This article is more than 5 years old. Information may no longer be current.

Venous thromboembolism and PJI: There is a story here

Issue: July 2014

ByJavad Parvizi, MD, FRCS

Add topic to email alerts

Receive an email when new articles are posted on

Please provide your email address to receive an email when new articles are posted on .

Subscribe

Added to email alerts

You've successfully added to your alerts. You will receive an email when new content is published.

Click Here to Manage Email Alerts

You've successfully added to your alerts. You will receive an email when new content is published.

Click Here to Manage Email Alerts

Back to Healio

We were unable to process your request. Please try again later. If you continue to have this issue please contact customerservice@slackinc.com.

Back to Healio

The orthopedic community continues to be concerned about venous thromboembolism after orthopedic procedures. There is no consensus on the best strategy for the prevention of venous thromboembolism following orthopedic procedures. One undisputable fact is that administration of anticoagulation needs to strike the right balance between its intended mission of preventing venous thromboembolism without causing other unintended problems such as bleeding.

The link between “aggressive” anticoagulation and periprosthetic joint infection (PJI) is being unraveled. A common finding of all clinical trials evaluating the efficacy of chemical anticoagulation agents is that the administration of potent anticoagulation can lead to a higher incidence of persistent wound drainage and bleeding. It is a known fact that persistent wound drainage, bleeding and hematoma formation can result in a higher incidence of PJI. The latter can be because of numerous reasons. Those with increased wound drainage are at risk of bacterial ingress into the joint that can result in colonization of the prosthesis and subsequent infection. Persistent wound drainage, bleeding and hematoma formation may all result in the need for reoperation that can in turn increase the likelihood of PJI. Patients with postoperative bleeding, hematoma formation and wound drainage are at higher risk of requiring allogeneic blood transfusion, which results in immunomodulation and increases the incidence of PJI. Incidentally, the higher rate of allogeneic blood transfusion may also partly explicate the higher incidence of mortality that is seen in patients receiving potent anticoagulation.

In their mission to guide the orthopedic community, both the American Association of Orthopedic Surgeons (AAOS) and the American College of Chest Physicians (ACCP) have put forth guidelines that are intended to minimize the risk of venous thromboembolism (VTE) after orthopedic procedures. Both of these guidelines have evaluated the available literature, whenever present, to reach their recommendations. The recent guidelines from both organizations have endorsed the use of less aggressive anticoagulation modalities such as mechanical agents and aspirin. The AAOS guidelines state that any form of anticoagulation are acceptable following total hip and knee arthroplasty. The ACCP, on the other hand, gives aspirin their highest endorsement (1B) as an effective prophylactic agent for prevention of VTE following total joint arthroplasty (TJA). Since January 2014, the Surgical Care Improvement Project has adopted the recent AACP guidelines, effectively endorsing aspirin as an acceptable anticoagulation modality for orthopedic procedures.

With the increasing scrutiny imposed on postoperative outcomes by the regulatory bodies in the United States and the payers, such as consideration to include readmission and reoperation as a quality metric, the issue of VTE prevention using agents that are effective but less harmful is gaining momentum.

The medical community also needs to recognize that there have been immense improvements in the practice of orthopedics. Most patients undergoing TJA receive regional anesthesia, with all its benefits related to VTE prevention, and are mobilized immediately. The patients are discharged from the hospital within a day or 2 days in most cases. These major changes in surgical and anesthesia techniques highlight the fact that any literature from the far past needs to be examined with caution as it may not be applicable to modern day surgical patients.

Moving forward, and in my personal opinion, potent anticoagulation agents will be replaced by mechanical modalities and aspirin that appear to be effective against VTE while not causing other complications such as bleeding. The challenge that lies ahead is to determine which patients are at extreme risk of VTE and in need of more potent agents. There has been a recent development on this front that aims to provide some guidance for selection of high-risk patients. It appears that more than 90% of patients undergoing TJA can safely receive aspirin as an anticoagulation prophylaxis, while risk profile can be used to detect those at higher risk for VTE and in need of more potent agents.

The future of orthopedics with regard to the prevention of VTE appears different. Individualization of care, recognition of the genetic basis of VTE and the opportunities that molecular science present will alter the manner in which we approach VTE prevention, and for that matter many other aspects of patient care.