Does thromboprophylaxis prevent venous thromboembolism after major orthopedic surgery?

Incidence and Risk Factors of Pulmonary Complications Following Femur Fracture Surgery in Patients Aged 80 Years and Older

Purpose

Femur fractures and subsequent surgical procedures are expected to increase with the growth of the older population. Despite the elevated risk of postoperative pulmonary complications in older patients, research focusing on those of very advanced age is limited. We aimed to investigate the incidence and risk factors of pulmonary complications following femur fracture surgery in patients ≥80 years.

Patients and Methods

This retrospective cohort study included patients aged ≥80 years admitted to the Orthopedic Surgery Department for femur fracture surgery between 2020 and 2022. We assessed the incidence and risk factors of postoperative pulmonary complications, defined as pneumonia, atelectasis, pulmonary edema, pleural effusion, and venous thromboembolism (VTE). We also examined risk factors for respiratory failure and 90-day mortality, using logistic regression models.

Results

The study included 479 patients with a mean age of 86.0 years, and 78.5% were women. Postoperative pulmonary complications occurred in 11.7% of patients, with pleural effusion being the most common (4.4%), followed by pneumonia and atelectasis. The incidence of VTE was 1.5%. Patients who developed pulmonary complications had significantly longer hospital stays (14 days vs 10 days; p<0.001), a greater proportion of patients needing oxygen supplementation (71.4% vs 31.4%; p<0.001), and higher all-cause 90-day mortality (14.3% vs 5.9%; p=0.042). Age, chronic lung disease, and Parkinson's disease were significant risk factors for pulmonary complications. Coronary artery disease, stroke, and prolonged surgery were significantly associated with respiratory failure, whereas internal fixation, coronary artery disease and older age were associated with 90-day mortality. Distal femur fractures were significant risk factors for VTE, while VTE prophylaxis methods were not associated with VTE risk.

Conclusion

At least one postoperative pulmonary complication occurred in 11.7% of the participants. Several comorbidities were associated with pulmonary complications, respiratory failure, and 90-day mortality, highlighting the importance of identifying these comorbidities prior to surgery.

Utilization of the Caprini risk assessment model(RAM) to predict venous thromboembolism after primary hip and knee arthroplasty: an analysis of the Healthcare Cost and Utilization Project(HCUP)

PURPOSE

This study aims to investigate the potential role of Caprini risk assessment model (RAM) in predicting the risk of venous thromboembolism (VTE) in patients undergoing total hip or knee arthroplasty (THA/TKA). No national study has investigated the role of Caprini RAM after primary THA/TKA.

METHODS

Data from The National Sample of Healthcare Cost and Utilization Project (HCUP) in 2019 were utilized for this study. The dataset consisted of 229,134 patients who underwent primary THA/TKA. Deep vein thrombosis (DVT) and pulmonary embolism (PE) were considered as VTE. The incidence of thrombosis was calculated based on different Caprini scores, and the risk of the Caprini indicator for VTE events was evaluated using a forest plot.

RESULTS

The prevalence of VTE after primary THA/TKA in the U.S. population in 2019 was found to be 4.7 cases per 1000 patients. Age, body mass index (BMI), and Caprini score showed a positive association with the risk of VTE (P < 0.05). The receiver operating characteristic (ROC) curve analysis indicated that a Caprini score of 9.5 had a sensitivity of 47.2% and a specificity of 82.7%, with an area under the curve (AUC) of 0.693 (95% CI, 0.677-0.710). The highest Youden index was 0.299. Multivariate logistic regression analysis revealed that malignancy, varicose vein, positive blood test for thrombophilia, history of thrombosis, COPD, hip fracture, blood transfusion, and age were significant risk factors for VTE. Based on these findings, a new risk stratification system incorporating the Caprini score was proposed.

CONCLUSIONS

Although the Caprini score does not seem to be a good predictive model for VTE after primary THA/TKA, new risk stratification for the Caprini score is proposed to increase its usefulness.

Risk factors for deep vein thrombosis after traumatic lower extremity fracture: A systematic review and meta-analysis

BACKGROUND

The study aimed to predict the risk factors of deep vein thrombosis of lower extremity after traumatic fracture of lower extremity, so as to apply effective strategies to prevent deep vein thrombosis of lower extremity, improve survival rate, and reduce medical cost.

METHODS

The English and Chinese literatures published from January 2005 to November 2023 were extracted from PubMed, Embase, Willey Library, Scopus, CNKI, Wanfang, and VIP databases. Statistical analysis was performed using Stata/SE 16.0 software.

RESULTS

A total of 13 articles were included in this paper, including 2699 venous thromboembolism (VTE) patients and 130,507 normal controls. According to the meta-results, 5 independent risk factors can be identified: history of VTE was the most significant risk factor for deep vein thrombosis after traumatic lower extremity fracture (risk ratio [RR] = 6.45, 95% confidence interval [CI]: 1.64-11.26); age (≥60) was the risk factor for deep vein thrombosis after traumatic lower extremity fracture (RR = 1.60, 95% CI: 1.02-2.18); long-term braking was a risk factor for deep vein thrombosis after traumatic lower extremity fracture (RR = 1.52, 95% CI: 1.11-1.93); heart failure was a risk factor for deep vein thrombosis after traumatic lower extremity fracture (RR = 1.92, 95% CI: 1.51-2.33); obesity was a risk factor for deep vein thrombosis after traumatic lower extremity fracture (RR = 1.59, 95% CI: 1.35-1.83).

CONCLUSION

The study confirmed that the history of deep vein thrombosis, age (60 + years), previous history of VTE, obesity, prolonged bed rest, and heart failure are all associated with an increased risk of VTE. By identifying these significant risk factors, we can more intensively treat patients at relatively high risk of VTE, thereby reducing the incidence of VTE. However, the limitation of the study is that the sample may not be diversified enough, and it fails to cover all potential risk factors, which may affect the universal applicability of the results. Future research should include a wider population and consider more variables in order to obtain a more comprehensive risk assessment.

Incidence and preventive treatment for deep vein thrombosis with our own preventive protocol in total hip and knee arthroplasty

The aim of the present study was to investigate the perioperative and postoperative incidence of deep vein thrombosis (DVT) and validate the effectiveness of our own preventive treatment protocol for venous thromboembolism (VTE) occurrence in lower extremity arthroplasty patients. The subjects were 1,054 patients (mean age: 74.3 years) who underwent total hip arthroplasty (THA) or total knee arthroplasty (TKA) at our institutions between April 2014 and March 2017. We examined the frequencies of pre- and post-operative DVT by lower extremity Doppler images, and the incidence rate at proximal or distal regions as well as that according to preoperative DVT status were evaluated. Preoperative DVT was detected in 6.5% (69 cases) of our cohort and those were located 1.4% (15 cases) at proximal and 5.1% (54 cases) at distal regions. A significantly higher rate of postoperative DVT development was observed in preoperative DVT+ THA patients (P = 0.0075), but not in TKA patients only with a higher tendency (P = 0.56). The overall incidence of DVT up to 2 weeks after surgeries was 27.3% (288 cases); however, the rate in proximal femur regions was suppressed to 2.8% (30 cases), and there was no symptomatic pulmonary thromboembolism (PTE) case. The results demonstrated the importance of regular Doppler examination for early detection of postoperative DVT occurrence and the following immediate treatment initiation. Our own VTE preventive treatment protocol could reduce the development of proximal DVT, and the periodic monitoring as well as prompt treatment might prevent the fatal PTE. osteoarthritis (OA), rheumatoid arthritis (RA).

Recent Advances on the Molecular Mechanism and Clinical Trials of Venous Thromboembolism

Venous thromboembolism is a condition that includes deep vein thrombosis and pulmonary embolism. It is the third most common cardiovascular disease behind acute coronary heart disease and stroke. Over the past few years, growing research suggests that venous thrombosis is also related to the immune system and inflammatory factors have been confirmed to be involved in venous thrombosis. The role of inflammation and inflammation-related biomarkers in cerebrovascular thrombotic disease is the subject of ongoing debate. P-selectin leads to platelet-monocyte aggregation and stimulates vascular inflammation and thrombosis. The dysregulation of miRNAs has also been reported in venous thrombosis, suggesting the involvement of miRNAs in the progression of venous thrombosis. Plasminogen activator inhibitor-1 (PAI-1) is a crucial component of the plasminogen-plasmin system, and elevated levels of PAI-1 in conjunction with advanced age are significant risk factors for thrombosis. In addition, it has been showed that one of the ways that neutrophils promote venous thrombosis is the formation of neutrophil extracellular traps (NETs). In recent years, the role of extracellular vesicles (EVs) in the occurrence and development of VTE has been continuously revealed. With the advancement of research technology, the complex regulatory role of EVs on the coagulation process has been gradually discovered. However, our understanding of the causes and consequences of these changes in venous thrombosis is still limited. Therefore, we review our current understanding the molecular mechanisms of venous thrombosis and the related clinical trials, which is crucial for the future treatment of venous thrombosis.

A prediction nomogram for deep venous thrombosis risk in patients undergoing primary total hip and knee arthroplasty: a retrospective study

INTRODUCTION

Deep venous thrombosis (DVT) prediction after total hip and knee arthroplasty remains challenging. Early diagnosis and treatment of DVT are crucial. This research aimed to develop a nomogram for early DVT prediction.

METHODS

A total of 317 patients undergoing primary total hip and knee arthroplasty in Sun Yat-sen Memorial Hospital were enrolled between May 2020 and September 2022. Data from May 2020 to February 2022 were used as the development datasets to build the nomogram model (n = 238). Using multivariate logistic regression, independent variables and a nomogram for predicting the occurrence of DVT were identified. Datasets used to validate the model for internal validation ranged from March 2022 to September 2022 (n = 79). The nomogram's capacity for prediction was also compared with the Caprini score.

RESULTS

For both the development and validation datasets, DVT was found in a total of 38 (15.97%) and 9 patients (11.39%) on post-operative day 7 (pod7), respectively. 59.6% patients were symptomatic DVT (leg swelling). The multivariate analysis revealed that surgical site (Knee vs. Hip), leg swelling and thrombin-antithrombin complex (TAT) were associated with DVT. The previously indicated variables were used to build the nomogram, and for the development and validation datasets, respectively. In development and validation datasets, the area under the receiver operating characteristic curve was 0.836 and 0.957, respectively. In both datasets, the predictive value of the Nomogram is greater than the Caprini score.

CONCLUSIONS

A proposed nomogram incorporating surgical site (Knee vs. Hip), leg swelling, and thrombin antithrombin complex (TAT) may facilitate the identification of patients who are more prone to develop DVT on pod7.

Serum levels of lead are associated with venous thromboembolism: a retrospective study based on the NHANES database (1999 to 2018)

Background

Venous thromboembolism (VTE) is a common clinical problem. While lead toxicity is known to affect the nervous, hematopoietic system, skeletal, and cardiovascular system, the relationship between blood lead levels and VTE remains unclear. This study explored whether there is a correlation between the levels of serum lead and VTE through a retrospective analysis based on data from the National Health and Nutrition Examination Survey (NHANES), so as to provide a reference for follow-up research and clinical practice.

Methods

According to the inclusion and exclusion criteria, subjects were enrolled from the NHANES (1999 to 2018) database and divided into a VTE group and a non-VTE group. The factors related to VTE were analyzed by single factor and multiple factor logistic regression analysis.

Results

A total of 31,081 subjects were included, of which 59 had VTE (0.19%). The higher the levels of serum lead, the higher the incidence of VTE. The univariate analysis revealed that age, male sex, history of cigarette use, hypertension, diabetes, and serum lead levels were factors associated with VTE in the population from the NHANES database. Further multivariate analysis revealed that age, history of cigarette use, hypertension, diabetes, and serum lead levels were factors associated with VTE.

Conclusions

The findings of this study suggest that higher serum levels of lead may be associated with VTE.

Risk factors for venous thromboembolism following surgical treatment of fractures: A systematic review and meta-analysis

This study aimed to determine the risk factors for postoperative venous thromboembolism (VTE) in patients treated surgically for fractures using a meta-analytic approach. Electronic searches were performed in PubMed, Embase, and the Cochrane library from inception until February 2022. The odds ratio (OR) and 95% confidence interval (CI) were applied to calculate the pooled effect estimate using the random-effects model. Sensitivity, subgroup, and publication bias tests were also performed. Forty-four studies involving 3 239 291 patients and reporting 11 768 VTE cases were selected for the meta-analysis. We found that elderly (OR: 1.72; 95% CI: 1.38-2.15; P < .001), American Society of Anesthesiologists (ASA) ≥ 3 (OR: 1.82; 95% CI: 1.46-2.29; P < .001), blood transfusion (OR: 1.82; 95% CI: 1.14-2.92; P = .013), cardiovascular disease (CVD) (OR: 1.40; 95% CI: 1.22-1.61; P < .001), elevated D-dimer (OR: 4.55; 95% CI: 2.08-9.98; P < .001), diabetes mellitus (DM) (OR: 1.36; 95% CI: 1.19-1.54; P < .001), hypertension (OR: 1.31; 95% CI: 1.09-1.56; P = .003), immobility (OR: 3.45; 95% CI: 2.23-5.32; P < .001), lung disease (LD) (OR: 2.40; 95% CI: 1.29-4.47; P = .006), obesity (OR: 1.52; 95% CI: 1.27-1.82; P < .001), peripheral artery disease (PAD) (OR: 2.13; 95% CI: 1.21-3.73; P = .008), prior thromboembolic event (PTE) (OR: 5.17; 95% CI: 3.14-8.50; P < .001), and steroid use (OR: 2.37; 95% CI: 1.73-3.24; P < .001) were associated with an increased risk of VTE. Additionally, regional anaesthesia (OR: 0.66; 95% CI: 0.45-0.96; P = .029) was associated with a reduced risk of VTE following surgical treatment of fractures. However, alcohol intake, cancer, current smoking, deep surgical site infection, fusion surgery, heart failure, hypercholesterolemia, liver and kidney disease, sex, open fracture, operative time, preoperative anticoagulant use, rheumatoid arthritis, and stroke were not associated with the risk of VTE. Post-surgical risk factors for VTE include elderly, ASA ≥ 3, blood transfusion, CVD, elevated D-dimer, DM, hypertension, immobility, LD, obesity, PAD, PTE, and steroid use.

Development and validation of a predictive nomogram for lower extremity deep vein thrombosis dislodgement in orthopedic patients

Objective

To analyze the risk factors of lower extremity deep venous thrombosis (DVT) detachment in orthopedic patients, and to establish a risk nomogram prediction model.

Methods

The clinical data of 334 patients with orthopedic DVT admitted to the Third Hospital of Hebei Medical University from January 2020 to July 2021 were retrospectively analyzed. General statistics included gender, age, BMI, thrombus detachment, inferior vena cava filter window type, filter implantation time, medical history, trauma history, operation, use of tourniquet, thrombectomy, anesthesia mode, anesthesia grade, operative position, blood loss during operation, blood transfusion, immobilization, use of anticoagulants, thrombus side, thrombus range, D-dimer content before filter implantation and during removal of inferior vena cava filter. Logistic regression was used to perform univariate and multivariate analysis on the possible factors of thrombosis detachment, screen out independent risk factors, establish a risk nomogram prediction model by variables, and internally verify the predictability and accuracy of the model.

Results

Binary logistic regression analysis showed that Short time window filter (OR = 5.401, 95% CI = 2.338–12.478), lower extremity operation (OR = 3.565, 95% CI = 1.553–8.184), use of tourniquet (OR = 3.871, 95% CI = 1.733–8.651), non-strict immobilization (OR = 3.207, 95% CI = 1.387–7.413), non-standardized anticoagulation (OR = 4.406, 95% CI = 1.868–10.390), distal deep vein thrombosis (OR = 2.212, 95% CI = 1.047–4.671) were independent risk factors for lower extremity DVT detachment in orthopedic patients (P &lt; 0.05). Based on these six factors, a prediction model for the risk of lower extremity DVT detachment in orthopedic patients was established, and the risk prediction ability of the model was verified. The C-index of the nomogram model was 0.870 (95% CI: 0.822–0.919). The results indicate that the risk nomogram model has good accuracy in predicting the loss of deep venous thrombosis in orthopedic patients.

Conclusion

The nomogram risk prediction model based on six clinical factors, including filter window type, operation condition, tourniquet use, braking condition, anticoagulation condition, and thrombosis range, has good predictive performance.

Comparison of the predictive power of the 2005 and 2010 Caprini risk assessment models for deep vein thrombosis in Chinese orthopedic patients at admission: A prospective cohort study

INTRODUCTION

Several DVT risk assessment tools have been developed and validated to stratify the patients. The 2005 and 2010 Caprini risk assessment models (RAMs) proved reliable in detecting deep vein thrombosis (DVT) and are widely used worldwide. Although the 2010 version was recently modified, the 2005 version is still more exact and popular in the surgical population. This study aimed to compare the predictive power of the 2005 and 2010 Caprini RAMs in Chinese orthopedic patients at admission and describe the incidence of DVT during hospitalization.

STUDY DESIGN

This prospective cohort study involved 2733 patients from the Arthritis Clinic and Research Center, Orthopedics and Traumatology Department, Orthopedic Oncology Department, and Spinal Surgery Department of Peking University People's Hospital from September 2018 to January 2019. The DVT risk scores and levels were determined for all patients using the 2005 and 2010 Caprini RAMs at admission. The sensitivity and specificity of the two tools were calculated. The patients were divided into the screened and unscreened groups according to whether or not a Doppler ultrasound (DUS) was performed. Depending upon the DUS results, the patients were divided into the DVT and non-DVT groups. The receiver operation characteristic (ROC) curve and the area under the curve (AUC) were evaluated to compare the predictive power.

RESULTS

Eighty-four patients had DVT in the four orthopedic departments, and the incidence of DVT was 3.1 %-17.2 %. The scores between the 2005 and 2010 Caprini RAMs differed (P < 0.001) among orthopedic patients at admission. Among DVT patients, the highest-risk patients accounted for 63.5 % and 52.9 % based on the 2005 and 2010 Caprini RAMs, respectively. The AUCs of the 2005 and 1020 Caprini RAMs were 0.669 ± 0.030 and 0.648 ± 0.032, respectively. There were no significant differences between the two ROC curves (P = 0.164).

CONCLUSION

The 2005 and 2010 Caprini RAMs showed a similar predictive power in detecting DVT, but neither met the high sensitivity criteria for screening DVT in orthopedic patients. The incidence of DVT in orthopedic patients was relatively high during hospitalization.

Clinical effectiveness and safety of aspirin and other anticoagulants for venous thromboembolism prophylaxis after major orthopedic surgery: a systematic review and meta-analysis of randomized clinical trials

Purpose

Patients undergoing major orthopedic surgeries, such as total hip replacement (THR), total knee replacement (TKR), and trauma surgery, are at an elevated risk of venous thromboembolism (VTE), causing significant morbidity and mortality. Previous studies have investigated aspirin as a thromboprophylactic agent for arthroplasty, besides trauma surgery. Therefore, we sought to analyze the efficacy of aspirin compared to that of other anticoagulants for VTE prophylaxis in patients undergoing major orthopedic surgeries.

Methods

This study was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The study protocol was registered with the PROSPERO register. Randomized controlled trials that investigated the use of aspirin for thromboprophylaxis in major orthopedic lower limb surgeries were included and analyzed. Quality analysis of the literature and level of evidence were assessed. The primary clinical outcome was VTE. Secondary clinical outcomes included mortality, bleeding events, and wound complications.

Results

Eight high-quality studies with level 2 evidence (published within 2006-2021) were included, comprising 6220 patients. The incidence of VTE with aspirin was not found to be more significant than other anticoagulants (risk ratio (RR) = 1.18, 95% CI: 0.89-1.58, P = 0.25). Regarding secondary outcomes, there were no significant differences between aspirin and other anticoagulants (mortality (RR = 1.40, 95% CI: 0.27-7.23, P = 0.69), bleeding events (RR = 0.89, 95% CI: 0.57-1.39, P = 0.61), or wound complications (RR = 0.64, 95% CI: 0.30-1.35, P = 0.24)).

Conclusion

The current meta-analysis did not show any difference between aspirin and other anticoagulants as thromboprophylactic agents in preventing VTE in patients who underwent major orthopedic surgeries.

Thrombin antithrombin complex concentration as an early predictor of deep vein thrombosis after total hip arthroplasty and total knee arthroplasty

Aim

Early predictive markers of venous thromboembolism (VTE) after total hip arthroplasty (THA)/total knee arthroplasty (TKA) remain unclear. Our study identified early predictive markers for VTE after THA/TKA.

Methods

A single-institution retrospective review study was conducted between May 2020 and April 2022 (n = 256). All patients underwent Doppler ultrasounds exam in preoperation and seventh day after surgery. Deep vein thrombosis (DVT) was defined by Doppler ultrasound of the lower extremities, which revealed thrombosis. Thrombin-antithrombin complex (TAT), thrombomodulin (TM), and plasmin-antiplasmin complex (PIC) concentration were tested from each patient’s preoperative and postoperative days 1, 4, 7, 14. These values were then accessed via receiver operating characteristic (ROC) curve analysis and further quantified the level of this risk by concentration.

Results

On postoperative day 1 (pod-1), all patients’ TAT and PIC concentrations were significantly higher than those preoperatively (p < 0.05). The levels of TAT and PIC in patients in the DVT group on pod-1 were significantly higher than those in the non-DVT group (p < 0.05). At pod-1, the TAT concentration for DVT patients was 49.47 ng/mL compared to 20.70 ng/mL for non-DVT patients, PIC was 3.72μg/mL compared to 1.65μg/mL. ROC curve analysis demonstrated that a TAT concentration of 24.3 ng/mL had a sensitivity of 87.9% and a specificity of 69.1%.

Conclusion

TAT levels on pod-1 may predict DVT early after THA/TKA, which makes it possible for early intervention to decrease the incidence of DVT.

Thromboelastography for the Prevention of Perioperative Venous Thromboembolism in Orthopedics

We have reviewed a large number of relevant literature to determine the deficiencies of orthopedics in the diagnosis and prevention of venous thromboembolism（VTE）events during the perioperative period, and found that the TEG technology has been widely used after liver transplantation, which may make up for the deficiencies. This review expounds the detection principle and latest thromboelastography (TEG) development, and highlights the advantages of TEG over previous screening methods in diagnosing hypercoagulability. By analyzing the correlation and consistency between TEG and conventional coagulation test, reliable indexes for diagnosing hypercoagulability and important parameters for guiding perioperative anticoagulation treatment were summarized. Furthermore, our work contributes to further studies of TEG in orthopedics. Based on the research results, we believe that TEG may help orthopedists to identify and predict VTE events, use anticoagulants, eventually reduce the occurrence of VTE events.

Incidence and risk factors for deep venous thrombosis of lower extremity after surgical treatment of isolated patella fractures

Background

Limited information exists on the incidence of postoperative deep venous thromboembolism (DVT) in patients with isolated patella fractures. The objective of this study was to investigate the postoperative incidence and locations of deep venous thrombosis (DVT) of the lower extremity in patients who underwent isolated patella fractures and identify the associated risk factors.

Methods

Medical data of 716 hospitalized patients was collected. The patients had acute isolated patella fractures and were admitted at the 3rd Hospital of Hebei Medical University between January 1, 2016, and February 31, 2019. All patients met the inclusion criteria. Medical data was collected using the inpatient record system, which included the patient demographics, patient’s bad hobbies, comorbidities, past medical history, fracture and surgery-related factors, hematological biomarkers, total hospital stay, and preoperative stay. Doppler examination was conducted for the diagnosis of DVT. Univariate analyses and multivariate logistic regression analyses were used to identify the independent risk factors.

Results

Among the 716 patients, DVT was confirmed in 29 cases, indicating an incidence of 4.1%. DVT involved bilateral limbs (injured and uninjured) in one patient (3.4%). DVT involved superficial femoral common vein in 1 case (3.4%), popliteal vein in 6 cases (20.7%), posterior tibial vein in 11 cases (37.9%), and peroneal vein in 11 cases (37.9%). The median of the interval between surgery and diagnosis of DVT was 4.0 days (range, 1.0-8.0 days). Six variables were identified to be independent risk factors for DVT which included age category (> 65 years old), OR, 4.44 (1.34-14.71); arrhythmia, OR, 4.41 (1.20-16.15); intra-operative blood loss, OR, 1.01 (1.00-1.02); preoperative stay (delay of each day), OR, 1.43 (1.15-1.78); surgical duration, OR, 1.04 (1.03-1.06); LDL-C (> 3.37 mmol/L), OR, 2.98 (1.14-7.76).

Conclusion

Incidence of postoperative DVT in patients with isolated patella fractures is substantial. More attentions should be paid on postoperative DVT prophylaxis in patients with isolated patella fractures. Identification of associated risk factors can help clinicians recognize the risk population, assess the risk of DVT, and develop personalized prophylaxis strategies.

Prevention of venous thromboembolism in patients undergoing major orthopedic surgery in China: a qualitative study of patients' perceptions

Background

Venous thromboembolism (VTE) is the third leading cause of cardiovascular-associated death worldwide, and VTE prevention is one of the top patient safety strategies that hospitals can adopt. This study aimed to understand patients’ perceptions of VTE prevention related to major orthopedic surgery in order to guide the clinical practice of medical staff and improve patient quality of life. Patients undergoing major orthopedic surgery should receive interventions to prevent VTE. To encourage patient participation, these interventions should be patient-centered. However, few studies have examined the perceptions of VTE prevention among patients undergoing major orthopedic surgery.

Methods

Participants were purposively selected from among patients undergoing major orthopedic surgery in the orthopedic department of a level-three, class-A hospital in Beijing, China. Data were collected through in-depth semi-structured interviews, and findings were based on a thematic content analysis. All interviews were held during each patient’s hospital stay.

Results

From eight patients who participated, the following themes were identified: (1) unclear understanding of VTE, (2) poor understanding of the severity of postoperative VTE, and (3) poor understanding of VTE prevention.

Conclusions

There are weak links in clinical care related to VTE prevention. We should aim to more completely understand patients’ needs, strengthen the health education provided to patients, and improve patient adherence to preventative measures.

Can we predict postoperative complications in elderly Chinese patients with hip fractures using the surgical risk calculator?

Purpose

Hip fractures are associated with poor prognosis in elderly patients partly due to the high rate of postoperative complications. This study was aimed to investigate whether the surgical risk calculator is suitable for predicting postoperative complications in elderly Chinese patients with hip fractures.

Methods

The incidence of postoperative complications among 410 elderly patients with hip fractures was predicted by the surgical risk calculator and then compared with the actual value. The risk calculator model was evaluated using the following three metrics: Hosmer–Lemeshow test for the goodness-of-fit of the model, receiver operating characteristic curve (ROC) (also referred as C-statistic) for the predictive specificity and sensitivity, and the Brier’s score test for predictive accuracy.

Results

Preoperative risk factors including gender, age, preoperative functional status, American Society of Anesthesiologists grade, hypertension, dyspnea, dialysis, previous cardio-vascular history, and cerebrovascular disease were positively correlated with the incidence of postoperative complications in elderly patients with hip fractures. The predicted complication incidence rate was well matched with the actual complication rate by Hosmer–Lemeshow test. The model had high sensitivity and specificity for predicting the mortality rate of these patients with a C-statistic index of 0.931 (95% CI [0.883, 0.980]). The surgical calculator model had an accuracy of 90% for predicting the reoperation rate (Brier’s score <0.01).

Conclusions

The surgical risk calculator could be useful for predicting mortality and reoperation in elderly patients with hip fracture. Patients and surgeons may use this simple calculator to better manage the preoperative risks.

Perioperative treatment of femoral neck fracture with deep venous thrombosis: A case report

Deep venous thrombosis (DVT) is an important cause of disability and mortality after major orthopedic surgery. The roles of perioperative treatment and prevention of DVT in patients with femoral neck fractures who require major surgery have not yet been well explored in Chinese clinical practice. Here we report a case of calf muscular venous thrombosis in a 55-year-old woman with femoral neck fracture before surgery. Preventive and treatment measures including the administration of heparin sodium, application of venous foot pump and placement of inferior vena cava filter were taken. The condition of the patient was stable during the perioperative period and the surgery was successful. Besides, postoperative examination showed that the femur healed well and the functional recovery was satisfactory. Our results suggest that femoral neck fracture patients combined with DVT can receive surgery after accurate preoperative assessment and proper preoperative treatment.

Incidence and risk factors for venous thromboembolism following surgical treatment of fractures below the hip: a meta-analysis

Venous thromboembolism (VTE) is a common complication after surgical treatment of fractures, which is associated with significant morbidity and mortality. Identifying the risk factors for VTE is important for preventive strategies to reduce the incidence of VTE. Therefore, we conducted a meta-analysis to evaluate the incidence of VTE and the risk factors influencing the development of VTE in patients who underwent surgery for fractures below the hip. PubMed, Embase, Web of Science, SinoMed (Chinese BioMedical Literature Service System, China) and CNKI (National Knowledge Infrastructure, China) databases were systematically searched to identify cohort or case-control studies that investigated the incidence and risk factors for VTE following surgical treatment of fractures below the hip. VTE risk ratios (RRs) were pooled by use of a fixed-effect model or a random-effect model, depending on the heterogeneity among the included studies. Heterogeneity between the studies was assessed by I² statistics. Twenty-three studies with a total of 191 294 patients who met the inclusion criteria were included in this meta-analysis. Our results demonstrated that age (≥60 years) (RR = 1·85, 95% confidence interval (CI): 1·34, 2·55; P = 0·000), previous VTE(RR = 5·25, 95% CI: 2·77, 9·96; P = 0·000), heart failure (RR = 1·74, 95% CI: 1·34, 2·27; P = 0·000), current smoking status (RR = 1·23, 95% CI: 1·07, 1·41; P = 0·004), hypertension (RR = 1·62, 95% CI: 1·27, 2·06; P = 0·000), hyperlipidaemia (RR = 2·16, 95% CI: 1·79, 2·62; P = 0·000), diabetes mellitus (RR = 1·46, 95% CI: 1·27, 1·68; P = 0·000), obesity (RR = 1·58, 95% CI: 1·35,·1·85; P = 0·000), multiple fractures (RR = 2·14, 95% CI: 1·00, 4·60; P = 0·050), varicose veins (RR = 3·07, 95% CI: 1·12, 8·47; P = 0·030), prolonged operation time (weighted mean differences (WMD) = 1·22, 95% CI: 0·63, 1·81; P = 0·000) and prolonged bed rest time (WMD = 3·12, 95% CI: 2·96, 3·29; P = 0·000) were associated with an increased risk of developing VTE. The other variables, including age (<60 years), previous smoking, immobility, pregnancy, cancer, open fractures and combination with trauma were not identified as significant risk factors for VTE. Almost all the risk factors mentioned above are in line with the known risk factors for VTE following surgery for fractures below the hip. Thus, surgeons should pay close attention to patients with these medical conditions in order to reduce the incidence of VTE following surgical treatment of fractures below the hip.

Incidence of Deep Vein Thrombosis and Pulmonary Embolism in the Elective Pediatric Orthopaedic Patient

BACKGROUND

Although venous thromboembolism (VTE) has been well studied in the pediatric trauma population, rates of VTE associated with elective pediatric orthopaedic procedures have not been addressed in current literature. The purpose of this retrospective study was to identify the incidence of VTE in the elective pediatric orthopaedic surgical population and delineate subsets of this population at greatest risk. This study may provide valuable data to begin the process of resolving the controversy surrounding deep vein thrombosis prophylaxis in the pediatric orthopaedic population.

METHODS

The Pediatric Health Information System was queried for patients admitted on an ambulatory or inpatient basis, aged below 18 years, from January 2006 to March 2011 during which an elective orthopaedic surgery was the principal procedure performed. Patients with diagnoses or procedures related to infection, trauma, malignancy, or coagulopathies were excluded. Patients admitted through the emergency department or whose orthopaedic procedure was not performed on the admission date were excluded. Age, sex, ethnicity, race, admission year, and all procedures/diagnoses were recorded. The presence of VTE at the index admission or any subsequent readmission within 90 days was recorded. All criteria were coded using ICD-9-CM codes. Generalized logistic regression analyses were used to identify factors related to VTE.

RESULTS

A total of 143,808 admissions (117,676 patients) matched the inclusion criteria. Thirty-three had a VTE during the index admission with an additional 41 at subsequent readmissions, for a total incidence of 0.0515% by admission and 0.0629% by patient. In the multivariable model, variables significantly (P<0.05) related to VTE included increasing age, admission type, diagnosis of metabolic conditions, obesity, and/or syndromes, and complications of implanted devices and/or surgical procedures. No procedure variables were significantly related to VTE in the multivariable model.

CONCLUSIONS

The incidence of VTE in this cohort of pediatric patients undergoing elective orthopaedic surgery was 0.0515%. In children, underlying diagnosis seems to be a stronger predictor of VTE than procedures performed. Diagnosis with a metabolic condition, syndrome, and/or obesity, complications of implanted devices and/or surgical procedures, older age, and admission as an inpatient were significantly related to the development of a VTE.

LEVEL OF EVIDENCE

Level IV—case series.

Clinical conundrums and challenges during geriatric orthopedic emergency surgeries

Despite so many advancements and innovations in anesthetic techniques, expectations and challenges have also grown in plenty. Cardiac, pediatric, obstetric and neuro-anesthesia have perfectly developed to fulfill the desired needs of respective patient population. However, geriatric anesthesia has been shown a lesser interest in teaching and clinical practices over the years as compared with other anesthetic sub-specialties. The large growing geriatric population globally is also associated with an increase number of elderly patients presenting for orthopedic emergency surgeries. Orthopedic emergency surgery in geriatric population is not only a daunting clinical challenge but also has numerous socio-behavioral and economic ramifications. Decision making in anesthesia is largely influenced by the presence of co-morbidities, neuro-cognitive functions and the current socio-behavioral status. Pre-anesthetic evaluation and optimization are extremely important for a better surgical outcome but is limited by time constraints during emergency surgery. The current review aims to highlight comprehensively the various clinical, social, behavioral and psychological aspects during pre-anesthetic evaluation associated with emergency orthopedic surgery in geriatric population.