Low rate of subclinical venous thrombosis in patients with haemophilia undergoing major orthopaedic surgery in the absence of pharmacological thromboprophylaxis

Haemophilia ◽  
2020 ◽  
Vol 26 (6) ◽  
pp. 1064-1071
Author(s):  
Géraldine Verstraete ◽  
Catherine Lambert ◽  
Frank Hammer ◽  
Cedric Hermans
Keyword(s):  
Venous Thrombosis ◽  
Orthopaedic Surgery ◽  
Major Orthopaedic Surgery ◽  
Pharmacological Thromboprophylaxis ◽  
Low Rate

Multicentric Study Evaluating Venous Thrombosis Among Patients with Haemophilia Undergoing Major Orthopaedic Surgery

Blood ◽  
2014 ◽  
Vol 124 (21) ◽  
pp. 1496-1496
Author(s):  
Cedric R. Hermans ◽  
Catherine Lambert ◽  
Pal André Holme
Keyword(s):  
Venous Thrombosis ◽  
Orthopaedic Surgery ◽  
Lower Limbs ◽  
Clotting Factor ◽  
Low Molecular Weight ◽  
Pharmacological Prophylaxis ◽  
Major Orthopedic Surgery ◽  
Major Orthopaedic Surgery ◽  
Clotting Factor Concentrates ◽  
Pharmacological Thromboprophylaxis

Abstract Deep venous thrombosis (DVT) is a common postoperative complication in patients undergoing major orthopaedic surgery of the lower limbs, such as total hip replacement (THR), total knee replacement (TKR), or hip fracture surgery (HFS). In the absence of thromboprophylaxis, subclinical venous thrombosis rates as high as 60% have been reported when using systematic bilateral phlebography after orthopaedic surgery. As a result, routine pharmacological thromboprophylaxis with low-molecular-weight heparin (LMWH) or a new oral anticoagulant agent is strongly recommended in patients undergoing these procedures. With the availability of efficient and safe clotting factor concentrates, THR, TKR, as well as ankle arthrodesis are frequently performed in subjects with haemophilia suffering from chronic haemophilic arthropathy. Yet, pharmacological prophylaxis of venous thromboembolism (VTE) in this patient group remains controversial. With the exception of retrospective case reports and small series, the incidence of VTE disease in haemophilic patients after major orthopaedic surgery is still unclear. Surveys suggest that more than half of hemophilia treatment centers in the United States and Europe use thromboprophylaxis in patients with haemophilia (PWH) who require major orthopedic surgery. However, this is not supported by evidence or surgical practice guidelines, and simply increases the risk of bleeding in such patients. Given the aging nature of the haemophilia population and the incidence of joint disease, the question of the thrombotic risk associated with major orthopaedic surgery and joint replacement surgery in particular is highly relevant. Few studies have addressed this issue and more information is needed on which to base optimal preventive strategies for venous thrombosis in patients with haemophilia undergoing elective major orthopedic surgery. We here report the results of 2 parallel and independent prospective studies from Belgium and Norway currently evaluating by systematic US-Doppler imaging the incidence of subclinical deep venous thrombosis in consecutive haemophilic patients referred for major orthopaedic surgery. In Belgium, the study has so far included 36 different patients (32 HA, 4HB) undergoing 50 major orthopaedic procedures of the lower limbs. In Norway, the study has involved 29 patients (26 HA, 3 HB, all with severe haemophilia) undergoing 29 orthopaedic procedures, most of the lower limbs. In both countries, most patients were treated with continuous infusion of clotting factor concentrates and none of them did receive antithrombotic pharmacological prophylaxis. In the 2 studies that included in total 65 patients undergoing 79 major orthopaedic procedures, no case of clinically patent DVT or PE was detected (Table 1). In total there were 5 cases of DVT evidenced by US imaging which were all distal, not complicated by PE and treated with a short course of low-molecular weight heparin in most cases. The overall incidence of subclinical DVT calculated on the whole population was 6%. In conclusion, these data provide for the first time multicentric and imaging-based evidence that the risk of DVT following major orthopaedic surgery among patients with haemophilia undergoing major orthopaedic surgery is very low and that systematic pharmacological thromboprophylaxis in this specific population is for most patients not required. The two studies are still ongoing and should include a larger number of participants in the future. Table 1Characteristics of patients with haemophilia undergoing major orthopaedic surgeryHTC BrusselsHTCOsloTotalPatients362965Haemophilia A322658Haemophilia B437Severe252954Moderate909Mild202Procedures502979Knee301141Ankle81220Hip729Femur404Lumbar101Elbow044Venous thrombosis415HTC: Haemophilia Treatment Center Disclosures No relevant conflicts of interest to declare.

Subclinical Deep Venous Thrombosis Affects 10 % of Haemophiliacs Undergoing Major Orthopaedic Surgery.

Blood ◽  
2008 ◽  
Vol 112 (11) ◽  
pp. 3377-3377 ◽  
Author(s):  
Cedric R. Hermans ◽  
Catherine Lambert
Keyword(s):  
Venous Thrombosis ◽  
Deep Venous Thrombosis ◽  
Orthopaedic Surgery ◽  
Ankle Arthrodesis ◽  
Lower Limbs ◽  
Clotting Factor ◽  
Decompressive Laminectomy ◽  
Short Course ◽  
Major Orthopedic Surgery ◽  
Major Orthopaedic Surgery

Abstract The management of venous thromboembolism (VTE) in patients with haemophilia undergoing major orthopaedic surgery requiring intensive replacement therapy remains controversial. Information about the incidence of proven VTE in this setting is lacking. Despite the absence of data, half of haemophilia comprehensive centers in Europe recently reported the use of pharmacological antithrombotic prophylaxis in this setting. We conducted a prospective study to evaluate the occurrence of deep venous thrombosis (DVT) of the lower limbs in all consecutive patients with haemophilia referred for major orthopaedic surgery at the Cliniques universitaires Saint-Luc, Brussels, Belgium. Screening for DVT by unilateral (13) or bilateral (16) compression ultrasonography (US) of the lower limbs was performed 5 to 12 days after 29 major orthopaedic surgeries (total hip replacement (5), total knee replacement (TKR) (15), ankle arthrodesis (4), decompressive laminectomy for lumbar stenosis (1), femoral osteosynthesis (4)) in 22 patients with severe (16), moderate (4) or mild (2) haemophilia A (20) or B (2), intensively treated with continuous infusion of clotting factor concentrate. None of the patients received pharmacological anti-thrombotic prophylaxis with LMWH. There was no case of clinical DVT or pulmonary embolism during the 3-months post-operative clinical surveillance. However distal DVT involving a single peroneal vein without proximal extension was identified in two patients with severe HA after TKR and in one patient with mild HB after decompressive laminectomy. The latter was efficiently treated with a short course of LMWH. The two others resolved spontaneously without antithrombotic therapy. In conclusion, sub-clinical DVT affects up to 10 % of patients with haemophilia undergoing major orthopedic surgery. All thrombotic events were distal and resolved spontaneously or with a short course of LMWH without complications. This study suggests that routine screening for DVT by compressive US is indicated in patients with haemophilia undergoing major orthopaedic surgery and not receiving pharmacological thromboprophylaxis. Further studies are needed to determine if systematic pharmacological prevention of DVT is required in this setting as in patients without haemophilia.

Post Discharge Clinically Overt Venous Thromboembolism in Orthopaedic Surgery Patients with Negative Venography -an Overview Analysis

1996 ◽  
Vol 76 (06) ◽  
pp. 0887-0892 ◽  
Author(s):  
Serena Ricotta ◽  
Alfonso lorio ◽  
Pasquale Parise ◽  
Giuseppe G Nenci ◽  
Giancarlo Agnelli
Keyword(s):  
Venous Thromboembolism ◽  
Orthopaedic Surgery ◽  
Diagnostic Methods ◽  
Future Research ◽  
Post Discharge ◽  
Pharmacological Prophylaxis ◽  
Vein Thrombosis ◽  
Overview Analysis ◽  
Major Orthopaedic Surgery

SummaryA high incidence of post-discharge venous thromboembolism in orthopaedic surgery patients has been recently reported drawing further attention to the unresolved issue of the optimal duration of the pharmacological prophylaxis. We performed an overview analysis in order to evaluate the incidence of late occurring clinically overt venous thromboembolism in major orthopaedic surgery patients discharged from the hospital with a negative venography and without further pharmacological prophylaxis. We selected the studies published from January 1974 to December 1995 on the prophylaxis of venous thromboembolism after major orthopaedic surgery fulfilling the following criteria: 1) adoption of pharmacological prophylaxis, 2) performing of a bilateral venography before discharge, 3) interruption of pharmacological prophylaxis at discharge in patients with negative venography, and 4) post-discharge follow-up of the patients for at least four weeks. Out of 31 identified studies, 13 fulfilled the overview criteria. The total number of evaluated patients was 4120. An adequate venography was obtained in 3469 patients (84.1%). In the 2361 patients with negative venography (68.1%), 30 episodes of symptomatic venous thromboembolism after hospital discharge were reported with a resulting cumulative incidence of 1.27% (95% C.I. 0.82-1.72) and a weighted mean incidence of 1.52% (95% C.I. 1.05-1.95). Six cases of pulmonary embolism were reported. Our overview showed a low incidence of clinically overt venous thromboembolism at follow-up in major orthopaedic surgery patients discharged with negative venography. Extending pharmacological prophylaxis in these patients does not appear to be justified. Venous thrombi leading to hospital re-admission are likely to be present but asymptomatic at the time of discharge. Future research should be directed toward improving the accuracy of non invasive diagnostic methods in order to replace venography in the screening of asymptomatic post-operative deep vein thrombosis.

Decisional capacity to consent to treatment and anaesthesia in patients over the age of 60 undergoing major orthopaedic surgery

2019 ◽  
Vol 59 (4) ◽  
pp. 247-254 ◽  
Author(s):  
Gabriele Mandarelli ◽  
Giovanna Parmigiani ◽  
Felice Carabellese ◽  
Silvia Codella ◽  
Paolo Roma ◽  
...  
Keyword(s):  
Informed Consent ◽  
Orthopaedic Surgery ◽  
Decisional Capacity ◽  
Capacity To Consent ◽  
Capacity Evaluation ◽  
Decision Making Capacity ◽  
Consent To Treatment ◽  
Major Orthopaedic Surgery ◽  
Pain Symptoms ◽  
State Examination

Despite growing attention to the ability of patients to provide informed consent to treatment in different medical settings, few studies have dealt with the issue of informed consent to major orthopaedic surgery in those over the age of 60. This population is at risk of impaired decision-making capacity (DMC) because older age is often associated with a decline in cognitive function, and they often present with anxiety and depressive symptoms, which could also affect their capacity to consent to treatment. Consent to major orthopaedic surgery requires the patient to understand, retain and reason about complex procedures. This study was undertaken to extend the literature on decisional capacity to consent to surgery and anaesthesia of patients over the age of 60 undergoing major orthopaedic surgery. Recruited patients ( N=83) were evaluated using the Aid to Capacity Evaluation, the Beck Depression Inventory, the State–Trait Anxiety Inventory Y, the Mini-Mental State Examination and a visual analogue scale for measuring pain symptomatology. Impairment of medical DMC was common in the overall sample, with about 50% of the recruited patients showing a doubtful ability, or overt inability, to provide informed consent. Poor cognitive functioning was associated with reduced medical DMC, although no association was found between decisional capacity and depressive, anxiety and pain symptoms. These findings underline the need of an in-depth assessment of capacity in older patients undergoing major orthopaedic surgery.

Continuous epidural infusion of ropivacaine for the prevention of postoperative pain after major orthopaedic surgery: A dose-finding study

Acute Pain ◽  
1998 ◽  
Vol 1 (2) ◽  
pp. 13-19 ◽  
Author(s):  
Terry Muldoon ◽  
Paul McConaghy ◽  
Alexander R Binning ◽  
Charles B Wallis ◽  
J Dennis R Connolly ◽  
...  
Keyword(s):  
Postoperative Pain ◽  
Orthopaedic Surgery ◽  
Epidural Infusion ◽  
Dose Finding ◽  
Continuous Epidural Infusion ◽  
Finding Study ◽  
Dose Finding Study ◽  
Major Orthopaedic Surgery

Major orthopaedic surgery and post-discharge DVT

The Lancet ◽  
1996 ◽  
Vol 348 (9022) ◽  
pp. 209-210 ◽  
Author(s):  
Jan W ten Cate ◽  
Martin H Prins
Keyword(s):  
Orthopaedic Surgery ◽  
Post Discharge ◽  
Major Orthopaedic Surgery

scholarly journals The measurement of cardiac troponins in patients undergoing major orthopaedic surgery

2010 ◽  
Vol 35 (3) ◽  
pp. 463-464 ◽  
Author(s):  
Giuseppe Lippi ◽  
Gianfranco Cervellin ◽  
Mario Plebani
Keyword(s):  
Orthopaedic Surgery ◽  
Major Orthopaedic Surgery ◽  
Cardiac Troponins
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