Introduction. Venous Thromboembolism is a well documented complication of Total hip and total knee replacement, and NICE guidelines recommend use of pharmacological prophylaxis routinely after these procedures. Current practice in our department is use of mechanical prophylaxis routinely, and chemical prophylaxis in high risk cases only. Previous departmental audit has shown VTE rates to be lower than the national average, however medical and haematology audit has contradicted this, and suggested that practices should be revised to include chemical prophylaxis routinely. This study seeks to determine whether we are seeing the full extent of the problem and whether our practices should be revised accordingly. Methods. Retrospective study of all patients presenting to our hospital with suspected DVT/PE from February 2009 – August 2009. Patients were identified through radiology records; every patient undergoing venous Doppler studies or CT pulmonary angiography were included. The casenotes of patients with positive scans were reviewed; and relevant information extracted from the notes. Results. 475 patients presenting with suspected DVT/PE between February 2009 and August 2009. 39 confirmed DVT; 37 confirmed PE. 87% admitted under acute medical intake. 2 confirmed DVT's in post operative THR/TKR patients, accounting for 5.1% of DVT's in this timeframe. No PE's following THR/TKR in this timeframe. Overall postoperative THR/TKR accounts for 2.6% of confirmed VTE in this hospital. Rates of DVT 1.19% of total hip replacements; 0.93% of total knee replacements. Discussion. Actual rates of VTE low amongst our post operative patients, suggesting current methods of thromboprohylaxis are effective. Changes in thromboprophylaxis practices probably not cost-effective; however it is difficult to justify not changing practices due to recent publication of NICE guidance. Rates comparable to previous audit, suggesting that patients are not being ‘missed by orthopaedic audit’

Abstract

Prolonged bedrest in hospitalized patients is a major risk factor for venous thromboembolism (VTE), especially in high risk patients with hip fracture. Thrombelastography (TEG) is a whole blood viscoelastic hemostatic assay with evidence that an elevated maximal amplitude (MA), a measure of clot strength, is predictive of VTE in orthopaedic trauma patients. The objective of this study was to compare the TEG MA parameter between patients with hip fracture who were more mobile post-operatively and discharged from hospital early to patients with hip fracture with reduced mobility and prolonged hospitalizations post-operatively.

In this prospective cohort study, TEG analysis was performed in patients with hip fracture every 24-hours from admission until post-operative day (POD) 5, then at 2- and 6-weeks post-operatively. Hypercoagulability was defined by MA > 65. Patients were divided into an early (within 5-day) and late (after 5-day) discharge group, inpatient at 2-weeks group, and discharge to MSK rehabilitation (MSK rehab), and long term care (LTC) groups. Two-sample t-test was used to analyze differences in MA between the early discharge and less mobile groups. All statistical tests were two-sided, and p-values < 0.05 were considered statistically significant.

In total, 121 patients with a median age of 81.0 were included. Patients in the early discharge group (n=15) were younger (median age 64.0) and more likely to ambulate without gait aids pre-injury (86.7%) compared to patients in the late discharge group (n=105), inpatients at 2-weeks (n=48), discharged to MSK rehab (n=30), and LTC (n=20). At two weeks post-operative, the early discharge group was significantly less hypercoagulable (MA=68.9, SD 3.0) compared to patients in the other four groups. At 6-weeks post-operative, the early discharge group was the only group to demonstrate a trend towards mean MA below the MA > 65 hypercoagulable threshold (MA=64.4, p=0.45). Symptomatic VTE events were detected in three patients (2.5%) post-operatively. All three patients had hospitalizations longer than five days after surgery.

In conclusion, our analysis of hypercoagulability secondary to reduced post-operative mobility demonstrates that patients with hip fracture who were able to mobilize independently sooner after hip fracture surgery, have a reduced peak hypercoagulable state. In addition, there is a trend towards earlier return to normal coagulation status as determined by the TEG MA parameter. Post-operative mobility status may play a role in determining individualized duration of thromboprophylaxis following hip fracture surgery. Future studies comparing TEG to clinically validated mobility tools may more closely evaluate the contribution of venous stasis due to reduced mobility on hypercoagulation following hip fracture surgery.

Prolonged bedrest in hospitalized patients is a major risk factor for venous thromboembolism (VTE), especially in high risk patients with hip fracture. Thrombelastography (TEG) is a whole blood viscoelastic hemostatic assay with evidence that an elevated maximal amplitude (MA), a measure of clot strength, is predictive of VTE in orthopaedic trauma patients. The objective of this study was to compare the TEG MA parameter between patients with hip fracture who were more mobile post-operatively and discharged from hospital early to patients with hip fracture with reduced mobility and prolonged hospitalizations post-operatively.

In this prospective cohort study, TEG analysis was performed in patients with hip fracture every 24-hours from admission until post-operative day (POD) 5, then at 2- and 6-weeks post-operatively. Hypercoagulability was defined by MA > 65. Patients were divided into an early (within 5-day) and late (after 5-day) discharge group, inpatient at 2-weeks group, and discharge to MSK rehabilitation (MSK rehab), and long term care (LTC) groups. Two-sample t-test was used to analyze differences in MA between the early discharge and less mobile groups. All statistical tests were two-sided, and p-values < 0.05 were considered statistically significant.

In total, 121 patients with a median age of 81.0 were included. Patients in the early discharge group (n=15) were younger (median age 64.0) and more likely to ambulate without gait aids pre-injury (86.7%) compared to patients in the late discharge group (n=105), inpatients at 2-weeks (n=48), discharged to MSK rehab (n=30), and LTC (n=20). At two weeks post-operative, the early discharge group was significantly less hypercoagulable (MA=68.9, SD 3.0) compared to patients in the other four groups. At 6-weeks post-operative, the early discharge group was the only group to demonstrate a trend towards mean MA below the MA > 65 hypercoagulable threshold (MA=64.4, p=0.45). Symptomatic VTE events were detected in three patients (2.5%) post-operatively. All three patients had hospitalizations longer than five days after surgery.

In conclusion, our analysis of hypercoagulability secondary to reduced post-operative mobility demonstrates that patients with hip fracture who were able to mobilize independently sooner after hip fracture surgery, have a reduced peak hypercoagulable state. In addition, there is a trend towards earlier return to normal coagulation status as determined by the TEG MA parameter. Post-operative mobility status may play a role in determining individualized duration of thromboprophylaxis following hip fracture surgery. Future studies comparing TEG to clinically validated mobility tools may more closely evaluate the contribution of venous stasis due to reduced mobility on hypercoagulation following hip fracture surgery.

The selection of venous thromboembolism (VTE) prophylaxis after total joint arthroplasty (TJA) has been controversial. Although the aspirin controversy is presumably resolved, there is no medical evidence for the “optimal” VTE prophylaxis regime for individual patients.

A risk-stratified multi-modal VTE prophylaxis protocol was developed and adopted by consensus. VTE risk factors and bleeding risk factors were categorised into six VTE/bleeding risk levels: (1) pre-operative vitamin K antagonists (VKA) use, (2) bleeding risk factors, (3) hypercoagulable state, (4) pre-operative anti-platelet therapy [clopidogrel use], (5) VTE risk factors, (6) no VTE or bleeding risk factors. The pharmacologic agents used for each risk level were: (1) resume VKA with low molecular weight heparin (LMWH) bridge, (2) pharmacologic agents contra-indicated and mechanical prophylaxis only, (3) VKA for 90 days with LMWH bridge, (4) resume anti-platelet therapy, (5) LMWH in hospital and discharge on aspirin for 90 days, (6) aspirin for 90 days (starting in hospital). In addition to pharmacologic treatment, all patients received multi-modal prophylaxis including early mobilisation, mechanical foot pumps, and neuraxial anesthesia when not contra-indicated. Prior to surgery, a VTE/bleeding risk factor checklist was completed determining the risk level. The intervention cohort included all TJA patients from January 1, 2010 to December 31, 2012. The comparison cohort included all TJA patients from the year prior to implementation of the protocol at the same community hospital. Thirty day all-cause non-elective re-admissions, 30 day same-site re-operations, 90 day VTE events, and protocol compliance were abstracted from the electronic medical record.

The intervention group consisted of 2679 patients (1075 hip arthroplasty patients and 1604 knee arthroplasty patients). The comparison group consisted of 1118 patients (323 hip arthroplasty patients and 795 knee arthroplasty patients). The 30 day all cause non-elective re-admission rate was 2.72% (73/2679) in the intervention group and 4.29% (48/1118) in the comparison group (p=0.0148). The 30 day same-site re-operation rate was 1.38% (37/2679) in the intervention group and 1.25% (14/1118) in the comparison group (p=0.8773). The 90 day VTE event rate was 1.57% (42/2679) in the intervention group and 3.40% (38/1118) in the comparison group (p=0.0007). The VTE rate was higher for knee arthroplasty patients 2.00% (32/1604) than for hip arthroplasty patients 0.93% (10/1075) (p=0.0379). The rate of VTE events was higher for patients that deviated from the VTE protocol 5.03% (10/199) than for all risk groups treated per the protocol 1.29% (32/2481) (p=0.0007).

The risk-stratified multi-modal VTE prophylaxis protocol simultaneously reduced 30 day all-cause non-elective re-admissions and 90 day VTE events. The possible causes for reducing 30 day re-admissions and reducing 90 day VTE events are: (1) reducing bleeding events by using aspirin for VTE prophylaxis in more than 80% of patients, (2) extending VTE prophylaxis to 90 days, and (3) using multi-modal prophylaxis. The risk-stratified multi-modal VTE prophylaxis protocol for total joint arthroplasty is consistent with 9 of the 10 recommendations in the AAOS Clinical Practice Guideline. The risk-stratification checklist provides a standardised tool to assess risks, discuss risks, and make shared decision with patients. Patient treatment that deviated from the protocol had a significantly higher VTE rate (5.03%). Protocol compliance increased each year from 91.1% in 2010 to 94.2% in 2012.

Surgeons want to counsel their patients accurately about the risks of rare complications. This is difficult for venous thromboembolism (VTE), as most studies report rates of asymptomatic disease. We calculated the rate of confirmed, symptomatic deep vein thrombosis (DVT) and pulmonary embolism (PE) after elective lower limb surgery in our hospital.

We scrutinised referrals for venous Doppler ultrasound and computed tomography pulmonary angiography, identifying all cases of DVT or PE over an 18 month period. These patients were cross-referenced with our elective orthopaedic database and Healthcare Resource Group coding data.

Out of 1071 total hip replacements, there were three DVTs and two PEs, giving an incidence of 0.28% for DVT and 0.19% for PE. Out of 1351 total knee replacements, there were four DVTs and three PEs (incidence 0.29% and 0.22% respectively). Out of 1988 non-arthroplasty hip and knee procedures, there were no DVTs and two PEs (incidence 0.1%). For 1763 elective surgical foot procedures, there were five DVTs (incidence 0.28%), and no PEs.

Currently, Rivaroxaban is offered to patients undergoing hip and knee replacement surgery, but other patients do not receive anticoagulants routinely. Our low incidence of VTE supports this policy and is reassuring for surgeons.

AIM

To study the incidence of thromboembolism among patients treated with ring fixators in lower limb injuries and their risk factor association.

Purpose

According to the National Institute for Clinical Excellence (NICE) a risk assessment for venous thromboembolism (VTE) should be conducted on all patients undergoing elective orthopaedic surgery. We looked at the patient outcome undergoing elective Ilizarov surgery in terms of symptomatic VTE occurring during or after frame management.

Since NICE issued guidance on preventing venous thromboembolism (VTE), the use of chemoprophylaxis has increased dramatically in trauma and orthopaedics. However, enthusiasm is tempered by a lack of data regarding the true incidence of VTE in everyday practice. We investigated the epidemiology of VTE among ambulatory patients with lower limb injuries within our Trust.

We identified all patients who suffered pulmonary embolism (PE) or deep vein thrombosis (DVT) over an 18 month period, and cross-referenced them with our trauma database. All lower limb injuries were included, whether operated or not. Hip fractures routinely receive dalteparin and were excluded.

There were 11,594 new attendances or post-operative attendances in all fracture clinics over 18 months. Of these, 4530 had lower limb injuries and were immobilised. There were 21 DVTs and 7 PEs in these patients, an incidence of 0.43% and 0.14% respectively. Of note, three DVTs were in patients with Achilles tendon rupture.

The incidence of symptomatic VTE is low in a population of ambulant patients with lower limb injuries in casts, without chemical thromboprophylaxis. Prophylaxis for VTE would thus have a large number needed to treat. The costs and complications of chemoprophylaxis should also be considered before it is introduced universally.

Background

Venous thromboembolisms are serious complications of arthroplasty of the lower extremities. Although early ambulation and active leg exercise is recommended, postoperative patients with surgical pain have difficulty in moving their legs. Therefore, we developed a novel leg exercise apparatus (LEX) to facilitate active leg movement even during the early postoperative period (Fig 1). LEX is a portable apparatus that allows patients to actively move their legs while in the supine position. LEX enables dorsiflexion, plantar flexion, combined eversion and inversion of the ankle, and multi-joint movement of the leg.

Introduction

This is a retrospective review of the incidence of deep venous thrombosis (DVT) in 679 consecutive unilateral primary hip arthroplasty procedures performed between January 2007 and December 2010 managed with no anticoagulants. Mean age at operation was 58 years. Mean BMI was 26. The prophylaxis regimen included hypotensive epidural anesthesia, compression stockings, intermittent calf compression, early mobilization and an antiplatelet agent.

The National Institute of Clinical Excellence (NICE) published guidance for reducing the risk of venous thromboembolism (VTE) in January 2010. This guidance has had a significant impact on the management of all inpatients. It is now mandatory to risk assess every inpatient and commence appropriate treatment if indicated. The guidelines specifically exclude outpatients although NICE recognises' that lower limb cast immobilisation is a risk factor for VTE. The purpose of our study was to establish the current practice for the management of outpatients treated with lower limb casts in England.

The NHS Choices website lists 166 acute hospitals in England. A telephone audit was conducted in February 2011. A member of the on call orthopaedic team was asked: 1. Are you aware of the NICE guidelines for VTE prophylaxis? 2. In your department, outpatients treated with a lower limb cast, are they risk assessed for VTE? 3. If a patient undergoes Open Reduction Internal Fixation (ORIF) for an ankle fracture and is discharged wearing a cast, are they given VTE prophylaxis? 4. If yes - for how long are they treated?

Responses were obtained from 150 eligible hospitals (1 FY1, 28 FY2, 44 ST1-ST2, 76 ST3+, 1 Consultant). 62% of responders stated that they were aware of the NICE guidance. 40% of responders stated that outpatients were routinely risk assessed for VTE. 32% of responders stated that ankle fractures treated with an ORIF and discharged wearing a cast would receive VTE prophylaxis. The duration of treatment varied from 5 days, to 6 weeks, to removal of cast.

The management of patients treated with a lower limb cast is variable and inconsistent throughout England. Although there are no national guidelines for this patient group, the routine risk assessment of outpatients was higher than anticipated by the authors. We recommend that if VTE prophylaxis is commenced as an inpatient, then it should be continued until the cast is removed.

A national quality improvement initiative identified potentially avoidable complications, including venous thromboembolism (VTE) as “never events.” While the intent of this designation was to improve system-wide performance and to decrease medical costs, its value in total joint arthroplasty has not been defined. We performed this study to assess the relative incidence of VTE related admissions following TKA, the relative costs associated with care directed towards this complication, and compliance with SCIP VTE prophylaxis guidelines. From a total of 2,221 TKA procedures accomplished over a 5 year interval, we identified 121 hospital readmissions (5.4 percent). Primary readmission diagnoses were obtained from hospital coding and physician medical record documentation. Readmissions were categorised into five major complication types: 1) limited motion, 2) noninfectious wound complications, 3) bleeding complications, 4) deep infections, and 5) VTE events. VTE chemoprophylaxis was reviewed to determine the agent utilised, therapeutic level, and duration. Hospital records were assessed to determine whether additional surgeries or other procedures were accomplished and whether patients received allogeneic transfusions during their readmission. Direct costs of readmission care were obtained from hospital reimbursement records. Limited motion (18%), non-infectious wound complication (14%), surgical site infection (10%), and bleeding (10%) were the most common reasons for readmission. VTE events were less frequent (3%) and all occurred despite standard of care prophylaxis. The cost to manage bleeding, wound complications, infection, and limited motion each exceeded the cost of VTE. These results challenge the identification of VTE as a “never event.”

Purpose:

Starting February 2012, our institution changed from enoxaparin (Lovenox) to the Factor Xa inhibitor, rivaroxaban (Xarelto) for venous thromboembolism prophylaxis after primary total hip (THA) and total knee arthroplasty (TKA). The purpose of our study was to compare rates of venous thromboembolism and rates of major bleeding between these two medications when used for venous thromboembolism prophylaxis after primary THA and TKA.

Background

Venous thromboembolism (VTE) is a common, costly, and morbid complication following TJA. Consequently, the current standard of care recommends that all TJA candidates receive some form of thromboprophylaxis postoperatively. Chemoprophylaxis, however, is not without its own risks and has been associated with greater risk of perioperative complications such as major bleeding, infection, stroke, and increased wound drainage. Mechanical compression devices serve as an alternative to chemoprophylaxis. Compression devices are thought to function by decreasing venous stasis and activating fibrinolysis. Intermittent pneumatic compression devices (IPCD) function by providing pressure at a constant cycle; whereas continuous enhanced circulation therapy (CECT) devices such as ActiveCare portable system (Medical Compression Systems, Or Akiva, Israel) function in a synchronized manner with the patient's own respiratory cycles. While both of these systems are widely utilized, there is scarce data comparing their effectiveness as thromboprophylatic agents following TJA. The purpose of this meta-analysis is to comparatively evaluate the efficacy of ActiveCare to IPCDs in the prevention of thromboembolic events following TJA.

Introduction

Patients undergoing total hip arthroplasty (THA) stand in the danger, a particularly high risk for venous thromboembolism (VTE). Fondaparinux and edoxaban, which inhibit FXa, indirectly and directly, respectively, have been used for prevention of VTE after THA in Japan. The aim of this study was to compare the efficacy of fondaparinux and edoxaban for VTE after elective THA in Japanese patients.

Introduction

Pulmonary emboli (PE) after total hip and knee arthroplasties is an uncommon event. However, once it happens, it may results in sudden death. Thus, the prophylaxis of venous thromboembolism (VTE), including symptomatic deep vein thrombosis (DVT) and PE, is one of the challenging trials for Orthopaedic surgeons. Many procedures have been developed, e.g. early mobilization, compression stocking, intermittent pneumatic compression (IPC) devices, and anticoagulation agents. However, the most effective treatment for prophylaxis against VTE after the arthroplasties remains undecided.

Recently, many low molecular weight heparin (LMWH) agents are developing, and these are strongly effective for anticoagulation. However, these agents sometimes lead to bleeding complications, and result in uncontrolled critical bleeding. We are introducing our protocol with conventional aspirin as VTE prophylaxis after the arithroplasties.

Introduction

Patients undergoing total knee arthroplasty (TKA) are at high risk of post operative venous thromboembolism (VTE). Edoxaban, the oral direct and selective factor Xa inhibitor, is available for preventing VTE after TKA. Recently, patients often take antiplatelet drugs including aspirin for their past illness. In our hospital, patients, in general, undergoing TKA receive edoxaban, but patients with aspirin for past illness receive only aspirin for preventing VTE. The aim of this study was to compare edoxaban and aspirin for preventing VTE in patients undergoing TKA.

Hypothesis

Pre-specified pooling of data from the four phase III RECORD studies was conducted to determine whether rivaroxaban significantly reduced the less-frequent clinical endpoint of symptomatic venous thromboembolism (VTE) and all-cause mortality after total hip or knee arthroplasty (THA or TKA, respectively), compared with standard North American and European enoxaparin regimens.

Introduction

In Japan, edoxaban has been used for the prevention of venous thromboembolism (VTE) after total knee arthroplasty (TKA) since June 2011. Edoxaban is an oral direct factor Xa inhibitor, expected to be more convenient for the postoperative treatment of TKA. Enoxaparin, a II and Xa inhibitor, was approved in Japan for the prevention of VTE in patients undergoing orthopedics surgery from 2008. In this study, the effect for the prevention of VTE after TKA was compared between these two drugs in Japanese patients.