Asia-Pacific venous thromboembolism consensus in knee and hip arthroplasty and hip fracture surgery: Part 1. Diagnosis and risk factors

Prediction model of deep vein thrombosis risk after lower extremity orthopedic surgery

Purpose

This investigation was conceived to engineer and appraise a pioneering clinical nomogram, crafted to bridge the extant chasm in literature regarding the postoperative risk stratification for deep vein thrombosis (DVT) in the aftermath of lower extremity orthopedic procedures. This novel tool offers a sophisticated and discerning algorithm for risk prediction, heretofore unmet by existing methodologies.

Methods

In this retrospective observational study, clinical records of hospitalized patients who underwent lower extremity orthopedic surgery were collected at the Wuxi TCM Hospital Affiliated to the Nanjing University of Chinese Medicine between Jan 2017 and Oct 2019. The univariate and multivariate analysis with the backward stepwise method was applied to select features for the predictive nomogram. The performance of the nomogram was evaluated with respect to its discriminant capability, calibration ability, and clinical utility.

Result

A total of 5773 in-hospital patients were eligible for the study, with the incidence of deep vein thrombosis being approximately 1 % in this population. Among 31 variables included, 5 of them were identified to be the predictive features in the nomogram, including age, mean corpuscular hemoglobin concentration (MCHC), D-dimer, platelet distribution width (PDW), and thrombin time (TT). The area under the receiver operating characteristic (ROC) curve in the training and validation cohort was 85.9 % (95%CI: 79.96 %-90.04 %) and 85.7 % (95%CI: 78.96 %-90.69 %), respectively. Both the calibration curves and decision curve analysis demonstrated the overall satisfactory performance of the model.

Conclusion

Our groundbreaking nomogram is distinguished by its unparalleled accuracy in discriminative and calibrating functions, complemented by its tangible clinical applicability. This innovative instrument is set to empower clinicians with a robust framework for the accurate forecasting of postoperative DVT, thus facilitating the crafting of bespoke and prompt therapeutic strategies, aligning with the rigorous standards upheld by the most esteemed biomedical journals.

Risk factors for venous thromboembolism after primary total joint arthroplasty: An analysis of 7511 Taiwanese patients

BACKGROUND

The need for thromboprophylaxis in Asian patients after primary total joint arthroplasty (TJA) remains inconclusive. We aimed to identify the risk factors for venous thromboembolism (VTE) events following primary TJA in a Taiwanese population.

METHODS

From January 2010 to December 2019, we studied 7511 patients receiving primary TJA from a single surgeon. We validated the incidence and risk factors for 30- and 90-day symptomatic VTE events, including age, sex, body mass index (BMI), smoking, medical comorbidities, VTE history, presence of varicose veins, total knee arthroplasty (TKA) vs total hip arthroplasty (THA), unilateral vs bilateral procedure and receipt of VTE prophylaxis, transfusion, and length of stay.

RESULTS

The incidence of 30- and 90-day symptomatic VTE events was 0.33% and 0.44%, respectively. Multivariate regression analysis showed that BMI ≥30 (adjusted odds ratio (aOR): 4.862, 95% CI, 1.776-13.313), bilateral TJA procedure (aOR: 2.665, 95% CI, 1.000-7.104), and presence of varicose veins (aOR: 9.946, 95% CI, 1.099-90.024) were associated with increased odds of 30-day symptomatic VTE events. Age ≥77 years (aOR, 2.358, 95% CI, 1.034-5.381) and BMI ≥30 (aOR: 2.832, 95% CI, 1.039-7.721) were associated with increased odds of 90-day symptomatic VTE events.

CONCLUSION

Age ≥77 years, BMI ≥30, bilateral TJA procedure, or presence of varicose veins may require pharmacological thromboprophylaxis because such patients have a higher risk of VTE after primary TJA.

Effect of Knee Valgus Deformity on Symptomatic Venous Thromboembolism and Prosthesis Revision Risk after Total Knee Arthroplasty: A Multicenter Retrospective Study

OBJECTIVE

Symptomatic venous thromboembolism (VTE) and prosthesis failure are the most serious complications after total knee arthroplasty (TKA). However, whether knee valgus deformity aggravates these complications has not been fully clarified. To study the difference between perioperative symptomatic VTE and prosthesis revision rate in patients with valgus knee osteoarthritis by comparing with patients undergoing TKA for varus deformity and analyze the reasons for revision. At the same time, the distribution and radiographic features of lower extremity deep venous thrombosis were recorded.

METHODS

The data of patients who underwent TKA in two tertiary hospitals from January 2016 to December 2020 were retrospectively reviewed, and a total of 8917 patients were included. According to preoperative manifestations of knee malformations, all patients were divided into two groups: valgus group (n = 412) and varus group (n = 8505). Main indicators included the incidence of symptomatic VTE and prosthesis revision. Secondary outcomes included general information on operative time, Kellgren and Lawrence score, total hospital stay, and total costs. The patient data of the two groups were analyzed by Pearson chi-square test, Student t test, or Mann-Whitney U test. The revision was evaluated using Kaplan-Meier survival analysis.

RESULTS

The proportion of valgus knees in TKA patients was 4.62% (412/8917). The incidence of VTE was 6.23‰ (53/8505) and 16.99‰ (7/412) in the varus and valgus groups, and the results were statistically different (p = 0.009). There was no significant difference in echogenicity, number of occluded vessels, and thrombus length between the valgus group (p = 0.102; p = 0.645; p = 0.684). Patients with valgus deformity had 12.14‰ (5/412) prosthesis revision, the incidence of varus deformity was 4.82‰ (41/8505), and the revision risk of valgus group was 2.5 times higher than varus group, and the results were statistically different (p = 0.043). The operation time and hospital stay in the valgus group were longer than those in the varus group, and the results were statistically different (p = 0.018; p < 0.001).

CONCLUSIONS

Valgus deformity increases risk of symptomatic VTE and prosthesis revision after TKA. These results have guiding significance for the prevention of complications after TKA in patients with valgus deformity.

Incidence and Distribution of Deep Vein Thrombosis Following Total Hip Arthroplasty Using an Anterolateral Supine Approach

Purpose

Venous thromboembolism (VTE) is a potential major complication in patients undergoing total hip arthroplasty (THA). However, the incidence of VTE following THA using anterolateral supine approach (ALS) has not been reported. The purpose of this study was to investigate the incidence of perioperative VTE and the distribution and characteristics of deep vein thrombosis (DVT) following ALS THA.

Patients and Methods

This retrospective single-arm study analyzed the 182 consecutive hips of 164 patients who underwent primary ALS THA. Pharmacological prophylaxis consisted of enoxaparin 20 mg twice daily for approximately 6 days starting 24 h postoperatively until duplex ultrasonography was performed to determine whether postoperative DVT was present. DVT was assessed by whole-leg Doppler ultrasound, and the location and characteristics of any thrombus were recorded. If pulmonary thromboembolism was suspected, contrast-enhanced computed tomography was performed.

Results

The overall incidence of VTE was 9.9% for DVT (18/182 hips) and 0.5% for pulmonary thromboembolism (1/182 hips). Most DVTs were in the soleal vein on the affected side and showed isoechoic or hypoechoic echogenicity. All thrombi were non-floating.

Conclusion

Following ALS THA with standard pharmacological prophylaxis and an early weight-bearing protocol, the incidence of perioperative DVT was approximately 10%, mostly occurring in the lower leg.

A multidisciplinary approach to post-operative fragility hip fracture care in Thailand - a narrative review

INTRODUCTION

Appropriate care and rehabilitation following surgery for fragility hip fractures in older adults is associated with better outcomes and a greater likelihood of achieving pre-injury functioning. Clinical guidelines specifically for the post-operative care and rehabilitation of patients with hip fractures are scarce; as such, country-specific protocols benchmarked against established guidelines are essential given the wide variation in cultures and beliefs, clinical practice and diverse healthcare systems in Asia. We aimed to provide clinically relevant recommendations for post-operative fragility hip fracture care and rehabilitation to improve patient outcomes and prevent subsequent fractures in Thailand.

METHODS

A targeted literature review was conducted to identify key evidence on various elements of post-hip fracture care and rehabilitation. Further discussions at a meeting and over email correspondence led to the development of the recommendations which amalgamate available evidence with the clinical experience of the multidisciplinary expert panel.

RESULTS

Our recommendations are categorized by one period domain - acute post-operative period, and five major domains during the post-operative period - rehabilitation, optimization of bone health, prevention of falls, nutritional supplementation, and prophylaxis for venous thromboembolism. A multidisciplinary approach should be central to the rehabilitation process with the involvement of orthopedists, geriatricians/internists, physiatrists, physical and occupational therapists, endocrinologists, pharmacists and nursing staff. Other key components of our recommendations which we believe contribute to better functional outcomes in older patients undergoing hip fracture surgery include comprehensive pre-operative assessments, early surgery, goal setting for recovery and rehabilitation, early mobilization, medication optimization, tailored exercise plans, adequate coverage with analgesia, assessment and appropriate management of osteoporosis with due consideration of the fracture risk, fall prevention plans, and nutritional assessment and support. Patients and their caregivers should be a part of the recovery process at every step, and they should be counseled and educated appropriately, particularly on the importance of adherence to their rehabilitation plan.

CONCLUSION

We have provided guidance on the critical domains of clinical care in the post-operative setting to optimize patient outcomes and prevent fracture recurrence. Our recommendations for post-operative care and rehabilitation of older adults with hip fracture can serve as a framework for hospitals across Thailand.

The impact of frailty evaluation on the risk of venous thromboembolism in patients with hip fracture following surgery: a meta-analysis

BACKGROUND

Frailty has been associated with a higher incidence of overall postoperative complications and mortality. However, the influence of frailty on the risk of venous thromboembolism (VTE) in patients with hip fracture following surgery remains unclear. We performed a meta-analysis to systematically evaluate the above association.

METHODS

PubMed, Embase, Cochrane Library, Wanfang and CNKI were searched for relevant observational studies comparing the incidence of postoperative VTE in patients of hip fracture with and without frailty. Data collection, literature searching, and statistical analysis were conducted independently by two authors. Using a heterogeneity-incorporating random-effects model, the results were pooled.

RESULTS

In this meta-analysis, 9509 patients from nine cohort studies were included. Pooled results showed that compared to those without frailty, patients with frailty at admission had a higher incidence of postoperative VTE (odds ratio [OR]: 2.59, 95% confidence interval [CI]: 1.25-5.39, p = 0.01; I2 = 66%). Subgroup analysis suggested the association between frailty and postoperative VTE was more remarkable in studies of patients with frailty prevalence < 50% (OR 6.28, 95% CI 3.31-11.90, p < 0.001; I2 = 8%) as compared to those ≥ 50% (OR 1.30, 95% CI 0.80-2.11, p = 0.28; I2 = 0%; p for subgroup difference < 0.001). Further meta-analyses showed that frailty at baseline was associated with a higher incidence of deep venous thrombosis (OR 3.15, 95% CI 1.33-7.47, p = 0.009; I2 = 59%), but not pulmonary embolism (OR 1.13, 95% CI 0.59-2.16, p = 0.72; I2 = 0%).

CONCLUSION

Frailty is associated with a higher incidence of postoperative VTE in patients with hip fracture.

Iliac vein compression syndrome by lumbar degenerative changes is associated with deep vein thrombosis after total knee arthroplasty

INTRODUCTION

This study aimed to identify whether iliac vein compression syndrome(IVCS) is associated with deep vein thrombosis(DVT) after total knee arthroplasty(TKA) and whether lower lumbar degenerative changes were risk factors for IVCS.

MATERIALS AND METHODS

A total of 259 consecutive patients who underwent TKA from January 2019 to March 2022 was retrospectively reviewed. Preoperative plain radiographs of lumbar spines and CT venography (CTV) for DVT diagnosis at postoperative 7 days were performed in all patients. Imaging findings of lower lumbar degenerative changes were analyzed on plain radiograph including lateral osteophytes, scoliosis, lateralolisthesis, retrolisthesis, anterolisthesis, and lower lumbar lordosis angle (LLLA). Percent compression at the left common iliac vein (LCIV) and right common iliac vein (RCIV) as well as DVT were evaluated on CTV. Moreover, IVCS was defined as greater than 50% of compression of the iliac vein on CTV.

RESULTS

DVT occurred in 79 patients (30.5%) after TKA. The overall occurrence of DVT was significantly higher in patients with IVCS of LCIV (52.8%) than those without (18.8%, P < 0.001). When DVT was further subdivided, compared to non-IVCS, IVCS of LCIV was significantly associated with bilateral DVT (P < 0.001, both), especially distal DVT (P < 0.001, both), and IVCS of RCIV was significantly associated with right-side DVT (P = 0.031), especially popliteal (P = 0.008) and distal DVT(P = 0.011). Female patients (OR: 3.945, P = 0.039), presence of left osteophyte (OR: 2.348, P = 0.006), and higher LLLA (OR: 1.082, P < 0.001) were significantly associated with IVCS of LCIV, and presence of right osteophyte (OR: 3.494, P = 0.017) was significantly associated with IVCS of RCIV.

CONCLUSION

IVCS was significantly associated with DVT after TKA and lumbar degenerative changes with lateral osteophytes and hyperlordosis were significant risk factors for IVCS.

Prevention of Venous Thromboembolism in Patients Undergoing Hip Fracture Surgery: A Survey of the Korean Hip Society

Purpose

The aim of this study was to assess the current status of venous thromboembolism (VTE) prevention in Korean patients with hip fractures.

Materials and Methods

A survey using a questionnaire on the experiences and protocols of VTE prevention was conducted among 570 members of the Korean Hip Society.

Results

A total of 97 surgeons responded, with a response rate of 17.0%. Of the 97 participants, 61.9% answered that they had encountered one or more cases of symptomatic VTE in the past year. Mechanical prophylaxis was applied most often (30.9%) until the point of ambulation in standard-risk patients and most often (34.0%) extended until discharge in high-risk patients. Chemical prophylaxis was most often prescribed for a particular period of time rather than for recovery of walking ability (24.7% in standard-risk patients and 26.8% in high-risk patients). Dual prophylaxis was administered in the standard-risk group by 58.8% of the participants and in the high-risk group by 83.5%. Among the participants, 73.2% answered that they had been attentive to wound complications during chemical prophylaxis. More than half of the participants (59.8%) reported that they did not perform routine screening for VTE after surgery.

Conclusion

The results of our survey provided information regarding the current status of VTE prevention for patients undergoing surgery for treatment of hip fractures in Korea as well as a baseline for establishment of educational programs and guidelines in the future.

Venous thromboembolism in orthopedic surgery: Global guidelines

Venous thromboembolism (VTE) is a severe complication that can occur after major orthopedic procedures. As VTE-related morbidity and mortality are a significant concern for both medical professionals and patients, and preventative measures are typically employed. Multiple organizations, including the American College of Chest Physicians (ACCP) and the American Academy of Orthopedic Surgeons (AAOS), have developed guidelines for VTE prophylaxis specifically in patients undergoing joint replacement procedures. However, recently, the International Consensus Meeting (ICM) was convened, which brought together over 600 experts from 68 countries and 135 international societies. These experts, spanning a range of medical disciplines including orthopedic surgery, anesthesia, cardiology, hematology, vascular, and internal medicine, conducted a comprehensive review of the literature using a strict Delphi process to generate practical recommendations for VTE prophylaxis across all types of orthopedic procedures. This review article summarizes some of the recommendations of the ICM.

Long-Term Nonoperative Management is Associated With Lower Mean 9-Year Follow-Up Survival Compared to Total Knee Arthroplasty in Knee Osteoarthritis Patients-Survival Analysis of a Nationwide South Korean Cohort

BACKGROUND

Total knee arthroplasty (TKA) and medications are both considered as a treatment for knee osteoarthritis. However, the impact of the TKA on long-term survival remains controversial. This study aimed to compare 9-year follow-up survival between a TKA group with a nonoperative medication group.

METHODS

From 2007 to 2009, knee osteoarthritis patients were divided into TKA (N = 2,228) and nonoperative medication (N = 76,430) groups, and followed for up to 9 years. The hazard ratio (HR) and subdistribution HR (SHR) were derived from Cox proportional hazards regressions and Fine and Gray analyses, respectively.

RESULTS

The TKA group had a significantly lower adjusted mortality rate (adjusted HR , 0.78, 95% confidence interval [CI], 0.68-0.9) than the nonoperative medication group. Dose-response relationship between medication possession ratio and mortalities for overall (adjusted HR , 1.02; 95% CI, 1.01-1.04) and cardiovascular (CV) death (adjusted SHR, 1.03; 95% CI, 1.01-1.05) was also found. Also, there were significant interactions that indicate stronger protective survival effects of the TKA in several covariates: age >75 years (P = .04 for overall; P = .009 for CV), hypertension (P = .006 for overall), and ischemic heart disease (P = .009 for CV).

CONCLUSIONS

This study suggests that TKA patients had better mean 9-year follow-up survival than the nonoperative medication group after adjusting for baseline differences. For overall death, including CV death, adjusted mortality rates were higher in the medication group and showed a dose-response relationship. Specifically, the protective effect of the TKA for overall or CV deaths was found to be higher for age >75, hypertension, or ischemic heart disease patients.

LEVEL OF EVIDENCE

III.

Established and Novel Risk Factors for 30-Day Readmission Following Total Knee Arthroplasty: A Modified Delphi and Focus Group Study to Identify Clinically Important Predictors

Thirty-day readmission following total knee arthroplasty (TKA) is an important outcome influencing the quality of patient care and health system efficiency. The aims of this study were (1) to ascertain the clinical importance of established risk factors for 30-day readmission risk and give clinicians the opportunity to suggest and discuss novel risk factors and (2) to evaluate consensus on the importance of these risk factors. This study was conducted in two stages: a modified Delphi survey followed by a focus group. Orthopaedic surgeons and anaesthetists involved in the care of TKA patients completed an anonymous survey to judge the clinical importance of risk factors selected from a systematic review and meta-analysis and to suggest other clinically meaningful risk factors, which were then discussed in a focus group designed using elements of nominal group technique. Eleven risk factors received a majority (≥50%) vote of high importance in the Delphi survey overall, and six risk factors received a majority vote of high importance in the focus group overall. Lack of consensus highlighted the fact that this is a highly complex problem which is challenging to predict and which depends heavily on risk factors which may be open to interpretation, difficult to capture, and dependent upon personal clinical experience, which must be tailored to the individual patient.

Risk Factors of Venous Thromboembolism in Inpatients With Colorectal Cancer in China

To explore the risk factors for venous thromboembolism (VTE) in inpatients with colorectal cancer. The demographic factors, comorbidities, and hematological indices of patients with colorectal cancer treated in our hospital from 2016 to 2021 were collected and recorded. Venous thromboembolism events, including deep venous thrombosis and/or pulmonary embolism, were recorded and the patients were divided into the VTE group and the non-VTE group. We compared clinical data between the two groups and explored risk factors for VTE. Comparing the clinical data of 293 cases of non-VTE group and 235 cases of VTE group, we found significant differences in age, smoking, temperature, amount of blood loss, differentiation degree, peripherally inserted central catheter (PICC), radiotherapy, anemia, infection, white blood cell count, prothrombin time (PT), PT%, prothrombin ratio, international normalized ratio, thrombin time, CA199 and CEA between the two groups (P < 0.05). Logistic regression analysis showed that age (P = 0.0444), temperature (P = 0.0317), amount of blood loss (P = 0.0067), PICC (P < 0.0001), chemotherapy (P = 0.0459), anemia (P = 0.0007), international normalized ratio (P = 0.003) and CA199 (p = 0.0234) were independent risk factors for VTE. Receiver operating characteristic curve analysis showed that the amount of blood loss predicted thrombosis better (AUC = 0.778, P < 0.001), when the cutoff value was 20 mL, the sensitivity was 76.17%, and the specificity was 79.18%, respectively. And PICC predicted thrombosis better (AUC = 0.808, P < 0.001), the sensitivity was 70.21%, and the specificity was 91.47%, respectively. Clinical parameters are associated with VTE in inpatients with colorectal cancer, which will help to guide clinicians to take effective measures to improve the patients' prognosis.

Quality evaluation of clinical practice guidelines for thromboprophylaxis in orthopaedic trauma based on AGREE II and AGREE-REX: a systematic review protocol

INTRODUCTION

Orthopaedic trauma patients are at high risk of venous thromboembolism (VTE). As VTE prophylaxis has gradually raised public concerns, guidelines related to this topic have increased over time. However, the existing recommendations of thromboprophylaxis guidelines in orthopaedic trauma patients are still inconsistent, and the quality of the guidelines and recommendations for the topic still lacks comprehensive assessments. This review aims to critically appraise clinical practice guidelines for thromboprophylaxis in orthopaedic trauma patients.

METHODS AND ANALYSIS

We will conduct a comprehensive literature search up to 31 October 2022 in databases (PubMed, EMBASE, CINAHL, Web of Science, the Cochrane Library, etc), academic websites and guideline repositories. The quality of the guidelines and recommendations will be assessed by five reviewers independently using the Appraisal of Guidelines Research and Evaluation II instrument (AGREE-II) and the AGREE - Recommendation EXcellence (AGREE-REX). We will summarise the characteristics of the guidelines and compare the differences between these recommendations.

ETHICS AND DISSEMINATION

This study will follow the Declaration of Helsinki and has received approval from the Ethics Committee on Biomedical Research, West China Hospital, Sichuan University (ethics approval no. 2021-989). The results will be summarised as a paper, disseminated through peer-reviewed journals, and will help guide further research in the future.

PROTOCOL REGISTRATION NUMBER

CRD42021273405.

Pharmacological thromboprophylaxis as a risk factor for early periprosthetic joint infection following primary total joint arthroplasty

Venous thromboembolism (VTE) prophylaxis has been suggested for patients who underwent total join arthroplasty (TJA). However, the morbidity of surgical site complications (SSC) and periprosthetic joint infection (PJI) has not been well evaluated. We aimed to evaluate the impact of VTE prophylaxis on the risk of early postoperative SSC and PJI in a Taiwanese population. We retrospectively reviewed 7511 patients who underwent primary TJA performed by a single surgeon from 2010 through 2019. We evaluated the rates of SSC and PJI in the early postoperative period (30-day, 90-day) as well as 1-year reoperations. Multivariate regression analysis was used to identify possible risk factors associated with SSC and PJI, including age, sex, WHO classification of weight status, smoking, diabetes mellitus (DM), rheumatoid arthritis(RA), Charlson comorbidity index (CCI), history of VTE, presence of varicose veins, total knee or hip arthroplasty procedure, unilateral or bilateral procedure, or receiving VTE prophylaxis or blood transfusion. The overall 90-day rates of SSC and PJI were 1.1% (N = 80) and 0.2% (N = 16). VTE prophylaxis was a risk factor for 90-day readmission for SSC (aOR: 1.753, 95% CI 1.081-2.842), 90-day readmission for PJI (aOR: 3.267, 95% CI 1.026-10.402) and all 90-day PJI events (aOR: 3.222, 95% CI 1.200-8.656). Other risk factors included DM, underweight, obesity, bilateral TJA procedure, younger age, male sex and RA. Pharmacological thromboprophylaxis appears to be a modifiable risk factor for SSC and PJI in the early postoperative period. The increased infection risk should be carefully weighed in patients who received pharmacological VTE prophylaxis.

Deep vein thrombosis after major orthopedic surgery in Taiwan: A prospective cross-sectional study and literature review

BACKGROUND/PURPOSE

Postoperative venous thromboembolism is an important complication in Taiwan. We prospectively investigated the occurrence of deep vein thrombosis (DVT) after major orthopedic surgery without pharmacologic thromboprophylaxis in a cohort of 120 patients (46 males, 74 females, median age 71 years) at our institute.

METHODS

Color duplex compression ultrasonography (CUS) was used to detect DVT before and after the operation, while contrast venography was performed postoperatively for comparison and validation.

RESULTS

Total knee arthroplasty (TKA, 57 cases) and total hip arthroplasty (23 cases) were the most commonly performed operations. The rate of postoperative DVT was 7.5% (9/120), including five with proximal DVT and four with distal DVT. All were detected in the limbs on the operated side. Four of them were symptomatic DVT cases. Venography was performed in 19 patients and confirmed most findings of CUS, indicating the effectiveness of CUS for detecting DVT. The type of surgery (TKA) was significantly correlated with postoperative DVT. No clinically symptomatic pulmonary embolism or sudden death events were noted.

CONCLUSION

Nine out of 120 (7.5%) orthopedic patients without pharmacologic thromboprophylaxis developed postoperative sonographic DVT in our study. The DVT rate is consistent with other reports from various Asian countries and evidence from meta-analyses.

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.

Tranexamic acid in a periarticular multimodal cocktail injection for blood management in total knee arthroplasty: a prospective randomized study

Background

This study aimed to assess the efficacy of tranexamic acid (TXA) mixed in a periarticular multimodal cocktail (PAMC) as a topical administration and to determine whether combined use of intravenous and topical administration is more effective than a single administration of TXA.

Methods

A total of 240 patients who underwent primary total knee arthroplasty (TKA) was enrolled for this prospective randomized controlled study. Patients were divided into three groups of 80 patients each. Baseline data were comparable for all groups. Average follow-up was 18.7 months. Group 1 consisted of patients who received intravenous (IV) TXA, Group 2 patients were those who received TXA in a PAMC injection for topical administration, and Group 3 consisted of patients who received a combination of both intravenous and topical administration of TXA. Primary outcomes were postoperative hemoglobin drop and amount of suction drainage. Secondary outcomes were estimated blood loss (EBL), postoperative transfusion rate, and complications.

Results

The mean postoperative hemoglobin drop was significantly lower in Group 3 (2.13 ± 0.77 g/dL, p=0.004), and there was no difference between Group 1 and Group 2 (2.56 ± 1.07 g/dL vs 2.55 ± 0.86 g/dL, p=0.999). The mean drainage amount was significantly lower in Group 3 (326.58 ± 57.55 ml, p<0.001), and there was no difference between Group 1 and Group 2 (367.93 ± 87.26 ml vs 397.66 ± 104.10 ml, p=0.072). Similarly, the mean EBL was significantly lower in Group 3 (p=0.003), and there was no significant difference between Group 1 and Group 2 (p=0.992). There were no significant differences in requirement for postoperative transfusion rate or incidence of complications among the three groups.

Conclusion

TXA mixed in a PAMC injection showed a similar effect to IV administration of TXA following TKA. Furthermore, combined use of both IV and PAMC injection provided better perioperative bleeding control with similar safety in patients without relevant comorbidities.

Trial registration

WHO ICTRP identifier KCT0005703. Retrospectively registered: 12/24/2020

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04551-8.