Venous thromboembolism rates in patients undergoing major hip and knee joint surgery at Waitemata District Health Board: a retrospective audit

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Network pharmacology prediction and molecular docking-based strategy to discover the potential pharmacological mechanism of Huang-Qi-Gui-Zhi-Wu-Wu decoction against deep vein thrombosis

BACKGROUND

Huangqi Guizhi Wuwu decoction (HQGZWWD) has been used to treat and prevent deep vein thrombosis (DVT) in China. However, its potential mechanisms of action remain unclear. This study aimed to utilize network pharmacology and molecular docking technology to elucidate the molecular mechanisms of action of HQGZWWD in DVT.

METHODS

We identified the main chemical components of HQGZWWD by reviewing the literature and using a Traditional Chinese Medicine Systems Pharmacology (TCMSP) database. We used GeneCards and Online Mendelian Inheritance in Man databases to identify the targets of DVT. Herb-disease-gene-target networks using Cytascape 3.8.2 software; a protein-protein interaction (PPI) network was constructed by combining drug and disease targets on the STRING platform. Additionally, we conducted Gene Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG) enrichment analyses. Finally, molecular docking verification of active components and core protein targets was conducted.

RESULTS

A total of 64 potential targets related to DVT were identified in HQGZWWD, with 41 active components; quercetin, kaempferol, and beta-sitosterol were the most effective compounds. The PPI network analysis revealed that AKT1, IL1B, and IL6 were the most abundant proteins with the highest degree. GO analysis indicated that DVT treatment with HQGZWWD could involve the response to inorganic substances, positive regulation of phosphorylation, plasma membrane protein complexes, and signaling receptor regulator activity. KEGG analysis revealed that the signaling pathways included pathways in cancer, lipid and atherosclerosis, fluid shear stress and atherosclerosis, and the phosphatidylinositol 3-kinases/protein kinase B(PI3K-Akt) and mitogen-activated protein kinase (MAPK) signaling pathways. The molecular docking results indicated that quercetin, kaempferol, and beta-sitosterol exhibited strong binding affinities for AKT1, IL1B, and IL6.

CONCLUSION

Our study suggests that AKT1, IL1B, and IL6 are promising targets for treating DVT with HQGZWWD. The active components of HQGZWWD likely responsible for its effectiveness against DVT are quercetin, kaempferol, and beta-sitosterol, they may inhibit platelet activation and endothelial cell apoptosis by regulating the PI3K/Akt and MAPK signaling pathways, slowing the progression of DVT.

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

INTRODUCTION

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

STUDY DESIGN

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

RESULTS

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

CONCLUSION

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

Plasma microRNAs as potential biomarkers in diagnosis of acute venous thromboembolism

OBJECTIVE

To assess the potential use of plasma microRNAs (miRNAs) in diagnosis of acute venous thromboembolism (VTE).

METHODS

Using BGISEQ-500 sequencing technology, we analyzed the miRNA profile of paired plasma samples from the acute and chronic phases of four patients with unprovoked VTE. Using real-time quantitative polymerase chain reaction (RT-qPCR), we verified nine upregulated named miRNAs in the acute phase in the plasma samples of 54 patients with acute VTE and 39 controls. We then compared the relative expression of the 9 candidate miRNAs between the acute VTE and control group, and plotted the receiver operating characteristic (ROC) curves of the differentially expressed miRNAs. We chose the miRNA with the greatest area under curve (AUC) to evaluate the effect of miRNA on coagulation and platelet function in the plasma samples of 5 healthy volunteers.

RESULTS

The plasma levels of miR-374b-3p, miR-660-5p, miR-378a-3p, miR-425-5p, miR-3613-5p, miR-130b-3p, miR-183-5p, and miR-103b were higher in patients with acute VTE than in the controls, with AUCs of 0.6776, 0.6614, 0.6648, 0.6885, 0.8048, 0.6871, 0.7298, and 0.7498, respectively, and P values of 0.0036, 0.0081, 0.0069, 0.0020,<0.0001, 0.0022, 0.0002, and < 0.0001, respectively. There were no significant differences in miR-193b-5p level between the acute VTE group and the control group. Fibrinogen (Fib), thrombin- antithrombin complex (TAT), tissue plasminogen activator-inhibitor complex (t-PAIC), and TAT/plasmin-α2-plasmin inhibitor complex (PIC) were decreased in the miR-3613-5p group when compared with the control group (P < 0.05) and the mean platelet aggregation rate was increased in the miR-3613 group (P < 0.05).

CONCLUSION

miRNAs can be potential biomarkers for diagnosing acute VTE, and miR-3613-5p may be involved in the formation, coagulation, and platelet functions in acute VTE.

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

Aim

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

Methods

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

Results

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

Conclusion

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

Thromboelastography for the Prevention of Perioperative Venous Thromboembolism in Orthopedics

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

Foot Pump Versus Low-Molecular-Weight Heparin for Preventing Deep Vein Thrombosis Following Surgery for Hip and Knee Replacement

Objective

To evaluate the comparative efficacy and safety of the use of foot pump versus low-molecular-weight heparin (LMWH) for preventing deep vein thrombosis (DVT) and pulmonary embolism (PE) in total knee replacement (TKR) and total hip replacement (THR).

Summary of background data

The use of chemoprophylactic agents in TKR and THR has been shown to result in increased complications like bleeding and wound drainage.

Methods

Relevant publications indexed in PubMed, Cochrane Library, Embas, Web of Science, Wanfang Data, CNKI, and VIPI were identified. Appropriate articles identified from the reference lists of the above searches were also reviewed.

Results

No significant difference in the rate of distal in the lower extremity was observed between the 2 groups (OR: 0.99; CI: 0.61–1.61; Z = 0.03; P = 0.97). No significant difference in the rate of proximal DVT in the lower extremity was observed between 2 groups (OR: 1.60, CI: 0.85–3.03, Z = 1.44, P = 0.15). No significant difference in the rate of PE was observed between 2 groups (OR 3.84, CI: 0.42 to 34.80, Z = 1.20, P = 0.23). But we found that postoperative drainage in foot pump group was less than that in LMWH group (OR -68.93, CI: −73.81 to −64.05, Z = 27.68, P &lt; 0.00001), and oozing in foot pump group was less than that in LMWH group (OR: 0.21; CI: 0.10–0.47; Z = 3.86, P = 0.0001).

Conclusion

The foot pump is a suitable alternative for TKR and THR patients in preventing DVT and PE, and can get less postoperative drainage and oozing side effects that are associated with LWMH.

Venous Thromboembolism Prophylaxis in Elective Spine Surgery

STUDY DESIGN

Review.

OBJECTIVE

Venothromboembolic (VTE) complications, composed of deep vein thrombosis and pulmonary embolism are commonly observed in the perioperative setting. There are approximately 500 000 postoperative VTE cases annually in the United States and orthopedic procedures contribute significantly to this incidence. Data on the use of VTE prophylaxis in elective spinal surgery is sparse. This review aims to provide an updated consensus within the literature defining the risk factors, diagnosis, and the safety profile of routine use of pharmacological prophylaxis for VTE in elective spine surgery patients.

METHODS

A comprehensive review of the literature and compilation of findings relating to current identified risk factors for VTE, diagnostic methods, and prophylactic intervention and safety in elective spine surgery.

RESULTS

VTE prophylaxis use is still widely contested in elective spine surgery patients. The outlined benefits of mechanical prophylaxis compared with chemical prophylaxis varies among practitioners.

CONCLUSION

The benefits of any form of VTE prophylaxis continues to remain a controversial topic in the elective spine surgery setting. A specific set of guidelines for implementing prophylaxis is yet to be determined. As more risk factors for thromboembolic events are identified, the complexity surrounding intervention selection increases. The benefits of prophylaxis must also continue to be balanced against the increased risk of bleeding events and neurologic injury.

Venous thromboembolism prevention protocol for adapting prophylaxis recommendations to the potential risk post total knee replacement: a randomized controlled trial

Background

Total knee replacement (TKR) is a major orthopedic surgery that is considered high risk for the development of venous thromboembolism (VTE).

Objective

The aim of this study is to evaluate the clinical outcomes that resulted from the use of a new proposed VTE risk stratification protocol for selecting a suitable extended VTE prophylaxis for post TKR surgery patients administered in conjunction with patient education programs.

Method

A randomized controlled trial was conducted in two medical centers in Saudi Arabia. A total of 242 patients were enrolled in the study, 121 patients in each group. The experimental group (A) was assessed by using the proposed VTE risk stratification protocol and also took part in patient education programs about TKR and its complications. The control group (B) was assessed by using the 2005 Caprini risk assessment tool and no education programs were given to this group. Both groups were followed for 35 days post operation.

Results

The mean age of the participants was 65.86 (SD 8.67) and the majority of them were female 137 (56.6%). The mean body mass index of the study sample was 32.46 (SD 5.51). There were no significant differences between the two groups except for surgery type; the proportion of bilateral TKR in group A was higher than in group B (69/121 (28.5%) vs. 40/121(16.5%), p<0.05). There were no confirmed pulmonary embolism cases in the study sample and diagnosis of deep-vein thrombosis was confirmed in 12/242 (5.0%) of patients: 1/121 (0.8%) in group A and 11/121 (9.1%) in group B (p<0.05). The readmission rate for all patients was 2.5% (6/242), all of whom were in group B (p<0.05).

Conclusion

The proposed VTE risk stratification protocol that was applied in conjunction with patient education programs reduced VTE complications and readmission events, post TKR surgery. Trial Registration: ClinicalTrials.gov: Identifier: NCT04031859.

Genetic effects of BDKRB2 and KNG1 on deep venous thrombosis after orthopedic surgery and the potential mediator

Deep venous thrombosis (DVT) is a common complication of orthopedic surgery. Genetic risk factors and high heritability carried a substantial risk of DVT. In this study, we aimed to investigate the potential association in the Han Chinese population between the polymorphisms of BDKRB2 and KNG1 and DVT after orthopedic surgery (DVTAOS). A total of 3,010 study subjects comprising 892 DVT cases and 2,118 controls were included in the study, and 39 single nucleotide polymorphisms (SNPs) in total (30 for BDKRB2 and 9 for KNG1) were chosen for genotyping. Two SNPs, rs710446 (OR = 1.27, P = 0.00016) and rs2069588 (OR = 1.29, P = 0.00056), were identified as significantly associated with DVTAOS. After adjusting for BMI, the significance of rs2069588 decreased (P = 0.0013). Haplotype analyses showed that an LD block containing rs2069588 significantly correlated with the DVTAOS risk. Moreover, bioinformatics analysis indicated that hsa-miR-758-5p and BDKRB2 formed miRNA/SNP target duplexes if the rs2069588 allele was in the T form, suggesting that rs2069588 may alter BDKRB2 expression by affecting hsa-miR-758-5p/single-nucleotide polymorphism target duplexes. Our results demonstrate additional evidence supporting that there is an important role for the KNG1 and BDKRB2 genes in the increased susceptibility of DVTAOS.

Resveratrol attenuates hydrogen peroxide‑induced apoptosis, reactive oxygen species generation, and PSGL‑1 and VWF activation in human umbilical vein endothelial cells, potentially via MAPK signalling pathways

Reactive oxygen species (ROS) are implicated in the pathogenesis of thrombosis. Studies have reported that resveratrol exhibits antioxidative activities, however, the effect and underlying mechanisms of resveratrol on venous thrombosis remain largely unknown. To investigate the effect of resveratrol on venous thrombosis and the underlying mechanisms, the present study investigated the effects of resveratrol on cell viability, apoptosis, ROS generation and the expression of thrombosis‑associated markers in human umbilical vein endothelial cells (HUVECs). HUVECs were pretreated with resveratrol for 2 h and incubated with hydrogen peroxide (H2O2) for 24 h prior to the evaluation of cell viability, ROS generation, apoptosis and thrombosis‑associated marker expression by performing MTT assays, 2',7'‑dichlorofluorescin diacetate reagent, flow cytometry, and reverse transcription‑quantitative polymerase chain reaction (RT‑qPCR) and western blot analysis, respectively. Subsequently, to validate whether resve-ratrol functions via mitogen‑activated protein kinase (MAPK) pathways, the expression of thrombosis‑associated markers was detected by western blot analysis and RT‑qPCR following treatment of cells with resveratrol and the MAPK pathway activators anisomycin and curcumin. The results demonstrated that cell viability was markedly reduced by H2O2, and resveratrol treatment reversed the reductions in cell viability in a dose‑dependent manner. In addition, the levels of cell apoptosis and ROS generation were significantly increased by H2O2 alone, and resveratrol also reduced these effects in a dose‑dependent manner. Furthermore, the mRNA and protein expression of caspase‑3, P‑selectin glycoprotein ligand‑1 and von Willebrand factor was upregulated by H2O2 treatment in HUVECs. However, resveratrol decreased the protein expression these proteins in a dose‑dependent manner. Resveratrol also significantly inhibited the induction of phosphorylated (p)‑p38, P‑c‑Jun N‑terminal kinase and P‑extracellular signal‑regulated kinase by H2O2, and these effects were attenuated by the MAPK pathway activators anisomycin and curcumin. In conclusion, these results indicate that resveratrol protected HUVECs against oxidative stress and apoptosis. Furthermore, to the best of our knowledge, the present study is the first to demonstrate that resveratrol attenuates the expression of thrombosis‑associated markers induced by H2O2, which may occur through the suppression of the MAPK signalling pathways, indicating a potential novel therapeutic approach to prevent venous thrombosis.

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Deep Vein Thrombosis and Pulmonary Embolism Considerations in Orthopedic Surgery

Patients undergoing orthopedic surgery have an increased risk for deep venous thrombosis (DVT) and pulmonary embolism (PE). These complications are considered detrimental, as they cause major postoperative morbidity and mortality and lead to a substantial health care burden. Because of the high incidence and serious nature of these complications, it is essential for orthopedic surgeons to have a comprehensive knowledge of the risk factors, diagnosis, and treatment of acute DVT and PE. Perioperative management of orthopedic patients to prevent postoperative DVT and PE and optimize postoperative outcomes is also discussed in this review.