Antiphospholipid Syndrome Increases Postoperative Complications After Total Hip and Knee Arthroplasty

BACKGROUND

Antiphospholipid syndrome (APS) is a systemic autoimmune condition that predisposes patients to venous thromboembolism (VTE). Although many studies have explored risk factors for VTE after joint reconstructive procedures, the impact of APS is still unclear.

MATERIALS AND METHODS

A retrospective cohort study was conducted using TriNetX, a health care database that includes 442,494 patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA). Ninety-day postoperative complications and 1- and 2-year surgical complications were compared between patients with and without preexisting APS. Patients underwent propensity score matching in a 1:1 ratio based on relevant comorbidities.

RESULTS

Patients undergoing THA or TKA with APS, compared with those without, had higher rates of deep venous thrombosis (hip: 9.2% vs 6.0%, odds ratio, 1.589, P=.022; knee: 10.5% vs 4.1%, odds ratio, 2.763, P<.001), pulmonary embolism (hip: 6.9% vs 3.6%, odds ratio, 1.992, P=.005; knee: 8.4% vs 3.0%, odds ratio, 2.989, P<.001), and anemia (hip: 24.8% vs 18.6%, odds ratio, 1.447, P=.004; knee: 18.5% vs 13.9%, odds ratio, 1.406, P=.007). Patients undergoing THA with APS also had higher rates of urinary tract infection (5.0% vs 2.8%, odds ratio, 1.842, P=.029) and pneumonia (3.7% vs 1.8%, odds ratio, 2.119, P=.025). APS did not impact rates of surgical complications or revision surgery.

CONCLUSION

Overall, APS heightens patients' risk for complications after THA and TKA. Specific anticoagulation protocols and preoperative risk stratification should be implemented to reduce the risk of adverse events. [Orthopedics. 202;4x(x):xx-xx.].

Venous Thromboembolism in Total Hip and Total Knee Arthroplasty

Importance

The optimal pharmacologic thromboprophylaxis agent after total hip and total knee arthroplasty is uncertain and consensus is lacking. Quantifying the risk of postoperative venous thromboembolism (VTE) and bleeding and evaluating comparative effectiveness and safety of the thromboprophylaxis strategies can inform care.

Objective

To quantify risk factors for postoperative VTE and bleeding and compare patient outcomes among pharmacological thromboprophylaxis agents used after total hip and knee arthroplasty.

Design, Setting, and Participants

This retrospective cohort study used data from a large health care claims database. Participants included patients in the United States with hip or knee arthroplasty and continuous insurance enrollment 3 months prior to and following their surgical procedure. Patients were excluded if they received anticoagulation before surgery, received no postsurgical pharmacological thromboprophylaxis, or had multiple postsurgery thromboprophylactic agents. In a propensity-matched analysis, patients receiving a direct oral anticoagulant (DOAC) were matched with those receiving aspirin.

Exposures

Aspirin, apixaban, rivaroxaban, enoxaparin, or warfarin.

Main Outcomes and Measures

The primary outcome was 30-day cumulative incidence of postdischarge VTE. Other outcomes included postdischarge bleeding.

Results

Among 29 264 patients included in the final cohort, 17 040 (58.2%) were female, 27 897 (95.2%) had inpatient admissions with median (IQR) length of stay of 2 (1-2) days, 10 948 (37.4%) underwent total hip arthroplasty, 18 316 (62.6%) underwent total knee arthroplasty; and median (IQR) age was 59 (55-63) years. At 30 days, cumulative incidence of VTE was 1.19% (95% CI, 1.06%-1.32%) and cumulative incidence of bleeding was 3.43% (95% CI, 3.22%-3.64%). In the multivariate analysis, leading risk factors associated with increased VTE risk included prior VTE history (odds ratio [OR], 5.94 [95% CI, 4.29-8.24]), a hereditary hypercoagulable state (OR, 2.64 [95% CI, 1.32-5.28]), knee arthroplasty (OR, 1.65 [95% CI, 1.29-2.10]), and male sex (OR, 1.34 [95% CI, 1.08-1.67]). In a propensity-matched cohort of 7844 DOAC-aspirin pairs, there was no significant difference in the risk of VTE in the first 30 days after the surgical procedure (OR, 1.14 [95% CI, 0.82-1.59]), but postoperative bleeding was more frequent in patients receiving DOACs (OR, 1.36 [95% CI, 1.13-1.62]).

Conclusions and Relevance

In this cohort study of patients who underwent total hip or total knee arthroplasty, underlying patient risk factors, but not choice of aspirin or DOAC, were associated with postsurgical VTE. Postoperative bleeding rates were lower in patients prescribed aspirin. These results suggest that thromboprophylaxis strategies should be patient-centric and tailored to individual risk of thrombosis and bleeding.

Prevalence of Cigarette Smoking among Professionally Active Adult Population in Poland and Its Strong Relationship with Cardiovascular Co-Morbidities-POL-O-CARIA 2021 Study

Smoking is a leading cause of preventable mortality. It affects both the health and economic situation within societies. The aim of the study is to perform an epidemiological analysis of smoking among professionally active adults in Poland in the years 2016–2020 and its Strong Relationship with Cardiovascular Co-morbidities. The article retrospectively analyzed the records of 1,450,455 who underwent occupational medicine examinations between 2016 and 2020. Statistical analyses performed using IBM SPSS Statistics 25 software were performed. In general, irrespective of the year of measurement, 11.6% of women and 17.1% of men declared smoking. After sorting by year of measurement, we found that the percentage of female smokers was decreasing, while that of males remained relatively consistent. In the case of BMI, it was found that among tobacco smokers the percentage of people with normal body weight decreases with successive years of measurement, while the percentage of overweight and level I obesity increases. Moreover, we analyzed in detail the occurrence of particular comorbidities in the group of people who declared smoking. The most common diseases in this group were: arterial hypertension (39%), lipid disorders (26.7%), and hypertension and lipid disorders (16.5%). Active preventive measures are necessary to reduce the number of smokers and the negative impact of smoking on the occurrence of comorbid diseases.

Tobacco control policies and smoking among older adults: a longitudinal analysis of 10 European countries

BACKGROUND AND AIMS

The impact of tobacco control on European older adults has not been studied, despite evidence that smoking cessation at old age can bring significant life expectancy gains. Our aim was to evaluate the impact of tobacco control policies on smoking among older adults in Europe from 2004 to 2013.

DESIGN

We used longitudinal data from the Survey of Health, Ageing and Retirement in Europe (SHARE, aged 50+ years) from four waves from 2004 to 2013. We used logistic regression models with clustered standard errors to determine whether the implementation of tobacco control policies was associated with changes in smoking status. Furthermore, we studied whether these associations varied by socio-demographic characteristics. Regression coefficients were converted to changes the probability of smoking [marginal effects (ME)].

MEASUREMENTS

Smoking status was the dependent variable, and the Tobacco Control Scale (TCS) was the explanatory variable, overall and by its main policy components (pricing and smoke-free policies). Covariates included age, sex, education and country and wave fixed-effects.

FINDINGS

A 10-point increase in TCS was associated with a lower probability of smoking by 1.6 percentage points [95% confidence interval (CI) = -3.208, -0.056] for those aged 50-65, but not for older Europeans. Among those with primary school or no education, the associated drop was of 1.5 percentage points (95% CI = -2.751, -0.253). By contrast, no significant relation between TCS and smoking was observed among those with high education. Higher TCS scores for pricing (ME = -0.636, 95% CI = -0.998, -0.275) and smoke-free policies (ME = -0.243, 95% CI = -0.445, -0.041) were associated with a significantly lower probability of smoking (P = 0.001 and P = 0.018, respectively).

CONCLUSION

Increases in tobacco taxes and smoke-free policies are significantly related with a reduction in smoking among European older adults, suggesting potential health gains for this rising share of the population. These policies may be more effective among the lowest educated.

Venous Thromboembolism and Bleeding Adverse Events in Lower Leg, Ankle, and Foot Orthopaedic Surgery with and without Anticoagulants

BACKGROUND

Currently, there is insufficient knowledge about the benefits of anticoagulant use for primary prevention of venous thromboembolism (VTE) and its inherent risk of bleeding adverse events in patients undergoing surgery distal to the knee.

METHODS

The study included patients who had undergone an orthopaedic procedure distal to the tibial articular surface when they were 18 years of age or older. Using retrospective information from a tertiary care referral center, we compared patient demographics, clinical findings, diagnostic reports, procedures performed, and the rate of symptomatic VTE and bleeding adverse events between patients who had and those who had not received anticoagulant prophylaxis. Propensity score matching was used to minimize selection bias due to prophylactic treatment allocation.

RESULTS

A total of 5,286 patients who had received anticoagulant prophylaxis for below-the-knee surgery were successfully matched with 5,286 patients who had not received anticoagulant prophylaxis for such surgery. After propensity score matching, the standardized difference between the groups was <0.1 for all baseline characteristics, indicating a negligible difference between the groups. Patients who received anticoagulant prophylaxis had a significantly lower risk of developing a VTE compared with patients who did not (39 patients [0.7%] versus 99 patients [1.9%]), with an odds ratio (OR) of 0.38 (95% confidence interval [CI], 0.25 to 0.56; p < 0.001). In contradistinction, patients who received anticoagulant prophylaxis had a significantly higher risk of developing a bleeding adverse event than those who did not (115 [2.2%] versus 55 [1.0%]; OR, 2.18 [95% CI, 1.55 to 3.09]; p < 0.001).

CONCLUSIONS

Anticoagulant prophylaxis reduced the risk of VTE after surgery distal to the tibial articular surface by 3-fold but resulted in a concomitant 2-fold increase in the risk of a bleeding adverse event. Large-scale, prospective studies are necessary to better understand the true incidence of such events, associated patient-specific risk factors, efficacy of various thromboprophylactic regimens, and patient-reported implications of such events.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Rivaroxaban for venous thromboembolism prevention after major orthopedic surgery: translating trial data into routine clinical practice

An established standard of care for the prevention of venous thromboembolism after major orthopedic surgery has been subcutaneous low-molecular-weight heparin. The non-vitamin K antagonist oral anticoagulant rivaroxaban has demonstrated superior efficacy and similar safety to all tested regimens of enoxaparin in large Phase III clinical studies of venous thromboembolism prevention after elective hip and knee arthroplasty. Despite regulatory approval of rivaroxaban for this indication, concerns remain among physicians regarding its optimal and effective use in routine clinical practice. Real-life studies, such as XAMOS and ORTHO-TEP, are providing physicians with more information on the routine use of rivaroxaban for venous thromboembolism prevention after orthopedic surgery, helping to establish its safety and effectiveness in everyday clinical care. Among the most important issues are the risk of bleeding complications, wound healing, timing of first dose, impact of type of anesthesia on thromboprophylaxis effectiveness, patient comorbidities and comedication use, periprocedural management, associated costs, and clinical outcomes in trauma-related fractures. Many of these issues are difficult to study in randomized, double-blind, Phase III trials, and can be assessed more readily using real-life data. In particular, real-life or noninterventional studies lack many of the strict inclusion and exclusion criteria associated with Phase III trials and involve unselected patients who often present with significant comorbidities or comedication use.

Rivaroxaban: an oral factor Xa inhibitor

BACKGROUND

Currently available anticoagulants utilized for venous thromboembolism (VTE) treatment and prevention and stroke prevention in patients with atrial fibrillation (AF) have proven effectiveness but are not optimally utilized because of barriers such as the need for subcutaneous administration and requisite routine laboratory monitoring. Rivaroxaban, a novel oral Xa inhibitor, is an alternative to standard therapies utilized for VTE prevention after elective orthopedic surgery, primary and secondary stroke prevention in nonvalvular AF, VTE treatment after an acute VTE event, and secondary prevention after the acute coronary syndromes (ACS).

OBJECTIVE

This article reviews the pharmacology, efficacy, and tolerability of rivaroxaban for VTE prophylaxis in post-orthopedic surgery and medically ill patients, stroke prevention in nonvalvular AF, adjunctive therapy in patients with ACS, and VTE treatment.

METHODS

International Pharmaceutical Abstracts and EMBASE were searched for English-only clinical trials and reviews published between 1970 and March 15, 2012. PubMed was searched for articles published between 1970 and June 30, 2012. Additional trials and reviews were identified from the citations of published articles.

RESULTS

Eighty-nine publications were identified: 10 clinical trials and 1 meta-analysis were used to obtain efficacy and tolerability data, and 1 analysis of pooled data from the clinical trials was included; 17 pharmacokinetic, pharmacodynamic, and drug-drug interaction studies were included; and 5 cost-analyses were reviewed. These data showed rivaroxaban to be noninferior to enoxaparin for thromboprophylaxis of VTE after total knee and total hip replacement surgery. It was also shown to be noninferior to vitamin K antagonist therapy for primary and recurrent stroke prevention in nonvalvular AF as well as for the treatment of VTE after an acute deep vein thrombosis or pulmonary embolism. It also showed benefit in lowering the risk for major adverse cardiovascular events after ACS. Differences in major bleeding rates were not statistically significant between rivaroxaban and comparators across the various studies, with the exception of ACS, in which there were higher rates of non-coronary artery bypass graft surgery related bleeding and intracranial hemorrhage.

CONCLUSIONS

Based on the findings of the studies reported in this review, rivaroxaban is an effective option for the prevention of VTE after orthopedic surgery, stroke prevention for nonvalvular AF, and treatment of VTE. At this time, rivaroxaban cannot be recommended for secondary risk reduction after ACS because of the increased bleeding risk.

Simultaneous bilateral total knee arthroplasty. A multicenter feasibility study

INTRODUCTION

The value and risk of simultaneous total knee arthroplasty (TKA) in patients with bilateral knee arthritis is a subject of debate.

HYPOTHESES

The risk of complications following simultaneous bilateral TKA will be increased compared to the rates published in the literature for unilateral TKA, and the clinical and functional outcomes will be poorer in this particular group.

MATERIALS AND METHODS

One hundred and twenty-three patients who underwent simultaneous bilateral TKA between 2005 and 2011 in five specialized, high volume centers were evaluated. The files were analyzed retrospectively after a mean 33 months of follow-up.

RESULTS

The mean hospital stay was 11 days. Mean blood loss was 4.1g/dL. A postoperative transfusion was performed in 68 patients (55%), with a mean 3.1 units of blood. The mean global IKS score increased from 90 to 150 points. Eighty patients would agree to undergo simultaneous bilateral TKA again (65%), and 70 would recommend this procedure to others (57%).

DISCUSSION

The hypothesis was not confirmed: the risk of complications was not increased compared to the generally accepted risk of a unilateral procedure. The risk of complications in this study was very similar to that published in the literature for the same therapeutic strategy. Therefore, there is no solid medical evidence to prevent recommending this strategy. The results of the participating centers suggest that this therapeutic approach should be continued in selected indications.

LEVEL OF EVIDENCE

IV, retrospective study.

Improving prevention and treatment of venous thromboembolism: clinical trial results

BACKGROUND

Venous thromboembolism (VTE) incurs considerable socioeconomic costs, partly owing to the fact that the treatment and prevention of VTE via effective thromboprophylaxis remains suboptimal in the inpatient and outpatient settings of many healthcare systems. A number of organizations-including the National Quality Forum, The Joint Commission, and the Centers for Medicare and Medicaid Services-have established measures to assess and reduce the healthcare burden of VTE. These improvement strategies focus on increasing the use of thromboprophylaxis, implementing existing guidelines, and improving awareness.

FINDINGS

Based on clinical trial results, the oral anti-coagulants rivaroxaban, apixaban, and dabigatran etexilate have been approved in many countries for the prevention of VTE in patients after elective hip or knee replacement surgery. Recently, dabigatran etexilate and rivaroxaban have also been approved in the US for the prevention of stroke and systemic embolism in patients with non-valvular atrial fibrillation. In addition, rivaroxaban is currently the only newer anti-coagulant that has been approved in Europe for the treatment of deep vein thrombosis and for the long-term prevention of recurrent VTE. These oral anti-coagulants have several advantages over established anti-coagulants, including no need for routine coagulation monitoring and only minimal food and drug interactions. These characteristics, together with convenient oral administration, may improve adherence and quality of life for patients, which could result in reductions in the rate of VTE.

CONCLUSIONS

These three oral agents have several advantages over established anti-coagulants and could, therefore, address the unmet needs of patients, physicians, and healthcare systems, with the potential to reduce the burden of anti-coagulant management and the occurrence of VTE.