The risk factor of preoperative deep vein thrombosis in patients undergoing total knee arthroplasty

Establishment and validation of a nomogram predicting the risk of deep vein thrombosis before total knee arthroplasty

PURPOSE

This study aimed to analyze the independent risk factors contributing to preoperative DVT in TKA and constructed a predictive nomogram to accurately evaluate its occurrence based on these factors.

METHODS

The study encompassed 496 patients who underwent total knee arthroplasty at our hospital between June 2022 and June 2023. The dataset was randomly divided into a training set (n = 348) and a validation set (n = 148) in a 7:3 ratio. The least absolute shrinkage and selection operator (LASSO) and multivariate logistic regression analysis were used to screen the predictors of preoperative DVT occurrence in TKA and construct a nomogram. The performance of the predictive models was evaluated using the concordance index (C-index), calibration curves, and the receiver operating characteristic (ROC) curves. Decision curve analysis was used to analyze the clinical applicability of nomogram.

RESULTS

A total of 496 patients who underwent TKA were included in this study, of which 28 patients were examined for lower extremity DVT preoperatively. Platelet crit, Platelet distribution width, Procalcitonin, prothrombin time, and D-dimer were predictors of preoperative occurrence of lower extremity DVT in the nomograms of the TKA patients. In addition, the areas under the curve of the ROC of the training and validation sets were 0.935 (95%CI: 0.880-0.990) and 0.854 (95%CI: 0.697-1.000), and the C-indices of the two sets were 0.919 (95%CI: 0.860-0.978) and 0.900 (95%CI: 0.791-1.009). The nomogram demonstrated precise risk prediction of preoperative DVT occurrence in TKA as confirmed by the calibration curve and decision curve analysis.

CONCLUSIONS

This Nomogram demonstrates great differentiation, calibration and clinical validity. By assessing individual risk, clinicians can promptly detect the onset of DVT, facilitating additional life monitoring and necessary medical interventions to prevent the progression of DVT effectively.

Preoperative risk factors for deep vein thrombosis in knee osteoarthritis patients undergoing total knee arthroplasty

BACKGROUND

To analyze the risk factors for preoperative deep vein thrombosis (DVT) in knee osteoarthritis (OA) patients undergoing total knee arthroplasty (TKA).

METHODS

In this retrospective study, a total of 584 knee OA patients undergoing TKA were enrolled. General information, medical records and preoperative laboratory examination results of the patients were collected. According to the results of Doppler ultrasonography for the lower extremities, the patients were divided into DVT group and non-DVT group. Univariate and multivariate logistic regression were used to identify independent risk factors for preoperative DVT in knee OA patients undergoing TKA.

RESULTS

The incidence of DVT before TKA was 6.85% (40 cases). The increase of ESR (Erythrocyte Sedimentation Rate), platelet crit, IL-6 (Interleukin-6), and PCT (Procalcitonin) were associated with the development of DVT before TKA. Factors as coronary heart disease (CHD), diabetes mellitus (DM), Chronic Kidney Disease (CKD), NLR (ratio of neutrophils to lymphocytes), lower limb venous blood stasis, the time from onset to admission, RBC, PLT were identified by multivariate logistic regression to be the independent risk factors for preoperative DVT in knee OA patients undergoing TKA.

CONCLUSIONS

DM, CKD, CHD, increased in ESR, IL-6 and PCT, blood stasis of the lower extremities, increased in PLT, platelet crit and the time from onset to admission, decreased in RBC, were high risk factors for preoperative DVT in knee OA patients undergoing TKA.

The application of Caprini Risk Assessment Model in evaluation of deep vein thrombosis for patients with end-stage osteoarthritis before arthroplasty

Background

Deep vein thrombosis (DVT) was a fatal complication of knee arthroplasty. We had neglected the risk factors of preoperative DVT although patients undergoing knee arthroplasty were at high risk for VTE. This study was to determine the risk factors for preoperative DVT and application of Caprini Risk Assessment Model (RAM) in patients with end-stage knee osteoarthritis (OA).

Methods

We retrospectively analyzed 1808 cases with end-stage knee OA undergoing primary knee arthroplasty from May 2015 to December 2020. Based on the results of ultrasonography in lower extremities, all patients were divided into non-DVT group and DVT group. Distribution of risk factors and risk levels were compared using χ² test between two groups. Binary logistic regression analysis was used to determine the risk factors and relationship of risk levels and preoperative DVT.

Results

The incidence of preoperative DVT was 5.53% (n = 100). Distribution of the study population by risk level was low, 4.09%; moderate, 23.95%; high, 66.98%; and highest 4.98%. Female (P = 0.002), age (P = 0.012), swollen legs (P = 0.035) and history of blood clots (P < 0.001) was correlated with preoperative DVT. Difference among four risk levels was significant (P = 0.007). Patients with highest risk level had statistically significant association with preoperative DVT (P = 0.005, OR = 2.93, 95%CI [1.375–6.246]).

Conclusion

The incidence of preoperative DVT was 5.53% in end-stage knee OA patients. The gender (female) and age were independent risk factors for preoperative DVT. The risk group classification by Caprini RAM was significantly associated with preoperative DVT. The usage of Caprini RAM before knee arthroplasty may be beneficial for prophylaxis of DVT.

Lower-Extremity Venous Ultrasound in DVT-Unlikely Patients with Positive D-Dimer Test

RATIONALE AND OBJECTIVES

To review the clinical data, D-dimer level and the ultrasonographic findings from complete venous ultrasound of the lower extremity in deep venous thrombosis (DVT)-unlikely patients with abnormal D-dimer test were compared to DVT-likely patients to ascertain the appropriate ultrasound examination protocol for patients in this group.

MATERIAL AND METHODS

A retrospective cohort study was conducted of all patients who underwent a complete (whole leg) venous ultrasound in one 13-month period. The medical history, demographic, clinical risk factors, and ultrasonographic findings of the patients with high clinical probability for deep vein thrombosis (Wells score ≥2), along with patients with a low clinical probability of deep vein thrombosis (Wells score ≤1) but with a D-dimer level higher than the threshold (≥500 ng/ml FEU) were evaluated.

RESULTS

There were 96 patients in the DVT-likely group and 86 patients in the DVT-unlikely group. The indication for ultrasound examination in the DVT-unlikely group was preoperative assessment to avoid the risk of pulmonary thromboembolism. The patients in the DVT-likely group had more positive ultrasound results for DVT (15.63% vs. 5.18%, p value = 0.03) than the patients in the DVT-unlikely group. In the DVT-unlikely group, the median D-dimer level in the patients with positive ultrasound for DVT showed statistically significantly higher levels than the patients with negative ultrasound for DVT did (2208 vs. 921 ng/ml FEU, p value = 0.02). The optimal D-dimer cut-off from the receiver operating characteristics analysis shows the maximized summation of sensitivity and specificity (80% and 66.67%) at 1251 ng/ml FEU. The prevalence of acute thrombus in a thigh vein in DVT-unlikely, preoperative patients is low (1.2%).

CONCLUSION

To minimize the number of unnecessary complete venous ultrasound lower-extremity examinations, the use of a higher D-dimer cut-off level and limiting proximal or thigh vein ultrasound examinations in the preoperative patient is considered.

Peri-Articular Injection of Tranexamic Acid Reduce Blood Loss and Transfusion Requirement During Total Knee Arthroplasty: A Meta-analysis

Background

The aim of this meta-analysis was to evaluate the efficacy and safety of peri-articular injection of tranexamic acid (TXA) during total knee arthroplasty (TKA) from clinical controlled trials.

Method

Eligible scientific articles published prior to October 2021 were retrieved from the PubMed, Springer, ScienceDirect and Cochrane Library databases. The statistical analysis was performed with RevMan 5.1.

Result

2 RCTs and 3 non-RCTs met the inclusion criteria. Meta-analysis showed significant differences in terms of hemoglobin reduction (MD = -1.04, 95% CI: -1.33 to -.76, P < .00001), total blood loss (MD = -342.80.70, 95% CI: -437.52 to -248.08, P < .00001), drainage volume (MD = -297.24, 95% CI: -497.26 to -97.23, P = .004) and blood transfusion rate (OR = .30, 95% CI: .14 to .62, P = .001) were found in the control group. No postoperative infection and deep venous thrombosis were found between 2 groups.

Conclusion

Peri-articular injection of TXA can effectively decrease perioperative blood loss and blood transfusion rate without increasing the incidence of postoperative complications during TKA.

Effect of Comorbidity Burden on the Risk of Venous Thromboembolic Events After Total Knee Arthroplasty

Background

Venous thromboembolic events (VTEs) are common after total knee arthroplasty (TKA). The rate of VTEs has improved with early mobilization, mechanical prophylaxis, and appropriate chemoprophylaxis. The aim of this study was to analyze the contribution of medical comorbidities to the risk of VTE after TKA

Method

Medicare claims from 2005 to 2014 were queried. International Classification of Diseases, Ninth revision (ICD-9), and Current Procedural Terminology codes were used to identify the diagnoses, procedures, and complications. 157,200 primary TKAs were age, sex, and Elixhauser Comorbidity Index (ECI) matched with 157,200 osteoarthritis controls. First instances of deep venous thrombosis (DVT) and pulmonary embolism were tracked at 90 days and 2 years. Odds ratios (ORs), confidence intervals, and P-values (p) were calculated and used to investigate the contribution of comorbidities.

Results

90 days after TKA or OA diagnosis, comorbidities were associated with 45% of the DVT risk, 38% of the PE risk. 1 in 92 patients would be expected to be diagnosed with VTE after TKA and 1 in 136 patients after only the diagnosis of osteoarthritis. After 90 days, medical comorbidities were associated with 70% of the DVT risk, 68% of the PE risk.

Conclusion

Nearly 50% of DVTs and 40% of PEs within 90 days of TKA may be related to the baseline health of OA patients. Venous thromboembolic events after TKA are a “never” event according to Center of Medicare and services that appropriate VTE prophylaxis likely cannot be neutralized.

Effectiveness of apixaban versus enoxaparin in preventing wound complications and deep venous thrombosis following total knee replacement surgery: A retrospective study

BACKGROUND

Enoxaparin, a thromboprophylactic drug that is widely used for preventing deep venous thrombosis (DVT) and surgical wound complications after total knee replacement surgery, can only be administered subcutaneously. Apixaban, a novel factor Xa inhibitor that could be comparable to enoxaparin, is an oral formulation and thus would be easier to manage.

OBJECTIVE

To compare the thromboprophylactic effectiveness of apixaban and enoxaparin in patients receiving total knee replacements.

METHODS

In this retrospective, single-institution study, the records of 200 patients who underwent elective total knee replacement surgery were reviewed. Of those, 120 patients had received enoxaparin 4000 IU daily (initiated 6 hours before surgery), whereas 80 had received apixaban 2.5 mg twice daily (initiated 12 hours after surgery), for 21 days. All patients were examined for major and minor surgical wound complications and DVT incidence during their hospital stay and 7-21 days after surgery.

RESULTS

No statistically significant differences (P ≥ .005) were found between the apixaban and enoxaparin groups with regard to minor and major surgical wound complications and DVT incidence. Patients in both groups were comparable in terms of age, hospital stay, and required blood transfusion units. Two enoxaparin-treated patients and one apixaban-treated patient developed DVT (1.5%) during the study period.

CONCLUSION

Oral apixaban is an effective alternative to enoxaparin as a thromboprophylactic drug for patients undergoing elective total knee replacement surgery.

No difference in the incidence or location of deep venous thrombosis according to use of pharmacological prophylaxis following total knee arthroplasty

Background

The incidence and characteristics of deep vein thrombosis (DVT) following total knee arthroplasty (TKA) without pharmacologic prophylaxis have not been fully investigated. This study aimed to determine whether there are any differences in the incidence, location, and characteristics of DVT following TKA with pharmacologic prophylaxis and without pharmacologic prophylaxis.

Methods

A total of 156 knees were retrospectively evaluated for DVT following TKA by duplex ultrasound on postoperative day 7, after excluding 60 knees from 216 consecutive knees because of antiplatelet or anticoagulant use before surgery, history of venous thromboembolism, or bleeding risk. The 156 knees included in the analysis were divided into two groups: with pharmacologic prophylaxis (n = 79) and without pharmacologic prophylaxis (n = 77).

Results

The overall incidence of DVT was 34% (54/156 knees). DVT was detected in 31.6% of knees with pharmacologic prophylaxis and in 37.6% of knees without pharmacologic prophylaxis; the difference was not statistically significant. Soleal vein thrombus was observed in 74.6% of the knees with DVT and non-floating thrombus was observed in 98.7%. There were no obvious between-group differences in thrombus characteristics such as compressibility, echogenicity, mean vein diameter, and whether the thrombus was attached to the vein wall or free-floating.

Conclusions

No differences were found in the incidence, location, or characteristics of DVT following TKA with or without pharmacological prophylaxis.

Perioperative prevalence of deep vein thrombosis in patients with percutaneous kyphoplasty: A retrospective study with routine ultrasonography

In recent years, deep venous thrombosis (DVT) after spine surgery has received extensive attention, but perioperative prevalence of DVT in patients undergoing percutaneous kyphoplasty (PKP) is lacking.To assess the perioperative prevalence of deep vein thrombosis (DVT) in patients undergoing PKP with routinely applied ultrasonography.We reviewed 1113 consecutive patients undergoing PKP from January 2014 to August 2017. The surgical procedure was bilateral PKP. All patients were routinely examined with ultrasonography when admitted to the hospital and on the first post-operative day. Clinical signs of DVT were checked and recorded before examination.Forty (3.6%) out of 1113 patients were diagnosed with DVT by ultrasonography. Of the 40 detected cases of DVT, only six (0.54%) patients presented with clinical signs of DVT, demonstrating that there were 34 (3.05%) asymptomatic cases. No patient presenting with clinically suspected pulmonary embolism (PE) was observed. Gender, body mass index (BMI), operative time, hypertension, diabetes, heart disease, and lower limb fracture were not significant risk factors for DVT (P > .05). In contrast, patient age, oncologic conditions, DVT history, and paraplegia appeared to be significant risk factors for DVT (P < .01). There was no significant difference in the incidence of DVT found between the three PKP surgical levels (P > .05).The total incidence of perioperative DVT diagnosed with ultrasonography in patients undergoing PKP was 3.6%, of which only 0.54% was symptomatic cases. It is necessary to assess DVT using ultrasonography during the perioperative procedure of PKP, especially for high-risk patients.Level of evidence: Level IV.

Prevalence and Risk Factors of Preoperative Deep Vein Thrombosis in Patients with End-Stage Knee Osteoarthritis

BACKGROUND

The purpose of this study is to determine the prevalence and the risk factors of DVT in end-stage OA patients.

METHODS

From March 2015 to June 2017, 521 patients with knee degenerative osteoarthritis undergoing knee arthroplasty were enrolled; 458 patients (87.9%) were admitted for primary total knee arthroplasty and 63 patients (12.1%) were admitted for unicompartmental knee arthroplasty. Parameters were compared using χ² or t-test for both the groups. Binary logistic regression analysis was used to determine risk factors.

RESULTS

The incidence of preoperative DVT was 6.7% (n = 35). Age in preoperative DVT group was significantly more than the non-DVT group (72.54 ± 6.53 vs. 68.65 ± 7.35, P = 0.002). Preoperative D-dimer >0.5 μg/mL (P < 0.001) was also associated with preoperative DVT in knee osteoarthritis patients. The incidence increased with age significantly (2.17% in <65 years, 6.86% in ≥65 <75 years, and 12.26% in ≥75 years) (P = 0.008). Thus, age (P = 0.041, OR 1.075, 95% CI [1.002-1.110]) and D-dimer >0.5 μg/mL (P < 0.001, OR 4.441, 95% CI [1.942-10.153]) were the independent risk factors for preoperative DVT in knee osteoarthritis patients.

CONCLUSIONS

The incidence of DVT in end-stage osteoarthritis was 6.7%. The results suggest that older people aged over 75 and D-dimer > 0.5 μg/mL were risk factors for DVT among patients admitted to the hospital for total knee arthroplasty. Instrumental screening should be encouraged, especially in subgroups at higher risk for preoperative DVT.

Comparison of Apixaban and Low Molecular Weight Heparin in Preventing Deep Venous Thrombosis after Total Knee Arthroplasty in Older Adults

PURPOSE

To compare the effect of apixaban and low molecular weight heparin (LMWH) in the prevention and treatment of deep venous thrombosis (DVT) after total knee arthroplasty in older adult patients.

MATERIALS AND METHODS

A total of 220 patients (average age of 67.8±6.4 years) undergoing total knee arthroplasty were randomly selected as research subjects and were divided into apixaban and LMWH groups (110 in each group).

RESULTS

The incidence of DVT was lower in the apixaban group than in the LMWH group (5.5% vs. 20.0%, p=0.001). Activated partial thromboplastin times (35.2±3.6 sec vs. 33.7±2.2 sec, p=0.010; 37.8±4.6 sec vs. 34.1±3.2 sec, p<0.001; 39.6±5.1 sec vs. 35.7±3.0 sec, p=0.032) and prothrombin times (14.0±1.0 sec vs. 12.8±0.9 sec, p<0.001; 14.5±1.2 sec vs. 13.0±1.1 sec, p<0.001; 15.3±1.4 sec vs. 13.2±1.3 sec, p=0.009) in the apixaban group at 1 week after surgery, 3 weeks after surgery, and the end of treatment were higher than those in the LMWH group. Platelet and fibrinogen levels in the apixaban group were lower than those of the LMWH group. Also, capillary plasma viscosity and erythrocyte aggregation in the apixaban group at 1 week after surgery, 3 weeks after surgery, and the end of treatment were lower than those in the LMWH group.

CONCLUSION

Apixaban, which elicits fewer adverse reactions and is safer than LMWH, exhibited better effects in the prevention and treatment of DVT after total knee arthroplasty in older adults.

The Role of Intraoperative Intermittent Pneumatic Compression Devices in Venous Thromboembolism Prophylaxis in Total Hip and Total Knee Arthroplasty

Venous thromboembolism (VTE) is a common complication after total hip arthroplasty (THA) and total knee arthroplasty (TKA), occurring in up to 85% of patients who are not treated with prophylaxis. The initiation of VTE development may occur intraoperatively. This study investigated whether this gap in VTE prophylaxis can be addressed by the use of intraoperative intermittent pneumatic compression devices (IPCDs) and if intraoperative IPCDs have a meaningful benefit in preventing symptomatic VTE. The authors defined symptomatic VTE as deep venous thrombosis in either lower extremity or a pulmonary embolism. The authors evaluated the medical records of 3379 patients who underwent THA or TKA at their institution in 2014 and 2015. Effects of various factors, including age, sex, body mass index, and smoking status, were compared between these 2 cohorts. Patients who experienced a symptomatic VTE were also matched by age, sex, and procedure type with randomly selected controls. In the patient sample, 47 patients (1.4%) developed VTE. Forty (1.2%) of these patients underwent TKA, whereas 7 (0.2%) underwent THA. Venous thromboembolism occurred less frequently in patients who received intraoperative IPCDs (0.8%) than in patients who did not receive them (1.5%); however, this difference did not reach statistical significance. Total knee arthroplasty was associated with increased odds of VTE compared with THA, as was female sex. These results did not show a statistically significant benefit to the intraoperative use of IPCDs. Pneumatic compression remains a fast, easy, low-cost, low-risk, intuitive intervention that can supplement the postoperative multimodal approach and is worthy of further study. Intraoperative IPCD use should be considered for patients with a higher risk of VTE. [Orthopedics. 2018; 41(1):e98-e103.].