Postdischarge thromboprophylaxis and mortality risk after hip-or knee-replacement surgery (original) (raw)
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Thrombosis research, 2012
BACKGROUND: The American College of Chest Physicians (ACCP) guidelines recommends thromboprophylaxis for total hip replacement (THR) and total knee replacement (TKR) patients. We examined alignment with ACCP thromboprophylaxis guidelines among THR/TKR patients, and compared symptomatic venous thromboembolism (VTE), bleeding event rates and risk factors for VTE between patients receiving ACCP-recommended thromboprophylaxis ('ACCP') and those who did not ('non-ACCP'). METHODS: This retrospective observational study used a large US health plan claims database that was linked to an inpatient database containing detailed inpatient medication use and a database containing date-of-death information. Patients who had THR/TKR surgery between April 01, 2004 and December 31, 2006 were included. Comparisons of VTE and bleeding events between ACCP and non-ACCP patients were analyzed using chi-squared tests and multivariate logistic regression. RESULTS: Of 3,497 linked patient...
BMJ Open, 2013
International guidelines recommend thrombosis prophylaxis after total hip arthroplasty (THA) and total knee arthroplasty (TKA) for up to 35 days. However, previous studies often have hospital stays (length of stay; LOS) of 8-12 days and not considering early mobilisation, which may reduce incidence of venous thromboembolic events (VTE). We investigated the incidence of any symptomatic thromboembolic events (TEEs) with only in-hospital prophylaxis if LOS ≤5 days after fast-track THA and TKA. Design: A prospective descriptive multicentre cohort study in fast-track THA and TKA from February 2010 to December 2011, with complete 90-day follow-up through the Danish National Patient Registry and patient files. Setting: 6 Danish high-volume centres with a similar standardised fast-track setup, including spinal anaesthesia, opioid-sparing analgesia, early mobilisation, functional discharge criteria and discharge to own home. Participants: 4924 consecutive unselected unilateral primary THA and TKAs in patients ≥18 years with no preoperative use of continuous 'potent' anticoagulative therapy (vitamin K antagonists). Exposure: Prophylaxis with low-molecular-weight heparin or factor Xa-inhibitors only during hospitalisation when LOS ≤5 days. Outcomes: Incidence of symptomatic TEE-related, VTErelated and VTE-related mortality ≤90 days postoperatively. Results: LOS ≤5 days and thromboprophylaxis only during hospitalisation occurred in 4659 procedures (94.6% of total). Median LOS and prophylaxis duration was 2 days (IQR 2-3) with 0.84% (95% CI 0.62% to 1.15%) TEE and 0.41% (0.26% to 0.64%) VTE during 90-day follow-up. VTE consisted of five pulmonary embolisms (0.11% (0.05% to 0.25%)) and 14 deep venous thrombosis (0.30% (0.18% to 0.50%)). There were four (0.09% (0.04% to 0.23%)) surgery-related deaths, of which 1 (0.02% (0.00% to 0.12%)) was due to pulmonary embolism, and 6 (0.13% (0.06% to 0.28%)) deaths of unknown causes after discharge. Conclusions: The low incidence of TEE and VTE suggests that in-hospital prophylaxis only, is safe in fasttrack THA and TKA patients with LOS of ≤5 days. Guidelines on thromboprophylaxis may need reconsideration in fast-track elective surgery.
HIP International, 2001
After total hip replacement, continued pharmacological prophylaxis following hospital discharge is controversial.The primary objective of our study was to determine the safety and efficacy of continued prophylaxis with nadroparin three weeks after hospital discharge. The secondary objective was to evaluate the association between a confirmed venous thromboembolism and risk factors for deep venous thrombosis.This study was an open-label, randomized, multicentre, prospective trial. Patients were evaluated for deep venous thrombosis with duplex ultrasonography at discharge and 3 weeks later. Walking ability (mobility score) was assessed at the same times. Patients without deep venous thrombosis at discharge were randomly assigned to continued nadroparin (n=155) versus no pharmacologic prophylaxis (n=141) for three weeks.The rate of deep venous thrombosis three weeks post discharge was significantly lower in the nadroparin group: two patients (1.3%) versus nine (6.4%) without prophylaxi...
Thromboprophylaxis in orthopedic surgery: how long is long enough?
American journal of orthopedics (Belle Mead, N.J.), 2009
Pharmacologic thromboprophylaxis with low-molecular-weight heparins, vitamin K antagonists, or fondaparinux is well tolerated and effective in preventing venous thromboembolism (VTE) in major orthopedic surgery but is often limited to in-hospital use. However, 45% to 80% of all symptomatic VTE events occur after hospital discharge. Extended-duration VTE prophylaxis for 28 to 35 days reduces risk for late VTE by up to 70%. In this article, I review the evidence supporting guideline recommendations regarding extended-duration prophylaxis after major orthopedic surgery and provide an overview of current and emerging literature regarding prevention of postoperative VTE in patients undergoing this surgery.
Indian Journal of Orthopaedics, 2013
Background: Postoperative thromboprophylaxis with low molecular weight heparin (LMWH) for an extended period of 4 weeks is now preferred over short term thromboprophylaxis in patients undergoing total hip/knee arthroplasty (THA/TKA). However, most of the data demonstrating the efficacy and safety of extended thromboprophylaxis and short term thromboprophylaxis is from clinical trials done in the West. In India, the data of the incidence of venous thromboembolism (VTE) following THA/TKA has been conflicting and the duration has not been clearly defined. The aim of the study was to evaluate and compare the efficacy of extended thromboprophylaxis over short term thromboprophylaxis in Indian patients undergoing elective THA/TKA surgeries. Materials and Methods: A prospective arm of 197 consecutive patients undergoing elective THA/TKA surgeries who were administered extended thromboprophylaxis for 4 weeks was compared with a historical group of 795 patients who were administered short term thromboprophylaxis for only 7-11 days. In both groups, LMWH (enoxaparin) was used in a dose of 40 mg subcutaneously, in addition to mechanical thromboprophylaxis. Primary efficacy endpoint was objectively confirmed venous thromboembolism (VTE). The presence of DVT was confirmed by a combination of pretest scoring, D-dimer, and Color Doppler Flow Imaging (CDFI) of deep veins of the legs, and pulmonary thromboembolism (PTE) was confirmed by ventilation perfusion (V/Q) scan or pulmonary angiography. Fisher's exact test and t test were used for the statistical analysis. The baseline confounding factors were compared between the two groups using t test for comparing the means for continuous data and Fisher's exact test for categorical data. Results: In the prospective arm, only 1 patient developed symptomatic PTE compared to 26 (3.27%) cases of VTE (20 cases of PTE and 6 cases of DVT) in the retrospective group. Conclusion: Extended thromboprophylaxis (for 4 weeks) was found to be more effective than short term thromboprophylaxis in minimizing the risk of postoperative VTE in patients who underwent THA/TKA.
A review of the evidence for and against thromboprophylaxis in total hip replacement
Acta orthopaedica Belgica
Total Replacement OR Arthroplasty. THR results in significant risk of thrombo-embolic complications with studies showing that as many as one half of patients suffer from DVT post-operatively. Prophylactic treatments are used to reduce the incidence of DVT. However, there are also risks associated with the use of prophylaxis, including excessive bleeding and major cardio-vascular events. Further investigation is required to determine which patients should be given what prophylaxis and for how long post THR.
Does thromboprophylaxis prevent venous thromboembolism after major orthopedic surgery?
Jornal Brasileiro de Pneumologia, 2013
OBJECTIVE: Pulmonary embolism (PE) is an important complication of major orthopedic surgery. The aim of this study was to evaluate the incidence of venous thromboembolism (VTE) and factors influencing the development of VTE in patients undergoing major orthopedic surgery in a university hospital. METHODS: Patients who underwent major orthopedic surgery (hip arthroplasty, knee arthroplasty, or femur fracture repair) between February of 2006 and June of 2012 were retrospectively included in the study. The incidences of PE and deep vein thrombosis (DVT) were evaluated, as were the factors influencing their development, such as type of operation, age, and comorbidities. RESULTS: We reviewed the medical records of 1,306 patients. The proportions of knee arthroplasty, hip arthroplasty, and femur fracture repair were 63.4%, 29.9%, and 6.7%, respectively. The cumulative incidence of PE and DVT in patients undergoing major orthopedic surgery was 1.99% and 2.22%, respectively. Most of the pat...
Venous thromboembolism following major orthopedic surgery: what is the risk after discharge?
Orthopedics, 2006
Guidelines recommend thromboprophylaxis for at least 10 days to prevent venous thromboembolism in patients undergoing high-risk orthopedic surgery, such as total hip arthroplasty (THA) or total knee arthroplasty (TKA). Furthermore, the recently updated ACCP guidelines also recommend extending the duration of thromboprophylaxis for 28 to 35 days following THA or hip fracture surgery as the risk for venous thromboembolism persists for up to 3 months after surgery. Extended-duration thromboprophylaxis (up to 6 weeks) with low-molecular-weight heparin is significantly more effective in preventing venous thromboembolism in orthopedic surgery patients than the recommended practice of at least 10 days. Extended-duration thromboprophylaxis may require risk stratification to identify high-risk patients. Current risk-assessment models have limitations and are not specific to orthopedic surgery patients; therefore, improvements may facilitate the use of extended-duration thromboprophylaxis in ...
Clinical and Applied Thrombosis/Hemostasis, 2014
We describe annual incidences and 6-month postoperative patterns of clinical venous thromboembolism (VTE) in 9078 patients undergoing major joint surgery in a Scandinavian hospital. In cohort I (1989-1999), low-molecular-weight heparin thromboprophylaxis for 7 to 10 days was uniformly introduced, 5-week thromboprophylaxis becoming routine after total hip replacement (THR), partially applied after hip fracture surgery (HFS), but not used after total knee replacement (TKR) thereafter cohort II). Mean annual VTE incidence was lower in cohort II than in cohort I after THR and HFS but not after TKR. In cohort I, the cumulative VTE incidence increased sharply during the first 5 postoperative weeks in all groups, subsequently plateauing up to 6 months postsurgery. In cohort II, this incidence remained low and stable during 5 weeks post-THR, rising gradually up to 6 months, with a comparable but less pronounced pattern following HFS but not TKR. In conclusion, the VTE risk after major joint surgery seems to persist after 5-and 1-week prophylaxis in patients undergoing hip surgery and TKR, respectively.