Does previous varicose vein surgery alter deep vein thrombosis risk after lower limb arthroplasty?

Multiple risk factors are associated with an incremental increase in acute venous thromboembolism risk after total joint arthroplasty: A pearldiver cohort study

INTRODUCTION

Several risk factors are associated with acute venous thromboembolism (VTE) after total joint arthroplasty (TJA). However, there is a lack of literature regarding the cumulative impact of multiple risk factors. To address this gap, we utilized the PearlDiver database, an insurance billing claims database containing de-identified data from 91 million orthopedic patients.

METHODS

The PearlDiver database was queried for records of patients who underwent total hip and knee arthroplasty from 2010 to 2019 using ICD-10 and CPT codes. Twelve persistent and two transient risk factors were analyzed for their association with the occurrence of acute VTE within three months after surgery. Univariate and logistic regression analyses with odds ratios (ORs) and confidence intervals (CIs) were conducted to determine the odds associated with each risk factor and the impact of multiple concurrent risk factors.

RESULTS

A total of 988,675 patients who underwent hip and knee arthroplasty met the inclusion criteria, of whom 1.5% developed acute VTE after three months. The prevalence of VTE risk factors ranged from 0.2 to 38.6%. Individual, persistent risk factors demonstrated 14-84% increased odds of VTE compared to a 1.2% increase for a transient risk factor (acute myocardial infarction). Three or more persistent risk factors were associated with a higher risk of VTE.

CONCLUSION AND RELEVANCE

Persistent risk factors were associated with a higher incidence of postoperative VTE than transient risk factors. An incremental increase in risk was noted if three or more persistent risk factors were present.

Severity of Chronic Venous Insufficiency on Primary Total Knee Arthroplasty Outcomes

BACKGROUND

More than 700,000 people in the United States undergo total knee arthroplasty (TKA) each year. Chronic venous insufficiency (CVI) affects 5% to 30% of adults, sometimes resulting in leg ulceration. These CVI cases in TKAs have been associated with worse outcomes; however, we found no study differentiating CVI severity.

METHODS

This retrospective study analyzed TKA outcomes at one institution from 2011 to 2021 using patient-specific codes. Analyses included short-term complications (< 90 days postoperative), long-term complications (< 2 years), and CVI status (yes/no; simple/complex/unclassified). Complex CVI consisted of pain, ulceration, inflammation, and/or other complications. Revisions within 2 years and readmissions within 90 days post-TKA were assessed. Composite complications included short-term and long-term complications, revisions, and readmissions. Multivariable logistic regressions predicted complication (any/long/short) as a function of CVI status (yes/no; simple/complex) and potential confounding variables. Of 7,665 patients, 741 (9.7%) had CVI. Among CVI patients, 247 (33.3%) had simple CVI, 233 (31.4%) had complex CVI, and 261 (35.2%) had unclassified CVI.

RESULTS

There was no difference in CVI versus control in composite complications (P = .722), short-term complications (P = .786), long-term complications (P = .15), revisions (P = .964), or readmissions (P = .438) postadjustment. Composite complication rates were 14.0% without CVI, 16.7% with complex CVI, and 9.3% with simple CVI. Complication rates differed between simple and complex CVI (P = .035).

CONCLUSION

Overall, CVI did not affect postoperative complications versus control. Patients who have complex CVI are at higher risk for post-TKA complications compared to those who have simple CVI.

Effects of Venous Insufficiency in Patients Undergoing Primary Total Knee Arthroplasty: An Analysis of 1.2 Million Patients

Chronic venous insufficiency (CVI) is extraordinarily prevalent in our aging population with over 30 million people in the United States suffering from the disease. There is a paucity of data analyzing the effects of CVI on outcomes following total knee arthroplasty (TKA). The purpose of this study was to utilize a nationwide administrative claims database to determine whether patients with CVI undergoing TKA have higher rates of: (1) in-hospital lengths of stay (LOS); (2) readmission rates; (3) medical complications; (4) implant-related complications; and (5) costs of care compared to controls. Using a nationwide database, we matched patients with CVI undergoing TKA to controls without CVI undergoing TKA in a 1:5 ratio by age, sex, and medical comorbidities associated with CVI. Primary outcomes analyzed within the study included LOS, 90-day readmission rates, 90-day medical complications, 2-year implant-related complications, in addition to 90-day total global episode of care costs. The query yielded 1,265,534 patients with (n = 210,926) and without (n = 1,054,608) CVI undergoing primary TKA. Patients with CVI had significantly longer LOS (4 vs. 3 days, p < 0.0001), higher 90-day readmission rates (20.96 vs. 15.34%; odds ratio [OR]: 1.46, 95% confidence interval [CI]: 1.44-1.48, p < 0.0001), and higher odds of medical complications (2.27 vs. 1.30%; OR: 1.76, 95% CI: 1.70-1.83, p < 0.0001) compared to matched controls. Patients with CVI also had higher odds of periprosthetic joint infections (2.23 vs. 1.03%; OR: 2.18, p < 0.0001) and implant-related complications in general (4.27 vs. 2.17%; OR: 2.01, 95% CI: 1.96-2.06, p < 0.0001). Additionally, patients with CVI had higher total global 90-day episode of care costs ($15,583.07 vs. $14,286.95, p < 0.0001). Patients with CVI undergoing TKA have increased LOS, higher odds of medical and implant complications, and increased costs of care compared to those without CVI. The study can be utilized by orthopaedic surgeons to counsel patients on the potential complications following this procedure. This is a level III, retrospective cohort study.

Varicose veins as a risk factor for venous thromboembolism in arthroplasty patients: Meta-analysis

OBJECTIVE

A meta-analysis to determine if patients with varicose veins are at an increased risk of venous thromboembolism (VTE) when undergoing major lower limb arthroplasty.

METHODS

Medline, Embase, and Cochrane Library databases were searched using appropriate terms for studies that reported post-operative VTE in patients who had lower limb arthroplasty with any history of varicose veins. Methodological quality of included studies was quantified using the Risk of Bias (ROB) assessment tools. Findings were reported using the meta-analysis of observational studies in epidemiology (MOOSE) checklist.

RESULTS

A total of 129 studies were identified with 11 observational studies being eligible for inclusion. This consisted of 265,194 patients who underwent lower limb arthroplasty, 2188 of which had pre-existing varicose veins. Overall, VTE occurred in 1845 patients, and 122 cases had varicose veins present at time of arthroplasty. Meta-analysis indicates that patients undergoing lower limb arthroplasty with varicose veins are at increased risk of having a VTE, OR 2.37, 95% CI 1.54-3.63, (p < 0.001). One study evaluated if previous varicose veins surgery influenced the risk of VTE in arthroplasty patients, OR 0.96 (95% CI 0.7-1.28), p = 0.429.

CONCLUSIONS

Varicose veins and lower limb arthroplasty are known independent risk factors for VTE. There is a paucity of data regarding the risk of VTE in patients undergoing lower limb arthroplasty who have co-existing varicose veins. This meta-analysis shows that patients with varicose veins are at an increased risk of VTE when undergoing major lower limb arthroplasty. Further studies are required in order to determine if such patients should undergo varicose vein surgery before undertaking major lower limb joint replacement.

Standard of care for lipedema in the United States

Background

Lipedema is a loose connective tissue disease predominantly in women identified by increased nodular and fibrotic adipose tissue on the buttocks, hips and limbs that develops at times of hormone, weight and shape change including puberty, pregnancy, and menopause. Lipedema tissue may be very painful and can severely impair mobility. Non-lipedema obesity, lymphedema, venous disease, and hypermobile joints are comorbidities. Lipedema tissue is difficult to reduce by diet, exercise, or bariatric surgery.

Methods

This paper is a consensus guideline on lipedema written by a US committee following the Delphi Method. Consensus statements are rated for strength using the GRADE system.

Results

Eighty-five consensus statements outline lipedema pathophysiology, and medical, surgical, vascular, and other therapeutic recommendations. Future research topics are suggested.

Conclusion

These guidelines improve the understanding of the loose connective tissue disease, lipedema, to advance our understanding towards early diagnosis, treatments, and ultimately a cure for affected individuals.

Deep vein thrombosis is accurately predicted by comprehensive analysis of the levels of microRNA-96 and plasma D-dimer

The aim of the present study was to investigate the association between platelet microRNA-96 (miR-96) expression levels and the occurrence of deep vein thrombosis (DVT) in orthopedic patients. A total of consecutive 69 orthopedic patients with DVT and 30 healthy individuals were enrolled. Ultrasonic color Doppler imaging was performed on lower limb veins after orthopedic surgery to determine the occurrence of DVT. An enzyme-linked fluorescent assay was performed to detect the levels of D-dimer in plasma. A quantitative polymerase chain reaction assay was performed to determine the expression levels of miR-96. Expression levels of platelet miR-96 were significantly increased in orthopedic patients after orthopedic surgery. miR-96 expression levels in orthopedic patients with DVT at days 1, 3 and 7 after orthopedic surgery were significantly increased when compared with those in the control group. The increased miR-96 expression levels were correlated with plasma D-dimer levels in orthopedic patients with DVT. However, for the orthopedic patients in the non-DVT group following surgery, miR-96 expression levels were correlated with plasma D-dimer levels. In summary, the present results suggest that the expression levels of miR-96 may be associated with the occurrence of DVT. The occurrence of DVT may be accurately predicted by comprehensive analysis of the levels of miR-96 and plasma D-dimer.

Diagnostic accuracy of deep vein thrombosis is increased by analysis using combined optimal cut-off values of postoperative plasma D-dimer levels

The present study aimed to evaluate the accuracy of analysis using optimal cut-off values of plasma D-dimer levels in the diagnosis of deep vein thrombosis (DVT). A total of 175 orthopedic patients with DVT and 162 patients without DVT were included in the study. Ultrasonic color Doppler imaging was performed on lower limb veins prior to and following orthopedic surgery in order to determine the types of orthopedic conditions that were present. An enzyme-linked fluorescent assay was performed to detect the expression levels of D-dimer in plasma, and receiver operating characteristic analysis was performed to predict the occurrence of DVT on the basis of the expression levels of D-dimer. After surgery, the expression levels of D-dimer in the plasma of DVT patients were significantly higher in comparison with those in orthopedic patients without DVT (P<0.05). When the patients were divided into subgroups according to the underlying orthopedic condition, the expression levels of D-dimer in the plasma of each subgroup were higher 1 day after orthopedic surgery in comparison to those prior to surgery (P<0.05). The diagnostic accuracy achieved using combined optimal cut-off values at 1 and 3 days post-surgery was significantly higher than the accuracy when using a single optimal cut-off value (P<0.05). In conclusion, detection of D-dimer expression levels at 1 day post-orthopedic surgery may be important in predicting DVT. In addition, the diagnostic accuracy of DVT is significantly increased by analysis using combined optimal cut-off values of D-dimer plasma expression levels.

Predicting of Venous Thromboembolism for Patients Undergoing Gynecological Surgery

The purpose of this study was to determine the risk stratification of deep venous thrombosis (DVT) in patients undergoing gynecological surgery. A retrospective study was conducted with a cohort of 739 consecutive female patients undergoing gynecological surgery between May 2008 and July 2013 in Beijing Chao-yang hospital. DVT of the leg was detected using complete compression and color Doppler ultrasound. Pulmonary embolism (PE) was diagnosed by computed tomography pulmonary angiogram (CTPA). The overall incidence of DVT was 9.20% (68/739) in this patient population, including 16 (2.17%) symptomatic DVT and 52 (7.04%) silent DVT. A total of 66 (97.06%) DVT events were found within 7 days of surgery and 2 (2.94%) after 1 week. 94.82% thrombi were located in distal vein, and the rest 5.18% located in proximal and distal veins. Among the 68 patients with DVT, 46 patients with suspected PE received CTPA and 21 (45.65%) were confirmed with PE. Six independent factors including varicose vein, bed rest time ≥ 48 h, length of operation ≥ 3 h, laparotomy surgery, hypertension, and age ≥ 50 years significantly increased the incidence of postoperative DVT on multivariate analysis. Patients with none risk factor are at low risk, with 1 or 2 risk factors are at moderate risk, and with ≥ 3 factors are at high risk of DVT. The incidence of postoperative DVT and PE after gynecological surgery is high in patients with moderate or high-risk level. Noninvasive detection of DVT in 7 days after surgery is necessary because most patients showed no typical symptoms. Appropriate prophylaxis could be performed in patients at moderate or high risk of DVT.

Risk factors for venous thromboembolism after total hip and total knee arthroplasty: a meta-analysis

INTRODUCTION

Venous thromboembolism (VTE) is a common complication after total hip arthroplasty (THA) or total knee arthroplasty (TKA) and may be the cause for a secondary PE and associated morbidity/mortality. We performed a systematic literature review of risk factors and risk reduction of VTE after THA or TKA.

MATERIALS AND METHODS

A systematic search of PubMed database, the Cochrane Library, OVID MEDLINE and American Academy of Orthopaedic Surgeons (AAOS), without restriction of publication data and language, was conducted. We performed a meta-analysis of ten factors for VTE after THA or TKA. Four authors independently assessed data extraction and quality of the studies using the Newcastle-Ottawa Scale (NOS) as quality assessment tool. Assessment of heterogeneity and analysis of data were operated by Review Manager 5.2.9.

RESULTS

Fourteen retrospective case-control or prospective cohort studies, which included 18,075 patients who developed VTE after THA or TKA of a total of 1,723,350 cases, were selected. Our results demonstrated that, among all ten factors investigated, 3 main risk factors were significantly associated with VTE after THA or TKA: history of VTE (RR > 10.6), varicose vein (RR > 2.7) and congestive cardiac failure (RR 2). There was also an increase of VTE risk ranging from 8 to 30 % for female gender < age (≥80) < hypertension < (active) cancer < obesity (BMI ≥ 30) < (black) race. Data analysis revealed that diabetes mellitus had no significant relationship with VTE after THA or TKA.

CONCLUSIONS

This study highlighted the role of nine significant risk factors in the development of VTE after THA or TKA. Among all risk factors, history of VTE seems the one main indication for more potent anticoagulation. All other risk factors need to be considered and discussed with patients individually and balanced against the risk of bleeding and infection. Individual patient risk assessment, rather than a "blanket policy", is considered the best management strategy before deciding on the type of chemical prophylaxis.

Risk factors for venous thromboembolism of total hip arthroplasty and total knee arthroplasty: a systematic review of evidences in ten years

Background

Risk factors for venous thromboembolism (VTE) of total joint arthroplasty (TJA) have been examined by many studies. A comprehensive systematic review of recent findings of high evidence level in this topic is needed.

Methods

We conducted a PubMed search for papers published between 2003 and 2013 that provided level-I and level-II evidences on risk factors for VTE of TJA. For each potential factors examined in at least three papers, we summarize the the number of the papers and confirmed the direction of statistically significant associations, e.g. “risk factor” “protective factor” or “controversial factor”.

Results

Fifty-four papers were included in the systematic review. Risk factors found to be associated with VTE of both total hip arthroplasty and total knee arthroplasty included older age, female sex, higher BMI, bilateral surgery, surgery time > 2 hours. VTE history was found as a VTE risk factor of THA but an controversial factor of TKA. Cemented fixation as compared to cementless fixation was found as a risk factor for VTE only of TKA. TKA surgery itself was confirmed as a VTE risk factor compared with THA surgery.

Conclusions

This systematic review of high level evidences published in recent ten years identified a range of potential factors associated with VTE risk of total joint arthroplasty. These results can provide informations in this topic for doctors, patients and researchers.

The national incidence of iatrogenic popliteal artery injury during total knee replacement

Introduction

The aim of this study was to characterize national characteristics of patients who have a total knee replacement complicated by popliteal artery injury by incidence and patient demographics.

Methods

All patients with ICD-9 confirmed total knee replacement who had an iatrogenic popliteal artery injury were included from the national in-patient sample from 1998 to 2011. Age, gender and race, procedure type, time to popliteal artery injury, limb outcome, length of stay and hospital inpatient charges were reported.

Results

A total of 1,297,369 patients underwent a total knee replacement of which 43 were complicated by popliteal artery injury (0.003%); 93% had osteoarthritis as their primary diagnosis. The mean age was 61.7 ± 12.3 years. In all, 96% of patients had their popliteal injuries detected intra-operatively or on the day of total knee replacement surgery. The majority of these patients either received stent placement (44%) or peripheral bypass (30%) as their treatment modality for popliteal artery injury. There were no amputations or deaths in this cohort. The median hospital charges for this group were $27,570 (2014 USD).

Conclusion

The national incidence of iatrogenic popliteal artery injury in patients undergoing TKR is 0.003%. There were no amputations in our study population and 96% of patients had their injury detected intra-operative or immediately post-operatively.