Effectiveness and safety of different duration of thromboprophylaxis in 16,865 hip replacement patients--a real-word, prospective observational study

Validation of registration of pharmacological treatment in the Danish Hip and Knee Arthroplasty Registers

The aim of this study was to validate registration of pharmacological treatment in the Danish Hip Arthroplasty Register (DHR) and Danish Knee Arthroplasty Register (DKR). We conducted a population-based study in the Capital Region of Denmark, January 2012 to April 2016. Positive predictive value (PPV) and sensitivity were calculated with 95% confidence intervals (CI) for antithrombotic, antihemorrhagic and antibiotic treatment registered in the DHR and DKR using electronic health records as the reference standard. For the DHR, the PPV and sensitivity were 77.9% (95% CI: 77.2-78.6) and 99.6% (95% CI: 99.4-99.7) for antithrombotic treatment, 70.9% (95% CI: 70.1-71.7) and 97.4% (95% CI: 97.1-97.7) for antihemorrhagic treatment, and 82.9% (95% CI: 82.2-83.5) and 99.4% (95% CI: 99.3-99.5) for antibiotic treatment, respectively. For the DKR, the PPV and sensitivity were 80.6% (95% CI: 79.8-81.4) and 99.6% (95% CI: 99.4-99.7) for antithrombotic treatment, and 84.4% (95% CI: 83.7-85.1) and 100.0% (95% CI: 99.9-100.0) for antibiotic treatment, respectively. The PPV and sensitivity for overall pharmacological treatment registered in the DHR and DKR were generally high and acceptable for use in research.

Association of CHA2 DS2 -VASc Score with Stroke, Thromboembolism, and Death in Hip Fracture Patients

OBJECTIVES

Patients undergoing hip fracture surgery have a 10 times increased risk of stroke compared with the general population. We aimed to evaluate the association between the CHA₂ DS₂ -VASc (congestive heart failure, hypertension, age ≥75 years, diabetes, previous stroke/TIA [transient ischemic attack]/systemic embolism (2 points), vascular disease, age 65-74 years, and female sex) score and the risk of stroke, thromboembolism, and all-cause mortality in patients with hip fracture with or without atrial fibrillation (AF).

DESIGN

Nationwide prospective cohort study.

SETTING

Danish hospitals.

PARTICIPANTS

Subjects were all incident hip fracture patients in Denmark age 65 years and older with surgical repair procedures between 2004 and 2016 (n = 78,096). Participants were identified using the Danish Multidisciplinary Hip Fracture Registry.

MEASUREMENTS

We calculated incidence rates, cumulative incidences, and hazard ratios (HRs) with 95% confidence intervals (CIs) by CHA₂ DS₂ -VASc score, stratified on AF history.

RESULTS

The cumulative incidence of ischemic stroke 1 year after hip fracture increased with ascending CHA₂ DS₂ -VASc score, and it was 1.9% for patients with a score of 1 and 8.6% for patients with a score above 5 in the AF group. Corresponding incidences in the non-AF group were 1.6% and 7.6%. Compared with a CHA₂ DS₂ -VASc score of 1, adjusted HRs were 5.53 (95% CI = 1.37-22.24) among AF patients and 4.91 (95% CI = 3.40-7.10) among non-AF patients with a score above 5. A dose-response-like association was observed for all cardiovascular outcomes. All-cause mortality risks and HRs were substantially higher for all CHA₂ DS₂ -VASc scores above 1 in both the AF group and the non-AF group.

CONCLUSION

Among patients with hip fracture, a higher CHA₂ DS₂ -VASc score was associated with increased risk of stroke, thromboembolism, and death. This finding applied both to patients with and without AF. Patients with high CHA₂ DS₂ -VASc scores had almost similar absolute risks for cardiovascular outcomes, irrespective of AF. J Am Geriatr Soc 68:1698-1705, 2020.

European guidelines on perioperative venous thromboembolism prophylaxis: Day surgery and fast-track surgery

: In recent years, day surgery and fast-track surgery have experienced a continuous increase in volume. Many procedures are now performed on an outpatient protocol, including general, orthopaedic, oncological, reconstructive or vascular surgery. The management of these patients is safe, but the incidence of venous thromboembolism in this population remains unknown. Several risk factors can be identified and stratified derived from studies of inpatient surgical management (e.g. Caprini score). Recommendations for thromboprophylaxis should be tailored from the assessment of both personal and procedure-related risk factors, although with a lack of evidence for application in outpatient management. For patients undergoing a low-risk procedure without additional risk factors, we recommend only general measures of thromboprophylaxis (early ambulation, optimal hydration) (Grade 1B). For patients undergoing a low-risk procedure with additional risk factors, or a high-risk procedure without additional risk factors, we recommend general measures of thromboprophylaxis (Grade 1B) and we suggest the administration of pharmacological prophylaxis with low molecular weight heparins (Grade 2B). For patients undergoing a high-risk procedure with additional risk factors we recommend general measures of thromboprophylaxis (Grade 1B) and pharmacological prophylaxis with low molecular weight heparins over other drugs (Grade 1B), or suggest specific mechanical measures in case of increased bleeding risk (Grade 2C). Pharmacological prophylaxis should last a minimum of 7 days (Grade 1B), although in selected cases of fast-track surgery, thromboprophylaxis could be limited to hospitalisation only (Grade 2C) and in specific cases of high-risk procedures, thromboprophylaxis could be extended for up to 4 weeks (Grade 2B).

Optimal duration of anticoagulant thromboprophylaxis in total hip arthroplasty: new evidence in 55,540 patients with osteoarthritis from the Nordic Arthroplasty Register Association (NARA) group

Background and purpose - The recommended optimal duration of the thromboprophylaxis treatment in total hip arthroplasty (THA) patients has been a matter of debate for years. We examined the association between short (1-5 days), standard (6-14 days), and extended (≥ 15 days) duration of thromboprophylaxis, with regards to the risk of venous thromboembolism (VTE), major bleeding, and death in unselected THA patients. Patients and methods - We performed a cohort study using prospectively collected data from the population-based hip arthroplasty registries, prescription databases, and patient administrative registries in Denmark and Norway. We included 55,540 primary THA patients with osteoarthritis Results - The 90-day cumulative incidence of VTE was 1.0% for patients with standard treatment (reference), 1.1% for those with short-term treatment (adjusted hazard ratio [aHR] of 1.1, 95% confidence interval (CI) 0.8-1.5) and 1.0% for those with extended treatment (aHR of 0.9, CI 0.8-1.2). The aHRs for major bleeding were 1.1 (CI 0.8-1.6) for short and 0.8 (CI 0.6-1.1) for extended vs. standard treatment. In addition, patients with short and extended treatment had aHRs for death of 1.2 (CI 0.8-1.8) and 0.8 (CI 0.5-1.1) vs. standard treatment, respectively. Patients who started short treatment postoperatively had an aHR for death of 1.8 (CI 1.1-3.1) and absolute risk difference of 0.2%, whereas patients who started short treatment preoperatively had an aHR for death of 0.5 (CI 0.2-1.2) and absolute risk difference of 0.3% compared with patients who had standard treatment with post- and preoperative start, respectively. Interpretation - In routine clinical practice, we observed no overall clinically relevant difference in the risks of VTE and major bleeding within 90 days of THA with respect to thromboprophylaxis duration. However, our data indicate that short-term thromboprophylaxis started postoperatively is associated with increased 90-day mortality. The significance of these data should be explored further.

Impact of hip arthroplasty registers on orthopaedic practice and perspectives for the future

Total hip arthroplasty (THA) registers are established in several countries to collect data aiming to improve the results after THA. Monitoring of adverse outcomes after THA has focused mainly on revision surgery, but patient-reported outcomes have also been investigated.Several surgery-related factors influencing the survival of the THA have been thoroughly investigated and have changed clinical practice. These factors include surgical approach, specific implants, the size of the components, type of fixation and different bone cements.Register data have been used to examine the risk of venous thromboembolism and bleeding after THA. These investigations have resulted in shorter duration of thromboprophylaxis and a reduced frequency of blood transfusion.Registers may provide specific information to surgeons on the outcome of all THAs that they have performed with a detailed analysis of revisions rates and reasons for the revisions.A number of other stakeholders can use register data to provide benchmarks. The National Joint Registry for England, Wales, Northern Ireland and the Isle of Man supplies data to the Orthopaedic Device Evaluation Panel (ODEP), which provides benchmarks at 3, 5, 7, 10, and 13 years graded from A*, A, B and C.Future perspectives: National registers have to play a major role in documenting the quality of THA in order to describe best practice and report implant outliers. The registers have to be used for research and post-market surveillance and register data may be a source for intelligent decision tools. Cite this article: EFORT Open Rev 2019;4 DOI: 10.1302/2058-5241.4.180091.

Postoperative Thromboprophylaxis With New Oral Anticoagulants is Superior to LMWH in Hip Arthroplasty Surgery: Findings from the Swedish Registry

BACKGROUND

Although the use of thromboprophylaxis is well established, there is no consensus on the preferred thromboprophylaxis regimen after THA; large, population-based studies offer an opportunity to examine this problem in a robust way that can complement results from randomized trials.

QUESTIONS/PURPOSES

Using data from a large national registry, we asked: (1) Is there any difference between low-molecular weight heparin (LMWH) and new oral anticoagulants in preventing symptomatic deep vein thrombosis (DVT) and pulmonary embolism (PE), after THA? (2) Are there any differences in safety parameters, such as bleeding, reoperations and mortality, between LMWH and new oral anticoagulants?

METHODS

Between 2008 and 2012, 78,066 THAs were performed in Sweden. This study evaluated 32,663 (42%) of them, selected through the merger of several national registries. These patients underwent unilateral THA due to primary osteoarthritis. They had not experienced any venous thromboembolic events 5 years before the index operation and were not prescribed potent antithrombotic agents, of any type, in the 6 months before the index operation. Additionally, their postoperative thromboprophylaxis was confirmed in a national registry by purchase of prescribed medications. We divided the cohort into two groups: those patients who received new oral anticoagulants (5752, 18%) and those who received LMWH (26,881, 82%) as postoperative thromboprophylaxis. Our primary endpoints were the frequencies of symptomatic DVT and symptomatic PE within 3 months of surgery. Our secondary comparison was a between-group comparison of bleeding (by way of diagnostic coding), reoperation, and mortality within 3 months of surgery. Odds ratios (OR) are presented with 95% confidence intervals (CIs) as pooled results for the two groups after adjustment for duration of thromboprophylaxis (short or extended for at least 28 days), year of the index operation, Elixhauser comorbidity index, sex, age and previous treatment with platelet aggregation inhibitors.

RESULTS

The risk of symptomatic DVT was lower in the group that received new oral anticoagulants than the group that received LMWH (0.3% versus 0.6%, OR, 0.47; 95% CI, 0.27-0.76; p = 0.026). The risk of symptomatic PE was lower in the group that received new oral anticoagulants than the group that received LMWH (0.1% versus 0.4%, OR, 0.36; 95% CI, 0.16-0.69; p = 0.005). There was no difference in the risk of bleeding (by way of diagnostic coding) (OR, 1.03; 95% CI, 0.82-1.28; p = 0.688), reoperation (OR, 1.02; 95% CI, 0.71-1.44; p = 0.860) or mortality (OR, 0.83; 95% CI, 0.31-1.88; p = 0.883) between groups.

CONCLUSIONS

New oral anticoagulants were associated with a lower risk of symptomatic DVT and symptomatic PE in this large, registry study, and we observed no differences in the risk of bleeding, reoperation, or death between the groups. Although we were able to control for a number of potential confounding variables, we cannot ascertain the indications that drove the prescription decisions in this setting, and there were important between-group differences in terms of duration of thromboprophylaxis (new oral anticoagulants generally were used for a longer period of time after surgery). Future studies, preferably large randomized trials with pragmatic inclusion criteria, to analyze symptomatic DVT, symptomatic PE and death are needed to confirm or refute our findings.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Guidelines for Perioperative Care in Elective Colorectal Surgery: Enhanced Recovery After Surgery (ERAS®) Society Recommendations: 2018

BACKGROUND

This is the fourth updated Enhanced Recovery After Surgery (ERAS®) Society guideline presenting a consensus for optimal perioperative care in colorectal surgery and providing graded recommendations for each ERAS item within the ERAS® protocol.

METHODS

A wide database search on English literature publications was performed. Studies on each item within the protocol were selected with particular attention paid to meta-analyses, randomised controlled trials and large prospective cohorts and examined, reviewed and graded according to Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system.

RESULTS

All recommendations on ERAS® protocol items are based on best available evidence; good-quality trials; meta-analyses of good-quality trials; or large cohort studies. The level of evidence for the use of each item is presented accordingly.

CONCLUSIONS

The evidence base and recommendation for items within the multimodal perioperative care pathway are presented by the ERAS® Society in this comprehensive consensus review.

Recommendations on thromboprophylaxis in major joint arthroplasty - many guidelines, little consensus?

Venous thromboembolic events remain a concern in total hip and knee arthroplasty. Consequently, several guidelines on thromboprophylaxis have been established. However, despite similarities in methodology for evaluation of evidence, discrepancies in guideline recommendations continue to exist. Furthermore, the results of older randomized clinical trials still have significant influence despite major improvements in perioperative care. In contrast, the results of recent large cohort studies with fewer thromboembolic events are mostly used only for background data. Here we outline some of the differences between the guidelines on thromboprophylaxis from the American College of Chest Physicians, the National Institute for Health and Care Excellence and the American Academy of Orthopedic Surgeons. We discuss differences in the methodology and focus of the guidelines potentially influencing the final recommendations. Future analyses are required, including data from modern care with early mobilization and short length of stay.

Impact of preadmission anti-inflammatory drug use on the risk of RBC transfusion in elderly hip fracture patients: a Danish nationwide cohort study, 2005-2016

BACKGROUND

Do prescription drugs with anti-inflammatory properties such as nonsteroidal anti-inflammatory drugs (NSAIDs), corticosteroids, and statins increase the risk of postoperative bleeding measured with RBC transfusion in elderly hip fracture surgery patients?

STUDY DESIGN AND METHODS

Using the Danish Multidisciplinary Hip Fracture Database, 74,791 patients aged 65 years or older with surgery-treated hip fracture were identified during 2005-2016, and their use of NSAIDs, corticosteroids, and statins was ascertained. For each drug, patients were categorized as nonusers (no prescription ≤365 days prior to surgery), former users (one prescription 91-365 days), and current users (one prescription ≤90 days). Information on surgical treatment, transfusion, other medication and comorbidities were collected using Danish nationwide registries. A log-binomial model was used to estimate relative risks for RBC transfusion within 7 days of surgery and corresponding 95% confidence intervals. Adjustments were made for patient- and surgery-related factors.

RESULTS

Former and current users of NSAIDs, corticosteroids, and statins accounted for 22%, 10%, and 24%, respectively. Current users of NSAIDs had an increased adjusted relative risk of transfusion (1.07; confidence interval, 1.04-1.10) compared to nonusers. There was no association between current users of corticosteroids and statins and risk of transfusion.

CONCLUSION

NSAID use within 90 days of a hip fracture surgery was associated with an increased risk of RBC transfusion. Thus, current use of NSAIDs can be associated with an increased risk of postoperative bleeding, but we cannot rule out the influence of confounding.

Excess risk of venous thromboembolism in hip fracture patients and the prognostic impact of comorbidity

Hip fracture patients were at increased excess risk of venous thromboembolism (VTE) up to 1 year following hip fracture. During the first year, interaction between hip fracture and comorbidity was observed among patients with severe and very severe comorbidity.

INTRODUCTION

We compared the risk of VTE in hip fracture patients with that in the general population. We also examined whether and to what extent the association between hip fracture and VTE varied by comorbidity level.

METHODS

Nationwide cohort study based on Danish health registries, 1995-2015. We identified hip fracture patients (n = 110,563) and sampled a comparison cohort without hip fracture from the general population (n = 552,774). Comorbidity was assessed using the Charlson comorbidity index. We calculated attributable fraction, as the proportion of the VTE rate, among persons exposed to both hip fracture and comorbidity, attributed to exposure interaction.

RESULTS

The cumulative incidences of VTE were 0.73% within 30 days and 0.83% within 31-365 days among hip fracture patients, and 0.05 and 0.43% in the general population. Adjusted hazard ratios (HRs) of VTE among hip fracture patients were 17.29 [95% confidence interval (CI) 14.74-20.28] during the first 30 days and 2.13 (95% CI 1.95-2.32) during 31-365 days following hip fracture. The relative risks of VTE were 1.03 (95% CI 0.96-1.11) and 1.11 (95% CI 1.00-1.23) after 1-5 years and 6-10 years. During the first 30 days and 31-365 days, 14%/28% of VTE rates and 5%/4% of VTE rates were attributable to the interaction between hip fracture and severe/very severe comorbidity, respectively. Mortality risks within 30 days of VTE were 29.4% in hip fracture and 11.0% in general population cohorts.

CONCLUSIONS

Hip fracture patients were at increased excess risk of VTE up to 1 year following their fracture. During the first year, interaction between hip fracture and comorbidity was observed among patients with severe and very severe comorbidity.

Incidence of venous thromboembolic events in enhanced recovery after surgery for colon cancer: a retrospective, population-based cohort study

AIM

Both the Danish and the National Institute of Clinical Excellence (NICE) guidelines recommend prolonged thromboprophylaxis (PT) with low-molecular-weight heparin (LMWH) for 28 days postoperatively after elective surgery for colon cancer. The evidence relies on data from two randomized clinical trials (RCTs) that included not only colon cancers but also other abdominal cancers or benign colorectal diseases. Neither of those studies investigated the risk of venous thromboembolism (VTE) under enhanced recovery after surgery (ERAS). We aim to describe the risk of VTE and estimate the cost of preventing one case of VTE by PT under ERAS.

METHOD

This was a retrospective study of 2230 patients undergoing elective surgery for colon cancer Stage I-III in the Capital Region of Denmark, 1 June 2008 to 31 December 2013. Patients who were discharged on postoperative day 28 or later, died during admission or were discharged with a vitamin K antagonist, novel oral anticoagulants or LMWH were excluded. Patients with rectal cancer only were not included. End-points were symptomatic VTE diagnosed within 60 days postoperatively.

RESULTS

Three-hundred and thirty patients were excluded. For the remaining 1893, the median length of stay (LOS) was 4 [interquartile range (IQR): 3-5] days. Of these 1893 patients, four (0.20%) experienced a nonfatal symptomatic VTE. All four patients had other postoperative complications before the VTE. The cost of each symptomatic VTE prevented is estimated to be between £63 709 and £111 455 when medication and home-care nursing are included.

CONCLUSION

The risk of symptomatic VTE after uncomplicated, elective surgery for colon cancer with ERAS seems negligible and the cost-effectiveness of PT to prevent one symptomatic VTE seems questionable.

Pharmacological thromboprophylaxis and its impact on venous thromboembolism following total knee and hip arthroplasty in Korea: A nationwide population-based study

BACKGROUND

Limited data is available regarding the pharmacological prophylaxis for venous thromboembolism (VTE) in Asian patients undergoing total knee arthroplasty or total hip arthroplasty (TKA/THA).

METHODS

We performed a population-based epidemiological study using the Health Insurance Review and Assessment Service database to estimate the rate of pharmacological thromboprophylaxis and its impact on VTE in Korean patients who underwent TKA/THA between 2009 and 2013.

RESULTS

We identified 306,912 cases (TKA, 261,260; THA, 45,652). The pharmacological thromboprophylaxis rate was 57.16% (TKA, 58.32%; THA, 50.51%), which increased from 42.81% in 2009 to 65.92% in 2013 (P = 0.0165). Both low-molecular-weight-heparin (22.42%) and rivaroxaban (22.71%) were the most common drugs for prophylaxis. The number of patients aged ≥ 60 years (87.31% vs. 81.01%, P < 0.0001), cases requiring general anesthesia (20.70% vs. 18.37%, P < 0.0001), and cases requiring long hospital stay (median, 13 days vs. 12 days, P < 0.0001) were significantly greater in the pharmacological prophylaxis group. The incidence of VTE within 3 months of surgery was 1.52% (TKA, 1.46%; THA, 1.87%). Patients with pharmacological prophylaxis had higher VTE rates (TKA, 1.69% vs. 1.14%; THA, 2.30% vs. 1.43%) than those without prophylaxis, with advanced age, use of general anesthesia, and a longer hospital stay increasing the risk of VTE. However, rivaroxaban significantly reduced the incidence of VTE following TKA (0.82% vs. 1.14%; odd ratio [OR], 0.72; 95% CI, 0.65-0.79). Moreover, ≥ 10 days of pharmacological thromboprophylaxis was significantly associated with lower incidence of VTE after TKA (1.33% vs. 1.52%; OR, 0.87; 95% CI, 0.81-0.94).

CONCLUSION

This represents the largest epidemiological study showing a gradual increase in the use of pharmacological prophylaxis in Korean patients undergoing TKA/THA. Although the incidence of VTE is still low without pharmacological prophylaxis, this study demonstrates that the incidence of VTE can be reduced further using appropriate pharmacological thromboprophylaxis strategies.

The Danish Hip Arthroplasty Register

Aim of database

The aim of the Danish Hip Arthroplasty Register (DHR) is to continuously monitor and improve the quality of treatment of primary and revision total hip arthroplasty (THA) in Denmark.

Study population

The DHR is a Danish nationwide arthroplasty register established in January 1995. All Danish orthopedic departments – both public and private – report to the register, and registration is compulsory.

Main variables

The main variables in the register include civil registration number, indication for primary and revision surgery, operation date and side, and postoperative complications. Completeness of primary and revision surgery is evaluated annually and validation of a number of variables has been carried out.

Descriptive data

A total of 139,525 primary THAs and 22,118 revisions have been registered in the DHR between January 1, 1995 and December 31, 2014. Since 1995, completeness of procedure registration has been high, being 97.8% and 92.0% in 2014 for primary THAs and revisions, respectively. Several risk factors, such as comorbidity, age, specific primary diagnosis and fixation types for failure of primary THAs, and postoperative complications, have been identified through the DHR. Approximately 9,000 primary THAs and 1,500 revisions are reported to the register annually.

Conclusion

The DHR is important for monitoring and improvement of treatment with THA and is a valuable tool for research in THA surgery due to the high quality of prospective collected data with long-term follow-up and high completeness. The register can be used for population-based epidemiology studies of THA surgery and can be linked to a range of other national databases.

Early ambulation and prevention of post-operative thrombo-embolic risk

The prevention of post-operative risk of venous thrombo-embolism (VTE) is of fundamental importance, but preventive methods have progressed with the introduction of direct oral anticoagulants (DOAC), the development of ambulatory surgery and enhanced recovery programs (ERP) after surgery. Surgery is, inherently a trigger for venous thrombo-embolic disease, as is prolonged immobilization. However, the risk of VTE is very low following ambulatory surgery, especially in this selected population. ERP, consists of a set of measures to optimize the patient's peri-operative management while reducing length of stay, costs and morbidity and mortality; one measure is the encouragement of early ambulation. This will undoubtedly have an impact on the incidence of VTE and lessen the need for prolonged thrombo-prophylaxis.