Preventing venous thromboembolic disease in patients undergoing elective total hip and knee arthroplasty.
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ABSTRACT:
SUBMITTER: Members of 2007 and 2011 AAOS Guideline Development Work Groups on PE/VTED Prophylaxis
PROVIDER: S-EPMC3326687 | biostudies-literature | 2012 Apr
REPOSITORIES: biostudies-literature
Publications
Preventing venous thromboembolic disease in patients undergoing elective total hip and knee arthroplasty.
Mont Michael M Jacobs Joshua J Lieberman Jay J Parvizi Jay J Lachiewicz Paul P Johanson Norman N Watters William W
The Journal of bone and joint surgery. American volume 20120401 8
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Project description:To study 90-day complications following total hip arthroplasty (THA) or total knee arthroplasty (TKA).In a population-based cohort of all Olmsted County residents who underwent a THA or TKA (1994-2008), we assessed 90-day occurrence and predictors of cardiac complications (myocardial infarction, cardiac arrhythmia or congestive heart failure), thromboembolic complications (deep venous thrombosis or pulmonary embolism) and mortality.90-day complication rates after THA and TKA were: cardiac, 6.9% and 6.7%; thromboembolic, 4.0% and 4.9%; and mortality, 0.7% and 0.4%, respectively. In multivariable-adjusted logistic regression analyses, ASA class III-IV (OR 6.1, 95% CI:1.6-22.8) and higher Deyo-Charlson comorbidity score (OR 1.2, 95% CI:1.0-1.4) were significantly associated with odds of 90-day cardiac event post-THA in patients with no known previous cardiac event. In those with known previous cardiac disease, ASA class III-IV (OR 4.4, 95% CI:2.0-9.9), male gender (OR 0.5, 95% CI:0.3-0.9) and history of thromboembolic disease (OR 3.2; 95% CI:1.4-7.0) were significantly associated with odds of cardiac complication 90 days post-THA. No significant predictors of thromboembolism were found in THA patients. In TKA patients with no previous cardiac history, age >65 years (OR 4.1, 95% CI:1.2-14.0) and in TKA patients with known cardiac disease, ASA class III-IV (OR 3.2, 95% CI:1.8-5.7) was significantly associated with odds of 90-day cardiac events. In TKA patients with no previous thromboembolic disease, male gender (OR 0.5, 95% CI:0.2-0.9) and higher Charlson index (OR 1.2, 95% CI:1.1-1.3) and in patients with known thromboembolic disease, higher Charlson index score (OR 1.2, 95% CI:1.1-1.4) was associated with odds of 90-day thromboembolic events.Older age, higher comorbidity, higher ASA class and previous history of cardiac/thromboembolic disease were associated with an increased risk.
| S-EPMC3315837 | biostudies-literature
Project description:BACKGROUND:Postoperative stroke is a rare but potentially devastating complication following total hip arthroplasty (THA) and total knee arthroplasty (TKA). The purpose of the current study was to determine the incidence, independent risk factors, and timing of stroke following THA and TKA utilizing the National Surgical Quality Improvement (NSQIP) database. METHODS:Patients who underwent elective primary THA and TKA were identified in the 2005-2016 NSQIP database. Thirty-day postoperative strokes were identified, timing was characterized, and an incidence curve was created. Multivariate analyses determined the independent predictors of these strokes. RESULTS:Of 333,117 patients identified, 286 (0.09%) experienced a stroke. Given that THA vs TKA was not a univariate predictor of stroke, the two procedures were considered together. The majority (65%) of strokes occurred before discharge. Of the strokes observed, 25% occurred by postoperative day one, 50% by postoperative day two, and 75% by postoperative day nine. Independent risk factors for postoperative stroke were: age (60-69 years old odds ratio [OR] = 4.2; 70-79 years old OR = 8.1; ?80 years old OR = 16.1), higher American Society of Anesthesiologists (ASA) score (ASA?3 OR = 1.7), and smoking [OR = 1.6). CONCLUSION:The incidence of stroke after THA/TKA was low at 0.09%, with the majority occurring prior to discharge and half occurring by postoperative day two. Patients who were older, sicker, or who were smokers were at greater risk of postoperative stroke. These findings can be used to council patients and to optimize patient care. LEVEL OF EVIDENCE:Level III, Retrospective comparative study.
| S-EPMC7498016 | biostudies-literature
Project description:ObjectivesPreoperative anaemia is associated with increased risks of postoperative complications, blood transfusion and mortality. This meta-analysis aims to review the best available evidence on the clinical effectiveness of preoperative iron in anaemic patients undergoing elective total hip (THR) or total knee replacement (TKR).DesignElectronic databases and handsearching were used to identify randomised and non-randomised studies of interventions (NRSI) reporting perioperative blood transfusion rates for anaemic participants receiving iron before elective THR or TKR. Searches of CENTRAL, MEDLINE, Embase, PubMed and other databases were conducted on 17 April 2019 and updated on 15 July 2020. Two investigators independently reviewed studies for eligibility and evaluated risk of bias using the Cochrane risk of bias tool for randomised controlled trials (RCTs) and a modified Newcastle-Ottawa scale for NRSIs. Data extraction was performed by ABS and checked by AB. Meta-analysis used the Mantel-Haenszel method and random-effects models.Results807 records were identified: 12 studies met the inclusion criteria, of which 10 were eligible for meta-analyses (one RCT and nine NRSIs). Five of the NRSIs were of high-quality while there were some concerns of bias in the RCT. Meta-analysis of 10 studies (n=2178 participants) showed a 39% reduction in risk of receiving a perioperative blood transfusion with iron compared with no iron (risk ratio 0.61, 95% CI 0.50 to 0.73, p<0.001, I2=0%). There was a significant reduction in the number of red blood cell units transfused with iron compared with no iron (mean difference -0.37units, 95% CI -0.47 to -0.27, p<0.001, I2=40%); six studies (n=1496). Length of stay was significantly reduced with iron, by an average of 2.08 days (95% CI -2.64 to -1.51, p<0.001, I2=40%); five studies (n=1140).ConclusionsPreoperative iron in anaemic, elective THR or TKR patients, significantly reduces the number of patients and number of units transfused and length of stay. However, high-quality, randomised trials are lacking.Prospero registration numberCRD42019129035.
| S-EPMC7783611 | biostudies-literature
Project description: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.
| S-EPMC7839761 | biostudies-literature
Project description:IntroductionDeep 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.MethodsA 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.ResultsFor 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.ConclusionsA 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.
| S-EPMC10568791 | biostudies-literature
Project description:Background: Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are cost-effective procedures that decrease pain and improve health-related quality of life for patients with advanced symptomatic arthritis, including rheumatoid arthritis (RA). Patients with RA have a longer length of stay (LOS) after THA or TKA than patients with osteoarthritis, yet the factors contributing to LOS have not been investigated. Purpose: We sought to identify the factors contributing to LOS for patients with RA undergoing THA and TKA at a single tertiary care orthopedic specialty hospital. Methods: We retrospectively reviewed data from a prospectively collected cohort of 252 RA patients undergoing either THA or TKA. Demographics, RA characteristics, medications, serologies, and disease activity were collected preoperatively. Linear regression was performed to explore the relationship between LOS (log-transformed) and possible predictors. A multivariate model was constructed through backward selection using significant predictors from a univariate analysis. Results: Of the 252 patients with RA, 83% were women; they had a median disease duration of 14 years and moderate disease activity at the time of arthroplasty. We had LOS data on 240 (95%) of the cases. The mean LOS was 3.4 ± 1.5 days. The multivariate analysis revealed a longer LOS for RA patients who underwent TKA versus THA, were women versus men, required a blood transfusion, and took preoperative opioids. Conclusion: Our retrospective study found that increased postoperative LOS in RA patients undergoing THA or TKA was associated with factors both non-modifiable (type of surgery, sex) and modifiable (postoperative blood transfusion, preoperative opioid use). These findings suggest that preoperative optimization of the patient with RA might focus on improving anemia and reducing opioid use in efforts to shorten LOS. More rigorous study is warranted.
| S-EPMC9096994 | biostudies-literature
Project description:BackgroundAs America's third highest opioid prescribers, orthopedic surgeons have contributed to the opioid abuse crisis. This study evaluated opioid use after primary total joint replacement. We hypothesized that patients who underwent total hip arthroplasty (THA) use fewer opioids than patients who underwent total knee arthroplasty (TKA) and that both groups use fewer opioids than prescribed.MethodsA prospective study of 110 patients undergoing primary THA or TKA by surgeons at an academic center during 2018 was performed. All were prescribed oxycodone 5 mg, 84 tablets, without refills. Demographics, medical history, and operative details were collected. Pain medication consumption and patient-reported outcomes were collected at 2 and 6 weeks postoperatively. Analysis of variance was performed on patient and surgical variables.ResultsSixty-one patients scheduled for THA and 49 for TKA were included. THA patients consumed significantly fewer opioids than TKA patients at 2 weeks (28.1 tablets vs 48.4, P = .0003) and 6 weeks (33.1 vs 59.3, P = .0004). Linear regression showed opioid use decreased with age at both time points (P = .0002). A preoperative mental health disorder was associated with higher usage at 2 weeks (58.3 vs 31.4, P < .0001) and 6 weeks (64.7 vs 39.2, P = .006). Higher consumption at 2 weeks was correlated with worse outcome scores at all time points.ConclusionsTKA patients required more pain medication than THA patients, and both groups received more opioids than necessary. In addition, younger patients and those with a preexisting mental health disorder required more pain medication. These data provide guidance on prescribing pain medication to help limit excess opioid distribution.
| S-EPMC7851352 | biostudies-literature
Project description:Importance:The efficacy of factor XIa inhibition for thromboprophylaxis is unknown. Osocimab is a long-acting, fully human monoclonal antibody that inhibits factor XIa. Objective:To compare different doses of osocimab with enoxaparin and apixaban for thromboprophylaxis in patients who have undergone knee arthroplasty. Design, Setting, and Participants:Randomized, open-label, adjudicator-blinded, phase 2 noninferiority trial with observer blinding for osocimab doses, conducted at 54 hospitals in 13 countries. Adult patients undergoing unilateral knee arthroplasty were randomized from October 2017 through August 2018 and followed up until January 2019. Interventions:Single intravenous osocimab postoperative doses of 0.3 mg/kg (n = 107), 0.6 mg/kg (n = 65), 1.2 mg/kg (n = 108), or 1.8 mg/kg (n = 106); preoperative doses of 0.3 mg/kg (n = 109) or 1.8 mg/kg (n = 108); or 40 mg of subcutaneous enoxaparin once daily (n = 105) or 2.5 mg of oral apixaban twice daily (n = 105) for at least 10 days or until venography. Main Outcomes and Measures:The primary outcome was venous thromboembolism incidence between 10 and 13 days postoperatively (assessed by mandatory bilateral venography performed 10 to 13 days after surgery or confirmed symptomatic deep vein thrombosis or pulmonary embolism). A 5% noninferiority margin compared with enoxaparin was chosen. The primary safety outcome of major or clinically relevant nonmajor bleeding was assessed until 10 to 13 days postoperatively. Results:Of 813 randomized participants (mean [SD] age, 66.5 years [8.2 years]; body mass index, 32.7 [5.7]; and 74.2% women), 600 were included in the per-protocol population used for the primary analysis. The primary outcome occurred in 18 patients (23.7%) receiving 0.3 mg/kg, 8 (15.7%) receiving 0.6 mg/kg, 13 (16.5%) receiving 1.2 mg/kg, and 14 (17.9%) receiving 1.8 mg/kg of osocimab postoperatively; 23 (29.9%) receiving 0.3 mg/kg and 9 (11.3%) receiving 1.8 mg/kg of osocimab preoperatively; 20 (26.3%) receiving enoxaparin; and 12 (14.5%) receiving apixaban. Osocimab given postoperatively met criteria for noninferiority compared with enoxaparin with risk differences (1-sided 95% CIs) of 10.6% (95% CI, -1.2% to ∞) at the 0.6-mg/kg dose; 9.9% (95% CI, -0.9% to ∞) at the 1.2-mg/kg dose, and 8.4% (95% CI, -2.6 to ∞) at the 1.8-mg/kg dose. The preoperative dose of 1.8 mg/kg of osocimab met criteria for superiority compared with enoxaparin with a risk difference of 15.1%; 2-sided 90% CI, 4.9% to 25.2%). Postoperative and preoperative doses of 0.3 mg/kg of osocimab did not meet the prespecified criteria for noninferiority, with risk differences (1-sided 95% CIs) of 2.6% (95% CI, -8.9% to ∞) and -3.6% (95% CI, -15.5% to ∞), respectively. Major or clinically relevant nonmajor bleeding was observed in up to 4.7% of those receiving osocimab, 5.9% receiving enoxaparin, and 2% receiving apixaban. Conclusions and Relevance:Among patients undergoing knee arthroplasty, postoperative osocimab 0.6 mg/kg, 1.2 mg/kg, and 1.8 mg/kg met criteria for noninferiority compared with enoxaparin, and the preoperative 1.8-mg/kg dose of osocimab met criteria for superiority compared with enoxaparin for the primary outcome of incidence of venous thromboembolism at 10 to 13 days postoperatively. Further studies are needed to establish efficacy and safety of osocimab relative to standard thromboprophylaxis. Trial Registration:ClinicalTrials.gov Identifier: NCT03276143.
| S-EPMC6990695 | biostudies-literature
Project description:We developed a computerized clinical decision support system (CCDSS) for venous thromboembolism (VTE) risk assessment. We aimed to demonstrate its relevance and evaluate associations between risk level and VTE incidence in patients undergoing total hip/knee arthroplasty. In this case-control study, VTE was confirmed using ultrasonography/computed tomography angiography in 1098 adults at a tertiary care hospital over five years (2013-2018). Postoperative VTE incidence was classified into three risk levels (moderate, high, and highest). The overall VTE incidence was 11.7%, which increased with a risk level of 0%, 5.8%, and 12.8% in moderate-risk, high-risk, and highest-risk patients, respectively. Highest-risk patients were significantly more likely to develop VTE than high-risk patients (odds ratio [OR] 2.4; 95% confidence interval [CI] 1.2-5.5; p = 0.01). VTE development was more likely in patients with risk scores ≥4 relative to those with risk scores of 2-3 (OR 1.8; 95% CI 1.2-2.7; p = 0.003) and -1 to 1 (OR 3.3; 95% CI 1.6-7.7; p < 0.001). This study indicates that risk level and VTE incidence are associated; our scoring system appears useful for patients undergoing total hip/knee arthroplasty.
| S-EPMC9163732 | biostudies-literature
Project description:Total knee arthroplasty (TKA) in the setting of previous hip fusion is rare with a paucity of evidence in the orthopaedic literature. Traditionally, TKA is performed supine, with the aid of knee-positioning devices allowing for hip flexion and range of motion of the knee to facilitate ease of surgical intervention. However, TKA using traditional positioning would not be possible in the presence of ipsilateral hip arthrodesis preventing hip motion. This case report describes a TKA performed for a 72-year-old woman with end-stage osteoarthritis of the right knee, ipsilateral hip arthrodesis, and leg-length discrepancy as the sequelae of slipped capital femoral epiphysis. We describe novel surgical positioning to be used to facilitate TKA in the absence of ipsilateral hip motion with bed modifications and the use of an extremity positioning device.
| S-EPMC7527288 | biostudies-literature