Risk-Stratified Venous Thromboembolism Prophylaxis After Total Joint Arthroplasty: Aspirin and Sequential Pneumatic Compression Devices vs Aggressive Chemoprophylaxis

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

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.

Aspirin prophylaxis is not associated with increased risk of venous thromboembolism in arthroplasty for femoral neck fractures: a non-inferiority study

PURPOSE

Venous thromboembolism (VTE) is a known complication of hip arthroplasty for femoral neck fractures (FNF) with various prophylactic anticoagulants utilized to decrease risk. The purpose of this study was to assess the efficacy and perioperative outcomes associated with aspirin for VTE prophylaxis following arthroplasty for FNF.

METHODS

Medical records of 1,220 patients who underwent hip hemiarthroplasty (HHA) or total hip arthroplasty (THA) at an urban academic center from 2011 to 2022 were retrospectively reviewed. Patient characteristics and perioperative outcomes, including length of stay (LOS), VTE, 90-day hospital encounters, and discharge disposition, were collected. Outcomes for patients prescribed aspirin (n = 214) were compared to those prescribed non-aspirin VTE prophylaxis (n = 1006) using propensity score matching.

RESULTS

Patients who received aspirin had higher rates of THA (36.0 vs 26.7%; p = 0.008). There were no significant risk-adjusted differences in the incidence of VTE (0.5 vs 0.5%, p = 1.000) and 90-day readmissions (10.4 vs 12.3%, p = 0.646) between patients prescribed aspirin and non-aspirin VTE prophylaxis, respectively. Patients prescribed non-aspirin agents had higher rates of non-home discharge (73.9 vs 58.5%; p < 0.001) and longer LOS (143.5 vs 124.9 h; p = 0.005). Sub-analysis of patients prescribed aspirin and non-aspirin prophylaxis based on comorbidity scores demonstrated no difference in VTE incidence for low (0.0 vs 1.6%, p = 1.000) and high scores (0.0 vs 0.0%, p = 1.000), respectively.

CONCLUSION

Aspirin is not associated with increased incidence of VTE after HHA or THA for FNF. Aspirin prophylaxis should be considered in hip fracture patients to mitigate bleeding risk, particularly those with low to intermediate VTE risk.

LEVEL OF EVIDENCE

Level III, Retrospective study.

Thromboprophylaxis with unilateral pneumatic device led to less edema and blood loss compared to enoxaparin after knee arthroplasty: randomized trial

BACKGROUND

Pharmacological and mechanical thromboprophylaxis are frequently used together after total knee arthroplasty (TKA). Most studies in this context compare anticoagulants versus a combination of these drugs with an intermittent pneumatic compression device (IPCD). However, there is uncertainty about the need for the combination of both and whether a unilateral IPCD would alone affect other important clinical outcomes: edema and blood loss. We compared the effects of enoxaparin versus unilateral portable IPCD after TKA on edema and blood loss. We hypothesised that unilateral IPCD would cause the same level of edema and the same blood loss as enoxaparin.

METHODS

In this open, randomized trial (1:1), adults with no history of coagulation disorders, anticoagulant use, venous thromboembolism, liver or malignant diseases underwent TKA. For 10 days, participants received the IPCD, used 24 h/day on the operated leg from the end of surgery, or 40 mg of enoxaparin, starting 12 h after surgery. All underwent the same rehabilitation and were encouraged to walk on the same day of surgery. We measured edema (thigh, leg and ankle circumference) before and on the third postoperative day. Blood loss (volume accumulated in the suction drain and drop of hemoglobin and hematocrit in 48 h) was a secondary outcome.

RESULTS

We randomized 150 patients and lost 3 to follow-up with enoxaparin and 2 with IPCD. There was no case of symptomatic venous thromboembolism. Four patients needed transfusions (three receiving enoxaparin), one had infection and one hemarthrosis (both in the enoxaparin group). Leg circumference increased by approximately 2 cm for enoxaparin group and 1.5 cm in IPCD (p <  0.001). The increase in ankle circumference was about 1.5 cm in the enoxaparin group (p <  0.001), and almost zero in IPCD (p = 0.447). Enoxaparin group lost 566.1 ml (standard deviation, SD, 174.5) of blood in the first 48 h, versus 420.8 ml (SD 142.5) in the IPCD.

CONCLUSIONS

Exclusively mechanical prophylaxis after TKA with portable IPCD only on the operated leg reduces leg and ankle swelling and post-operative blood loss compared to exclusively pharmacological prophylaxis with enoxaparin. Portable devices that can prevent deep vein thrombosis and pulmonary embolism without increasing blood loss or other risks should be further investigated.

TRIAL REGISTRATION

REBEC RBR-8k2vpx. Registration date: 06/04/2019.

Total Joint Arthroplasty Training (Prehabilitation and Rehabilitation) in Lower Extremity Arthroplasty

Lower extremity total joint arthroplasty (TJA) has an established track record of success and a subset of patients who fail to experience desired improvements. Current TJA success can be attributed to refined surgical techniques, improved preparation of patients for surgery, and enhanced postoperative recovery protocols. One aspect of preoperative patient preparation and enhanced postoperative recovery includes training regimens intended to prepare patients for TJA and facilitate TJA functional recovery (often referred to as using the jargon prehabilitation and rehabilitation). The importance of prehabilitation and rehabilitation is open to debate because of historically insufficient and inconsistent evidence. This review aims to provide direction for future investigative efforts by presenting an overview of current preoperative and postoperative TJA training/exercise programs within the framework of utility, timing, form, setting, and cost.

Equivalent VTE rates after total joint arthroplasty using thromboprophylaxis with aspirin versus potent anticoagulants: retrospective analysis of 4562 cases across a diverse healthcare system

BACKGROUND

Guidelines support aspirin thromboprophylaxis for primary total hip and knee arthroplasty (THA and TKA) but supporting evidence has come from high volume centers and the practice remains controversial.

METHODS

We studied 4562 Medicare patients who underwent elective primary THA (1736, 38.1%) or TKA (2826, 61.9%) at 9 diverse hospitals. Thirty-day claims data were combined with data from the health system's electronic medical records to compare rates of venous thromboembolism (VTE) between patients who received prophylaxis with: (1) aspirin alone (47.3%), (2) a single, potent anticoagulant (29%), (3) antiplatelet agents other than aspirin or multiple anticoagulants (21.5%), or (4) low-dose subcutaneous unfractionated heparin or no anticoagulation (2.2%). Sub-analyses separately evaluating THA, TKA and cases from lower volume hospitals (n = 975) were performed.

RESULTS

The 30-day VTE incidence was 0.6% (29/4562). VTE rates were equal in patients receiving aspirin and those receiving a single potent anticoagulant (0.5% in both groups). Patients with VTE were significantly older than patients without VTE (mean 76.5 vs. 73.1 years, P = 0.04). VTE rate did not associate with sex or hospital case volume. On bivariate analysis considering age, aspirin did not associate with greater VTE risk compared to a single potent anticoagulant (OR = 2.1, CI = 0.7-6.3) with the numbers available. Odds of VTE were increased with use of subcutaneous heparin or no anticoagulant (OR = 6.4, CI = 1.2-35.6) and with multiple anticoagulants (OR = 3.6, CI = 1.1-11.2). THA and TKA demonstrated similar rates of VTE (0.5% vs. 0.7%, respectively, P = 0.43). Of 975 cases done at lower volume hospitals, 387 received aspirin, none of whom developed VTE.

CONCLUSIONS

This study provides further support for aspirin as an effective form of pharmacological VTE prophylaxis after total joint arthroplasty in the setting of a multi-modal regimen using 30-day outcomes. VTE occurred in 0.7% of primary joint arthroplasties. Aspirin prophylaxis did not associate with greater VTE risk compared to potent anticoagulants in the total population or at lower volume hospitals.

Weight-Based Aspirin Dosing May Further Reduce the Incidence of Venous Thromboembolism Following Primary Total Joint Arthroplasty

BACKGROUND

Obesity poses a challenge to thromboembolic prophylaxis following total joint arthroplasty (TJA). The purpose of this study is to evaluate a weight-based aspirin dosing regimen for prevention of venous thromboembolism (VTE) following TJA.

METHODS

This is a retrospective observational study of 2403 patients who underwent primary total hip or knee arthroplasty at one institution. A weight-based aspirin dosing regimen for VTE prophylaxis was administered to 1247 patients: patients weighing ≥120 kg received 325 mg aspirin twice daily (BID) and those weighing <120 kg received 81 mg aspirin BID for 4 weeks. In total, 1156 patients in the comparison cohort received 81 mg aspirin BID. VTE and gastrointestinal bleeding events were identified through chart review at 42 days and 6 months postoperatively. A multivariable logistic regression was performed to adjust for covariates.

RESULTS

The weight-based aspirin cohort had a significantly lesser incidence of VTE at 42 days (P = .03, relative risk [RR] 0.31, 95% confidence interval 0.12-0.82) and 6 months (P = .03, RR 0.38, 95% confidence interval 0.18-0.80). There was no difference in VTE incidence between total hip arthroplasty and total knee arthroplasty cases (P = .8). There was no difference in gastrointestinal bleeding events between the cohorts at 42 days (P = .69) or 6 months (P = .92). Subanalysis of patients weighing ≥120 kg demonstrated a significant difference between the cohorts with a VTE incidence of 3.48% and 0% in the 81 mg and weight-based cohorts, respectively (P = .02).

CONCLUSION

Patients prescribed a weight-based aspirin regimen had significantly fewer VTEs after TJA compared to historical controls with an RR reduction of 69% at 6 weeks and 62% at 6 months postoperatively. This suggests the need to factor patient weight when determining postoperative VTE prophylaxis with aspirin.

A risk-stratified approach to venous thromboembolism prophylaxis with aspirin or warfarin following total hip and knee arthroplasty: A cohort study

INTRODUCTION

Venous thromboembolism (VTE) and bleeding events following total knee and hip arthroplasty (TKA/THA) are associated with significant morbidity. Clinical guidelines recommend administration of pharmacologic VTE prophylaxis post-operatively, although controversy exists regarding optimal prophylactic strategies.

METHODS

We performed a retrospective cohort study in patients who underwent elective TKA/TKA in an academic medical center. Patients were stratified by surgery type (TKA/THA) and VTE risk determined by a novel risk stratification protocol and compared pre- and post-protocol implementation. Patients received warfarin pre-protocol and either aspirin or warfarin post-protocol for VTE prophylaxis. Natural language processing identified VTE events and ICD codes were used to identify bleeding events, with all events validated manually.

RESULTS

A total of 1379 surgeries were included for analysis, 839 TKAs and 540 THAs. Post-protocol implementation, 445 (94.1%) patients following TKA and 294 (97.4%) patients following THA received aspirin for VTE prophylaxis. A significant reduction in bleeding events (hazard ratio [HR] = 0.19, p = 0.048) was observed in low-risk THA patients treated with aspirin (post-protocol) compared patients treated with warfarin (pre-protocol). Bleeding events did not differ significantly between low-risk TKA patients treated with aspirin or warfarin. No significant differences in VTE events were observed following the protocol implementation.

CONCLUSIONS

The use of a novel risk stratification system to guide VTE prophylaxis selection between aspirin or warfarin following TKA and THA appears safe and effective. Among low-risk patients, aspirin use was associated with fewer bleeding events following THA, without an observed increase in VTE events.

Role of real-world digital data for orthopedic implant automated surveillance: a systematic review

INTRODUCTION

Data collection automation through the reuse of real-world digital data from clinical data warehouses (CDW) could represent a great opportunity to improve medical device monitoring. For instance, this approach is starting to be used for the design of automated decision support systems for joint replacement monitoring. However, a number of obstacles remains, such as data quality and interoperability through the use of common and regularly updated terminologies, and the use of a Unique Device Identifier (UDI).

AREAS COVERED

To present the existing models of automated surveillance of orthopedic devices, a systematic review of initiatives using real-world digital health data to monitor joint replacement surgery was performed following the PRISMA 2020 guidelines. The main objective was to identify the data sources, the target populations, the population size, the device location, and the main results of studies on such initiatives.

EXPERT OPINION

Analysis of the identified studies showed that real-world digital data offer many opportunities for improving the automation of monitoring in orthopedics. The contribution of real-world data, especially through natural language processing, UDI use in CDW and the integration of device databases, is needed for automated and more robust health surveillance.

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

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.

Low dose aspirin is effective in preventing venous thromboembolism in patients undergoing primary total knee arthroplasty

INTRODUCTION

Venous thromboembolism (VTE) is a known complication after total knee arthroplasty (TKA) with well-established morbidity, mortality, and significant healthcare expenditure. However, no standard form of prophylaxis against VTE currently exists.

METHODS

A retrospective review was performed identifying 12,866 TKA cases and post-operative VTE events using either 325 mg aspirin or 81 mg aspirin twice daily (BID).

RESULTS

133 VTE cases were diagnosed of the 9413 TKA on 325 mg aspirin BID compared to 8 VTE cases out of 3453 TKA on 81 mg aspirin BID (1.41% vs. 0.23%, p < 0.001).

CONCLUSION

81 mg aspirin BID significantly improved post-operative VTE rates over 325 mg aspirin BID.

Multimodal thromboprophylaxis in low-risk patients undergoing lower limb arthroplasty: A retrospective observational cohort analysis of 1400 patients with ultrasound screening

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.

Interaction Between Low-Dose Aspirin and Nonsteroidal Anti-Inflammatory Drugs Can Compromise Aspirin's Efficacy in Preventing Venous Thrombosis Following Total Joint Arthroplasty

Total joint arthroplasty is a rapid recovery procedure with patients optimized quickly in preparation for discharge. Two significant postoperative goals are effective pain management and prevention of postoperative venous thromboembolism (VTE). Low-risk patients receive aspirin 81 mg twice daily for VTE prophylaxis; this dosing regimen has been reduced over the past few years from 325 mg to 162 mg to 81 mg twice daily. Unless contraindications exist, all patients receive multimodal pain management that includes the use of celecoxib or meloxicam. Upon reduction of the aspirin dose to 81 mg twice daily, we rapidly identified 2 patients who developed a pulmonary embolus when celecoxib or meloxicam was administered concurrently with aspirin. The interaction between nonsteroidal anti-inflammatory drugs (NSAIDs) and low-dose aspirin varies among the different NSAIDs. It is also highly dependent on numerous factors, including time of administration, dose of aspirin, and both pharmacodynamics and dose of the NSAID. Real-world outcomes of concomitant administration of NSAIDs with low-dose aspirin led to increased incidence of VTE, possibly due to competitive inhibition of aspirin at platelet receptor sites. This interaction was mitigated by altering the administration times of both agents.

Topical Vancomycin Powder and Dilute Povidone-Iodine Lavage Reduce the Rate of Early Periprosthetic Joint Infection After Primary Total Knee Arthroplasty

BACKGROUND

Vancomycin powder and dilute povidone-iodine lavage (VIP) was introduced to reduce the incidence of periprosthetic joint infection (PJI) in high-risk total knee arthroplasty (TKA) patients. We hypothesize that VIP can reduce the incidence of early PJI in all primary TKA patients, regardless of preoperative risk.

METHODS

An infection database of primary TKAs performed before a VIP protocol was implemented (January 2012-December 2013), during a time when only high-risk TKAs received VIP (January 2014-December 2015), and when all TKAs received VIP (January 2016-September 2019) at an urban, university-affiliated, not-for-profit orthopedic hospital was retrospectively reviewed to identify patients with PJI. Criteria used for diagnosis of PJI were the National Healthcare Safety Network and Musculoskeletal Infection Society guidelines.

RESULTS

VIP reduced early primary TKA PJI incidence in both the high-risk and all-risk cohorts compared with the pre-VIP cohort by 44.6% and 56.4%, respectively (1.01% vs 0.56% vs 0.44%, P = .0088). In addition, after introducing VIP to all-risk TKA patients, compared with high-risk TKA patients, the relative risk of PJI dropped an additional 21.4%, but this finding did not reach statistical significance (0.56% vs 0.44%, P = .4212). There were no demographic differences between the 3 VIP PJI cohorts.

CONCLUSION

VIP is associated with a reduced early PJI incidence after primary TKA, regardless of preoperative risk. With the literature supporting its safety and cost-effectiveness, VIP is a value-based intervention, but given the nature of this historical cohort study, a multicenter randomized controlled trial is underway to definitively confirm its efficacy.

Bleeding and thromboembolism risk of standard antithrombotic prophylaxis after hip or knee replacement within an enhanced recovery program

INTRODUCTION

Prevention of venous thromboembolism (VTE) generally consists of low molecular weight heparin (LMWH) or direct oral anticoagulants (DOACs) after total hip arthroplasty (THA) or total knee arthroplasty (TKA). Enhanced recovery after surgery (ERAS) protocols may reduce the VTE risk after these procedures. The aim of this study was to compare the risk of VTE and the risk of bleeding complications in a non-selected population of primary THA and TKA cases done within an ERAS protocol.

HYPOTHESIS

The risk of postoperative VTE after primary THA and TKA is lower than the risk of bleeding complications within an ERAS protocol.

METHODS

This was a prospective observational study conducted on a national scale in France. All patients who underwent primary unilateral THA or TKA at one of 11 participating hospitals between October 2016 and October 2017 were enrolled and followed for 3 months. The occurrence of a VTE or major bleeding event was recorded. No patients were lost to follow-up at 3 months.

RESULTS

Of the 1110 THA cases, there were 5 VTE (0.4%) and 19 bleeding events (1.7%). Of the 893 TKA cases, there were 9 VTE (1.0%) and 14 bleeding events (1.7%). There was no significant difference in the VTE incidence and bleeding event incidence after THA and TKA. The overall incidence of bleeding complications (1.7%) was significantly greater than the overall incidence of VTE complications (0.7%) (p=0.005). This was the case after THA (p=0.004) but not after TKA.

DISCUSSION

The primary finding of this study is that bleeding complications are significantly more common than VTE complications after THA or TKA within an ERAS protocol. Based on these findings, the cost-benefit ratio of antithrombotic prophylaxis by LMWH or DOACs in this context should be reassessed.

LEVEL OF EVIDENCE

IV; Prospective cohort study without control group.

Stratifying Venous Thromboembolism Risk in Arthroplasty: Do High-Risk Patients Exist?

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.

Patient-Centered Care: Total Hip Arthroplasty for Displaced Femoral Neck Fracture Does Not Increase Infection Risk

INTRODUCTION

Total hip arthroplasty (THA) is often used for displaced femoral neck fracture. In this study, institutional hip arthroplasty data were compared with the National American College of Surgeons National Surgical Quality Improvement Program (NSQIP) data for any differences in outcomes between our hospital, with an integrated hip fracture care pathway, and those of the country as a whole.

METHODS

Elective THA was compared with arthroplasty performed for acute fracture. Outcomes for both groups included thromboembolic event (VTE), death, and deep prosthetic infection.

RESULTS

Institutional data revealed no increased rate of infection after THA for fracture compared with elective. National Surgical Quality Improvement Program analysis revealed higher infection rates in fracture arthroplasty. There was an increased VTE rate in fracture performed for arthroplasty compared with elective in both institutional and NSQIP data.

CONCLUSIONS

When performed at an academic medical center with an integrated care program, THA for fracture can have similar infection rates to elective THA. By contrast, national data showed significantly higher rates of infection and VTE for arthroplasty for fracture compared with elective. The contrast in complication rates may be related to well-functioning comprehensive interdisciplinary pathways. Patient-centered care pathways may be optimal for hip fracture patients.

Lower limb joint repair and replacement: an overview

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.

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

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.

Bundled Payment Arrangements: Keys to Success

The Centers for Medicare & Medicaid Services is committed to moving 50% of its fee-for-service care to value-based alternative payment models by 2018. The Comprehensive Care for Joint Replacement model is a mandatory agency program that bundles lower extremity joint arthroplasties into episodes of care that extend from the index admission to 90 days after discharge. This program, which began on April 1, 2016, includes many of the hospitals that perform total joint arthroplasties. As with other bundled payment arrangements, this model is built around seven principles that orthopaedic surgeons should be familiar with to maximize participation.

Respiratory Synchronized Versus Intermittent Pneumatic Compression in Prevention of Venous Thromboembolism After Total Joint Arthroplasty: A Systematic Review and Meta-Analysis

The objective of this study was to evaluate the efficacy of respiratory synchronized compression devices (RSCDs) versus nonsynchronized intermittent pneumatic compression devices (NSIPCDs) in preventing venous thromboembolism (VTE) after total joint arthroplasty. A systematic literature review was conducted. Data regarding surgical procedure, deep vein thrombosis, pulmonary embolism, mortality, and adverse events were abstracted. Compared with control groups, the risk ratio of deep vein thrombosis development was 0.51 with NSIPCDs and 0.47 with RSCDs. This review demonstrates that RSCDs may be marginally more effective at preventing VTE events than NSIPCDs. Furthermore, the addition of mechanical prophylaxis to any chemoprophylactic regimen increases VTE prevention.

Increased Incidence of Bleeding and Wound Complications With Factor-Xa Inhibitors After Total Joint Arthroplasty

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.

The 5 Clinical Pillars of Value for Total Joint Arthroplasty in a Bundled Payment Paradigm

BACKGROUND

Our large, urban, tertiary, university-based institution reflects on its 4-year experience with Bundled Payments for Care Improvement. We will describe the importance of 5 clinical pillars that have contributed to the early success of our bundled payment initiative. We are convinced that value-based care delivered through bundled payment initiatives is the best method to optimize patient outcomes while rewarding surgeons and hospitals for adapting to the evolving healthcare reforms.

METHODS

We summarize a number of experiences and lessons learned since the implementation of Bundled Payments for Care Improvement at our institution.

RESULTS

Our experience has led to the development of more refined clinical pathways and coordination of care through evidence-based approaches. We have established that the success of the bundled payment program rests on the following 5 main clinical pillars: (1) optimizing patient selection and comorbidities; (2) optimizing care coordination, patient education, shared decision making, and patient expectations; (3) using a multimodal pain management protocol and minimizing narcotic use to facilitate rapid rehabilitation; (4) optimizing blood management, and standardizing venous thromboembolic disease prophylaxis treatment by risk standardizing patients and minimizing the use of aggressive anticoagulation; and (5) minimizing post-acute facility and resource utilization, and maximizing home resources for patient recovery.

CONCLUSION

From our extensive experience with bundled payment models, we have established 5 clinical pillars of value for bundled payments. Our hope is that these principles will help ease the transition to value-based care for less-experienced healthcare systems.

Is combined use of intravenous and intraarticular tranexamic acid superior to intravenous or intraarticular tranexamic acid alone in total knee arthroplasty? A meta-analysis of randomized controlled trials

BACKGROUND

Tranexamic acid (TXA) has been proven to be effective in reducing blood loss and transfusion rate after total knee arthroplasty (TKA) without increasing the risk of deep vein thrombosis (DVT) and pulmonary embolism (PE). Recently, an increasing number of studies have been interested in applying combined intravenous (IV) with intraarticular (IA) tranexamic acid in total knee arthroplasty. The purpose of this meta-analysis was to compare the blood loss and complications of combined TXA with IV TXA or IA TXA on TKA.

METHODS

Systematic search of literatures were conducted to identify related articles that were published in PubMed, MEDLINE, Embase, the Cochrane Library, SpringerLink, ClinicalTrials.gov, and Ovid from their inception to September 2016. All studies that compare blood loss and complications of combined TXA and IV TXA or IA TXA on TKA were included. Main outcomes were collected and analyzed by the Review Manager 5.3.

RESULTS

Five studies were included in the present meta-analysis. There was significant difference in total blood loss and blood volume of drainage when compared combined TXA group with IV TXA group or IA TXA group (P < 0.05). There was no difference in transfusion rate and thromboembolic complications when comparing combined TXA with IV TXA or IA TXA alone (P > 0.05).

CONCLUSIONS

Compared with administration of IA TXA or IV TXA alone on TKA, combined use of TXA has advantages in reducing total blood loss and blood volume of drainage without increasing the incidence of thromboembolic complications. We recommend combined TXA as the preferred option for patients undergoing TKA.

Improvement in Total Joint Replacement Quality Metrics: Year One Versus Year Three of the Bundled Payments for Care Improvement Initiative

BACKGROUND

In January 2013, a large, tertiary, urban academic medical center began participation in the Bundled Payments for Care Improvement (BPCI) initiative for total joint arthroplasty, a program implemented by the Centers for Medicare & Medicaid Services (CMS) in 2011. Medicare Severity-Diagnosis Related Groups (MS-DRGs) 469 and 470 were included. We participated in BPCI Model 2, by which an episode of care includes the inpatient and all post-acute care costs through 90 days following discharge. The goal for this initiative is to improve patient care and quality through a patient-centered approach with increased care coordination supported through payment innovation.

METHODS

Length of stay (LOS), readmissions, discharge disposition, and cost per episode of care were analyzed for year 3 compared with year 1 of the initiative. Multiple programs were implemented after the first year to improve performance metrics: a surgeon-directed preoperative risk-factor optimization program, enhanced care coordination and home services, a change in venous thromboembolic disease (VTED) prophylaxis to a risk-stratified protocol, infection-prevention measures, a continued emphasis on discharge to home rather than to an inpatient facility, and a quality-dependent gain-sharing program among surgeons.

RESULTS

There were 721 Medicare primary total joint arthroplasty patients in year 1 and 785 in year 3; their data were compared. The average hospital LOS decreased from 3.58 to 2.96 days. The rate of discharge to an inpatient facility decreased from 44% to 28%. The 30-day all-cause readmission rate decreased from 7% to 5%; the 60-day all-cause readmission rate decreased from 11% to 6%; and the 90-day all-cause readmission rate decreased from 13% to 8%. The average 90-day cost per episode decreased by 20%.

CONCLUSIONS

Mid-term results from the implementation of Medicare BPCI Model 2 for primary total joint arthroplasty demonstrated decreased LOS, decreased discharges to inpatient facilities, decreased readmissions, and decreased cost of the episode of care in year 3 compared with year 1, resulting in increased value to all stakeholders involved in this initiative and suggesting that continued improvement over initial gains is possible.