Internal and Emergency Medicine

, Volume 7, Issue 3, pp 243–249

Venous thromboembolism after major orthopaedic surgery: a population-based cohort study

  • Davide Imberti
  • Cosetta Bianchi
  • Antonella Zambon
  • Andrea Parodi
  • Luca Merlino
  • Massimo Gallerani
  • Giovanni Corrao
IM - ORIGINAL

Abstract

Venous thromboembolism (VTE) is an important cause of morbidity and mortality following major orthopaedic surgery. However, the incidence of VTE and the role of additional risk factors have not yet been well explored in Italian clinical practice. The objective of the study is to estimate the incidence of VTE in the 3 months following elective hip and knee replacement (HR, KR) in a large cohort of patients, and the association between some selected risk factors and the occurrence of VTE. A large cohort study based on the record linkage between automated archives of the National Health System was analysed. In particular, all the residents in the Lombardy Region (Italy) who underwent HR and KR between 2005 and 2008 were followed for 3 months after surgery. The odds ratio (OR) of VTE associated with selected known risk factors was estimated by multivariate logistic regression. Amongst the 69,770 patients included in the study, 2,393 experienced at least one VTE event during the follow-up; the overall risk of VTE after HR or KR was 3.4%. The adjusted odds of experiencing a VTE event was higher in male patients (OR 1.11; 95% confidence interval 1.01–1.21), aged 60 years or older (1.30; 1.00–1.68), undergoing KR (1.47; 1.35–1.61), with previous deep vein thrombosis (1.96; 1.20–3.19), pulmonary embolism (3.25; 1.84–5.75) or cancer (1.21; 1.00–1.46). In conclusion, the incidence of VTE after elective HR and KR in the Italian clinical practice is high. Our results suggest the need of optimising the management of thromboprophylaxis to further reduce postoperative VTE.

Keywords

Venous thromboembolism Orthopedic surgery Risk factors 

References

  1. 1.
    Shorr AF, Kwong LM, Sarnes M, Happe L, Farrelly E, Mody-Patel N (2007) Venous thromboembolism after orthopedic surgery: implications of the choice for prophylaxis. Thromb Res 121:17–24PubMedCrossRefGoogle Scholar
  2. 2.
    Bergqvist D, Benoni G, Bjorgell O, Fredin H, Hedlundh U, Nicolas S, Nilsson P, Nylander G (1996) Low-molecular-weight heparin (enoxaparin) as prophylaxis against venous thromboembolism after total hip replacement. N Engl J Med 335:696–700PubMedCrossRefGoogle Scholar
  3. 3.
    Comp PC, Spiro TE, Friedman RJ, Whitsett TL, Johnson GJ, Gardiner GA, Gardiner GA Jr, Landon GC, Jove M (2001) Prolonged enoxaparin therapy to prevent venous thromboembolism after primary hip or knee replacement. Enoxaparin Clinical Trial Group. J Bone Joint Surg Am 83-A:336–345PubMedGoogle Scholar
  4. 4.
    Nakase J, Toribatake Y, Mouri Y, Seki H, Kitaoka K, Tomita K (2009) Heparin versus danaproid for prevention of venous thromboembolism after hip surgery. J Orthop Surg (Hong Kong) 17:6–9Google Scholar
  5. 5.
    Geerts WH, Bergqvist D, Pineo GF, Heit JA, Samama CM, Lassen MR, Colwell CW (2008) Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 133:381S–453SPubMedCrossRefGoogle Scholar
  6. 6.
    Alikhan R, Peters F, Wilmott R, Cohen AT (2004) Fatal pulmonary embolism in hospitalised patients: a necropsy review. J Clin Pathol 57:1254–1257PubMedCrossRefGoogle Scholar
  7. 7.
    Eikelboom JW, Quinlan DJ, Douketis JD (2001) Extended-duration prophylaxis against venous thromboembolism after total hip or knee replacement: a meta-analysis of the randomised trials. Lancet 358:9–15PubMedCrossRefGoogle Scholar
  8. 8.
    Ganz DA, Glynn RJ, Mogun H, Knight EL, Bohn RL, Avorn J (2000) Adherence to guidelines for oral anticoagulation after venous thrombosis and pulmonary embolism. J Gen Intern Med 15:776–781PubMedCrossRefGoogle Scholar
  9. 9.
    Geerts W (2009) Prevention of venous thromboembolism: a key patient safety priority. J Thromb Haemost 7(Suppl 1):1–8PubMedCrossRefGoogle Scholar
  10. 10.
    Hull RD, Pineo GF, Stein PD, Mah AF, MacIsaac SM, Dahl OE, Butcher M, Brant RF, Ghali WA, Bergqvist D, Raskob GE (2001) Extended out-of-hospital low-molecular-weight heparin prophylaxis against deep venous thrombosis in patients after elective hip arthroplasty: a systematic review. Ann Intern Med 135:858–869PubMedGoogle Scholar
  11. 11.
    Imberti D, Prisco D (2005) Venous thromboembolism prophylaxis in medical patients: future perspectives. Thromb Res 116:365–375PubMedCrossRefGoogle Scholar
  12. 12.
    Mantilla CB, Horlocker TT, Schroeder DR, Berry DJ, Brown DL (2002) Frequency of myocardial infarction, pulmonary embolism, deep venous thrombosis, and death following primary hip or knee arthroplasty. Anesthesiology 96:1140–1146PubMedCrossRefGoogle Scholar
  13. 13.
    Leclerc JR, Gent M, Hirsh J, Geerts WH, Ginsberg JS (1998) The incidence of symptomatic venous thromboembolism after enoxaparin prophylaxis in lower extremity arthroplasty: a cohort study of 1, 984 patients. Canadian Collaborative Group. Chest 114:115S–118SPubMedCrossRefGoogle Scholar
  14. 14.
    Verhaeghe R (2005) Extended prophylaxis of venous thromboembolism in major orthopaedic surgery. Acta Orthop Belg 71:255–259PubMedGoogle Scholar
  15. 15.
    Corrao G, Cesana G, Merlino L (2008) Pharmacoepidemiological research and linking of electronic databases available in the Italian region of Lombardy. Biomed Stat Clin Epidemiol 2:117–125Google Scholar
  16. 16.
    ISTAT: Censimento Generale della Popolazione e delle Abitazioni. Available at:http://www.dawinciistatit/MD
  17. 17.
    Claes N, Buntinx F, Vijgen J, Arnout J, Vermylen J, Fieuws S, Van LH (2005) The Belgian Improvement Study on Oral Anticoagulation Therapy: a randomized clinical trial. Eur Heart J 26:2159–2165PubMedCrossRefGoogle Scholar
  18. 18.
    Edmonds MJ, Crichton TJ, Runciman WB, Pradhan M (2004) Evidence-based risk factors for postoperative deep vein thrombosis. ANZ J Surg 74:1082–1097PubMedCrossRefGoogle Scholar
  19. 19.
    Gangireddy C, Rectenwald JR, Upchurch GR, Wakefield TW, Khuri S, Henderson WG, Henke PK (2007) Risk factors and clinical impact of postoperative symptomatic venous thromboembolism. J Vasc Surg 45:335–341PubMedCrossRefGoogle Scholar
  20. 20.
    Glynn RJ, Danielson E, Fonseca FA, Genest J, Gotto AM Jr, Kastelein JJ, Koenig W, Libby P, Lorenzatti AJ, MacFadyen JG, Nordestgaard BG, Shepherd J, Willerson JT, Ridker PM (2009) A randomized trial of rosuvastatin in the prevention of venous thromboembolism. N Engl J Med 360:1851–1861PubMedCrossRefGoogle Scholar
  21. 21.
    Isma N, Svensson PJ, Gottsater A, Lindblad B (2009) Prospective analysis of risk factors and distribution of venous thromboembolism in the population-based Malmo Thrombophilia Study (MATS). Thromb Res 124:663–666PubMedCrossRefGoogle Scholar
  22. 22.
    Lacut K, van der Maaten J, Le GG, Cornily G, Mottier D, Oger E (2008) Antiplatelet drugs and risk of venous thromboembolism: results from the EDITH case–control study. Haematologica 93:1117–1118PubMedCrossRefGoogle Scholar
  23. 23.
    Jewell NP (2004) Statistics for epidemiology. Chapman and Hall, Boca RatonGoogle Scholar
  24. 24.
    Schabenberger O (2008) Introducing the GLIMMIX procedure for generalized linear mixed models. SAS Institute Inc., Cary (2008)Google Scholar
  25. 25.
    Hanley JA, McNeil BJ (1982) The meaning and use of the area under a receiver operating characteristic (ROC) curve. Radiology 143:29–36PubMedGoogle Scholar
  26. 26.
    The Thrombosis Interest Group of Canada: Clinical Guide—The prevention of deep vein thrombosis in medical patients, 2008. Available at http://www.tigc.org/pdf/PrevDVTMedPat.pdf
  27. 27.
    Ageno W, Squizzato A, Garcia D, Imberti D (2006) Epidemiology and risk factors of venous thromboembolism. Semin Thromb Hemost 32:651–658PubMedCrossRefGoogle Scholar
  28. 28.
    Severinsen MT, Johnsen SP, Tjonneland A, Overvad K, Dethlefsen C, Kristensen SR (2010) Body height and sex-related differences in incidence of venous thromboembolism: a Danish follow-up study. Eur J Intern Med 21:268–272PubMedCrossRefGoogle Scholar
  29. 29.
    Davidson HC, Mazzu D, Gage BF, Jeffrey RB (1996) Screening for deep venous thrombosis in asymptomatic postoperative orthopedic patients using color Doppler sonography: analysis of prevalence and risk factors. AJR Am J Roentgenol 166:659–662PubMedGoogle Scholar
  30. 30.
    Samama MM (2000) An epidemiologic study of risk factors for deep vein thrombosis in medical outpatients: the Sirius study. Arch Intern Med 160:3415–3420PubMedCrossRefGoogle Scholar
  31. 31.
    Imberti D, Dallasta C (2008) Clinical benefits of rivaroxaban for thromboprophylaxis after major orthopaedic surgery. Adv Orthop 1:8–16Google Scholar
  32. 32.
    Blom JW, Doggen CJ, Osanto S, Rosendaal FR (2005) Malignancies, prothrombotic mutations, and the risk of venous thrombosis. JAMA 293:715–722PubMedCrossRefGoogle Scholar
  33. 33.
    Corrao G, Zambon A, Conti V, Nicotra F, La VC, Fornari C, Cesana G, Contiero P, Tagliabue G, Nappi RE, Merlino L (2008) Menopause hormone replacement therapy and cancer risk: an Italian record linkage investigation. Ann Oncol 19:150–155PubMedCrossRefGoogle Scholar
  34. 34.
    Randelli F, Biggi F, Della RG, Grossi P, Imberti D, Landolfi R, Palareti G, Prisco D Italian intersociety consensus statement on antithrombotic prophylaxis in hip and knee replacement and in femoral neck fracture surgery. J Orthop Traumatol. doi:10.1007/s10195-010-0125-8
  35. 35.
    Fattore G, Colangelo I, Martelli E, Cheli A, Del Sasso L (2004) Methods and costs of venous thromboembolism prophylaxis in orthopedic surgery in Italy. Pharmacoecon Italian Res Articles 6:69–80Google Scholar

Copyright information

© SIMI 2011

Authors and Affiliations

  • Davide Imberti
    • 1
  • Cosetta Bianchi
    • 2
  • Antonella Zambon
    • 3
  • Andrea Parodi
    • 3
  • Luca Merlino
    • 4
  • Massimo Gallerani
    • 1
  • Giovanni Corrao
    • 3
  1. 1.Internal Medicine DepartmentUniversity Hospital of Ferrara, University HospitalFerraraItaly
  2. 2.Pricing and HEOR, Bayer Schering PharmaMilanItaly
  3. 3.Unit of Biostatistics and Epidemiology, Department of StatisticsUniversity of Milano-BicoccaMilanItaly
  4. 4.Operative Unit of Territorial Health Services, Region of LombardyMilanItaly

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