Postorthopedic Surgery Joint Replacement Surgery Venous Thromboembolism Prophylaxis

Use of Fondaparinux Following Elective Lumbar Spine Surgery Is Associated With a Reduction in Symptomatic Venous Thromboembolism

STUDY DESIGN

Retrospective cohort study.

OBJECTIVE

To assess the impact of fondaparinux on venous thromboembolism (VTE) following elective lumbar spine surgery in high-risk patients.

METHODS

Matched patient cohorts who did or did not receive inpatient fondaparinux starting postoperative day 2 following elective lumbar spine surgery were compared. All patients received 1 month of acetyl salicylic acid 325 mg following discharge. The primary outcome was a symptomatic DVT (deep vein thrombosis) or PE (pulmonary embolus) within 30 days of surgery. Secondary outcomes included prolonged wound drainage, epidural hematoma, and transfusion.

RESULTS

A significantly higher number of DVTs were diagnosed in the group that did not receive inpatient VTE prophylaxis (3/102, 2.9%) compared with the fondaparinux group (0/275, 0%, P = .02). Increased wound drainage was seen in 18.5% of patients administered fondaparinux, compared with 25.5% of untreated patients (P = .15). Deep infections were equivalent (2.2% with fondaparinux vs 4.9% control, P = .18). No epidural hematomas were noted, and the number of transfusions after postoperative day 2 and 90-day return to operating room rates were equivalent.

CONCLUSIONS

Patients receiving fondaparinux had lower rates of symptomatic DVT and PE and a favorable complication profile when compared with matched controls. The retrospective nature of this work limits the safety and efficacy claims that can be made about the use of fondaparinux to prevent VTE in elective lumbar spine surgery patients. Importantly, this work highlights the potential safety of this regimen, permitting future high-quality trials.

A patient with shortness of breath after total hip replacement

Clinical presentation of pulmonary embolism (PE) frequently is nonspecific, making patient evaluation and diagnosis challenging. Clinicians must be alert for signs and symptoms of PE in patients with risk factors and have a low threshold for ordering appropriate imaging and laboratory tests. Initial treatment concentrates on patient oxygenation and stabilization; further management of PE depends on the patient's hemodynamic stability and right ventricular strain. This article focuses on a minimally symptomatic patient with a history of hip fracture and total hip replacement who was found to have a saddle PE.

A comparison of apixaban and dabigatran etexilate for thromboprophylaxis following hip and knee replacement surgery

INTRODUCTION

Patients who have undergone hip or knee replacement surgery are exposed to a high risk of developing a post-operative venous thromboembolus and so have a need for an effective, medication-based, thrombosis prophylaxis. New orally active anticoagulants have been available for a few years now. These specific substances directly block either thrombin (e.g., dabigatran etexilate) or Factor Xa (e.g., apixaban). It is not clear whether there are any efficacy differences between these two substances because there have never been any head-to-head studies carried out.

MATERIALS AND METHODS

We have carried out a study comparing two new orally active anticoagulants dabigatran etexilate (Pradaxa^®) and apixaban (Eliquis^®) that were each given to two groups of 200 patients respectively, who had undergone elective hip or knee arthroplasty (100 each). Each patient was assessed for pre- and post-operative hemoglobin concentrations, post-operative blood loss, the number of transfused erythrocyte concentrates, the duration of wound secretion, clinical thromboembolic complications (deep vein thrombosis, pulmonary embolism, myocardial infarct), as well as gastrointestinal, intracranial or wound-related bleeding complications.

RESULTS

Dabigatran etexilate treatment led to a significant increase in the duration of wound secretion in both arthroplasty groups when compared to apixaban: wound secretion lasted 1.2 days longer on average in the dabigatran etexilate group than in the apixaban group (4.1 ± 2.1 vs. 2.9 ± 1.8 days). There were no significant differences observed between the two anticoagulant groups when comparing pre- and post-operative Hb values, post-operative blood loss and the other clinical parameters.

CONCLUSIONS

Thus, it appears that the direct thrombin inhibitor, dabigatran etexilate, is associated with a longer period of wound secretion following the implantation of hip and knee endoprostheses than that associated with the Factor Xa inhibitor, apixaban.