is a suitable standard thromboprophylactic agent following total hip arthroplasty. Hip Int 2022; 32:286-290. [PMID: 33601921 DOI: 10.1177/1120700021990544] [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] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Aspirin is increasingly recognised as an efficacious thromboprophylactic agent with a superior safety profile compared to alternatives. Following our institution's previously published experience we implemented a risk-stratified protocol utilising aspirin as standard. We now present retrospective review of standard use of aspirin on fatal pulmonary embolism, all-cause mortality, and venous thromboembolism (VTE) following total hip arthroplasty (THA). METHODS A consecutive series of elective THAs was identified. Prospectively maintained databases were analysed to yield demographic data and identify deaths or readmission data. Patients who died within 90 postoperative days underwent review of the complete medical record. RESULTS 4204 THAs were included in the study cohort. VTE prophylaxis prescription was available in 3805. 2560 received aspirin (67.3%), 1049 enoxaparin (27.6%) and 193 warfarin (5.1%); there were no differences in 90-day all-cause mortality (p = 0.780) or VTE (p = 1) between groups. CONCLUSION Our large series continues to demonstrate that aspirin for thromboprophylaxis following THA is effective in risk-stratified patients. Furthermore, we demonstrate that introduction of a departmental protocol establishing aspirin as standard practice was not associated with increased mortality or incidence of thromboembolism. Taken in conjunction with our previous cohort our series encompasses 11,420 consecutive THAs. There has been a single death following fatal PE in the aspirin group (0.02%) compared to 5 in the LMWH group (0.2%) and 1 in the warfarin group (0.06%). We join calls for large-scale randomised controlled trials to elucidate the place of aspirin in VTE prevention following hip arthroplasty.
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Wang KY, Puvanesarajah V, Raad M, Barry K, Srikumaran U, Thakkar SC. The BTK Safety Score: A Novel Scoring System for Risk Stratifying Patients Undergoing Simultaneous Bilateral Total Knee Arthroplasty. J Knee Surg 2022; 36:702-709. [PMID: 34979584 DOI: 10.1055/s-0041-1741000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Selection of appropriate candidates for simultaneous bilateral total knee arthroplasty (si-BTKA) is crucial for minimizing postoperative complications. The aim of this study was to develop a scoring system for identifying patients who may be appropriate for si-BTKA. Patients who underwent si-BTKA were identified in the National Surgical Quality Improvement Program database. Patients who experienced a major 30-day complication were identified as high-risk patients for si-BTKA who potentially would have benefitted from staged bilateral total knee arthroplasty. Major complications included deep wound infection, pneumonia, renal insufficiency or failure, cerebrovascular accident, cardiac arrest, myocardial infarction, pulmonary embolism, sepsis, or death. The predictive model was trained using randomly split 70% of the dataset and validated on the remaining 30%. The scoring system was compared against the American Society of Anesthesiologists (ASA) score, the Charlson Comorbidity Index (CCI), and legacy risk-stratification measures, using area under the curve (AUC) statistic. Total 4,630 patients undergoing si-BTKA were included in our cohort. In our model, patients are assigned points based on the following risk factors: +1 for age ≥ 75, +2 for age ≥ 82, +1 for body mass index (BMI) ≥ 34, +2 for BMI ≥ 42, +1 for hypertension requiring medication, +1 for pulmonary disease (chronic obstructive pulmonary disease or dyspnea), and +3 for end-stage renal disease. The scoring system exhibited an AUC of 0.816, which was significantly higher than the AUC of ASA (0.545; p < 0.001) and CCI (0.599; p < 0.001). The BTK Safety Score developed and validated in our study can be used by surgeons and perioperative teams to risk stratify patients undergoing si-BTKA. Future work is needed to assess this scoring system's ability to predict long-term functional outcomes.
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Affiliation(s)
- Kevin Y Wang
- Department of Orthopedic Surgery, The Johns Hopkins University, Baltimore, Maryland
| | - Varun Puvanesarajah
- Department of Orthopedic Surgery, The Johns Hopkins University, Baltimore, Maryland
| | - Micheal Raad
- Department of Orthopedic Surgery, The Johns Hopkins University, Baltimore, Maryland
| | - Kawsu Barry
- Department of Orthopedic Surgery, The Johns Hopkins University, Baltimore, Maryland
| | - Umasuthan Srikumaran
- Department of Orthopedic Surgery, The Johns Hopkins University, Baltimore, Maryland
| | - Savyasachi C Thakkar
- Department of Orthopedic Surgery, The Johns Hopkins University, Baltimore, Maryland
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Fontalis A, Berry DJ, Shimmin A, Slullitel PA, Buttaro MA, Li C, Malchau H, Haddad FS. Prevention of early complications following total hip replacement. SICOT J 2021; 7:61. [PMID: 34851264 PMCID: PMC8634898 DOI: 10.1051/sicotj/2021060] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 10/29/2021] [Indexed: 01/01/2023] Open
Abstract
Total hip arthroplasty (THA) has been quoted as "the operation of the century", owing to its efficacy and the substantial improvements evidenced with respect to functional patient outcomes and quality of life. However, early postoperative complications are often inevitable, hence it is imperative to take every step to prevent them and minimise morbidity and mortality. This manuscript focuses on the most common early complications following THA, namely venous thromboembolism (VTE), prosthetic joint infection, periprosthetic fracture, instability, and leg length inequality. It aims to outline effective risk stratification strategies and prevention measures that could apply to the wider Orthopaedic community.
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Affiliation(s)
- Andreas Fontalis
- Department of Trauma and Orthopaedic Surgery, University College London Hospitals, London NW1 2BU, UK - University College London, Division of Surgery and Interventional Science, Gower Street, London, WC1E 6BT, UK
| | | | - Andrew Shimmin
- Melbourne Orthopaedic Group, Windsor, Victoria 3181, Australia - Monash University, Windsor, Ontario N9B 3P4, Australia
| | - Pablo A Slullitel
- Institute of Orthopaedics "Carlos E. Ottolenghi", Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Martin A Buttaro
- Institute of Orthopaedics "Carlos E. Ottolenghi", Italian Hospital of Buenos Aires, Buenos Aires, Argentina
| | - Cao Li
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, 137 South LiYuShan Road, Urumqi, Xinjiang 830054, China
| | - Henrik Malchau
- Harvard Medical School, Harvard University, Boston, MA 02115, USA
| | - Fares S Haddad
- Department of Trauma and Orthopaedic Surgery, University College London Hospitals, London NW1 2BU, UK - University College London, Division of Surgery and Interventional Science, Gower Street, London, WC1E 6BT, UK
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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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Bass AR, Zhang Y, Mehta B, Do HT, Russell LA, Sculco PK, Goodman SM. Periprosthetic Joint Infection Is Associated with an Increased Risk of Venous Thromboembolism Following Revision Total Knee Replacement: An Analysis of Administrative Discharge Data. J Bone Joint Surg Am 2021; 103:1312-1318. [PMID: 33750744 DOI: 10.2106/jbjs.20.01486] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Little is known about the relationship between infection and the risk of risk of venous thromboembolism (VTE) following orthopaedic surgery. We assessed the 90-day risk of VTE following revision total knee replacement to measure the association between periprosthetic joint infection and the risk of postoperative VTE. METHODS We used New York Statewide Planning and Research Cooperative System data to identify all New York State residents undergoing revision total knee replacement from 1998 to 2014. ICD-9-CM (International Classification of Diseases, Ninth Revision, Clinical Modification) codes were used to identify comorbidities and to classify the indication for revision total knee replacement as aseptic, infection, or fracture. The primary outcome was any diagnosis code for VTE recorded for the revision surgery and/or subsequent admissions within 90 days. A multivariable logistic regression model that included demographic characteristics and comorbidities was used to estimate the risk of VTE after revision for infection or fracture, with aseptic revision as the reference group. RESULTS The present study included 25,441 patients who were managed with revision total knee replacement; the indication for revision was aseptic for 17,563 patients (69%), infection for 7,075 (28%), and fracture for 803 (3%). The mean age (and standard deviation) was 66 ± 12 years, 15,592 (61%) of the patients were female, 3,198 (13%) were Black, 1,192 (5%) were smokers, and 4,222 (17%) were obese. Seven hundred and nineteen patients (2.8%) had VTE within the 90 days after revision total knee replacement, including 387 (1.5%) during the admission for the revision procedure. The 90-day incidence of VTE was 2.1% after aseptic revision, 4.3% after revision for infection, and 5.9% after revision for fracture. The adjusted odds ratio (aOR) for VTE relative to aseptic revision was 2.01 (95% confidence interval [CI], 1.72 to 2.35) for septic revision total knee replacement and 2.62 (95% CI, 1.91 to 3.6) for fracture. A history of VTE was also a strong risk factor for VTE following revision total knee replacement (aOR, 2.01; 95% CI, 1.48 to 2.71). CONCLUSIONS We found that the odds of VTE after revision total knee replacement for infection were double those after aseptic revision total knee replacement. Although fracture accounts for a small percentage of revision total knee replacements, the risk of VTE was 2.6-fold higher after these procedures. The indication for revision total knee replacement should be considered when choosing postoperative VTE prophylaxis. LEVEL OF EVIDENCE Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
| | - Yi Zhang
- Hospital for Special Surgery, New York, NY
| | | | - Huong T Do
- Hospital for Special Surgery, New York, NY
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Muscatelli SR, Charters MA, Hallstrom BR. Time for an Update? A Look at Current Guidelines for Venous Thromboembolism Prophylaxis After Hip and Knee Arthroplasty and Hip Fracture. Arthroplast Today 2021; 10:105-107. [PMID: 34337116 PMCID: PMC8318891 DOI: 10.1016/j.artd.2021.06.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 06/02/2021] [Accepted: 06/16/2021] [Indexed: 11/19/2022] Open
Abstract
Venous thromboembolism is a well-established complication of total hip and knee arthroplasty and hip fracture surgery. Clinical practice guidelines have been proposed to help clinicians provide prophylaxis against this risk. However, most guidelines reference data that are becoming outdated because of new advances in perioperative protocols. Recent data would suggest that aspirin may be appropriate for most patients after total hip and knee replacement and a more potent chemoprophylaxis for higher risk patients. Low-molecular-weight heparin remains the recommended choice after hip fracture surgery, although there is a paucity of recent literature in this patient population. There are randomized trials currently underway in the arthroplasty population that may guide clinicians in the appropriate choice of chemoprophylaxis. These studies should inform updates to the current clinical practice guidelines.
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Affiliation(s)
- Stefano R. Muscatelli
- Department of Orthopaedic Surgery, University of Michigan Health System, Ann Arbor, MI, USA
| | | | - Brian R. Hallstrom
- Department of Orthopaedic Surgery, University of Michigan Health System, Ann Arbor, MI, USA
- Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) Coordinating Center, University of Michigan Health System, Ann Arbor, MI, USA
- Corresponding author. 1500 E. Medical Center Dr., TC 2912, Ann Arbor, MI 48109-5328, USA. Tel.: +1 734 646 9191.
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Haller JM, Working ZM, Ross HL, Gililland JM, Kubiak EN. Fewer Hip Dislocations With Anterior Total Hip Arthroplasty for Displaced Femoral Neck Fracture. Orthopedics 2021; 44:e248-e252. [PMID: 33416894 DOI: 10.3928/01477447-20210104-02] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The primary goal of this study was to compare dislocation rates with an anterior approach vs a posterior approach for patients who underwent total hip arthroplasty (THA) for displaced femoral neck fracture. A retrospective review was conducted of patients who underwent THA for acute femoral neck fracture at the authors' level I trauma center. All patients had at least 1 year of follow-up. Modified Harris Hip Score (mHHS) and EuroQol 5D-5L score were obtained to assess hip function and overall quality of life at a minimum of 12 months postoperatively. The study population included 76 patients (posterior, 22; anterior, 54), with mean follow-up of 39 months (range, 12-125 months). Significantly more postoperative complications occurred in the posterior group compared with the anterior group (7 vs 4, respectively; P=.006). In addition, significantly more hip dislocations occurred in the posterior group compared with the anterior group (3 vs 1, respectively; P=.037). The study did not show a difference in mHHS (anterior, 82; posterior, 77; P=.411). The findings suggest that an anterior-based approach to THA may result in fewer complications than a posterior-based approach for patients who have displaced femoral neck fracture. Patients should be counseled on the higher perioperative risk after surgery compared with patients undergoing elective THA. Patients undergoing THA with an anterior approach for femoral neck fracture can expect to achieve good hip functional outcome and good quality of life 12 months after surgery. [Orthopedics. 2021;44(2):e248-e252.].
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Rooney T, Barrack RL, Clohisy JC, Nunley RM, Lawrie CM. Is Apixaban Safe and Effective for Venous Thromboembolism Prophylaxis After Primary Total Hip and Total Knee Arthroplasties? J Arthroplasty 2021; 36:S328-S331. [PMID: 33888386 DOI: 10.1016/j.arth.2021.03.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 03/07/2021] [Accepted: 03/10/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is a serious complication of total hip arthroplasty (THA) and total knee arthroplasty (TKA). Apixaban is approved for VTE prophylaxis. This study seeks to ascertain the risk of VTE and bleeding complications in patients undergoing primary THA and TKA receiving apixaban for postoperative VTE prophylaxis for one of the following indications: high risk for VTE, previously on apixaban, and contraindication to the use of aspirin. METHODS This is a retrospective cohort study of patients who underwent primary THA or TKA over a 17-month period and were prescribed apixaban for thromboprophylaxis postoperatively. RESULTS 230 patients were included in the study, 110 TKA and 120 THA. The primary reasons for high-risk VTE status included personal and family history of VTE, and 13% were taking apixaban preoperatively for atrial fibrillation. 1 patient (0.43%) who underwent TKA had a DVT with PE. 2.6% of patients had wound complications requiring operative treatment, and 0.87% of THA patients underwent revision arthroplasty. CONCLUSION The use of apixaban for VTE prophylaxis after primary THA and TKA in patients at high risk for VTE, in patients previously on apixaban, and in patients with a contraindication to the use of aspirin is associated with a low risk of VTE and bleeding complications.
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Affiliation(s)
- Timothy Rooney
- Washington University School of Medicine, Department of Orthopaedic Surgery, St. Louis, MO
| | - Robert L Barrack
- Washington University School of Medicine, Department of Orthopaedic Surgery, St. Louis, MO
| | - John C Clohisy
- Washington University School of Medicine, Department of Orthopaedic Surgery, St. Louis, MO
| | - Ryan M Nunley
- Washington University School of Medicine, Department of Orthopaedic Surgery, St. Louis, MO
| | - Charles M Lawrie
- Washington University School of Medicine, Department of Orthopaedic Surgery, St. Louis, MO
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Utilization Patterns, Efficacy, and Complications of Venous Thromboembolism Prophylaxis Strategies in Revision Hip and Knee Arthroplasty as Reported by American Board of Orthopaedic Surgery Part II Candidates. J Arthroplasty 2021; 36:2364-2370. [PMID: 33674164 DOI: 10.1016/j.arth.2021.01.072] [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: 11/30/2020] [Revised: 01/18/2021] [Accepted: 01/26/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The optimum venous thromboembolism (VTE) prophylaxis strategy to minimize risk of VTE and bleeding complications following revision total hip and knee arthroplasty (rTHA/rTKA) is controversial. The purpose of this study is to describe current VTE prophylaxis patterns following revision arthroplasty procedures to determine efficacy, complication rates, and prescribing patterns for different prophylactic strategies. METHODS The American Board of Orthopaedic Surgery Part II (oral) examination case list database was analyzed. Current Procedural Terminology codes for rTHA/rTKA were queried and geographic region, VTE prophylaxis strategy, and complications were obtained. Less aggressive prophylaxis patterns were defined if only aspirin and/or sequential compression devises were utilized. More aggressive VTE prophylaxis patterns were considered if any of low-molecular-weight heparin (enoxaparin), warfarin, rivaroxaban, fondaparinux, or other strategies were used. RESULTS In total, 6387 revision arthroplasties were included. The national rate of less aggressive VTE prophylaxis strategies was 35.3% and more aggressive in 64.7%. Use of less aggressive prophylaxis strategy was significantly associated with patients having no complications (89.8% vs 81.9%, P < .001). Use of more aggressive prophylaxis patterns was associated with higher likelihood of mild thrombotic (1.2% vs 0.3%, P < .001), mild bleeding (1.7% vs 0.6%, P < .001), moderate thrombotic (2.6% vs 0.4%, P < .001), moderate bleeding (6.2% vs 4.0%, P < .001), severe bleeding events (4.4% vs 2.4%, P < .001), infections (6.4% vs 3.8%, P < .001), and death within 90 days (3.1% vs 1.3%, P < .001). There were no significant differences in rates of fatal pulmonary embolism (0.1% vs 0.04%, P = .474). Subgroup analysis of rTHA and rTKA patients showed similar results. CONCLUSION The individual rationale for using a more aggressive VTE prophylaxis strategy was unknown; however, more aggressive strategies were associated with higher rates of bleeding and thrombotic complications. Less aggressive strategies were not associated with a higher rate of thrombosis. LEVEL OF EVIDENCE Therapeutic Level III.
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16
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Zhang XC, Sun MJ, Pan S, Rui M, Zhao FC, Zha GC, Pang Y, Zheng X, Guo KJ. Intravenous administration of tranexamic acid in total hip arthroplasty does not change the blood coagulopathy: a prospective thrombelastography analysis. J Orthop Surg (Hong Kong) 2021; 28:2309499020959516. [PMID: 32985369 DOI: 10.1177/2309499020959516] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE Despite the wide use of tranexamic acid (TXA) in the perioperative period of total hip arthroplasty (THA), whether the hemostatic state changes after the application of intravenous (IV)-TXA are still unknown. The aim of this study was to investigate whether IV administration of TXA changes the blood coagulation following primary THA via thrombelastography (TEG) analysis and conventional laboratory tests. METHODS A total of 174 patients who underwent primary THA from September 2016 to July 2018 were selected. They were randomly divided into two groups, 86 patients with IV administration of 15 mg/kg TXA and 88 controls without TXA usage. Demographic data, TEG paremeters, d-dimer levels, fibrin degradation products, hemoglobin, hematocrit concentration, platelet, transfusion rates, perioperative blood loss, and the occurrence of deep vein thrombosis were collected. TEG and conventional laboratory tests were performed the day before operation, the first day after operation, and seventh day after operation. RESULTS There were no differences with regard to TEG or conventional laboratory tests between the two groups (p > 0.05). The total blood loss and drain blood loss in the TXA group were significantly lower than those in the control group (p < 0.05). The transfusion rates and the volume of blood transfusion of the control group were higher than those of the TXA group (p < 0.05). CONCLUSION The administration of IV-TXA resulted in a significant reduction in total blood loss, transfusion volumes, and transfusion rates without the increase of thromboembolic complications. Moreover, it was confirmed that TXA would not change the coagulation via the TEG analysis.
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Affiliation(s)
- Xing-Chen Zhang
- Department of Orthopaedics, 117910The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Ma-Ji Sun
- Department of Orthopaedics, 117910The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Sheng Pan
- Department of Orthopaedics, 117910The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Min Rui
- Department of Orthopaedics, Jiangsu Jiangyin People's Hospital, Jiangyin, China
| | - Feng-Chao Zhao
- Department of Orthopaedics, 71069The First Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Guo-Chun Zha
- Department of Orthopaedics, 117910The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Yong Pang
- Department of Orthopaedics, 117910The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Xin Zheng
- Department of Orthopaedics, 117910The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
| | - Kai-Jin Guo
- Department of Orthopaedics, 117910The Affiliated Hospital of Xuzhou Medical University, Xuzhou, China
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17
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Harrison-Brown M, Scholes C, Douglas SL, Farah SB, Kerr D, Kohan L. Multimodal thromboprophylaxis in low-risk patients undergoing lower limb arthroplasty: A retrospective observational cohort analysis of 1400 patients with ultrasound screening. J Orthop Surg (Hong Kong) 2021; 28:2309499020926790. [PMID: 32484038 DOI: 10.1177/2309499020926790] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
PURPOSE This study reports the results of a multimodal thromboprophylaxis protocol for lower limb arthroplasty involving risk stratification, intraoperative calf compression, aspirin prophylaxis and early (within 4 h) post-operative mobilisation facilitated by the use of local infiltration analgesia. The study also aimed to identify risk factors for venous thromboembolism (VTE) within a 3-month period following surgery for patients deemed not at elevated risk. METHODS Patients undergoing knee/hip arthroplasty or hip resurfacing were preoperatively screened for VTE risk factors, and those at standard risk were placed on a thromboprophylaxis protocol consisting of intraoperative intermittent calf compression during surgery, 300 mg/day aspirin for 6 weeks from surgery and early mobilisation. Patients were screened bilaterally for deep vein thrombosis (DVT) on post-operative days 10-14. If proximal DVT was detected, patients were anticoagulated and outcomes were recorded. Symptomatic VTE within 3 months of surgery were recorded separately. Patient notes were retrospectively collated and cross-validated against ultrasound reports. RESULTS At initial screening, the rate of proximal DVT was 0.54% (1.1% for knee and 0.27% for hip), and distal DVT was 6.63% (20.11% for knee and 2.31% for hip). One small, nonfatal pulmonary embolism (PE) was detected within 3 months of surgery (0.28% of total knee arthroplasty patients or 0.07% of total). All proximal DVTs were treated successfully with anticoagulants; however, one patient suffered a minor PE approximately 10 months post-operatively. Regression analysis identified knee implant and advanced age as independent risk factors for VTE in this cohort. CONCLUSION Although knee arthroplasty patients remained at higher risk than hip replacement/resurfacing patients, the incidence and outcomes of VTE remained positive compared with protocols involving extended immobilisation, and episodes of PE were extremely rare. Thus, we conclude that patients at standard preoperative risk of VTE may safely be taken through the post-operative recovery process with a combination of intraoperative mechanical prophylaxis, early mobilisation and post-operative aspirin, with closer attention required for older patients and those undergoing knee surgery.
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Affiliation(s)
| | | | | | - Sami B Farah
- Joint Orthopaedic Centre, Sydney, Australia.,A.M. Orthopaedics, Sydney, Australia
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18
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Crawford DA, Andrews RL, Morris MJ, Hurst JM, Lombardi AV, Berend KR. Ambulatory Portable Pneumatic Compression Device as Part of a Multimodal Aspirin-Based Approach in Prevention of Venous Thromboembolism in Outpatient Total Knee Arthroplasty. Arthroplast Today 2020; 6:378-380. [PMID: 32577481 PMCID: PMC7303536 DOI: 10.1016/j.artd.2020.05.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Revised: 05/04/2020] [Accepted: 05/08/2020] [Indexed: 12/19/2022] Open
Abstract
Background The purpose of this study is to review the incidence of symptomatic venous thromboembolism (VTE) in patients undergoing outpatient primary total knee arthroplasty (TKA) who used a portable pneumatic compression device as part of their VTE prophylaxis protocol. Methods A retrospective review of all outpatient primary TKA procedures in which patients used ambulatory pneumatic compression pumps as part of their multimodal VTE prophylaxis was performed from 2016 through 2018. This yielded a cohort of 1131 patients (1453 TKAs). An aspirin (ASA)-based protocol was used in patients with standard VTE risk receiving either 81 mg or 325 mg of ASA twice daily for 6 weeks postoperatively. High-risk patients received a stronger chemoprophylaxis for 2 weeks followed by ASA for 4 weeks. Pneumatic compression pumps were worn for 23 hours/day for 14 days. Results VTE prophylaxis medication was 81-mg ASA in 56% of patients, 325-mg ASA in 10% of patients, and stronger chemoprophylaxis in 34% of patients. Patients were considered morbidly obese (body mass index >40 kg/m2) in 267 (18.4%) procedures. Ninety-seven (6.7%) patients had a preoperative history of VTE event. Forty-nine duplex ultrasounds were performed (3.3% of TKAs). Confirmed VTE events were documented in only 5 (0.3%) patients. All VTEs occurred in high-risk patients who were discharged on stronger chemoprophylaxis. The time (days) to VTE was 3, 3, 7, 45, and 88 days. Conclusion The use of portable pneumatic compression pumps as part of a multimodal VTE prophylaxis protocol aided in a very low rate of symptomatic VTE events in patients undergoing outpatient primary TKA.
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Affiliation(s)
| | | | - Michael J Morris
- Joint Implant Surgeons, Inc., New Albany, OH, USA.,Mount Carmel Health System, New Albany, OH, USA
| | - Jason M Hurst
- Joint Implant Surgeons, Inc., New Albany, OH, USA.,Mount Carmel Health System, New Albany, OH, USA
| | - Adolph V Lombardi
- Joint Implant Surgeons, Inc., New Albany, OH, USA.,Mount Carmel Health System, New Albany, OH, USA.,Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Keith R Berend
- Joint Implant Surgeons, Inc., New Albany, OH, USA.,Mount Carmel Health System, New Albany, OH, USA
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19
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Landy DC, Bradley AT, King CA, Puri L. Stratifying Venous Thromboembolism Risk in Arthroplasty: Do High-Risk Patients Exist? J Arthroplasty 2020; 35:1390-1396. [PMID: 32057606 DOI: 10.1016/j.arth.2020.01.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 01/03/2020] [Accepted: 01/08/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND While there are many possible complications associated with total joint arthroplasty (TJA), venous thromboembolism (VTE) is both frequent and potentially severe. Despite this importance, there are inconsistent recommendations for prophylaxis based on patient risk factors. METHODS A predictive model was constructed to compare low-molecular-weight heparin(LMWH) and aspirin (ASA) for prevention of VTE-associated complications following TJA.The model used risks from prior prophylaxis studies to estimate the risk of developing a symptomatic deep vein thrombosis, pulmonary embolism, thrombocytopenia, and operative or nonoperative site bleeding. We also evaluated the progression to 4 possible final health states: postphlebitis syndrome, intracranial hemorrhage, death, or baseline health. Within published ranges, we selected assumptions that were favorable to LMWH such that these analyses represent a best case scenario for LMWH or an alternative more aggressive low-molecular-weight heparin alternative (LMWHA). Events and outcomes were assigned quality-adjusted life-year (QALY) losses according to prior studies to determine the effect on patients' outcomes for ASA and LMWHA prophylaxis. RESULTS Assessing VTE risk populations from 0.2% to 2% with life expectancies ranging from 5 to 40 years postoperatively, patients with a risk ratio less than 3.7 showed increased expected QALY with ASA compared to LMWHA. For patients with a baseline VTE risk of 1% and a 15 year life expectancy, a risk ratio of 13.4 was needed to identify patients that would benefit from LMWHA. With life expectancy increased to 30 years, the risk ratio needed to idetify these patients was 7.4. CONCLUSION Patients undergoing TJA should receive ASA chemoprophylaxis in nearly all situations, unless the patient has a significantly increased VTE risk compared to the baseline population and a long life expectancy.
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Affiliation(s)
- David C Landy
- Hospital for Special Surgery, Department of Orthopaedic Surgery, New York, NY
| | | | - Connor A King
- Orthopaedic Surgery Department, University of Chicago, Chicago, IL
| | - Lalit Puri
- Northshore University HealthSystem, Skokie, IL
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20
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Azboy I, Groff H, Goswami K, Vahedian M, Parvizi J. Low-Dose Aspirin Is Adequate for Venous Thromboembolism Prevention Following Total Joint Arthroplasty: A Systematic Review. J Arthroplasty 2020; 35:886-892. [PMID: 31733981 DOI: 10.1016/j.arth.2019.09.043] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 09/09/2019] [Accepted: 09/26/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Patients undergoing total joint arthroplasty (TJA) are at risk of developing venous thromboembolism (VTE) without adequate prophylaxis. Since the American Academy of Orthopedic Surgeons issued guidelines in 2007 recommending aspirin 325 mg bis in die for 6 weeks, aspirin has been favored as the main VTE prophylaxis. However, the appropriate dose and duration of aspirin are not well-studied. This systematic review aims to identify any differences between high and low dose as well as duration for aspirin thromboprophylaxis after TJA as outlined by previous studies. METHODS A search was performed using Ovid MEDLINE, EMBASE, and PubMed, including articles up to July 2016. Studies were included if they contained at least 1 cohort that underwent TJA with aspirin as the sole chemoprophylaxis and reported either (1) symptomatic VTE or (2) secondary outcomes such as major bleeding or 90-day mortality. RESULTS Forty-five papers were included. There were no significant differences in symptomatic pulmonary embolism, symptomatic deep vein thrombosis, 90-day mortality, or major bleeding between patients receiving low-dose or high-dose aspirin. Patients treated with aspirin for <4 weeks had a higher risk of major bleeding (1.59%) vs patients treated for 4 weeks (0.15%), which may be attributed to premature cessation or differential reporting. Patients treated with aspirin for <4 weeks had a statistically higher 90-day mortality (1.95%) vs patients treated for 4 weeks (0.07%). There was no significant difference between incidence of pulmonary embolism or deep vein thrombosis and the durations of aspirin treatment. CONCLUSION This review suggests that low-dose aspirin is not inferior to high-dose aspirin for VTE thromboprophylaxis in TJA patients. Additionally, patients treated with aspirin for less than 4 weeks may have a higher risk of major bleeding and 90-day mortality compared to patients treated for a longer duration.
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Affiliation(s)
- Ibrahim Azboy
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA; Department of Orthopaedics and Traumatology, Istanbul Medipol University School of Medicine, Istanbul, Turkey
| | - Hannah Groff
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Karan Goswami
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Mohammed Vahedian
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Javad Parvizi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
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21
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Guan Z. Changes in expression of serum chemokine CXCL13 and IL-6 after hip replacement, and the relationship with lower limb vein thrombus. Exp Ther Med 2020; 19:2113-2118. [PMID: 32104273 DOI: 10.3892/etm.2019.8365] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 12/02/2019] [Indexed: 01/02/2023] Open
Abstract
Changes in the expression of serum chemokine CXC ligand 13 (CXCL13) and interleukin-6 (IL-6), and the relationship with lower limb vein thrombus were explored. A total of 128 patients undergoing hip replacement in The First Affiliated Hospital of Guizhou University of Traditional Chinese Medicine from May 2017 to June 2019 were selected, and the patients suffering from lower limb vein thrombus were enrolled as group A and other patients not suffering from it were enrolled as group B. Enzyme-linked immuno-sorbent assay was employed to determine the levels of serum chemokine CXCL13 and IL-6, and receiver operating characteristic curves of serum chemokine CXCL13 and IL-6 levels in diagnosing restenosis after surgery were drawn. Pearson's correlation coefficient was adopted to analyze the correlation between serum chemokine CXCL13 and IL-6, and the logistic regression analysis to analyze the risk factors affecting hip replacement in patients. The levels of serum CXCL13 and IL-6 in group A were significantly higher than those in group B (both P<0.001). The specificity and sensitivity of serum CXCL13 level in diagnosis of lower limb vein thrombus after hip replacement were 61.76 and 80.00%, respectively, and those of serum IL-6 level in diagnosis were 70.59 and 66.67%, respectively. Serum CXCL13 level was positively correlated with serum IL-6 level (P<0.001), and age, body mass index (BMI), CXCL13 level and IL-6 level of the patients were independent risk factors affecting the efficacy of hip replacement. Serum CXCL13 level and serum IL-6 level can be used as biological indexes for prediction of early lower limb vein thrombus after hip replacement, and logistic regression analysis revealed that the age of the patients, BMI, diabetes history, hyperlipidemia history, hypertension history, CXCL13 level and IL-6 level are independent risk factors affecting the efficacy of hip replacement.
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Affiliation(s)
- Zhiyu Guan
- Department of Tramotology and Orthopedics, The First Affiliated Hospital of Guizhou University of Traditional Chinese Medicine, Guiyang, Guizhou 550001, P.R. China
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22
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Abstract
In the last few years, much has been published concerning total joint arthroplasty, and debates and discussions to new questions and points of view started many years ago. In this commentary, we report the latest evidence of best practice in the field of lower limb arthroplasty; this evidence is based on a literature search conducted by using PubMed and Scopus databases with a time limit of five years. We found novel evidence regarding cemented and not cemented implant, implant design, anticoagulant use, tourniquets, and other aspects of joints replacement surgery that we consider a common part of modern orthopedic practice. We specifically focus on lower limb joint replacement.
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Affiliation(s)
- Rocco Aicale
- Department of Musculoskeletal Disorders, School of Medicine and Surgery, University of Salerno, Baronissi, Italy.,Clinica Ortopedica, Ospedale San Diovanni di Dio e Ruggi D'Aragona, Salerno, Italy
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, School of Medicine and Surgery, University of Salerno, Baronissi, Italy.,Clinica Ortopedica, Ospedale San Diovanni di Dio e Ruggi D'Aragona, Salerno, Italy.,Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, Queen Mary University of London, London, UK.,School of Pharmacy and Bioengineering, Faculty of Medicine, Institute of Science and Technology in Medicine, Guy Hilton Research Centre, Keele University, Stoke-on-Trent, UK
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23
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Gage BF, Bass AR, Lin H, Woller SC, Stevens SM, Al-Hammadi N, Anderson JL, Li J, Rodriguez T, Miller JP, McMillin GA, Pendleton RC, Jaffer AK, King CR, Whipple B, Porche-Sorbet R, Napoli L, Merritt K, Thompson AM, Hyun G, Hollomon W, Barrack RL, Nunley RM, Moskowitz G, Dávila-Román V, Eby CS. Effect of Low-Intensity vs Standard-Intensity Warfarin Prophylaxis on Venous Thromboembolism or Death Among Patients Undergoing Hip or Knee Arthroplasty: A Randomized Clinical Trial. JAMA 2019; 322:834-842. [PMID: 31479138 PMCID: PMC6724181 DOI: 10.1001/jama.2019.12085] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
IMPORTANCE The optimal international normalized ratio (INR) to prevent venous thromboembolism (VTE) in warfarin-treated patients with recent arthroplasty is unknown. OBJECTIVE To determine the safety and efficacy of a target INR of 1.8 vs 2.5 for VTE prophylaxis after orthopedic surgery. DESIGN, SETTING, AND PARTICIPANTS The randomized Genetic Informatics Trial (GIFT) of Warfarin to Prevent Deep Vein Thrombosis enrolled 1650 patients aged 65 years or older initiating warfarin for elective hip or knee arthroplasty at 6 US medical centers. Enrollment began in April 2011 and follow-up concluded in October 2016. INTERVENTIONS In a 2 × 2 factorial design, participants were randomized to a target INR of 1.8 (n = 823) or 2.5 (n = 827) and to either genotype-guided or clinically guided warfarin dosing. For the first 11 days of therapy, open-label warfarin dosing was guided by a web application. MAIN OUTCOMES AND MEASURES The primary outcome was the composite of VTE (within 60 days) or death (within 30 days). Participants underwent screening duplex ultrasound postoperatively. The hypothesis was that an INR target of 1.8 would be noninferior to an INR target of 2.5, using a noninferiority margin of 3% for the absolute risk of VTE. Secondary end points were bleeding and INR values of 4 or more. RESULTS Among 1650 patients who were randomized (mean age, 72.1 years; 1049 women [63.6%]; 1502 white [91.0%]), 1597 (96.8%) received at least 1 dose of warfarin and were included in the primary analysis. The rate of the primary composite outcome of VTE or death was 5.1% (41 of 804) in the low-intensity-warfarin group (INR target, 1.8) vs 3.8% (30 of 793) in the standard-treatment-warfarin group (INR target, 2.5), for a difference of 1.3% (1-sided 95% CI, -∞ to 3.05%, P = .06 for noninferiority). Major bleeding occurred in 0.4% of patients in the low-intensity group and 0.9% of patients in the standard-intensity group, for a difference of -0.5% (95% CI, -1.6% to 0.4%). The INR values of 4 or more occurred in 4.5% of patients in the low-intensity group and 12.2% of the standard-intensity group, for a difference of -7.8% (95% CI, -10.5% to -5.1%). CONCLUSIONS AND RELEVANCE Among older patients undergoing hip or knee arthroplasty and receiving warfarin prophylaxis, an international normalized ratio goal of 1.8 compared with 2.5 did not meet the criterion for noninferiority for risk of the composite outcome of VTE or death. However, the trial may have been underpowered to meet this criterion and further research may be warranted. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01006733.
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Affiliation(s)
- Brian F. Gage
- Department of Medicine, Washington University in St Louis, St Louis, Missouri
| | - Anne R. Bass
- Department of Medicine, Hospital for Special Surgery, New York, New York
| | - Hannah Lin
- Department of Medicine, Washington University in St Louis, St Louis, Missouri
- Department of Medical Education, University of Massachusetts, Worcester
| | - Scott C. Woller
- Department of Medicine, Intermountain Medical Center, Salt Lake City, Utah
- Department of Medicine, University of Utah, Salt Lake City
| | - Scott M. Stevens
- Department of Medicine, Intermountain Medical Center, Salt Lake City, Utah
- Department of Medicine, University of Utah, Salt Lake City
| | - Noor Al-Hammadi
- Department of Medicine, Washington University in St Louis, St Louis, Missouri
| | - Jeffrey L. Anderson
- Department of Medicine, University of Utah, Salt Lake City
- Department of Cardiology, Intermountain Medical Center, Salt Lake City, Utah
| | - Juan Li
- Department of Medicine, Washington University in St Louis, St Louis, Missouri
| | - Tomás Rodriguez
- Department of Medicine, Washington University in St Louis, St Louis, Missouri
| | - J. Philip Miller
- Department of Medicine, Washington University in St Louis, St Louis, Missouri
| | | | | | - Amir K. Jaffer
- Department of Medicine, New York Presbyterian Queens Hospital, New York
| | - Cristi R. King
- Department of Medicine, Washington University in St Louis, St Louis, Missouri
| | - Brandi Whipple
- Department of Medicine, Washington University in St Louis, St Louis, Missouri
| | | | - Lynnae Napoli
- Department of Medicine, University of Utah, Salt Lake City
| | - Kerri Merritt
- Department of Medicine, Hospital for Special Surgery, New York, New York
| | - Anna M. Thompson
- Department of Medicine, Washington University in St Louis, St Louis, Missouri
- Department of Medical Education, University of Central Florida College of Medicine, Orlando
| | - Gina Hyun
- Department of Medicine, Washington University in St Louis, St Louis, Missouri
- Department of Radiology, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Wesley Hollomon
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, New York
| | - Robert L. Barrack
- Department of Orthopedic Surgery, Washington University in St Louis, St Louis, Missouri
| | - Ryan M. Nunley
- Department of Orthopedic Surgery, Washington University in St Louis, St Louis, Missouri
| | - Gerard Moskowitz
- Department of Medicine, Washington University in St Louis, St Louis, Missouri
| | - Victor Dávila-Román
- Department of Medicine, Washington University in St Louis, St Louis, Missouri
| | - Charles S. Eby
- Department of Medicine, Washington University in St Louis, St Louis, Missouri
- Department of Pathology and Immunology, Washington University in St Louis, St Louis, Missouri
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24
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DeRogatis MJ, Wintermeyer E, Sperring TR, Issack PS. Modular Fluted Titanium Stems in Revision Hip Arthroplasty. J Bone Joint Surg Am 2019; 101:745-754. [PMID: 30994593 DOI: 10.2106/jbjs.18.00753] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Michael J DeRogatis
- Department of Orthopaedic Surgery, New York - Presbyterian Hospital, New York, NY
| | - Elke Wintermeyer
- Department of Orthopaedic Surgery, New York - Presbyterian Hospital, New York, NY.,Department of Trauma and Reconstructive Surgery, BG Trauma Center, Tuebingen, Germany
| | - Thomas R Sperring
- Department of Orthopaedic Surgery, New York - Presbyterian Hospital, New York, NY
| | - Paul S Issack
- Department of Orthopaedic Surgery, New York - Presbyterian Hospital, New York, NY
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25
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Runner RP, Gottschalk MB, Staley CA, Pour AE, Roberson JR. Utilization Patterns, Efficacy, and Complications of Venous Thromboembolism Prophylaxis Strategies in Primary Hip and Knee Arthroplasty as Reported by American Board of Orthopedic Surgery Part II Candidates. J Arthroplasty 2019; 34:729-734. [PMID: 30685257 DOI: 10.1016/j.arth.2018.12.015] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Revised: 11/19/2018] [Accepted: 12/12/2018] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Many strategies for venous thromboembolism (VTE) prophylaxis following hip and knee arthroplasty exist, with extensive controversy regarding the optimum strategy to minimize risk of VTE and bleeding complications. Data from the American Board of Orthopedic Surgery Part II (oral) Examination case list database was analyzed to determine efficacy, complication rates, and prescribing patterns for different prophylactic strategies. METHODS The American Board of Orthopedic Surgery case database was queried utilizing Current Procedural Terminology codes 27447 and 27130 for primary total knee and hip arthroplasty, respectively. Geographic region, patient age, gender, deep vein thrombosis prophylaxis strategy, and complications were obtained. Less aggressive prophylaxis patterns were considered if only aspirin and/or sequential compression devises were utilized. More aggressive VTE prophylaxis patterns were considered if any of low-molecular-weight heparin (enoxaparin), warfarin, rivaroxaban, fondaparinux, or other strategies was used. RESULTS In total, 22,072 cases of primary joint arthroplasty were analyzed from 2014 to 2016. The national rate of less aggressive VTE prophylaxis strategies was 45.4%, while more aggressive strategies were used in 54.6% of patients. Significant regional differences in prophylactic strategy patterns exist between the 6 regions. The predominant less aggressive prophylaxis pattern was aspirin with sequential compression devises at 84.8% with 14.8% receiving aspirin alone. Use of less aggressive prophylaxis strategy was significantly associated with patients having no complications (95.5% vs 93.0%). Use of more aggressive prophylaxis patterns was associated with higher likelihood of mild thrombotic (0.9% vs 0.2%), mild bleeding (1.3% vs 0.4%), moderate thrombotic (1.2% vs 0.4%), moderate bleeding (2.7% vs 2.1%), severe thrombotic (0.1% vs 0.0%), severe bleeding events (1.2% vs 0.9%), infections (1.9% vs 1.3%), and death within 90 days (0.7% vs 0.3%). Similar results were found in subgroup analysis of total hip and knee arthroplasty patients. CONCLUSION It was not possible to ascertain the individual rationale for use of more aggressive VTE prophylaxis strategies; however, more aggressive strategies were associated with higher rates of bleeding and thrombotic complications. Less aggressive strategies were not associated with a higher rate of thrombosis. LEVEL OF EVIDENCE Therapeutic Level III. DISCLAIMER All views expressed in the study are the sole views of the authors and do not represent the views of the American Board of Orthopedic Surgery.
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Affiliation(s)
| | | | | | - Aidin E Pour
- Department of Orthopaedic Surgery, University of Michigan Health System, Ann Arbor, MI
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Woon CYL, Shah RR, Pardi BM, Schwartz BE, Goldstein JM, Cipparrone NE, Goldstein WM. Aspirin Alone Is Not Enough to Prevent Deep Venous Thrombosis After Total Joint Arthroplasty. Orthopedics 2019; 42:48-55. [PMID: 30602046 DOI: 10.3928/01477447-20181227-02] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2018] [Accepted: 12/03/2018] [Indexed: 02/03/2023]
Abstract
Thromboembolic events after total joint arthroplasty are potentially devastating complications. This study evaluated the efficacy of 4 different anticoagulants in preventing deep venous thrombosis and pulmonary embolism after total joint arthroplasty. The demographics and anticoagulant use (warfarin, enoxaparin, and aspirin with and without outpatient mechanical pumps) for patients who underwent primary unilateral total joint arthroplasties performed by a single surgeon from January 2013 to October 2014 were retrospectively reviewed. All patients underwent lower extremity ultrasound at the 3-week postoperative visit. A total of 613 primary unilateral total joint arthroplasties met the study inclusion criteria. There were 288 primary total knee arthroplasties and 325 primary total hip arthroplasties. The patients were 62.2% female, having a mean age of 67.6±10.6 years and a mean body mass index of 30.2±5.9 kg/m2. There were 119 patients in group 1 (aspirin alone), 40 patients in group 2 (aspirin plus pumps), 246 patients in group 3 (warfarin), and 208 patients in group 4 (enoxaparin). The overall 3-week symptomatic and asymptomatic deep venous thrombosis and symptomatic pulmonary embolism rates in the entire cohort were 5.7% and 0.3%, respectively. The venous thromboembolism rate was significantly affected by the anticoagulant of choice (P<.01). Compared with aspirin alone, warfarin decreased the risk of venous thromboembolism (P<.01). Increasing age led to increased risk of venous thromboembolism (P=.05). This study indicated that aspirin chemoprophylaxis alone was not as efficacious as warfarin and enoxaparin in preventing asymptomatic and symptomatic venous thromboembolism found during routine postoperative surveillance with lower extremity ultrasound. Aspirin alone may be inadequate and should be augmented with an outpatient mechanical pump as part of multimodal prophylaxis. [Orthopedics. 2019; 42(1):48-55.].
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Piccinin MA, Sayeed Z, Kozlowski R, Bobba V, Knesek D, Frush T. Bundle Payment for Musculoskeletal Care: Current Evidence (Part 1). Orthop Clin North Am 2018; 49:135-146. [PMID: 29499815 DOI: 10.1016/j.ocl.2017.11.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
In the face of escalating costs and variations in quality of care, bundled payment models for total joint arthroplasty procedures are becoming increasingly common, both through the Centers for Medicare & Medicaid Services and private payer organizations. The effective implementation of these payment models requires cooperation between multiple service providers to ensure economic viability without deterioration in care quality. This article introduces a stepwise model for the financial analysis of bundled contracts for use in negotiations between hospitals and private payer organizations.
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Affiliation(s)
- Meghan A Piccinin
- Department of Orthopaedic Surgery, College of Osteopathic Medicine, Michigan State University, Detroit Medical Center, 4707 St Antoine Street, Detroit, MI 48201, USA
| | - Zain Sayeed
- Department of Orthopaedics, Institute of Innovations and Clinical Excellence, Detroit Medical Center, 4201 St Antoine Street, Detroit, MI 48201, USA.
| | - Ryan Kozlowski
- Department of Orthopaedics, Musculoskeletal Institute of Surgical Excellence, Detroit Medical Center, 4201 St Antoine Street, Detroit, MI 48201, USA
| | - Vamsy Bobba
- Department of Orthopaedics, Musculoskeletal Institute of Surgical Excellence, Detroit Medical Center, 4201 St Antoine Street, Detroit, MI 48201, USA
| | - David Knesek
- Department of Orthopaedics, Musculoskeletal Institute of Surgical Excellence, Detroit Medical Center, 4201 St Antoine Street, Detroit, MI 48201, USA
| | - Todd Frush
- Department of Orthopaedics, Musculoskeletal Institute of Surgical Excellence, Detroit Medical Center, 4201 St Antoine Street, Detroit, MI 48201, USA
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Garfinkel JH, Gladnick BP, Roland N, Romness DW. Increased Incidence of Bleeding and Wound Complications With Factor-Xa Inhibitors After Total Joint Arthroplasty. J Arthroplasty 2018; 33:533-536. [PMID: 28947374 DOI: 10.1016/j.arth.2017.08.039] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 08/12/2017] [Accepted: 08/29/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Factor-Xa inhibitors have been introduced for prevention of venous thromboembolism (VTE) after joint arthroplasty. However, these agents could also be associated with bleeding or wound complications after surgery. METHODS We retrospectively reviewed a consecutive series of 59 patients (31 knees, 28 hips) undergoing joint arthroplasty at a high-volume joint arthroplasty referral center, both before and after implementation of a new VTE risk-stratification tool at our institution. Patients with a history of VTE, bilateral procedures, or medical conditions already requiring VTE chemoprophylaxis were excluded. We reviewed the medical records to determine (1) type of VTE prophylaxis used, (2) incidence of bleeding/wound complications in the postoperative period, (3) incidence of VTE in the postoperative period, and (4) change in serum hemoglobin. RESULTS Twenty-seven patients (46%) were given aspirin for VTE prophylaxis, while 32 patients (54%) received a factor-Xa inhibitor. There were no new VTE complications in either group. And 6 of 32 patients (18.7%) in the Xa inhibitor group had a postoperative bleeding/wound complication (4 delayed healing/blistering, 1 hematoma/excessive ecchymosis, and 1 readmission for cellulitis). There were no (0%) bleeding/wound complications in the aspirin group (P = .03). The change in hemoglobin level was -2.76 g/dL in patients receiving aspirin vs -2.84 g/dL in patients receiving a Xa inhibitor (P = .73). CONCLUSION In our study of total joint patients, factor-Xa inhibitors were associated with a higher incidence of bleeding/wound complications. The choice of VTE prophylaxis should be based on the perceived risks of bleeding and wound complications compared to the risks of VTE in each patient.
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Affiliation(s)
| | - Brian P Gladnick
- OrthoVirginia, Adult Hip and Knee Reconstruction, Arlington, Virginia; Virginia Hospital Center, Arlington, Virginia
| | | | - David W Romness
- OrthoVirginia, Adult Hip and Knee Reconstruction, Arlington, Virginia; Virginia Hospital Center, Arlington, Virginia
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Abstract
BACKGROUND The use of chemoprophylaxis to prevent thromboembolic disease after primary THA and TKA can be associated with postoperative bleeding complications. Mechanical prophylaxis has been studied as an alternative to chemoprophylaxis with greater safety in patients undergoing THA, but no data have been published comparing the safety of chemoprophylaxis versus mechanical methods for patients undergoing TKA. The risk of readmission resulting from bleeding and venous thromboembolism (VTE) has also not been determined for patients undergoing THA or TKA when treated with low-molecular-weight heparin (LMWH) alone compared with mechanical prophylaxis plus aspirin (ASA). QUESTION/PURPOSES We sought to answer four questions: For the THA and TKA cohorts, respectively, (1) was the incidence of readmission resulting from VTE and bleeding complications higher with LMWH than mobile compression plus ASA; and (2) was the incidence of wound bleeding complications higher with LMWH than mechanical compression plus ASA? For the TKA cohort specifically, (3) was the frequency of systemic bleeding events and complications related to chemical prophylaxis higher with LMWH compared with mechanical compression plus ASA? (4) Was there a difference in symptomatic VTEs between LMWH and mechanical compression plus ASA? METHODS Between November 2008 and April 2011, 632 patients underwent primary THA and TKA. Seventy-two patients (11%) were identified before surgery as being at high risk for VTE (31 patients) or bleeding (41 patients) and were excluded from the study. Five hundred sixty patients (89%) were considered to be at standard risk for VTE and bleeding and comprise the study cohort. Between November 2008 and November 2009, 252 patients (76 THAs, 176 TKAs) underwent THA and TKA and were treated with LMWH (5 mg dalteparin given subcutaneously daily for 14 days) and in-hospital nonmobile mechanical compression. Between November 2009 and April 2011, a total of 308 patients undergoing THA and TKA (108 THAs, 200 TKAs) were treated using a mobile compression device plus oral aspirin once daily for 2 weeks after surgery. All complications and readmissions that occurred within 6 weeks of surgery were noted. There were no differences between the VTE treatment groups with regard to age, sex, or body mass index. RESULTS For the THA cohort, there was no difference in the frequency of readmission for a bleeding complication (wound or systemic) between the two groups (2.6% for LMWH versus 0.9% for mobile compression; p = 0.57; odds ratio [OR], 2.9). Patients undergoing TKA treated with LMWH had higher readmission rates within 6 weeks of surgery because of a bleeding complication, a wound infection, or the development of a VTE (6.8% for LMWH versus 1.5% for mobile compression; p = 0.015; OR, 4.8). For the THA cohort, there was higher wound bleeding complication frequency with LMWH (9.2% for LMWH versus 0.9% for mechanical compression; p = 0.009; OR, 10.9). Patients undergoing TKA treated with LMWH had a higher frequency of wound bleeding complications or infection (3.9% for LMWH versus 0.5% for mobile compression; p = 0.028; OR, 8.2). Patients undergoing TKA treated with LMWH had higher rates of systemic bleeding or a complication secondary to LMWH administration (2.8% for LMWH versus 0% for mobile compression; p = 0.022; OR, 12.8). No difference was noted in the rate of symptomatic VTEs between either group (for THA: 2.6% for the LMWH group versus 1.9% for the mechanical compression group; p = 1; for TKA: 1.1% versus 0%, respectively; p = 0.22). CONCLUSIONS Based on these results, we advocate for routine use of mobile mechanical compression devices in the prevention of VTEs and complications associated with more potent chemical anticoagulants. However, more focused randomized clinical trials are needed to validate these findings. LEVEL OF EVIDENCE Level III, therapeutic study.
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Bateman DK, Dow RW, Brzezinski A, Bar-Eli HY, Kayiaros ST. Correlation of the Caprini Score and Venous Thromboembolism Incidence Following Primary Total Joint Arthroplasty-Results of a Single-Institution Protocol. J Arthroplasty 2017; 32:3735-3741. [PMID: 28734614 DOI: 10.1016/j.arth.2017.06.042] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Revised: 06/13/2017] [Accepted: 06/26/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Venous thromboembolism (VTE), including pulmonary embolism (PE) and deep vein thrombosis, is a serious complication after total joint arthroplasty (TJA). Risk assessment models are increasingly used to provide patient-specific risk stratification. A recently implemented protocol mandates calculation of a Caprini Score for all surgical patients at our institution. We investigated the accuracy of the Caprini Score in predicting VTE events following TJA. METHODS A retrospective review of patients undergoing primary total hip (THA) and total knee arthroplasty (TKA) over a 1-year time period was performed. The 90-day postoperative incidence of emergency department evaluations, hospital readmissions, medical complications, need for revision surgery, and symptomatic VTE was recorded. "Preoperative" Caprini Scores routinely recorded per protocol and calculated during review ("Calculated") were compared and assessed for relationship with VTE events. A "VTEstimator" Score was calculated for each patient. RESULTS Three hundred seventy-six arthroplasties (151 TKA and 225 THA) meeting inclusion criteria were identified. Ten patients (2.5%) had symptomatic VTE postoperatively, with 3 pulmonary embolism (0.8%) and 7 deep vein thrombosis (1.8%). Eight VTE (5.3%) occurred following TKA and 2 (0.9%) occurred following THA. For each surgical characteristic evaluated, no significant difference was observed between mean Preoperative or Calculated Caprini Scores for patients with and without VTE (P > .05). Additionally, the distribution of VTEstimator Scores for patients with and without VTE was not significantly different (P = .93). CONCLUSION The Caprini risk assessment model does not appear to provide clinically useful risk stratification for TJA patients. Alternative risk stratification protocols may provide assistance in balancing safety and efficacy of thromboprophylaxis.
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Affiliation(s)
- Dexter K Bateman
- Rutgers Robert Wood Johnson Medical School, Department of Orthopaedic Surgery, New Brunswick, New Jersey
| | - Robert W Dow
- Rutgers Robert Wood Johnson Medical School, Department of Orthopaedic Surgery, New Brunswick, New Jersey
| | - Andrzej Brzezinski
- Rutgers Robert Wood Johnson Medical School, Department of Orthopaedic Surgery, New Brunswick, New Jersey
| | - Howard Y Bar-Eli
- Rutgers Robert Wood Johnson Medical School, Department of Orthopaedic Surgery, New Brunswick, New Jersey
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Courtney PM, Boniello AJ, Levine BR, Sheth NP, Paprosky WG. Are Revision Hip Arthroplasty Patients at Higher Risk for Venous Thromboembolic Events Than Primary Hip Arthroplasty Patients? J Arthroplasty 2017; 32:3752-3756. [PMID: 28807468 DOI: 10.1016/j.arth.2017.07.028] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Revised: 06/29/2017] [Accepted: 07/17/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The purpose of this study is to determine whether revision total hip arthroplasty (THA) is associated with increased rates of deep vein thrombosis (DVT) and pulmonary embolism (PE) when compared to primary THA. METHODS We queried the American College of Surgeons National Surgical Quality Improvement Program database for all primary and revision THA cases from 2011 to 2014. Demographic data, medical comorbidities, and venous thromboembolic rates within 30 days of surgery were compared between the primary and revision THA groups. RESULTS Revision THA had a higher rate of DVT than the primary THA (0.6% vs 0.4%, P = .016), but there was no difference in the rate of PE (0.3% vs 0.2%, P = .116). When controlling for confounding variables, revision surgery alone was not a risk factor for DVT (odds ratio 0.833, 95% confidence interval 0.564-1.232) or PE (odds ratio 1.009, 95% confidence interval 0.630-1.616). Independent risk factors for DVT include age >70 years, malnutrition, infection, operating time >3 hours, general anesthesia, American Society of Anesthesiologists classification 4 or greater, and kidney disease (all P < .05). Probability of DVT ranged from 0.2% with zero risk factors to 10% with all risk factors. Independent risk factors for PE included age >70 years, African American ethnicity, and operating time >3 hours (all P < .05) with probabilities of PE postoperatively ranging from 0.2% to 1.1% with all risk factors. CONCLUSION Revision surgery alone is not a risk factor for venous thromboembolism after hip arthroplasty. Surgeons should weigh the risks and benefits of more aggressive anticoagulation in certain high-risk patients.
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Affiliation(s)
- P Maxwell Courtney
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Anthony J Boniello
- Department of Orthopaedic Surgery, Drexel University College of Medicine, Philadelphia, Pennsylvania
| | - Brett R Levine
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
| | - Neil P Sheth
- Department of Orthopaedic Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Wayne G Paprosky
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, Illinois
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Azboy I, Barrack R, Thomas AM, Haddad FS, Parvizi J. Aspirin and the prevention of venous thromboembolism following total joint arthroplasty: commonly asked questions. Bone Joint J 2017; 99-B:1420-1430. [PMID: 29092979 PMCID: PMC5742873 DOI: 10.1302/0301-620x.99b11.bjj-2017-0337.r2] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 07/19/2017] [Indexed: 12/17/2022]
Abstract
The number of arthroplasties being performed
increases each year. Patients undergoing an arthroplasty are at
risk of venous thromboembolism (VTE) and appropriate prophylaxis
has been recommended. However, the optimal protocol and the best
agent to minimise VTE under these circumstances are not known. Although
many agents may be used, there is a difference in their efficacy
and the risk of bleeding. Thus, the selection of a particular agent relies
on the balance between the desire to minimise VTE and the attempt
to reduce the risk of bleeding, with its undesirable, and occasionally
fatal, consequences. Acetylsalicylic acid (aspirin) is an agent for VTE prophylaxis
following arthroplasty. Many studies have shown its efficacy in
minimising VTE under these circumstances. It is inexpensive and
well-tolerated, and its use does not require routine blood tests.
It is also a ‘milder’ agent and unlikely to result in haematoma
formation, which may increase both the risk of infection and the
need for further surgery. Aspirin is also unlikely to result in persistent
wound drainage, which has been shown to be associated with the use
of agents such as low-molecular-weight heparin (LMWH) and other
more aggressive agents. The main objective of this review was to summarise the current
evidence relating to the efficacy of aspirin as a VTE prophylaxis
following arthroplasty, and to address some of the common questions
about its use. There is convincing evidence that, taking all factors into account,
aspirin is an effective, inexpensive, and safe form of VTE following
arthroplasty in patients without a major risk factor for VTE, such
as previous VTE. Cite this article: Bone Joint J 2017;99-B:1420–30.
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Affiliation(s)
- I Azboy
- Rothman Institute at Thomas Jefferson University Hospital, Sheridan Building, Suite 1000, 125 South 9th Street, Philadelphia, PA 19107, USA
| | - R Barrack
- Washington University Orthopedics, Barnes Jewish Hospital, 660 South Euclid Avenue, Campus Box 8233, St. Louis, Missouri 63110, USA
| | - A M Thomas
- The Royal Orthopaedic Hospital, Bristol Road South, Birmingham B31 2AP, UK
| | - F S Haddad
- University College London Hospitals, 235 Euston Road, London NW1 2BU, UK and NIHR University College London Hospitals Biomedical Research Centre, UK
| | - J Parvizi
- Rothman Institute at Thomas Jefferson University Hospital, Sheridan Building, Suite 1000, 125 South 9th Street, Philadelphia, PA 19107, USA
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Nam JH, Kim DH, Yoo JH, Hwang JH, Chang JD. Does preoperative mechanical prophylaxis have additional effectiveness in preventing postoperative venous thromboembolism in elderly patients with hip fracture?-Retrospective case-control study. PLoS One 2017; 12:e0187337. [PMID: 29121664 PMCID: PMC5679592 DOI: 10.1371/journal.pone.0187337] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Accepted: 10/18/2017] [Indexed: 11/26/2022] Open
Abstract
Background Elderly patients undergoing hip fracture surgery (HFS) are at increased risk of postoperative venous thromboembolism (VTE). To reduce this risk, combined postoperative mechanical and chemical thromboprophylaxis has been routinely performed after HFS in these patients. This retrospective case-control study was conducted to evaluate the additional effectiveness of preoperative mechanical thromboprophylaxis for the prevention of VTE following HFS in elderly patients. Methods Of 539 consecutive patients aged 70 years or older undergoing HFS, 404 (control group) did not receive preoperative mechanical thromboprophylaxis, while 135 (study group) received mechanical thromboprophylaxis using an intermittent pneumatic compression device and graduated compression stockings from the time of admission until surgery. All patients received combined postoperative mechanical and chemical thromboprophylaxis following HFS in accordance with the same protocol. The incidence of symptomatic VTE confirmed based on clinical symptoms and 3-dimensional CT angiography within one month of surgery was investigated in both groups. Results The American Society of Anesthesiologists grade was higher (p = 0.016) in the study group and more patients in this group had concomitant cardiovascular and neurologic diseases (p = 0.005 and p = 0.009, respectively). In addition, more patients in the study group had received anticoagulant medication preinjury owing to comorbidities (39% vs 28%, p = 0.025). The overall incidences of symptomatic deep vein thrombosis (DVT) and pulmonary embolism (PE) were 7.4% and 3.7%, and 2.2% and 1.5% in the control and study groups, respectively. According to multiple logistic regression, symptomatic DVT significantly reduced in the study group (OR 0.28, p = 0.042), while there was no significant difference in the incidence of symptomatic PE between the two groups (p = 0.223). Conclusions Preoperative mechanical thromboprophylaxis may confer an additional benefit by preventing postoperative VTE without adding more risk of perioperative bleeding in elderly patients with hip fracture.
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Affiliation(s)
- Ji-Hoon Nam
- Department of Orthopaedic Surgery, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Dae-Hwan Kim
- Department of Orthopaedic Surgery, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Je-Hyun Yoo
- Department of Orthopaedic Surgery, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
- * E-mail:
| | - Ji-Hyo Hwang
- Department of Orthopaedic Surgery, Kangnam Sacred Heart Hospital, Seoul, Republic of Korea
| | - Jun-Dong Chang
- Department of Orthopaedic Surgery, Dongtan Sacred Heart Hospital, Hwasung, Republic of Korea
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Affiliation(s)
- James T Ninomiya
- 1Department of Orthopaedic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin 2West Texas Orthopedics, Midland, Texas 3Houston Methodist Hospital, Houston, Texas
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Reducing blood loss, decreasing transfusion rates, and postoperative venous thromboembolism prophylaxis in total hip arthroplasty. CURRENT ORTHOPAEDIC PRACTICE 2017. [DOI: 10.1097/bco.0000000000000508] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ricciardi BF, Oi KK, Daines SB, Lee YY, Joseph AD, Westrich GH. Patient and Perioperative Variables Affecting 30-Day Readmission for Surgical Complications After Hip and Knee Arthroplasties: A Matched Cohort Study. J Arthroplasty 2017; 32:1074-1079. [PMID: 27876255 DOI: 10.1016/j.arth.2016.10.019] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Revised: 10/08/2016] [Accepted: 10/13/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Changes in reimbursement for total hip and knee arthroplasties (THA and TKA) have placed increased financial burden of early readmission on hospitals and surgeons. Our purpose was to characterize factors of 30-day readmission for surgical complications after THA and TKA at a single, high-volume orthopedic specialty hospital. METHODS Patients with a diagnosis of osteoarthritis and who were readmitted within 30 days of their unilateral primary THA or TKA procedure between 2010 and 2014. Readmitted patients were matched to nonreadmitted patients 1:2. Patient and perioperative variables were collected for both cohorts. A conditional logistic regression was performed to assess both the patient and perioperative factors and their predictive value toward 30-day readmission. RESULTS Twenty-one thousand eight hundred sixty-four arthroplasties (THA = 11,105; TKA = 10,759) were performed between 2010 and 2014 at our institution, in which 60 patients (THA = 37, TKA = 23) were readmitted during this 5-year period. The most common reasons for readmission were fracture (N = 14), infection (N = 14), and dislocation (N = 9). Thirty-day readmission for THA was associated with increased procedure time (P = .05), length of stay (LOS) shorter than 2 days (P = .04), discharge to a skilled nursing facility (P = .05), and anticoagulation use other than aspirin (P = .02). Thirty-day readmission for TKA was associated with increased tourniquet time (P = .02), LOS <3 days (P < .01), and preoperative depression (P = .02). In the combined THA/TKA model, a diagnosis of depression increased 30-day readmission (odds ratio 3.5 [1.4-8.5]; P < .01). CONCLUSION Risk factors for 30-day readmission for surgical complications included short LOS, discharge destination, increased procedure/tourniquet time, potent anticoagulation use, and preoperative diagnosis of depression. A focus on risk factor modification and improved risk stratification models are necessary to optimize patient care using readmission rates as a quality benchmark.
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Affiliation(s)
- Benjamin F Ricciardi
- Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, New York
| | - Kathryn K Oi
- Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, New York
| | - Steven B Daines
- Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, New York
| | - Yuo-Yu Lee
- Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, New York
| | - Amethia D Joseph
- Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, New York
| | - Geoffrey H Westrich
- Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, New York
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Haynes J, Barrack RL, Nam D. Mobile pump deep vein thrombosis prophylaxis: just say no to drugs. Bone Joint J 2017; 99-B:8-13. [PMID: 28042112 DOI: 10.1302/0301-620x.99b1.bjj-2016-0165.r1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 06/07/2016] [Indexed: 11/05/2022]
Abstract
AIMS The purpose of this article was to review the current literature pertaining to the use of mobile compression devices (MCDs) for venous thromboembolism (VTE) following total joint arthroplasty (TJA), and to discuss the results of data from our institution. PATIENTS AND METHODS Previous studies have illustrated higher rates of post-operative wound complications, re-operation and re-admission with the use of more aggressive anticoagulation regimens, such as warfarin and factor Xa inhibitors. This highlights the importance of the safety, as well as efficacy, of the chemoprophylactic regimen. RESULTS Studies have shown a symptomatic VTE rate of 0.92% with use of MCDs for prophylaxis, which is comparable with rates seen with more aggressive anticoagulation protocols. A prior prospective study found that use of a pre-operative risk stratification protocol based on personal history of deep vein thrombosis, family history of VTE, active cancer, or a hypercoaguable state allowed for the avoidance of aggressive prophylactic anticoagulation in over 70% of patients while maintaining a low incidence of symptomatic VTE. CONCLUSION Further investigation is needed into the role of aspirin in VTE prophylaxis as well as the efficacy of MCDs as stand-alone prophylactic treatment. Cite this article: Bone Joint J 2017;99-B(1 Supple A):8-13.
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Affiliation(s)
- J Haynes
- Washington University Orthopedics, Barnes Jewish Hospital, 660 S. Euclid Avenue, Campus Box 8233, St. Louis, MO, 63110, USA
| | - R L Barrack
- Washington University Orthopedics, Barnes Jewish Hospital, 660 S. Euclid Avenue, Campus Box 8233, St. Louis, MO, 63110, USA
| | - D Nam
- Washington University Orthopedics, Barnes Jewish Hospital, 660 S. Euclid Avenue, Campus Box 8233, St. Louis, MO, 63110, USA
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Affiliation(s)
- James T Ninomiya
- Department of Orthopaedic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
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Abstract
UNLABELLED The efficient and effective function of the Achilles tendon is essential for normal gait and sporting performance. The optimal technique for the operative repair of the Achilles midsubstance rupture remains controversial. Suboptimal outcomes are common even after successful Achilles repair. Factors contributing to poor outcomes include a tenuous soft tissue envelope (leading to wound complications, peritendinous adhesions, and poor tendon healing,) as well as failure to maintain appropriate musculotendinous length, even after successful repair.We present a new technique using the InternalBrace (IB) and a modification of the Percutaneous Achilles Repair System (PARS; Arthrex Inc, Naples, FL), the Achilles Mid-Substance Speed Bridge Repair. This IB approach is knotless, respects the soft tissue envelope, and allows the appropriate musculotendinous length to be set intraoperatively. The IB principle enables direct fixation to bone allowing early mobilization while minimizing the risk of knot slippage, accelerating recovery, and allowing for restoration of normal function. LEVEL OF EVIDENCE Level V, expert opinion.
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Affiliation(s)
- James R McWilliam
- New York Medical College, Valhalla, NY, USA Specialty Orthopaedics, PLLC, Harrison, NY, USA
| | - Gordon Mackay
- University of Stirling, Scotland, United Kingdom The MacKay Clinic, Ltd., Scotland, United Kingdom
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