Risk factors for deep vein thrombosis even using low-molecular-weight heparin after total knee arthroplasty

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Abstract

Background

With an increase in deep vein thrombosis (DVT) following total knee arthroplasty (TKA) in the Asian population, most surgeons today use a form of prophylactic anticoagulant agents in patients after TKA. Nevertheless, DVT occasionally develops even in these patients with prophylaxis. The purpose of this study was to identify the risk factors for DVT after TKA in cases of postoperative low-molecular-weight heparin (LMWH) use.

Methods

We designed a retrospective study with 103 patients who underwent primary TKA. From the second postoperative day, 60 mg of LMWH was subcutaneously injected into the patients daily. On the seventh postoperative day, patients had computed tomography angiography to check whether they had DVT. Regarding risk factors, we investigated patients’ gender, age, surgical site (unilateral/bilateral), body mass index, method of anesthesia, preoperative hypertension, diabetes, hypercholesterolemia status, and prothrombin time/international normalized ratio from electronic medical records. We analyzed the statistical significance of these risk factors.

Results

Statistically significant factors in the single-variable analysis were surgical site (unilateral/bilateral), body mass index, preoperative hypertension status, and anesthesia method. Multiple logistic regression analysis with these factors revealed that the surgical site (unilateral/bilateral, p = 0.024) and anesthesia method ( p = 0.039) were significant factors for the occurrence of postoperative DVT after TKA.

Conclusions

Patients undergoing simultaneous bilateral TKAs and patients undergoing TKA with general anesthesia need more attention regarding DVT even with chemoprophylaxis using LMWH after TKA.

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Most cited references 40

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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.

Yngve Falck-Ytter, Charles Francis, Norman A Johanson … (2012)

VTE is a serious, but decreasing complication following major orthopedic surgery. This guideline focuses on optimal prophylaxis to reduce postoperative pulmonary embolism and DVT. The methods of this guideline follow those described in Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines in this supplement. In patients undergoing major orthopedic surgery, we recommend the use of one of the following rather than no antithrombotic prophylaxis: low-molecular-weight heparin; fondaparinux; dabigatran, apixaban, rivaroxaban (total hip arthroplasty or total knee arthroplasty but not hip fracture surgery); low-dose unfractionated heparin; adjusted-dose vitamin K antagonist; aspirin (all Grade 1B); or an intermittent pneumatic compression device (IPCD) (Grade 1C) for a minimum of 10 to 14 days. We suggest the use of low-molecular-weight heparin in preference to the other agents we have recommended as alternatives (Grade 2C/2B), and in patients receiving pharmacologic prophylaxis, we suggest adding an IPCD during the hospital stay (Grade 2C). We suggest extending thromboprophylaxis for up to 35 days (Grade 2B). In patients at increased bleeding risk, we suggest an IPCD or no prophylaxis (Grade 2C). In patients who decline injections, we recommend using apixaban or dabigatran (all Grade 1B). We suggest against using inferior vena cava filter placement for primary prevention in patients with contraindications to both pharmacologic and mechanical thromboprophylaxis (Grade 2C). We recommend against Doppler (or duplex) ultrasonography screening before hospital discharge (Grade 1B). For patients with isolated lower-extremity injuries requiring leg immobilization, we suggest no thromboprophylaxis (Grade 2B). For patients undergoing knee arthroscopy without a history of VTE, we suggest no thromboprophylaxis (Grade 2B). Optimal strategies for thromboprophylaxis after major orthopedic surgery include pharmacologic and mechanical approaches.

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Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy.

Clifford W Colwell, William Ray, Michael R. Lassen … (2004)

This article discusses the prevention of venous thromboembolism (VTE) and is part of the Seventh American College of Chest Physicians Conference on Antithrombotic and Thrombolytic Therapy: Evidence-Based Guidelines. Grade 1 recommendations are strong and indicate that the benefits do, or do not, outweigh risks, burden, and costs. Grade 2 suggests that individual patients' values may lead to different choices (for a full understanding of the grading see Guyatt et al, CHEST 2004; 126:179S-187S). Among the key recommendations in this chapter are the following. We recommend against the use of aspirin alone as thromboprophylaxis for any patient group (Grade 1A). For moderate-risk general surgery patients, we recommend prophylaxis with low-dose unfractionated heparin (LDUH) (5,000 U bid) or low-molecular-weight heparin (LMWH) [ 3,400 U daily) [both Grade 1A]. For high-risk general surgery patients with multiple risk factors, we recommend combining pharmacologic methods (LDUH three times daily or LMWH, > 3,400 U daily) with the use of graduated compression stockings and/or intermittent pneumatic compression devices (Grade 1C+). We recommend that thromboprophylaxis be used in all patients undergoing major gynecologic surgery (Grade 1A) or major, open urologic procedures, and we recommend prophylaxis with LDUH two times or three times daily (Grade 1A). For patients undergoing elective total hip or knee arthroplasty, we recommend one of the following three anticoagulant agents: LMWH, fondaparinux, or adjusted-dose vitamin K antagonist (VKA) [international normalized ratio (INR) target, 2.5; range, 2.0 to 3.0] (all Grade 1A). For patients undergoing hip fracture surgery (HFS), we recommend the routine use of fondaparinux (Grade 1A), LMWH (Grade 1C+), VKA (target INR, 2.5; range, 2.0 to 3.0) [Grade 2B], or LDUH (Grade 1B). We recommend that patients undergoing hip or knee arthroplasty, or HFS receive thromboprophylaxis for at least 10 days (Grade 1A). We recommend that all trauma patients with at least one risk factor for VTE receive thromboprophylaxis (Grade 1A). In acutely ill medical patients who have been admitted to the hospital with congestive heart failure or severe respiratory disease, or who are confined to bed and have one or more additional risk factors, we recommend prophylaxis with LDUH (Grade 1A) or LMWH (Grade 1A). We recommend, on admission to the intensive care unit, all patients be assessed for their risk of VTE. Accordingly, most patients should receive thromboprophylaxis (Grade 1A).

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Differences in short-term complications between spinal and general anesthesia for primary total knee arthroplasty.

Andrew Pugely, Christopher Martin, Yubo Gao … (2013)

Spinal anesthesia has been associated with lower postoperative rates of deep-vein thrombosis, a shorter operative time, and less blood loss when compared with general anesthesia. The purpose of the present study was to identify differences in thirty-day perioperative morbidity and mortality between anesthesia choices among patients undergoing total knee arthroplasty.

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Author and article information

Contributors

Joon Kyu Lee:

ORCID: http://orcid.org/0000-0003-3710-5714

ndfi@naver.com

Journal

Journal ID (nlm-ta): Knee Surg Relat Res

Journal ID (iso-abbrev): Knee Surg Relat Res

Title: Knee Surgery & Related Research

Publisher: BioMed Central (London )

ISSN (Print): 2234-0726

ISSN (Electronic): 2234-2451

Publication date (Electronic): 7 September 2021

Publication date PMC-release: 7 September 2021

Publication date Collection: 2021

Volume: 33

Electronic Location Identifier: 29

Affiliations

[1 ]GRID grid.411120.7, ISNI 0000 0004 0371 843X, Department of Orthopaedic Surgery, , Konkuk University Medical Center, ; 120-1, Neungdong-ro, Gwangjin-gu Seoul, 05030 South Korea

[2 ]GRID grid.258676.8, ISNI 0000 0004 0532 8339, Research Institute of Medical Science, , Konkuk University School of Medicine, ; 120-1, Neungdong-ro, Gwangjin-gu Seoul, 05030 South Korea

[3 ]GRID grid.413860.8, ISNI 0000 0004 0629 867X, Department of Orthopaedic Surgery, , Cheongju St. Mary’s Hospital, ; 173-19 Jusung-ro, Cheongwon-gu, Cheongju-si, Chungcheongbuk-do 28323 South Korea

[4 ]GRID grid.477505.4, Department of Orthopaedic Surgery, , Hallym University Kangnam Sacred Heart Hospital, ; 1, Singil-ro, Yeongdeungpo-gu, Seoul, 07741 South Korea

[5 ]GRID grid.488421.3, ISNI 0000000404154154, Department of Orthopaedic Surgery, , Hallym University Sacred Heart Hospital, ; 22 Gwanpyeong-ro, 170beon-gil, Dongan-gu, Anyang-si, Gyeonggi-do 14068 South Korea

Author information

Joon Kyu Lee http://orcid.org/0000-0003-3710-5714

Article

Publisher ID: 109

DOI: 10.1186/s43019-021-00109-z

PMC ID: 8425132

PubMed ID: 34493344

SO-VID: dcaa814a-39c2-4ed7-a921-9a83f116fe8d

License:

Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

History

Date received : 23 March 2021

Date accepted : 12 July 2021

Custom metadata

ScienceOpen disciplines: Surgery

Keywords: deep vein thrombosis,total knee arthroplasty,anticoagulant agent,low-molecular-weight-heparin,risk factor

Data availability:

ScienceOpen disciplines: Surgery

Keywords: deep vein thrombosis, total knee arthroplasty, anticoagulant agent, low-molecular-weight-heparin, risk factor

Risk factors for deep vein thrombosis even using low-molecular-weight heparin after total knee arthroplasty

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Abstract

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Karger: Dermatology

Most cited references 40

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.

Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy.

Differences in short-term complications between spinal and general anesthesia for primary total knee arthroplasty.

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