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Zhou Y, Moon C, Szatkowski J, Moore D, Stevens J. Evaluating ChatGPT responses in the context of a 53-year-old male with a femoral neck fracture: a qualitative analysis. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:927-955. [PMID: 37776392 PMCID: PMC10858115 DOI: 10.1007/s00590-023-03742-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 09/18/2023] [Indexed: 10/02/2023]
Abstract
PURPOSE The integration of artificial intelligence (AI) tools, such as ChatGPT, in clinical medicine and medical education has gained significant attention due to their potential to support decision-making and improve patient care. However, there is a need to evaluate the benefits and limitations of these tools in specific clinical scenarios. METHODS This study used a case study approach within the field of orthopaedic surgery. A clinical case report featuring a 53-year-old male with a femoral neck fracture was used as the basis for evaluation. ChatGPT, a large language model, was asked to respond to clinical questions related to the case. The responses generated by ChatGPT were evaluated qualitatively, considering their relevance, justification, and alignment with the responses of real clinicians. Alternative dialogue protocols were also employed to assess the impact of additional prompts and contextual information on ChatGPT responses. RESULTS ChatGPT generally provided clinically appropriate responses to the questions posed in the clinical case report. However, the level of justification and explanation varied across the generated responses. Occasionally, clinically inappropriate responses and inconsistencies were observed in the generated responses across different dialogue protocols and on separate days. CONCLUSIONS The findings of this study highlight both the potential and limitations of using ChatGPT in clinical practice. While ChatGPT demonstrated the ability to provide relevant clinical information, the lack of consistent justification and occasional clinically inappropriate responses raise concerns about its reliability. These results underscore the importance of careful consideration and validation when using AI tools in healthcare. Further research and clinician training are necessary to effectively integrate AI tools like ChatGPT, ensuring their safe and reliable use in clinical decision-making.
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Affiliation(s)
- Yushy Zhou
- Department of Surgery, The University of Melbourne, St. Vincent's Hospital Melbourne, 29 Regent Street, Clinical Sciences Block Level 2, Melbourne, VIC, 3010, Australia.
- Department of Orthopaedic Surgery, St. Vincent's Hospital, Melbourne, Australia.
| | - Charles Moon
- Department of Orthopaedic Surgery, Cedars-Sinai Medical Centre, Los Angeles, CA, USA
| | - Jan Szatkowski
- Department of Orthopaedic Surgery, Indiana University Health Methodist Hospital, Indianapolis, IN, USA
| | - Derek Moore
- Santa Barbara Orthopedic Associates, Santa Barbara, CA, USA
| | - Jarrad Stevens
- Department of Orthopaedic Surgery, St. Vincent's Hospital, Melbourne, Australia
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Kalkwarf KJ, Yang Y, Mora S, Wolf DA, Robertson RD, Holcomb JB, Drake SA. The silent killer: Previously undetected pulmonary emboli that result in death after discharge. Injury 2023; 54:111016. [PMID: 37717493 DOI: 10.1016/j.injury.2023.111016] [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: 04/07/2023] [Revised: 08/19/2023] [Accepted: 09/02/2023] [Indexed: 09/19/2023]
Abstract
INTRODUCTION Pulmonary embolism (PE) is a recognized cause of death in hospitalized trauma patients, yet less is known about PE after discharge. PATIENTS & METHODS All post-discharge, autopsy-demonstrated, fatal PE resulting from trauma within a large US county over six years were analyzed. Counts, percentages, mean values, SD, and IQR were calculated for all variables. RESULTS 1848 trauma deaths were reviewed, of which 85% had an autopsy. Eighty-five patients died from PE after discharge from their initial injury. 53% were initially treated at non-trauma centers, and 9% did not seek medical assistance. 75% were injured by falling, and most injuries occurred in the lower extremities. 86% had an ISS <16, but 87% needed assistance or were bed-bound after injury, despite 75% having no mobility limitations before the injury. 53% died within one month of injury, and 91% within the first year. Before death, only 11% were prescribed chemical thromboprophylaxis or an antiplatelet agent, and only 8% were diagnosed with venous thromboembolism before death. CONCLUSIONS Fatal PE after discharge typically occurred following activity-limiting lower extremity injuries with an ISS<16.
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Affiliation(s)
- Kyle J Kalkwarf
- The University of Arkansas for Medical Sciences, Department of General Surgery, Division of Trauma and Acute Care Surgery, 4301W. Markham St. Slot 520-1, Little Rock, Arkansas 72205, United States.
| | - Yijiong Yang
- The University of Texas Health Science Center at Houston, 7000 Fannin St, Houston, Texas 77030, United States; Florida State University College of Nursing, Vivian M. Duxbury Hall, 98 Varsity Way, Office 412, Tallahassee, Florida, 32306-4310, United States
| | - Stephen Mora
- Harris Health System, 1504 Taub Loop, Houston, Texas 77030, United States
| | - Dwayne A Wolf
- Harris County Institute of Forensic Sciences, 1861 Old Spanish Trail, Houston, Texas 77030, United States; Lucas County Coroner's Office, 2595 Arlington Avenue, Toledo, Ohio 43614, United States
| | - Ronald D Robertson
- The University of Arkansas for Medical Sciences, Department of General Surgery, Division of Trauma and Acute Care Surgery, 4301W. Markham St. Slot 520-1, Little Rock, Arkansas 72205, United States
| | - John B Holcomb
- The University of Alabama at Birmingham, Department of Surgery, Center for Injury Science, 619 19th St S, Birmingham, Alabama 35249, United States
| | - Stacy A Drake
- Texas A&M College of Nursing, 2121W. Holcombe Blvd, Houston, Texas 77030, United States; Bowling Green State University, College of Health and Human Services, School of Nursing, 332 Central Hall, Bowling Green, Ohio 43403, United States
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Za P, Papalia GF, Franceschetti E, Rizzello G, Adravanti P, Papalia R. Aspirin is a safe and effective thromboembolic prophylaxis after total knee arthroplasty: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc 2023; 31:4407-4421. [PMID: 37449989 DOI: 10.1007/s00167-023-07500-1] [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: 12/24/2022] [Accepted: 07/03/2023] [Indexed: 07/18/2023]
Abstract
PURPOSE Patients undergoing total knee arthroplasty (TKA) are at high risk for thromboembolic events compared to non-surgical patients. Both anticoagulants and antiplatelet agents are used as antithrombotic prophylaxis in TKA. The aim of this review is to understand the role of aspirin in the prevention of thromboembolic events and to compare its efficacy and safety with the main anticoagulants used in antithromboembolic prophylaxis in TKA. METHODS A systematic review and meta-analysis was performed according to the PRISMA guidelines. An electronic systematic search was conducted using PubMed, Scopus, and the Cochrane Central Registry to evaluate studies that compared aspirin with other anticoagulants, in terms of deep venous thrombosis and pulmonary embolism after TKA. The meta-analysis compared the rate of complications between aspirin and other anticoagulants. RESULTS Thirteen studies were included in the systematic review for a total of 163,983 patients, and 10 studies were included in the meta-analysis. The meta-analysis demonstrated no statistically significant differences between aspirin and other anticoagulants in terms of the rate of deep venous thrombosis (OR 0.93, 95% CI 0.81-1.08, p = 0.35) and pulmonary embolism (OR 0.89, 95% CI 0.56-1.41, p = 0.61). CONCLUSION Aspirin is safe, effective, and not inferior to other main anticoagulants in preventing thromboembolic events following TKA.
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Affiliation(s)
- Pierangelo Za
- Department of Orthopaedic and Trauma Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128, Rome, Italy
- Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128, Rome, Italy
| | - Giuseppe Francesco Papalia
- Department of Orthopaedic and Trauma Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128, Rome, Italy.
- Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128, Rome, Italy.
| | - Edoardo Franceschetti
- Department of Orthopaedic and Trauma Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128, Rome, Italy
- Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128, Rome, Italy
| | - Giacomo Rizzello
- Department of Orthopaedic and Trauma Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128, Rome, Italy
- Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128, Rome, Italy
| | - Paolo Adravanti
- Department of Orthopaedic and Trauma Surgery, Casa di Cura Città of Parma, 43123, Parma, Italy
| | - Rocco Papalia
- Department of Orthopaedic and Trauma Surgery, Università Campus Bio-Medico di Roma, Via Alvaro del Portillo, 21, 00128, Rome, Italy
- Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128, Rome, Italy
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Naung Tun H, Kyaw MT, Rafflenbeul E, López Suástegui X. Role of Direct Oral Anticoagulants for Post-operative Venous Thromboembolism Prophylaxis. Eur Cardiol 2022; 17:e11. [PMID: 35620356 PMCID: PMC9127635 DOI: 10.15420/ecr.2021.55] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 01/28/2022] [Indexed: 11/19/2022] Open
Abstract
Venous thromboembolism (VTE) is one of the leading causes of post-operative morbidity and mortality. Over previous decades, heparin and warfarin were the predominant therapeutic options for post-operative thromboprophylaxis. However, their use is limited by drawbacks including a narrow therapeutic range, numerous food and drug interactions, and the need for regular monitoring for dose adjustments. Recently, direct oral anticoagulants (DOACs), such as dabigatran etexilate (a direct thrombin inhibitor) and apixaban, rivaroxaban and edoxaban (direct factor Xa inhibitors), have been developed to overcome these issues. DOACs have shown promising results in Phase III clinical trials for post-operative VTE prophylaxis. This review summarises the pharmacological profile of DOACs and highlights the use of DOACs in post-operative VTE prophylaxis based on the available clinical trial data.
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Affiliation(s)
- Han Naung Tun
- Larner College of Medicine, University of Vermont, Burlington, VT, US
| | - May Thu Kyaw
- Heart and Vascular Centre, Victoria Hospital, Yangon, Myanmar
| | - Erik Rafflenbeul
- Department of Cardiology, Schoen Clinic Hamburg Eilbek, Hamburg, Germany
| | - Xiuhtlaulli López Suástegui
- Emergency Department, Intensive Care Unit Hospital Regional de Alta Especialidad de Zumpango, Instituto Mexicano del Seguro Social, Zumpango de Ocampo, Mexico
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Hongnaparak T, Janejaturanon J, Iamthanaporn K, Tanutit P, Yuenyongviwat V. Aspirina versus rivaroxabana na prevenção do tromboembolismo venoso após artroplastia total do joelho: Um ensaio clínico randomizado, controlado e duplo-cego. Rev Bras Ortop 2021; 57:741-746. [PMID: 36226201 PMCID: PMC9550362 DOI: 10.1055/s-0041-1735941] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 05/14/2021] [Indexed: 10/31/2022] Open
Abstract
Resumo
Objetivo A aspirina (ácido acetilsalicílico, AAS) e a rivaroxabana são anticoagulantes que vêm ganhando popularidade devido à facilidade de uso na prevenção do tromboembolismo venoso (TEV) após artroplastia total do joelho (ATJ). Este estudo teve como objetivo avaliar a eficácia do AAS em comparação com a da rivaroxabana na profilaxia de TEV em pacientes submetidos a ATJ.
Método Quarenta pacientes com osteoartrite primária do joelho, que seriam submetidos a ATJ, foram randomizados em dois grupos. No total, 20 pacientes do grupo AAS usaram aspirina oral, na dose de 300 mg/dia, para a profilaxia do TEV após ATJ; e 20 pacientes do grupo rivaroxabana receberam uma dose oral de 10 mg/dia. No 4° e 14° dias do pós-operatório, trombose venosa profunda (TVP) dos membros inferiores no lado da cirurgia foi detectada por meio de ultrassonografia duplex. Foram registradas outras complicações durante catorze dias.
Resultados Não foram detectados achados positivos de TVP com a ultrassonografia duplex nos grupos de pacientes, e não se observou a ocorrência de embolia pulmonar. No total, 4 pacientes apresentaram equimose subcutânea no 4° dia do pós-operatório (2 pacientes no grupo AAS e 2 pacientes no grupo rivaroxabana; p = 1,0), e outros 4 pacientes, no 14° dia do pós-operatório (1 paciente no grupo AAS e 3 pacientes no grupo rivaroxabana; p = 0,292). Nenhum paciente da amostra apresentou hematoma da ferida cirúrgica, sangramento de órgão importante, infecção da ferida, ou necessidade de nova cirurgia.
Conclusão A aspirina e a rivaroxabana apresentaram eficácia comparável na prevenção do TEV, sem aumentar a incidência de complicações da ferida e sangramento após ATJ.
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Affiliation(s)
- Theerawit Hongnaparak
- Departamento de Ortopedia, Faculdade de Medicina, Universidade Prince of Songkla, Songkhla, Tailândia
| | - Jiranuwat Janejaturanon
- Departamento de Ortopedia, Faculdade de Medicina, Universidade Prince of Songkla, Songkhla, Tailândia
| | - Khanin Iamthanaporn
- Departamento de Ortopedia, Faculdade de Medicina, Universidade Prince of Songkla, Songkhla, Tailândia
| | - Pramot Tanutit
- Departamento de Radiologia, Faculdade de Medicina, Universidade Prince of Songkla, Songkhla, Tailândia
| | - Varah Yuenyongviwat
- Departamento de Ortopedia, Faculdade de Medicina, Universidade Prince of Songkla, Songkhla, Tailândia
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Hovik O, Amlie EJ, Jenssen KK. No Increased Risk of Venous Thromboembolism in High-Risk Patients Continuing Their Dose of 75 mg Aspirin Compared to Healthier Patients Given Low-Molecular-Weight Heparin. J Arthroplasty 2021; 36:3589-3592. [PMID: 34176693 DOI: 10.1016/j.arth.2021.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2021] [Revised: 05/11/2021] [Accepted: 06/06/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Optimum venous thromboembolism (VTE) prophylaxis for patients undergoing total hip or knee arthroplasty remains undefined. The purpose of this study is to compare complication rates among total joint arthroplasty patients using either low-dose aspirin (75 mg once daily) or low-molecular-weight heparin (LMWH; Fragmin/dalteparin 5000 U) for VTE prophylaxis. METHODS This is a prospective observational study. All total hip or knee arthroplasties from 2014 to 2020 were included. One thousand eighty-four patients already taking aspirin 75 mg as primary or secondary prophylaxis for cardiovascular disease continued their daily aspirin dose throughout their hospital stay and after discharge without any other kind of thromboprophylaxis. Five thousand ten patients not already taking aspirin were given LMWH for 12-14 days starting the day of surgery. Both groups consisted of patients undergoing either primary or revision total hip or knee arthroplasty. The aspirin group was older (73 ± 7.8 vs 66 ± 10.2 years, P < .01, 95% CI -7.6, -6.3) with more comorbidities but otherwise did not differ from the LMWH group. Outcome measures were recorded at 3-month follow-up and included the following complications: clinically deep venous thrombosis (DVT), pulmonary embolism (PE), deep infection, blood transfusion, and death. RESULTS The aspirin group had 0.28% DVT and 0.28% PE, and the LMWH group had 0.24% DVT and 0.16% PE (P = .42 and .74, respectively). No difference in deep infection, allogenic blood transfusion, or mortality was found. CONCLUSION No statistically significant difference in complication rates was found between aspirin 75 mg and LMWH used for VTE prophylaxis. Aspirin 75 mg daily is safe for VTE prophylaxis after total hip or knee arthroplasty.
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Affiliation(s)
- Oystein Hovik
- Orthopaedic Department, Lovisenberg Diaconal Hospital, Oslo, Norway
| | - Einar J Amlie
- Orthopaedic Department, Lovisenberg Diaconal Hospital, Oslo, Norway
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Olukoya O, Fultang J. Aspirin Compared With Other Anticoagulants for Use as Venous Thromboembolism Prophylaxis in Elective Orthopaedic Hip and Knee Operations: A Narrative Literature Review. Cureus 2021; 13:e18249. [PMID: 34692356 PMCID: PMC8526075 DOI: 10.7759/cureus.18249] [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: 09/24/2021] [Indexed: 11/05/2022] Open
Abstract
Although total hip and knee arthroplasty are effective methods for treating arthritis, they have an associated risk of venous thromboembolism (VTE). To reduce this risk, prophylactic agents including aspirin, low-molecular-weight Heparin, vitamin K antagonists, and direct oral anticoagulants are employed for up to 35 days after surgery. This narrative literature review utilised a systematic approach to critically assess the current evidence surrounding the use of aspirin for VTE prophylaxis compared to anticoagulants. An advanced multistage electronic search was performed in May 2021 using the OVID/Medline and Embase online libraries to identify available studies relevant to the subject from 1974. Additional studies identified during the review process were also included. The final studies meeting the inclusion criteria were then assessed using the Critical Appraisal Skills Programme tool. A total of 12 (60%) studies (two meta-analyses, three randomised trials, seven retrospective studies) favoured aspirin over anticoagulants for VTE prophylaxis. A total of 15 (75%) studies (two meta-analyses, three randomised trials, nine retrospective, one matched cohort) reported that aspirin had better bleeding profiles and complication rates, which was statistically significant in seven (46.7%) studies (one randomised trial, six retrospective studies). A total of eight studies (one randomised trial, six retrospective studies, one matched cohort) reported statistically significant results for aspirin. Five (62.5%) studies reported aspirin to be superior for VTE prophylaxis, while seven (87.5%) reported aspirin to be superior in terms of bleeding complications. The current evidence indicates that aspirin is superior to anticoagulants, in their various iterations, for VTE prophylaxis in terms of their bleeding profiles.
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Affiliation(s)
- Olatomiwa Olukoya
- Neurocritical Care, National Hospital for Neurology and Neurosurgery, London, GBR
| | - Joshua Fultang
- Surgery, University of Glasgow, Glasgow, GBR
- General Surgery, University Hospital Ayr/University of West of Scotland, Ayr, GBR
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Tanavalee A. Should prophylaxis of venous thromboembolism in Asian patients undergoing knee and hip arthroplasty and hip fracture surgery be an issue? Knee Surg Relat Res 2021; 33:23. [PMID: 34325748 PMCID: PMC8323214 DOI: 10.1186/s43019-021-00105-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Aree Tanavalee
- Chulalongkorn University Faculty of Medicine, 1873 Rama IV Road, Pathumwan, Bangkok, 10330, Thailand.
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Muscatelli SR, Charters MA, Hallstrom BR. Time for an Update? A Look at Current Guidelines for Venous Thromboembolism Prophylaxis After Hip and Knee Arthroplasty and Hip Fracture. Arthroplast Today 2021; 10:105-107. [PMID: 34337116 PMCID: PMC8318891 DOI: 10.1016/j.artd.2021.06.015] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2021] [Revised: 06/02/2021] [Accepted: 06/16/2021] [Indexed: 11/19/2022] Open
Abstract
Venous thromboembolism is a well-established complication of total hip and knee arthroplasty and hip fracture surgery. Clinical practice guidelines have been proposed to help clinicians provide prophylaxis against this risk. However, most guidelines reference data that are becoming outdated because of new advances in perioperative protocols. Recent data would suggest that aspirin may be appropriate for most patients after total hip and knee replacement and a more potent chemoprophylaxis for higher risk patients. Low-molecular-weight heparin remains the recommended choice after hip fracture surgery, although there is a paucity of recent literature in this patient population. There are randomized trials currently underway in the arthroplasty population that may guide clinicians in the appropriate choice of chemoprophylaxis. These studies should inform updates to the current clinical practice guidelines.
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Affiliation(s)
- Stefano R. Muscatelli
- Department of Orthopaedic Surgery, University of Michigan Health System, Ann Arbor, MI, USA
| | | | - Brian R. Hallstrom
- Department of Orthopaedic Surgery, University of Michigan Health System, Ann Arbor, MI, USA
- Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI) Coordinating Center, University of Michigan Health System, Ann Arbor, MI, USA
- Corresponding author. 1500 E. Medical Center Dr., TC 2912, Ann Arbor, MI 48109-5328, USA. Tel.: +1 734 646 9191.
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Rooney T, Barrack RL, Clohisy JC, Nunley RM, Lawrie CM. Is Apixaban Safe and Effective for Venous Thromboembolism Prophylaxis After Primary Total Hip and Total Knee Arthroplasties? J Arthroplasty 2021; 36:S328-S331. [PMID: 33888386 DOI: 10.1016/j.arth.2021.03.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 03/07/2021] [Accepted: 03/10/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Venous thromboembolism (VTE) is a serious complication of total hip arthroplasty (THA) and total knee arthroplasty (TKA). Apixaban is approved for VTE prophylaxis. This study seeks to ascertain the risk of VTE and bleeding complications in patients undergoing primary THA and TKA receiving apixaban for postoperative VTE prophylaxis for one of the following indications: high risk for VTE, previously on apixaban, and contraindication to the use of aspirin. METHODS This is a retrospective cohort study of patients who underwent primary THA or TKA over a 17-month period and were prescribed apixaban for thromboprophylaxis postoperatively. RESULTS 230 patients were included in the study, 110 TKA and 120 THA. The primary reasons for high-risk VTE status included personal and family history of VTE, and 13% were taking apixaban preoperatively for atrial fibrillation. 1 patient (0.43%) who underwent TKA had a DVT with PE. 2.6% of patients had wound complications requiring operative treatment, and 0.87% of THA patients underwent revision arthroplasty. CONCLUSION The use of apixaban for VTE prophylaxis after primary THA and TKA in patients at high risk for VTE, in patients previously on apixaban, and in patients with a contraindication to the use of aspirin is associated with a low risk of VTE and bleeding complications.
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Affiliation(s)
- Timothy Rooney
- Washington University School of Medicine, Department of Orthopaedic Surgery, St. Louis, MO
| | - Robert L Barrack
- Washington University School of Medicine, Department of Orthopaedic Surgery, St. Louis, MO
| | - John C Clohisy
- Washington University School of Medicine, Department of Orthopaedic Surgery, St. Louis, MO
| | - Ryan M Nunley
- Washington University School of Medicine, Department of Orthopaedic Surgery, St. Louis, MO
| | - Charles M Lawrie
- Washington University School of Medicine, Department of Orthopaedic Surgery, St. Louis, MO
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Todd F, Yeomans D, Whitehouse MR, Matharu GS. Does venous thromboembolism prophylaxis affect the risk of venous thromboembolism and adverse events following primary hip and knee replacement? A retrospective cohort study. J Orthop 2021; 25:301-304. [PMID: 34140759 DOI: 10.1016/j.jor.2021.05.030] [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: 03/15/2021] [Accepted: 05/23/2021] [Indexed: 10/21/2022] Open
Abstract
Background The optimum chemical venous thromboembolism (VTE) prophylactic agents following total hip and knee replacement (THR and TKR) remain unknown. NICE recommends multiple agents, including direct oral anticoagulants (DOACs), low-molecular weight heparin (LMWH), and aspirin. We assessed whether VTE prophylaxis affected the risk of VTE and adverse events following primary THR and TKR. Materials and methods We reviewed 982 elective primary THRs (59%) and TKRs (41%) at a large tertiary centre during 2018. The primary outcome was any VTE (DVT and/or PE) within 90-days. Secondary outcomes were adverse events within 90-days (major bleeding and wound complications). The association between VTE prophylaxis and outcomes was assessed. Results The overall prevalence of VTE and adverse events were 2.7% (n = 27) and 15.2% (n = 136) respectively. The most common agents used were DOAC ± LMWH (50.7%, n = 498), followed by aspirin ± LMWH (35.5%, n = 349) and LMWH alone (4.7%, n = 46). The risk of VTE (aspirin ± LMWH = 3.7%, DOAC = 2.0%, LMWH = 2.2%) was not significantly different between agents (p = 0.294). The risk of any adverse event was significantly higher (p < 0.001) with aspirin ± LMWH (16.1%; n = 56) and LMWH (28.3%; n = 13) compared with DOACs ± LMWH (7.0%; n = 35) in TKRs only, there was no differences between agents for adverse events in THRs (p = 0.644). Conclusions Choice of thromboprophylaxis did not influence the risk of VTE following primary THR and TKR. DOACs (+/- LMWH) were associated with the lowest risk of adverse events. Large multicentre trials are still needed to assess the efficacy and safety of these agents following THR and TKR.
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Affiliation(s)
- F Todd
- Southmead Hospital, Bristol, United Kingdom
| | - D Yeomans
- Southmead Hospital, Bristol, United Kingdom
| | - M R Whitehouse
- Southmead Hospital, Bristol, United Kingdom.,Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, Southmead Hospital, Bristol, United Kingdom.,National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, United Kingdom
| | - G S Matharu
- Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, Southmead Hospital, Bristol, United Kingdom
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O'Toole RV, Stein DM, Frey KP, O'Hara NN, Scharfstein DO, Slobogean GP, Taylor TJ, Haac BE, Carlini AR, Manson TT, Sudini K, Mullins CD, Wegener ST, Firoozabadi R, Haut ER, Bosse MJ, Seymour RB, Holden MB, Gitajn IL, Goldhaber SZ, Eastman AL, Jurkovich GJ, Vallier HA, Gary JL, Kleweno CP, Cuschieri J, Marvel D, Castillo RC. PREVENTion of CLots in Orthopaedic Trauma (PREVENT CLOT): a randomised pragmatic trial protocol comparing aspirin versus low-molecular-weight heparin for blood clot prevention in orthopaedic trauma patients. BMJ Open 2021; 11:e041845. [PMID: 33762229 PMCID: PMC7993181 DOI: 10.1136/bmjopen-2020-041845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 01/27/2021] [Accepted: 02/25/2021] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Patients who sustain orthopaedic trauma are at an increased risk of venous thromboembolism (VTE), including fatal pulmonary embolism (PE). Current guidelines recommend low-molecular-weight heparin (LMWH) for VTE prophylaxis in orthopaedic trauma patients. However, emerging literature in total joint arthroplasty patients suggests the potential clinical benefits of VTE prophylaxis with aspirin. The primary aim of this trial is to compare aspirin with LMWH as a thromboprophylaxis in fracture patients. METHODS AND ANALYSIS PREVENT CLOT is a multicentre, randomised, pragmatic trial that aims to enrol 12 200 adult patients admitted to 1 of 21 participating centres with an operative extremity fracture, or any pelvis or acetabular fracture. The primary outcome is all-cause mortality. We will evaluate non-inferiority by testing whether the intention-to-treat difference in the probability of dying within 90 days of randomisation between aspirin and LMWH is less than our non-inferiority margin of 0.75%. Secondary efficacy outcomes include cause-specific mortality, non-fatal PE and deep vein thrombosis. Safety outcomes include bleeding complications, wound complications and deep surgical site infections. ETHICS AND DISSEMINATION The PREVENT CLOT trial has been approved by the ethics board at the coordinating centre (Johns Hopkins Bloomberg School of Public Health) and all participating sites. Recruitment began in April 2017 and will continue through 2021. As both study medications are currently in clinical use for VTE prophylaxis for orthopaedic trauma patients, the findings of this trial can be easily adopted into clinical practice. The results of this large, patient-centred pragmatic trial will help guide treatment choices to prevent VTE in fracture patients. TRIAL REGISTRATION NUMBER NCT02984384.
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Affiliation(s)
- Robert V O'Toole
- Department of Orthopaedics, University of Maryland Baltimore, Baltimore, Maryland, USA
| | - Deborah M Stein
- Department of Surgery, University of California in San Francisco, San Francisco, California, USA
| | - Katherine P Frey
- METRC Coordinating Center, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Nathan N O'Hara
- Department of Orthopaedics, University of Maryland Baltimore, Baltimore, Maryland, USA
| | - Daniel O Scharfstein
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah, USA
| | - Gerard P Slobogean
- Department of Orthopaedics, University of Maryland Baltimore, Baltimore, Maryland, USA
| | - Tara J Taylor
- METRC Coordinating Center, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Bryce E Haac
- Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Anthony R Carlini
- METRC Coordinating Center, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Theodore T Manson
- Department of Orthopaedics, University of Maryland Baltimore, Baltimore, Maryland, USA
| | - Kuladeep Sudini
- METRC Coordinating Center, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - C Daniel Mullins
- Department of Pharmaceutical Health Services Research, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Stephen T Wegener
- Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Reza Firoozabadi
- Department of Orthopaedic Surgery and Sports Medicine, University of Washington - Harborview Medical Center, Seattle, Washington, USA
| | - Elliott R Haut
- Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Michael J Bosse
- Department of Orthopaedic Surgery, Atrium Health, Charlotte, North Carolina, USA
| | - Rachel B Seymour
- Department of Orthopaedic Surgery, Atrium Health, Charlotte, North Carolina, USA
| | - Martha B Holden
- Department of Orthopaedic Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Ida Leah Gitajn
- Department of Orthopaedics, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Samuel Z Goldhaber
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Alexander L Eastman
- Department of Surgery, University of Texas Southwestern Medical School, Dallas, Texas, USA
| | - Gregory J Jurkovich
- Department of Surgery, University of California Davis, Davis, California, USA
| | - Heather A Vallier
- Department of Orthopaedics, MetroHealth System, Cleveland, Ohio, USA
| | - Joshua L Gary
- Department of Orthopedic Surgery, University of Texas McGovern Medical School, Houston, Texas, USA
| | - Conor P Kleweno
- Department of Orthopaedic Surgery and Sports Medicine, University of Washington - Harborview Medical Center, Seattle, Washington, USA
| | - Joseph Cuschieri
- Department of Surgery, University of Washington - Harborview Medical Center, Seattle, Washington, USA
| | - Debra Marvel
- PREVENT CLOT Stakeholder Committee, Baltimore, Maryland, USA
| | - Renan C Castillo
- METRC Coordinating Center, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
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