Symptomatic In-Hospital Deep Vein Thrombosis and Pulmonary Embolism Following Hip and Knee Arthroplasty Among Patients Receiving Recommended Prophylaxis A Systematic Review

Institute of Social and Preventive Medicine, Lausanne University Hospital, Switzerland.
JAMA The Journal of the American Medical Association (Impact Factor: 30.39). 01/2012; 307(3):294-303. DOI: 10.1001/jama.2011.2029
Source: PubMed

ABSTRACT Symptomatic venous thromboembolism (VTE) after total or partial knee arthroplasty (TPKA) and after total or partial hip arthroplasty (TPHA) are proposed patient safety indicators, but its incidence prior to discharge is not defined.
To establish a literature-based estimate of symptomatic VTE event rates prior to hospital discharge in patients undergoing TPHA or TPKA.
Search of MEDLINE, EMBASE, and the Cochrane Library (1996 to 2011), supplemented by relevant articles.
Reports of incidence of symptomatic postoperative pulmonary embolism or deep vein thrombosis (DVT) before hospital discharge in patients who received VTE prophylaxis with either a low-molecular-weight heparin or a subcutaneous factor Xa inhibitor or oral direct inhibitor of factors Xa or IIa.
Meta-analysis of randomized clinical trials and observational studies that reported rates of postoperative symptomatic VTE in patients who received recommended VTE prophylaxis after undergoing TPHA or TPKA. Data were independently extracted by 2 analysts, and pooled incidence rates of VTE, DVT, and pulmonary embolism were estimated using random-effects models.
The analysis included 44,844 cases provided by 47 studies. The pooled rates of symptomatic postoperative VTE before hospital discharge were 1.09% (95% CI, 0.85%-1.33%) for patients undergoing TPKA and 0.53% (95% CI, 0.35%-0.70%) for those undergoing TPHA. The pooled rates of symptomatic DVT were 0.63% (95% CI, 0.47%-0.78%) for knee arthroplasty and 0.26% (95% CI, 0.14%-0.37%) for hip arthroplasty. The pooled rates for pulmonary embolism were 0.27% (95% CI, 0.16%-0.38%) for knee arthroplasty and 0.14% (95% CI, 0.07%-0.21%) for hip arthroplasty. There was significant heterogeneity for the pooled incidence rates of symptomatic postoperative VTE in TPKA studies but less heterogeneity for DVT and pulmonary embolism in TPKA studies and for VTE, DVT, and pulmonary embolism in TPHA studies.
Using current VTE prophylaxis, approximately 1 in 100 patients undergoing TPKA and approximately 1 in 200 patients undergoing TPHA develops symptomatic VTE prior to hospital discharge.

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    • "Patients undergoing major orthopaedic surgery, including total hip arthroplasty, total knee arthroplasty and hip fracture surgery, are at high risk of developing post-operative deep vein thrombosis (DVT) and pulmonary embolism (PE), collectively known as venous thromboembolism (VTE). With contemporary surgical techniques and current methods of VTE prophylaxis, about 1–3% of patients develop a symptomatic DVT and 0.2–1.1% a PE within 35 days of surgery [1] [2] [3]. In view of these risks, current guidelines, including those issued by the American College of Chest Physician (ACCP) and the American Association of Orthopedic Surgeons (AAOS), recommend that patients undergoing knee or hip arthroplasty should receive some form of prophylaxis against VTE [2] [4]. "
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    ABSTRACT: The direct thrombin inhibitor, dabigatran, and the selective factor Xa inhibitors, rivaroxaban and apixaban, are new oral anticoagulants that are approved in many countries for prevention of venous thromboembolism in patients undergoing elective hip or knee arthroplasty. All have a rapid onset of action, a low potential for food and drug interactions and a predictable anticoagulant effect that obviates the need for routine coagulation monitoring. These agents offer a convenient alternative to conventional anticoagulant drug regimens, including parenteral low-molecular-weight heparins and fondaparinux, and oral adjusted-dose vitamin K antagonists, for the prevention of venous thromboembolism in this surgical setting. This review summarizes the pharmacology, clinical trial results, bleeding risk and practical use of these new oral anticoagulants in clinical orthopaedic practice. Potential issues to be considered when using these oral anticoagulants include renal impairment, potential drug interactions, neuraxial anaesthesia and management of bleeding.
    Best practice & research. Clinical haematology 06/2013; 26(2):171-82. DOI:10.1016/j.beha.2013.07.003 · 2.55 Impact Factor
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    • "Patients undergoing TKA are at higher risk for developing DVT; however, the rate of symptomatic DVT is higher after THA [1] [3] [4]. With evolving surgical technique, and methods of preventing VTE, the rate of VTE has decreased over time [1]. "
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    ABSTRACT: Venous thromboembolism (VTE) is a common complication after total hip and total knee arthroplasty. Currently used methods of VTE prophylaxis after these procedures have important limitations, including parenteral administration, and unpredictable plasma levels requiring frequent monitoring and dose adjustment leading to decreased patient compliance with recommended guidelines. New oral anticoagulants have been demonstrated in clinical trials to be equally efficacious to enoxaparin and allow for fixed dosing without the need for monitoring. Rivaroxaban is one of the new oral anticoagulants and is a direct factor Xa inhibitor that has demonstrated superior efficacy to that of enoxaparin. However, the data also suggest that rivaroxaban has an increased risk of bleeding compared to enoxaparin. This paper reviews the available data on the efficacy and safety of rivaroxaban for VTE prophylaxis after total hip and total knee arthroplasty.
    02/2013; 2013:762310. DOI:10.1155/2013/762310
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    • "Further research into this explanation is needed, including investigating this association in a larger population and elucidation of potential mechanisms. Two (2%) study subjects developed deep vein thrombosis within 90 days postoperatively in this cohort; this finding is consistent with current literature [8]. Although no conclusions may be drawn from this study alone, the fact that about 1.5% of the population undergoing joint replacement can be expected to develop VTE is evidence that a subset of patients exists for whom VTE continues to be a concern. "
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    ABSTRACT: Background. Patients undergoing joint replacement remain at increased risk for venous thromboembolism (VTE) compared to other types of surgery, regardless of thromboprophylactic regimen. The pathophysiologic processes rendering this group of patients at risk for VTE are multifactorial. Procedure-specific and patient-specific exposures play a role in the postoperative development of VTE, including the development of anti-phospholipid antibodies (aPL). Methods. We measured three aPL (anti-cardiolipin, anti-β2 glycoprotein, and lupus anticoagulant) in 123 subjects undergoing total knee or hip arthroplasty to describe the presence of these antibodies preoperatively and to describe the rate of postoperative seroconversion among those people who were negative preoperatively. Postoperative antibodies were measured at day 7, 14, and 21. Results. The prevalence of aPL antibodies in the preoperative period was 44%, positive subjects were more likely to be smokers (P = 0.05) and were less likely to have undergone a previous arthroplasty procedure (P = 0.002). Subjects seroconverted in a 21 day postoperative period at a rate of 79%. Conclusions. These pilot data suggest that the prevalence of aPL in this population both preoperatively and postoperatively is higher than previously expected. Further studies are needed to describe aPL in a larger population and to establish their clinical significance in populations undergoing joint replacement surgeries.
    10/2012; 2012:142615. DOI:10.1155/2012/142615
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