Considerable debate exists regarding which agent(s) should be preferred for venous thromboembolism (VTE) chemical prophylaxis following joint replacement. We assessed the practice of surgeons regarding VTE chemical prophylaxis for primary THR and TKR, pre and post issuing of updated NICE guidance in 2018. A survey, circulated through the British Hip Society and regional trainee networks/collaboratives, was completed by 306 UK surgeons at 187 units. VTE chemical prophylaxis prescribing patterns for surgeons carrying out primary THR (n=258) and TKR (n=253) in low-risk patients were assessed post publication of 2018 NICE recommendations. Prescribing patterns before and after the NICE publication were subsequently explored. Questions were also asked about surgeon equipoise for participation in future RCTs. Following the new guidance, 34% (n=87) used low-molecular weight heparin (LMWH) alone, 33% (n=85) aspirin (commonly preceded by LMWH), and 31% (n=81) direct oral anticoagulants (DOACs: with/without preceding LMWH) for THR. For TKR, 42% (n=105) used aspirin (usually monotherapy), 31% (n=78) LMWH alone, and 27% (n=68) DOAC (with/without preceding LMWH). NICE guidance changed the practice of 34% of hip and 41% of knee surgeons, with significantly increased use of aspirin preceded by LMWH for THR (before=25% vs. after=73%;p<0.001), and aspirin for TKR (before=18% vs. after=84%;p<0.001). Significantly more regimens were NICE guidance compliant after the 2018 update for THR (before=85.7% vs. after=92.6%;p=0.011) and TKR (before=87.0% vs. after=98.8%;p<0.001). Support from surgeons for future RCTs was dependent on the clinical question, ranging from 48% participation in trials (effectiveness of aspirin vs. a DOAC) to 79% (effectiveness of 14 days LMWH vs. 28 days LMWH). Over one-third of surveyed surgeons changed their VTE chemical prophylaxis in response to 2018 NICE recommendations, with more THR and TKR surgeons now compliant with latest NICE guidance. The major change in practice was an increased use of aspirin for VTE chemical prophylaxis. Furthermore, there is an appetite amongst UK surgeons for participating in future RCTs, with a trial comparing standard versus extended duration LMWH likely feasible in current practice

Aims. The place of thromboprophylaxis in arthroplasty surgery remains controversial, with a challenging requirement to balance prevention of potentially fatal venous thrombo-embolism with minimising wound-related complications leading to deep infection. We compared the incidence of fatal pulmonary embolism in patients undergoing elective primary total hip arthroplasty (THA) between those receiving aspirin, warfarin and low molecular weight heparin (LMWH) for the chemical component of a multi-modal thromboprophylaxis regime. Patients and Methods. A prospective audit database was used to identify patients who had died within 42 and 90 days of surgery respectively between April 2000 and December 2012. A case note review was performed to ascertain the causes of death. Results. During this period 7983 THAs were performed. The rate of mortality was 0.43% and 0.58% at 42 and 90 days respectively. The groups comprised 1571 patients (19.7%) on warfarin, 1838 (23.0%) on LMWH and 4574 (57.3%) on aspirin. The 90-day mortality for these three groups was 0.38%, 1.09% and 0.43% respectively. The higher mortality rate for LMWH was significant (p < 0.05). There were six fatal pulmonary emboli (PEs) (0.08%). A total of three occurred within 42 days, all in the LMWH group. A total of three occurred between 42 and 90 days; one on warfarin, two on LMWH. The leading causes of death in all three groups were lower respiratory tract infections and myocardial infarction. Conclusion. We confirmed that fatal PE following elective THA with a multi-modal prophylaxis regime is rare. We further found that LMWH conferred no benefit over aspirin in this context, and is associated with a higher all-cause rate of mortality. Take home message: This study proposes that aspirin may be an appropriate thromboprophylaxis agent when used as part of a multi-modal regimen, suggesting current guidelines should be reviewed. Cite this article: Bone Joint J 2016;98-B:585–8

Aims. Thromboprophylaxis following Total Hip Replacement (THR) surgery remains controversial, balancing VTE prevention against wound leakage and subsequent deep infection. We analysed the 90 day cause of death post THR in our institution after the implementation of new thromboprophylactic policy of low dose aspirin for low risk patients, as part of a multimodal regime. Those at high risk were anticoagulated. Patients and methods. The PAS database was used to identify patients undergoing primary THR between January 2012 and June 2017 at The Royal Derby Hospital, and all deaths within 90 days. Trauma cases were excluded. Case note review and Coroner's verdict were utilised to ascertain cause of death. Results were compared to a previous study at the same institution prior to the introduction of the new policy, where thromboprophylaxis was decided upon by surgeon preference for either LMWH, aspirin or warfarin. Results. During this period 4021 THRs were performed. The rate of mortality was 0.22% at 90 days. This compares to 0.58% in the previous study with the only other factor changing being the rapidity of post op mobilization. Of the 9 deaths, only one was due to fatal pulmonary embolism. None of the deaths were at high risk of VTE. This compared to 5 fatal pulmonary embolism deaths in1838 patients in the previous study in the LMWH group. The leading causes of death were heart failure and lower respiratory tract infection. Conclusion. Our institution reports a similar 90 day (0.22%) mortality using aspirin to that in the last 5 years on the NJR (0.3%) in which over 80% use LMWH. We confirm that fatal PE following elective THR with a multi-modal prophylaxis regime is rare. Changing to low dose aspirin in low risk patients is a safe option

Routine prophylaxis for venous thromboembolic disease after total hip replacement (THR) is recommended. Pneumatic compression with foot pumps seems to provide an alternative to chemical agents. However, the overall number of patients investigated in randomised clinical trials has been too small to draw evidence-based conclusions. This randomised clinical trial was carried out to compare the effectiveness and safety of mechanical versus chemical prophylaxis of DVT in patients after THR. Inclusion criteria were osteoarthritis of the hip and age less than 80 years. Exclusion criteria included a history of thromboembolic disease, heart disease, and bleeding diatheses. There were 216 consecutive patients considered for inclusion in the trial who were randomised either for management with the A-V Impulse System foot pump. We excluded 16 patients who did not tolerate continuous use of the foot pump or with low-molecular-weight heparin (LMWH). Patients were monitored for DVT using serial duplex sonography at 3, 10 and 45 days after surgery. DVT was detected in three of 100 patients in the foot-pump group and with six of 100 patients in the LMWH group (p < 0.05). The mean post-operative drainage was 259 ml in the foot-pump group and 328 ml in the LMWH group (p < 0.05). Patients in the foot-pump group had less swelling of the thigh (10 mm compared with 15 mm; p < 0.05). One patient developed heparin-induced thrombocytopenia. This study confirms the effectiveness and safety of mechanical prophylaxis of DVT in THR. Some patients cannot tolerate the foot pump

Introduction. Many pharmacologic agents have been used for venous thromboembolism (VTE) prophylaxis after elective total hip arthroplasty (THA). Rivaroxaban was the first novel oral anticoagulant approved for THA patients, but its actual efficacy and safety in clinical practice, beyond randomized trials, is unknown. Materials and Methods. This is a retrospective study, using the Truven Health MarketScan database, of anticoagulation medication prescriptions after elective THA, in both commercially insured (CI) and Medicare supplement insured (MS) patients, from 2010 to 2015. After exclusions, there were 83,179 CI and 50,534 MS patients available for analysis. There were 12,876 new users of warfarin (W) and 10,892 new users of rivaroxaban (R) in CI patients, and 7,416 new users of W and 4,739 new users of R in MS patients. We asked the following questions: (1) What were the trends and predictive factors for anticoagulant use after elective THA? (2) What was the actual clinical efficacy: frequency of deep vein thrombosis (DVT) and pulmonary embolism (PE), and frequency of adverse events within 90 days with the two most commonly used oral agents, rivaroxaban and warfarin, from June 2011 to September 2015? Data was analyzed for each anticoagulant by odds ratios using logistic regression models with stabilized inverse probability treatment weighting. Results. There was a change in use of anticoagulants after R approval. Use of W decreased from approximately 50% each in 2010 in both insurance cohorts to 10% in CI patients and 30% in MS patients in 4th quarter 2015. The use of R increased from 0 to 33% in both cohorts from 2011 to 2015. In the multivariate analysis, in CI patients, females had lower odds of getting R, and patients in Western region had higher odds of getting R; in MS patients, increasing age had reduced odds of getting rivaroxiban, but Western region and surgery in 2015 had higher odds. Patients with capitated insurance plans and renal impairment had lower odds of R initiation, but a history of cardiovascular disease or hypertension had higher odds. In 90 days after THA, patients given R had significantly lower odds ratio of both DVT and PE in both CI patients (DVT: 1.54 with W, 0.54 with R; PE: 2.12 with W, 0.73 with R) and MS patients (DVT: 3.01 W, 1.73 R; PE: 4.09 W, 1.88 R). With logistic regression analysis, users of W had significantly higher odds ratio of both DVT (CI 2.63 and MS 1.78) and PE (CI 2.60 and MS 2.09) than R. There was no significant difference in rates of bleeding between W and R, but W had higher odds ratio than R of prosthetic joint infection (PJI) in both CI (1.574) and MS (1.790) cohorts. Conclusions. There has been an increase in VTE prophylaxis with R, and a decrease in both W and LMWH use after elective THA over four years. Patient factors, insurance type, and comorbidities were associated with this change. In actual clinical efficacy, R had lower odds ratio of both DVT and PE than W, and bleeding risks were similar. The association of W with an increased odds ratio of PJI compared to R requires further study

Aims

We studied the safety and efficacy of multimodal thromboprophylaxis in patients with a history of venous thromboembolism (VTE) who undergo total hip arthroplasty (THA) within the first 120 postoperative days, and the mortality during the first year. Multimodal prophylaxis includes discontinuation of procoagulant medications, VTE risk stratification, regional anaesthesia, an intravenous bolus of unfractionated heparin prior to femoral preparation, rapid mobilization, the use of pneumatic compression devices, and chemoprophylaxis tailored to the patient’s risk of VTE.

Aims

To determine the outcomes following revision surgery of metal-on-metal hip arthroplasties (MoMHA) performed for adverse reactions to metal debris (ARMD), and to identify factors predictive of re-revision.

Objectives

Few studies have assessed outcomes following non-metal-on-metal hip arthroplasty (non-MoMHA) revision surgery performed for adverse reactions to metal debris (ARMD). We assessed outcomes following non-MoMHA revision surgery performed for ARMD, and identified predictors of re-revision.

Tranexamic acid (TXA), an inhibitor of fibrinolysis, reduces blood loss after total knee arthroplasty. However, its effect on minimally invasive total hip arthroplasty (THA) is not clear. We performed a prospective, randomised double-blind study to evaluate the effect of two intravenous injections of TXA on blood loss in patients undergoing minimally invasive THA.

In total, 60 patients (35 women and 25 men with a mean age of 58.1 years; 17 to 84) who underwent unilateral minimally invasive uncemented THA were randomly divided into the study group (30 patients, 20 women and ten men with a mean age of 56.5 years; 17 to 79) that received two intravenous injections 1 g of TXA pre- and post-operatively (TXA group), and a placebo group (30 patients, 15 women and 15 men with a mean age of 59.5 years; 23 to 84). We compared the peri-operative blood loss of the two groups. Actual blood loss was calculated from the maximum reduction in the level of haemoglobin. All patients were followed clinically for the presence of venous thromboembolism.

The TXA group had a lower mean intra-operative blood loss of 441 ml (150 to 800) versus 615 ml (50 to 1580) in the placebo (p = 0.044), lower mean post-operative blood loss (285 ml (120 to 570) versus 392 ml (126 to 660) (p = 0.002), lower mean total blood loss (1070 ml (688 to 1478) versus 1337 ml (495 to 2238) (p = 0.004) and lower requirement for transfusion (p = 0.021). No patients in either group had symptoms of venous thromboembolism or wound complications.

This prospective, randomised controlled study showed that a regimen of two intravenous injections of 1 g TXA is effective for blood conservation after minimally invasive THA.

Cite this article: Bone Joint J 2015;97-B:905–10.

We report a systematic review and meta-analysis of published randomised controlled trials evaluating the efficacy of tranexamic acid (TXA) in reducing blood loss and transfusion in total hip replacement (THR). The data were evaluated using the generic evaluation tool designed by the Cochrane Bone, Joint and Muscle Trauma Group. We identified 11 clinical trials which were suitable for detailed extraction of data. There were no trials that used TXA in revision THR. A total of seven studies (comprising 350 patients) were eligible for the blood loss outcome data. The use of TXA reduced intra-operative blood loss by a mean of 104 ml (95% confidence interval (CI) −164 to −44, p = 0.0006, heterogeneity I² 0%), postoperative blood loss by a mean of 172 ml (95% CI −263 to −81, p = 0.0002, heterogeneity I² 63%) and total blood loss by a mean of 289 ml (95% CI −440 to −138, p < 0.0002, heterogeneity I² 54%).

TXA led to a significant reduction in the proportion of patients requiring allogeneic blood transfusion (risk difference −0.20, 95% CI −0.29 to −0.11, p < 0.00001, I² 15%). There were no significant differences in deep-vein thrombosis, pulmonary embolism, infection rates or other complications among the study groups.

We report a retrospective review of the incidence of venous thromboembolism in 463 consecutive patients who underwent primary total hip arthroplasty (487 procedures). Treatment included both total hip replacement and hip resurfacing, and the patients were managed without anticoagulants. The thromboprophylaxis regimen included an antiplatelet agent, generally aspirin, hypotensive epidural anaesthesia, elastic compression stockings and early mobilisation. In 258 of these procedures (244 patients) performed in 2005 (cohort A) mechanical compression devices were not used, whereas in 229 (219 patients) performed during 2006 (cohort B) bilateral intermittent pneumatic calf compression was used.

All operations were performed through a posterior mini-incision approach. Patients who required anticoagulation for pre-existing medical problems and those undergoing revision arthroplasty were excluded. Doppler ultrasonographic screening for deep-vein thrombosis was performed in all patients between the fourth and sixth post-operative days. All patients were reviewed at a follow-up clinic six to ten weeks after the operation. In addition, reponse to a questionnaire was obtained at the end of 12 weeks post-operatively.

No symptomatic calf or above-knee deep-vein thrombosis or pulmonary embolism occurred. In 25 patients in cohort A (10.2%) and in ten patients in cohort B (4.6%) asymptomatic calf deep-vein thromboses were detected ultrasonographically. This difference was statistically significant (p = 0.03). The regimen followed by cohort B offers the prospect of a low incidence of venous thromboembolism without subjecting patients to the higher risk of bleeding associated with anticoagulant use.

We have investigated the effect of using tranexamic acid (TXA) during peri-acetabular osteotomy (PAO) on peri-operative blood loss and blood transfusion requirements. In addition we analysed whether the use of TXA was associated with an increased risk of venous thromboembolism (VTE) following this procedure.

A consecutive series of 96 PAOs, performed by a single surgeon, were reviewed. A total of 48 patients received TXA and 48 did not. The TXA group received a continuous infusion of TXA at a rate of 10 mg/kg/h. The primary outcome measure was the requirement for blood transfusion. Secondary outcomes included total blood loss, the decrease in the level of haemoglobin in the blood, the length of hospital stay, and the complications of this treatment.

The mean rate of transfusion was significantly lower in the TXA group (62.5% vs 12.5%, p < 0.001). The mean blood loss was also significantly reduced in the TXA group (1.9 L (standard deviation (sd) 0.9) vs 1.5 L (sd 0.7), p < 0.01). No post-operative episodes of VTE were identified in either group.

The use of TXA reduced the blood loss and the rate of transfusion after PAO significantly, without adverse effects such as an increased rate of VTE.

Cite this article: Bone Joint J 2015;97-B:1604–7.

Despite increasing scientific investigation, the best method for preventing post-operative deep-vein thrombosis remains unclear. In the wake of the publication of the Pulmonary Embolism Prevention trial and the Scottish Intercollegiate Guidelines Network (SIGN) on the prevention of thromboembolism, we felt that it was timely to survey current thromboprophylactic practices. Questionnaires were sent to all consultants on the register of the British Orthopaedic Association. The rate of response was 62%. The survey showed a dramatic change in practice towards the use of chemoprophylaxis since the review by Morris and Mitchell in 1976. We found that there was a greater uniformity of opinion and prescribing practices in Scotland, consistent with the SIGN guidelines, than in the rest of the UK. We argue in favour of the use of such documents which are based on a qualitative review of current scientific literature.

We examined the one-year risk of symptomatic venous thromboembolism (VTE) following primary total hip replacement (THR) among Danish patients and a comparison cohort from the general population. From the Danish Hip Arthroplasty Registry we identified all primary THRs performed in Denmark between 1995 and 2010 (n = 85 965). In all, 97% of patients undergoing THR received low-molecular-weight heparin products during hospitalisation. Through the Danish Civil Registration System we sampled a comparison cohort who had not undergone THR from the general population (n = 257 895). Among the patients undergoing THR, the risk of symptomatic VTE was 0.79% between 0 and 90 days after surgery and 0.29% between 91 and 365 days after surgery. In the comparison cohort the corresponding risks were 0.05% and 0.12%, respectively. The adjusted relative risks of symptomatic VTE among patients undergoing THR were 15.84 (95% confidence interval (CI) 13.12 to 19.12) during the first 90 days after surgery and 2.41 (95% CI 2.04 to 2.85) during 91 to 365 days after surgery, compared with the comparison cohort. The relative risk of VTE was elevated irrespective of the gender, age and level of comorbidity at the time of THR.

We concluded that THR was associated with an increased risk of symptomatic VTE up to one year after surgery compared with the general population, although the absolute risk is small.

Little is known about the efficacy of graduated compression stockings in preventing venous thromboembolism after hip surgery. We conducted a prospective, randomised single-blind study to determine whether the addition of compression stockings to fondaparinux conferred any additional benefit.

The study included 874 patients, of whom 795 could be evaluated (400 in the fondaparinux group and 395 in the fondaparinux plus compression stocking group). Fondaparinux was given post-operatively for five to nine days, either alone or combined with wearing stockings, which were worn for a mean 42 days (35 to 49).

The study outcomes were venous thromboembolism, or sudden death before day 42. Duplex ultrasonography was scheduled within a week of day 42. Safety outcomes were bleeding and death from venous thromboembolism.

The prevalence of deep-vein thrombosis was similar in the two groups 5.5% (22 of 400) in the fondaparinux group and 4.8 (19 of 395) in the fondaparinux plus stocking group (odds ratio 0.88, 95% confidence interval 0.46 to 1.65, p = 0.69). Major bleeding occurred in only one patient.

The addition of graduated compression stockings to fondaparinux appears to offer no additional benefit over the use of fondaparinux alone.