Primary Joint Arthroplasty Surgery: Is the Risk of Major Bleeding Higher in Elderly Patients? A Retrospective Cohort Study

Outcomes Following Total Hip Arthroplasty in Patients Who Have Von Willebrand Disease Depend on Postoperative Anticoagulation

BACKGROUND

Von Willebrand disease (VWD) is the most common congenital bleeding disorder. This autosomal dominant condition arises from quantitative or qualitative defects of Von Willebrand factor. To our knowledge, this study leveraged a national database to characterize the largest VWD cohort of total hip arthroplasty (THA) patients to date, assessing 90-day postoperative adverse events and 5-year revision-free survival.

METHODS

Adult patients who underwent primary THA for osteoarthritis were identified from January 2010 to October 2021 in a nationwide database. Patients who had and did not have VWD were matched (4:1) on age, sex, and Elixhauser Comorbidity Index and compared with multivariable logistic regression. Patients were then categorized based upon venous thromboembolism (VTE) chemoprophylaxis prescription patterns to compare bleeding and thrombotic adverse events.

RESULTS

Of 544,851 THA patients, VWD was identified in 309 patients (0.06%). The matched cohorts contained 1,221 patients who did not have VWD and 306 patients who have VWD. On multivariable analysis, VWD patients had increased odds of 90-day VTE (odds ratio [OR] = 1.86) and hematoma (OR = 3.40) (P < .05 for all). No difference in 5-year revision-free survival was found. The VWD patients receiving aspirin or no prescriptions had greater odds of VTE (OR = 2.39, P = .048). Those on other chemoprophylaxis agents had greater odds of hematoma (OR = 4.84, P = .006).

CONCLUSIONS

Patients with VWD undergoing THA had increased odds of 90-day VTE if using aspirin or no prescriptions, or hematoma if using other chemoprophylaxis. There is a delicate balancing act of clotting versus bleeding that must be considered in managing such patients, but it was reassuring that no difference in overall 5-year revision-free survival was found.

Obesity and the Risk of Venous Thromboembolism after Major Lower Limb Orthopaedic Surgery: A Literature Review

The risk of venous thromboembolism following total joint arthroplasty is significantly greater than those of other types of elective orthopaedic procedures. This risk is increased in obesity due to the associated prothrombotic physiological and hematological changes that predispose to embolic events. The prevalence of obesity is increasing in the aging population, which contributes to a further increase in the risk of postoperative thrombosis in the older patients. There is a lack of clear evidence regarding dosing information for thromboprophylaxis medications in patients with obesity. As a result, the currently available thromboprophylaxis guidelines do not provide specific recommendations for this group. Suboptimal dosing regimens for these medications can place these patients at a risk of bleeding or clotting complications postsurgery. Hence any increase in dosage may require intensive surveillance for the residual anticoagulant effects and careful balancing of risks and benefits on an individual basis. Our review discusses the basis for increased thrombotic risk in obesity, the evidence supporting dosage recommendations, and the implications of the current guidelines for pharmacological thromboprophylaxis in patients with obesity undergoing lower limb arthroplasty.

Bone Density May Be a Promising Predictor for Blood Loss during Total Hip Arthroplasty

Background: Total hip arthroplasty (THA), which is performed mostly in elderly individuals, can result in substantial blood loss and thereby imposes a significant physical burden and risk of blood transfusion. The femoral neck cut and reamed acetabulum are the main sites of intraoperative bleeding. Whether the bone density in that region can be used to predict the amount of blood loss in THA is unknown. Methods: We retrospectively analyzed adult patients undergoing primary THA in the Department of Orthopedics, Peking Union Medical College Hospital, from January 2018 to January 2020. All these patients underwent primary unilateral THA. Patients had their bone mineral density (BMD) recorded within the week before surgery and were stratified and analyzed for perioperative blood loss. Multivariable regressions were utilized to adjust for differences in demographics and comorbidities among groups. Results: A total of 176 patients were included in the study. Intraoperative blood loss was 280.1 ± 119.56 mL. Pearson correlation analysis showed a significant correlation between blood loss and preoperative bone density of both the femoral greater trochanter (R = 0.245, p = 0.001) and the Ward’s triangle (R = 0.181, p = 0.016). Stepwise multiple linear regression showed that preoperative bone density of the greater trochanter (p = 0.015, 95% CI: 0.004–0.049) and sex (p = 0.002) were independent risk factors for THA bleeding. The area under the receiver operating characteristic curve (AUROC) of the greater trochanter and Ward’s triangle was 0.593 (95% CI: 0.507–0.678, p = 0.035) and 0.603 (95% CI: 0.519–0.688, p = 0.018), respectively. The cutoff T value on the femoral greater trochanter for predicting higher bleeding was −1.75. Conclusions: In THA patients, preoperative bone density values of the femoral greater trochanter and sex could be promising independent predictors for bleeding during surgery. Osteoporosis and female patients might have lower blood loss in the THA operation.

Prophylaxis for Venous Thromboembolic Events in Elective Total Hip and Total Knee Arthroplasty

Venous thromboembolism (VTE) is a serious complication after major orthopaedic operations, such as a total hip (THA) and knee (TKA) arthroplasty. Therefore, perioperative VTE prophylaxis is recommended; a multitude of modern options are available, including both pharmacologic (aspirin, unfractionated and lowmolecular-weight heparin, vitamin K antagonists, and novel oral anticoagulants) and/or mechanical interventions (early mobilization, graduated compression stockings, intermittent pneumatic compression devices, and venous foot pumps). However, because of the abundance of these possibilities, it is crucial to understand the benefits and drawbacks of each VTE prophylaxis option to ensure that the optimal treatment plan is developed for each patient. The American College of Chest Physicians (AACP) and the American Academy of Orthopaedic Surgeons (AAOS) have both published individual guidelines on VTE prophylaxis regimens, alongside numerous studies evaluating the efficacy and outcomes of the different prophylaxis modalities. The purpose of this review is to provide a summary of the evidence on VTE prophylaxis after elective total hip and knee arthroplasty based on current guidelines and highlight the major concerns and potential complications.

Total Knee Arthroplasty in Octogenarians: Should We Still Be so Restrictive?

Demand for total knee arthroplasty (TKA) in octogenarians will increase in subsequent years as society ages. We conducted a retrospective observational study in octogenarians operated on with TKA between 2015 and 2019, comparing preoperative and postoperative Knee Society Score (KSS), Knee Society Function Score (KSFS), extension and flexion balance, and radiologic alignment using a paired Student t-test. A chi-squared test was used to correlate mortality with Charlson comorbidities index score and with ASA scale. Kaplan-Meier analysis was performed to calculate patient survival. In this period 36 patients ≥80 years underwent TKA, with a mean age of 81.6 years. Of these, 24 patients (66.7%) were classified as ASA II and 12 (33.3%) as ASA III. Sixteen patients (44.4%) were Charlson 0, 14 (38.9%) Charlson 1, two (5.6%) Charlson 2, and four (11.1%) Charlson 3. KSS, KSFS, flexion and extension range, and radiologic alignment were statistically significant (p < 0.001) when comparing preoperatory and post-operatory data. No correlation (p > 0.05) was found between mortality and ASA or Charlson score. Seven patients (19.4%) suffered a medical complication and two patients experienced surgical complications. Four patient died (11.1%) during follow-up. The mean patient survival was 67.4 months. Patients ≥80 years achieve clinical improvement after TKA. Comorbidities, not age, are the burden for surgery in older patients.

Perioperative Management of Chronic Antithrombotic Agents in Elective Hip and Knee Arthroplasty

Total hip and knee arthroplasty are common major orthopedic operations being performed on an increasing number of patients. Many patients undergoing total joint arthroplasty (TJA) are on chronic antithrombotic agents due to other medical conditions, such as atrial fibrillation or acute coronary syndrome. Given the risk of bleeding associated with TJAs, as well as the risk of thromboembolic events in the post-operative period, the management of chronic antithrombotic agents perioperatively is critical to achieving successful outcomes in arthroplasty. In this review, we provide a concise overview of society guidelines regarding the perioperative management of chronic antithrombotic agents in the setting of elective TJAs and summarize the recent literature that may inform future guidelines. Ultimately, antithrombotic regimen management should be patient-specific, in consultation with cardiology, internal medicine, hematology, and other physicians who play an essential role in perioperative care.

Advanced Age Is Not a Barrier to Total Knee Arthroplasty: A Detailed Analysis of Outcomes and Complications in an Elderly Cohort Compared With Average Age Total Knee Arthroplasty Patients

BACKGROUND

Life expectancy and higher complication rates have made the routine use of total knee arthroplasty (TKA) in elderly patients disputed by some authors. The purpose of this study was to assess patient and implant survivorship, complication and revision rates, and patient-reported outcomes (PROMS) in a cohort of patients aged above 80 years undergoing TKA. A comparison with a propensity matched cohort of patients of average age within our database for TKA was performed.

METHODS

A retrospective review of prospectively collected data identified 644 patients over the age of 80 years undergoing a TKA within a 14-year period. After calculating the average age of all TKA patients within the reviewed database, a cohort deemed average age was created within 1 standard deviation of the average age and matched using the following criteria: gender, surgeon, diagnosis, procedure type, and year. The primary outcomes were survivorship of the implant and the patient. The secondary outcomes were complications, transfusion rates, discharge destination, and PROMS.

RESULTS

The revision rate was low for both groups (P = .051). Implant survivorship at 10 years was similar (P = .07). Mortality rate was higher in the elderly (P < .001). General complication rate was higher in the elderly (P = .031). Surgical complications rates were similar (P = .702). The PROMS at final follow-up were 4% lower in the elderly (P < .001).

CONCLUSION

TKA in the elderly is a safe procedure. With measures minimizing the perioperative complications and blood loss, the outcome can be expected to be similar to patients of average age. The projected implant and patient survivorship in the elderly cohort is long enough to suggest that TKA in the elderly could have a high impact on remaining quality of life. Level III retrospective study.

Differences in Reported Outcomes in Industry-Funded vs Nonfunded Studies Assessing Thromboprophylaxis After Total Joint Arthroplasty

BACKGROUND

There are numerous studies discussing thromboprophylaxis after total joint arthroplasty (TJA), with varying conclusions. Patient inclusion criteria may be different for each study, which may lead to selection bias and misrepresentation of data. This study aimed to investigate if industry funding impacted patient demographics and overall reported outcomes of studies analyzing venous thromboembolism (VTE) prevention after TJA.

METHODS

Electronic searches were completed using Ovid, PubMed, and Embase databases. Studies were included if (1) they are published in the English language between 2000 and 2016; (2) they included patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA); and (3) they evaluated prevention and control of postoperative VTE with at least one of the following thromboprophylactic agents: aspirin, enoxaparin, dalteparin, dabigatran, apixaban, rivaroxaban, dabigatran, ximelagatran, fondaparinux, or coumadin. Data were extracted and analyzed via mixed-effect logistic regression.

RESULTS

Fifty-seven studies were included; 29 were industry funded, and 28, nonfunded. There were no significant differences between patient's age, body mass index, or revision exclusions between funded and nonfunded studies. Funded studies reported less pulmonary embolisms, fewer events of major bleeding, and significantly less 90-day mortality compared with nonfunded studies.

CONCLUSION

Industry-funded studies reported less pulmonary embolisms, major bleeding, and mortality compared with nonfunded studies. Detailed demographic data were missing from the literature, and we were unable to demonstrate the cause of different reported outcomes between industry-funded and nonfunded studies. Further investigations should be aimed toward understanding how funded studies report less adverse outcomes in analyzing VTE after TJA.