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Risk stratification will drive decline in VTE rates in orthopedic patients
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LISBON, Portugal — Being better able to predict which patients need thromboprophylaxis following hip and knee arthroplasty is the way forward to reduce the incidence of thrombosis, according to a presentation by Banne Nemeth, MD, PhD, at the EFORT Annual Congress.
“I think risk stratification is essential to do,” he said.
“We have to work toward the decline in [venous thromboembolism] VTE and we have to give less prophylaxis in the low-risk patients, whereas we need to intensify thromboprophylaxis in high-risk patients,” Nemeth said.
According to Nemeth, the same type of individualized approaches used in other areas of orthopaedics, such as individualizing the implants selected based on specific patient characteristics, should apply when prescribing thromboprophylaxis for patients who undergo total joint arthroplasty.
The good news, he said, is “new surgical approaches and post-surgical care have all contributed to the decline of thrombosis.”
Fast-track TJR surgery, which is associated with more rapid, postoperative mobilization, among other features, is one such strategy that has played a role in reducing the thrombosis risk, Nemeth said.
“It is even estimated that if we do not give any form of thromboprophylaxis, the risk is only 3.5%,” he said.
Nemeth discussed several studies during his presentation that provide information about effective approaches to prevent thrombosis events in patients undergoing TJR, which is considered high-risk surgery.
Importantly, he said orthopaedic surgeons must take the heterogeneity of their patients into account when prescribing thromboprophylaxis and surgeons should modify their prescribing practices accordingly, particularly for patients who are older or obese, have difficulty mobilizing or have a history of VTE.
Nemeth concluded by summarizing the latest European Society of Anaesthesiology guidelines for VTE prevention in orthopaedic surgery, which address appropriate use of aspirin, low-molecular-weight heparin (LMWH) or direct oral anticoagulants (DOAC).
No thromboprophylaxis is needed for a low-risk patient undergoing a low-risk procedure, such as knee arthroscopy, but “if you have a low-risk surgery in a high-risk patient, for example someone with a history of VTE, the risk is still considerable. They advise you to use aspirin,” he said, noting aspirin is also recommended for cases of high-risk surgery, such as TJR, performed in low-risk patients.
“Otherwise, you should give them low-molecular-weight heparin or DOAC. So, I do not say you have to use this. But, this is what I want to emphasize, [which] is that they say you should do this. So, you have to stratify between being a low- and a high-risk patient, which is currently impossible” Nemeth said.
He and his colleagues are now developing a prediction model especially for VTE risk following TJR using a large dataset. Nemeth said the corresponding validation study is being developed. – by Susan M. Rapp
Reference:
Nemeth B. Thromboprophylaxis following orthopedic surgery: Is prediction the future? Presented at: EFORT Annual Congress; June 5-7, 2019; Lisbon, Portugal.
Disclosure: Nemeth reports he received a research grant from Sanofi-Aventis.