In order to compare the effect of oral apixaban (a factor Xa inhibitor) with subcutaneous enoxaparin on major venous thromboembolism and major and non-major clinically relevant bleeding after total knee and hip replacement, we conducted a pooled analysis of two previously reported double-blind randomised studies involving 8464 patients. One group received apixaban 2.5 mg twice daily (plus placebo injection) starting 12 to 24 hours after operation, and the other received enoxaparin subcutaneously once daily (and placebo tablets) starting 12 hours (± 3) pre-operatively. Each regimen was continued for 12 days (. ± . 2) after knee and 35 days (. ± . 3) after hip arthroplasty. All outcomes were centrally adjudicated. Major venous thromboembolism occurred in 23 of 3394 (0.7%) evaluable apixaban patients and in 51 of 3394 (1.5%) evaluable enoxaparin patients (risk difference, apixaban minus enoxaparin, -0.8% (95% confidence interval (CI) -1.2 to -0.3); two-sided p = 0.001 for superiority). Major bleeding occurred in 31 of 4174 (0.7%) apixaban patients and 32 of 4167 (0.8%) enoxaparin patients (risk difference -0.02% (95% CI -0.4 to 0.4)). Combined major and clinically relevant non-major bleeding occurred in 182 (4.4%) apixaban patients and 206 (4.9%) enoxaparin patients (risk difference -0.6% (95% CI -1.5 to 0.3)). Apixaban 2.5 mg twice daily is more effective than enoxaparin 40 mg once daily without increased bleeding

In recent years, many changes have taken place regarding agents used for chemical thromboprophylaxis in elective joint replacement. Enoxaparin, Rivaroxaban, Dabigatran and Apixaban are all now recommended in NICE CG92 and their use varies nationally. Whilst data exists comparing oral anticoagulants to Enoxaparin, there is little data on the comparative efficacy of the individual oral anticoagulants. This study analyses data from Warrington Hospital, where each of the above oral anticoagulants was used trustwide in 3 successive years following hip and knee arthroplasty. We analysed similar 4–5 month periods in 2010(Rivaroxiban), 2011(Dabigatran) and 2012(Apixaban). The study was done prospectively and data was collected contemporaneously. The total sample size was 475 patients. Data was collected through electronic hospital patient records. Patients were excluded if data was incomplete. We defined our primary outcome as any complication requiring the drug to be omitted or stopped. We found that for Rivaroxaban, 7 of 129 patients had the drug omitted or stopped (5.4%, 95% confidence interval 1.0–9.8), for Dabigatran 19 of 150 patients, (12.7%, 95% confidence interval 6.4–19.0) and for Apixaban 10 of 196 patients (5.1%, 95% confidence interval 0.9–9.3). For Rivaroxaban and Apixaban, there were no confirmed thromboembolic events; however, for Dabigatran, there were six VTEs. All three had bleeding complications, which were well below the figures published for Enoxaparin. Apixaban registered the lowest rate in our study (5.1%). This data suggests that Apixaban is a safe oral anticoagulant in elective total knee and hip replacement

In recent years, many changes have taken place regarding agents used for chemical thromboprophylaxis in elective joint replacement. Enoxaparin, Rivaroxaban, Dabigatran and Apixaban are all now recommended in NICE CG92 and their use varies nationally. While data exist comparing oral anticoagulants to Enoxaparin, there is little data on the comparative efficacy of the individual oral anticoagulants. This study analyses data from Warrington Hospital, where each of the above oral anticoagulants was used trustwide in 3 successive years following hip and knee arthroplasty. We analysed similar 4–5 month periods in 2010 (Rivaroxiban), 2011 (Dabigatran) and 2012 (Apixaban). The study was done prospectively and data was collected contemporaneously. The total sample size was 475 patients. Data was collected through electronic hospital patient records. Patients were excluded if data was incomplete. We defined our primary outcome as any complication requiring the drug to be omitted or stopped. We found that for Rivaroxaban, 7 of 129 patients had the drug omitted or stopped (5.4%, 95% confidence interval 1.0–9.8), for Dabigatran 19 of 150 patients, (12.7%, 95% confidence interval 6.4–19.0) and for Apixaban 10 of 196 patients (5.1%, 95% confidence interval 0.9–9.3). For Rivaroxaban and Apixaban, there were no confirmed thromboembolic events; however, for Dabigatran, there were six VTEs. All three had bleeding complications, which were well below the figures published for Enoxaparin. Apixaban registered the lowest rate in our study (5.1%). This data suggests that Apixaban is a safe oral anticoagulant in elective total knee and hip replacement

Aims. We investigated the efficacy and safety profile of commonly used venous thromboembolism (VTE) prophylaxis agents following hip and knee arthroplasty. Methods. A systematic search of PubMed, Embase, Cochrane Library, Web of Science, and OrthoSearch was performed. Prophylaxis agents investigated were aspirin (< 325 mg and ≥ 325 mg daily), enoxaparin, dalteparin, fondaparinux, unfractionated heparin, warfarin, rivaroxaban, apixaban, and dabigatran. The primary efficacy outcome of interest was the risk of VTE, whereas the primary safety outcomes of interest were the risk of major bleeding events (MBE) and wound complications (WC). VTE was defined as the confirmed diagnosis of any deep vein thrombosis and/or pulmonary embolism. Network meta-analysis combining direct and indirect evidence was performed. Cluster rank analysis using the surface under cumulative ranking (SUCRA) was applied to compare each intervention group, weighing safety and efficacy outcomes. Results. Of 86 studies eligible studies, cluster rank analysis showed that aspirin < 325 mg daily (SUCRA-VTE 89.3%; SUCRA-MBE 75.3%; SUCRA-WC 71.1%), enoxaparin (SUCRA-VTE 55.7%; SUCRA-MBE 49.8%; SUCRA-WC 45.2%), and dabigatran (SUCRA-VTE 44.9%; SUCRA-MBE 52.0%; SUCRA-WC 41.9%) have an overall satisfactory efficacy and safety profile. Conclusion. We recommend the use of either aspirin < 325 mg daily, enoxaparin, or dabigatran for VTE prophylaxis following hip and knee arthroplasty. Cite this article: Bone Joint J 2024;106-B(9):924–934

Background. The incidence of bleeding following primary TKR has increased with the use of chemical thromboprophylaxis. Our aim was to compare Clexane, Apixaban and Rivaroxaban in terms of frequency and volume of bleeding episodes, need for blood transfusion, return to theatre and incidence of VTE events. Methods. Between February and May 2014, a consecutive series of 132 primary TKRs were studied prospectively. The wound dressings of these patients were assessed daily to look for signs of bleeding and classified into: Mild (< 50p size coin), moderate (> 50p size coin) or Severe (blood seeping through the dressing). Follow up was up to minimum of 30 days post discharge. Results. Apixaban, Rivaroxaban & Clexane were used in 64, 23 and 45 patients respectively. Eleven patients had at least 1 day of mild bleeding, 8 had at least 1 day of moderate bleeding and 11 had at least 1 day of severe bleeding. Ten patients had 1 or more doses omitted because of bleeding. However, there was no statistical significance in distribution of bleeding episodes or doses omitted due to bleeding amongst the three drugs (chi squared test). There was also no correlation between number of severe bleeding episodes and the need for blood transfusion. There were two VTE events recorded; 1 PE each in the Apixaban and Rivaroxaban groups. Two cases in the Apixaban group and 1 case in the Clexane group returned to theatre for washout of haematoma. Conclusion. There was an 8% incidence of severe bleeding in our study group. The incidence of bleeding problems following TKR was similar in the Apixaban, Rivaroxaban & Clexane groups. Level of evidence. III - Evidence from case, correlation, and comparative studies

Abstract. Introduction. Neck of femur (NOF) fracture patients are at risk of developing venous thromboembolisms (VTE). VTE risks could be reduced by adhering to the National Institute for Health and Care Excellence (NICE) recommendation for 1 month of prophylaxis with low molecular weight heparin. This audit aimed to assess and improve local compliance to national guidelines on VTE prophylaxis in NOF fracture patients following discharge. Methods. A retrospective consecutive case series of all NOF fractures treated at our institution from May – July 2021 was conducted. Those not eligible for outpatient VTE prophylaxis were excluded (anticoagulated for other indications, completed prophylactic course in hospital, inpatient death, pharmacological prophylaxis contraindicated). The agent and duration of VTE prophylaxis, and the occurrence of clinically significant VTE or bleeds were recorded. A re-audit was conducted in March 2022. Results. From May – July 2021, only 1/65 (1.5%) patient was discharged on a VTE prophylaxis regime consistent with NICE guidelines (1 enoxaparin, 56 rivaroxaban, 6 apixaban; 58 35-day course, 5 28-day course). A quick-guide document summarising the standard inpatient and outpatient VTE prophylaxis regimes for various orthopaedic indications was designed and widely disseminated. In March 2022, 30/34 (88.2%) patients were discharged with enoxaparin and 24/34 (70.6%) received a 28-day course. There were no cases of clinically significant VTE or bleeds in both cycles. Conclusion. Local compliance to national guidelines improved significantly with the implementation of a standardised VTE prophylaxis protocol. Our quick-guide document is a reproducible way of communicating consensus and ensuring consistency within a department

To determine whether pre-operative cessation of anticoagulant or antiplatelet medication is necessary for patients undergoing total shoulder arthroplasty (TSA) or reverse total shoulder arthroplasty (RTSA). A prospectively maintained database was used to identify 213 consecutive patients treated with TSA or RTSA performed by a single surgeon across 3 centres. This cohort included 24 patients on an anticoagulant agent (warfarin, apixaban, rivaroxaban, dabigatran), 52 patients on an antiplatelet agent (aspirin, clopidogrel), and a control group of 137 patients not on anticoagulant or antiplatelet medication. Patients on anticoagulant or antiplatelet medications continued these agents peri-operatively. Outcomes included haemoglobin drop, intra-operative blood loss, operative time, transfusion requirements and post-operative complications. The mean age of the cohort was 74.3 years (range 47 – 93) and 75 (35.2%) of the patients were male. TSA was performed in 63 cases and RTSA in 150 cases. The mean haemoglobin drop in the control group was 17.3 g/L, compared to 19.3 g/L in the anticoagulant group (p = 0.20) and 15.6 g/L in the anti-platelet group (p = 0.14). The mean intra-operative blood loss in the control group was 107.8 mL, compared to 143.0 mL in the anticoagulant group (p = 0.03) and 134.3 mL in the anti-platelet group (0.02). The mean operative time in the control group was 49.3 minutes, compared to 47.1 minutes in the anticoagulant group (p = 0.56) and 50.3 minutes in the anti-platelet group (p = 0.78). Post-operatively no patients developed a wound infection or haematoma requiring intervention. Three patients not on anticoagulant or antiplatelet medication developed pulmonary embolism. Continuing anticoagulant or antiplatelet medication was associated with higher intra-operative blood loss, but produced no statistically significant differences in haemoglobin drop, operative time, transfusion requirements or post-operative complications. We now do not routinely stop any anticoagulant or antiplatelet medication for patients undergoing total shoulder arthroplasty

Introduction. Cardiac events have been found to occur with increased frequency in total joint arthroplasty (TJA) patients >65 y/o without known coronary artery disease (CAD). Avoidance of readmissions for cardiac events is paramount with bundled payment programs. It has been thought that many of these patients may have undiagnosed CAD because of sedentary life styles brought on by chronic osteoarthritis. The purpose of this study is to assess with Coronary Computed Tomographic Angiography (CCTA) the prevalence and severity of CAD in patients >65 y/o for elective TJA. Methods. 126 elective patients that were part of a total hip and knee bundled payment program were referred for cardiac evaluation with CCTA if they were >65 but <70 y/o with a history of heart disease or 2 risk factors or were >70 y/o. CCTA was acquired on all patients unless they had a history of a severe allergic reaction to contrast, GFR <50 ml/min., the presence of atrial fibrillation, or declined the test. All images were evaluated by an experienced reader. Arterial narrowing of 70% diameter or greater was classified as significant CAD. Intermediate lesions <70% were reclassified as significant if CT-FFR (Functional flow reserve) was < or = 0.80. Results. Excluding the 12 patients with known CAD who had stents or coronary artery bypass graft (CABG), the remaining 114 patients were classified into three groups. 34/114 (29.8%) had no CAD (Group A). 75/114 (65.8%) had (Group B). 5/114 (4.4%) had > or = 70% stenosis. Group C included one patient who had <70% stenosis but had CT-FFR <80%. Of 17 patients with known CAD with >70% or heart CT-FFR <80%, or prior stents/CABG, one patient was predicted to be high risk of a cardiac event because of a complex plaque with an ulcer, history of suppressed paroxysmal atrial fibrillation, and withdrawal from apixaban. He was nurse navigated throughout his hospital course and post discharge only to be recalled to the hospital to be rescued with cardiac stenting. Conclusion. Patients >65 y/o having TJA without a cardiac history were found to have a 4.4% prevalence of significant CAD. When added to the patients with known CAD, the overall prevalence was 13.5%. One patient had complex plaque predictive of a cardiac event. As the US population ages and TJA becomes more prevalent with greater pressure to reduce costs by bundling and shifting to outpatient surgery, further data needs to be collected to better understand CAD in TJA patients >65 y/o

Aims

The aim of this study was to evaluate the healthcare costs and benefits of enoxaparin compared to aspirin in the prevention of symptomatic venous thromboembolism (VTE) after total hip arthroplasty (THA) or total knee arthroplasty (TKA) using data from the CRISTAL trial.

Major orthopaedic surgeries such as total hip and total knee replacements are considered a major risk factor for venous thromboembolism (VTE). Without prophylaxis, DVT occurs in 10–40% of general surgical or medical patients and 40–60% of patients following major orthopaedic surgery. There has, however, been a perception that VTE is less common in Asia than in Western countries. New evidence has emerged recently that contradicts this perception. Results from multinational epidemiological studies (SMART, AIDA, ENDORSE) clearly showed that the rate of venographic and symptomatic thrombosis after major joint replacement in Asian patients is similar to that previously reported in patients in Western countries. However, thromboprophylaxis is not routinely used in Asia, even in situations considered high risk in Western countries. The ENDORSE study reported that less than 20% of at-risk surgical patients in Asia received prophylaxis compared with over 80% in Western countries. This leaves the majority of patients at risk of developing VTE and VTE-related conditions, which continues after hospital discharge. Current guidelines recommend the use of thromboprophylaxis for at least 10 days and up to 35 days in patients undergoing total joint replacement. Available anticoagulants are effective at preventing VTE but are associated with various limitations, such as parenteral administration as in the case of UFH and LMWH. A narrow therapeutic window, unpredictable pharmacology, frequent coagulation monitoring and dose-adjustment as in the case of vitamin K antagonists (VKAs). Several new, oral anticoagulants are in advanced clinical development, including the direct thrombin inhibitor, dabigatran, and the direct Factor Xa inhibitors, rivaroxaban and apixaban

Aims

Current guidelines recommend surgery within 48 hours among patients presenting with hip fractures; however, optimal surgical timing for patients on oral anticoagulants (OACs) remains unclear. Individual studies are limited by small sample sizes and heterogeneous outcomes. The aim of this study was to conduct a systematic review and meta-analysis to summarize the effect of pre-injury OACs on time-to-surgery (TTS) and all-cause mortality among older adults with hip fracture treated surgically.

Aims

Malignancy and surgery are risk factors for venous thromboembolism (VTE). We undertook a systematic review of the literature concerning the prophylactic management of VTE in orthopaedic oncology patients.

The October 2012 Research Roundup³⁶⁰ looks at: whether you can escape your genes; oral prophylaxis for DVT; non-responders and the internet; metal-on-metal, mice and damaged livers; sleeping on the job; cartilage contact stress in the normal human hip; and a perfect reason to subscribe to 360.

Venous thromboembolism (VTE) remains an immediate threat to patients following total hip and knee replacement. While there is a strong consensus that steps should be taken to minimise the risk to patients by utilising some forms of prophylaxis for the vast majority of patients, the methods utilised have been extremely variable. Clinical practice guidelines (CPGs) have been published by various professional organisations for over 25 years to provide recommendations to standardise VTE prophylaxis. Historically, these recommendations have varied widely depending in underlying assumptions, goals, and methodology of the various groups. This effort has previously been exemplified by the American College of Chest Physicians (ACCP) and the American Academy of Orthopaedic Surgeons (AAOS). The former group of medical specialists targeted minimising venographically proven deep vein thrombosis (DVT) (the vast majority of which are asymptomatic) as their primary goal prior to 2012. The latter group of surgeons targeted minimising symptomatic VTE. As a result prior to 2012, the recommendations of the two groups were widely divergent. In the past year, both groups have reassessed the current literature with the principal goals of minimising symptomatic VTE events and bleeding complications. As a result, for the first time the CPGs of these two major subspecialty organisations are in close agreement.

The National Institute for Health and Clinical Excellence (NICE) has thus far relied on historical data and predominantly industry-sponsored trials to provide evidence for venous thromboembolic (VTE) prophylaxis in joint replacement patients. We argue that the NICE guidelines may be reliant on assumptions that are in need of revision. Following the publication of large scale, independent observational studies showing little difference between low-molecular-weight heparins and aspirin, and recent changes to the guidance provided by other international bodies, should NICE reconsider their recommendations?

Cite this article: Bone Joint Res 2014;3:146–9.

Although patients with a history of venous thromboembolism (VTE) who undergo lower limb joint replacement are thought to be at high risk of further VTE, the actual rate of recurrence has not been reported.

The purpose of this study was to identify the recurrence rate of VTE in patients who had undergone lower limb joint replacement, and to compare it with that of patients who had undergone a joint replacement without a history of VTE.

From a pool of 6646 arthroplasty procedures (3344 TKR, 2907 THR, 243 revision THR, 152 revision TKR) in 5967 patients (68% female, mean age 67.7; 21 to 96) carried out between 2009 and 2011, we retrospectively identified 118 consecutive treatment episodes in 106 patients (65% female, mean age 70; 51 to 88,) who had suffered a previous VTE. Despite mechanical prophylaxis and anticoagulation with warfarin, we had four recurrences by three months (3.4% of 118) and six by one year (5.1% of 118). In comparison, in all our other joint replacements the rate of VTE was 0.54% (35/6528).

The relative risk of a VTE by 90 days in patients who had undergone a joint replacement with a history of VTE compared with those with a joint replacement and no history of VTE was 6.3 (95% confidence interval, 2.3 to 17.5). There were five complications in the previous VTE group related to bleeding or over-anticoagulation.

Cite this article: Bone Joint J 2014;96-B:1515–19.