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Bocea BA, Catrina BI, Roman MD, Ion NCI, Fleaca SR, Mohor CI, Raluca AO, Moga SI, Mihaila RG. Incidence of Subclinical Deep Vein Thrombosis after Total Hip and Knee Arthroplasty Is Not Correlated with Number of Tranexamic Acid Doses. J Clin Med 2024; 13:3834. [PMID: 38999401 PMCID: PMC11242633 DOI: 10.3390/jcm13133834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2024] [Revised: 06/23/2024] [Accepted: 06/26/2024] [Indexed: 07/14/2024] Open
Abstract
Background: Recent studies increasingly highlight the efficacy of tranexamic acid administration in total hip arthroplasty (THA) and total knee arthroplasty (TKA). However, the optimal dosage of tranexamic acid is still controversial. Methods: The current study analyzes the efficiency of tranexamic acid dosage and the number of administrations in THA and TKA. The objective of this study is to compare the incidence of deep vein thrombosis (DVT) based on the number of dosages. We divided the patients into two groups; one group received a single dosage, and the other group received two dosages. Doppler ultrasound examinations were conducted on the lower limbs of all patients at both six and thirty days postoperatively. The second objective is to compare the decrease in hemoglobin (Hb) in the two groups. Results: The results show that there is no difference in DVT incidence between the patients with different TXA numbers of dosages. There is no statistically significant decrease in Hb between the two groups at day one and day five postoperatively. Day one shows a statistically higher average in the two-dose group, approximately 0.06 g/dL, and day five shows a slightly elevated average in the single-dose group, approximately 0.06 g/dL. Blood transfusion requirements show no significant differences in the groups; one patient in the single-dose tranexamic acid group needed transfusion at day five postoperatively, while two patients in each group required immediate postoperative transfusion. Conclusion: There was no increase in the incidence of deep vein thrombosis among patients receiving two dosages of tranexamic acid.
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Affiliation(s)
- Bogdan-Axente Bocea
- Faculty of Medicine Sibiu, Lucian Blaga University, Str. Lucian Blaga Nr. 2A, 550169 Sibiu, Romania; (B.-A.B.); (N.C.I.I.); (S.R.F.); (C.-I.M.); (A.O.R.); (R.G.M.)
- County Clinical Emergency Hospital, 550245 Sibiu, Romania;
| | - Bianca-Iulia Catrina
- Faculty of Medicine Sibiu, Lucian Blaga University, Str. Lucian Blaga Nr. 2A, 550169 Sibiu, Romania; (B.-A.B.); (N.C.I.I.); (S.R.F.); (C.-I.M.); (A.O.R.); (R.G.M.)
- County Clinical Emergency Hospital, 550245 Sibiu, Romania;
| | - Mihai-Dan Roman
- Faculty of Medicine Sibiu, Lucian Blaga University, Str. Lucian Blaga Nr. 2A, 550169 Sibiu, Romania; (B.-A.B.); (N.C.I.I.); (S.R.F.); (C.-I.M.); (A.O.R.); (R.G.M.)
- County Clinical Emergency Hospital, 550245 Sibiu, Romania;
| | - Nicolas Catalin Ionut Ion
- Faculty of Medicine Sibiu, Lucian Blaga University, Str. Lucian Blaga Nr. 2A, 550169 Sibiu, Romania; (B.-A.B.); (N.C.I.I.); (S.R.F.); (C.-I.M.); (A.O.R.); (R.G.M.)
- County Clinical Emergency Hospital, 550245 Sibiu, Romania;
| | - Sorin Radu Fleaca
- Faculty of Medicine Sibiu, Lucian Blaga University, Str. Lucian Blaga Nr. 2A, 550169 Sibiu, Romania; (B.-A.B.); (N.C.I.I.); (S.R.F.); (C.-I.M.); (A.O.R.); (R.G.M.)
- County Clinical Emergency Hospital, 550245 Sibiu, Romania;
| | - Cosmin-Ioan Mohor
- Faculty of Medicine Sibiu, Lucian Blaga University, Str. Lucian Blaga Nr. 2A, 550169 Sibiu, Romania; (B.-A.B.); (N.C.I.I.); (S.R.F.); (C.-I.M.); (A.O.R.); (R.G.M.)
- County Clinical Emergency Hospital, 550245 Sibiu, Romania;
| | - Antonescu Oana Raluca
- Faculty of Medicine Sibiu, Lucian Blaga University, Str. Lucian Blaga Nr. 2A, 550169 Sibiu, Romania; (B.-A.B.); (N.C.I.I.); (S.R.F.); (C.-I.M.); (A.O.R.); (R.G.M.)
- County Clinical Emergency Hospital, 550245 Sibiu, Romania;
| | | | - Romeo Gabriel Mihaila
- Faculty of Medicine Sibiu, Lucian Blaga University, Str. Lucian Blaga Nr. 2A, 550169 Sibiu, Romania; (B.-A.B.); (N.C.I.I.); (S.R.F.); (C.-I.M.); (A.O.R.); (R.G.M.)
- County Clinical Emergency Hospital, 550245 Sibiu, Romania;
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Statistical Fragility of Venous Thromboembolism Prophylaxis Following Total Joint Arthroplasty. Arthroplast Today 2023; 20:101111. [PMID: 36923060 PMCID: PMC10008837 DOI: 10.1016/j.artd.2023.101111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Revised: 12/25/2022] [Accepted: 01/22/2023] [Indexed: 03/18/2023] Open
Abstract
Background Statistical fragility is a quantitative measure of the robustness of the statistical conclusions drawn in a study. Although statistical fragility has been comprehensively evaluated in the arthroplasty literature, the statistical fragility of large-scale randomized trials evaluating venous thromboembolism (VTE) prophylaxis has not been evaluated. The purpose of this study was to determine the utility of applying the fragility index (FI) and the fragility quotient (FQ) analysis to randomized controlled trials (RCTs) evaluating VTE prophylaxis following total joint arthroplasty. Methods A systematic review was performed by searching multiple databases to identify RCTs that evaluated VTE prophylaxis following total joint arthroplasty from 2000 to 2020. The FI was determined by manipulating each reported dichotomous outcome event until a reversal of significance was appreciated with 2 × 2 contingency tables. The associated FQ was determined by dividing the FI by the sample size. Results Thirty-two RCTs were ultimately included for analysis. The overall FI incorporating all 32 RCTs was only 7 (interquartile range 3-9), suggesting that the reversal of only 7 events is required to change study significance. The associated FQ was determined to be 0.01. Of the RCTs that reported lost-to-follow-up data, the majority of studies had lost-to-follow-up numbers greater than 7. Conclusions Our findings suggest that RCTs evaluating VTE prophylaxis following total hip arthroplasty and total knee arthroplasty may lack statistical stability as few outcome events are required to reverse the significance of outcomes. Future randomized trials should consider reporting FI and FQ along with the P value analysis to provide better context to the integrity of statistical stability.
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Oliveira GBF, Neves PDMM, Oliveira HA, Catarino DGM, Alves LBO, Cavalcanti AB, Rosa RG, Veiga VC, Azevedo LC, Berwanger O, Lopes RD, Avezum Á. Rivaroxaban in Outpatients with Mild or Moderate COVID-19: Rationale and Design of the Study CARE (CARE - Coalition COVID-19 Brazil VIII). Arq Bras Cardiol 2023; 120:e20220431. [PMID: 37018790 PMCID: PMC10392853 DOI: 10.36660/abc.20220431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 10/28/2022] [Accepted: 11/23/2022] [Indexed: 04/07/2023] Open
Abstract
BACKGROUND Previous studies have demonstrated a high risk of arterial and venous thromboembolic events as a consequence of direct viral damage to endothelial cells by SARS-CoV-2 and a procoagulant milieu due to increased biomarkers, such as D-dimer, fibrinogen, and factor VIII. Although randomized controlled trials of antithrombotic therapies have been conducted in hospitalized patients, few have evaluated the role of thromboprophylaxis in an outpatient setting. OBJECTIVE To assess whether antithrombotic prophylaxis with rivaroxaban reduces the risk of venous or arterial thrombotic events, invasive ventilatory support, and death in COVID-19 outpatients. METHODS The COVID Antithrombotic Rivaroxaban Evaluation (CARE) study, a multicenter, randomized, open-label, controlled trial of rivaroxaban 10 mg once daily for 14 days or local standard treatment alone to prevent adverse outcomes, is registered in clinicaltrials.gov (NCT04757857). The inclusion criteria are adults with confirmed or suspected SARS-CoV-2 infection and mild or moderate symptoms without indication for hospitalization, within 7 days of symptom onset, and 1 risk factor for COVID-19 complication (> 65 years, hypertension, diabetes mellitus, asthma, chronic obstructive pulmonary disease or other chronic lung diseases, smoking, immunosuppression, or obesity). The primary composite endpoint, which includes venous thromboembolism, invasive mechanical ventilation, major acute cardiovascular events, and mortality within 30 days of randomization, will be assessed according to the intention-to-treat principle. All patients will provide informed consent. A significance level of 5% will be used for all statistical tests. RESULTS Major thrombotic and bleeding outcomes, hospitalizations, and deaths will be centrally adjudicated by an independent clinical events committee blinded to the assigned treatment groups. CONCLUSION The CARE study will provide relevant and contemporary information about the potential role of thromboprophylaxis in outpatients with COVID-19.
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Affiliation(s)
- Gustavo B. F. Oliveira
- Centro Internacional de PesquisaHospital Alemão Oswaldo CruzSão PauloSPBrasilCentro Internacional de Pesquisa, Hospital Alemão Oswaldo Cruz, São Paulo, SP – Brasil
| | - Precil Diego M. M. Neves
- Centro Internacional de PesquisaHospital Alemão Oswaldo CruzSão PauloSPBrasilCentro Internacional de Pesquisa, Hospital Alemão Oswaldo Cruz, São Paulo, SP – Brasil
| | - Haliton A. Oliveira
- Centro Internacional de PesquisaHospital Alemão Oswaldo CruzSão PauloSPBrasilCentro Internacional de Pesquisa, Hospital Alemão Oswaldo Cruz, São Paulo, SP – Brasil
| | - Daniela Ghidetti Mangas Catarino
- Centro Internacional de PesquisaHospital Alemão Oswaldo CruzSão PauloSPBrasilCentro Internacional de Pesquisa, Hospital Alemão Oswaldo Cruz, São Paulo, SP – Brasil
| | - Lucas B. O. Alves
- Centro Internacional de PesquisaHospital Alemão Oswaldo CruzSão PauloSPBrasilCentro Internacional de Pesquisa, Hospital Alemão Oswaldo Cruz, São Paulo, SP – Brasil
| | - Alexandre B. Cavalcanti
- Instituto de PesquisasHCORSão PauloSPBrasilInstituto de Pesquisas HCOR, São Paulo, SP – Brasil
| | - Regis G. Rosa
- Hospital Moinhos de VentoPorto AlegreRSBrasilHospital Moinhos de Vento, Porto Alegre, RS – Brasil
| | - Viviane C. Veiga
- A Beneficência Portuguesa de São PauloSão PauloSPBrasilA Beneficência Portuguesa de São Paulo, São Paulo, SP – Brasil
| | - Luciano C.P. Azevedo
- Hospital Sírio LibanêsInstituto de Pesquisa e EnsinoSão PauloSPBrasilHospital Sírio Libanês – Instituto de Pesquisa e Ensino, São Paulo, SP – Brasil
| | - Otávio Berwanger
- Hospital Israelita Albert EinsteinSão PauloSPBrasilHospital Israelita Albert Einstein, São Paulo, SP – Brasil
| | - Renato D. Lopes
- Duke UniversityMedical CenterDurhamNCEUADuke University Medical Center, Durham, NC – EUA
- Instituto Brasileiro de Pesquisas ClínicasSão PauloSPBrasilInstituto Brasileiro de Pesquisas Clínicas, São Paulo, SP – Brasil
| | - Álvaro Avezum
- Centro Internacional de PesquisaHospital Alemão Oswaldo CruzSão PauloSPBrasilCentro Internacional de Pesquisa, Hospital Alemão Oswaldo Cruz, São Paulo, SP – Brasil
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Yi YH, Gong S, Gong TL, Zhou LY, Hu C, Xu WH. New Oral Anticoagulants for Venous Thromboembolism Prophylaxis in Total Hip and Knee Arthroplasty: A Systematic Review and Network Meta-Analysis. Front Pharmacol 2022; 12:775126. [PMID: 35111051 PMCID: PMC8801787 DOI: 10.3389/fphar.2021.775126] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Accepted: 11/26/2021] [Indexed: 11/29/2022] Open
Abstract
Background: There is controversy over whether use of new oral anticoagulants (NOACs) associates with increased hemorrhage risk compared with non-NOAC. Meanwhile, determining which NOAC to use remains unclear. We aimed to summarize the evidence about NOACs in venous thromboembolism (VTE) prevention for patients with total hip and knee arthroplasty (THA and TKA). Methods: We searched RCTs assessing NOACs for VTE prophylaxis in adults undergoing THA and TKA in Medline, Embase, and Cochrane up to May 2021. Primary outcomes were VTE [included deep vein thrombosis (DVT) and pulmonary embolism (PE)], major VTE, and major bleeding. The rank probabilities of each treatment were summarized by the surface under the cumulative ranking curve area (SUCRA). Results: 25 RCTs with 42,994 patients were included. Compared with non-NOAC, NOACs were associated with a decreased risk of VTE (RR 0.68; 95% CI 0.55–0.84) and major VTE (RR = 0.52; 95% CI 0.35–0.76). Additionally, rivaroxaban, apixaban, and edoxaban but not dabigatran and betrixaban, did confer a higher efficacy compared with non-NOAC. None of the individual NOACs increased the risk of bleeding, while apixaban and betrixaban were even associated with a decreased risk of bleeding. In the comparison of different NOACs, rivaroxaban was associated with the greatest benefits in VTE (SUCRA = 79.6), DVT (SUCRA = 88.8), and major VTE (SUCRA = 89.9) prevention. Furthermore, subgroup analysis confirmed that NOACs associated with a higher efficacy tendency in patients with follow-up duration <60 days than follow-up duration ≥60 days. Conclusion: Evidence suggests that NOACs exert more benefits on VTE prophylaxis, and none of the individual NOACs increased hemorrhage compared with non-NOAC. Among various NOACs, rivaroxaban is recommended in patients with lower bleeding risk, and apixaban is recommended in patients with higher bleeding risk. Systematic Review Registration: [https://www.crd.york.ac.uk/prospero/], identifier [CRD42021266890].
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Affiliation(s)
- Yi-Hu Yi
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Song Gong
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Tian-Lun Gong
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ling-Yun Zhou
- Department of Pharmacy, Third Xiangya Hospital, Central South University, Changsha, China
| | - Can Hu
- Department of Pharmacy, Third Xiangya Hospital, Central South University, Changsha, China
| | - Wei-Hua Xu
- Department of Orthopaedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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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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