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Greatest risk of symptomatic pulmonary embolism found in first week following TJA
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Results of a retrospective study of patients who underwent primary and revision total joint arthroplasty and received warfarin as prophylaxis showed most symptomatic pulmonary emboli occurred during the first week following arthroplasty.
“The majority of pulmonary emboli occur within the early days after joint replacement, and this has two implications,” Javad Parvizi, MD, FRCS, told Orthopedics Today. “One is the fact that perhaps anticoagulation for a long period of time after joint replacement may not be warranted, and the second is that possibly warfarin makes these patients hypercoagulable, which then puts them at risk for developing embolism early.”
Parvizi and his colleagues identified the medical records of 26,415 consecutive patients who underwent primary and revision total joint arthroplasty (TJA) between January 2000 and December 2010, and documented symptomatic pulmonary emboli (PE) that occurred within 90 days of arthroplasty.
Overall, 24,567 patients were anticoagulated with warfarin beginning the evening of surgery and continued warfarin prophylaxis for 6 weeks postoperatively; 1,824 patients received a modified aspirin protocol of one low-dose of warfarin the night of the procedure and then aspirin for 6 weeks postoperatively; and 24 patients received subcutaneous heparin or heparin derivatives.
Javad Parvizi
The incidence of symptomatic PE was 1.77% among patients undergoing knee procedures and 0.46% in patients undergoing hip procedures, according to study results. The investigators noted a higher tendency to develop PE following TJA among women vs. men and a higher incidence of PE with increasing age, as the highest incidence of PE in the 71-year-old to 80-year-old group and the lowest incidence in the 41-year-old to 50-year-old group.
PE occurred at a median time of 2 days postoperatively. Investigators found 81% of PE cases occurred within the first 3 postoperative days, 89% of PEs occurred within the first postoperative week and 94% of PEs occurred by the end of the second postoperative week. The researchers noted patients who received aspirin prophylaxis experienced PE on postoperative days 3, 4, 6 and 11. Patients who received heparin-based prophylaxis experienced PEs on postoperative days 2 and 43.
“We did not expect that percentage of pulmonary emboli to happen within the first week. We felt that the distribution would be a little more even,” Parvizi said.
A multivariate analysis showed revision TJA, a Charlson Comorbidity Index greater than or equal to three and atrial fibrillation were associated with a later occurrence of PE.
“We have been able to identify patients who are at higher risk for pulmonary embolism and developed an app,” Parvizi said. “It can be used to identify patients and classify or categorize [patients] into low risk, medium risk and high risk for pulmonary embolism, which would then allow the surgeons to refine the anticoagulation protocol for the means or risk level for these patients and not treat everybody the same.” – by Casey Tingle
- Reference:
- Parvizi J, et al. J Arthroplasty. 2015;doi:10.1016/j.arth.2015.01.004.
- For more information:
- Javad Parvizi, MD, FRCS, can be reached at the Rothman Institute at Thomas Jefferson University, Sheridan Building, Suite 1000, 125 S. 9th St., Philadelphia, PA 19107; email: parvj@aol.com.
Disclosure: Parvizi reports he is a paid consultant for Zimmer, Smith & Nephew, ConvTec, TissueGene, CeramTec and Medtronic; has stock or stock options in Hip Innovation Technology, CD Diagnostics and PRN; and receives royalties, financial or material support from SLACK Incorporated.