Low risk of thromboembolic complications after fast-track hip and knee arthroplasty

Abstract

Background and purposePharmacological prophylaxis can reduce the risk of deep venous thrombosis (DVT), pulmonary embolism (PE), and death, and it is recommended 10–35 days after total hip arthroplasty (THA) and at least 10 days after total knee arthroplasty (TKA). However, early mobilization might also reduce the risk of DVT and thereby the need for prolonged prophylaxis, but this has not been considered in the previous literature. Here we report our results with short-duration pharmacological prophylaxis combined with early mobilization and reduced hospitalization.Patients and methods1,977 consecutive, unselected patients were operated with primary THA, TKA, or bilateral simultaneous TKA (BSTKA) in a well-described standardized fast-track set-up from 2004–2008. Patients received DVT prophylaxis with low-molecular-weight heparin starting 6–8 h after surgery until discharge. All re-admissions and deaths within 30 and 90 days were analyzed using the national health register, concentrating especially on clinical DVT (confirmed by ultrasound and elevated D-dimer), PE, or sudden death. Numbers were correlated to days of prophylaxis (LOS).ResultsThe mean LOS decreased from 7.3 days in 2004 to 3.1 days in 2008. 3 deaths (0.15%) were associated with clotting episodes and overall, 11 clinical DVTs (0.56%) and 6 PEs (0.30%) were found. The vast majority of events took place within 30 days; only 1 death and 2 DVTs occurred between 30 and 90 days. During the last 2 years (854 patients), when patients were mobilized within 4 h postoperatively and the duration of DVT prophylaxis was shortest (1–4 days), the mortality was 0% (95% CI: 0–0.5). Incident cases of DVT in TKA was 0.60% (CI: 0.2–2.2), in THA it was 0.51% (CI: 0.1–1.8), and in BSTKA it was 0% (CI: 0–2.9). Incident cases of PE in TKA was 0.30% (CI: 0.1–1.7), in THA it was 0% (CI: 0–1.0), and in BSTKA it was 0% (CI: 0–2.9).InterpretationThe risk of clinical DVT, and of fatal and non-fatal PE after THA and TKA following a fast-track set-up with early mobilization, short hospitalization, and short duration of DVT prophylaxis compares favorably with published regimens with extended prophylaxis (up to 36 days) and hospitalization up to 11 days. This calls for a reconsideration of optimal duration of chemical thromboprophylaxis.

Prevention of VTE in Orthopedic Surgery Patients

“…6 This has obvious limitations because of important changes in surgical care, including changes in operative technique, earlier ambulation, and earlier discharge that have had an impact on rates of thrombosis and bleeding. For instance, although the average length of stay after HFS in the 1960s was 35 days, 7 current averages of 3.2 days have been reported in a large cohort after arthroplasties, 8 and early mobilization starts at 2 to 4 h after surgery. 8 Randomized controlled trial (RCT) data typically showed a symptomatic VTE event rate of 15% to 30% without prophylaxis prior to 1980, 6,[9][10][11][12] and observational data suggest a further drop from around 5% to 1% to 2% in the years from 1989 to 2001.…”

“…For instance, although the average length of stay after HFS in the 1960s was 35 days, 7 current averages of 3.2 days have been reported in a large cohort after arthroplasties, 8 and early mobilization starts at 2 to 4 h after surgery. 8 Randomized controlled trial (RCT) data typically showed a symptomatic VTE event rate of 15% to 30% without prophylaxis prior to 1980, 6,[9][10][11][12] and observational data suggest a further drop from around 5% to 1% to 2% in the years from 1989 to 2001. 13 In recent years, there have been no large placebo controlled trials, and we did not identify any large, well-designed cohort studies to provide a baseline risk relevant to current practice.…”

Fast-Track Hip and Knee Arthroplasty (Literature Review)

“…Husted с соавторами также исследовали час-тоту встречаемости тромбоэмболических ослож-нений при ускоренной реабилитации [25]. В про-спективном когортном исследовании оценивалось влияние на показатели смертности кратковре-менной фармакологической тромбопрофилакти-ки Тэла и ТГВ в сочетании с ранней мобилиза-цией и короткой госпитализацией.…”

Accelerated postoperative rehabilitation: multidisciplinary issue. Part 1

“…Наряду с ранней активизацией ис-пользуются пневмокомпрессия нижних конечно-стей и различные варианты антикоагулянтов. Наря-ду с парентеральными препаратами (низкомолеку-лярные гепарины и фондапарнукс натрия) в послед-нее время стали применять пероральные препараты, не требующие лабораторного мониторинга, -даби-гатрана этексилат (прадакса) и ривароксоабан (кса-релто), что обеспечивает комфорт больным и их большую мобильность [4,12].…”