J Korean Med Sci.  2015 Dec;30(12):1865-1873. 10.3346/jkms.2015.30.12.1865.

Clinical Performance of the 1st American Academy of Orthopaedic Surgeons Clinical Guideline on Prevention of Symptomatic Pulmonary Embolism after Total Knee Arthroplasty in Korean Patients

• Na YG
• Fang R
• Kim YH
• Cho KJ
• Kim TK

• KMID: 2359973
• DOI: http://doi.org/10.3346/jkms.2015.30.12.1865

Abstract

We sought to document the clinical performance of the 1st American Academy of Orthopaedic Surgeons (AAOS) guideline on the prevention of symptomatic pulmonary embolism (PE) after total knee arthroplasty (TKA) in Korean patients, in terms of the proportions of the each risk-stratified group, efficacy and safety. Consecutive 328 patients underwent TKA were preoperatively assessed for the risks of PE and bleeding and categorized into 4 groups: 1) standard risk, 2) high risk for PE, 3) high risk for bleeding, and 4) high risks both for PE and bleeding. One of three options was administered according to the groups (aspirin in group 1 or 4; enoxaparin and following aspirin in group 2; antithrombotic stocking in group 3). Incidences of symptomatic deep vein thrombosis (DVT) and PE, and major or minor bleeding complications were evaluated. Majority of the patients (86%) were assessed to be with standard risks both for PE and bleeding. No patient experienced symptomatic DVT or PE and major bleeding. Eleven percent of the patients discontinued chemoprophylaxis because of bleeding-related wound complication. In conclusion, the 1st AAOS guideline functions successfully in Korean patients undergoing TKA in terms of prevention of symptomatic DVT and PE while avoiding major bleeding complications.

Keyword

Arthroplasty, Replacement, Knee; Venous Thromboembolism; Pulmonary Embolism; Venous Thrombosis; Hemorrhage; Chemoprevention; Aspirin; Enoxaparin; AAOS Guideline

MeSH Terms

Aged
Arthroplasty, Replacement, Knee/*adverse effects
Aspirin/administration & dosage
Cohort Studies
Enoxaparin/administration & dosage
Female
Fibrinolytic Agents/administration & dosage
Humans
Male
Middle Aged
Orthopedics
Postoperative Complications/etiology/*prevention & control
Postoperative Hemorrhage/etiology/prevention & control
*Practice Guidelines as Topic
Pulmonary Embolism/etiology/*prevention & control
Republic of Korea
Retrospective Studies
Risk Factors
Societies, Medical
Stockings, Compression
Venous Thrombosis/etiology/prevention & control
Aspirin
Enoxaparin
Fibrinolytic Agents

Reference

1. Geerts WH, Pineo GF, Heit JA, Bergqvist D, Lassen MR, Colwell CW, Ray JG. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004; 126:338S–400S.

2. Johanson NA, Lachiewicz PF, Lieberman JR, Lotke PA, Parvizi J, Pellegrini V, Stringer TA, Tornetta P 3rd, Haralson RH 3rd, Watters WC 3rd. Prevention of symptomatic pulmonary embolism in patients undergoing total hip or knee arthroplasty. J Am Acad Orthop Surg. 2009; 17:183–196.

3. Haas SB, Barrack RL, Westrich G, Lachiewicz PF. Venous thromboembolic disease after total hip and knee arthroplasty. J Bone Joint Surg Am. 2008; 90:2764–2780.

4. Parvizi J, Azzam K, Rothman RH. Deep venous thrombosis prophylaxis for total joint arthroplasty: American Academy of Orthopaedic Surgeons guidelines. J Arthroplasty. 2008; 23:2–5.

5. Burnett RS, Clohisy JC, Wright RW, McDonald DJ, Shively RA, Givens SA, Barrack RL. Failure of the American College of Chest Physicians-1A protocol for lovenox in clinical outcomes for thromboembolic prophylaxis. J Arthroplasty. 2007; 22:317–324.

6. Callaghan JJ, Dorr LD, Engh GA, Hanssen AD, Healy WL, Lachiewicz PF, Lonner JH, Lotke PA, Ranawat CS, Ritter MA, et al. American Colleg of Chest Physicians. Prophylaxis for thromboembolic disease: recommendations from the American College of Chest Physicians--are they appropriate for orthopaedic surgery? J Arthroplasty. 2005; 20:273–274.

7. Geerts WH, Bergqvist D, Pineo GF, Heit JA, Samama CM, Lassen MR, Colwell CW. American College of Chest Physicians. Prevention of venous thromboembolism: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008; 133:381S–453S.

8. Parvizi J, Ghanem E, Joshi A, Sharkey PF, Hozack WJ, Rothman RH. Does "Excessive" Anticoagulation Predispose to Periprosthetic Infection? J Arthroplasty. 2007; 22:24–28.

9. Eikelboom JW, Karthikeyan G, Fagel N, Hirsh J. American Association of Orthopedic Surgeons and American College of Chest Physicians Guidelines for Venous Thromboembolism Prevention in Hip and Knee Arthroplasty Differ: What Are the Implications for Clinicians and Patients? Chest. 2009; 135:513–520.

10. Jacobs JJ, Mont MA, Bozic KJ, Della Valle CJ, Goodman SB, Lewis CG, Yates AC Jr, Boggio LN, Watters WC 3rd, Turkelson CM, et al. American Academy of Orthopaedic Surgeons clinical practice guideline on: preventing venous thromboembolic disease in patients undergoing elective hip and knee arthroplasty. J Bone Joint Surg Am. 2012; 94:746–747.

11. NICE. NICE clinical guideline 46: venous thromboembolism-Reducing the risk of venous thromboembolism (deep vein thrombosis and pulmonary embolism) in inpatients undergoing surgery. National Institute for Health and Clinical Excellence (United Kindom);2007.

12. Fitzgerald RH Jr, Spiro TE, Trowbridge AA, Gardiner GA Jr, Whitsett TL, O'Connell MB, Ohar JA, Young TR. Enoxaparin Clinical Trial Group. Prevention of venous thromboembolic disease following primary total knee arthroplasty. A randomized, multicenter, open-label, parallel-group comparison of enoxaparin and warfarin. J Bone Joint Surg Am. 2001; 83-A:900–906.

13. Turpie AG, Bauer KA, Caprini JA, Comp PC, Gent M, Muntz JE. Apollo Investigators. Fondaparinux combined with intermittent pneumatic compression vs. intermittent pneumatic compression alone for prevention of venous thromboembolism after abdominal surgery: a randomized, double-blind comparison. J Thromb Haemost. 2007; 5:1854–1861.

14. Klatsky AL, Armstrong MA, Poggi J. Risk of pulmonary embolism and/or deep venous thrombosis in Asian-Americans. Am J Cardiol. 2000; 85:1334–1337.

15. Stein PD, Kayali F, Olson RE, Milford CE. Pulmonary thromboembolism in Asians/Pacific Islanders in the United States: analysis of data from the National Hospital Discharge Survey and the United States Bureau of the Census. Am J Med. 2004; 116:435–442.

16. Kim YH, Yoo JH, Kim JS. Factors leading to decreased rates of deep vein thrombosis and pulmonary embolism after total knee arthroplasty. J Arthroplasty. 2007; 22:974–980.

17. Cho KY, Kim KI, Khurana S, Bae DK, Jin W. Is routine chemoprophylaxis necessary for prevention of venous thromboembolism following knee arthroplasty in a low incidence population? Arch Orthop Trauma Surg. 2013; 133:551–559.

18. Kim GH, Park BY, Bae TY, Kang JW, In Y. Can enoxaparin reduce thromboembolism related events after primary TKA in Asian patients? J Arthroplasty. 2013; 28:1862–1867.

19. Kim KI, Cho KY, Jin W, Khurana SS, Bae DK. Recent Korean perspective of deep vein thrombosis after total knee arthroplasty. J Arthroplasty. 2011; 26:1112–1116.

20. Lee SH, Cho KY, Khurana S, Kim KI. Less blood loss under concomitant administration of tranexamic acid and indirect factor Xa inhibitor following total knee arthroplasty: a prospective randomized controlled trial. Knee Surg Sports Traumatol Arthrosc. 2013; 21:2611–2617.

21. Park KH, Cheon SH, Lee JH, Kyung HS. Incidence of venous thromboembolism using 64 channel multidetector row computed tomography-indirect venography and anti-coagulation therapy after total knee arthroplasty in Korea. Knee Surg Relat Res. 2012; 24:19–24.

22. Yhim HY, Jang MJ, Bang SM, Kim KH, Kim YK, Nam SH, Bae SH, Kim SH, Mun YC, Kim I, et al. Incidence of venous thromboembolism following major surgery in Korea: from the Health Insurance Review and Assessment Service database. J Thromb Haemost. 2014; 12:1035–1043.

23. Falck-Ytter Y, Francis CW, Johanson NA, Curley C, Dahl OE, Schulman S, Ortel TL, Pauker SG, Colwell CW Jr. American College of Chest Physicians. 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:e278S–e325S.

24. Leizorovicz A, Turpie AGG, Cohen AT, Wong L, Yoo MC, Dans A. The Smart Study Group. Epidemiology of venous thromboembolism in Asian patients undergoing major orthopedic surgery without thromboprophylaxis. The SMART Study. J Thromb Haemost. 2005; 3:28–34.

25. Zivelin A, Rosenberg N, Faier S, Kornbrot N, Peretz H, Mannhalter C, Horellou MH, Seligsohn U. A single genetic origin for the common prothrombotic G20210A polymorphism in the prothrombin gene. Blood. 1998; 92:1119–1124.

26. Turpie AG, Bauer KA, Eriksson BI, Lassen MR. Fondaparinux vs enoxaparin for the prevention of venous thromboembolism in major orthopedic surgery: a meta-analysis of 4 randomized double-blind studies. Arch Intern Med. 2002; 162:1833–1840.

27. Koh IJ, Kim TK, Chang CB, Cho HJ, In Y. Trends in Use of Total Knee Arthroplasty in Korea From 2001 to 2010. Clin Orthop Relat Res. 2012.

28. Brighton TA, Eikelboom JW, Mann K, Mister R, Gallus A, Ockelford P, Gibbs H, Hague W, Xavier D, Diaz R, et al. Aspire Investigators. Low-dose aspirin for preventing recurrent venous thromboembolism. N Engl J Med. 2012; 367:1979–1987.

29. Mont MA, Jacobs JJ. AAOS clinical practice guideline: preventing venous thromboembolic disease in patients undergoing elective hip and knee arthroplasty. J Am Acad Orthop Surg. 2011; 19:777–778.

30. Bang SM, Jang MJ, Kim KH, Yhim HY, Kim YK, Nam SH, Hwang HG, Bae SH, Kim SH, Mun YC, et al. Korean Society of Thrombosis and Hemostasis. Prevention of venous thromboembolism, 2nd edition: Korean Society of Thrombosis and Hemostasis Evidence-based Clinical Practice Guidelines. J Korean Med Sci. 2014; 29:164–171.