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In-hospital thromboprophylaxis used alone seen as safe practice with fast-track TJA
The investigators noted that in light of their findings thromboprophylaxis use should be reconsidered in the modern arthroplasty setting.
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The rate of thromboembolic events was 0.84% among about 4,500 fast-track unilateral total hip arthroplasty or total knee arthroplasty patients who had a median hospital stay of 2 days and only received thromboprophylaxis during that time, according to research by investigators from Denmark.
Christoffer C. Jørgensen, MD, and colleagues found a 0.41% rate of venous thromboembolic events (VTEs) at the same follow-up in their prospective multicenter cohort study. The findings lead them to conclude that it is safe to limit administration of thromboprophylaxis to the hospital stay alone in patients who undergo fast-track total hip arthroplasty (THA) or total knee arthroplasty (TKA) and are discharged to their own home within 5 days.
Jørgensentold Orthopaedics Today Europe that what is most groundbreaking about these findings is that “about 95% of almost 5,000 patients with thromboprophylaxis for a median of 2 days had VTEs comparable to or lower than in previous studies with prophylaxis of 30 days to 35 days.”
The study included 4,924 consecutive unselected unilateral THAs and TKAs performed in 4,718 patients at six Danish clinics. None of the patients used continuous “potent” anticoagulative therapy prior to surgery, and during their hospital stays of 5 days or less, the VTE prophylaxis they were administered consisted of either low-molecular weight heparin or factor Xa-inhibitors.
Jørgensen told Orthopaedics Today Europe that the investigators all used a similar fast-track protocol for the study. “There were minor differences with regard to the protocols used at the participating departments, mainly considering the use of NSAIDs/COX-2 inhibitors and also regarding the use of postoperative restrictions in THA. However, none of this should influence incidence of venous thromboembolic events,” he said.
“Early mobilization seems to be the most critical factor for fewer thromboembolic events after total joint arthroplasty. This also makes sense from a pathophysiological point of view, as mobilization in itself may prevent the occurrence of thromboembolic events. However, it is important to remember that patients are difficult to mobilize if they have insufficient analgesia, are dizzy from opioids or hindered by drains and catheters, etc. Consequently, all the elements of the fast-track methodology need to be included in order to facilitate early mobilization,” Jørgensen said.
Of the documented VTEs, five were pulmonary embolisms (0.11%), one of which was fatal, and 14 were deep venous thrombosis (0.30%).
Given these findings, which support discontinuing thromboprophylaxis after discharge from hospital in this patient population, Jørgensen and colleagues wrote in their study that “guidelines on postoperative thromboprophylaxis need reconsideration in modern elective surgical procedures.”
Jørgensen noted the possibility that some thromboembolic events may have went undetected as a potential limitation of the study. “In addition, our study cannot be used to analyze differences between the specific antithrombotic drugs used or to identify the ideal duration of thromboprophylaxis. However, this was not the aim of the study; rather, we wanted to investigate whether thromboprophylaxis only during hospitalization was safe in patients admitted for 5 days or less,” he told Orthopaedics Today Europe.
Per Kjaersgaard-Andersen, MD, Chief Medical Editor of Orthopaedics Today Europe, who was an investigator involved in this study, said, “My clinic was one of the six fast-track units entering patients into the current study. Over a few years our THA and TKA set-up changed dramatically from a stay in clinic of about 7 days to 10 days after surgery with mobilization on day 1 or day 2 after surgery, to the current status with mobilization on the day of surgery and discharge on average 2.3 days after surgery. As DVT prophylaxis is the subject of ongoing discussion in the Scandinavian area, and also is not a risk-free prophylaxis, we in our clinic were much in favor of shortening the duration of this treatment. The current study has proven that treatment only for few days after surgery is safe, and my open question now is whether DVT prophylaxis after primary THA or TKA in modern units using fast-track protocols is needed at all.” – by Christian Ingram and Susan M. Rapp
- Reference:
- Jørgensen CC. BMJ. 2013;doi:10.1136/bmjopen-2013-003965.
- For more information:
- Christoffer C. Jørgensen, MD, can be reached at the Section for Surgical Pathophysiology 7621, Rigshospitalet, Blegdamsvej 9, DK-2100 Copenhagen, Denmark; email: christoffer.calov.joergensen@regionh.dk.
- Per Kjaersgaard-Andersen, MD, can be reached at can be reached at Orthopaedics Today Europe, 6900 Grove Road, Thorofare, NJ 08086, USA; email: orthopaedics@healio.com.
Disclosures: Two of the study’s co-authors are board members of the Health Care initiatives, Biomet Rapid Recovery. Jørgensen and Kjaersgaard-Andersen have no relevant financial disclosures.