Thromboprophylaxis only during hospitalisation in fast-track hip and knee arthroplasty, a prospective cohort study

Abstract

ObjectivesInternational guidelines recommend thrombosis prophylaxis after total hip arthroplasty (THA) and total knee arthroplasty (TKA) for up to 35 days. However, previous studies often have hospital stays (length of stay; LOS) of 8–12 days and not considering early mobilisation, which may reduce incidence of venous thromboembolic events (VTE). We investigated the incidence of any symptomatic thromboembolic events (TEEs) with only in-hospital prophylaxis if LOS ≤5 days after fast-track THA and TKA.DesignA prospective descriptive multicentre cohort study in fast-track THA and TKA from February 2010 to December 2011, with complete 90-day follow-up through the Danish National Patient Registry and patient files.Setting6 Danish high-volume centres with a similar standardised fast-track setup, including spinal anaesthesia, opioid-sparing analgesia, early mobilisation, functional discharge criteria and discharge to own home.Participants4924 consecutive unselected unilateral primary THA and TKAs in patients ≥18 years with no preoperative use of continuous ‘potent’ anticoagulative therapy (vitamin K antagonists).ExposureProphylaxis with low-molecular-weight heparin or factor Xa-inhibitors only during hospitalisation when LOS ≤5 days.OutcomesIncidence of symptomatic TEE-related, VTE-related and VTE-related mortality ≤90 days postoperatively.ResultsLOS ≤5 days and thromboprophylaxis only during hospitalisation occurred in 4659 procedures (94.6% of total). Median LOS and prophylaxis duration was 2 days (IQR 2–3) with 0.84% (95% CI 0.62% to 1.15%) TEE and 0.41% (0.26% to 0.64%) VTE during 90-day follow-up. VTE consisted of five pulmonary embolisms (0.11% (0.05% to 0.25%)) and 14 deep venous thrombosis (0.30% (0.18% to 0.50%)). There were four (0.09% (0.04% to 0.23%)) surgery-related deaths, of which 1 (0.02% (0.00% to 0.12%)) was due to pulmonary embolism, and 6 (0.13% (0.06% to 0.28%)) deaths of unknown causes after discharge.ConclusionsThe low incidence of TEE and VTE suggests that in-hospital prophylaxis only, is safe in fast-track THA and TKA patients with LOS of ≤5 days. Guidelines on thromboprophylaxis may need reconsideration in fast-track elective surgery.Trial RegistrationClinicalTrials.gov: NCT01557725

Effectiveness and safety of different duration of thromboprophylaxis in 16,865 hip replacement patients - A real-word, prospective observational study

“…This approach is reportedly associated with a low risk of VTE [20]. Our data should also been interpreted in light of the median length of hospital stay after THR surgery in Denmark of 4.3 days, which is comparable to recent data from United States [41], but shorter than in other countries (http://stats.oecd.org/index.aspx?…”

“…We categorized the duration of pharmacological thromboprophylaxis prescribed in conjunction with THR as short-term (1-6 days), standard (7-27 days), or extended (N28 days) based on available guidelines for thromboprophylaxis and clinical practice in Denmark [19,20]. Allocation of duration of treatment was almost solely dependent on the local guidelines at the individual departments, thus, all patients operated at one department will receive the same length of treatment irrespective of their risk.…”

Thromboprophylaxis

“…The authors concluded that the risk of clinical VTE with the fast-track regimen and short duration of thromboprophylaxis compared favorably with extended prophylaxis after conventional surgery (up to 4 weeks). These findings were further verified in a recent prospective cohort study (4924 patients) on fast-track hip and knee arthroplasty, where prophylaxis (LMWH or factor Xa inhibition) was used during hospitalization when length of stay was shorter than 5 days [ 8 ]. Again the incidence of VTE was very low and there was only one FPE (0.02 %).…”

Enhanced Recovery After Surgery (ERAS): good for now, but what about the future?

“…Le risque de complications thromboemboliques, par exemple, peut être un problème moins significatif dans la RRAC que dans les modèles de soins traditionnels, ne nécessitant probablement pas une prophylaxie conventionnelle prolongée si une mobilisation postopératoire précoce est instaurée, comme le montrent les programmes de chirurgie accélérée de remplacements de hanche et de genou. 13 Dans ce contexte, les « données probantes » antérieures en faveur de la prophylaxie prolongée ont toujours inclus des interventions associées à de longues DDS ne focalisant pas sur une mobilisation précoce. Un autre aspect est le problème bien connu du délirium postopératoire et des troubles tardifs des fonctions cognitives qui ont, là encore, une pathogénie multifactorielle incluant la douleur, les troubles du sommeil, l'utilisation d'opioïdes et la réponse inflammatoire.…”

“…For instance, the risk of thromboembolic complications, which may be a less significant problem in ERAS than in traditional models of care, probably does not require the conventional extended prophylaxis if early postoperative mobilization is instituted, as shown with fast-track hip and knee replacement. 13 In this context, the previous ''evidence'' for prolonged prophylaxis has always included procedures with a long LOS with no focus on early mobilization. Another aspect is the well-recognized problem of postoperative delirium and late cognitive dysfunction where, again, the pathogenesis is multifactorial, including pain, sleep disturbances, opioid use, and the inflammatory response.…”