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Yılmaz MK, Abbaszadeh A, Restrepo C, Azboy I, Parvizi J. Aspirin is an Effective Prophylaxis for Venous Thromboembolism After Revision Hip and Knee Arthroplasty. J Arthroplasty 2024; 39:S385-S390. [PMID: 38997046 DOI: 10.1016/j.arth.2024.06.061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 06/24/2024] [Accepted: 06/26/2024] [Indexed: 07/14/2024] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) following revision total joint arthroplasty (TJA) poses significant risks despite prophylactic measures. The optimal VTE prophylaxis agent for revision TJA remains unclear. This study aimed to compare aspirin against various anticoagulant agents regarding efficacy and safety in preventing symptomatic VTE events after revision TJA. METHODS A retrospective analysis included 4,575 patients undergoing revision TJA between 2008 and 2020. Of these, 2,091 received aspirin, while 2,484 received other anticoagulants. Demographic, procedural, and outcome data were collected. Logistic regression models were used to identify predictors of symptomatic VTE. RESULTS The aspirin group showed a significantly lower incidence of symptomatic VTE compared to the other anticoagulant group (0.53 versus 2.54%, P < .001). Logistic regression confirmed a higher risk of VTE with other anticoagulants (odds ratio: 0.2 to 0.26, P < .001), while blood transfusion (odds ratio: 2.72, P = .001) were identified as risk factors. CONCLUSIONS This study demonstrated that aspirin is a viable and potentially safer option than other anticoagulants, exhibiting comparable efficacy in preventing VTE events in revision TJA. Balancing effectiveness and safety is crucial, considering patient-specific risk factors and bleeding tendencies. This large cohort study demonstrated that aspirin was associated with a more effective and safer VTE prophylaxis agent, compared to other anticoagulants, in patients undergoing revision TJA.
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Affiliation(s)
- Mehmet K Yılmaz
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania; Faculty of Medicine, Department of Orthopaedics and Traumatology, İstanbul Medipol University, İstanbul, Turkey
| | - Ahmad Abbaszadeh
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Camilo Restrepo
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Ibrahim Azboy
- Faculty of Medicine, Department of Orthopaedics and Traumatology, İstanbul Medipol University, İstanbul, Turkey
| | - Javad Parvizi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania; International Joint Center, Acibadem Hospital, Maslak, Istanbul, Turkey
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Cheok T, Beveridge A, Berman M, Coia M, Campbell A, Tse TTS, Doornberg JN, Jaarsma RL. Efficacy and safety of commonly used thromboprophylaxis agents following hip and knee arthroplasty. Bone Joint J 2024; 106-B:924-934. [PMID: 39216864 DOI: 10.1302/0301-620x.106b9.bjj-2023-1252.r2] [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: 09/04/2024]
Abstract
Aims We investigated the efficacy and safety profile of commonly used venous thromboembolism (VTE) prophylaxis agents following hip and knee arthroplasty. Methods A systematic search of PubMed, Embase, Cochrane Library, Web of Science, and OrthoSearch was performed. Prophylaxis agents investigated were aspirin (< 325 mg and ≥ 325 mg daily), enoxaparin, dalteparin, fondaparinux, unfractionated heparin, warfarin, rivaroxaban, apixaban, and dabigatran. The primary efficacy outcome of interest was the risk of VTE, whereas the primary safety outcomes of interest were the risk of major bleeding events (MBE) and wound complications (WC). VTE was defined as the confirmed diagnosis of any deep vein thrombosis and/or pulmonary embolism. Network meta-analysis combining direct and indirect evidence was performed. Cluster rank analysis using the surface under cumulative ranking (SUCRA) was applied to compare each intervention group, weighing safety and efficacy outcomes. Results Of 86 studies eligible studies, cluster rank analysis showed that aspirin < 325 mg daily (SUCRA-VTE 89.3%; SUCRA-MBE 75.3%; SUCRA-WC 71.1%), enoxaparin (SUCRA-VTE 55.7%; SUCRA-MBE 49.8%; SUCRA-WC 45.2%), and dabigatran (SUCRA-VTE 44.9%; SUCRA-MBE 52.0%; SUCRA-WC 41.9%) have an overall satisfactory efficacy and safety profile. Conclusion We recommend the use of either aspirin < 325 mg daily, enoxaparin, or dabigatran for VTE prophylaxis following hip and knee arthroplasty.
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Affiliation(s)
- Tim Cheok
- Department of Orthopaedic Surgery, Lyell McEwin Hospital, Adelaide, Australia
- Department of Orthopaedic Surgery, Palmerston North Hospital, Palmerston North, New Zealand
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Alexander Beveridge
- Department of Orthopaedic Surgery, Palmerston North Hospital, Palmerston North, New Zealand
- School of Medicine, Cardiff University, Neuadd Meirionnydd, Cardiff, UK
| | - Morgan Berman
- Department of Orthopaedic Surgery, Monash Medical Centre, Melbourne, Australia
| | - Martin Coia
- Department of Orthopaedic Surgery, Palmerston North Hospital, Palmerston North, New Zealand
| | - Alexander Campbell
- Department of Orthopaedic Surgery, Middlemore Hospital, Auckland, New Zealand
| | - Tycus T S Tse
- Department of Orthopaedic Surgery, Palmerston North Hospital, Palmerston North, New Zealand
| | - Job N Doornberg
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
- Department of Orthopaedic Surgery, Flinders Medical Centre, Adelaide, Australia
- Department of Orthopaedic Surgery, University Medical Centre Groningen, Groningen, Netherlands
| | - Ruurd L Jaarsma
- College of Medicine and Public Health, Flinders University, Adelaide, Australia
- Department of Orthopaedic Surgery, Flinders Medical Centre, Adelaide, Australia
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Dubin JA, Bains SS, Hameed D, Remily EA, Moore MC, Mont MA, Nace J, Delanois RE. Trends in Deep Vein Thrombosis Prophylaxis After Total Knee Arthroplasty: 2016 to 2021. J Arthroplasty 2024; 39:S328-S332. [PMID: 38325530 DOI: 10.1016/j.arth.2024.01.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 12/19/2023] [Accepted: 01/28/2024] [Indexed: 02/09/2024] Open
Abstract
BACKGROUND In 2011, the American Academy of Orthopaedic Surgeons released a consensus recommending venous thromboembolism (VTE) prophylaxis after total knee arthroplasty (TKA). The purpose of our study was to examine (1) incidences of postoperative complications, including pulmonary embolism (PE), deep vein thrombosis (DVT), and transfusion rates; (2) trends from 2016 to 2021 in VTE prophylaxis; and (3) independent risk factors for 90-day total complications following TKA between aspirin, enoxaparin, rivaroxaban, and warfarin. METHODS Using a national, all-payer database from 2016 to 2021, we identified all patients who underwent primary TKA. Exclusions included all patients who had prescribed anticoagulants within 1 year prior to TKA, hypercoagulable states, and cancer. Data were collected on baseline demographics, including age, sex, diabetes, and a comorbidity index, in each of the VTE prophylaxis cohorts. Postoperative outcomes included rates of PE, DVT, and transfusion. Multivariable regressions were performed to determine independent risk factors for total complications at 90 days following TKA. RESULTS From 2016 to 2021, aspirin was the most used anticoagulant (n = 62,054), followed by rivaroxaban (n = 26,426), enoxaparin (n = 20,980), and warfarin (n = 13,305). The cohort using warfarin had the highest incidences of PE (1.8%) and DVT (5.7%), while the cohort using aspirin had the lowest incidences of PE (0.6%) and DVT (1.6%). The rates of aspirin use increased the most from 2016 to 2021 (32.1% to 70.8%), while the rates of warfarin decreased the most (19.3% to 3.0%). Enoxaparin, rivaroxaban, and warfarin were independent risk factors for total complications at 90 days. CONCLUSIONS An epidemiological analysis of VTE prophylaxis use from 2016 to 2021 shows an increase in aspirin following TKA compared to other anticoagulant cohorts in a nationally representative population. This approach provides more insight and a better understanding of anticoagulation trends over this time period in a nationally representative sample.
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Affiliation(s)
- Jeremy A Dubin
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland
| | - Sandeep S Bains
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland
| | - Daniel Hameed
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland
| | - Ethan A Remily
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland
| | - Mallory C Moore
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland
| | - Michael A Mont
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland
| | - James Nace
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland
| | - Ronald E Delanois
- LifeBridge Health, Sinai Hospital of Baltimore, Rubin Institute for Advanced Orthopedics, Baltimore, Maryland
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Harris IA, Sidhu VS, MacDessi SJ, Solomon M, Haddad FS. Aspirin for thromboembolic prophylaxis. Bone Joint J 2024; 106-B:642-645. [PMID: 38946290 DOI: 10.1302/0301-620x.106b7.bjj-2024-0621] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Affiliation(s)
- Ian A Harris
- School of Clinical Medicine, South Western Sydney Clinical School, Faculty of Medicine and Health, UNSW Sydney, Sydney, Australia
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Sydney, Australia
- Institute of Musculoskeletal Health, School of Public Health, The University of Sydney, Sydney, Australia
| | - Verinder S Sidhu
- School of Clinical Medicine, South Western Sydney Clinical School, Faculty of Medicine and Health, UNSW Sydney, Sydney, Australia
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Sydney, Australia
| | - Samuel J MacDessi
- School of Clinical Medicine, South Western Sydney Clinical School, Faculty of Medicine and Health, UNSW Sydney, Sydney, Australia
- Orthopaedic Department, St George Private Hospital, Sydney, Australia
| | - Michael Solomon
- Orthopaedic Department, Prince of Wales Hospital, Sydney, Australia
- Faculty of Medicine and Health Sciences, University of New South Wales, Randwick, Australia
| | - Fares S Haddad
- The Bone & Joint Journal , London, UK
- University College London Hospitals NHS Foundation Trust, London, UK
- The Princess Grace Hospital, London, UK
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Aspirin or enoxaparin for VTE prophylaxis after primary partial, total or revision hip or knee arthroplasty: A secondary analysis from the CRISTAL cluster randomized trial. PLoS One 2024; 19:e0298152. [PMID: 38626226 PMCID: PMC11020928 DOI: 10.1371/journal.pone.0298152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 01/09/2024] [Indexed: 04/18/2024] Open
Abstract
BACKGROUND This study compares aspirin to enoxaparin for symptomatic VTE prophylaxis within 90 days of any type of hip or knee arthroplasty performed for any diagnosis, in patients enrolled in the CRISTAL trial. MATERIALS AND METHODS CRISTAL was a cluster-randomised crossover, registry-nested non-inferiority trial across 31 hospitals in Australia. The primary publication was restricted to patients undergoing primary total hip or knee arthroplasty for a diagnosis of osteoarthritis. This report includes all enrolled patients undergoing hip or knee arthroplasty procedures (partial or total, primary or revision) performed for any indication. Hospitals were randomized to administer patients aspirin (100mg daily) or enoxaparin (40mg daily), for 35 days after hip arthroplasty and 14 days after knee arthroplasty. Crossover occurred after the patient enrolment target had been met for the first group. The primary outcome was symptomatic VTE within 90 days. Analyses were performed by randomization group. RESULTS Between April 20, 2019 and December 18, 2020, 12384 patients were enrolled (7238 aspirin group and 5146 enoxaparin). Of these, 6901 (95.3%) given aspirin and 4827 (93.8%) given enoxaparin (total 11728, 94.7%) were included in the final analyses. Within 90 days, symptomatic VTE occurred in 226 (3.27%) aspirin patients and 85 (1.76%) enoxaparin patients, significant for the superiority of enoxaparin (estimated treatment difference 1.85%, 95% CI 0.59% to 3.10%, p = 0.004). Joint-related reoperation within 90 days was lower in the enoxaparin group (109/4827 (2.26%) vs 171/6896 (2.47%) with aspirin, estimated difference 0.77%; 95% CI 0.06% to 1.47%, p = 0.03). There were no significant differences in the other secondary outcomes. CONCLUSION In patients undergoing hip or knee arthroplasty (of any type, performed for any indication) enrolled in the CRISTAL trial, aspirin compared to enoxaparin resulted in a significantly higher rate of symptomatic VTE and joint-related reoperation within 90 days. These findings extend the applicability of the CRISTAL trial results. TRIAL REGISTRATION Anzctr.org.au, identifier: ACTRN12618001879257.
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Sidhu V, Badge H, Churches T, Maree Naylor J, Adie S, A Harris I. Comparative effectiveness of aspirin for symptomatic venous thromboembolism prophylaxis in patients undergoing total joint arthroplasty, a cohort study. BMC Musculoskelet Disord 2023; 24:629. [PMID: 37537580 PMCID: PMC10401792 DOI: 10.1186/s12891-023-06750-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 07/24/2023] [Indexed: 08/05/2023] Open
Abstract
BACKGROUND This study compares the symptomatic 90-day venous thromboembolism (VTE) rates in patients receiving aspirin to patients receiving low-molecular weight heparin (LMWH) or direct oral anticoagulants (DOACs), after total hip (THA) and total knee arthroplasty (TKA). METHODS Data were collected from a multi-centre cohort study, including demographics, confounders and prophylaxis type (aspirin alone, LMWH alone, aspirin and LMWH, and DOACs). The primary outcome was symptomatic 90-day VTE. Secondary outcomes were major bleeding, joint related reoperation and mortality within 90 days. Data were analysed using logistic regression, the Student's t and Fisher's exact tests (unadjusted) and multivariable regression (adjusted). RESULTS There were 1867 eligible patients; 365 (20%) received aspirin alone, 762 (41%) LMWH alone, 482 (26%) LMWH and aspirin and 170 (9%) DOAC. The 90-day VTE rate was 2.7%; lowest in the aspirin group (1.6%), compared to 3.6% for LMWH, 2.3% for LMWH and aspirin and 2.4% for DOACs. After adjusted analysis, predictors of VTE were prophylaxis duration < 14 days (OR = 6.7, 95% CI 3.5-13.1, p < 0.001) and history of previous VTE (OR = 2.4, 95% CI 1.1-5.8, p = 0.05). There were no significant differences in the primary or secondary outcomes between prophylaxis groups. CONCLUSIONS Aspirin may be suitable for VTE prophylaxis following THA and TKA. The comparatively low unadjusted 90-day VTE rate in the aspirin group may have been due to selective use in lower-risk patients. TRIAL REGISTRATION This study was registered at ClinicalTrials.gov, trial number NCT01899443 (15/07/2013).
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Affiliation(s)
- Verinder Sidhu
- School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, Sydney, NSW, Australia.
- Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Liverpool, Australia.
- Australian Catholic University, School of Public and Allied Health, North Sydney, 8-20 Napier Street, 2069, Australia.
| | - Helen Badge
- School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, Sydney, NSW, Australia
- Australian Catholic University, School of Public and Allied Health, North Sydney, 8-20 Napier Street, 2069, Australia
| | - Timothy Churches
- School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, Sydney, NSW, Australia
- Australian Catholic University, School of Public and Allied Health, North Sydney, 8-20 Napier Street, 2069, Australia
| | - Justine Maree Naylor
- School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, Sydney, NSW, Australia
- Australian Catholic University, School of Public and Allied Health, North Sydney, 8-20 Napier Street, 2069, Australia
| | - Sam Adie
- School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, Sydney, NSW, Australia
- Australian Catholic University, School of Public and Allied Health, North Sydney, 8-20 Napier Street, 2069, Australia
| | - Ian A Harris
- School of Clinical Medicine, UNSW Medicine and Health, UNSW Sydney, Sydney, NSW, Australia
- Australian Catholic University, School of Public and Allied Health, North Sydney, 8-20 Napier Street, 2069, Australia
- Institute of Musculoskeletal Health, School of Public Health, The University of Sydney, Sydney, NSW, Australia
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Abourisha E, Srinivasan A, Bishnoi A, Rudge S, Best A, Chatterji U. Aspirin as a thromboprophylaxis agent after revision knee arthroplasty: A retrospective analysis. J Orthop 2023; 41:23-27. [PMID: 37275515 PMCID: PMC10238834 DOI: 10.1016/j.jor.2023.05.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/08/2023] [Accepted: 05/15/2023] [Indexed: 06/07/2023] Open
Abstract
Introduction Total knee arthroplasty is a common and effective procedure. Although complication rates are low, certain complications such as venous thromboembolism are potentially serious. The optimal prophylactic agent and dosage after revision knee arthroplasty remains unclear. The main objective of this work was to study the efficacy and safety of aspirin as a thromboprophylaxis agent following revision knee arthroplasties. Patients and methods A retrospective review of patients undergoing revision knee arthroplasty between 2013 and 2020at a University Teaching Hospital was undertaken. The primary outcome was the development of a symptomatic thromboembolic event requiring treatment within 90 days post-surgery. The secondary outcomes were adverse events associated with aspirin therapy: surgical site infection rate; incidence of major bleeding; readmission rate and mortality within 90 days post-surgery. Results 490 patients were included. 374 (76.3%) received prophylactic aspirin (150 mg once daily for 28 days) and 75 (15.3%) patients received dalteparin for 28 days due to contraindication to aspirin use. Those already receiving other thromboprophylaxis agents for pre-existing comorbidities continued these after relevant medical consultation. The overall rates of venous thromboembolism and symptomatic DVT after aspirin prophylaxis were 0.6% (3/490) and 0.8% (3/374), respectively. VTE incidence did not significantly differ between those administered aspirin and other agents. No patient experienced major bleeding within 90 postoperative days. Only 2 of 490 (0.4%) patients had wound infection requiring readmission; neither received prophylactic aspirin. Conclusion Extended out-of-hospital thromboembolic prophylaxis with aspirin may be at least as effective as other agents in patients undergoing revision knee arthroplasty. Aspirin is safe, effective, and cheap compared with other agents.
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Affiliation(s)
| | | | | | - Simon Rudge
- University Hospitals of Leicester NHS Trust, UK
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Kirschner N, Anil U, Shah A, Teo G, Schwarzkopf R, Long WJ. Role of non-ASA VTE prophylaxis in risk for manipulation following primary total knee arthroplasty. Arch Orthop Trauma Surg 2023; 143:2135-2140. [PMID: 35674820 DOI: 10.1007/s00402-022-04488-0] [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: 01/23/2022] [Accepted: 05/16/2022] [Indexed: 11/02/2022]
Abstract
INTRODUCTION Stiffness and decreased range of motion frequently lead to hindrance of activities of daily living and dissatisfaction follow total knee arthroplasty (TKA). This study aims to evaluate the effect of non-aspirin (ASA) chemoprophylaxis and determine patient-related risk factors for stiffness and need for manipulation under anesthesia (MUA) following primary TKA. MATERIALS AND METHODS A review of all patients undergoing primary TKA from 2013 to 2019 at a single academic orthopedic hospital was conducted. The primary outcome measure was MUA performed post-operatively. Chi-square analysis and Mann-Whitney U test were used to determine statistically significant relationships between risk factors and outcomes. Significance was set at p < 0.05. Univariate logistic regression was performed to control for identified independent risk factors for MUA. RESULTS A total of 11,550 patients undergoing primary TKA from January 2013 to September 2019 at an academic medical center were included in the study. Increasing age and Charlson Comorbidity Index were associated with statistically significant decreased odds of MUA (0.93, 95% CI: 0.92-0.94, p < 0.001, OR 0.71, 95% CI 0.63-0.79, p < 0.001). Active smokers had a 2.01 increased odds of MUA (OR 2.01, 95% CI 1.28, 3.02, p < 0.001). There was no significant difference in rates of MUA between ASA and non-ASA VTE prophylaxis (p 0.108). CONCLUSIONS Younger age, lower CCI, and history of smoking are associated with a higher rate, while different chemical VTE prophylaxis does not influence rate of MUA after TKA. Arthroplasty surgeons should consider these risk factors when counseling patient preoperatively. Understanding each patients' risk for MUA allows surgeons to appropriately set preoperative expectations and reasonable outcome goals.
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Affiliation(s)
- Noah Kirschner
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, 301 East 17th St, New York, NY, 10003, USA.
| | - Utkarsh Anil
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, 301 East 17th St, New York, NY, 10003, USA
| | - Akash Shah
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, 301 East 17th St, New York, NY, 10003, USA
| | - Greg Teo
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, 10021, USA
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, NYU Langone Orthopedic Hospital, 301 East 17th St, New York, NY, 10003, USA
| | - William J Long
- Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY, 10021, USA
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Anil U, Kirschner N, Teo GM, Lygrisse KA, Sicat CS, Schwarzkopf R, Aggarwal VK, Long WJ. Aspirin thromboprophylaxis following primary total knee arthroplasty is associated with a lower rate of early prosthetic joint infection compared with other agents. J Arthroplasty 2023; 38:S345-S349. [PMID: 36828050 DOI: 10.1016/j.arth.2023.02.041] [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: 11/20/2022] [Revised: 02/13/2023] [Accepted: 02/15/2023] [Indexed: 02/26/2023] Open
Abstract
BACKGROUND Patients undergoing total knee arthroplasty (TKA) are at increased risk of venous thromboembolism (VTE). Aspirin has been shown to be effective at reducing rates of VTE. In select patients, more potent thromboprophylaxis is indicated, which has been associated with increased rates of bleeding and wound complications. This study aimed to evaluate the effect of thromboprophylaxis choice on rates of early prosthetic joint infection (PJI) following TKA. METHODS A review of 11,547 primary TKA patients from 2013 to 2019 at a single academic orthopaedic hospital was conducted. The primary outcome measure was PJI within 90 days of surgery as measured by Musculoskeletal Infection Society criteria. There were 59 (0.5%) patients diagnosed with early PJI. Chi-square and Welch-Two Sample t-tests were used to determine statistically significant relationships between thromboprophylaxis and demographic variables. Significance was set at p<0.05. Multivariate logistic regression adjusted for age, body mass index, sex, and Charlson comorbidity index was performed to identify and control for independent risk factors for early PJI. RESULTS There was a statistically significant difference in the rates of early PJI between the aspirin and non-aspirin group (0.3 vs 0.8%, p<0.001). Multivariate logistic regressions revealed that patients given aspirin thromboprophylaxis had significantly lower odds of PJI (odds ratios (OR)=0.51, 95% Confidence Interval (CI) 0.29 to 0.89, p=0.019) compared to non-aspirin patients. CONCLUSIONS The use of aspirin thromboprophylaxis following primary TKA is independently associated with a lower rate of early PJIs. Arthroplasty surgeons should consider aspirin as the gold standard thromboprophylaxis in all patients in which it is deemed medically appropriate and should carefully weigh the morbidity of PJI in patients when non-aspirin thromboprophylaxis is considered.
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Affiliation(s)
- Utkarsh Anil
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY.
| | - Noah Kirschner
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | - Greg M Teo
- Hospital for Special Surgery, New York, NY
| | | | - Chelsea S Sicat
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | - Vinay K Aggarwal
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
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Tarabichi S, Chen AF, Higuera CA, Parvizi J, Polkowski GG. 2022 American Association of Hip and Knee Surgeons Symposium: Periprosthetic Joint Infection. J Arthroplasty 2023:S0883-5403(23)00065-7. [PMID: 36738863 DOI: 10.1016/j.arth.2023.01.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 01/23/2023] [Accepted: 01/24/2023] [Indexed: 02/06/2023] Open
Abstract
Periprosthetic joint infection (PJI) is the leading cause of failure in patients undergoing total joint arthroplasty. This article is a brief summary of a symposium on PJI that was presented at the annual AAHKS meeting. It will provide an overview of current technqiues in the prevention, diagnosis, and management of PJI. It will also highlight emerging technologies in this setting.
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Affiliation(s)
- Saad Tarabichi
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Antonia F Chen
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Carlos A Higuera
- Levitetz Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, Florida
| | - Javad Parvizi
- Rothman Orthopaedic Institute at Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Gregory G Polkowski
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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11
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McLoughlin J, Farrow L, Ashcroft GP. Prevalence of aspirin resistance among the arthroplasty population: A pilot study. Musculoskeletal Care 2022; 20:676-680. [PMID: 35170209 DOI: 10.1002/msc.1619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 01/25/2022] [Accepted: 01/28/2022] [Indexed: 06/14/2023]
Affiliation(s)
| | - Luke Farrow
- University of Aberdeen, Aberdeen, Scotland, UK
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12
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Ludwick L, Shohat N, Van Nest D, Paladino J, Ledesma J, Parvizi J. Aspirin May Be a Suitable Prophylaxis for Patients with a History of Venous Thromboembolism Undergoing Total Joint Arthroplasty. J Bone Joint Surg Am 2022; 104:1438-1446. [PMID: 35700090 DOI: 10.2106/jbjs.21.00601] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND In recent years, aspirin has become a popular agent for venous thromboembolism (VTE) prophylaxis following total joint arthroplasty (TJA). Yet patients with a history of VTE are often given more aggressive prophylactic agents because of their increased baseline risk. The purpose of this study was to assess whether aspirin is an effective prophylactic agent in patients with a history of VTE. METHODS This was a single-institution, retrospective cohort study. The electronic clinical records of 36,333 patients undergoing TJA between 2008 and 2020 were reviewed. Data on demographic characteristics, comorbidities, intraoperative factors, and postoperative complications were collected. A propensity score-matched analysis was performed, as well as a multivariate regression analysis to account for confounders. RESULTS Of the 36,333 patients undergoing TJA, 1,087 patients (3.0%) had a history of VTE and were not receiving chronic non-aspirin. The risk for subsequent VTE was significantly higher (p = 0.03) in patients with a history of VTE (1.4%) compared with patients without prior VTE (0.9%). However, the incidence of VTE was not significantly lower (p = 0.208) in patients with a history of VTE who received aspirin (0.4%) compared with patients who received other VTE prophylaxis (1.5%). Propensity score matching showed no difference in VTE rates between the 2 groups (2.2% compared with 0.55%; p = 0.372). In a regression analysis accounting for VTE risk, the administration of aspirin was not associated with an increased risk for subsequent VTE (adjusted odds ratio, 0.32 [95% confidence interval, 0.02 to 1.66]; p = 0.274). CONCLUSIONS Our findings suggest that, although patients with a history of VTE have an increased baseline risk for subsequent VTE, aspirin may be a suitable VTE prophylaxis in this group of patients. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Leanne Ludwick
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Noam Shohat
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania.,Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Israel
| | - Duncan Van Nest
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Joseph Paladino
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Jonathan Ledesma
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Javad Parvizi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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Chisari E, Tan TL, Shah R, Levitsky M, Piuzzi N, Higuera C, Santana D, Satwah S, Parvizi J. Aspirin Is an Effective Prophylaxis for Venous Thromboembolism in Ambulatory Patients with Femoral Neck Fracture Undergoing Hip Arthroplasty. J Bone Joint Surg Am 2022; 104:603-609. [PMID: 35030114 DOI: 10.2106/jbjs.21.00168] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Although aspirin has been adopted as an effective and safe prophylaxis against venous thromboembolism (VTE) by the arthroplasty community, the role of aspirin in the prevention of VTE in the setting of arthroplasty for trauma remains insufficiently known. Therefore, the present multicenter study investigated the efficacy of aspirin as VTE prophylaxis for patients with femoral neck fracture undergoing total hip arthroplasty or hemiarthroplasty. METHODS We reviewed the medical records of 1,141 patients with femoral neck fracture who underwent total hip arthroplasty or hemiarthroplasty from 2008 to 2018 at 3 different institutions. Data on patient demographic characteristics, body mass index, history of VTE, and comorbidities were obtained from an electronic chart query and were confirmed by reviewing the medical records manually. Patients were allocated to cohorts based on the type of prophylaxis administered: aspirin (n = 454) and other anticoagulants (n = 687). Patients were then propensity score-matched on the basis of the risk score calculated using a previously validated tool and the remaining confounding variables. The primary outcome was the development of symptomatic VTE, namely deep vein thrombosis (DVT) or pulmonary embolism (PE) confirmed by appropriate imaging, within 90 days after the surgical procedure. A bivariable analysis was performed. RESULTS The overall VTE rate was 1.98% for patients who received aspirin compared with 6.7% for patients who received other anticoagulants (p < 0.001). After propensity score matching and regression modeling, aspirin was found to be noninferior to more potent anticoagulation in preventing VTE after both total hip arthroplasty and hemiarthroplasty. CONCLUSIONS Aspirin is an effective option for VTE prophylaxis in patients with femoral neck fracture who undergo hip arthroplasty. Based on the patient management benefits of aspirin for elective arthroplasty and the present study, we suggest its use in standard-risk ambulatory patients. LEVEL OF EVIDENCE Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Emanuele Chisari
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Timothy L Tan
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Roshan Shah
- Adult Reconstruction, Columbia University Irving Medical Center, New York, NY
| | - Matthew Levitsky
- Adult Reconstruction, Columbia University Irving Medical Center, New York, NY
| | - Nicolas Piuzzi
- Department of Orthopaedic Surgery, Orthopaedic and Rheumatologic Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Carlos Higuera
- Department of Orthopaedic Surgery, Cleveland Clinic, Weston, Florida
| | - Daniel Santana
- Department of Orthopaedic Surgery, Orthopaedic and Rheumatologic Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Syona Satwah
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Javad Parvizi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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Tang A, Zak SG, Waren D, Iorio R, Slover JD, Bosco JA, Schwarzkopf R. Low-Dose Aspirin is Safe and Effective for Venous Thromboembolism Prevention in Patients Undergoing Revision Total Knee Arthroplasty: A Retrospective Cohort Study. J Knee Surg 2022; 35:553-559. [PMID: 32898907 DOI: 10.1055/s-0040-1716377] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Venous thromboembolism (VTE) events are rare, but serious complications of total joint replacement affect patients and health care systems due to the morbidity, mortality, and associated cost of its complications. There is currently no established universal standard of care for prophylaxis against VTE in patients undergoing revision total knee arthroplasty (rTKA). The aim of this study was to determine whether a protocol of 81-mg aspirin (ASA) bis in die (BID) is safe and/or sufficient in preventing VTE in patients undergoing rTKAs versus 325-mg ASA BID. In 2017, our institution adopted a new protocol for VTE prophylaxis for arthroplasty patients. Patients initially received 325-mg ASA BID for 1 month and then changed to a lower dose of 81-mg BID. A retrospective review from 2011 to 2019 was conducted identifying 1,438 consecutive rTKA patients and 90-day postoperative outcomes including VTE, gastrointestinal, and wound bleeding complications, acute periprosthetic joint infection, and mortality. In the 74 months prior to protocol implementation, 1,003 rTKAs were performed and nine VTE cases were diagnosed (0.90%). After 26 months of the protocol change, 435 rTKAs were performed with one VTE case identified (0.23%). There was no significant difference in rates or odds in postoperative pulmonary embolism (PE; p = 0.27), DVT (p = 0.35), and total VTE rates (p = 0.16) among patients using either protocol. There were also no differences in bleeding complications (p = 0.15) or infection rate (p = 0.36). No mortalities were observed. In the conclusion, 81-mg ASA BID is noninferior to 325-mg ASA BID in maintaining low rates of VTE and may be safe for use in patients undergoing rTKA.
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Affiliation(s)
- Alex Tang
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Stephen G Zak
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Daniel Waren
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Richard Iorio
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - James D Slover
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Joseph A Bosco
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
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Aspirin Use for Venous Thromboembolism Prevention Is Safe and Effective in Overweight and Obese Patients Undergoing Revision Total Hip and Knee Arthroplasty. J Arthroplasty 2021; 36:S337-S344. [PMID: 33376036 DOI: 10.1016/j.arth.2020.12.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 11/29/2020] [Accepted: 12/06/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Venous thromboembolism (VTE), defined as pulmonary embolism or deep venous thrombosis, is a rare but serious complication following revision total hip arthroplasty (RTHA) and revision total knee arthroplasty (RTKA). Previous studies show that obesity may be associated with an increased risk for pulmonary embolism, wound complications, and infection. With no current universal standard of care for VTE prophylaxis, we sought to determine whether aspirin prescribed (ASA) is safe and effective in obese patients undergoing RTHA/RTKA. METHODS A retrospective review of 1578 consecutive RTHA/RTKA cases (751 RTHAs and 827 RTKAs) was conducted identifying patients prescribed 325 or 81 mg ASA. Ninety-day postoperative VTE rates, bleeding, wound complications, deep infections, and mortality were collected. Cohorts were stratified according to body mass index (BMI): normal (18-24.9 kg/m2), overweight (25-29.9 kg/m2), obese (30-34.9 kg/m2), severely obese (35-39.9 kg/m2), and morbidly obese (≥40 kg/m2). RESULTS The cohort comprised of 335 patients with a normal BMI, 511 were overweight, 408 obese, 232 severely obese, and 92 morbidly obese. Total VTE rates were statistically similar between BMI groups (0.90% vs 0.78% vs 0.74% vs 0.43% vs 0%, P = .89). There were no differences in bleeding rates (0.90% vs 0% vs 0% vs 0.43% vs 0%, P = .08), wound complications (0.30% vs 0.20% vs 0.25% vs 0% vs 0%, P = .93), infection (1.49% vs 1.57% vs 0.98% vs 1.29% vs 1.09%, P = .66), or mortality (0% vs 0.20% vs 0% vs 0% vs 0%, P = .72). CONCLUSION ASA is safe and effective for VTE prevention in obese patients with similar complication rates to nonobese patients undergoing RTHA/RTKA.
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Grosso MJ, Kozaily E, Parvizi J, Austin MS. Aspirin Is Safe for Venous Thromboembolism Prophylaxis for Patients With a History of Gastrointestinal Issues. J Arthroplasty 2021; 36:S332-S336. [PMID: 33610409 DOI: 10.1016/j.arth.2021.01.069] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 01/06/2021] [Accepted: 01/24/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The safety of acetylsalicylic acid (ASA, aspirin) in patients with prior history of gastroesophageal reflux or peptic ulcer disease remains unclear. The purpose of this study was to determine the safety of ASA for venous thromboembolism (VTE) prophylaxis after total joint arthroplasty in patients with prior history of gastrointestinal (GI) issues. METHODS This was an institutional, retrospective cohort study of 19,044 patients who underwent primary total hip and total knee arthroplasty from 2013 to 2019. We divided the patients into two cohorts based on the presence or absence of pre-existing GI issues. Patient demographics, VTE prophylaxis, and postoperative complications were collected. The primary outcome measure was GI bleed. RESULTS In our series, 3090 patients had a preoperative GI issue and 15,954 did not have a GI issue. ASA was the most common mode of VTE prophylaxis (89%), followed by Coumadin (4.7%), direct oralanticoagulants (4.2%), low-molecular-weight heparin (1.7%), and others (0.4%). In the cohort of patients given ASA, there was no significant difference in postoperative GI bleeding between those with (2/1781, 0.11%) and without preoperative GI issues (8/7,628, 0.10%, P = 1.0). In the overall cohort, history of preoperative GI issues was associated with an increased risk of postoperative GI bleeding (0.32% vs 0.11%, P = .031). In logistic regression analysis, ASA was associated with a protective effect against GI bleed (OR = 0.09, 95% CI 0.01-0.40, P = .003). CONCLUSION ASA is safe for VTE prophylaxis after total joint arthroplasty in patients with history of GI issues and is not associated with an increased risk of postoperative GI bleeds.
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Affiliation(s)
- Matthew J Grosso
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA; Connecticut Joint Replacement Institute, Hartford, CT
| | - Elie Kozaily
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Javad Parvizi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | - Matthew S Austin
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
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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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Mencia MM, Beharry A, Hernandez Cruz PP. Revision Total Hip Arthroplasty in Jehovah's Witnesses at a Public Hospital: Practical Recommendations for a Low-Resource Setting. Cureus 2021; 13:e15761. [PMID: 34290937 PMCID: PMC8289400 DOI: 10.7759/cureus.15761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/17/2021] [Indexed: 12/02/2022] Open
Abstract
Revision total hip arthroplasty (THA) is a major reconstructive procedure traditionally associated with significant blood loss. Jehovah’s Witnesses (JW) do not accept blood or blood product transfusions because of their religious beliefs. When confronted with a JW patient requiring a complex arthroplasty procedure, surgeons face moral and ethical questions and may be reluctant to perform surgery. A successful outcome depends on several factors including surgical and anesthetic expertise, a range of revision implants, and a multimodal blood management protocol. While these resources are readily available in a developed country, in many of the developing Caribbean islands, the healthcare system is underfunded and under-resourced. Here, we describe our experience performing a revision THA on a JW patient in the Caribbean. Through this case report, we aim to illustrate our approach to blood management by exploring the fundamental elements that were employed in a low-resource setting. We believe that the extrapolation of these crucial principles to the broader category of primary arthroplasty in the general population can be used to reduce the rate of blood transfusion, increase access to surgery, and improve outcomes.
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Affiliation(s)
- Marlon M Mencia
- Department of Clinical Surgical Sciences, The University of the West Indies, St. Augustine, TTO
| | - Allan Beharry
- Department of Surgery, Port of Spain General Hospital, Port of Spain, TTO
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Watts PJ, Kopstein M, Harkness W, Cornett B, Dziadkowiec O, Jenkins P, Hicks ME, Hassan S, Scherbak D. A Retrospective Analysis Comparing Post-Operative Bleeding with Various Doses of Aspirin after Lower Extremity Joint Arthroplasty or Revision. Pharmacotherapy 2021; 41:616-622. [PMID: 34050970 DOI: 10.1002/phar.2598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 04/21/2021] [Accepted: 04/22/2021] [Indexed: 11/09/2022]
Abstract
STUDY OBJECTIVE Previous studies have shown that aspirin is noninferior to other anticoagulation therapies in preventing postoperative venous thromboembolism following lower extremity arthroplasty or revision; however, its optimal dosing for this indication is less clear. This study aims to compare the odds of bleeding between different aspirin dosages following lower extremity joint arthroplasty or revision. DESIGN This is a 3-year retrospective multi-center cohort study across the United States and its territories. SETTING This study included patients admitted for total hip or knee arthroplasty or revision and were treated with prophylactic aspirin. PATIENTS, INTERVENTION, MEASUREMENTS Patients were assigned to groups based on a total daily aspirin dose of 81, 162, 325, or 650 mg. Data were analyzed for postsurgical bleeding and thromboembolism events occurring during the initial admission and up to 40 days following surgery. Other exploratory variables included type of surgery, hip or knee arthroplasty, length of stay, and patient demographic data. MAIN RESULTS Among 53,848 patients receiving aspirin, 3922 received a total daily dose of 81 mg, 19,341 received a total daily dose of 162 mg, 5256 received a total daily dose of 325 mg, and 25,329 received a total daily dose of 650 mg. Bleeding occurred in 466 (0.87%) patients and venous thromboembolism (VTE) in 209 patients (0.39%). The odds of bleeding were compared using logistic regression, with the 650-mg dose as the reference group. None were statistically significant for bleeding between all studied aspirin doses: 81 mg (OR 1.12, 95% CI 0.83-1.51, p = 0.451), 162 mg (OR 0.83, 95% CI 0.67-1.03, p = 0.097), and 325 mg (OR 0.83, 95% CI 0.59-1.13, p = 0.245). The odds of VTE were also not statistically significant: 81 mg (OR 0.71, 95% CI 0.40-1.17, p = 0.181), 162 mg (OR 0.75 95% CI 0.54-1.03, p = 0.072), and 325 mg (OR 1.00, 95% CI 0.64-1.53, p = 0.989). CONCLUSIONS There were no significant differences in the odds of bleeding or venous thromboembolism among all studied aspirin dosages in patients receiving aspirin for thromboprophylaxis following lower extremity joint arthroplasty or revision.
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Affiliation(s)
- Paula J Watts
- Graduate Medical Education, HCA HealthONE - Sky Ridge Medical Center, Lone Tree, Colorado, USA.,Rocky Vista University, Parker, Colorado, USA.,Critical Care and Pulmonary Consultants, Greenwood Village, Colorado, USA
| | - Michael Kopstein
- Graduate Medical Education, HCA HealthONE - Sky Ridge Medical Center, Lone Tree, Colorado, USA.,Rocky Vista University, Parker, Colorado, USA.,Inova Loudoun Hospital, Leesburg, Virginia, USA
| | - Weston Harkness
- Graduate Medical Education, HCA HealthONE - Sky Ridge Medical Center, Lone Tree, Colorado, USA.,Rocky Vista University, Parker, Colorado, USA.,Graduate Medical Education, Samaritan Health Services, Corvallis, Oregon, USA
| | | | | | - Patrick Jenkins
- Graduate Medical Education, HCA HealthONE - Sky Ridge Medical Center, Lone Tree, Colorado, USA.,Rocky Vista University, Parker, Colorado, USA
| | - Mary E Hicks
- Graduate Medical Education, HCA HealthONE - Sky Ridge Medical Center, Lone Tree, Colorado, USA.,Rocky Vista University, Parker, Colorado, USA.,Critical Care and Pulmonary Consultants, Greenwood Village, Colorado, USA
| | - Shakib Hassan
- Graduate Medical Education, HCA HealthONE - Sky Ridge Medical Center, Lone Tree, Colorado, USA.,Rocky Vista University, Parker, Colorado, USA.,Critical Care and Pulmonary Consultants, Greenwood Village, Colorado, USA
| | - Dmitriy Scherbak
- Graduate Medical Education, HCA HealthONE - Sky Ridge Medical Center, Lone Tree, Colorado, USA.,Rocky Vista University, Parker, Colorado, USA.,Critical Care and Pulmonary Consultants, Greenwood Village, Colorado, USA
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Petersen PB, Lindberg-Larsen M, Jørgensen CC, Kehlet H. Venous thromboembolism after fast-track elective revision hip and knee arthroplasty - A multicentre cohort study of 2814 unselected consecutive procedures. Thromb Res 2021; 199:101-105. [PMID: 33485092 DOI: 10.1016/j.thromres.2021.01.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 12/07/2020] [Accepted: 01/06/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) prophylaxis is much debated within total hip and knee arthroplasty (THA/TKA). Revision hip and knee arthroplasty (rTHA/rTKA) are more extensive procedures, but data on the risk of postoperative VTE is conflicting and there are no specific guidelines for thromboprophylaxis. Furthermore, data on rTHA/rTKA within a fast-track protocol is sparse. Thus, we aimed at evaluating the incidence and time course of VTE in unselected elective rTHA/rTKA within our established multicentre fast-track collaboration with in-hospital only thromboprophylaxis if length of stay (LOS) ≤ 5 days. METHODS We used an observational study design of unselected consecutive fast-track elective major component rTHA/rTKA from 6 dedicated fast-track centres between 2010 and 2018. We obtained information on revisions through Danish hip and knee arthroplasty registers and complete (>99%) 90 days follow-up through the Danish National Patient Registry in combination with chart review. RESULTS We included 2814 procedures with median LOS 3 days [2-5] and 21% had LOS >5 days. The 90-day incidence of VTE was 0.42% (n = 12), with 8 (0.28%) DVT and 4 (0.14%) PE, after median 14 days [IQR: 11-23] with the latest on day 31. CONCLUSION The 90-day incidence of VTE after elective fast-track rTHA and rTKA was about 0.4% which is comparable to the 90-day VTE incidence after primary fast-track THA, TKA and unicompartmental knee arthroplasty. Future investigations should focus on identification of high-risk patients while the surgical trauma per se may be less important.
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Affiliation(s)
| | - Martin Lindberg-Larsen
- Orthopaedic Research Unit, Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Department of Clinical Research, University of Southern Denmark, Denmark; Lundbeck Foundation Centre for Fast-track Hip and Knee Arthroplasty, Copenhagen, Denmark
| | - Christoffer Calov Jørgensen
- Section for Surgical Pathophysiology, Rigshospitalet, Copenhagen, Denmark; Lundbeck Foundation Centre for Fast-track Hip and Knee Arthroplasty, Copenhagen, Denmark
| | - Henrik Kehlet
- Section for Surgical Pathophysiology, Rigshospitalet, Copenhagen, Denmark; Lundbeck Foundation Centre for Fast-track Hip and Knee Arthroplasty, Copenhagen, Denmark
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Comparable efficacy of 100 mg aspirin twice daily and rivaroxaban for venous thromboembolism prophylaxis following primary total hip arthroplasty: a randomized controlled trial. Chin Med J (Engl) 2021; 134:164-172. [PMID: 33410616 PMCID: PMC7817327 DOI: 10.1097/cm9.0000000000001305] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background: Aspirin has demonstrated safety and efficacy for venous thromboembolism (VTE) prophylaxis following total hip arthroplasty (THA); however, inconsistent dose regimens have been reported in the literature. This study aimed to evaluate and compare the safety and efficacy of 100 mg aspirin twice daily with rivaroxaban in VTE prophylaxis following THA. Methods: Patients undergoing elective unilateral primary THA between January 2019 and January 2020 were prospectively enrolled in the study and randomly allocated to receive 5 weeks of VTE prophylaxis with either oral enteric-coated aspirin (100 mg twice daily) or rivaroxaban (10 mg once daily). Medication safety and efficacy were comprehensively evaluated through symptomatic VTE incidence, deep vein thrombosis (DVT) on Doppler ultrasonography, total blood loss (TBL), laboratory bloodwork, Harris hip score (HHS), post-operative recovery, and the incidence of other complications. Results: We included 70 patients in this study; 34 and 36 were allocated to receive aspirin and rivaroxaban prophylaxis, respectively. No cases of symptomatic VTE occurred in this study. The DVT rate on Doppler ultrasonography in the aspirin group was not significantly different from that in the rivaroxaban group (8.8% vs. 8.3%, χ2 = 0.01, P = 0.91), confirming the non-inferiority of aspirin for DVT prophylaxis (χ2 = 2.29, P = 0.01). The calculated TBL in the aspirin group (944.9 mL [658.5–1137.8 mL]) was similar to that in the rivaroxaban group (978.3 mL [747.4–1740.6mL]) (χ2 = 1.55, P = 0.12). However, there were no significant inter-group differences in HHS at post-operative day (POD) 30 (Aspirin: 81.0 [78.8–83.0], Rivaroxaban: 81.0 [79.3–83.0], χ2 = 0.43, P = 0.67) and POD 90 (Aspirin: 90.0 [89.0–92.0], Rivaroxaban: 91.5 [88.3–92.8], χ2 = 0.77, P = 0.44), the incidence of bleeding events (2.9% vs. 8.3%, χ2 = 0.96, P = 0.33), or gastrointestinal complications (2.9% vs. 5.6%, χ2 = 1.13, P = 0.29). Conclusion: In terms of safety and efficacy, the prophylactic use of 100 mg aspirin twice daily was not statistically different from that of rivaroxaban in preventing VTE and reducing the risk of blood loss following elective primary THA. This supports the use of aspirin chemoprophylaxis following THA as a less expensive and more widely available option for future THAs. Trial Registration: Chictr.org, ChiCTR18000202894; http://www.chictr.org.cn/showproj.aspx?proj=33284
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Singh V, Shahi A, Saleh U, Tarabichi S, Oliashirazi A. Persistent Wound Drainage among Total Joint Arthroplasty Patients Receiving Aspirin vs Coumadin. J Arthroplasty 2020; 35:3743-3746. [PMID: 32788061 DOI: 10.1016/j.arth.2020.07.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 06/20/2020] [Accepted: 07/02/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Persistent wound drainage (PWD) is one of the major risk factors for periprosthetic joint infections (PJI), arguably the most dreaded complications after a total hip and knee arthroplasty (THA and TKA). The aim of this study is to identify the rates of PWD among THA and TKA patients who received aspirin (ASA) or Coumadin for postoperative venous thromboembolism (VTE) prophylaxis. METHODS Retrospective review of 5516 primary THA and TKA was performed. Patients with PWD were identified. Chi-square test was used to compare the incidences of PWD, 30-day VTE, and PJI at 6 months between the ASA and Coumadin groups. Multivariate regression model was used to identify independent risk factors for PWD using Charlson and Elixhauser comorbidity indexes. RESULTS The prevalence of PWD was 6.4% (353/5516). Patients receiving ASA had lower incidence of PWD (3.2% vs 8.5%, P < .0001) while having comparable rates of 30-day VTE (1.3% vs 1.4%, P = .722) and PJI at 6 months (1.8% vs 1.4%, P = .233) compared to those receiving Coumadin. Risk factors for PWD were diabetes (odds ratio [OR], 19.3; 95% confidence interval [CI], 11.8-23.2), rheumatoid arthritis (OR, 15.3; 95% CI, 10.8-17.2), morbid obesity (OR, 13.2; 95% CI, 9.7-17.5), chronic alcohol use (OR, 3.5; 95% CI, 1.8-5.5), hypothyroidism (OR, 1.9; 95% CI, 1.1-3.2), and Coumadin (OR, 1.7; 95% CI, 1.2-2.2). CONCLUSION Use of ASA is associated with significantly lower rates of PWD after THA and TKA when compared to Coumadin while being equally efficacious at preventing VTE. Coumadin was found to be an independent risk factor for PWD.
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Affiliation(s)
| | - Alisina Shahi
- Cooper Bone and Joint Institute at Cooper University Hospital, Camden, NJ
| | - Usama Saleh
- Orthopaedic Department, Med Care Hospital, Dubai, UAE
| | | | - Ali Oliashirazi
- Oliashirazi Institute at Marshall University, Huntington, WV
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25
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Zambelli R, Bastos MD, Rezende SM. Prophylaxis of Venous Thromboembolism in Ankle and Foot Surgeries. Rev Bras Ortop 2020; 56:697-704. [PMID: 34900096 PMCID: PMC8651438 DOI: 10.1055/s-0040-1715512] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 06/01/2020] [Indexed: 11/21/2022] Open
Abstract
Venous thromboembolism (VTE) is among the most feared complications by orthopedists both for due to its potentially lethal outcome and the uncertainties related to its prevention. Despite the vast literature on VTE prevention in major orthopedic surgeries, little is known about it in ankle and foot procedures. In orthopedics, adequate thromboprophylaxis requires a careful assessment of the thrombotic and hemorrhagic risks based on the procedure to be performed, as well as and knowledge on anticoagulant agents. The presentis review has the goal of assessing the risk of developingdiscusses VTE risk assessment, the modalities of thromboprophylaxis modalities, and the drugs used, with an emphasis on foot and ankle surgeries.
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Affiliation(s)
- Roberto Zambelli
- Pós-Graduação em Ciências Aplicadas à Saúde do Adulto, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brasil.,Serviço de Ortopedia, Rede Mater Dei de Saúde, Belo Horizonte, Minas Gerais, Brasil
| | - Marcos de Bastos
- Assessoria de Políticas de Saúde e Informações (ASPASI), Hospital Governador Israel Pinheiro (HGIP), Instituto de Previdência dos Servidores do Estado de Minas Gerais (IPSEMG), Belo Horizonte, Minas Gerais, Brasil.,Faculdade da Saúde e Ecologia Humana (FASEH), Vespasiano, Minas Gerais, Brasil
| | - Suely Meireles Rezende
- Departamento de Medicina Interna, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Minas Gerais, Brasil
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26
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Tang A, Zak S, Iorio R, Slover J, Bosco J, Schwarzkopf R. Low-Dose Aspirin Is Safe and Effective for Venous Thromboembolism Prevention in Patients Undergoing Revision Total Hip Arthroplasty: A Retrospective Cohort Study. J Arthroplasty 2020; 35:2182-2187. [PMID: 32334898 DOI: 10.1016/j.arth.2020.03.040] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 03/22/2020] [Accepted: 03/24/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Currently, there is no established universal standard of care for prophylaxis against venous thromboembolism (VTE) in orthopedic patients undergoing revision total hip arthroplasty (rTHA). The aim of this study is to determine whether a protocol of 81-mg aspirin (ASA) bis in die (BID) is safe and/or effective in preventing VTE in patients undergoing rTHAs vs 325-mg ASA BID. METHODS In 2017, a large academic medical center adopted a new protocol for VTE prophylaxis in arthroplasty patients at standard risk. Initially, patients received 325-mg ASA BID but switched to 81-mg ASA BID. A retrospective review (2011-2019) was performed to identify 1361 consecutive rTHA patients and their associated 90-day postoperative complications such as VTE, including pulmonary embolism (PE) and/or deep vein thrombosis (DVT), as the primary outcome; and gastrointestinal and wound bleeding, acute periprosthetic joint infection, and mortality as the secondary outcome. RESULTS From 2011 to 2017, 973 rTHAs were performed and 13 total VTE cases were diagnosed (1.34%). From 2017 to 2019, 388 rTHAs were performed with 3 total VTE cases identified (0.77%). Chi-squared analyses and logistic regression models showed no differences in rates or odds in postoperative PE (P = .09), DVT (P = .79), PE and DVT (P = .85), and total VTE (P = .38) using either dose. There were also no differences between bleeding complications (P = .14), infection rate (P = .46), and mortality (P = .53). CONCLUSION Using a protocol of 81-mg of ASA BID is noninferior to 325-mg ASA BID and may be safe and effective in maintaining low rates of VTE in patients undergoing rTHA.
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Affiliation(s)
- Alex Tang
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | - Stephen Zak
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | - Richard Iorio
- Department of Orthopedic Surgery, Brigham and Women's Hospital, Boston, MA
| | - James Slover
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | - Joseph Bosco
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY
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27
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Review of Therapeutic Options for the Prevention of VTE in Total Joint Arthroplasty. Geriatrics (Basel) 2020; 5:geriatrics5010018. [PMID: 32197389 PMCID: PMC7151331 DOI: 10.3390/geriatrics5010018] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 03/11/2020] [Accepted: 03/15/2020] [Indexed: 01/09/2023] Open
Abstract
Hip and knee arthroplasty patients are at high risk of perioperative venous thromboembolic events (VTE). VTE has been well studied in this population and it is recommended that total joint arthroplasty recipients receive chemoprophylactic anticoagulation due to risk factors inherent to the surgical intervention. There are few concise resources for the orthopedic surgeon that summarize data regarding post-operative anticoagulation in the context of currently available therapeutic options and perioperative standards of practice. The periodic reexamination of literature is essential as conclusions drawn from studies predating perioperative protocols that include early mobilization and sequential compression devices as standards of practice in total joint arthroplasty are no longer generalizable to modern-day practice. We reviewed a large number of recently published research studies related to post-operative anticoagulation in total joint arthroplasty populations that received a high Level of Evidence grade. Current literature supports the use of oral aspirin regimens in place of more aggressive anticoagulants, particularly among low risk patients. Oral aspirin regimens appear to have the additional benefit of lower rates of bleeding and wound complications. Less consensus exists among high risk patients and more potent anticoagulants may be indicated. However, available evidence does not demonstrate clear superiority among current options, all of which may place patients at a higher risk of bleeding and wound complications. In this situation, chemoprophylactic selection should reflect specific patient needs and characteristics.
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28
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Goswami K, Stevenson KL, Parvizi J. Intraoperative and Postoperative Infection Prevention. J Arthroplasty 2020; 35:S2-S8. [PMID: 32046826 DOI: 10.1016/j.arth.2019.10.061] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 10/29/2019] [Accepted: 10/29/2019] [Indexed: 02/01/2023] Open
Abstract
Implementation of strategies for prevention of surgical site infection and periprosthetic joint infection is gaining further attention. We provide an overview of the pertinent evidence-based guidelines for infection prevention from the World Health Organization, the Centers for Disease Control and Prevention, and the second International Consensus Meeting on Musculoskeletal Infection. Future work is needed to ascertain clinical efficacy, optimal combinations, and the cost-effectiveness of certain measures.
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Affiliation(s)
- Karan Goswami
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
| | | | - Javad Parvizi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA
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29
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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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30
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Li WT, Klement MR, Foltz C, Sinensky A, Yazdi H, Parvizi J. Highlighting the Roles of Anemia and Aspirin in Predicting Ninety-Day Readmission Following Aseptic Revision Total Joint Arthroplasty. J Arthroplasty 2020; 35:490-494. [PMID: 31606291 DOI: 10.1016/j.arth.2019.09.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2019] [Revised: 08/21/2019] [Accepted: 09/07/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Revision total joint arthroplasties (TJAs) are associated with an increased rate of complications. To date, it is unclear what drives readmission after aseptic revision arthroplasty and what measures can be taken to possibly avoid them. The purpose of this study is to (1) determine the reasons for readmission after aseptic revision TJA and (2) identify patient-specific or postoperative risk factors through a multivariate analysis. METHODS A retrospective study examined 1503 cases of aseptic revision TJA between 2009 and 2016 at an urban tertiary care hospital. Eighty-seven cases (5.8%) of readmission within 90 days of index surgery were identified. Bivariate and multivariate analyses were performed to assess independent risk factors for readmission. RESULTS The reasons for readmission were infection (38%), wound complications (22%), and dislocation/instability of the prosthetic joint (13%). Only preoperative anemia was associated with an increased odds ratio (OR) of readmission (OR 1.82, 95% confidence interval [CI] 1.126-2.970, P = .015), whereas postoperative venous thromboembolism prophylaxis with aspirin (OR 0.58, 90% CI 0.340-0.974, P = .039) and discharge to an inpatient rehab facility (OR 0.22, 95% CI 0.051-0.950, P = .042) were associated with significantly lower odds of readmission. CONCLUSION Based on this single institutional study, addressing preoperative anemia and considering the implementation of aspirin for venous thromboembolism prophylaxis may be 2 targets to potentially reduce readmission after aseptic revision TJA.
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Affiliation(s)
| | | | - Carol Foltz
- Rothman Orthopaedic Institute, Philadelphia, PA
| | | | - Hamidreza Yazdi
- Department of Orthopaedic Surgery, Iran University of Medical Sciences, Tehran, Iran
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31
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Aspirin Thromboprophylaxis Confers No Increased Risk for Aseptic Loosening Following Cementless Primary Hip Arthroplasty. J Arthroplasty 2019; 34:2978-2982. [PMID: 31383492 DOI: 10.1016/j.arth.2019.07.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 07/06/2019] [Accepted: 07/10/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Aspirin has been shown to be a safe and cost-effective thromboprophylaxis agent with equivalent preventive efficacy to warfarin and fewer side-effects. However, animal studies have suggested delayed bone healing with aspirin and other inhibitors of prostaglandin synthesis. The impact of aspirin on aseptic loosening following cementless total hip arthroplasty (THA) has yet to be explored. Our aim was to determine if patients receiving aspirin for thromboprophylaxis had higher rates of aseptic loosening vs patients receiving warfarin after THA. METHODS We identified 11,262 consecutive primary uncemented THA performed between 2006 and 2017. Postoperatively, either warfarin (target international normalized ratio 1.5-2.0) or aspirin chemoprophylaxis were prescribed for 4 weeks. We recorded demographics, length of stay, body mass index, preoperative nonsteroidal antiinflammatory drug use, and Elixhauser comorbidity index. All revisions because of aseptic loosening within 1 year of the index procedure were identified radiographically, confirmed intraoperatively, and did not fulfill Musculoskeletal Infection Society criteria for periprosthetic infection. Multivariate logistic regression analysis was performed. RESULTS There was no difference (P = .14) in the rates of revision for aseptic loosening between patients in the aspirin cohort (14/4530; 0.31%; P = .14) and the warfarin cohort (36/6682; 0.54%). After accounting for confounding variables, no significant difference was noted in aseptic loosening rates between patients treated with aspirin vs those treated with warfarin (adjusted odds ratio 0.51; P = .11). Perioperative nonsteroidal antiinflammatory drug was not significantly associated with aseptic loosening (adjusted odds ratio 1.20; P = .67). CONCLUSION While multiple agents are available for venous thromboprophylaxis, there is increasing evidence in favor of the use of aspirin. This study allays the notion that aspirin increases the rates of aseptic loosening following uncemented hip arthroplasty.
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32
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Warren JA, Sundaram K, Kamath AF, Molloy RM, Krebs VE, Mont MA, Piuzzi NS. Venous Thromboembolism Rates Did Not Decrease in Lower Extremity Revision Total Joint Arthroplasty From 2008 to 2016. J Arthroplasty 2019; 34:2774-2779. [PMID: 31153709 DOI: 10.1016/j.arth.2019.05.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2019] [Revised: 04/24/2019] [Accepted: 05/06/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND In revision total knee arthroplasty (rTKA) and revision total hip arthroplasty (rTHA), venous thromboembolism (VTE) has been reported to be a relatively common and potentially serious complication. To mitigate this risk, strategies such as rapid recovery programs and thromboprophylaxis guidelines have been utilized. This study sought to identify the annual incidence and recent trends of VTE (defined as the presence of deep vein thrombosis [DVT] and/or pulmonary embolism [PE] in the same patient), DVT, PE, and mortality in the 30-day period after rTKA and rTHA. METHODS We identified 30,406 rTKA and rTHA patients from 2008 to 2016 using the National Surgical Quality Improvement Program database. Thirty-day incidences for VTE, DVT, PE, and mortality for each year and the overall study period were calculated. Bivariate and multivariate regressions were performed using patient demographics and comorbidities to assess trends in the outcomes of interest. RESULTS The overall incidences of 30-day VTE, DVT, PE, and mortality for rTKA were 1.2%, 0.9%, 0.4%, and 0.5%. Bivariate analysis revealed no significant change over the study period for VTE (P = .137), DVT (P = .406), PE (P = .121; 99% confidence interval 0.112-0.129), and mortality (P = .463). The incidences over the study period of VTE, DVT, PE, and mortality in rTHA were 1.0%, 0.7%, 0.4%, and 0.7%. Bivariate analysis revealed no changes in VTE (P = .393), DVT (P = .376), and PE (P = .602). However, bivariate analysis revealed significant decrease in mortality (P = .010) over the study period. CONCLUSION Within 30 days of surgery, approximately 1 in 83 rTKA patients and 1 in 100 rTHA patients experienced a VTE. Furthermore, the rates of VTE remained largely unchanged from 2008 to 2016. Further research regarding the optimal individualized prophylaxis algorithm in rTKA and rTHA is warranted to prevent this complication. This study represents the first investigation of thromboembolic events in rTHA and rTKA.
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Affiliation(s)
- Jared A Warren
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Kavin Sundaram
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Atul F Kamath
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Robert M Molloy
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Viktor E Krebs
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Michael A Mont
- Department of Orthopedic Surgery, Lenox Hill Hospital, New York, NY
| | - Nicolas S Piuzzi
- Department of Orthopedic Surgery, Cleveland Clinic, Cleveland, OH
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33
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Baumgartner C, Maselli J, Auerbach AD, Fang MC. Aspirin Compared with Anticoagulation to Prevent Venous Thromboembolism After Knee or Hip Arthroplasty: a Large Retrospective Cohort Study. J Gen Intern Med 2019; 34:2038-2046. [PMID: 31236894 PMCID: PMC6816584 DOI: 10.1007/s11606-019-05122-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 12/04/2018] [Accepted: 03/05/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND Although guidelines now allow the use of aspirin as an alternative to anticoagulants for venous thromboembolism prophylaxis after knee or hip arthroplasty, there is limited data on contemporary use and outcomes with aspirin. OBJECTIVE To describe the use of pharmacologic thromboprophylaxis and to assess venous thromboembolic risk with aspirin compared with anticoagulation after knee or hip arthroplasty. DESIGN Retrospective cohort study using data from the US MedAssets database. PATIENTS Adults with a principal discharge diagnosis of knee or hip arthroplasty between January 1, 2013, and December 31, 2014. MAIN MEASURES We identified charges for medications used for thromboprophylaxis within 7 days after the index surgery from billing records. The primary outcome was postoperative venous thromboembolism identified by International Classification of Diseases, 9th edition codes, from the index hospitalization, rehospitalization within 30 days, or during an outpatient visit within 90 days postoperatively. We compared postoperative thromboembolic risk in patients receiving aspirin-only and those receiving anticoagulants using propensity score-adjusted multivariable logistic regression models. KEY RESULTS We identified 74,234 patients with knee arthroplasty and 36,192 with hip arthroplasty who received pharmacologic thromboprophylaxis. Aspirin-only was used in 27.9% of all patients, while 24.2% and 24.1% received warfarin or enoxaparin as prophylactic monotherapy, respectively. Postoperative venous thromboembolism occurred in 495 (0.67%) patients undergoing knee arthroplasty and 145 (0.40%) undergoing hip arthroplasty. Aspirin-only was not related to increased odds of postoperative venous thromboembolism compared with anticoagulants in multivariable adjusted analyses (odds ratio [OR] 0.70; 95% confidence interval [CI], 0.56-0.87, and OR 0.93; 95% CI, 0.62-1.38 for knee or hip arthroplasty, respectively). CONCLUSIONS More than a fourth of all patients received aspirin as the sole antithrombotic agent after knee or hip arthroplasty. Postoperative thromboprophylaxis with aspirin-only was not associated with a higher risk of postoperative venous thromboembolism compared with anticoagulants after hip or knee arthroplasty.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Anticoagulants/administration & dosage
- Arthroplasty, Replacement, Hip/adverse effects
- Arthroplasty, Replacement, Hip/statistics & numerical data
- Arthroplasty, Replacement, Knee/adverse effects
- Arthroplasty, Replacement, Knee/statistics & numerical data
- Aspirin/administration & dosage
- Databases, Factual
- Female
- Humans
- Male
- Middle Aged
- Platelet Aggregation Inhibitors/administration & dosage
- Postoperative Complications/prevention & control
- Retrospective Studies
- Venous Thromboembolism/epidemiology
- Venous Thromboembolism/prevention & control
- Young Adult
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Affiliation(s)
- Christine Baumgartner
- Division of Hospital Medicine, University of California, San Francisco, San Francisco, CA, USA.
- Department of General Internal Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Judith Maselli
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Andrew D Auerbach
- Division of Hospital Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Margaret C Fang
- Division of Hospital Medicine, University of California, San Francisco, San Francisco, CA, USA
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Bautista M, Muskus M, Tafur D, Bonilla G, Llinás A, Monsalvo D. Thromboprophylaxis for Hip Revision Arthroplasty: Can We Use the Recommendations for Primary Hip Surgery? A Cohort Study. Clin Appl Thromb Hemost 2019; 25:1076029618820167. [PMID: 30808211 PMCID: PMC6714914 DOI: 10.1177/1076029618820167] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The risk of thromboembolic events after hip revision arthroplasty might be higher than in
primary hip arthroplasty. However, evidence regarding the use of thromboprophylaxis in
revisions is scarce. The purpose of this study is to determine whether thromboprophylaxis
recommendations for primary arthroplasty produce similar results in hip revision
arthroplasty. This comparative cohort study retrospectively analyzed consecutive patients
undergoing primary hip arthroplasty and hip revision surgery between March 2004 and
December 2015, who received thromboprophylaxis according to local clinical practice
guidelines for primary hip arthroplasty. The prevalence of deep vein thrombosis and
pulmonary embolism and the presence of major bleeding events were assessed during
hospitalization and at 3 months after discharge and compared between groups. The overall
prevalence of thromboembolic events in the hip revision surgery cohort and in the primary
hip cohort was 1.62% and 1.35%, respectively (P = .801). The 38.4% of hip
revision patients and 20.3% of primary hip patients presented major bleeding events.
Thromboembolic disease outcomes with the use of a standardized thromboprophylaxis regimen
were similar in both cohorts, regardless of the high variability of hip revision surgery
and the increased risk of complications. Implementation of this regimen is recommended in
patients requiring joint replacement revision surgery.
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Affiliation(s)
- Maria Bautista
- 1 Department of Orthopedics and Traumatology, Hospital Universitario Fundación Santa Fe de Bogotá, Bogota, Colombia.,2 School of Medicine, Universidad del Rosario, Bogota, Colombia
| | - Meilyn Muskus
- 1 Department of Orthopedics and Traumatology, Hospital Universitario Fundación Santa Fe de Bogotá, Bogota, Colombia
| | - Daniela Tafur
- 1 Department of Orthopedics and Traumatology, Hospital Universitario Fundación Santa Fe de Bogotá, Bogota, Colombia.,3 School of Medicine, Universidad de Los Andes, Bogotá, Colombia
| | - Guillermo Bonilla
- 1 Department of Orthopedics and Traumatology, Hospital Universitario Fundación Santa Fe de Bogotá, Bogota, Colombia.,2 School of Medicine, Universidad del Rosario, Bogota, Colombia.,3 School of Medicine, Universidad de Los Andes, Bogotá, Colombia
| | - Adolfo Llinás
- 1 Department of Orthopedics and Traumatology, Hospital Universitario Fundación Santa Fe de Bogotá, Bogota, Colombia.,3 School of Medicine, Universidad de Los Andes, Bogotá, Colombia
| | - Daniel Monsalvo
- 1 Department of Orthopedics and Traumatology, Hospital Universitario Fundación Santa Fe de Bogotá, Bogota, Colombia
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35
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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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Tan TL, Foltz C, Huang R, Chen AF, Higuera C, Siqueira M, Hansen EN, Sing DC, Parvizi J. Potent Anticoagulation Does Not Reduce Venous Thromboembolism in High-Risk Patients. J Bone Joint Surg Am 2019; 101:589-599. [PMID: 30946192 DOI: 10.2106/jbjs.18.00335] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Based on current guidelines from the American Academy of Orthopaedic Surgeons (AAOS), a number of prophylactic modalities for the prevention of venous thromboembolism in total joint arthroplasty may be used. It is common practice that more potent prophylactic agents are used for patients at higher risk of venous thromboembolism. However, we are aware of no studies that have investigated the efficacy of potent anticoagulation in higher-risk individuals. Therefore, the purpose of our study was to test the hypothesis that low-molecular-weight heparin and warfarin result in a reduction in venous thromboembolism events in high-risk patients. METHODS A retrospective, multi-institutional study of 60,467 primary and revision total joint arthroplasties from 2000 to 2015 was performed. Identified medications were classified as aspirin, low-molecular-weight heparin, or warfarin. Patients with unavailable venous thromboembolism prophylaxis information or those not receiving the aforementioned prophylaxis were excluded. Information pertinent to the objective of this study was collected and a venous thromboembolism risk score was calculated based on 26 variables. Treatment outcomes assessed included 90-day rate of symptomatic venous thromboembolism and periprosthetic joint infection. Propensity score matching was performed (1:1), as well as logistic regression analysis on the total sample. RESULTS Aspirin prophylaxis demonstrated a lower rate of deep vein thrombosis, pulmonary embolism, and venous thromboembolism than warfarin and low-molecular-weight heparin alone throughout all risk scores. In the matched propensity score analysis, low-molecular-weight heparin and warfarin demonstrated increased odds of venous thromboembolism for both standard-risk and high-risk patients undergoing total knee arthroplasties compared with aspirin. For primary total hip arthroplasty, warfarin demonstrated an increased risk for high-risk patients and low-molecular-weight heparin demonstrated an increased risk for standard-risk patients. The prevalence of periprosthetic joint infection was higher in patients receiving warfarin (p < 0.001 for both comparisons of warfarin with aspirin and low-molecular-weight heparin). CONCLUSIONS The results of this multi-institutional study demonstrate that the use of warfarin and low-molecular-weight heparin in higher-risk patients does not necessarily result in a reduction in symptomatic venous thromboembolism. Aspirin administered to higher-risk patients seems to be as effective as potent anticoagulation and more effective than warfarin. LEVEL OF EVIDENCE Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Timothy L Tan
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Carol Foltz
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Ronald Huang
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Antonia F Chen
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | | | - Erik N Hansen
- University of California San Francisco, San Francisco, California
| | - David C Sing
- University of California San Francisco, San Francisco, California
| | - Javad Parvizi
- Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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Is Obesity Associated With Increased Risk of Deep Vein Thrombosis or Pulmonary Embolism After Hip and Knee Arthroplasty? A Large Database Study. Clin Orthop Relat Res 2019; 477:523-532. [PMID: 30624321 PMCID: PMC6382191 DOI: 10.1097/corr.0000000000000615] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Deep venous thrombosis (DVT) and pulmonary embolus (PE) remain an important cause of morbidity and mortality after THA and TKA. Prior recommendations have advocated for more aggressive prophylaxis for patients with obesity, whereas the evidence supporting these recommendations is conflicting and often based on underpowered studies. QUESTIONS/PURPOSES (1) What is the association between obesity and DVT and PE after primary and revision THA and TKA? (2) Is there a body mass index (BMI) threshold beyond which DVT and PE risk is elevated? METHODS We reviewed the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from 2008 to 2016 to evaluate the reported 30-day rates of DVT, PE, and combined venous thromboembolism (VTE) after primary THA, primary TKA, revision THA, and revision TKA according to BMI as a continuous variable and a categorical variable as defined by the World Health Organization cutoffs for underweight, normal weight, overweight, and obesity. This database is risk-adjusted and designed to capture complications after surgery, thus making it ideal for this study. The diagnosis of DVT and PE is included in the ACS-NSQIP database for any DVT or PE requiring treatment. Proximal versus distal DVT is not specified within the database. Multivariate logistic regression was performed to determine if obesity was independently associated with DVT and PE risk by controlling for age, sex, race, American Society of Anesthesiologists score, diabetes, hypertension, smoking status, general anesthesia, and hypoalbuminemia. RESULTS After controlling for potential confounding variables such as medical comorbidities and procedure type, patients undergoing primary and revision THA and TKA with World Health Organization classification as underweight (BMI < 18.5 kg/m), overweight (BMI 25-29.9 kg/m), Class I obese (BMI 30-34.9 kg/m), Class II obese (BMI 35-39.9 kg/m), or Class III obese (BMI ≥ 40 kg/m) did not demonstrate an association with increased risk of DVT compared with patients classified as normal weight (BMI 18.5-25 kg/m). Compared with patients undergoing primary THA classified as normal weight, the risk of PE was elevated in patients with Class II obesity (odds ratio [OR], 2.36; 95% confidence interval [CI], 1.23-4.50; p = 0.009) and all heavier categories. Compared with patients undergoing TKA classified as normal weight, the risk of PE was elevated in patients classified as overweight (OR, 1.56; 95% CI, 1.03-2.36; p = 0.035) and all heavier categories. CONCLUSIONS This large administrative database study suggests that patient classification as overweight or obese is associated with increased risk of development of PE but not DVT after primary THA or TKA. Because aggressive pharmacologic anticoagulation regimens can decrease the DVT rate but have not been shown to affect the rate of PE or death, the data do not currently support increased anticoagulation in patients with obesity without other risk factors for VTE undergoing THA or TKA. Additional studies are required to refine VTE prophylaxis protocols to reduce PE risk while maintaining acceptable postoperative bleeding risk. LEVEL OF EVIDENCE Level III, therapeutic study.
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Arnold WV, Bari AK, Buttaro M, Huang R, Mirez JP, Neira I, Poojary A, Purtill JJ, Quevedo MS, García Ricaurte JC, Scuderi G, Thakur H, Tozun IR. General Assembly, Prevention, Postoperative Factors: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S169-S174. [PMID: 30348574 DOI: 10.1016/j.arth.2018.09.067] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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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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Bovonratwet P, Malpani R, Ottesen TD, Tyagi V, Ondeck NT, Rubin LE, Grauer JN. Aseptic revision total hip arthroplasty in the elderly. Bone Joint J 2018; 100-B:143-151. [DOI: 10.1302/0301-620x.100b2.bjj-2017-0895.r1] [Citation(s) in RCA: 45] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aims The aim of this study was to compare the rate of perioperative complications following aseptic revision total hip arthroplasty (THA) in patients aged ≥ 80 years with that in those aged < 80 years, and to identify risk factors for the incidence of serious adverse events in those aged ≥ 80 years using a large validated national database. Patients and Methods Patients who underwent aseptic revision THA were identified in the 2005 to 2015 National Surgical Quality Improvement Program (NSQIP) database and stratified into two age groups: those aged < 80 years and those aged ≥ 80 years. Preoperative and procedural characteristics were compared. Multivariate regression analysis was used to compare the risk of postoperative complications and readmission. Risk factors for the development of a serious adverse event in those aged ≥ 80 years were characterized. Results The study included 7569 patients aged < 80 years and 1419 were aged ≥ 80 years. Multivariate analysis showed a higher risk of perioperative mortality, pneumonia, urinary tract infection and the requirement for a blood transfusion and an extended length of stay in those aged ≥ 80 years compared with those aged < 80 years. Independent risk factors for the development of a serious adverse event in those aged ≥ 80 years include an American Society of Anesthesiologists score of ≥ 3 and procedures performed under general anaesthesia. Conclusion Even after controlling for patient and procedural characteristics, aseptic revision THA is associated with greater risks in patients aged ≥ 80 years compared with younger patients. This is important for counselling and highlights the need for medical optimization in these vulnerable patients. Cite this article: Bone Joint J 2018;100-B:143–51.
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Affiliation(s)
- P. Bovonratwet
- Yale School of Medicine, 47
College Street, New Haven, Connecticut
06520, USA
| | - R. Malpani
- Yale School of Medicine, 47
College Street, New Haven, Connecticut
06520, USA
| | - T. D. Ottesen
- Yale School of Medicine, 47
College Street, New Haven, Connecticut
06520, USA
| | - V. Tyagi
- Yale School of Medicine, 47
College Street, New Haven, Connecticut
06520, USA
| | - N. T. Ondeck
- Yale School of Medicine, 47
College Street, New Haven, Connecticut
06520, USA
| | - L. E. Rubin
- Yale School of Medicine, 47
College Street, New Haven, Connecticut
06520, USA
| | - J. N. Grauer
- Yale School of Medicine, 47
College Street, New Haven, Connecticut
06520, USA
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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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Parvizi J, Ceylan HH, Kucukdurmaz F, Merli G, Tuncay I, Beverland D. Venous Thromboembolism Following Hip and Knee Arthroplasty: The Role of Aspirin. J Bone Joint Surg Am 2017; 99:961-972. [PMID: 28590382 DOI: 10.2106/jbjs.16.01253] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Javad Parvizi
- 1The Rothman Institute at Thomas Jefferson University, Philadelphia, Pennsylvania 2Bezmialem Vakif University, Istanbul, Turkey 3Thomas Jefferson University, Philadelphia, Pennsylvania 4Musgrave Park Hospital, Belfast, United Kingdom
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Parvizi J, Shohat N, Gehrke T. Prevention of periprosthetic joint infection: new guidelines. Bone Joint J 2017; 99-B:3-10. [PMID: 28363888 DOI: 10.1302/0301-620x.99b4.bjj-2016-1212.r1] [Citation(s) in RCA: 107] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Accepted: 01/04/2017] [Indexed: 12/13/2022]
Abstract
The World Health Organization (WHO) and the Centre for Disease Control and Prevention (CDC) recently published guidelines for the prevention of surgical site infection. The WHO guidelines, if implemented worldwide, could have an immense impact on our practices and those of the CDC have implications for healthcare policy in the United States. Our aim was to review the strategies for prevention of periprosthetic joint infection in light of these and other recent guidelines. Cite this article: Bone Joint J 2017;99-B(4 Supple B):3-10.
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Affiliation(s)
- J Parvizi
- Thomas Jefferson University, Rothman Institute Sheridan Building, Suite 1000, 25 S 9th Street, Philadelphia, PA 19107, USA
| | - N Shohat
- Tel Aviv University, Tel Aviv, Israel and Thomas Jefferson University, Rothman Institute at Sheridan Building, Suite 1000, 125 S 9th Street, Philadelphia, PA 19107, USA
| | - T Gehrke
- HELIOS ENDO-Klinik Hamburg, Holstrenstraße 2, 22767 Hamburg, Germany
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