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Opportunities for improvement: anticoagulation in patients undergoing total knee or hip replacement

  • Original Article
  • Published:
Journal of Orthopaedic Science

Abstract

Background

According to guidelines, initiation of pharmacological thromboprophylaxis after total knee or hip replacement is recommended and associated with improved patient outcomes. However, data on how these recommendations are followed in clinical practice are sparse.

Methods

All patients undergoing first-time total knee or hip replacement in Denmark 2008–2011 were identified. By cross-referencing Danish nationwide registries, quantitative use of anticoagulants administered orally and subcutaneously post-discharge was assessed by number of claimed prescriptions after surgery. Logistic regression analysis was used to identify factors associated with initiation of prophylaxis.

Results

A total of 50,389 patients were included in the study (median age 69, inter-quartile range 62–76). Novel oral anticoagulants were initiated in 14.7 % of the patients and heparins/fondaparinux in 2.3 % of the patients. The use of anticoagulants increased from 6.3 % in 2008 to 30.0 % of patients in 2011. Among patients initiating prophylaxis with a novel oral anticoagulant post-discharge, almost all were treated according to guidelines in terms of treatment duration. Factors significantly associated with an increased chance of prophylaxis among total hip replacement patients were: age (per 10-year increments) and female gender.

Conclusions

Use of pharmacological thromboprophylaxis after total knee or hip replacement was low, but increasing during the study period. This is probably due to increased availability of novel oral anticoagulants. Further initiatives to increase guideline recommended use of prophylactic anticoagulation after orthopaedic surgery are warranted.

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References

  1. Geerts WH, Bergqvist D, Pineo GF, Heit JA, Samama CM, Lassen, Colwell CW, American College of Chest P. Prevention of venous thromboembolism: American College of Chest Physicians evidence-based clinical practice guidelines. 8th ed. Chest. 2008;133(6 Suppl):381S–453S.

    Article  CAS  PubMed  Google Scholar 

  2. Falck-Ytter Y, Francis CW, Johanson NA, Curley C, Dahl OE, Schulman S, Ortel TL, Pauker SG, Colwell CW Jr. Prevention of VTE in orthopedic surgery patients: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2012;141(2 Suppl):e278S–325S.

    PubMed Central  CAS  PubMed  Google Scholar 

  3. Surgeons. AAoO. American Academy of Orthopaedic Surgeons website: number of total knee replacements http://orthoinfo.aaos.org/topic.cfm?topic=a00377; number of total hip replacements http://orthoinfo.aaos.org/topic.cfm?topic=a00389. Accessed 03 June 2013.

  4. Galasko CS, Edwards DH, Fearn CB, Barber HM. The value of low dosage heparin for the prophylaxis of thromboembolism in patients with transcervical and intertrochanteric femoral fractures. Acta Orthop Scand. 1976;47(3):276–82.

    Article  CAS  PubMed  Google Scholar 

  5. Sautter RD, Koch EL, Myers WO, Ray JR 3rd, Mazza JJ, Larson DE, Chen HM, Milbauer JP, Treuhaft PS, Plotka ED, et al. Aspirin-sulfinpyrazone in prophylaxis of deep venous thrombosis in total hip replacement. JAMA (J Am Med Assoc). 1983;250(19):2649–54.

    Article  CAS  Google Scholar 

  6. Borgstroem S, Greitz T, Van Der Linden W, Molin J, Rudics I. Anticoagulant prophylaxis of venous thrombosis in patients with fractured neck of the femur; a controlled clinical trial using venous phlebography. Acta Chir Scand. 1965;129:500–8.

    CAS  PubMed  Google Scholar 

  7. Eskeland G, Solheim K, Skjorten F. Anticoagulant prophylaxis, thromboembolism and mortality in elderly patients with hip fractures. A controlled clinical trial. Acta Chir Scand. 1966;131(1):16–29.

    CAS  PubMed  Google Scholar 

  8. Husted H, Otte KS, Kristensen BB, Orsnes T, Wong C, Kehlet H. Low risk of thromboembolic complications after fast-track hip and knee arthroplasty. Acta Orthop. 2010;81(5):599–605.

    Article  PubMed Central  PubMed  Google Scholar 

  9. Eikelboom JW, Quinlan DJ, Douketis JD. Extended-duration prophylaxis against venous thromboembolism after total hip or knee replacement: a meta-analysis of the randomised trials. Lancet. 2001;358(9275):9–15.

    Article  CAS  PubMed  Google Scholar 

  10. Neumann I, Rada G, Claro JC, Carrasco-Labra A, Thorlund K, Akl EA, Bates SM, Guyatt GH. Oral direct Factor Xa inhibitors versus low-molecular-weight heparin to prevent venous thromboembolism in patients undergoing total hip or knee replacement: a systematic review and meta-analysis. Ann Intern Med. 2012;156(10):710–9.

    Article  PubMed  Google Scholar 

  11. Sobieraj DM, Coleman CI, Tongbram V, Chen W, Colby J, Lee S, Kluger J, Makanji S, Ashaye A, White CM. Comparative effectiveness of low-molecular-weight heparins versus other anticoagulants in major orthopedic surgery: a systematic review and meta-analysis. Pharmacotherapy. 2012;32(9):799–808.

    Article  CAS  PubMed  Google Scholar 

  12. Gomez-Outes A, Terleira-Fernandez AI, Suarez-Gea ML, Vargas-Castrillon E. Dabigatran, rivaroxaban, or apixaban versus enoxaparin for thromboprophylaxis after total hip or knee replacement: systematic review, meta-analysis, and indirect treatment comparisons. BMJ (Clin Res Ed). 2012;344:e3675.

    Google Scholar 

  13. Loke YK, Kwok CS. Dabigatran and rivaroxaban for prevention of venous thromboembolism–systematic review and adjusted indirect comparison. J Clin Pharm Ther. 2011;36(1):111–24.

    Article  CAS  PubMed  Google Scholar 

  14. Alves C, Batel-Marques F, Macedo AF. Apixaban and rivaroxaban safety after hip and knee arthroplasty: a meta-analysis. J Cardiovasc Pharmacol Ther. 2012;17(3):266–76.

    Article  CAS  PubMed  Google Scholar 

  15. Adam SS, McDuffie JR, Lachiewicz PF, Ortel TL, Williams JW. Comparative effectiveness of newer oral anticoagulants and standard anticoagulant regimens for thromboprophylaxis in patients undergoing total hip or knee replacement. Washington, DC: Department of Veterans Affairs; 2012.

  16. Eriksson BI, Dahl OE, Huo MH, Kurth AA, Hantel S, Hermansson K, Schnee JM, Friedman RJ, Group R-NIS. Oral dabigatran versus enoxaparin for thromboprophylaxis after primary total hip arthroplasty (RE-NOVATE II*). A randomised, double-blind, non-inferiority trial. Thromb Haemost. 2011;105(4):721–9.

    Article  CAS  PubMed  Google Scholar 

  17. Beyer-Westendorf J, Lutzner J, Donath L, Tittl L, Knoth H, Radke OC, Kuhlisch E, Stange T, Hartmann A, Gunther KP, Weiss N, Werth S. Efficacy and safety of thromboprophylaxis with low-molecular-weight heparin or rivaroxaban in hip and knee replacement surgery: findings from the ORTHO-TEP registry. Thromb Haemost. 2013;109(1):154–63.

    Article  CAS  PubMed  Google Scholar 

  18. Lynge E, Sandegaard JL, Rebolj M. The Danish National Patient Register. Scand J Public Health. 2011;39(7 Suppl):30–3.

    Article  PubMed  Google Scholar 

  19. Gaist D, Sorensen HT, Hallas J. The Danish prescription registries. Dan Med Bull. 1997;44(4):445–8.

    CAS  PubMed  Google Scholar 

  20. Fosbol EL, Gislason GH, Jacobsen S, Abildstrom SZ, Hansen ML, Schramm TK, Folke F, Sorensen R, Rasmussen JN, Kober L, Madsen M, Torp-Pedersen C. The pattern of use of non-steroidal anti-inflammatory drugs (NSAIDs) from 1997 to 2005: a nationwide study on 4.6 million people. Pharmacoepidemiol Drug Saf. 2008;17(8):822–33.

    Article  PubMed  Google Scholar 

  21. Olesen JB, Lip GY, Kamper AL, Hommel K, Kober L, Lane DA, Lindhardsen J, Gislason GH, Torp-Pedersen C. Stroke and bleeding in atrial fibrillation with chronic kidney disease. New Engl J Med. 2012;367(7):625–35.

    Article  CAS  PubMed  Google Scholar 

  22. Olesen JB, Lip GY, Hansen ML, Hansen PR, Tolstrup JS, Lindhardsen J, Selmer C, Ahlehoff O, Olsen AM, Gislason GH, Torp-Pedersen C. Validation of risk stratification schemes for predicting stroke and thromboembolism in patients with atrial fibrillation: nationwide cohort study. BMJ (Clin Res Ed). 2011;342:d124.

    Article  Google Scholar 

  23. Selby R, Borah BJ, McDonald HP, Henk HJ, Crowther M, Wells PS. Impact of thromboprophylaxis guidelines on clinical outcomes following total hip and total knee replacement. Thromb Res. 2012;130(2):166–72.

    Article  CAS  PubMed  Google Scholar 

  24. Arcelus JI, Felicissimo P, Investigators D. Venous thromboprophylaxis duration and adherence to international guidelines in patients undergoing major orthopaedic surgery: results of the international, longitudinal, observational DEIMOS registry. Thromb Res. 2013;131(6):e240–6.

    Article  CAS  PubMed  Google Scholar 

  25. Bergqvist D, Arcelus JI, Felicissimo P, Investigators E. Evaluation of the duration of thromboembolic prophylaxis after high-risk orthopaedic surgery: the ETHOS observational study. Thromb Haemost. 2012;107(2):270–9.

    Article  CAS  PubMed  Google Scholar 

  26. Pedersen AB, Mehnert F, Johnsen SP, Husted S, Sorensen HT. Venous thromboembolism in patients having knee replacement and receiving thromboprophylaxis: a Danish population-based follow-up study. J Bone Joint Surg Am. 2011;93(14):1281–7.

    Article  PubMed  Google Scholar 

  27. Sørensen R, Gislason G, Torp-Pedersen C, Olesen JB, Fosbøl EL, Hvidtfeldt MW, Karasoy D, Lamberts M, Charlot M, Køber L, Weeke P, Lip GY, Hansen ML. Dabigatran use in Danish atrial fibrillation patients in 2011: a nationwide study. BMJ Open. 2013;3(5):e002758. doi:10.1136/bmjopen-2013-002758.

    Article  PubMed Central  PubMed  Google Scholar 

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Authors and Affiliations

  1. Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark

    Mads Thorsberger, Thomas Jensen, Jonas Olesen, Peter Weeke, Liv Wahlsten, Per Jensen, Gunnar Gislason, Lars Koeber & Emil Fosbøl

  2. Department of Health Science and Technology, Aalborg University, Aalborg, Denmark

    Christian Torp-Pedersen

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  1. Mads Thorsberger
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  2. Thomas Jensen
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  3. Jonas Olesen
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  4. Peter Weeke
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Correspondence to Mads Thorsberger.

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Thorsberger, M., Jensen, T., Olesen, J. et al. Opportunities for improvement: anticoagulation in patients undergoing total knee or hip replacement. J Orthop Sci 20, 1036–1045 (2015). https://doi.org/10.1007/s00776-015-0762-0

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  • DOI: https://doi.org/10.1007/s00776-015-0762-0

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