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Smeets MJR, Kristiansen EB, Nemeth B, Huisman MV, Cannegieter SC, Pedersen AB. Risks of major bleeding and venous thromboembolism in patients undergoing total hip or total knee arthroplasty using therapeutic dosages of DOACs. J Thromb Thrombolysis 2024:10.1007/s11239-024-03015-9. [PMID: 39014273 DOI: 10.1007/s11239-024-03015-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/21/2024] [Indexed: 07/18/2024]
Abstract
About 1.5% of patients undergoing total hip (THA) or total knee arthroplasty (TKA) still develop postoperative venous thromboembolism (VTE), indicating that the current thromboprophylaxis strategy is not optimal. To evaluate the feasibility of therapeutic dosages of direct oral anticoagulants (DOACs) as thromboprophylaxis for high VTE risk patients, we determined the risks of major bleeding and VTE in patients who underwent THA/TKA and were treated with DOACs in therapeutic dosages for atrial fibrillation (AF). We conducted a registry-based cohort study from 2010 to 2018 in Denmark and included AF patients on therapeutic DOACs dose who underwent THA/TKA. AF patients were utilized as proxy since they have a life-long indication for therapeutic anticoagulant medication. The 49-days cumulative incidence (with death as competing risk) of major bleeding was assessed. The same was done for VTE at 49- and 90-days. 1,354 THA and TKA procedures were included. The 49-days cumulative incidence of major bleeding was 1.40% (95%Confidence Interval[CI] 0.88-2.14%). Most bleeding events occurred at the surgical site. The cumulative incidence of VTE at 49-days was 0.59% (95%CI 0.28-1.13%) and 0.74% (95%CI 0.38-1.32%) at 90-days. The incidence of major bleeding in THA/TKA patients on DOACs in therapeutic dosages was in line with previously reported incidences among THA/TKA patients on thromboprophylaxis dosages, while the incidence of VTE was relatively low. These data provide a solid basis for the design of randomized controlled trials to establish the safety and efficacy of therapeutic dosages of DOACs to prevent VTE in high-risk patients.
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Affiliation(s)
- Mark J R Smeets
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
| | - Eskild Bendix Kristiansen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Banne Nemeth
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Orthopaedic Surgery, Leiden University Medical Center, Leiden, The Netherlands
| | - Menno V Huisman
- Department of Internal Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Suzanne C Cannegieter
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Internal Medicine - Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Alma Becic Pedersen
- Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark.
- Department of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark.
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Mori Y, Tarasawa K, Tanaka H, Mori N, Fushimi K, Fujimori K, Aizawa T. Surgery on admission and following day reduces hip fracture complications: a Japanese DPC study. J Bone Miner Metab 2024:10.1007/s00774-024-01534-2. [PMID: 38987506 DOI: 10.1007/s00774-024-01534-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Accepted: 06/09/2024] [Indexed: 07/12/2024]
Abstract
INTRODUCTION The efficacy of early surgery in preventing complications among Japanese elderly patients with hip fractures requires further investigation. This study aims to use a comprehensive Japanese hip fracture case database to determine whether surgery within the day of admission and the following day reduces the incidence of complications and mortality during hospitalization in elderly hip fracture patients. MATERIALS AND METHODS We retrospectively analyzed the Japanese National Administrative DPC (Diagnosis Procedure Combination) database from April 2016 to March 2022. Approximately 1100 DPC-affiliated hospitals consistently provided medical records with consent for research. The study investigated the association between postoperative pneumonia, deep vein thrombosis, pulmonary embolism, and mortality during hospitalization after propensity score matching, focusing on surgeries conducted on the day of admission and the following day. RESULTS After one-to-one propensity score matching for age, gender, and comorbidity, we identified 146,441 pairs of patients who underwent surgery either within the day of admission and the following day or after the third day of admission. Surgery on the third day or later was independently associated with increased risks of pneumonia, deep vein thrombosis, pulmonary embolism, and mortality during hospitalization with risk ratios of 1.367 (95% CI 1.307-1.426), 1.328 (95% CI 1.169-1.508), 1.338 (95% CI 1.289-1.388), and 1.167 (95% CI 1.103-1.234), respectively. CONCLUSION A comprehensive study of elderly Japanese patients with hip fractures in the DPC database showed that surgery on admission and the following day is crucial for preventing complications like pneumonia, deep vein thrombosis, pulmonary embolism, and mortality during hospitalization.
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Affiliation(s)
- Yu Mori
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan.
| | - Kunio Tarasawa
- Department of Health Administration and Policy, Tohoku University Graduate School of Medicine, 2-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Hidetatsu Tanaka
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Naoko Mori
- Department of Radiology, Akita University Graduate School of Medicine, 1-1-1 Hondo, Akita, 010-8543, Japan
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School of Medicine and Dental Sciences, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8519, Japan
| | - Kenji Fujimori
- Department of Health Administration and Policy, Tohoku University Graduate School of Medicine, 2-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
| | - Toshimi Aizawa
- Department of Orthopaedic Surgery, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, Miyagi, 980-8574, Japan
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Xu SL, Li K, Cao WW, Chen SH, Ren SB, Zhang BF, Zhang YM. The association between admission mean corpuscular volume and preoperative deep venous thrombosis in geriatrics hip fracture: a retrospective study. BMC Musculoskelet Disord 2024; 25:40. [PMID: 38191314 PMCID: PMC10773051 DOI: 10.1186/s12891-023-07147-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 12/22/2023] [Indexed: 01/10/2024] Open
Abstract
OBJECTIVE This study evaluated the association between admission MCV and preoperative deep vein thrombosis (DVT) in geriatric hip fractures. METHODS Older adult patients with hip fractures were screened between January 2015 and September 2019. The demographic and clinical characteristics of the patients were collected at the largest trauma center in northwest China. MCV was measured at admission and converted into a categorical variable according to the quartile. Multivariate binary logistic regression and generalized additive model were used to identify the linear and nonlinear association between MCV and preoperative DVT. Analyses were performed using EmpowerStats and the R software. RESULTS A total of 1840 patients who met the criteria were finally enrolled and divided into four groups according to their MCV levels. The mean MCV was 93.82 ± 6.49 (80.96 to 105.91 fL), and 587 patients (31.9%) were diagnosed with preoperative DVT. When MCV was a continuous variable, the incidence of preoperative DVT increased with mean corpuscular volume. In the fully adjusted model, admission MCV was positively correlated with the incidence of preoperative DVT (OR: 1.03; 95% CI: 1.01-1.05; P = 0.0013). After excluding the effect of other factors, each additional 1fL of MCV increased the prevalence of preoperative DVT by 1.03 times as a continuous variable. CONCLUSION MCV was linearly associated with preoperative DVT in geriatric patients with hip fractures and could be considered a predictor of DVT risk. The MCV may contribute to risk assessment and preventing adverse outcomes in the elderly. STUDY REGISTRATION This study is registered on the website of the Chinese Clinical Trial Registry (ChiCTR: ChiCTR2200057323).
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Affiliation(s)
- Shuai-Liang Xu
- Department of Joint Surgery, Honghui Hospital, Xi'an Jiaotong University, No. 555 Youyi East Road, Beilin District, Xi'an, 710054, Shaanxi Province, China
- Xi'an Medical University, Beilin District, Xi'an, Shaanxi Province, China
| | - Kun Li
- Department of Joint Surgery, Honghui Hospital, Xi'an Jiaotong University, No. 555 Youyi East Road, Beilin District, Xi'an, 710054, Shaanxi Province, China
| | - Wen-Wen Cao
- Department of Joint Surgery, Honghui Hospital, Xi'an Jiaotong University, No. 555 Youyi East Road, Beilin District, Xi'an, 710054, Shaanxi Province, China
| | - Shao-Hua Chen
- Department of Joint Surgery, Honghui Hospital, Xi'an Jiaotong University, No. 555 Youyi East Road, Beilin District, Xi'an, 710054, Shaanxi Province, China
| | - Shang-Bo Ren
- Department of Joint Surgery, Honghui Hospital, Xi'an Jiaotong University, No. 555 Youyi East Road, Beilin District, Xi'an, 710054, Shaanxi Province, China
| | - Bin-Fei Zhang
- Department of Joint Surgery, Honghui Hospital, Xi'an Jiaotong University, No. 555 Youyi East Road, Beilin District, Xi'an, 710054, Shaanxi Province, China.
| | - Yu-Min Zhang
- Department of Joint Surgery, Honghui Hospital, Xi'an Jiaotong University, No. 555 Youyi East Road, Beilin District, Xi'an, 710054, Shaanxi Province, China
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Wang Z, Lu Y, Wang P, Fei C, Li S, Xue H, Li Z, Wang Q, Zhang K, Ma T. Suboptimal Use of DOACs Post-Discharge for Geriatric Hip Fractures with Isolated Calf Deep Vein Thrombosis: Do Clinician Prescribing Preferences and Patient Compliance Alters Clinical Outcomes? Clin Interv Aging 2023; 18:1423-1436. [PMID: 37663122 PMCID: PMC10473050 DOI: 10.2147/cia.s421422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Accepted: 08/06/2023] [Indexed: 09/05/2023] Open
Abstract
Introduction This study aimed to examine the impacts of DOACs compliance and prescribing preferences on clinical outcomes in elderly hip fracture patients with isolated calf deep vein thrombosis (ICDVT). Methods We conducted a retrospective cohort study that evaluated 702 patients who underwent surgical treatment combined with ICDVT in an academic university hospital between January 2016 and October 2021. DOACs compliance was investigated through telephone and outpatient follow-up, and ICDVT clinical outcomes were collected 30 and 90 days post-discharge, respectively. Variables of interest were collected through the electronic medical record system, and data were analyzed after adjusting for predictors of non-completely dissolved (CD) of ICDVT. Results The DOACs compliance survey revealed that 375 (53.42%) patients were fully adherent, 270 (38.46%) were fairly adherent, and 57 (8.12%) were poorly adherent. Approximately 62% of patients had ICDVT dissipation within 30 days after discharge, reaching 94% within 90 days. DOACs QD/BID regimen is often based on economic status, activity capacity, discharge destination and post-operative weight-bearing activities (p<0.05).The mechanism of injury, ASA classification, surgical technique and timing of ICDVT formation were significantly correlated with DOACs 14/28 days regimen (p<0.05).Multivariate analysis revealed that rural patients [OR 1.518 (95% CI, 1.117-2.236)], pre-operative ICDVT[OR 2.816 (95% CI, 1.862-4.259)] and thrombus length [OR 1.157 (95% CI, 1.263-1.821)] were ICDVT risk factors for non-CD. Furthermore, DOACs fair compliance [OR 0.087 (95% CI, 0.042-0.178)], DOACs full compliance [OR 0.283 (95% CI, 0.139-0.579)], and hospitalization duration [OR 0.793 (95% CI, 0.694-0.907)] were ICDVT protective factors for CD. Conclusion Better compliance with DOACs benefits early ICDVT dissipation, but final clinical outcomes have to be validated with longer follow-up periods. When managing elderly patients with hip fractures, indications for anticoagulation should be considered and individualized protocols should be used.
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Affiliation(s)
- Zhimeng Wang
- Department of Orthopedics and Traumatology, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, 710000, People’s Republic of China
| | - Yao Lu
- Department of Orthopedics and Traumatology, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, 710000, People’s Republic of China
| | - Pengfei Wang
- Department of Orthopedics and Traumatology, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, 710000, People’s Republic of China
| | - Chen Fei
- Department of Orthopedics and Traumatology, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, 710000, People’s Republic of China
| | - Shuhao Li
- Department of Orthopedics and Traumatology, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, 710000, People’s Republic of China
| | - Hanzhong Xue
- Department of Orthopedics and Traumatology, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, 710000, People’s Republic of China
| | - Zhong Li
- Department of Orthopedics and Traumatology, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, 710000, People’s Republic of China
| | - Qian Wang
- Department of Orthopedics and Traumatology, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, 710000, People’s Republic of China
| | - Kun Zhang
- Department of Orthopedics and Traumatology, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, 710000, People’s Republic of China
| | - Teng Ma
- Department of Orthopedics and Traumatology, Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, 710000, People’s Republic of China
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Yagi T, Mannheimer B, Reutfors J, Ursing J, Giunta DH, Kieler H, Linder M. Bleeding events among patients concomitantly treated with direct oral anticoagulants and macrolide or fluoroquinolone antibiotics. Br J Clin Pharmacol 2023; 89:887-897. [PMID: 36098510 PMCID: PMC10092847 DOI: 10.1111/bcp.15531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 08/11/2022] [Accepted: 08/19/2022] [Indexed: 01/18/2023] Open
Abstract
Fluoroquinolones and macrolides may, due to a potential drug-drug interaction, increase the concentration of any concomitantly administered direct oral anticoagulant (DOAC) and thereby increase the risk of severe bleeding. However, clinical evidence for such an effect is scarce. The present study aimed to evaluate the association between the use of fluoroquinolones or macrolides and bleeding events in patients with concomitant DOAC use. This was a nationwide cohort study including 19 288 users of DOACs in 2008-2018 using information from Swedish national health registers. We compared the incidence of bleeding events associated with use of fluoroquinolones or macrolides using doxycycline as a negative control. Cox regression was used to calculate crude and adjusted hazard ratios (aHRs) in time windows of various length of follow-up after the start of antibiotic use. The incidence rates for fluoroquinolones and macrolides ranged from 12 to 24 and from 12 to 53 bleeding events per 100 000 patients in the investigated time windows. The aHRs (95% confidence interval) for use of fluoroquinolones and macrolides were 1.29 (0.69-2.44) and 2.60 (0.74-9.08) at the concomitant window, 1.31 (0.84-2.03) and 1.79 (0.75-4.29) at 30 days, and 1.34 (0.99-1.82) and 1.28 (0.62-2.65) at 150 days, respectively. With regard to fluoroquinolones, the present study suggests that the risk of bleeding when combined with DOACs, if any, is small. Codispensation of macrolides in patients on DOACs was not associated with an increased risk of bleeding. However, due to the small number of macrolide users, the results must be interpreted with caution.
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Affiliation(s)
- Tatsuya Yagi
- Department of Medicine Solna, Centre for Pharmacoepidemiology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Buster Mannheimer
- Department of Clinical Science and Education at Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Johan Reutfors
- Department of Medicine Solna, Centre for Pharmacoepidemiology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Johan Ursing
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Diego Hernan Giunta
- Department of Medicine Solna, Centre for Pharmacoepidemiology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Helle Kieler
- Department of Medicine Solna, Centre for Pharmacoepidemiology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Marie Linder
- Department of Medicine Solna, Centre for Pharmacoepidemiology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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Xue Z, Tu W, Gao J, Dong Z, Yuan J, Lang J. Optimal preoperative timing for prevention of deep vein thrombosis (DVT) in patients over 60 years of age with intertrochanteric fractures. Eur J Trauma Emerg Surg 2022; 48:4197-4203. [PMID: 35445814 DOI: 10.1007/s00068-022-01969-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 03/15/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE To investigate the incidence and risk factors of preoperative DVT in elderly patients with intertrochanteric fracture of the femur and determine the optimal preoperative time. METHODS Electronic medical records of 358 patients over 60 years of age with intertrochanteric fractures from May 1, 2016, to May 1, 2019, were retrospectively analyzed. The preoperative group was divided into DVT and non-DVT. Univariate analysis was used for preliminary comparison, and multivariate logistic regression analysis was used to identify independent risk factors associated with DVT development. ROC curve was drawn to analyze the specificity and sensitivity of risk factors for DVT diagnosis. The diagnostic value of the model was analyzed by the ROC curve of multivariable combined diagnosis. RESULTS A total of 358 patients who met the criteria were enrolled. The total prevalence of DVT before surgery was 8.38%. Multivariate logistic regression analysis showed that smoking status, preoperative time, albumin (ALB), D-dimer level, diabetes mellitus, and hypertension were independent risk factors for preoperative DVT. Preoperative time has the best sensitivity and specificity for diagnosing the occurrence of preoperative DVT. The ROC curve analysis model of multivariable combined diagnosis has a better diagnostic value. CONCLUSIONS In this study, elderly patients with intertrochanteric femur fracture had a higher incidence of deep vein thrombosis before surgery. Early identification of DVT-related risk factors may contribute to individualized risk assessment and preventing adverse outcomes in patients with intertrochanteric fractures.
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Affiliation(s)
- ZhiQiang Xue
- Department of Orthopaedics, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325035, Zhejiang Province, China
| | - WangJie Tu
- Department of Orthopaedics, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325035, Zhejiang Province, China
| | - JianQing Gao
- Department of Orthopaedics, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325035, Zhejiang Province, China
| | - ZeTao Dong
- Department of Orthopaedics, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325035, Zhejiang Province, China
| | - JianDong Yuan
- Department of Orthopaedics, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325035, Zhejiang Province, China
| | - JunZhe Lang
- Department of Orthopaedics, First Affiliated Hospital of Wenzhou Medical University, Wenzhou, 325035, Zhejiang Province, China.
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Emergency Department Visits After Total Joint Arthroplasty for Concern for Deep Vein Thromboses. J Am Acad Orthop Surg 2021; 29:e1193-e1199. [PMID: 33443385 DOI: 10.5435/jaaos-d-20-00878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 12/16/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Concern for deep vein thrombosis (DVT) is the most common reason for emergency department (ED) referral after total joint arthroplasty (TJA) at our institution. We aim to investigate the referral pathway, together with the cost and outcomes associated with patients who access an ED because of concern for DVT after TJA. METHODS We reviewed a consecutive series of all primary hip and knee arthroplasty patients who accessed the ED for concern for DVT within 90 days of surgery over a one-year period. The referral source and costs associated with the ED visit were collected. A propensity-matched control cohort (n = 252) that was not referred to the ED for DVT was used to compare patient-reported outcomes measures. RESULTS In 2018, 108/10,445 primary TJA patients (1.0%) accessed the ED for concern about DVT. The most common reason for accessing the ED was self-referral (69, 64%), followed by orthopaedic on-call referral (21, 19%). Only 15 patients (14%) were found to have ultrasonography evidence of DVT. The mean cost for accessing the ED for DVT for patients with public insurance was $834 (range $394-$2,877). When compared with the control cohort, patients who accessed the ED for DVT had significantly lower postoperative functionality scores (52.5 versus 65.9, P < 0.001). DISCUSSION At our institution, 1% of patients who undergo primary TJA accessed the ED for concern for DVT at substantial cost, with only a small portion testing positive for DVT. Self-referral is by far the most common pathway. Additional investigations will be aimed at determining better pathways for DVT work-up, while ensuring appropriate management.
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Brown T, Yeoh SE, Pang D, Gabbott B. Interventions for the primary prevention of venous thromboembolism for hip fracture surgery. Hippokratia 2021. [DOI: 10.1002/14651858.cd015011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Tamara Brown
- Usher Institute; The University of Edinburgh; Edinburgh UK
| | - Su Ern Yeoh
- BHF Glasgow Cardiovascular Research Centre (GCRC); University of Glasgow; Glasgow UK
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Thiengwittayaporn S, Budhiparama N, Tanavalee C, Tantavisut S, Sorial RM, Li C, Kim KI. Asia-Pacific venous thromboembolism consensus in knee and hip arthroplasty and hip fracture surgery: Part 3. Pharmacological venous thromboembolism prophylaxis. Knee Surg Relat Res 2021; 33:24. [PMID: 34384504 PMCID: PMC8359614 DOI: 10.1186/s43019-021-00100-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 04/04/2021] [Indexed: 12/12/2022] Open
Affiliation(s)
- Satit Thiengwittayaporn
- Department of Orthopaedic Surgery, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Dusit, Bangkok, Thailand
| | - Nicolaas Budhiparama
- Nicolaas Institute of Constructive Orthopaedics Research and Education Foundation for Arthroplasty and Sports Medicine, Medistra Hospital, Jakarta, Indonesia
| | - Chotetawan Tanavalee
- Department of Orthopaedic Surgery, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Saran Tantavisut
- Department of Orthopaedic Surgery, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Rami M Sorial
- Department of Orthopaedics, Nepean Hospital, Penrith, New South Wales, Australia
| | - Cao Li
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Xinjiang, China
| | - Kang-Il Kim
- Department of Orthopaedic Surgery, Center for Joint Diseases, Kyung Hee University Hospital at Gangdong, 892 Dongnam-ro, Gangdong-gu, Seoul, 134-727, South Korea. .,Department of Orthopaedic Surgery, School of Medicine, Kyung Hee University, Seoul, South Korea.
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Terakami T, Nagaya S, Hayashi K, Furusho H, Fujino N, Kato T, Asakura H, Morishita E. Effect on Plasma Protein S Activity in Patients Receiving the Factor Xa Inhibitors. J Atheroscler Thromb 2021; 29:1059-1068. [PMID: 34334529 PMCID: PMC9252639 DOI: 10.5551/jat.62951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
AIMS Measurement of protein S (PS) activity in patients taking direct oral anticoagulants (DOACs) using reagents based on a clotting assay results in falsely high PS activity, thus masking inherited PS deficiency, which is most frequently seen in the Japanese population. In this study, we investigated the effect of factor Xa (FXa) inhibitors on PS activity using the reagent on the basis of the chromogenic assay, which was recently developed in Japan. METHODS The study enrolled 152 patients (82 males and 70 females; the average age: 68.5±14.0 years) receiving three FXa inhibitors (rivaroxaban, edoxaban, and apixaban). PS activity was measured using the reagents on the basis of the clotting and chromogenic assays. RESULTS PS activity measured by the clotting assay reagents exhibited falsely high values depending on the plasma concentrations of FXa inhibitors in patients taking either rivaroxaban or edoxaban. However, none of the three FXa inhibitors affected PS activity when measured using the chromogenic assay. CONCLUSION In patients taking rivaroxaban or edoxaban, inherited PS deficiency is likely missed because the levels of PS activity measured using the reagents based on the clotting assay are falsely high. However, we report that three FXa inhibitors do not affect PS activity measured by the chromogenic assay. When measuring the levels of PS activity in patients undergoing DOACs, the principles of each reagent should be understood. Furthermore, plasma samples must be collected at the time when plasma concentrations of DOACs are lowest or the DOAC-Stop reagent should be used.
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Affiliation(s)
- Takako Terakami
- Department of Clinical Laboratory Science, Division of Health Sciences, Graduate School of Medical Science, Kanazawa University.,Department of Clinical Laboratory, Kanazawa University Hospital
| | - Satomi Nagaya
- Department of Clinical Laboratory Science, Division of Health Sciences, Graduate School of Medical Science, Kanazawa University
| | - Kenshi Hayashi
- Department of Clinical Laboratory Science, Division of Health Sciences, Graduate School of Medical Science, Kanazawa University
| | - Hiroshi Furusho
- Department of Cardiology, Ishikawa Prefectural Central Hospital
| | - Noboru Fujino
- Department of Clinical Laboratory Science, Division of Health Sciences, Graduate School of Medical Science, Kanazawa University.,Department of Cardiology, Kanazawa University Hospital
| | - Takeshi Kato
- Department of Cardiology, Kanazawa University Hospital
| | | | - Eriko Morishita
- Department of Clinical Laboratory Science, Division of Health Sciences, Graduate School of Medical Science, Kanazawa University.,Department of Hematology, Kanazawa University Hospital
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Georgeades C, Van Arendonk K, Gourlay D. Venous thromboembolism prophylaxis after pediatric trauma. Pediatr Surg Int 2021; 37:679-694. [PMID: 33462655 DOI: 10.1007/s00383-020-04855-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/29/2020] [Indexed: 11/24/2022]
Abstract
In recent years, there has been an increased focus on developing and validating venous thromboprophylaxis guidelines in the pediatric trauma population. We review the current literature regarding the incidence of and risk factors for venous thromboembolism (VTE) and the use of prophylaxis in the pediatric trauma population. Risk factors such as age, injury severity, central venous catheters, mental status, injury type, surgery, and comorbidities can lead to a higher incidence of VTE. Risk stratification tools have been developed to determine whether mechanical and/or pharmacologic prophylaxis should be implemented depending on the degree of VTE risk. When VTE risk is high, pharmacologic prophylaxis, such as with low molecular weight heparin, is often initiated. However, the timing and duration of VTE prophylaxis is dependent on patient factors including ambulatory status and contraindications such as bleeding. In addition, the utility of screening ultrasound for VTE surveillance has been evaluated and though they are not widely recommended, no formal guidelines exist. While more research has been done in recent years to assess the most appropriate type, timing, and duration of VTE prophylaxis, further studies are warranted to create optimal guidelines for decreasing the risk of VTE after pediatric trauma.
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Affiliation(s)
- Christina Georgeades
- Division of Pediatric Surgery, Children's Wisconsin, 999 N 92nd Street, Suite 320, Milwaukee, WI, 53226, USA. .,Department of Surgery, Medical College of Wisconsin, 8701 W. Watertown Plank Road, Milwaukee, WI, 53226, USA.
| | - Kyle Van Arendonk
- Division of Pediatric Surgery, Children's Wisconsin, 999 N 92nd Street, Suite 320, Milwaukee, WI, 53226, USA
| | - David Gourlay
- Division of Pediatric Surgery, Children's Wisconsin, 999 N 92nd Street, Suite 320, Milwaukee, WI, 53226, USA
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Nemeth B, Nelissen R, Arya R, Cannegieter S. Preventing VTE following total hip and knee arthroplasty: Is prediction the future? J Thromb Haemost 2021; 19:41-45. [PMID: 33043553 PMCID: PMC7839761 DOI: 10.1111/jth.15132] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 09/21/2020] [Accepted: 09/28/2020] [Indexed: 12/15/2022]
Abstract
Venous thromboembolism (VTE) is a common complication following total hip arthroplasty (THA) and total knee arthroplasty (TKA). Many guidelines advise on the ideal pharmacological thromboprophylaxis strategy; however, despite its use, approximately 1.5% of patients still develop symptomatic VTE. Considering the large number of THAs and TKAs performed worldwide (2.5 million in total), the impact of VTE following these interventions is enormous. This paper discusses a concept how to further lower rates of VTE and bleeding complications following surgery. By stratifying patients according to their risk, we can optimize the balance between VTE and bleeding for each individual. This way, low-risk patients may be safely withheld from treatment (and avoid unnecessary bleeding complications and costs), whereas high-risk patients should receive adequate therapy (for instance, an increased thromboprophylaxis dosage and duration). An individualized strategy requires a well-functioning VTE prediction model following THA and TKA to help physicians to decide on optimal thromboprophylaxis therapy.
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Affiliation(s)
- Banne Nemeth
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
- Department of Orthopaedic SurgeryLeiden University Medical CenterLeidenThe Netherlands
| | - Rob Nelissen
- Department of Orthopaedic SurgeryLeiden University Medical CenterLeidenThe Netherlands
| | - Roopen Arya
- King’s Thrombosis CentreKing’s College Hospital NHS Foundation TrustLondonUnited Kingdom
| | - Suzanne Cannegieter
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenThe Netherlands
- Division of Thrombosis and HaemostasisLeiden University Medical CenterLeidenThe Netherlands
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13
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Stahl CC, Funk LM, Schumacher JR, Zarzaur BL, Scarborough JE. The Relative Impact of Specific Postoperative Complications on Older Patients Undergoing Hip Fracture Repair. Jt Comm J Qual Patient Saf 2020; 47:210-216. [PMID: 33451895 DOI: 10.1016/j.jcjq.2020.12.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Revised: 11/16/2020] [Accepted: 12/10/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Hip fractures affect a vulnerable population and are associated with high rates of morbidity, mortality, and resource utilization. Although postoperative complications are a known driver of mortality and resource utilization, the comparative impacts of specific complications on outcomes is unknown. This study assessed which complications are associated with the highest effects on mortality and resource utilization for older patients who undergo hip fracture repair. METHODS Patients ≥ 65 years of age who underwent hip fracture repair during 2016-2017 included in the Hip Fracture Targeted ACS NSQIP (American College of Surgeons National Surgical Quality Improvement Program) database populated the data set. Prolonged hospitalization (≥ 75th percentile) and 30-day mortality and readmission were the primary outcomes. Population attributable fractions (PAFs) were used to quantify the anticipated reduction in the primary outcomes that would result from complete prevention of 10 postoperative complications. RESULTS Of 17,755 patients across 117 hospitals, 70.9% were female, 26.0% were over age 90, 22.8% had an American Society of Anesthesiologists (ASA) score of 4-5, and 53.9% presented with an intertrochanteric fracture. Postoperative delirium affected 29.8% of patients and was associated with death (PAF 18.0%; 95% confidence interval [CI] = 13.2-22.5), prolonged hospitalization (PAF 14.3%; 95% CI = 12.7-15.8), and readmission (PAF 15.0%; 95% CI = 11.3-18.6). Pneumonia affected 4.1% of patients and was associated with death (PAF 10.9%; 95% CI = 8.9-12.8), prolonged hospitalization (PAF 4.0%; 95% CI = 3.5-4.5), and readmission (PAF 9.1%; 95% CI = 7.5-10.7). The impact of the other eight complications was comparatively small. CONCLUSION Postoperative delirium and pneumonia are the highest-impact complications for older hip fracture repair patients. These complications should be prioritized in quality improvement efforts that target this patient population.
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Mi B, Chen L, Tong D, Panayi AC, Ji F, Guo J, Ou Z, Zhang Y, Xiong Y, Liu G. Delayed surgery versus nonoperative treatment for hip fractures in post-COVID-19 arena: a retrospective study of 145 patients. Acta Orthop 2020; 91:639-643. [PMID: 32896189 PMCID: PMC8023940 DOI: 10.1080/17453674.2020.1816617] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - Following the outbreak of COVID-19 in December 2019, in China, many hip fracture patients were unable to gain timely admission and surgery. We assessed whether delayed surgery improves hip joint function and reduces major complications better than nonoperative therapy. Patients and methods - In this retrospective observational study, we collected data from 24 different hospitals from January 1, 2020, to July 20, 2020. 145 patients with hip fractures aged 65 years or older were eligible. Clinical data was extracted from electronic medical records. The primary outcomes were visual analogue scale (VAS) score and Harris Hip Score. Major complications, including deep venous thrombosis (DVT) and pneumonia within 1 month and 3 months, were collected for further analysis. Results - Of the 145 hip fracture patients 108 (median age 72; 70 females) received delayed surgery and 37 (median age 74; 20 females) received nonoperative therapy. The median time from hip fracture injury to surgery was 33 days (IQR 24-48) in the delayed surgery group. Hypertension, in about half of the patients in both groups, and cerebral infarction, in around a quarter of patients in both groups, were the most common comorbidities. Both VAS score and Harris Hip Score were superior in the delayed surgery group. At the 3-month follow-up, the median VAS score was 1 in the delayed surgery group and 2.5 in the nonoperative group (p < 0.001). Also, the percentage of complications was higher in the nonoperative group (p = 0.004 for DVT, p < 0.001 for pulmonary infection). Interpretation - In hip fracture patients, delayed surgery compared with nonoperative therapy significantly improved hip function and reduced various major complications.
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Affiliation(s)
- Bobin Mi
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China;
| | - Lang Chen
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China;
| | - Dake Tong
- Department of Orthopedics, Shanghai Ninth People’s Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China;
| | - Adriana C Panayi
- Department of Plastic Surgery, Brigham and Women’s Hospital, Harvard Medical College, Boston, USA;
| | - Fang Ji
- Department of Orthopedics, Changhai Hospital, Shanghai, China;
| | - Junfei Guo
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Zhiyong Ou
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yingze Zhang
- Department of Orthopaedic Surgery, Third Hospital of Hebei Medical University, Shijiazhuang, China
| | - Yuan Xiong
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China;
| | - Guohui Liu
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China; ,Correspondence:
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Zhang S, Htet KS, Tan XY, Wang X, Wang W, Chua W. Short-duration chemoprophylaxis might reduce incidence of deep vein thrombosis in Asian patients undergoing total knee arthroplasty. Knee Surg Relat Res 2020; 32:58. [PMID: 33148340 PMCID: PMC7640418 DOI: 10.1186/s43019-020-00077-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Accepted: 10/13/2020] [Indexed: 12/23/2022] Open
Abstract
Background Venous thromboembolism (VTE) is a serious complication that may occur after total knee arthroplasty (TKA), leading to the recommendation of routine chemoprophylaxis by international guidelines. This study aims to determine if short-duration chemoprophylaxis after TKA reduces the incidence of VTE in an Asian population. Methods A retrospective study of 316 patients who underwent unilateral primary TKA between 1 January 2011 and 31 December 2013 was conducted. All patients received mechanical prophylaxis. One hundred seventeen patients (37%) received additional chemoprophylaxis, whereas 199 patients (63%) did not. A Doppler ultrasound (DUS) of both lower limbs was conducted for all patients within 6 days after surgery (median = 3 days) to assess for both proximal and distal DVT. Chemoprophylaxis in the form of enoxaparin (low molecular weight heparin; LMWH), aspirin, or heparin was administered until patients had a normal DUS, for a median duration of 4 days. Patients were followed up clinically for a minimum of 6 months to monitor for delayed or recurrent VTE and at least 2 years for patient-reported outcome measures. Results Overall, 24 patients (7.59%) developed deep vein thrombosis (DVT): three proximal and 21 distal DVTs. Twenty-three of the 24 patients were asymptomatic. Twenty of 199 patients (10.05%) with only mechanical prophylaxis developed DVT, whereas four of 117 patients (3.42%) with additional chemoprophylaxis developed DVT. Multivariate analysis showed that chemoprophylaxis use was associated with reduced incidence of DVT (odds ratio = 0.19, p value = 0.011). Other factors associated with increased DVT incidence include female gender (odds ratio = 5.45, p value = 0.034), positive history of cancer (odds ratio = 5.14, p value = 0.044), and increased length of stay in hospital (odds ratio = 1.19, p value < 0.001). Conclusions Our study has shown that despite the low incidence of DVT in Asian patients undergoing TKA, short-duration chemoprophylaxis might be effective in reducing the incidence of DVT. However, most DVTs observed in our study were distal and may be of limited clinical significance. Further studies are needed to investigate the impact of chemoprophylaxis use on the incidence of PE and overall mortality rates among Asian patients.
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Affiliation(s)
- Siyuan Zhang
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Drive, Singapore, 117597, Singapore.
| | - Kway Swar Htet
- Department of Orthopaedic Surgery, National University Hospital, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Xin Yang Tan
- Yong Loo Lin School of Medicine, National University of Singapore, 10 Medical Drive, Singapore, 117597, Singapore
| | - Xinyu Wang
- Department of Orthopaedic Surgery, National University Hospital, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Wilson Wang
- Department of Orthopaedic Surgery, National University Hospital, 1E Kent Ridge Road, Singapore, 119228, Singapore
| | - Weiliang Chua
- Department of Orthopaedic Surgery, National University Hospital, 1E Kent Ridge Road, Singapore, 119228, Singapore.
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Abstract
Thirty per cent of patients presenting with proximal femoral fractures are receiving anticoagulant treatment for various other medical reasons. This pharmacological effect may necessitate reversal prior to surgical intervention to avoid interference with anaesthesia or excessive peri/post-operative bleeding. Consequently, delay to surgery usually occurs. Platelet inhibitors (aspirin, clopidogrel) either alone or combined do not need to be discontinued to allow acute hip surgery. Platelet transfusions can be useful but are rarely needed. Vitamin K antagonists (VKA, e.g. warfarin) should be reversed in a timely fashion and according to established readily accessible departmental protocols. Intravenous vitamin K on admission facilitates reliable reversal, and platelet complex concentrate (PCC) should be reserved for extreme scenarios. Direct oral anticoagulants (DOAC) must be discontinued prior to hip fracture surgery but the length of time depends on renal function ranging traditionally from two to four days. Recent evidence suggests that early surgery (within 48 hours) can be safe. No bridging therapy is generally recommended. There is an urgent need for development of new commonly available antidotes for every DOAC as well as high-level evidence exploring DOAC effects in the acute hip fracture surgical setting.
Cite this article: EFORT Open Rev 2020;5:699-706. DOI: 10.1302/2058-5241.5.190071
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Affiliation(s)
- Ioannis V Papachristos
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, UK
| | - Peter V Giannoudis
- Academic Department of Trauma & Orthopaedics, School of Medicine, University of Leeds, UK.,NIHR Leeds Biomedical Research Unit, Chapel Allerton Hospital, Leeds, UK
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Fourman MS, Shaw JD, Nwasike CO, Boakye LAT, Dombrowski ME, Vaudreuil NJ, Wawrose RA, Lunardini DJ, Lee JY. Use of Fondaparinux Following Elective Lumbar Spine Surgery Is Associated With a Reduction in Symptomatic Venous Thromboembolism. Global Spine J 2020; 10:844-850. [PMID: 32905722 PMCID: PMC7485070 DOI: 10.1177/2192568219878418] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
STUDY DESIGN Retrospective cohort study. OBJECTIVE To assess the impact of fondaparinux on venous thromboembolism (VTE) following elective lumbar spine surgery in high-risk patients. METHODS Matched patient cohorts who did or did not receive inpatient fondaparinux starting postoperative day 2 following elective lumbar spine surgery were compared. All patients received 1 month of acetyl salicylic acid 325 mg following discharge. The primary outcome was a symptomatic DVT (deep vein thrombosis) or PE (pulmonary embolus) within 30 days of surgery. Secondary outcomes included prolonged wound drainage, epidural hematoma, and transfusion. RESULTS A significantly higher number of DVTs were diagnosed in the group that did not receive inpatient VTE prophylaxis (3/102, 2.9%) compared with the fondaparinux group (0/275, 0%, P = .02). Increased wound drainage was seen in 18.5% of patients administered fondaparinux, compared with 25.5% of untreated patients (P = .15). Deep infections were equivalent (2.2% with fondaparinux vs 4.9% control, P = .18). No epidural hematomas were noted, and the number of transfusions after postoperative day 2 and 90-day return to operating room rates were equivalent. CONCLUSIONS Patients receiving fondaparinux had lower rates of symptomatic DVT and PE and a favorable complication profile when compared with matched controls. The retrospective nature of this work limits the safety and efficacy claims that can be made about the use of fondaparinux to prevent VTE in elective lumbar spine surgery patients. Importantly, this work highlights the potential safety of this regimen, permitting future high-quality trials.
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Affiliation(s)
| | - Jeremy D. Shaw
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | | | | | | | | | | | - Joon Y. Lee
- University of Pittsburgh Medical Center, Pittsburgh, PA, USA,Joon Y. Lee, University of Pittsburgh Medical Center, Suite 1010, Kaufmann Medical Building, 3471 Fifth Avenue, Pittsburgh, PA 15213, USA.
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18
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Gold PA, Ng TY, Coury JR, Garbarino LJ, Sodhi N, Mont MA, Scuderi GR. Can the Caprini score predict thromboembolism and guide pharmacologic prophylaxis after primary joint arthroplasty? J Orthop 2020; 21:345-349. [PMID: 32773985 DOI: 10.1016/j.jor.2020.07.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 07/03/2020] [Accepted: 07/21/2020] [Indexed: 12/17/2022] Open
Abstract
Aims Venous thromboembolism (VTE) has a 30-day mortality rate of between 10 and 30%. The Caprini score is a VTE risk assessment model, which assigns points to 20 past medical history and current health factors. We hypothesized that the Caprini score could predict VTE incidence and recommend prophylaxis following total joint arthroplasty. Patients and methods We performed a retrospective review of prospectively collected institutional data identifying Caprini scores on 2155 primary hip (n = 840) and knee (n = 1315) arthroplasties. Surgeons were blinded to Caprini scores when prescribing VTE prophylaxis. Patients were separated into prophylaxis groups receiving Aspirin (81 mg BID or 325 mg BID) or other (Rivaroxaban, Warfarin, Enoxaparin, Apixaban, Dabigatran, Heparin). Univariate, multivariate, and Cohen's effect size analyses assessed the predictive power of the Caprini score on VTE incidence. Results The mean Caprini score was 9.49 (5-25). A majority, 83% (1792) of patients were in the Aspirin group, and 17% (363) in the other group. Other prophylaxis patients had statistically significantly higher Caprini scores (10 vs. 9, p < 0.0001). Twenty-five (1.2%) patients developed VTE. Controlling for prophylaxis, higher Caprini scores increased VTE risk, but this wasn't statistically significant (p = 0.16). Multivariate analysis showed a non-significant effect for patients with BMIs >40 or Caprini scores ≥11 to predict VTE incidence in the Aspirin or other prophylaxis groups (p = 0.52 and p = 0.15 respectively). Cohen's effect size was small, comparing Caprini scores in patients who had and had not had a VTE in both Aspirin and other prophylaxis groups (Cohen's d = 0.25 and d = 0.16 respectively). Conclusion Surgeons rely on stronger pharmacologic prophylaxis for a select high risk group of their primary lower extremity total joint arthroplasty patients. When controlling for prophylaxis, the Caprini score had a small effect size and did not have the predictive power necessary to guide treatment.
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Affiliation(s)
- Peter A Gold
- Department of Orthopaedic Surgery, Long Island Jewish Medical Center, Northwell Health, Queens, NY, USA
| | - Terence Y Ng
- Donald and Barbara Zucker School of Medicine at Hofstra, Northwell Health, Hempstead, NY, USA
| | - Josephine R Coury
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Luke J Garbarino
- Department of Orthopaedic Surgery, Long Island Jewish Medical Center, Northwell Health, Queens, NY, USA
| | - Nipun Sodhi
- Department of Orthopaedic Surgery, Long Island Jewish Medical Center, Northwell Health, Queens, NY, USA
| | - Michael A Mont
- Department of Orthopaedic Surgery, Lenox Hill Hospital, Northwell Health, New York, NY, USA
| | - Giles R Scuderi
- Department of Orthopedics, Zucker School of Medicine at Hofstra/Northwell, New York, NY, USA.,Department of Orthopedics, Northwell Orthopedic Service Line, New York, NY, USA.,Department of Orthopedics, Adult Reconstruction Lenox Hill Hospital, Lenox Hill Hospital, New York, NY, USA
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19
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Herlihy DR, Thomas M, Tran QH, Puttaswamy V. Primary prophylaxis for venous thromboembolism in people undergoing major amputation of the lower extremity. Cochrane Database Syst Rev 2020; 7:CD010525. [PMID: 32692430 PMCID: PMC7389147 DOI: 10.1002/14651858.cd010525.pub3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND People undergoing major amputation of the lower limb are at increased risk of venous thromboembolism (VTE). Risk factors for VTE in amputees include advanced age, sedentary lifestyle, longstanding arterial disease and an identifiable hypercoagulable condition. Evidence suggests that pharmacological prophylaxis (e.g. heparin, factor Xa inhibitors, vitamin K antagonists, direct thrombin inhibitors, antiplatelets) is effective in preventing deep vein thrombosis (DVT), but is associated with an increased risk of bleeding. Mechanical prophylaxis (e.g. antiembolism stockings, intermittent pneumatic compression and foot impulse devices), on the other hand, is non-invasive and has minimal side effects. However, mechanical prophylaxis is not always appropriate for people with contraindications such as peripheral arterial disease (PAD), arteriosclerosis or bilateral lower limb amputations. It is important to determine the most effective thromboprophylaxis for people undergoing major amputation and whether this is one treatment alone or in combination with another. This is an update of the review first published in 2013. OBJECTIVES To determine the effectiveness of thromboprophylaxis in preventing VTE in people undergoing major amputation of the lower extremity. SEARCH METHODS The Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register, Cochrane Central Register of Controlled Trials, MEDLINE, Embase and Cumulative Index to Nursing and Allied Health Literature databases, the World Health Organization International Clinical Trials Registry Platform and ClinicalTrials.gov trials registers to 5 November 2019. We planned to undertake reference checking of identified trials to identify additional studies. We did not apply any language restrictions. SELECTION CRITERIA We included randomised controlled trials and quasi-randomised controlled trials which allocated people undergoing a major unilateral or bilateral amputation (e.g. hip disarticulation, transfemoral, knee disarticulation and transtibial) of the lower extremity to different types or regimens of thromboprophylaxis (including pharmacological or mechanical prophylaxis) or placebo. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies, extracted data and assessed risk of bias. We resolved any disagreements by discussion. Outcomes of interest were VTE (DVT and pulmonary embolism (PE)), mortality, adverse events and bleeding. We used GRADE criteria to assess the certainty of the evidence. The two included studies compared different treatments, so we could not pool the data in a meta-analysis. MAIN RESULTS We did not identify any eligible new studies for this update. Two studies with a combined total of 288 participants met the inclusion criteria for this review. Unfractionated heparin compared to low molecular weight heparin One study compared unfractionated heparin with low molecular weight heparin and found no evidence of a difference between the treatments in the prevention of DVT (odds ratio (OR) 1.23, 95% confidence interval (CI) 0.28 to 5.35; 75 participants; very low-certainty evidence). No bleeding events occurred in either group. Deaths and adverse events were not reported. This study was open-label and therefore at a high risk of performance bias. Additionally, the study did not report the method of randomisation, so the risk of selection bias was unclear. Heparin compared to placebo In the second study, there was no evidence of a benefit from heparin use in preventing PE when compared to placebo (OR 0.84, 95% CI 0.35 to 2.01; 134 participants; low-certainty evidence). Similarly, no evidence of improvement was detected when the level of amputation was considered, with a similar incidence of PE between the two treatment groups: above knee amputation (OR 0.79, 95% CI 0.31 to 1.97; 94 participants; low-certainty evidence); and below knee amputation (OR 1.53, 95% CI 0.09 to 26.43; 40 participants; low-certainty evidence). Ten participants died during the study; five underwent a post-mortem and three were found to have had a recent PE, all of whom had been on placebo (low-certainty evidence). Bleeding events were reported in less than 10% of participants in both treatment groups, but the study did not present specific data (low-certainty evidence). There were no reports of other adverse events. This study did not report the methods used to conceal allocation of treatment, so it was unclear whether selection bias occurred. However, this study appeared to be free from all other sources of bias. No study looked at mechanical prophylaxis. AUTHORS' CONCLUSIONS We did not identify any eligible new studies for this update. As we only included two studies in this review, each comparing different interventions, there is insufficient evidence to make any conclusions regarding the most effective thromboprophylaxis regimen in people undergoing lower limb amputation. Further large-scale studies of good quality are required.
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Affiliation(s)
- David Rb Herlihy
- Department of Vascular Surgery, Royal North Shore Hospital, Sydney, Australia
| | - Matthew Thomas
- Department of Vascular Surgery, Freeman Hospital, The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Quoc H Tran
- Department of Vascular Surgery, Royal North Shore Hospital, Sydney, Australia
| | - Vikram Puttaswamy
- Department of Vascular Surgery, Royal North Shore Hospital, Sydney, Australia
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Caron A, Depas N, Chazard E, Yelnik C, Jeanpierre E, Paris C, Beuscart JB, Ficheur G. Risk of Pulmonary Embolism More Than 6 Weeks After Surgery Among Cancer-Free Middle-aged Patients. JAMA Surg 2020; 154:1126-1132. [PMID: 31596449 DOI: 10.1001/jamasurg.2019.3742] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Importance The risk of postoperative pulmonary embolism has been reported to be highest during the first 5 weeks after surgery. However, how long the excess risk of postoperative pulmonary embolism persists remains unknown. Objective To assess the duration and magnitude of the late postoperative risk of pulmonary embolism among cancer-free middle-aged patients by the type of surgery. Design, Setting, and Participants Case-crossover analysis to compute the respective risks of pulmonary embolism after 6 types of surgery using data from a French national inpatient database, which covers a total of 203 million inpatient stays over an 8-year period between 2007 and 2014. Participants were cancer-free middle-aged adult patients (aged 45 to 64) with a diagnosis of a first pulmonary embolism. Exposures Hospital admission for surgery. Surgical procedures were classified into 6 types: (1) vascular surgery, (2) gynecological surgery, (3) gastrointestinal surgery, (4) hip or knee replacement, (5) fractures, and (6) other orthopedic operations. Main Outcomes and Measures Diagnosis of a first pulmonary embolism. Results A total of 60 703 patients were included (35 766 [58.9%] male; mean [SD] age, 56.6 [6.0] years). The risk of postoperative pulmonary embolism was elevated for at least 12 weeks after all types of surgery and was highest during the immediate postoperative period (1 to 6 weeks). The excess risk of postoperative pulmonary embolism ranged from odds ratio (OR), 5.24 (95% CI, 3.91-7.01) for vascular surgery to OR, 8.34 (95% CI, 6.07-11.45) for surgery for fractures. The risk remained elevated from 7 to 12 weeks, with the OR ranging from 2.26 (95% CI, 1.81-2.82) for gastrointestinal operations to 4.23 (95% CI, 3.01-5.92) for surgery for fractures. The risk was not clinically significant beyond 18 weeks postsurgery for all types of procedures. Conclusions and Relevance The risk of postoperative pulmonary embolism is elevated beyond 6 weeks postsurgery regardless of the type of procedure. The persistence of this excess risk suggests that further randomized clinical trials are required to evaluate whether the duration of postoperative prophylactic anticoagulation should be extended and to define the optimal duration of treatment with regard to both the thrombotic and bleeding risks.
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Affiliation(s)
- Alexandre Caron
- University Lille, CHU Lille, EA 2694, Santé publique: épidémiologie et qualité des soins, Lille, France
| | - Nicolas Depas
- University Lille, CHU Lille, EA 2694, Santé publique: épidémiologie et qualité des soins, Lille, France
| | - Emmanuel Chazard
- University Lille, CHU Lille, EA 2694, Santé publique: épidémiologie et qualité des soins, Lille, France
| | - Cécile Yelnik
- University Lille, Inserm, CHU Lille, U995, Lille Inflammation Research International Center, Lille, France
| | - Emmanuelle Jeanpierre
- University Lille, Inserm, CHU Lille, Institut Pasteur de Lille, U1011, EGID, Lille, France
| | - Camille Paris
- University Lille, CHU Lille, Hematology Transfusion Institute, Lille, France
| | - Jean-Baptiste Beuscart
- University Lille, CHU Lille, EA 2694, Santé publique: épidémiologie et qualité des soins, Lille, France
| | - Grégoire Ficheur
- University Lille, CHU Lille, EA 2694, Santé publique: épidémiologie et qualité des soins, Lille, France
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Segon YS, Summey RD, Slawski B, Kaatz S. Surgical venous thromboembolism prophylaxis: clinical practice update. Hosp Pract (1995) 2020; 48:248-257. [PMID: 32589468 DOI: 10.1080/21548331.2020.1788893] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
BACKGROUND Perioperative medicine continues to evolve as new literature emerges. This article provides an update on prevention of venous thromboembolism (VTE) in surgical patients. METHODS We reviewed articles on VTE prevention in surgical patients published in peer-reviewed journals since the publication of 2012 ACCP guidelines on VTE prevention in surgical patients. RESULTS Methods of VTE prophylaxis include aggressive ambulation, mechanical prophylaxis, and pharmacological prophylaxis. In non-orthopedic surgery, the overall approach remains assessment of thrombosis risk with the recommendation to use a risk assessment tool such as the modified Caprini score. Low molecular weight heparin (LMWH) appears to be more effective than unfractionated heparin (UFH) for VTE prophylaxis in non-orthopedic surgery. For orthopedic surgery, recent studies now recognize aspirin as an option for VTE prophylaxis after total hip arthroplasty, total knee arthroplasty, and hip fracture surgery. Extended prophylaxis with LMWH reduces the risk of symptomatic VTE in high risk abdominal and pelvic cancer surgery without an appreciable increase in risk of bleeding and decreased symptomatic VTE in major orthopedic surgery but with more minor but not major bleeding. Prophylactic Inferior vena cava (IVC) filter placement or surveillance compression ultrasonography is not recommended in management or detection of VTE in surgical patients. CONCLUSIONS This article aims to provide insight into data from last several years which has potential to change clinical practices in perioperative setting.
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Affiliation(s)
- Yogita Sharma Segon
- Division of General Internal Medicine, Medical College of Wisconsin , Milwaukee, Wisconsin, USA
| | - Robert D Summey
- Division of Hospital Medicine, Henry Ford Hospital , Detroit, Michigan. USA
| | - Barbara Slawski
- Division of General Internal Medicine, Medical College of Wisconsin , Milwaukee, Wisconsin, USA
| | - Scott Kaatz
- Division of Hospital Medicine, Henry Ford Hospital , Detroit, Michigan. USA
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22
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Kahn SR, Shivakumar S. What's new in VTE risk and prevention in orthopedic surgery. Res Pract Thromb Haemost 2020; 4:366-376. [PMID: 32211571 PMCID: PMC7086463 DOI: 10.1002/rth2.12323] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 01/06/2020] [Accepted: 01/29/2020] [Indexed: 12/21/2022] Open
Abstract
A State of the Art lecture titled "What's New in VTE Risk and Prevention in Orthopedic Surgery" was presented at the ISTH congress in 2019. Patients undergoing orthopedic surgery have long been recognized to be at increased risk of venous thromboembolism (VTE) and were among the first patient groups to be studied in VTE prophylaxis trials. From the late 1950s to 2010s, prophylaxis trials in major orthopedic surgery tended to focus on venographic deep vein thrombosis and assessed thromboprophylaxis in all patients based on a population approach. In general, anticoagulants were favored over mechanical prophylaxis or aspirin, and longer-duration prophylaxis was favored over shorter durations. As discussed in this paper, more recently, orthopedic prophylaxis has started to become more nuanced and individualized. Modern trials are focusing on symptomatic VTE as outcomes; there has been a resurgence in interest in aspirin for prophylaxis, and there has been a slow move to studying ways to evaluate VTE risk in patients undergoing orthopedic surgery and recommending thromboprophylaxis to patients based on individual attributes, in whom risk stratification and weighing of benefit versus risk of thromboprophylaxis is becoming key. We also touch on VTE risk and guideline recommendations to prevent VTE in 2 other commonly encountered orthopedic populations: patients undergoing knee arthroscopy and those with distal leg fractures. Finally, we summarize relevant new data on this topic presented during the 2019 ISTH annual congress in Melbourne.
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Affiliation(s)
- Susan R. Kahn
- Department of MedicineMcGill UniversityLady Davis Institute/Jewish General HospitalMontrealQCCanada
| | - Sudeep Shivakumar
- Department of MedicineDalhousie UniversityQEII Health Sciences CentreHalifaxNSCanada
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Abstract
In the last few years, much has been published concerning total joint arthroplasty, and debates and discussions to new questions and points of view started many years ago. In this commentary, we report the latest evidence of best practice in the field of lower limb arthroplasty; this evidence is based on a literature search conducted by using PubMed and Scopus databases with a time limit of five years. We found novel evidence regarding cemented and not cemented implant, implant design, anticoagulant use, tourniquets, and other aspects of joints replacement surgery that we consider a common part of modern orthopedic practice. We specifically focus on lower limb joint replacement.
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Affiliation(s)
- Rocco Aicale
- Department of Musculoskeletal Disorders, School of Medicine and Surgery, University of Salerno, Baronissi, Italy.,Clinica Ortopedica, Ospedale San Diovanni di Dio e Ruggi D'Aragona, Salerno, Italy
| | - Nicola Maffulli
- Department of Musculoskeletal Disorders, School of Medicine and Surgery, University of Salerno, Baronissi, Italy.,Clinica Ortopedica, Ospedale San Diovanni di Dio e Ruggi D'Aragona, Salerno, Italy.,Barts and the London School of Medicine and Dentistry, Centre for Sports and Exercise Medicine, Mile End Hospital, Queen Mary University of London, London, UK.,School of Pharmacy and Bioengineering, Faculty of Medicine, Institute of Science and Technology in Medicine, Guy Hilton Research Centre, Keele University, Stoke-on-Trent, UK
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24
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Smith SR, Katz JN, Losina E. Cost-Effectiveness of Alternative Anticoagulation Strategies for Postoperative Management of Total Knee Arthroplasty Patients. Arthritis Care Res (Hoboken) 2019; 71:1621-1629. [PMID: 30369093 PMCID: PMC6487236 DOI: 10.1002/acr.23803] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Accepted: 10/23/2018] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To evaluate the cost-effectiveness of prolonged (35-day) and standard-duration (14-day) anticoagulation therapy following total knee arthroplasty (TKA). METHODS Using Markov modeling, we assessed clinical and economic outcomes of 14-day and 35-day anticoagulation therapy following TKA with rivaroxaban, low molecular weight heparin (LMWH), fondaparinux, warfarin, and aspirin. Incidence of complications of TKA and anticoagulation therapy (deep vein thrombosis [DVT], pulmonary embolism [PE], prosthetic joint infection [PJI], and bleeding) were derived from published literature. Daily costs ranged from $1 (aspirin) to $43 (fondaparinux). Primary outcomes included quality-adjusted life years (QALYs), direct medical costs, and incremental cost-effectiveness ratios (ICERs) at 1 year post-TKA. The preferred regimen was the regimen with highest QALYs maintaining an ICER below the willingness-to-pay threshold ($100,000/QALY). We conducted probabilistic sensitivity analyses, varying complication incidence and anticoagulation efficacy, to evaluate the impact of parameter uncertainty on model results. RESULTS Aspirin resulted in the highest cumulative incidence of DVT and PE, while prolonged fondaparinux led to the largest reduction in DVT incidence (15% reduction compared to no prophylaxis). Despite differential bleeding rates (ranging from 3% to 6%), all strategies had similar incidence of PJI (1% to 2%). Prolonged rivaroxaban was the least costly strategy ($3,300 at 1 year post-TKA) and the preferred regimen in the base case. In sensitivity analyses, prolonged rivaroxaban and warfarin had similar likelihoods of being cost-effective. CONCLUSION Extending postoperative anticoagulation therapy to 35 days increases QALYs compared to standard 14-day prophylaxis. Prolonged rivaroxaban and prolonged warfarin are most likely to be cost-effective post-TKA; the costs of fondaparinux and LMWH precluded their being preferred strategies.
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Affiliation(s)
- Savannah R. Smith
- George Washington University School of Medicine and Health Sciences, Washington, DC
- Orthopedic and Arthritis Center for Outcomes Research (OrACORe), Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, MA
- Policy and Innovation eValuation in Orthopedic Treatments (PIVOT) Center, Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, MA
| | - Jeffrey N. Katz
- Orthopedic and Arthritis Center for Outcomes Research (OrACORe), Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, MA
- Policy and Innovation eValuation in Orthopedic Treatments (PIVOT) Center, Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
| | - Elena Losina
- Orthopedic and Arthritis Center for Outcomes Research (OrACORe), Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, MA
- Policy and Innovation eValuation in Orthopedic Treatments (PIVOT) Center, Department of Orthopedic Surgery, Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
- Department of Biostatistics, Boston University School of Public Health, Boston, MA
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25
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Pedersen AB, Andersen IT, Overgaard S, Fenstad AM, Lie SA, Gjertsen JE, Furnes O. Optimal duration of anticoagulant thromboprophylaxis in total hip arthroplasty: new evidence in 55,540 patients with osteoarthritis from the Nordic Arthroplasty Register Association (NARA) group. Acta Orthop 2019; 90:298-305. [PMID: 31060431 PMCID: PMC6718178 DOI: 10.1080/17453674.2019.1611215] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - The recommended optimal duration of the thromboprophylaxis treatment in total hip arthroplasty (THA) patients has been a matter of debate for years. We examined the association between short (1-5 days), standard (6-14 days), and extended (≥ 15 days) duration of thromboprophylaxis, with regards to the risk of venous thromboembolism (VTE), major bleeding, and death in unselected THA patients. Patients and methods - We performed a cohort study using prospectively collected data from the population-based hip arthroplasty registries, prescription databases, and patient administrative registries in Denmark and Norway. We included 55,540 primary THA patients with osteoarthritis Results - The 90-day cumulative incidence of VTE was 1.0% for patients with standard treatment (reference), 1.1% for those with short-term treatment (adjusted hazard ratio [aHR] of 1.1, 95% confidence interval (CI) 0.8-1.5) and 1.0% for those with extended treatment (aHR of 0.9, CI 0.8-1.2). The aHRs for major bleeding were 1.1 (CI 0.8-1.6) for short and 0.8 (CI 0.6-1.1) for extended vs. standard treatment. In addition, patients with short and extended treatment had aHRs for death of 1.2 (CI 0.8-1.8) and 0.8 (CI 0.5-1.1) vs. standard treatment, respectively. Patients who started short treatment postoperatively had an aHR for death of 1.8 (CI 1.1-3.1) and absolute risk difference of 0.2%, whereas patients who started short treatment preoperatively had an aHR for death of 0.5 (CI 0.2-1.2) and absolute risk difference of 0.3% compared with patients who had standard treatment with post- and preoperative start, respectively. Interpretation - In routine clinical practice, we observed no overall clinically relevant difference in the risks of VTE and major bleeding within 90 days of THA with respect to thromboprophylaxis duration. However, our data indicate that short-term thromboprophylaxis started postoperatively is associated with increased 90-day mortality. The significance of these data should be explored further.
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Affiliation(s)
- Alma B Pedersen
- Department of Clinical Epidemiology, Aarhus University Hospital, Denmark; ,Correspondence:
| | | | - Soren Overgaard
- Department of Orthopaedic Surgery and Traumatology, Odense University Hospital, Department of Clinical Research, University of Southern Denmark, Odense, Denmark;
| | - Anne Marie Fenstad
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway;
| | - Stein Atle Lie
- Department of Clinical Medicine, University of Bergen, Norway; ,Department of Clinical Dentistry, University of Bergen, Bergen, Norway
| | - Jan-Erik Gjertsen
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway; ,Department of Clinical Medicine, University of Bergen, Norway;
| | - Ove Furnes
- The Norwegian Arthroplasty Register, Department of Orthopedic Surgery, Haukeland University Hospital, Bergen, Norway; ,Department of Clinical Medicine, University of Bergen, Norway;
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26
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Zhang W, Zhang PX. [Analysis of prophylactic effect of extended-duration anticoagulant drugs in elderly patients undergoing hip fracture]. JOURNAL OF PEKING UNIVERSITY. HEALTH SCIENCES 2019; 51:501-504. [PMID: 31209422 DOI: 10.19723/j.issn.1671-167x.2019.03.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To evaluate the prophylactic effect of extended-duration anticoagulant drugs on venous thromboembolism, and to explore the time of drug prevention for venous thromboembolism after hip fracture. METHODS A retrospective analysis of 143 patients undergoing hip fractures from November 2017 to October 2018 in Peking University People's Hospital was conducted to investigate the relationship between the extended-duration anticoagulant drug and the morbidity of venous thromboembolism and bleeding during the treatment. All the drug prevention programs for the patients included in the study were implemented in accordance with the 2016 edition of the Guidelines for Prevention of Venous Thrombosis in Orthopaedic Surgery by Orthopaedic Society of Chinese Medical Association. The patients in the two groups were followed up for venous thromboembolism and bleeding during the medication within 5 weeks after the fracture. Venous thromboembolism included symptomatic and asymptomatic deep venous thrombosis of the lower extremities, pulmonary thromboembolism, and all the patients with deep venous thrombosis of the lower extremities required vascular ultrasound results to obtain clear evidence. The results of vascular ultrasound were the basis for determining deep venous thrombosis. Bleeding conditions were included, but not limited to gastrointestinal bleeding, wound bleeding, intracranial hemorrhage, intraspinal hematoma, and fundus hemorrhage. RESULTS There were no pulmonary thromboembolism in both groups after surgery. The morbidity of deep venous thrombosis was 22.09% and 8.77% in the 2-week and 4-week groups (P=0.037), the time to deep venous thrombosis in the two groups was (17.32±7.75) days and (29.20±0.17) days after surgery. One case of bleeding occurred during the use of anticoagulant drugs in both groups, the morbidity of bleeding during the treatment was 1.16% and 1.75% (P=0.769), respectively. CONCLUSION Extended-duration anticoagulant drugs to 4 weeks after surgery can significantly reduce the morbidity of postoperative venous thromboembolism, and does not increase the risk of bleeding. Patients with a risk of bleeding should carefully assess the risks and benefits of drug prevention and choose the best treatment.
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Affiliation(s)
- W Zhang
- Department of Trauma and Orthopaedics, Peking University People's Hospital, Beijing 100044, China
| | - P X Zhang
- Department of Trauma and Orthopaedics, Peking University People's Hospital, Beijing 100044, China
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27
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Safety of direct oral anticoagulants versus traditional anticoagulants in venous thromboembolism. J Thromb Thrombolysis 2019; 48:439-453. [DOI: 10.1007/s11239-019-01878-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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28
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Nelson G, Bakkum-Gamez J, Kalogera E, Glaser G, Altman A, Meyer LA, Taylor JS, Iniesta M, Lasala J, Mena G, Scott M, Gillis C, Elias K, Wijk L, Huang J, Nygren J, Ljungqvist O, Ramirez PT, Dowdy SC. Guidelines for perioperative care in gynecologic/oncology: Enhanced Recovery After Surgery (ERAS) Society recommendations-2019 update. Int J Gynecol Cancer 2019; 29:651-668. [PMID: 30877144 DOI: 10.1136/ijgc-2019-000356] [Citation(s) in RCA: 391] [Impact Index Per Article: 78.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 02/18/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND This is the first updated Enhanced Recovery After Surgery (ERAS) Society guideline presenting a consensus for optimal perioperative care in gynecologic/oncology surgery. METHODS A database search of publications using Embase and PubMed was performed. Studies on each item within the ERAS gynecologic/oncology protocol were selected with emphasis on meta-analyses, randomized controlled trials, and large prospective cohort studies. These studies were then reviewed and graded according to the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system. RESULTS All recommendations on ERAS protocol items are based on best available evidence. The level of evidence for each item is presented accordingly. CONCLUSIONS The updated evidence base and recommendation for items within the ERAS gynecologic/oncology perioperative care pathway are presented by the ERAS® Society in this consensus review.
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Affiliation(s)
- Gregg Nelson
- Division of Gynecologic Oncology, Tom Baker Cancer Centre, Calgary, Alberta, Canada
| | - Jamie Bakkum-Gamez
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Eleftheria Kalogera
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Gretchen Glaser
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Alon Altman
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Larissa A Meyer
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jolyn S Taylor
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Maria Iniesta
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Javier Lasala
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Gabriel Mena
- Department of Anesthesiology and Perioperative Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Michael Scott
- Department of Anesthesia, Virginia Commonwealth University Hospital, Richmond, Virginia, USA
| | - Chelsia Gillis
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Kevin Elias
- Division of Gynecologic Oncology, Brigham and Women's Hospital, Dana-Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts, USA
| | - Lena Wijk
- Department of Obstetrics and Gynecology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Jeffrey Huang
- Department of Anesthesiology, Oak Hill Hospital, Brooksville, Florida, USA
| | - Jonas Nygren
- Departments of Surgery and Clinical Sciences, Ersta Hospital and Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Olle Ljungqvist
- Department of Surgery, Faculty of Medicine and Health, School of Health and Medical Sciences, Örebro University, Örebro, Sweden
| | - Pedro T Ramirez
- Department of Gynecologic Oncology and Reproductive Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Sean C Dowdy
- Division of Gynecologic Oncology, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
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29
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Babic B, De Roulet A, Volpe A, Nilubol N. Is VTE Prophylaxis Necessary on Discharge for Patients Undergoing Adrenalectomy for Cushing Syndrome? J Endocr Soc 2018; 3:304-313. [PMID: 30652131 PMCID: PMC6330172 DOI: 10.1210/js.2018-00278] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 12/07/2018] [Indexed: 11/19/2022] Open
Abstract
Background Patients with Cushing syndrome (CS) have an increased risk for venous thromboembolism (VTE). However, it is unclear whether patients undergoing adrenalectomy for CS are at increased risk for postoperative VTE. The aim of this study was to determine the rate of postoperative VTE in patients undergoing adrenalectomy for CS. Methods A retrospective analysis of patients in the American College of Surgeons National Surgical Quality Improvement Program database who underwent adrenalectomy from 2005 to 2016 was performed. We compared the clinical characteristics and 30-day postoperative VTE occurrence in patients with and without CS. Results A total of 4217 patients were analyzed; 2607 (61.8%) were female and 310 (7.4%) had CS. The overall prevalence of postoperative VTE was 1.0% (n = 45). The rates of VTE were higher in patients with CS (2.6% vs 0.9%; P = 0.007). In the two groups, CS was associated with younger age, increased body mass index, and diabetes mellitus (P < 0.001). CS was also associated with longer length of operation and longer hospital length of stay (P < 0.001). In the subgroup of patients who had diagnosed VTE, CS was associated with longer length of operation (P < 0.001). Rates of laparoscopic vs open surgery were equivalent between patients with and without CS, and VTE events did not differ. The median time to VTE event was 14.5 days (range, 1 to 23 days) in the CS group and 4 days (range, 2 to 25 days) in the group without CS. Conclusions The prevalence of postoperative VTE was increased in patients undergoing adrenalectomy for CS. In patients with CS undergoing adrenalectomy, VTE prophylaxis for 28 days should be considered upon discharge.
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Affiliation(s)
- Bruna Babic
- Department of Surgery, New York Presbyterian-Queens, Flushing, New York
| | - Amory De Roulet
- Department of Surgery, New York Presbyterian-Queens, Flushing, New York
| | - Anita Volpe
- Department of Surgery, New York Presbyterian-Queens, Flushing, New York
| | - Naris Nilubol
- Endocrine Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, Maryland
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30
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Senay A, Trottier M, Delisle J, Banica A, Benoit B, Laflamme GY, Malo M, Nguyen H, Ranger P, Fernandes JC. Incidence of symptomatic venous thromboembolism in 2372 knee and hip replacement patients after discharge: data from a thromboprophylaxis registry in Montreal, Canada. Vasc Health Risk Manag 2018; 14:81-89. [PMID: 29780248 PMCID: PMC5951148 DOI: 10.2147/vhrm.s150474] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Low-molecular-weight heparin (LMWH) is a recommended anticoagulant for thromboprophylaxis after major orthopedic surgery. Dabigatran etexilate is an oral anticoagulant recognized as noninferior to LMWH. We aimed to assess the incidence of symptomatic venous thromboembolic events (VTEs) after discharge in patients who underwent joint replacement, using a hospital registry. Patients and methods Patients who underwent total knee and hip arthroplasty between September 2011 and March 2015 were selected. Subcutaneous enoxaparin (30 mg twice daily) was given during hospitalization. At discharge, patients received either enoxaparin 30 mg twice daily/40 mg once daily or dabigatran 220 mg/150 mg once daily. Patients were seen or called at 2, 6, and 12 weeks after surgery. Outcomes were the number of VTEs, including deep venous thrombosis, pulmonary embolism, and the number of major/minor bleeding events after discharge. Results After discharge, 1468 patients were prescribed enoxaparin and 904 dabigatran (1396 total knee arthroplasty and 976 total hip arthroplasty patients). Mean age was 66±10 years, and 60% were female. The cumulative incidence of VTEs during the 12-week follow-up was 0.7%. One patient sustained a VTE during the switch window. Seven patients sustained a pulmonary embolism (0.3%). There was no statistical difference between the total knee arthroplasty and total hip arthroplasty groups. The incidence of major and minor bleeding events during follow-up was 0.3% and 30.3%, respectively. These events had a higher incidence in the dabigatran group compared to the enoxaparin group after discharge (p<0.05), but not between knee and hip replacement groups for major bleeding events. Conclusion A pharmaceutical prophylaxis protocol using LMWH and dabigatran during the post-discharge period resulted in low incidences of VTE and equivalence between treatments. However, the increased number of major and minor bleeding events in patients taking dabigatran is of concern regarding the safety and needs to be evaluated using analyses adjusted for risk factors.
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Affiliation(s)
- Andréa Senay
- Faculty of Pharmacy, Université de Montréal, Montréal, QC, Canada.,Department of Orthopaedic Surgery, Hôpital du Sacré-Coeur de Montréal, Montréal, QC, Canada
| | - Milanne Trottier
- Faculty of Medicine, Université de Montréal, Montréal, QC, Canada
| | - Josée Delisle
- Department of Orthopaedic Surgery, Hôpital du Sacré-Coeur de Montréal, Montréal, QC, Canada.,Department of Orthopaedic Surgery, Hôpital Jean-Talon, Montréal, QC, Canada
| | - Andreea Banica
- Department of Orthopaedic Surgery, Hôpital du Sacré-Coeur de Montréal, Montréal, QC, Canada.,Department of Orthopaedic Surgery, Hôpital Jean-Talon, Montréal, QC, Canada
| | - Benoit Benoit
- Department of Orthopaedic Surgery, Hôpital du Sacré-Coeur de Montréal, Montréal, QC, Canada.,Department of Orthopaedic Surgery, Hôpital Jean-Talon, Montréal, QC, Canada
| | - G Yves Laflamme
- Department of Orthopaedic Surgery, Hôpital du Sacré-Coeur de Montréal, Montréal, QC, Canada.,Department of Orthopaedic Surgery, Hôpital Jean-Talon, Montréal, QC, Canada
| | - Michel Malo
- Department of Orthopaedic Surgery, Hôpital du Sacré-Coeur de Montréal, Montréal, QC, Canada.,Department of Orthopaedic Surgery, Hôpital Jean-Talon, Montréal, QC, Canada
| | - Hai Nguyen
- Department of Orthopaedic Surgery, Hôpital Jean-Talon, Montréal, QC, Canada
| | - Pierre Ranger
- Department of Orthopaedic Surgery, Hôpital du Sacré-Coeur de Montréal, Montréal, QC, Canada.,Department of Orthopaedic Surgery, Hôpital Jean-Talon, Montréal, QC, Canada
| | - Julio C Fernandes
- Department of Orthopaedic Surgery, Hôpital du Sacré-Coeur de Montréal, Montréal, QC, Canada.,Faculty of Medicine, Université de Montréal, Montréal, QC, Canada.,Department of Orthopaedic Surgery, Hôpital Jean-Talon, Montréal, QC, Canada
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31
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Scheres LJJ, Lijfering WM, Cannegieter SC. Current and future burden of venous thrombosis: Not simply predictable. Res Pract Thromb Haemost 2018; 2:199-208. [PMID: 30046722 PMCID: PMC6055567 DOI: 10.1002/rth2.12101] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 03/09/2018] [Indexed: 12/23/2022] Open
Abstract
Venous thrombosis is a major contributor to the global disease burden. In this review we aim to answer two important questions: (1) are we making progress in reducing this disease burden and (2) how can we further improve? To answer these questions, we first evaluated the disease burden, that is, the incidence of first venous thrombosis over the past decade(s) and discuss its most important determinants. We found that the incidence of first venous thrombosis remained relatively unchanged, despite an increase in risk factor prevalence and a rise in identification of subsegmental pulmonary emboli due to enhanced image quality and utilization. This is, however, balanced by improved thromboprophylaxis strategies, resulting in an overall unchanged venous thrombosis incidence. We can further improve by developing, validating, and implementing risk assessment strategies, allowing us to identify persons at high or low risk in whom thromboprophylaxis can be provided or withheld, respectively.
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Affiliation(s)
- Luuk J. J. Scheres
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenthe Netherlands
- Department of Vascular MedicineAcademic Medical CenterAmsterdamthe Netherlands
| | - Willem M. Lijfering
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenthe Netherlands
| | - Suzanne C. Cannegieter
- Department of Clinical EpidemiologyLeiden University Medical CenterLeidenthe Netherlands
- Department of Internal MedicineSection of Thrombosis and HemostasisLeiden University Medical CenterLeidenthe Netherlands
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32
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Childers CP, Siletz AE, Singer ES, Faltermeier C, Hu QL, Ko CY, Golladay GJ, Kates SL, Wick EC, Maggard-Gibbons M. Surgical Technical Evidence Review for Elective Total Joint Replacement Conducted for the AHRQ Safety Program for Improving Surgical Care and Recovery. Geriatr Orthop Surg Rehabil 2018; 9:2151458518754451. [PMID: 29468091 PMCID: PMC5813847 DOI: 10.1177/2151458518754451] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 11/30/2017] [Accepted: 12/28/2017] [Indexed: 12/12/2022] Open
Abstract
Background: Use of enhanced recovery pathways (ERPs) can improve patient outcomes, yet national implementation of these pathways remains low. The Agency for Healthcare Research and Quality (AHRQ; funder), the American College of Surgeons, and the Johns Hopkins Medicine Armstrong Institute for Patent Safety and Quality have developed the Safety Program for Improving Surgical Care and Recovery—a national effort to catalyze implementation of practices to improve perioperative care and enhance recovery of surgical patients. This review synthesizes evidence that can be used to develop a protocol for elective total knee arthroplasty (TKA) and total hip arthroplasty (THA). Study Design: This review focuses on potential components of the protocol relevant to surgeons; anesthesia components are reported separately. Components were identified through review of existing pathways and from consultation with technical experts. For each, a structured review of MEDLINE identified systematic reviews, randomized trials, and observational studies that reported on these components in patients undergoing elective TKA/THA. This primary evidence review was combined with existing clinical guidelines in a narrative format. Results: Sixteen components were reviewed. Of the 10 preoperative components, most were focused on risk factor assessment including anemia, diabetes mellitus, tobacco use, obesity, nutrition, immune-modulating therapy, and opiates. Preoperative education, venous thromboembolism (VTE) prophylaxis, and bathing/Staphylococcus aureus decolonization were also included. The routine use of drains was the only intraoperative component evaluated. The 5 postoperative components included early mobilization, continuous passive motion, extended duration VTE prophylaxis, early oral alimentation, and discharge planning. Conclusion: This review synthesizes the evidence supporting potential surgical components of an ERP for elective TKA/THA. The AHRQ Safety Program for Improving Surgical Care and Recovery aims to guide hospitals and surgeons in identifying the best practices to implement in the surgical care of TKA and THA patients.
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Affiliation(s)
| | - Anaar E Siletz
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Emily S Singer
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | | | - Q Lina Hu
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,American College of Surgeons, Chicago, IL, USA
| | - Clifford Y Ko
- Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.,American College of Surgeons, Chicago, IL, USA
| | - Gregory J Golladay
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Stephen L Kates
- Department of Orthopaedic Surgery, Virginia Commonwealth University, Richmond, VA, USA
| | - Elizabeth C Wick
- Armstrong Institute for Patient Safety and Quality, Johns Hopkins University, Baltimore, MD, USA
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Cimminiello C, Prandoni P, Agnelli G, Di Minno G, Polo Friz H, Scaglione F, Boracchi P, Marano G, Harenberg J. Thromboprophylaxis with enoxaparin and direct oral anticoagulants in major orthopedic surgery and acutely ill medical patients: a meta-analysis. Intern Emerg Med 2017; 12:1291-1305. [PMID: 28756546 DOI: 10.1007/s11739-017-1714-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 07/24/2017] [Indexed: 11/25/2022]
Abstract
Subjects undergoing major orthopedic surgery and acutely ill hospitalized medical patients represent a population at medium-high risk for venous thromboembolism (VTE). They are treated with low molecular weight heparin (LMWH) and direct oral anticoagulants [DOACs] for VTE prevention. We conducted a meta-analysis of phase III randomized clinical trials evaluating LMWH enoxaparin versus DOACs for prophylaxis of VTE by combining studies including patients undergoing elective total hip and knee replacement surgery, and acutely ill hospitalized medical subjects. Studies were searched using PubMed, MEDLINE, and EMBASE databases until December 2016. Differences in clinical outcomes for efficacy and safety endpoints between treatment groups were expressed as risk differences with 95% confidence intervals (95% CI), using random effects regression models. Fourteen RCTs were considered (60,467 subjects). Overall mortality, symptomatic deep venous thrombosis, non-fatal pulmonary embolism (PE) major bleeding (MB) and clinically relevant non-major bleeding (CRNMB) are not different between treatment regimens. Treatment with LMWH enoxaparin is associated with a lower risk of fatal PE plus VTE-related death compared therapy with DOACs (RD = 0.040%, 95% CI 0.001-0.080%, p = 0.0434). Subgroup analysis shows an incidence of MB (RD = 0.181%, 95% CI 0.029-0.332%, p = 0.0033) and CRNMB (RD = 0.546%, 95% CI 0.009-1.082%, p = 0.0462) in patients treated with 40 mg OD enoxaparin compared to DOACs. In major orthopedic surgery and acutely ill hospitalized medical patients, DOACs do not offer clear advantages in terms of clinical efficacy compared to enoxaparin. The advantage of the latter in terms of major and CRNMB, when used at a dose of 40 mg, is statistically significant, but small in terms of clinical relevance.
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Affiliation(s)
- Claudio Cimminiello
- Studies and Research Center of the Italian Society of Angiology and Vascular Patholog (Società Italiana di Angiologia e Patologia Vascolare, SIAPAV), via Gorizia 22, 20144, Milan, Italy
| | - Paolo Prandoni
- Vascular Medicine Unit, Department of Cardiothoracic and Vascular Sciences, University of Padua, Via Giustiniani 2, 35128, Padua, Italy
| | - Giancarlo Agnelli
- Internal and Cardiovascular Medicine-Stroke Unit, University of Perugia, Piazzale Menghini 1, 06100, Perugia, Italy
| | - Giovanni Di Minno
- Department of Clinical and Experimental Medicine, Federico II, University Hospital, Via S. Pansini 5, Naples, Italy
| | - Hernan Polo Friz
- Department of Medicine, Vimercate Hospital, Azienda Ospedaliera di Desio e Vimercate, via Santi Cosma e Damiano 10, 20871, Vimercate, Italy.
| | - Francesco Scaglione
- Department of Oncology and Onco-Hematology, University of Milan, Via Vanvitelli 32, 20129, Milan, Italy
| | - Patrizia Boracchi
- Laboratory of Medical Statistics, Department of Clinical Sciences and Community Health, Epidemiology and Biometry G. A. Maccacaro, University of Milan, Via C. Vanzetti 5, 20133, Milan, Italy
| | - Giuseppe Marano
- Laboratory of Medical Statistics, Department of Clinical Sciences and Community Health, Epidemiology and Biometry G. A. Maccacaro, University of Milan, Via C. Vanzetti 5, 20133, Milan, Italy
| | - Job Harenberg
- Medical Faculty Mannheim, Ruprecht-Karls University Heidelberg, Theodor-Kutzer Ufer 1-3, 68167, Mannheim, Germany
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Bonutti PM, Sodhi N, Patel YH, Sultan AA, Khlopas A, Chughtai M, Kolisek FR, Williams N, Mont MA. Novel venous thromboembolic disease (VTED) prophylaxis for total knee arthroplasty-aspirin and fish oil. ANNALS OF TRANSLATIONAL MEDICINE 2017; 5:S30. [PMID: 29299477 DOI: 10.21037/atm.2017.11.22] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background Despite the demonstrated success of multiple anticoagulation therapies for post-operative prophylaxis of thromboembolic disease in lower extremity arthroplasties, each modality comes with a unique set of limitations. Thus, the ideal anticoagulation medication which provides adequate therapy with minimal cost, complications, or added patient work is yet to be defined. One promising novel thrombophylactic supplement is fish oil, as many preliminary clinical trials have demonstrated a protective effect of fish oil against thrombosis in multiple clinical settings. In addition, others have demonstrated synergistic effect when combined with aspirin. However, there are paucity of studies that compared combined aspirin and fish oil therapy for venous thromboembolism prophylaxis with other pharmacological agents, especially in the field of orthopaedics. Therefore, this study evaluated: (I) risk of post-operative deep vein thrombosis (DVT) and pulmonary embolism (PE), and (II) bleeding complications; among patients who had primary total knee arthroplasty (TKA) and received one of the following regimens: (i) 325 mg aspirin and mechanical pulsatile stocking; (ii) rivaroxaban; or (iii) 325 mg aspirin and 1,000 mg fish oil. Methods This was a 6-year prospective study analyzing the postoperative thromboembolic prophylaxis received by patients who underwent primary TKA. Patients who had a previous history of thromboembolic disease were excluded from the study due to an increased risk of recurrent clot formation. A total of 850 patients were enrolled. A total of 300 patients enrolled between October 2011 and June 2013 received 325 mg aspirin and mechanical pulsatile stocking, while 250 patients enrolled between June 2013 and December 2014 received rivaroxaban. A total of 300 patients enrolled between January 2015 and July 2017 received 325 mg aspirin and 1,000 mg fish oil. Major venous thromboembolic events (VTEs) and bleeding complications within the first 90 days post-operatively were recorded in each cohort. The odds ratios (ORs) and 95% confidence intervals (CIs), for thromboembolic and bleeding events were calculated and compared between the aspirin and fish oil cohort vs. aspirin and pulsatile stocking cohort, and aspirin and fish oil cohort vs. rivaroxaban cohort. A P value of <0.05 was used to determine statistical significance. Results A total of 25 DVT events were recorded including 1 of 300 (0.33%) in the aspirin and fish oil cohort, 22 of 300 (7.33%) in the aspirin and pulsatile stocking cohort and 2 of 250 (0.8%) in the rivaroxaban cohort. When comparing ORs, patients who received aspirin and fish oil demonstrated significantly lower risk for thromboembolic events when compared to the aspirin and pulsatile stocking group (OR: 0.045; 95% CI: 0.0061-0.3394; P<0.05). When compared to the rivaroxaban cohort the ORs did not differ significantly (OR: 0.416; 95% CI: 0.0376-4.6223; P>0.05). In addition, no PE events were recorded in any of the cohorts. When compared to rivaroxaban, the fish oil and aspirin cohort demonstrated significantly lower incidence of bleeding episodes (1 of 300, 0.33% vs. 30 of 250 patients, 12%; OR: 0.0278; 95% CI: 0.0038-0.2051; P<0.05). No bleeding events were recorded in the aspirin and pulsatile stocking cohort. Conclusions This study demonstrated the potentially synergistic anti-thromboembolic effect of aspirin and fish oil in the prevention of post-operative venous thromboembolism in primary TKA patients. Based on the results from this study, the authors conclude that the combination of aspirin and fish oil maybe an excellent thromboprophylactic modality for patients to use after TKA. These results warrant further, larger prospective studies analyzing the use of fish oil supplements in VTE prophylaxis.
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Affiliation(s)
- Peter M Bonutti
- Department of Orthopaedic Surgery, Bonutti Clinic, Effingham, Illinois, USA
| | - Nipun Sodhi
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Yatindra H Patel
- School of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Assem A Sultan
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Anton Khlopas
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Morad Chughtai
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Frank R Kolisek
- Department of Orthopaedic Surgery, OrthoIndy, Greenwood, IN, USA
| | - Nick Williams
- Department of Orthopaedic Surgery, Bonutti Clinic, Effingham, Illinois, USA
| | - Michael A Mont
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio, USA
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35
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Atkinson HDE. The negatives of knee replacement surgery: complications and the dissatisfied patient. ORTHOPAEDICS AND TRAUMA 2017; 31:25-33. [DOI: 10.1016/j.mporth.2016.09.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
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Lazarova B, Kapedanovska Nestorovska A, Sterjev Z, Suturkova L. Evaluation of costs and outcomes associated with pharmacological thromboprophylaxis (unfractionated heparin and low molecular weight heparins) of venous thromboembolism at orthopedic ward in Clinical Hospital Stip. MAKEDONSKO FARMACEVTSKI BILTEN 2017. [DOI: 10.33320/maced.pharm.bull.2017.63.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Clinical trials have shown Low-molecular weight heparins (LMWHs) to be at least as safe and efficacious as unfractionated heparin (UFH) for preventing venous thromboembolism (VTE) in patients undergoing major orthopedic surgery who are at highest risk of developing VTE. The retrospective study was conducted at orthopedic department in Clinical Hospital – Stip for period of 12 months (January-December 2013), where LMWHs and UFH are accepted thromboprophylaxis options. 320 patients (144 males and 157 females, medium age 58 years and 70 years, respectively) were hospitalized for various types of major orthopedic surgical interventions. 212 (66%) patients were admitted because of hip or knee fractures, 26 (8%) had conditions after hip or knee fractures and 82 (26%) were hospitalized for removal or implanting of osteosynthetic devices. After the surgical intervention, patients were subjected to anticoagulant prophylaxis (UFH or LMWHs). Which type of prophylaxis will be used depended exclusively on the surgeon’s decision. VTE complications resulting death were observed in 8 (2.5%) out of 13 patients. Death because of PE occurred in 2 (25%) out of 8 patients, compared to 6 (75%) patients who had fatal DVT complications. The average hospital cost for patients treated with LMWHs prophylaxis as first line thromboprophylaxis option was 52831.92 MKD/patient compared to 70082.24 MKD/patient for UFH first line thromboprophylaxis option. We observed that LMWHs thromboprophylaxis, applied in recommended doses subcutaneously once a day, is potentially more effective and cost saving option compared to UFH and should be considered as pharmacological treatment of first choice for the prevention of VTE (DVT and PE) in patients recovering from major orthopedic surgery at the orthopedic department in Clinical Hospital Stip.
Keywords: Thromboprophylaxis, major orthopedic surgery, LMWHs, UFH
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Affiliation(s)
- Biljana Lazarova
- Clinical Hospital Stip, Ljuben Ivanov bb, 2000 Stip, R. Macedonia
| | | | - Zoran Sterjev
- Faculty of Pharmacy, Ss. Cyril and Methodius University, Majka Tereza 47, 1000 Skopje, R. Macedonia
| | - Ljubica Suturkova
- Faculty of Pharmacy, Ss. Cyril and Methodius University, Majka Tereza 47, 1000 Skopje, R. Macedonia
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Hip Replacement Surgery in 14-Year-Old Girl with Factor V Deficiency: Haemostatic Treatment and Thromboprophylaxis. Case Rep Hematol 2016; 2016:5024692. [PMID: 27872768 PMCID: PMC5107212 DOI: 10.1155/2016/5024692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 10/02/2016] [Accepted: 10/09/2016] [Indexed: 11/17/2022] Open
Abstract
Factor V (FV) is a pivotal coagulation factor present in plasma and platelets. It plays an essential role in secondary haemostasis acting as a cofactor in the prothrombinase complex, catalysing the conversion of prothrombin to thrombin. There is little evidence on the management of mayor orthopaedic surgery in paediatric or adolescents subjects with this coagulopathy and almost no information about thromboprophylaxis in these situations. We report a case of a hip replacement in a 14-year-old girl with moderate FV deficiency (0.07 IU mL−1). As haemostatic replacement, inactivated fresh frozen plasma (FFP) was transfused at doses of 600 mL (15 mL kg−1, 45 kg weight) 2 hours before surgery and then sequential FFP infusions of 250 mL (7 mL kg−1) every 12 hours for 7 days. Plasma factor VIII, von Willebrand factor antigen, and von Willebrand ristocetin cofactor were monitored to avoid supranormal levels. Since the patient was sexually mature (Marshall and Tanner stage 5) with the hormone replacement therapy, she was immobilized and the surgery was considered as a high thrombotic risk. Thus, low molecular weight heparin was administered at doses of intermediate risk (Enoxaparin 20 mg daily, by weight) after finishing the daily infusion of plasma: 24 hours and during the 7 days after intervention. No tranexamic acid was used. No haemorrhagic or thrombotic adverse event was described.
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Gao Y, Long A, Xie Z, Meng Y, Tan J, Lv H, Zhang L, Zhang L, Tang P. The compliance of thromboprophylaxis affects the risk of venous thromboembolism in patients undergoing hip fracture surgery. SPRINGERPLUS 2016; 5:1362. [PMID: 27588255 PMCID: PMC4990524 DOI: 10.1186/s40064-016-2724-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Accepted: 06/30/2016] [Indexed: 01/20/2023]
Abstract
Objective Venous thromboembolism (VTE) is major problem after hip fracture surgery with substantial morbidity and mortality. This study aimed to assess the postoperative compliance of thromboprophylaxis in elderly patients undergoing hip fracture surgery and to confirm the correlation between compliance and VTE risk. Methods This retrospective cohort study included consecutive elderly hip fracture patients who undergoing surgery. According to the thromboprophylaxis regimens, patients were divided into non-compliant group (<14days), poor compliant group (14–27days) and good compliant group (≥28days). The primary outcome was the incidence of symptomatic DVT, PE within 6weeks postoperatively. Results Between 2008 and 2012, 1214 eligible patients were included in this study. 761 (64.7%) patients were non-compliant, 224 (19.0%) patients were poor compliant, and 192 (16.3%) patients were good compliant. The overall VTE rate was 7.9% (73/1177), PE rate was 0.3% (4/1177). The VTE rate in good compliant group was lowest among three groups (4.2 vs. 5.4 vs. 9.6%, P=0.013), but the PE rates showed no significant differences (0 vs. 0.9 vs. 0.3%, P=0.241). The multivariate analysis showed that non-compliance was an independent risk factor of suffering VTE undergoing hip fracture surgery. Conclusions In this study we found fewer than 1 in 5 patients maintained compliant with thromboprophylaxis guidelines after discharge following hip surgery. This is particularly concerning because those who were non-compliant had a higher risk of VTE postoperatively compared with those who were good compliant.
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Affiliation(s)
- Yuan Gao
- Department of Orthopaedics, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853 People's Republic of China
| | - Anhua Long
- Department of Orthopaedics, Beijing Luhe Hospital, Capital Medical University, Beijing, 101149 People's Republic of China.,School of Medicine, Nankai University, Tianjing, 300071 People's Republic of China
| | - Zongyan Xie
- School of Medicine, Nankai University, Tianjing, 300071 People's Republic of China
| | - Yutong Meng
- Department of Orthopaedics, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853 People's Republic of China.,School of Medicine, Nankai University, Tianjing, 300071 People's Republic of China
| | - Jing Tan
- Department of Orthopaedics, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853 People's Republic of China
| | - Houchen Lv
- Department of Orthopaedics, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853 People's Republic of China
| | - Licheng Zhang
- Department of Orthopaedics, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853 People's Republic of China
| | - Lihai Zhang
- Department of Orthopaedics, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853 People's Republic of China
| | - Peifu Tang
- Department of Orthopaedics, Chinese PLA General Hospital, 28 Fuxing Road, Haidian District, Beijing, 100853 People's Republic of China
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