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Patients with OA, RA have similar risks of VTE following TKA
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Patients with osteoarthritis and rheumatoid arthritis who underwent total knee arthroplasty had similar postoperative risks for developing deep vein thrombosis, according to study findings.
The Japanese Study of Prevention and Actual Situation of Venous Thromboembolism After Total Knee Arthroplasty, a hospital-based, prospective cohort study, was used to recruit 1,288 patients who underwent total knee arthroplasty (TKA), 1,084 of whom had osteoarthritis (OA) and 204 of whom had rheumatoid arthritis (RA). Mean patient age at time of TKA was 75 years in patients with OA and 67.5 years for patients with RA.
No medication was taken by 593 patients who underwent TKA, whereas pharmacological thromboprophylaxis with fondaparinux was utilized in 357 patients; enoxaparin was utilized in 222 patients, unfractionated heparin was utilized in 71 patients, antiplatelet agents were utilized in 45 patients, aspirin was utilized in 41 patients, ticlopidine was utilized in two patients and cilostazol was utilized in two patients.
Pulmonary embolism was reported in one patient with OA treated with fondaparinux 7 days after TKA, and on day 13 after TKA in one patient with OA who received no medication. Through day 10, the rate of deep vein thrombosis (DVT) was 24.3% in all patients. Venous thromboembolism (VTE) was seen in 24.3% of patients with OA and 24% of patients with RA; however, multivariate analyses showed neither type of disease affected the risk for VTE, according to the researchers.
Rates of major bleeding after TKA were 1.3% in patients with OA and 0.5% in patients with RA, and analysis showed the differences were not significant. No fatal incidents of bleeding were observed. - by Shirley Pulawski
Disclosure: The researchers report their research was supported by a grant from the Japanese National Hospital Organization.
Perspective
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Leonard H. Calabrese, DO
Clearly after total knee replacement it is vital to prevent venous thromboembolism (VTE) given the high rate of DVT traditionally observed (30% to 40%) in the absence of prophylaxis. Advances in postoperative management have dramatically reduced the incidence of symptomatic pulmonary embolism to less than 1%. An important question for which there is surprisingly little data is whether the rates of such complications differ between patients with osteoarthritis, which is the most common indication, or rheumatoid arthritis (RA).
At a glance, I would suspect RA to be of higher risk given that they have a systemic inflammatory disease and from our knowledge of high rates of DVT in other autoimmune and autoinflammatory diseases, such as SLE and vasculitis. Previous studies have been limited and thus it is somewhat surprising and reassuring that in a large study of 1,288 patients from Japan who were rigorously followed that the overall risks of VTE between these groups were equivalent. If this is “true,” then it gives us pause to ask why.
Unfortunately, this trial has serious limitations in that treatment/prophylaxis regimes were not matched and, in reality, the RA group received more potent agents, especially fondaparinux. Thus, there may be channeling to more aggressive therapies for the RA group. Also unknown are the effects of NSAIDs glucocorticoids and disease-modifying antirheumatic drugs on this equation, although no obvious mechanisms emerged. I am comforted by the remarkably low overall event rates in both groups, which reassure me that advances in perioperative care are making a huge difference.
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