Title: Incidence of symptomatic Venous Thrombo Embolism (VTE), with or without chemoprophylaxis, in patients undergoing Total Knee Replacement: A comparative study
Authors: Tom Jose, Murukan Babu, Georgy J Kuruvilla
DOI: https://dx.doi.org/10.18535/jmscr/v5i7.146
Abstract
Background: The incidence of Venous Thrombo Embolism (VTE) in Western population undergoing major orthopaedic surgery without any thromboprophylaxis has been reported to range from 32% to 88%. But there is a firm belief that this complication is rare in Asian patients. Majority of publications on thromboembolic disease are from the West and some studies from Asia often contradict this. They say, routine chemoprophylaxis is perhaps not justified in every patient, instead high level of suspicion and close clinical monitoring is only what is required. The issue has acquired greater significance in Indian subjects in recent times as there is an exponential increase in the number of joint replacement surgeries and surgeries for lower limb fractures. Very few studies have been published from India on the subject and very little is known about the true incidence of the condition. In this context this study was designed.
Objectives: To study the incidence of symptomatic VTE in patients with and without chemoprophylaxis
Methods: 110 patients who underwent Total Knee Replacement (26 bilateral and 84 unilateral knees) during a period between October 2011 and October 2013 were studied for the occurrence of symptomatic VTE. All of these,110 patients received chemoprophylaxis. Each of these patients were assessed for 1 month for any clinical signs or symptoms that may show the presence of underlying VTE—such as, fever, calf swelling, pain or tenderness of calf. If there was suspicion of VTE, an ultrasound examination was carried out and VTE was confirmed. The results from this study were compared with 57 patients who underwent surgery during the period 2008 -2011 who received no chemoprophylaxis.
Results: Among the 110 patients who received chemoprophylaxis only one person developed symptomatic VTE (0.9%). There was no significant bleeding or wound healing problems which needed specific procedures or discontinuation of treatment. In the group of 57 which didn’t receive chemoprophylaxis, 5 patients developed symptomatic VTE (8.7%).
Conclusion: The study shows a significant reduction in VTE with chemoprophylaxis and hence routine chemoprophylaxis in every patient undergoing Total Knee Replacement is clearly justified
Keywords-Venous thromboembolism, Chemoprophylaxis, Total Knee Replacement, Deep vein thrombosis.
References
1. Ngoh ChinLiew ,YunusGul et al. Postoperative Venous Thromboembolism in Asia: A Critical Appraisal of its IncidenceAsian Journal of Surgery Volume 26, Issue 3, July 2003, Pages 154-158
2. SC Srivastava Absence of pulmonary embolism in AsiansBr Med J, i (1964), pp. 772-773
3. KS Dhillon, A Askander, S DoraismayPostoperative deep-vein thrombosis in Asian patients is not a rarity: a prospective study of 88 patients with no prophylaxisJ Bone Joint Surg Br, 78 (1996), pp. 427-430
4. GV Shead, R NarayananIncidence of post-operative venous thromboembolism in South IndiaBr J Surg, 67 (1980), pp. 813-814
5. Lee WS, Kim KI, Lee HJ, et al. The incidence of pulmonary embolism and deep vein thrombosis after knee arthroplasty in Asians remains low: a meta-analysis. Clin Orthop Relat Res 2013; 471:1523–1532.
6. Lee AD, Stephen E, Agarwal S, et al. Venous thrombo-embolism in India. Eur J Vasc Endovasc Surg 2009; 37:482–485.
7. Preventing venous thromboembolic disease in patients undergoing elective hip and knee arthroplasty evidence-based guideline and evidence report Adopted by the American Academy of OrthoPaedic Surgeons Board of Directors September 23, 2011
8. Chung LH, Chen WM, Chen CF, Chen TH, Liu CL. Deep vein thrombosis after total knee arthroplasty in Asian patients without prophylactic anticoagulation. Orthopedics 2011; 34:15.
9. Nikolaou, V.S., Desy, N.M., Bergeron, S.G. et al, Total knee replacement and chemical thromboprophylaxis: current evidence. Curr Vasc Pharmacol. 2011;9:33 ([Review]).
10. Kim, Y.H., Kim, J.S. Incidence and natural history of deep-vein thrombosis after total knee arthroplasty: a prospective randomized study. J Bone Joint Surg Br. 2002;84-B:566.
11. Shepherd A, Mills C Fatal pulmonary embolism following hip and knee replacement: a study of 2153 cases using routine mechanical prophylaxis and selective chemoprophylaxis. Hip Int 2006;16:53–6.
12. Lachiewicz PF, Soileau ES. Mechanical calf compression and aspirin prophylaxis for total knee arthroplasty. Clin Orthop 2007;464:61–64.
13. Geerts WH, Bergqvist D, Pineo GF, et al. Prevention of venous thromboembolism: American College of Chest Physicians evidence-based clinical practice guidelines (8th edi.). Chest 2008(Suppl);133:381–453.
14. Leclerc JR, Gent M, Hirsh J, et al. The incidence of symptomatic venous thrombo- embolism during and after prophylaxis with enoxaparin a multi-institutional cohort study of patients who underwent hip or knee arthroplasty. Arch Intern Med 1998;158: 873 –878.
15. Cusick LA, Beverland DE. The incidence of fatal pulmonary embolism after primary hip and knee replacement in a consecutive series of 4253 patients. J Bone Joint Surg [Br] 2009;91-B:645–648.
16. Altintaş F, Gürbüz H, Erdemli B, et al. Venous thromboembolism prophylaxis in major orthopaedic surgery: a multicenter, prospective, observational study. Acta Orthop Traumatol Turc 2008;42:322–327
17. Dorr LD, Gendelman V, Maheshwari AV, et al. Multimodal thromboprophylaxis for total hip and knee arthroplasty based on risk assessment. J Bone Joint Surg [Am] 2007;89-A:2648–2657.
18. Lachiewicz PF, Soileau ES. Multimodal prophylaxis for THA with mechanical com- pression. Clin Orthop 2006;453:225–230.
19. Callaghan JJ, Warth LC, Hoballah JJ, Liu SS, Wells CW. Evaluation of deep venous thrombosis prophylaxis in low-risk patients undergoing total knee arthro- plasty. J Arthroplasty 2008;23(Suppl):20–24.
20. Sachs RA, Smith JH, Kuney M, Paxton L. Does anticoagulation do more harm than good?: a comparison of patients treated without prophylaxis and patients treated with low-dose warfarin after total knee arthroplasty. JArthroplasty 2003;18:389–395