Abstract
Introduction
Pulmonary embolism (PE) complicates up to 1% of total joint arthroplasties (TJA). Many PE treatment guidelines call for immediate initiation of therapeutic anticoagulation. Options include Xa inhibitors, Enoxaparin, and Warfarin. Deciding between these is a balance of the efficacy and the risks. Little data exists regarding the risks of each of these treatment options for treating PE in arthroplasty patients.
Methods
We examined the records of 29,270 patients who underwent a primary total joint arthroplasty (TJA), defined as a unilateral total knee arthroplasty (TKA) (18,987) or total hip arthroplasty (THA) (10,283), between 2/2016 and 12/2018 at our institution and identified 338 (242 TKA, 96 THA) patients who developed an in-hospital PE treated with therapeutic anticoagulation. The patients were treated with therapeutic doses of Xa inhibitors, enoxaparin or warfarin. The type and frequency of complications were determined and classified as major or minor. Major complication included: bleeding requiring surgery, GI bleed requiring treatment, >2 unit transfusion and mortality. Minor complications included wound drainage, bleeding not requiring surgery, and thrombocytopenia.
Results
Overall complication rates were high for all treatments. Xa inhibitors had the lowest complication rate at 14% compared to 20% for enoxaparin and 20.7% for warfarin though the difference did not quite reach statistical significance (p=.054). Both major and minor complication were lower with Xa inhibitors, but again the difference was not statistically significant (p=0.67). There was no significant difference in complications between TKA groups (p=0.73) or THA groups (p=0.83). Gender and body mass index were not predictive of major or minor complications.
Discussion
Our results demonstrate high complication rates associated with modern therapeutic anticoagulation protocols for perioperative PE following TJA. Patients who receive therapeutic anticoagulation postoperatively are at high risk for complication. Xa inhibitors may decrease these risks, but larger studies are required.
